1. Urinary Incontinence Tova Ablove, Alev Wilk Primary Care Conference, 6/22/05

2. Urinary Incontinence No Financial Disclosures No Financial Disclosures

3. Objectives Overview of Urinary Incontinence in Women: Dr. Ablove Overview of Urinary Incontinence in Women: Dr. Ablove Presentation of Cases: Dr. Wilk Presentation of Cases: Dr. Wilk Initial Management Issues: Initial Management Issues:  Urodynamic testing for all women? OR  Therapy trials based on history and exam only: medication, pelvic floor exercises, pessary?

4. Incontinence 14% of healthy postmenopausal have daily incontinence. 41% of healthy postmenopausal have incontinence at least once per month. Brown et al. obstetrics and gynecology 1996

5. Types of Urinary Incontinence Mixed symptoms –combination of stress and urge incontinence Urge –urine loss accompanied by urgency resulting from abnormal Bladder contractions Stress –urine loss resulting from sudden increased intra- abdominal pressure (eg, laugh, cough, sneeze) Sudden increase in intra-abdominal pressure Uninhibited detrusor contractions Urethral pressure

6. Urinary Incontinence and OAB z Urgency Frequency Nocturia SUI Mixed (UUI+SUI) UUI OAB Detrol ® LA

7. Evaluation History History Physical Physical Labs Labs Testing Testing

8. History HPI HPI  Identify #1 complaint  Frequency & duration of sx Medications Medications Musculo-skeletal Musculo-skeletal  Mobility- screen for falls  Back pain/disease Autoimmune  MS  Fibromyalgia  IBS  Crohns Heart failure Neurologic/psychiatric  Stroke, depression, dementia

9. History Diabetes Diabetes Gynecologic Gynecologic  Hormonal status  Prolapse  STDs  Sexual activity  Pregnancy  Chronic pelvic pain Bladder disease  Interstitial cystitis  Cancer  Chronic cystitis Kidney disease  Infections  Stones  Insufficiency

11. Physical Examination Perform general, abdominal (including bladder palpation), and neurologic exams Perform general, abdominal (including bladder palpation), and neurologic exams Perform pelvic and rectal exam in females and rectal exam in males Perform pelvic and rectal exam in females and rectal exam in males Observe for urine loss with vigorous cough Observe for urine loss with vigorous cough Check for urinary retention Check for urinary retention Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; January 1996. AHCPR publication 96- 0686.

12. Pelvic Anatomy

13. Pelvic Exam

14. Laboratory Tests Urinalysis Urinalysis  to evaluate for hematuria, pyuria, bacteriuria, glucosuria, proteinuria Urine culture Urine culture Wet mount Wet mount Vaginal cultures Vaginal cultures Herpes cultures not usually done on initial evaluation Herpes cultures not usually done on initial evaluation Blood work if compromised renal function is suspected Blood work if compromised renal function is suspected

15. Treatments Treat patient’s most bothersome form of voiding dysfunction first. Treat patient’s most bothersome form of voiding dysfunction first. Treat conditions that can mimic or exacerbate overactive bladder Treat conditions that can mimic or exacerbate overactive bladder The objective is to improve quality of life.

16. Treatable Conditions That Mimic or Exacerbate OAB Urinary tract infection Urinary tract infection Urogenital aging Urogenital aging Bladder outlet obstruction Bladder outlet obstruction Prolapse * Prolapse * Stress incontinence * Stress incontinence *

17. Treatments Overactive bladder Drugs anticholinergic, local estrogen Drugs anticholinergic, local estrogen Pelvic floor rehab Pelvic floor rehab Bladder drill Bladder drill Treat bladder outlet obstruction Treat bladder outlet obstruction Acupuncture Acupuncture Neuromodulation Neuromodulation Botox injections Botox injections

18. Drugs Predominant anticholinergic or antimuscurinic action Oxybutnin Oxybutnin Tolterodine Tolterodine Hyoscyamine Hyoscyamine Imipramine Imipramine Darifenacin Darifenacin Solifenacin Solifenacin Close follow up needed especially in geriatric patients

19. Treatments: Stress Incontinence Pelvic floor rehabilitation Pelvic floor rehabilitation Local estrogen Local estrogen Incontinence pessary Incontinence pessary Collagen Collagen Surgery Surgery

20. OAB: When to Consider Referral to a Specialist Symptoms do not respond to initial treatment within 2–3 months Symptoms do not respond to initial treatment within 2–3 months Hematuria without infection on urinalysis Hematuria without infection on urinalysis Symptoms suggestive of poor bladder emptying (hesitancy, poor stream, terminal dribbling) Symptoms suggestive of poor bladder emptying (hesitancy, poor stream, terminal dribbling) Evidence of unexplained neurologic or metabolic disease Evidence of unexplained neurologic or metabolic disease Significant pelvic organ prolapse is present Significant pelvic organ prolapse is present Abrams P, Wein AJ. The Overactive Bladder: A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998.

21. Stress Incontinence: When to Consider Referral to a Specialist If patient desires treatment and is not interested in conservative therapy or has tried and failed conservative therapy.

22. When to refer for Cystoscopy To rule out stones, cancer, foreign bodies, chronic inflammation To rule out stones, cancer, foreign bodies, chronic inflammation To confirm normal anatomy prior to surgery. To confirm normal anatomy prior to surgery.  Recurrent UTIs especially if they are resistant to therapy  Hematuria  Irritative bladder symptoms especially in postmenopausal women and smokers  Recurrent incontinence  With suspicion of interstitial cystitis

23. When to Refer for Urodynamics? Urinary retention Urinary retention Incontinence that fails initial therapy Incontinence that fails initial therapy History of Neurologic disease History of Neurologic disease Prolapse desiring surgery Prolapse desiring surgery Prolapse as part of the clinical picture of incontinence Prolapse as part of the clinical picture of incontinence Prior pelvic surgery Prior pelvic surgery Mixed incontinence Mixed incontinence 1996 Agency for Health Care Policy and Research Weider et al 2001 Handa et al 1995

24. Case One 48 y.o. woman with polyuria (every 30 minutes while awake) and pelvic pressure for 6 months 48 y.o. woman with polyuria (every 30 minutes while awake) and pelvic pressure for 6 months Voiding diary- frequency 16x/24hrs, nocturia 1- 2x/night, no leak episodes Voiding diary- frequency 16x/24hrs, nocturia 1- 2x/night, no leak episodes No dysuria, postvoid fullness, constipation No dysuria, postvoid fullness, constipation Three uncomplicated vaginal births; tubal ligation; Leep procedure 1993 Three uncomplicated vaginal births; tubal ligation; Leep procedure 1993 Premenstrual syndrome dysphoria on fluoxetine Premenstrual syndrome dysphoria on fluoxetine

25. Case One Denies tobacco or alcohol use; CNA Denies tobacco or alcohol use; CNA Exam: NL cardiovascular, GI, Kidney. Genital: pelvic floor “prolapse to introitus”; negative UA & glucose; PVR: 100cc. Exam: NL cardiovascular, GI, Kidney. Genital: pelvic floor “prolapse to introitus”; negative UA & glucose; PVR: 100cc. Recommendations: Recommendations:  Oxybutinin for “overactive bladder”?  Pelvic Floor Physical Therapy Program?  Referral to subspecialty?

26. Case Two 76 y.o. woman with stress and urge incontinence, urinary leakage; nocturia 1-2x per night 76 y.o. woman with stress and urge incontinence, urinary leakage; nocturia 1-2x per night Urinary frequency, constipation, postvoid fullness Urinary frequency, constipation, postvoid fullness G6P6; s/p oophorectomy, partial colectomy G6P6; s/p oophorectomy, partial colectomy Depression, COPD, HTN, schizophrenia, anxiety Depression, COPD, HTN, schizophrenia, anxiety Current smoker: 63 pack years; no alcohol; retired RN and widowed Current smoker: 63 pack years; no alcohol; retired RN and widowed

27. Case Two Albuterol, cogentin, valium, benadryl, depakote, advair, meclizine, zyprexa, piroxicam, quinine, risperidone, trazodone Albuterol, cogentin, valium, benadryl, depakote, advair, meclizine, zyprexa, piroxicam, quinine, risperidone, trazodone Exam: Stable cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA. PVR 60cc. Exam: Stable cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA. PVR 60cc. Recommendations: Recommendations:  Estrogen?  Pelvic Floor Physical Therapy Program?  Referral to subspecialty?

28. Case Three 55 y.o. woman with stress incontinence when she coughs, laughs, or exercises 55 y.o. woman with stress incontinence when she coughs, laughs, or exercises No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation G 0 P 0 G 0 P 0 Depression on Celexa Depression on Celexa

29. Case Three Denies tobacco or alcohol use; Recently divorced Denies tobacco or alcohol use; Recently divorced Exam: NL cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA. PVR 60cc. Exam: NL cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA. PVR 60cc. Recommendations: Recommendations:  Estrogens?  Pessary?  Pelvic Floor Physical Therapy Program?  Referral to subspecialty?

30. Case Four 44 y.o. woman with stress incontinence and urinary leakage, nocturia x2 at night 44 y.o. woman with stress incontinence and urinary leakage, nocturia x2 at night No dribbling, urgency, frequency, dysuria, constipation No dribbling, urgency, frequency, dysuria, constipation Four vaginal, uneventful vaginal deliveries; hysterectomy and bladder suspension procedure 1990 Four vaginal, uneventful vaginal deliveries; hysterectomy and bladder suspension procedure 1990 HTN, fibromyalgia, GERD on ranitidine and atenolol HTN, fibromyalgia, GERD on ranitidine and atenolol

31. Case Four Denies tobacco or alcohol use; CNA Denies tobacco or alcohol use; CNA Exam: NL cardiovascular, GI, Kidney. Genital: atrophic vulva & pelvic floor laxity; negative UA. PVR 40cc. Exam: NL cardiovascular, GI, Kidney. Genital: atrophic vulva & pelvic floor laxity; negative UA. PVR 40cc. Has attempted Kegel exercises without improvement Has attempted Kegel exercises without improvement Recommendations: Recommendations:  Medications? Pessary?  Pelvic Floor Physical Therapy Program?  Referral to subspecialty?

32. Case Five 36 y.o. woman with stress incontinence recently exacerbated by URI symptoms 36 y.o. woman with stress incontinence recently exacerbated by URI symptoms No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation. No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation. G 5 P 5, s/p C-section 1988 G 5 P 5, s/p C-section 1988 Intermittent asthma, neck pain Intermittent asthma, neck pain Ortho evra patch, prn maxair, skelaxin Ortho evra patch, prn maxair, skelaxin

33. Case Five Denies tobacco or alcohol use; Bus driver Denies tobacco or alcohol use; Bus driver Exam: NL cardiovascular, GI, Kidney. Genital: grossly normal; negative UA. PVR 20cc Exam: NL cardiovascular, GI, Kidney. Genital: grossly normal; negative UA. PVR 20cc Has attempted Kegel exercises without improvement Has attempted Kegel exercises without improvement Recommendations: Recommendations:  Medications? Pessary?  Pelvic Floor Physical Therapy Program?  Referral to subspecialty?