Disability and Incontinence

Patient assessmentPatient management

Incontinence is more common in disabled

Major effect on QoL

Major economic burden

Increasing issue as survival improves

Leads to isolation, depression and death

Overall management

Individual patient focussed

Coordinated multidisciplinary

Community based

Realistic

Cost effective

Ongoing care

Improved QoL, Independence

…small interventions can lead to major improvements……

Urinary Incontinence

Physical declineGeneral decline

Vicious cycle

Causes of Incontinence

SUI Stress Incontinence : 50%UUI Urge Incontinence : 20%MUI Mixed Incontinence: 30%

Higher UUI in Disabled

Non Urinary tractAgeingReduced mobilityPoly pharmacyIatrogenicPsychogenicCognitive impairment

Causes of Incontinence

• D Delirium• I Infection• A Atrophic vaginitis• P Psychogenic• P Pharmacologic• E Excess urine• R Restricted mobility• S Stool impaction

Assessement

• Systematic• History• Examination• Investigations• Diagnosis / define goals• Treatment• Follow up

History

• General: Medical, systems, social supports, environmental

Specific: Urinary symptoms, Incontinence severity, current management.

Examination

• General : Mobility, IQ/ cognition, BMI, Hand function

• Specific : Focused neurology, Abdominal, Pelvic floor ( Prolapse / Incontinence ), Rectal ( Constipation )

Investigations

• MSU : Haematuria, UTI• Bloods : Creatinine, Glucose, Ca++• Flow and Residual• Bladder diary [ 24 hrs vs 3 days ] Think Compliance

and cooperation• QoL Score ICIQ ( useful - not validated )

• Renal US• Urodynamics: Rarely required ( pre op )

Diagnosis and management plan

• Patient/ care giver expectation• Ability to deliver• Know local referral pathways

AdditionalChronic pain: adds to difficultyHaematuria : referralUTI : Treat and reviewProlapse : Refer

Levels of evidence

Grades of recommendation

Outcome objectives

Management strategy

• Clinical / physical• Drugs• Environmental• Behavioral / Social• Rehabilitate• Integrate support

Success in caregiver management

• Under pinning: Life long love…..

• Problem solve: careful observation

• Consequences: role change, emotional change, financial change, sleep, social isolation, reduced intimacy

Management UUI

• General: • Scheduled void [ b ], restrict fluids [ b ], stop

smoking [ c ], avoid caffeine [ a ]• Specific: • Bladder retraining [ a ] 70%• Anticholinergics [ a ] 70% ( low dose, not in

retention , glaucoma ) ; new B3 agonist

Management UUI

• Neuromodulation: Sacral vs Post tibial [ a ] 60 – 80% expensive, intensive required expertise

• Botox: [ a ] 75% expensive, repeated 6 – 12 monthly, may cause retention

• Catheter: patient preference depends on mobility

• Augmentation: rarely required

Management SUI : Female

• General: timed void [b ], reduce caffeine [ a ], reduce weight [ b ], reduce fluids [ b ], reduce smoking [ b ].

• Specific: Pelvic floor exercises [ a ] 30% , oestrogen cream [ c ] 30%, surgery [ a ].

Sling procedures for female SUI

Grade A evidence75 – 90% cure10 yrs durable

First choiceSimilar outcomes in disabled / elderly

Low risk retention

Management Male SUI

Majority Post RRPWait 6 – 12 monthsAUSACC coverage in NZ90% dry or 1 security pad

Male sling for lower volume incontinence60% effective

Long term catheter or diversion

Management mixed UI

• Manage predominant symptoms first in step wise manner

• Lower success

Summary

• Listen and set realistic goals• “3 day trial” and review• Modify plan if required• Refer if complex or fail

Remember…. A small intervention can lead to a major improvement…..