Presented by: Kristopher Bedi, D.O. September 7, 2018
Incontinence in the Female Patient for the Primary Care
Physician
• Be able to diagnose and begin basic treatment of uncomplicated urinary incontinence in the female patient
• Differentiate between the different causes of urinary incontinence in the female patient
• Obtain the ability to counsel female patients on the full range of treatments for urinary incontinence
• Identify complicated causes of urinary incontinence in the female patient that requires expertise care
Objectives
Background
• 10 to 70% of women affected in community setting (1)
–25% of young women (5)
–44-57% of middle-aged and postmenopausal women (5)
–75% of older women (5)
• Up to 50% of nursing home patients affected (1)
• Estimated annual direct cost in the US is $19.5 billion (5)
• 6% of nursing home admissions at a direct cost of $3 billion
Lower Urinary Tract Symptoms
• Storage symptoms • Voiding symptoms • Urinary Incontinence is a storage symptom • Complaint of any involuntary loss of urine
Types of Incontinence
• Urge Incontinence (DOI) • Stress Urinary Incontinence (SUI) • Mixed Urinary Incontinence • Nocturnal Enuresis • Postmicturation leakage • Continuous urinary incontinence • Chronic urinary retention • Coital urinary incontinence • Extraurethral urinary incontinence • Functional urinary incontinence • Occult stress incontinence • Insensible urinary incontinence • Postural urinary incontinence
Evaluation
• Agency for Health Care Policy and Research (AHCPR) • International Consultation on Incontinence (ICI) • American College of Obstetrics and Gynecology
(ACOG)
Evaluation
• Work-up should reliably distinguish SUI and DOI • Minimum evaluation
–History –Urinalysis –Physical examination –Demonstration of stress incontinence –Assessment of urethral mobility –Measurement of postvoid residual volume
History
• Review of Systems Presence, severity and duration of symptoms Effects on sexual function Presence of symptoms suggesting neurologic disease Voiding diary
History
• Past Medical History Previous conservative, medical or surgical treatment Coexisting disease / medication (DIAPPERS) Delirium Infection Atrophy Pharmaceuticals Psychologic disorders Excessive urine output Restricted mobility Stool impaction
History
• Social History Lifestyle: i.e., exercise, smoking, fluid intake
• Patient desire for and extent of treatment • Patient goals and expectations • Support systems • Cognitive function
Physical Examination
• General Status BMI, mobility, mental status
• Abdominal/Flank exam Masses, scars, bladder distention
• Pelvic Assess for atrophy, sensation, prolapse Bimanual exam
Physical Examination
• Urine dipstick testing with urine microscopy and urine culture when indicated
• Renal function assessment when kidney disease is suspected.
• Uroflowmetry
Physical Examination
• Simple Cystometrogram • Imaging Pelvic U/S or CT with contrast Upper urinary tract imaging: o Hematuria o Neurogenic bladder o Flank pain o Severe prolapse – untreated o Suspected extra-urethral incontinence o Poor bladder compliance
Physical Examination
• Cystourethroscopy Hematuria Bladder pain Evaluation of fistula Recurrent SUI Suspected urethral diverticulum Chronic UTI
Physical Examination
• Urodynamic Testing Unclear diagnosis after basic office evaluation After treatment failure Initial and long-term surveillance for neurogenic bladder Complicated incontinence Prior pelvic floor surgery
Exam Summary
• History including voiding diary • Focused physical exam including pelvic floor muscle
strength and evaluation for urethral hypermobility • UA and reflex culture • Simple cystometrogram to reproduce subjective SUI • Measurement of postvoid residual volume
Initial Management
• Complicated incontinence should be referred for specialized care Hematuria Recurrent UTI (>3/year or 2 in 3 months) Obstructive voiding or fistula Significant prolapse (3rd degree) h/o pelvic radiation or radical surgery Previous incontinence surgery
Initial Management
• Goal is to identify Stress Urinary Incontinence Urgency and frequency with or without Urge Incontinence Mixed incontinence
• Caution! - frequency and urgency are common symptoms in both SUI and DOI
First…Rule-Out!
• Treat transient causes of incontinence first DIAPPERS Diet (caffeine, excessive fluid intake) Obesity
First Line Treatment for SUI, DOI and Mixed Incontinence
• Lifestyle Modifications Decrease caffeine intake!!! Weight Reduction!!!
• Treat estrogen deficiency and UTI Reassess after appropriate interval
First Line Treatment for SUI, DOI and Mixed Incontinence
• Supervised pelvic floor muscle training
• Timed voiding for DO/DOI Requires frequent follow-up
First Line Treatment for SUI, DOI and Mixed Incontinence
• Medication -Antimuscarinics for DO/DOI o Side Effects generally dry mouth and constipation oTarget M2, M3 receptors
-Beta-agonists -OnabotulinumtoxinA -Ongoing clinical trials for duloxetine use in SUI
First Line Treatment for SUI, DOI and Mixed Incontinence
• In patients with mixed incontinence consider treating the most bothersome symptom first
• Patients with POP may have improvement in symptoms with vaginal devices
Initial Treatment Length
• Treat for 8 to 12 weeks Then reassess If little to no improvement with adequate treatment,
consider referral to specialist
• Maintain regular follow-up for patients doing well on treatment
Specialized Management
• Complicated cases or failed treatment often require additional testing urine cytology cystourethroscopy urinary tract imaging urodynamic testing
Specialized Management
• Prolapse treatment may be necessary Surgery o Anterior/posterior colporrophy o Sacrocolpopexy o Colpectomy/colpocliesis
Pessary management
Stress Incontinence
• Surgical Treatment Procedures supported by Level 1 evidence o Retropubic Colposuspensions o Synthetic midurethral slings o Urethral bulking o Autologous fascial bladder neck slings
Stress Incontinence
• Tension-free midurethral sling is the most common procedure performed today Retropubic midurethral sling has the most evidence (TVT)
85% cure rate Transobturator sling Similar efficacy to TVT Single incision mini-sling Lower subjective and objective cure rates
Stress Incontinence
• FDA Safety Communication – July 2011 Update on serious complications associated with
transvaginal placement of surgical mesh for treatment of pelvic organ prolapse Currently does not apply to polypropylene sling mesh
Stress Incontinence
• For patients with Intrinsic Sphincter Deficiency (ISD), periurethral bulking may be an option with or without midurethral sling placement
Urge Incontinence
• Antimuscarinic medication May need increased dosages May need AM and PM dosing May need combination medication Often requires side effect monitoring and management
Urge Incontinence
• Beta-agonists Mirabegron o Target Beta-3 adrenergic receptors o Decreased side effect profile o Caution in hypertensive patients
OnabotulinumtoxinA o Indicated in neurogenic bladder o FDA approved for use in overactive bladder
Urge Incontinence
• Sacral neuromodulation Implantable device
• Tibial nerve stimulation Requires multiple treatments
• Tricyclic antidepressants Anticholinergic and alpha-adrenergic properties
Case 1
• 43yo P4 with no significant PMH reports a 1 year history of incontinence with coughing and running that has increased in severity. Reports 3-5 episodes per week.
Case 1
• BMI = 23 • Normal PE with no evidence of prolapse • Urine dipstick is negative
Case 1
• Simple CMG demonstrates leak with Valsalva in standing position. Normal bladder sensation with good compliance.
Case 1
• Mild Stress Urinary Incontinence Physical Therapy Bladder training Moderate fluid intake if necessary Reassess in 3 months
Case 2
• 43yo P4 with no significant PMH reports a 13 year history of incontinence with coughing and running. Now with urgency and vaginal pain x6 weeks that has increased over the last 3 weeks. Treated 6 weeks ago for UTI that was proven later to be culture negative.
Case 2
• BMI=23 • PE: 2nd degree anterior and posterior prolapse under
low pressure. Tender urethral palpation with no discharge.
• Urine dipstick is negative
Case 2
• Complicated Urinary Incontinence suspicious for urethral diverticulum Schedule for cystourethroscopy
Objectives
• Be able to diagnose and begin basic treatment of uncomplicated urinary incontinence in the female patient
• Differentiate between the different causes of urinary incontinence in the female patient
• Obtain the ability to counsel female patients on the full range of treatments for urinary incontinence
• Identify complicated causes of urinary incontinence in the female patient that requires expertise care
References
1. Abrams, P. Incontinence 2nd ed. Plymouth, UK: Health Publication Ltd. 2002
2. Wilson, L. Annual Direct Cost of Urinary Incontinence. Obstet Gynecol 2001; 98:398-406
3. Abrams, P., et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and Treatment of Urinary Incontinence, Pelvic Organ Prolapse, and Fecal Incontinence. Neurourology and Urodynamics 2010; 29:213-240
4. Bent, A.E., Cundiff, G.W., Swift, S.E. Ostergard’s Urogynecology and Pelvic Floor Dysfunction, Sixth Edition. Lippincott Williams & Wilkins, 2008
5. ACOG Practice Bulletin Number 155 Urinary Incontinence in Women. Obstet Gynecol June 2015 (Reaffirmed 2018)
Helpful Links
• Bladder diary from The National Institute of Diabetes and Digestive and Kidney Diseases: – www.niddk.nih.gov/health-information/health-topics/urologic-
disease/daily-bladder-diary/Documets/diary_508.pdf
• American Urogynecologic Society, Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction position statement on mesh midurethral slings for stress urinary incontinence – http://www.augs.org/p/cm/ld/fid=599