Urinary Incontinence

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  • Review clinical types and presentations of urinary incontinence Initial evaluation Sensitivity/specificity of symptoms Examination Initial Treatment When and Where to refer for further evaluation: Urodynamic testing? Urethral cystoscopy?
  • Urge urinary incontinence is caused by uncontrollable contractions of the detrusor muscle; there may be very little warning time, and the volume of leakage is usually large. Stress incontinence occurs when the pressure on the bladder is greater than the urethral pressure, resulting in a sudden loss of urine (usually a small volume). Stress incontinence is typically due to weakened or damaged pelvic floor muscles. Mixed incontinence occurs when the symptoms of OAB and stress incontinence are present in the same person. Individuals with mixed incontinence may experience leakage of urine due to a sudden uncontrollable urge to urinate and when coughing or sneezing. Detrol ® LA is not indicated for stress or mixed incontinence.
  • Patients with OAB experience urgency with or without urge incontinence. Frequency and nocturia are usually associated with urgency. However, the presence of these symptoms individually does not constitute a diagnosis of OAB.
  • In the differential diagnosis of OAB, the physical examination should include a general examination, abdominal examination (including palpation of the bladder), and a neurologic evaluation. Pelvic and/or rectal examinations should be performed in women and rectal examinations in men. The patient should be observed for urine loss on vigorous coughing, a sign of possible stress incontinence. If necessary, further evaluations can be conducted to establish an appropriate diagnosis. However, most patients can be diagnosed using the approaches listed here.
  • The differential diagnosis of OAB should include urinalysis to rule out hematuria, pyuria, bacteriuria, glucosuria, and proteinuria. Additional blood work (such as measures of glucose, BUN, creatinine, and calcium) should be performed, as appropriate.
  • In certain situations, healthcare professionals should consider referring patients to specialists in OAB. Patients should be referred if their bladder symptoms do not respond to initial treatment within 2 or 3 months. The finding of hematuria without infection on urinalysis is another cause for referral. Referrals should be made when patients have symptoms suggestive of poor bladder emptying (such as hesitancy, poor stream, or terminal dribbling). Patients with unexplained neurologic or metabolic disease should also be referred to the appropriate specialists.
  • This is urinary incontinence and occurs in the following fashion: The patient will feel the urge to urinate. She will go to the bathroom and attempt to urinate. She will be unsuccessful. Then, she will go back and sit down or go to bed, at which time she will lose a large amount of urine. This has been a problem since at least a month or so before she was admitted to the hospital. Unfortunately, this has caused the patient to cease using Lasix as was prescribed on her discharge summary.
  • Urinary Incontinence

    1. 1. Urinary Incontinence Tova Ablove, Alev Wilk Primary Care Conference, 6/22/05
    2. 2. Urinary Incontinence <ul><li>No Financial Disclosures </li></ul>
    3. 3. Objectives <ul><li>Overview of Urinary Incontinence in Women: Dr. Ablove </li></ul><ul><li>Presentation of Cases: Dr. Wilk </li></ul><ul><li>Initial Management Issues: </li></ul><ul><ul><li>Urodynamic testing for all women? OR </li></ul></ul><ul><ul><li>Therapy trials based on history and exam only: medication, pelvic floor exercises, pessary? </li></ul></ul>
    4. 4. Incontinence <ul><li>14% of healthy postmenopausal have daily incontinence. </li></ul><ul><li>41% of healthy postmenopausal have incontinence at least once per month. </li></ul><ul><li>Brown et al. obstetrics and gynecology 1996 </li></ul>
    5. 5. Types of Urinary Incontinence <ul><li>Mixed symptoms </li></ul><ul><ul><li>combination of stress and urge incontinence </li></ul></ul><ul><li>Urge </li></ul><ul><ul><li>urine loss accompanied by urgency resulting from abnormal Bladder contractions </li></ul></ul><ul><li>Stress </li></ul><ul><ul><li>urine loss resulting from sudden increased intra-abdominal pressure (eg, laugh, cough, sneeze) </li></ul></ul>Sudden increase in intra-abdominal pressure Uninhibited detrusor contractions Urethral pressure
    6. 6. Urinary Incontinence and OAB Detrol ® LA z <ul><li>Urgency </li></ul><ul><li>Frequency </li></ul><ul><li>Nocturia </li></ul>SUI Mixed (UUI+SUI) UUI OAB OAB
    7. 7. Evaluation <ul><li>History </li></ul><ul><li>Physical </li></ul><ul><li>Labs </li></ul><ul><li>Testing </li></ul>
    8. 8. History <ul><li>HPI </li></ul><ul><ul><li>Identify #1 complaint </li></ul></ul><ul><ul><li>Frequency & duration of sx </li></ul></ul><ul><li>Medications </li></ul><ul><li>Musculo-skeletal </li></ul><ul><ul><li>Mobility- screen for falls </li></ul></ul><ul><ul><li>Back pain/disease </li></ul></ul><ul><li>Autoimmune </li></ul><ul><ul><li>MS </li></ul></ul><ul><ul><li>Fibromyalgia </li></ul></ul><ul><ul><li>IBS </li></ul></ul><ul><ul><li>Crohns </li></ul></ul><ul><li>Heart failure </li></ul><ul><li>Neurologic/psychiatric </li></ul><ul><ul><li>Stroke, depression, dementia </li></ul></ul>
    9. 9. History <ul><li>Diabetes </li></ul><ul><li>Gynecologic </li></ul><ul><ul><li>Hormonal status </li></ul></ul><ul><ul><li>Prolapse </li></ul></ul><ul><ul><li>STDs </li></ul></ul><ul><ul><li>Sexual activity </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Chronic pelvic pain </li></ul></ul><ul><li>Bladder disease </li></ul><ul><ul><li>Interstitial cystitis </li></ul></ul><ul><ul><li>Cancer </li></ul></ul><ul><ul><li>Chronic cystitis </li></ul></ul><ul><li>Kidney disease </li></ul><ul><ul><li>Infections </li></ul></ul><ul><ul><li>Stones </li></ul></ul><ul><ul><li>Insufficiency </li></ul></ul>
    10. 11. Physical Examination <ul><li>Perform general, abdominal (including bladder palpation), and neurologic exams </li></ul><ul><li>Perform pelvic and rectal exam in females and rectal exam in males </li></ul><ul><li>Observe for urine loss with vigorous cough </li></ul><ul><li>Check for urinary retention </li></ul>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.
    11. 12. Pelvic Anatomy
    12. 13. Pelvic Exam
    13. 14. Laboratory Tests <ul><li>Urinalysis </li></ul><ul><ul><li>to evaluate for hematuria, pyuria, bacteriuria, glucosuria, proteinuria </li></ul></ul><ul><li>Urine culture </li></ul><ul><li>Wet mount </li></ul><ul><li>Vaginal cultures </li></ul><ul><li>Herpes cultures not usually done on initial evaluation </li></ul><ul><li>Blood work if compromised renal function is suspected </li></ul>
    14. 15. Treatments <ul><li>Treat patient’s most bothersome form of voiding dysfunction first. </li></ul><ul><li>Treat conditions that can mimic or exacerbate overactive bladder </li></ul><ul><li>The objective is to improve quality of life. </li></ul>
    15. 16. Treatable Conditions That Mimic or Exacerbate OAB <ul><li>Urinary tract infection </li></ul><ul><li>Urogenital aging </li></ul><ul><li>Bladder outlet obstruction </li></ul><ul><li>Prolapse * </li></ul><ul><li>Stress incontinence * </li></ul>
    16. 17. Treatments <ul><li>Overactive bladder </li></ul><ul><ul><li>Drugs anticholinergic, local estrogen </li></ul></ul><ul><ul><li>Pelvic floor rehab </li></ul></ul><ul><ul><li>Bladder drill </li></ul></ul><ul><ul><li>Treat bladder outlet obstruction </li></ul></ul><ul><ul><li>Acupuncture </li></ul></ul><ul><ul><li>Neuromodulation </li></ul></ul><ul><ul><li>Botox injections </li></ul></ul>
    17. 18. Drugs <ul><li>Predominant anticholinergic or antimuscurinic action </li></ul><ul><li>Oxybutnin </li></ul><ul><li>Tolterodine </li></ul><ul><li>Hyoscyamine </li></ul><ul><li>Imipramine </li></ul><ul><li>Darifenacin </li></ul><ul><li>Solifenacin </li></ul><ul><li>Close follow up needed especially in geriatric patients </li></ul>
    18. 19. Treatments: Stress Incontinence <ul><li>Pelvic floor rehabilitation </li></ul><ul><li>Local estrogen </li></ul><ul><li>Incontinence pessary </li></ul><ul><li>Collagen </li></ul><ul><li>Surgery </li></ul>
    19. 20. OAB: When to Consider Referral to a Specialist <ul><li>Symptoms do not respond to initial treatment within 2–3 months </li></ul><ul><li>Hematuria without infection on urinalysis </li></ul><ul><li>Symptoms suggestive of poor bladder emptying (hesitancy, poor stream, terminal dribbling) </li></ul><ul><li>Evidence of unexplained neurologic or metabolic disease </li></ul><ul><li>Significant pelvic organ prolapse is present </li></ul>Abrams P, Wein AJ. The Overactive Bladder: A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998.
    20. 21. Stress Incontinence: When to Consider Referral to a Specialist <ul><li>If patient desires treatment and is not interested in conservative therapy or has tried and failed conservative therapy. </li></ul>
    21. 22. When to refer for Cystoscopy <ul><li>To rule out stones, cancer, foreign bodies, chronic inflammation </li></ul><ul><li>To confirm normal anatomy prior to surgery. </li></ul><ul><ul><li>Recurrent UTIs especially if they are resistant to therapy </li></ul></ul><ul><ul><li>Hematuria </li></ul></ul><ul><ul><li>Irritative bladder symptoms especially in postmenopausal women and smokers </li></ul></ul><ul><ul><li>Recurrent incontinence </li></ul></ul><ul><ul><li>With suspicion of interstitial cystitis </li></ul></ul>
    22. 23. When to Refer for Urodynamics? <ul><li>Urinary retention </li></ul><ul><li>Incontinence that fails initial therapy </li></ul><ul><li>History of Neurologic disease </li></ul><ul><li>Prolapse desiring surgery </li></ul><ul><li>Prolapse as part of the clinical picture of incontinence </li></ul><ul><li>Prior pelvic surgery </li></ul><ul><li>Mixed incontinence </li></ul>1996 Agency for Health Care Policy and Research Weider et al 2001 Handa et al 1995
    23. 24. Case One <ul><li>48 y.o. woman with polyuria (every 30 minutes while awake) and pelvic pressure for 6 months </li></ul><ul><li>Voiding diary- frequency 16x/24hrs, nocturia 1-2x/night, no leak episodes </li></ul><ul><li>No dysuria, postvoid fullness, constipation </li></ul><ul><li>Three uncomplicated vaginal births; tubal ligation; Leep procedure 1993 </li></ul><ul><li>Premenstrual syndrome dysphoria on fluoxetine </li></ul>
    24. 25. Case One <ul><li>Denies tobacco or alcohol use; CNA </li></ul><ul><li>Exam: NL cardiovascular, GI, Kidney. Genital: pelvic floor “prolapse to introitus”; negative UA & glucose; PVR: 100cc. </li></ul><ul><li>Recommendations: </li></ul><ul><ul><li>Oxybutinin for “overactive bladder”? </li></ul></ul><ul><ul><li>Pelvic Floor Physical Therapy Program? </li></ul></ul><ul><ul><li>Referral to subspecialty? </li></ul></ul>
    25. 26. Case Two <ul><li>76 y.o. woman with stress and urge incontinence, urinary leakage; nocturia 1-2x per night </li></ul><ul><li>Urinary frequency, constipation, postvoid fullness </li></ul><ul><li>G6P6; s/p oophorectomy, partial colectomy </li></ul><ul><li>Depression, COPD, HTN, schizophrenia, anxiety </li></ul><ul><li>Current smoker: 63 pack years; no alcohol; retired RN and widowed </li></ul>
    26. 27. Case Two <ul><li>Albuterol, cogentin, valium, benadryl, depakote, advair, meclizine, zyprexa, piroxicam, quinine, risperidone, trazodone </li></ul><ul><li>Exam: Stable cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA. PVR 60cc. </li></ul><ul><li>Recommendations: </li></ul><ul><ul><li>Estrogen? </li></ul></ul><ul><ul><li>Pelvic Floor Physical Therapy Program? </li></ul></ul><ul><ul><li>Referral to subspecialty? </li></ul></ul>
    27. 28. Case Three <ul><li>55 y.o. woman with stress incontinence when she coughs, laughs, or exercises </li></ul><ul><li>No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation </li></ul><ul><li>G 0 P 0 </li></ul><ul><li>Depression on Celexa </li></ul>
    28. 29. Case Three <ul><li>Denies tobacco or alcohol use; Recently divorced </li></ul><ul><li>Exam: NL cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA. PVR 60cc. </li></ul><ul><li>Recommendations: </li></ul><ul><ul><li>Estrogens? </li></ul></ul><ul><ul><li>Pessary? </li></ul></ul><ul><ul><li>Pelvic Floor Physical Therapy Program? </li></ul></ul><ul><ul><li>Referral to subspecialty? </li></ul></ul>
    29. 30. Case Four <ul><li>44 y.o. woman with stress incontinence and urinary leakage, nocturia x2 at night </li></ul><ul><li>No dribbling, urgency, frequency, dysuria, constipation </li></ul><ul><li>Four vaginal, uneventful vaginal deliveries; hysterectomy and bladder suspension procedure 1990 </li></ul><ul><li>HTN, fibromyalgia, GERD on ranitidine and atenolol </li></ul>
    30. 31. Case Four <ul><li>Denies tobacco or alcohol use; CNA </li></ul><ul><li>Exam: NL cardiovascular, GI, Kidney. Genital: atrophic vulva & pelvic floor laxity; negative UA. PVR 40cc. </li></ul><ul><li>Has attempted Kegel exercises without improvement </li></ul><ul><li>Recommendations: </li></ul><ul><ul><li>Medications? Pessary? </li></ul></ul><ul><ul><li>Pelvic Floor Physical Therapy Program? </li></ul></ul><ul><ul><li>Referral to subspecialty? </li></ul></ul>
    31. 32. Case Five <ul><li>36 y.o. woman with stress incontinence recently exacerbated by URI symptoms </li></ul><ul><li>No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation. </li></ul><ul><li>G 5 P 5 , s/p C-section 1988 </li></ul><ul><li>Intermittent asthma, neck pain </li></ul><ul><li>Ortho evra patch, prn maxair, skelaxin </li></ul>
    32. 33. Case Five <ul><li>Denies tobacco or alcohol use; Bus driver </li></ul><ul><li>Exam: NL cardiovascular, GI, Kidney. Genital: grossly normal; negative UA. PVR 20cc </li></ul><ul><li>Has attempted Kegel exercises without improvement </li></ul><ul><li>Recommendations: </li></ul><ul><ul><li>Medications? Pessary? </li></ul></ul><ul><ul><li>Pelvic Floor Physical Therapy Program? </li></ul></ul><ul><ul><li>Referral to subspecialty? </li></ul></ul>

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