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