UPDATE
IN
FEMALE URINARY
INCONTINENCE 2011
Identifying Potential Urinary
Incontinence In Women
Update in Female Urinary
Incontinence
Identifying Potential Urinary
Incontinence:
•
ASK !!
•
How
questions are asked is important.
•
Understanding
normal bladder function
is
important.
•
Understanding
basic abnormal patterns
is
important.
URINARY INCONTINENCE
URINARY
INCONTINENCE:
The
involuntary
passage
of urine
[any amount].
URINARY INCONTINENCE
INCONTINENCE IS AT BEST: • EMBARRASSING. AT WORST: • Totally disabling.• One of the major factors for admission to high care residential facilities
PREVALENCE
In 2010, nearly
4.8 million Australians
were
living with incontinence
•
This figure included:
–
4.6 million
community-dwelling
Australians (aged 15 years or over)
–
128,500
people living in residential aged
care
(aged 60 years or over)
•
Under-reported
– Study by Pearson, Tucker
et al confirmed this and looked at
COST OF INCONTINENCE
IN 2010
“In 2010, the total financial cost of
incontinence was estimated to be
MECHANISMS OF CONTINENCE
•
To maintain continence the forces which
tend to
retain
urine
MUST exceed
those
forces which tend to
expel
urine.
•
Even the
slightest imbalance
in any area
may lead to
incontinence
.
MECHANISMS OF CONTINENCE
•
There are
many different causes of
incontinence.
•
Some are best controlled with:
behavioral techniques.
pelvic floor exercises
medication.
Mechanisms of Continence
•
The control of Lower urinary tract
function is an enigma.
•
Dr Richard Turner-Warwick once
likened the bladder to a
‘bumble
bee’
.
- “ The bumble bee is curious. It is
fat, round
, has
no aerodynamics
and should not be able to fly. But
the bumble bee
doesn’t know about
aerodynamics
so it flies anyway!”
Complex Disorders of Bladder Function
Physiology
Physiology
of
Lower urinary
tract Function:
•
The bladder
has its own
autonomous
contractility
.
Animation courtesy of Prof J Gillespie, Physiologist
Urogenital Tract Function:
Physiology
•
We are not
born
continent
.
•
The
voluntary
control
of the
bladder [ & bowel]
is gained as
higher
centres
and
nerve
pathways
develop.
UROGYNAECOLOGY -
UPDATE 2011
MECHANISMS OF CONTINENCE
Next:
•
Perception of bladder filling [sensory nerveimpulses travel up to the higher centres].
•
Still unable to inhibitbladder emptying
[inhibitory nerve
impulses still do not travel down the spinal cord].
•
Still incontinent.“Mum, I need to do
UROGYNAECOLOGY -
UPDATE 2011
MECHANISMS OF CONTINENCE
Then:
•
Inhibitory impulses
travel
down
the spinal
cord.
•
Inhibition
of voiding
reflex.
MECHANISMS OF CONTINENCE:
Where can things go wrong?
•
Interference at any level may cause incontinence. E.g. 1. Brain 2. Spinal cord 3. Peripheral nerves 4. Bladder 5. Urethra 6. Pelvic floorCONTINENCE:
IMPORTANT ASPECTS
•
URINE PRODUCTION•
BLADDER STORAGE & EMPTYING•
URETHRAL COMPETENCE.•
ROTATIONAL URETHRAL DESCENT.•
FISTULA URINE PRODUCTIONKIDNEYS & BLADDER
MEDICATIONS & the Lower Urinary
Tract
URINE OUTPUT
APPROPRIATE URINE
OUTPUT:
•
The urine output should be1.5 litres/24hrs.
•
If it is excessive, consider: 1. Bad habit2. Diabetes
•
Excessive nocturnalvolumes - common in the elderly.
UROGYNAECOLOGY
-
UPDATE 2011
EXCESSIVE URINE OUTPUT
Management:
•
Exclude &/or treat
diabetes.
•
Exclude
large residual.
•
Restore
appropriate urine
output.
UROGYNAECOLOGY
-
UPDATE 2011
EXCESSIVE URINE OUTPUT
Medical treatment:
•
Diuretic in the afternoon
if excess nocturnal
volume.
•
Minirin
- anti-diuretic
hormone
[usually combine with a
diuretic to prevent fluid
overload and electrolyte
imbalance].
•
NOT
treated surgically. KIDNEYS & BLADDERINCONTINENCE -
Excessive output
Urinary diary Excessive output: • Bad habit, • Diabetes MSSU, ? Cytology Exclude Residual Excessive residual: •ISC•Correct bad habit
UROGYNAECOLOGY –
excessive urine
output
TAKE HOME MESSAGE:
•
Always obtain urinary diary,
•
Urine output should be 1.5L/24hrs,
•
Check residual - be cautious of
‘ultrasound residual’,
CONTINENCE:
IMPORTANT ASPECTS
•
URINE PRODUCTION.•
BLADDER STORAGE & EMPTYING•
URETHRAL COMPETENCE.•
ROTATIONAL URETHRAL DESCENT.•
FISTULABladder Storage:
• To allow the bladder to fill, thedetrusor muscle must remain
relaxed.
• One should NEVER HAVE to rush to the toilet!
• This muscle often becomes
overactive causing urgency, urge incontinence nocturia & enuresis.
CONTINENCE:
PATHOPHSIOLOGY OF INCONTINENCE:
OVERACTIVE BLADDER
• SYMPTOMS: frequency, nocturia, urgency, urge incontinence
• CAUSES:
• Idiopathic - familial tendency – genes on chromosomes 4, 8, 12, 13, 22.
• Onset at any age [e.g. Childhood].
• Usually longer duration than first admitted. • Males = Females.
• Neurological : 1. Sudden onset.
2. Often more severe.
CONTINENCE:
Bladder Storage, OAB
DIAGNOSED BY:
•
History
of frequency urgency urge
incontinence.
•
F/V Chart
- Small frequent voids.
•
Childhood enuresis
or
FH
enuresis/urgency.
•
Be
aware
of
sudden onset
of symptoms.
•
MSSU for culture/cytology.
• Imaging & Urodynamic confirmation when appropriate.
OVERACTIVE BLADDER:
MANAGEMENT
TREATMENT:
•
Behavioral modification.•
Pelvic floor muscle re-education.•
Medication.•
Surgery: Sacral Nerve Stimulation27
Lifestyle Changes
28 Influence ASCENDING PATHWAYS Pontine micturition centre External urethral sphincter Bladder Peri- aqueductal grey Pre-frontal cortex Pelvic Floor Exercises:
• Sensory pelvic floor relay sensations of bladder fullness.
• Ascending fibres from the sacral spinal cord relay the information to the peri-
aqueductal grey region.
NEUROMODULATION
Pelvic floor
INFLUENCE DESCENDING PATHWAYS Pontine micturition centre PMN Onuf’s nucleus Bladder External urethral sphincter
Alter Nerve-muscle
transmission
:
•Medication
• BotoxMEDICATIONS
& the Lower Urinary Tract
How do medications work?
Stop the release &/or uptake of
Acetylcholine at the nerve –
Medications:
[alone or in combination]•
Propantheline 15-30mg tds
•
Tofranil
25 - 50mg nocte
•
Ditropan
2.5-5mg bd-tds
•
Oxytrol
1 patch twice a week
•
Vesicare
5-10mg daily
[or divided dose]•
Enablex
7.5-15mg daily
[or divided dose]•
Detrusitol
1-2mg bd
•
Fesoterodine [not yet available]
MEDICATIONS
& the Lower Urinary Tract
REMEMBER:
Medications can also exacerbate incontinence
•
Cholinergic agents
•
Bowel stimulants incl maxolon
•
Methotrexate
INCONTINENCE –
Overactive detrusor
Urinary diary Excessive output: •Bad habit •Diabetes Small frequent voids MSSU Cytology Organ Imaging Large Residual ?ISC Reduce intake to 1.5 L/24hrs •Lifestyle changes•Pelvic floor physio
•Anticholinergics Refer if:
•Sudden onset
•Severe
•Failed response Frequency urgency nocturia etc.
OAB:
Take Home Message
•
Suspect from
history and usually familial
.
•
Urine output
chart.
•
MSSU culture
[& cytology if recent onset].
•
Exclude residual
[caution with ultrasound report].•
Begin treatment:
Pelvic floor re-education, Lifestyle.
Medication.
•
Refer
if not responding, severe or sudden
onset .
MECHANISMS OF CONTINENCE:
BLADDER EMPTYING
BLADDER EMPTYING:
•
Must be complete. 1. Normal detrusor contraction. 2. Sustained contraction.•
Retention of urine is not due to obstruction in the female.BLADDER EMPTYING:
INEFFICIENT BLADDER CONTRACTION
TREATMENT:•
Medication: 1. Bethanechol 2. Phenoxybenzamine 3. Minipress•
Intermittent catheter•
?Sacral Nerve Stimulation•
Avoid Urethrotomy, Urethral dilatation and hydrodilatationCONTINENCE:
IMPORTANT ASPECTS
•
URINE PRODUCTION.•
BLADDER STORAGE & EMPTYING•
URETHRAL COMPETENCE.•
ROTATIONAL URETHRAL DESCENT.•
FISTULAUROGYNAECOLOGY -
UPDATE 2011
Urethral Sphincter deficiency
Urethral Sphincter deficiency [ISD].
•
Unconscious dribbling
•
Incontinence with exertion
UROGYNAECOLOGY -
UPDATE 2011
Urethral Sphincter deficiency
URETHRAL CLOSURE:
•
Normal urethra:1. Adequate sphincter
2. Adequate length
3. Normal epithelium
4. Normal blood flow
•
Poor urethral closure [USD]caused by:1. Increased age 2. Oestrogen lack
3. Medications [minipress] 4. Surgery
UROGYNAECOLOGY -
UPDATE 2011
POOR URETHRAL CLOSURE [ISD]
TREATMENT:
•
Medication: 1. Alpha agonists [phenylpropanolamine] 2. ?Duloxetine 3.Local Oestrogen
•
Peri-urethral bulking agents•
Pelvic floor physiotherapyUROGYNAECOLOGY -
UPDATE 2011
POOR URETHRAL CLOSURE [ISD]
TAKE HOME MESSAGE:
•
ISD increases with age,
•
Suspected if unconscious dribbling,
•
Diagnosed by Urodynamics [UPP’s],
•
Difficult to treat,
CONTINENCE:
IMPORTANT ASPECTS
•
URINE PRODUCTION.•
BLADDER STORAGE & EMPTYING•
URETHRAL COMPETENCE.•
ROTATIONAL URETHRAL DESCENT.•
FISTULAUROGYNAECOLOGY -
UPDATE 2011
Stress urinary Incontinence
STRESS INCONTINENCE:
•
SYMPTOM
•
SIGN
UROGYNAECOLOGY -
UPDATE 2011
STRESS INCONTINENCE
GENUINE STRESS INCONTINENCE:
• Incontinence with exertion, not with urgency.
• Rotational urethral descent.
1. Disrupted retropubic
supports [pubo-urethral ligament].
2. Dysfunctional pelvic floor.
3. Separation of the levator ani muscle removes
support for the ligament.
PELVIC FLOOR MUSCLE
UROGYNAECOLOGY -
UPDATE 2011
Mechanism of Stress Incontinence
PELVIC FLOOR MUSCLE
NORMAL Normal:
•Cough transmitted
equally to bladder and proximal urethra
• Pressures cancel out.
• No incontinence with cough or exertion
UROGYNAECOLOGY -
UPDATE 2011
Stress incontinence
• Urethra torn away
from its retropubic supports. • Cough transmitted only to bladder. • Higher pressure in bladder than urethra. • INCONTINENCE Stress Incontinence
STRESS INCONTINENCE:
TREATMENT
TREATMENT:•
Conservative: 1. Pelvic floor rehabilitation [physio]. 2. Local Oestrogens if post- menopausal.•
Surgery: Trans-vaginal Tape. Obturator Tape.NOT anterior repair.
PELVIC FLOOR MUSCLE
STRESS INCONTINENCE:
SURGICAL MANAGEMENT
TREATMENT MUST:
•
SUPPORT the urethra.
•
Prevent rotational descent on
exertion.
•
Procedures with maximal success
achieve both.
INCONTINENCE –
Stress Incontinence
Urinary diary Exertional incontinence Conservative treatment UrodynamicsSurgery for GSI Treat OAD also if present Unconscious dribbling ISD: •Local Oestrogens, •Bulking agent Small frequent voids
Stress Urinary Incontinence:
Take home message
•
Treat
symptom
conservatively but the
only operate on the
condition.
•
Always obtain urine output chart.
•
Conservative treatment first.
•
Urodynamic evaluation ‘a must’ before
surgery.
CONTINENCE:
IMPORTANT ASPECTS
•
URINE PRODUCTION.•
BLADDER STORAGE & EMPTYING•
URETHRAL COMPETENCE.•
ROTATIONAL URETHRAL DESCENT.•
FISTULAUrogynaecology Update:
Summary
•
Thorough
History.
•
Urine output chart
[frequency/volume].
•
Examination
as appropriate.
•
Exclude
residual
.
•
MSSU
[+cytology if over 45 yrs].
Urogynaecology Update:
Summary
Begin
conservative
treatment:
•
Pelvic floor re-education
•
Local oestrogens
Urogynaecology Update:
Summary
Refer
for urodynamics/specialist
advice if:
•
Failed
conservative treatment.
•
Sudden onset
of symptoms.
•
Moderate to severe
symptoms.
•
Surgery
contemplated.
Incontinence:
Case Studies 1
Mrs. LS Aet 38yrs G2P2
•
3-4 month history of frequency/urgency/urge
incontinence. Sl anxiety. Some work
stresses.
•
PH: nil signif
•
Medications: nil
•
O/E pelvic findings normal, ?sl Bell’s palsy.
Incontinence:
Case Studies 1
•
Other investigations:
•
Urinalysis: NAD
•
Urodynamic studies
•
CT scan: Large frontal lobe tumour extending
into corpus callosum.
•
Neuological consult
•
Neurosurgery
•
Urgency controlled with Ditropan 5mg bd
•
Survived 5 years
Incontinence:
Case Studies 1
Important features:
•
Sudden onset of severe symptoms
•
Think of other causes:
Infection, tumours
Incontinence:
Case Studies 2
Miss BC Aet. 23 G0P0
•
Lifelong history frequency, urgency, urge
incontinence. No bowel symptoms.
•
Enuresis as child – occasionally now
•
PH Anxiety, depression, neurofibromatosis
previous medication for frequency urgency
•
Medications: Yasmin Efexor
•
O/E: Normal pelvic findings, no neurological
deficits.
Incontinence:
Case Studies 2
Investigations:
•
Urinalysis NAD
•
Urine output chart
•
Urodynamics
Overactive detrusor - familial
Incontinence:
Case Studies 2
Management:
•
Anticholinergics
Various combinations tried but either
insufficient response or excessive side
effects.
•
Sacral Nerve Stimulation:
Incontinence:
Case Studies
After Before
SACRAL NERVE STIMULATION:
Gold standard for intractable OAB
STIMULATION OF 3rd SACRAL NERVE
IMPROVES:
•
OVERACTIVE BLADDER.
•
VOIDING DIFFICULTIES.
[Detrusor/sphincter dyssinergia].
•
PELVIC PAIN
[especially when associated
with either of the above problems].
SACRAL NERVE
STIMULATION
Test Phase
•Needle inserted in 3rd Sacral Foramen •GA – no paralysis •X-ray imaging•Levator and toe response
•Need 50% or more improvement
SACRAL NERVE
STIMULATION
NEW ‘TINED’ LEAD
DEVELOPED TO ALLOW:
• Minimally invasive
technique.
• Percutaneous
placement.
• Use as test lead and
implanted lead.
• Quadripolar to ensure
optimal contact with the nerve.
Anchoring ‘Tines’
SACRAL NERVE
STIMULATION
TINED LEAD
WITH PULSE
GENERATOR
SACRAL NERVE
STIMULATION
Neuromodulation:
Technique
Easy
as
a
Walk
SACRAL NERVE
STIMULATION
VOIDED VOLUMES BEFORE & DURING PNE
0 50 100 150 200 250 300 350 400 450
AVG VOIDED VOLUME 1 AVG VOIDED VOL 2
PATIENTS
ML
S
SACRAL NERVE
STIMULATION
VOIDED VOLUMES PRE & POST PNE AND POST IMPLANT
0 50 100 150 200 250 300 350 400 450 PATIENTS ML S
. AVG VOIDED VOL 1
AVG VOIDED VOL 2 AVG VOIDED VOL 3
SACRAL NERVE
STIMULATION
VOIDED VOLUMES PRE & POST IMPLANT
0 50 100 150 200 250 300 350 400 PATIENTS ML S
. AVG VOIDED VOL 1
SACRAL NERVE
STIMULATION
QUALITY OF LIFE DATA:
Cappellano et al [Milan] Incontinent Episodes 0 1 2 3 4 5 6 7 8
Pre-implant Pos t-implant Incontinent Episodes
Overactive bladder Hyperreflexia
SACRAL NERVE
STIMULATION
QUALITY OF LIFE DATA:
Cappellano et al [Milan].
Quality of Life 0 10 20 30 40 50 60 70 80Pre im plant Post im plant Quality of Life
Overactive bladder Hyperreflexia
BOTOX
– Destroys Motor & Sensory
Neuromuscular Junction
1. Synaptic binding of the toxin
2. Internalisation of the toxin
3. Nerve sprouting
4. Restoration of the neuro-muscular junction
BOTOX
Injection technique
Incontinence:
Case Studies 3
Mrs. JA Aet. 68 G2P2 NVD’s
•
Aware of prolapse for years.
•
Incontinence with exertion, No frequency or
urgency
•
No Bowel disturbance
•
PH Nil Sig, No medications
•
O/E Atrophic change, Gde 3 cystocele, No
posterior descent, Good pelvic floor muscle
tone
Incontinence:
Case Studies 3
•
Investigations:
•
Urine output chart
Polyuria
Urinalysis – glycosuria
GTT – diabetic
Incontinence :
Case Studies 3
•
Further Investigations:
•
Urodynamic studies
Incontinence:
Case Studies 3
Management:
•
Treat diabetes
•
Reduce intake to ensure output 1.5L/24hrs
•
Local Oestrogen
– Ovestin 3 x week
•
? Conservative treatment
•
Patient requested surgical repair of prolapse
•
Anterior vaginal repair, Obturator tape procedure
Incontinence:
Case Studies 3
Important features:
•
Urine output chart – polyuria
•
Cystocele does NOT cause incontinence
•
Different causes of incontinence require
different treatments.
UROGYNAECOLOGY -
UPDATE 2011 INCONTINENCE - SURGERYRetro-pubic VAGINAL TAPE Procedures
• ‘Modern’ form of ‘sling’ procedure.
• Allows fixation NOT elevation.
• Works by ‘obstructive’ effect.
• Long term results 10 yr data appears encouraging.
• Quick and easy but…
Reactions to tape.
Obstructive problems still occur.
UROGYNAECOLOGY -
UPDATE 2011
STRESS INCONTINENCE
Obturator TVT:
•
Are gradually replacing the ‘retro-pubic’
approach.
•
Less risk of
bladder perforation
.
•
Less risk of
haemorrhage
.
•
Probably less risk of
obstruction
.
Surgery for Stress incontinence
Obturator TVT
AMS MONARC Procedure
:
•
Trans- Obturator Tape
J & J Procedure
•
TVT-”O”
UROGYNAECOLOGY -
UPDATE 2011
STRESS INCONTINENCE - Obturator
Stress Incontinence
More Recent Developments
MORE RECENT: - Mini-slings
•
MINI-ARC Precise [AMS] and several
‘clones’ now appearing.
Mini-Arc Precise
UROGYNAECOLOGY -
UPDATE 2011
STRESS INCONTINENCE - Obturator
Stress Incontinence
More Recent Developments
•
At this stage I have 3 years
experience with the
Mini-Arc/ Mini-
Arc Precise.
•
Advantages:
– ease, less invasive again
but early days.
UROGYNAECOLOGY
– UPDATE 2011
Trans-urethral Macroplastique
2 o’clock position 6 o’clock position 10 o’clock positionNeedle inserted at 6, 10 & 2 o’clock Injection - Multiple [3] Injection Sites
ISD
Macroplastique
Needle insertion Sphincter incompetence Closure after 2 injectionsUROGYNAECOLOGY -
UPDATE 2011
Urinary incontinence
AIM:
To Restore Continence • Safely • Effectively• With Minimal or No Side Effects
Careful Planning is Needed
UROGYNAECOLOGY -
UPDATE 2011
STRESS INCONTINENCE
The result of this
careful planning will
allow the bladder
to fill.
UROGYNAECOLOGY -
UPDATE 2011
STRESS INCONTINENCE
It will allow normal
voluntary
UROGYNAECOLOGY -
UPDATE 2011
STRESS INCONTINENCE
Stop the tap from leaking
UROGYNAECOLOGY -
UPDATE 2011
STRESS INCONTINENCE
Then –
No-one will get their feet wet!!!
Continence Foundation of
Australia
CFA
SA Continence Resource Centre
Blacks Road, Gilles Plains
Tel:
1300 885 886
[SA & NT callers only]
OR
[08] 8266 5260
www.continencesa.org.au
U
RO
G
YNAECOLOGICAL
S
OCIETY
OF
A
USTRALASIA - UGSA
• Expanding the horizons in Female Health Care.
• Established by the UroGynaecologists of Australasia.
• Improve standards of care, improve teaching and training methods not only for Subspecial ists &
. trainees but for other relevant medical and allied health care professionals
