Download Lower Urinary Tract Problems in Women

Lower Urinary Tract
Problems
in Women
Ellie Stewart CNS Urogynaecology
Guys and St Thomas NHS Foundation
Trust
QOL and incontinence
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Incontinence has a massive impact on QOL
Under reporting due to embarrassment
Often don’t seek help until problem is severe
Male doctors, no time, unsympathetic, don’t
understand
It affects: Relationships, work, friends, day to
day activities, finances
BUT…….Symptoms are easily improved with
help and an understanding of the problem
Assessment
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Vital to ensure you are treating correctly.
Simple ‘must dos’ at initial assessment in community or
hospital:
Take history
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symptoms, duration, cause,
Exclude UTI- urinalysis
Exclude constipation
Measure post void residual- ISC or bladder scan
Bladder diary- monitor input and output at least 3 days (NICE 2013)
Try and see what main problem is and advise
Information leaflets on intranet
Examine to assess pelvic floor tone or for prolapse- if feel confident
to do so
Seek help
Onward referral
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Red flags:
Microscopic haematuria in
women >50 years
Visible haematuria
Recurrent UTIs with
haematuria in women >40
Suspected malignant urinary
tract mass
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Specialist service referral:
Persisting bladder/ urethral
pain
Benign pelvic mass
Faecal incontinence
Neurological disease
Voiding difficulties
Urogenital fistulae
Previous continence surgery
Previous pelvic cancer
surgery or radiotherapy
Types of Urinary Incontinence
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Stress urinary incontinence
Overactive bladder
Urge incontinence
Overflow incontinence
Bladder outlet obstruction
Functional incontinence
Stress Incontinence
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When? Who? Symptoms..
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Common in women following
childbirth
Menopause
Post hysterectomy
Leakage when intra-abdominal
pressure increases- cough, sneeze,
laugh, run, jump
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Treatments
Pelvic floor exercises
Vaginal cones and electrical
stimulation
Weight loss, constipation
prevention
Surgery- TVT,
colposuspension, periurethral injectables, sphincter
surgery
Pelvic floor exercises
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Pelvic Floor
Muscles
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Fast and slow twitch
exercises
Offer for at least 3 months as
first line treatment
How often? Lying sitting or
standing?
The ‘knack’
Squeezy app
NICE 2013: 8 contractions x3
daily
WHAT ABOUT GADGETS?
BIOFEEDBACK DEVICES
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Not routinely used for
women with OAB or in
combination with pelvic
floor exercises
Consider in women who
cant contract pelvic floor
muscles- aids motivation
and adherence
Surgical management
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Stress incontinence:
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TVT
TVTo
Colposuspension
Macroplastique
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Medical management
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Stress Incontinence:
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Duloxetine- not as a first line treatment, or
second line- may offer if women prefer
pharmacological treatment to surgical treatment
Counsel as to the side effects- nausea and
vomiting
Wean off slowly as its an SSRI
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Overactive bladder
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Symptoms:
Frequency
Urgency
Urge incontinence
Nocturia
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Treatments:
Pelvic floor exercises
Caffeine reduction
Fluid advice- type, how
much, when
Bladder diary
Bladder retraining
Medications
Botox
LIFESTYLE CHANGES
Fluids
May irritate the bladder:
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Caffeine (tea, coffee, green
tea, hot chocolate)
Artificial sweetener
Fizzy drinks
Tomatos
Citrus fruits and juices
Blackcurrant juice
Alcohol
May not irritate the
bladder:
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Water
Fruit and herbal teas
(avoid nettle and fennel)
Milk
Diluted fruit juice
Bladder retraining
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Bladder training aims to:
Increase bladder capacity
Reduce frequency of toilet visits
Increase the time between voids
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Lifestyle changes
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Learn urge suppression techniques- pressure sensor in big toes,
sit on hard surface, contract pelvic floor muscle
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Should be tried for a minimum of 6 weeks before trying
medications (NICE 2013)
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Medical Management
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Overactive Bladder
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Antimuscarinics
Oestrogens- vagifem, ovestin
Betmiga- beta 3-adrenoceptor agonist
PTNS- percutaneous tibial nerve stimulation
Botilium toxin A
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Anticholinergics for OAB- how do
they work?
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Block nerve impulses to the bladder which
decreases the ability of the bladder muscle to
contract
Can help the bladder hold on to more urine
Most Common Side Effects as they are non selective:
Dry mouth
Constipation
Blurred vision
Tiredness
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What antimuscarinics should be
used?
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First line:
Oxybutinin IR, tolterodine IR, darifenacin
Transdermal patch if unable to tolerate oral
medications
Others available are:
Solifenacin, fesoterodine
Mirabegron/ Betmiga
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Beta 3-adrenoceptor agonist
Less dry mouth and constipation
Some patients experience tachycardia/
palpitations, keep an eye on BP
Use once antimuscarinics tried and not
successful or if experiencing intolerable dry
mouth and constipation
Or in conjunction with vesicare- combination
therapy
Vaginal Oestrogens
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Offer topical vaginal oestrogens in post
menopausal women with vaginal atrophy
Not to use systemic HRT
Vagifem 10mcg
Ovestin 0.1%
Orthogynest 0.01%
Vaginal Lubrications
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Replens vaginal moisturiser/ hylaofemme in
those not suitable for oestrogens
Sylk
Yes- water and oil based
Senselle
Pjur
Moisturise vagina, don’t treat the dryness
Percutaneous Tibial Nerve
Stimulation
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The use of PTNS is
supported as a second
line therapy
12 week course for half
an hour each time
Only to be used after
MDT and failure of
conservative mgm and
the woman doesn’t
want botox- NICE
2013
Botilium Toxin A
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After MDT review, for
women with OAB caused by
proven detrusor overactivity
not responding to
conservative treatments
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Short term management,
lasts approx 9-12 months
High risk of needing to
intermittently catheterise1/3 of patients
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Surgical management
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Overactive bladder:
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Sacral nerve stimulation- NICE 2013- shouldn’t
be offered to treat OAB
Augmentation cystoplasty
Urinary diversion
Detrusor myectomy
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Pessaries
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Small medical device inserted into the vagina to
function as a supportive structure for the uterus
and/or bladder and rectum.
latex or silicone.
Comes in different shapes and sizes.
Needs to be replaced every 3 to 6 months.
Some pessaries need to be removed, cleaned and
reinserted every night- inflatoball, cube.
They do not stop the prolapse from worsening.
Not suitable for all types of prolapse
Indications
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Pessaries are generally recommended as a
conservative form of treatment for pelvic
organ prolpse in women who are:
1. Awaiting surgery
2. Pregnant or want to have more children
in the future
3. Unable or choose not to undergo surgery.
Type of pessaries
Prolapse Types
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Anterior Compartment
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Posterior Compartment
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Uterine Prolapse
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Vault Prolpase
Minimum Standards for Continence
Care 2014
To encourage improvements in standards of
Continence care
 Shows ideal structure of continence services
 Shows what training is required for those working in
continence care
How care should be delivered:
Level 1: Community based staff
Level 2: Specialist continence teams
Level 3: Local MDTs
Level 4: regional expert MDTs
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Use of mesh for prolapse and
incontinence surgery
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In Scotland concerns were raised about the number of
women experiencing complications following insertion
of trans vaginal mesh devices
Suspended the use of polypropylene transvaginal mesh
procedures
Now- not using transvaginal mesh
But are using vault support and sometimes hysteropexy
Common problems:
Pain
Removal of tape
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Recent report:
Importance of MDT assessment, review and
audit of the operations
Importance of informed consent- development
of standard consent forms and patient
information
Reporting of incidents and improved data
collection- database of all surgeries performed
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‘Scottish Independent review of the use, safety
and efficacy of transvaginal mesh implants and
treatment of stress urinary incontinence and
pelvic organ prolapse in women’
Interim report: 2.10.15
Take Home Messages……
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Ask the question, don’t expect people to
volunteer information about their incontinence
Little, simple things can really improve QOL
Full assessment vital
Refer in to secondary care for more complex
problems