Download Incontinentie bij de actieve bevolking

Incontinentie bij de actieve
bevolking
Prof. dr. S. De Wachter
Senior Staflid – UZ Antwerpen
Docent – Universiteit Antwerpen
“Incontinence is the condition
in which
unvoluntary loss of urine occurs”
New ICS definition 2002
Incontinence prevalence
•  1,5 – 5 % men
•  10 – 25 % women
15 to 64 years old
•  More 60 : prevalence 15 – 30 %
Incontinence prevalence
•  1,5 – 5 % men
•  10 – 25 % women
15 to 64 years old
•  More 60 : prevalence 15 – 30 %
Incontinence treatment ?
•  How many consult a doctor: 54 % if severe
30 % of total group!!!
Incontinence treatment ?
•  How many consult a doctor: 54 % if severe
30 % of total group!!!
•  Many do not want to be examined/treated especially
women and elderly
Requirements for continence
•  Normal drainage of urine from kidneys
•  Congenital : Ectopic ureter
•  Acquired: Fistula
•  Normal bladder function
•  Filling phase: Urge incontinence
•  Voiding phase: Overflow incontinence
•  Normal urethral function
•  Stress incontinence
Requirements for continence
•  Normal drainage of urine from kidneys
•  Congenital : Ectopic ureter
•  Acquired: Fistula
•  Normal bladder function
•  Filling phase: Urge incontinence
•  Voiding phase: Overflow incontinence
•  Normal urethral function
•  Stress incontinence
Requirements for continence
•  Normal drainage of urine from kidneys
•  Congenital : Ectopic ureter
•  Acquired: Fistula
•  Normal bladder function
•  Filling phase: Urge incontinence
•  Voiding phase: Overflow incontinence
•  Normal urethral function
•  Stress incontinence
Potentially Reversible Causes
D
I
A
P
P
E
R
S
- Delirium, mental dysfunction
- Infection
- Atrophic vaginitis or urethritis
- Pharmaceuticals
- Psychological disorders
- Endocrine disorders
- Restricted mobility
- Stool impaction
Belgian epidemiological survey in women
De Ridder et al., Int J Clin Pract, 67:192-193, 2013
Types incontinentie
Prevalentie van urge vs. stress incontinentie
Urge Incontinence
Stress Incontinence
Mixed Incontinence
Vrouwen
Booth C and Pascoe D Hospital Pharmacy 2002; 9: 65-68
Mannen
Overactive bladder
Urgency
Urgency incontinence
OAB: Clinical Definition
“Urgency, with or without urgency incontinence, usually
associated with frequency and nocturia”
Key Symptoms:
•  Urgency: Sudden, compelling desire to void that is difficult to defer
•  Frequency: The need to frequently urinate (>8 micturitions/24 hours)
•  Incontinence: Involuntary loss of urine
•  The International Continence Society (ICS) defines OAB as:
•  Nocturia: waking up at night one or more times to void
Abrams P, et al. Neurourol 2002; 21: 167-178.
Wein A et al. J Urol. 2006 Mar;175: :S5-S10.
Corcos J, Schick E. Can J of Urology 2004; 11(3):2278-2284.
Types of OAB
OAB Dry
•  urgency, frequency without incontinence
•  men more likely to have OAB dry
•  up to 64% of those with OAB have “dry” OAB, without urgency
incontinence
OAB Wet
•  urgency incontinence
•  women suffer more from OAB wet
36%
64%
Mixed Incontinence
•  involuntary leakage associated with urgency and also with
exertion, effort, sneezing or coughing
•  considered a combination of stress and urgency incontinence
Corcos J, Schick E. Can J of Urology 2004; 11(3):2278-2284.
Kirby M, et al. Int J Clin Pract 2006; 60: 1263–127.
OAB Dry
OAB Wet
Prevalence of OAB by Age and Gender
Men: 2.4% (Incontinent)
50
Women: 9.3% (Incontinent)
Prevalence (%)
20
Men: 13.6% (Continent)
Women: 7.6% (Continent)
15
10
5
0
<25
25-34
35-44
45-54
Age (years)
Stewart WF et al. World J Urol. 2003;20:327-336.
55-64
65+
prevalence in UK population
Prevalence of OAB in context of other illnesses
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
OAB
Asthma
Angina
Diabetes
National Overactive BLadder Evaluation (NOBLE) study:
Similar Prevalence Among Men and Women (USA)
35
Men
30
Women
Prevalence (%)
25
20
15
10
5
0
<25
25-34
35-44
45-54
55-64
65-74
Age (years)
Stewart WF et al. World J Urol. 2003;20:327-336.
75+
OAB Syndrome – Quality of Life scores
90
70
Healthy
Diabetes
60
Depression
SF-36 Score
80
Overactive
bladder
50
40
10
0
Komaroff AL et al. Am J Med. 1996;101:281-290.
Kobelt-Nguyen G et al. 27th Annual Meeting of ICS, 1997.
Aetiology of Detrusor Overactivity
•  The aetiology of Detrusor overactivity may be neurogenic,
myogenic, or both
•  Neurogenic
•  Reduced suprapontine inhibition
•  Damaged axonal paths in spinal cord
•  Increased afferent input
•  Myogenic theory
Partial
denervation
↑ Excitability
↑ Electrical coupling
between myocytes
Propagation of
coordinated
contractions
Diagnosis:
Initial Evaluation
Diagnosis based on presenting symptomatology
and does not require invasive tests:
• Examine Potential risk factors
• Thorough history
• Nature of symptoms
• Physical examination
• Urinalysis
• Bladder diary
• Medications Influencing Bladder Function
• Differential Diagnosis of OAB
Milson I. BJOG. 2006 113; Suppl 2: 2-8.
Nitti V, Taneja S. Int J Clin Pract. 2005; 59: 825-830.
Wein A, et al. J Urol. 2006;175: :S5-S10.
Impact van OAB
Emotionele effecten
•  gêne
•  schaamte
•  sociale beperking
Verstoring van de
dagelijks activiteiten
•  nabijheid van toiletten is
belangrijk
•  reductie van de
vochtinname
•  neiging om sexuele
contacten te vermijden
•  onafhankelijkheid
verliezen
Economische impact
•  kosten voor bescherming
(pampers) en speciale
kledij en bedlinnen
•  verlies van werk
•  droogkuiskosten
Comorbidities of OAB
P < 0.0001
Sleep disturbances are reported by many patients
with OAB
•  correlated with poor health
11,556 adult patients with OAB and 11,556 controls
matched on propensity score
Adapted from Darkow T, et al. Pharmacotherapy. 2005;25:511-519.
QoL: Physical Impact of OAB
Sleep disturbances are reported by many patients
with OAB
•  correlated with poor health
Brunton S, et al. Curr Med Res Opin 2005; 21: 71-80.
Wein A, et al. J Urol. 2006;175: :S5-S10.
Diagnosis: Bladder Diary
Diagnosis: General OAB Risk Factors
Smoking
•  Relationship exists between smoking and UI
•  Partly due to nicotine’s possible contractile effect on the
bladder
•  Chronic/frequent coughing can lead to damaged urethral and
vaginal supports as well as perineal nerve damage
Obesity
•  Increased pressure on bladder
•  Greater urethral mobility
•  Possible impaired blood flow or innervation to bladder
Diagnosis: OAB Risk Factors for Women
Pregnancy and Childbirth
•  Can flatten, stretch, and weaken many of the pelvic floor
muscles
•  Evidence that # of vaginal births related to increased OAB
risk and incontinence later in life
Menopause
•  Weakens urethra’s ability to maintain tight seal
•  Lack of estrogen weakens detrusor
ü  can cause the urethra to open unexpectedly during physical activity
Pelvic surgery
•  Weaken and damage pelvic floor muscles
•  Women undergone removal of uterus have 40% increased
risk of UI
Diagnosis: OAB Risk Factors for Men
Benign Prostatic Obstruction (BPO)
•  Strongly reduced urinary flow due to urethral obstruction
•  OAB often coexists with BPO
Prostate/Bladder Surgery
•  2 to 3 times more likely to experience UI than those without
the surgery
Which Patient - Which Treatment
Diagnosis of the problem
Understanding the major component
•  SUI associated with exertion onset in reproductive years
•  Urgency incontinence associated with urgency in post
menopausal women
•  Mixed incontinence affects approximately 30%
Having a clear picture of the patient’s goals from
treatment
Non Pharmacological Treatments
Behaviour Modification
•  Dietary and fluid management
•  Timed voiding
•  Adjustment of medication
Lessen symptom severity
Physiotherapy
•  Pelvic floor exercises
•  Biofeedback
•  FES
Improvement of pelvic floor neuromuscular function –
improving bladder and urethral function
Pharmacological Treatments
Anticholinergics = most important
•  Focus on urgency and urgency incontinence
Local oestrogen therapy = additional
•  Improve urethral and bladder function in urogenital atrophy
Surgery reserved for the management of severe SUI
Werkingsmechanisme van antimuscarinica in geval
van OAB
Acetylcholine bindt op
muscarinereceptoren
Contractie van de
detrusor
Acetylcholine
Muscarinereceptoren
Detrusor
OAB Treatment Options
Non-pharmacological Treatments
- Supportive commercial products
- Behavioural techniques
Pharmacological Treatment
- Antimuscarinics
oxybutynin IR/ER
tolterodine IR/ER
solifenacin succinate
trospium chloride
darifenacin
Surgical/ Invasive Treatment
- Botulinum toxin
- Neuromodulation
- Augmentation enterocystoplasty
Botulinum toxin injection
Dilute 100-300 U of BoNTA into 10-30 ml of saline
Inject targeting the trigone, base of the bladder and
lateral walls
Rigid cystoscope: 25 Gauge Williams needle,
inject approximately 0.5- 1.0 ml into 20-30 sites
Submucosal versus intradetrusor
Sacral neuromodulation
Stress incontinence
Pathophysiology
•  Intrinsic sphincter deficiency
•  Urethral hypermobility
Treatment
•  Pelvic floor physiotherapy
•  Success +/- 70%
•  Surgery
•  Mid-urethral tape
•  Bulking agents
•  Artificial Urethral Sfincter
•  Colposuspension
•  Fascial sling
Mid-urethral sling
•  TOT / TVT – O
•  TVT
Results midurethral slings
•  One-day clinic
•  6 weeks no sexual activities / no lifting > 5kg
•  Success 2y : 90%
•  Success 5y : 50-70%
Complications of sling surgery
Epidemiology of surgically managed POP & SUI
“Risk rises with failure”
11%
lifetime risk of one operation for POP or SUI
29%
risk of second operation
31%
risk of third operation
41%
risk of fourth operation
67%
risk of fifth operation
Olsen et al; 1997
Complications of sling surgery
•  Bleeding (1-2.5%)
• 
Few require re-intervention
•  Bladder perforation (3-14%)
•  Voiding dysfunction (2-20%)
• 
Incomplete emptying / UTI / CIC
•  De Novo urgency (0-15%)
•  Erosion (1-2%)
• 
Rare, but potentially severe
Treatment
•  Pelvic floor physiotherapy
•  Success +/- 70%
•  Surgery
•  Mid-urethral tape
•  Bulking agents
•  Artificial Urethral Sfincter
•  Colposuspension
•  Fascial sling
Artificial Urinary Sphincter
Summary
•  Urinary incontinence
•  Prevalent problem
•  Underreported
•  Strong impact on QoL / professional life
•  Overactive bladder vs Stress incontinence
•  Conservative treatment
•  Good to excellent results
•  Surgical treatment
•  Only second line treatment
•  Good results - Complications
Questions?