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Urinary Incontinence Tova Ablove, Alev Wilk Primary Care Conference, 6/22/05 Urinary Incontinence No Financial Disclosures Objectives Overview of Urinary Incontinence in Women: Dr. Ablove Presentation of Cases: Dr. Wilk Initial Management Issues: Urodynamic testing for all women? OR Therapy trials based on history and exam only: medication, pelvic floor exercises, pessary? Incontinence 14% of healthy postmenopausal have daily incontinence. 41% of healthy postmenopausal have incontinence at least once per month. Brown et al. obstetrics and gynecology 1996 Types of Urinary Incontinence Urge – urine loss accompanied by urgency resulting from abnormal Bladder contractions Stress – urine loss resulting from sudden increased intraabdominal pressure (eg, laugh, cough, sneeze) Mixed symptoms – combination of stress and urge incontinence Sudden increase in intra-abdominal pressure Uninhibited detrusor contractions Urethral pressure Urinary Incontinence and OAB OAB SUI z Mixed (UUI+SUI) UUI • Urgency • Frequency • Nocturia Detrol® LA Evaluation History Physical Labs Testing History HPI Identify #1 complaint Frequency & duration of sx Medications Musculo-skeletal Mobility- screen for falls Back pain/disease Autoimmune MS Fibromyalgia IBS Crohns Heart failure Neurologic/psychiatric Stroke, depression, dementia History Diabetes Gynecologic Hormonal status Prolapse STDs Sexual activity Pregnancy Chronic pelvic pain Bladder disease Interstitial cystitis Cancer Chronic cystitis Kidney disease Infections Stones Insufficiency Physical Examination Perform general, abdominal (including bladder palpation), and neurologic exams Perform pelvic and rectal exam in females and rectal exam in males Observe for urine loss with vigorous cough Check for urinary retention 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 960686. Pelvic Anatomy Pelvic Exam Laboratory Tests Urinalysis to evaluate for hematuria, pyuria, bacteriuria, glucosuria, proteinuria Urine culture Wet mount Vaginal cultures Herpes cultures not usually done on initial evaluation Blood work if compromised renal function is suspected Treatments Treat patient’s most bothersome form of voiding dysfunction first. Treat conditions that can mimic or exacerbate overactive bladder The objective is to improve quality of life. Treatable Conditions That Mimic or Exacerbate OAB Urinary tract infection Urogenital aging Bladder outlet obstruction Prolapse * Stress incontinence * Treatments Overactive bladder Drugs anticholinergic, local estrogen Pelvic floor rehab Bladder drill Treat bladder outlet obstruction Acupuncture Neuromodulation Botox injections Drugs Predominant anticholinergic or antimuscurinic action Oxybutnin Tolterodine Hyoscyamine Imipramine Darifenacin Solifenacin Close follow up needed especially in geriatric patients Treatments: Stress Incontinence Pelvic floor rehabilitation Local estrogen Incontinence pessary Collagen Surgery OAB: When to Consider Referral to a Specialist Symptoms do not respond to initial treatment within 2–3 months Hematuria without infection on urinalysis Symptoms suggestive of poor bladder emptying (hesitancy, poor stream, terminal dribbling) Evidence of unexplained neurologic or metabolic disease Significant pelvic organ prolapse is present Abrams P, Wein AJ. The Overactive Bladder: A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998. Stress Incontinence: When to Consider Referral to a Specialist If patient desires treatment and is not interested in conservative therapy or has tried and failed conservative therapy. When to refer for Cystoscopy To rule out stones, cancer, foreign bodies, chronic inflammation To confirm normal anatomy prior to surgery. Recurrent UTIs especially if they are resistant to therapy Hematuria Irritative bladder symptoms especially in postmenopausal women and smokers Recurrent incontinence With suspicion of interstitial cystitis When to Refer for Urodynamics? Urinary retention Incontinence that fails initial therapy History of Neurologic disease Prolapse desiring surgery Prolapse as part of the clinical picture of incontinence Prior pelvic surgery Mixed incontinence 1996 Agency for Health Care Policy and Research Weider et al 2001 Handa et al 1995 Case One 48 y.o. woman with polyuria (every 30 minutes while awake) and pelvic pressure for 6 months Voiding diary- frequency 16x/24hrs, nocturia 12x/night, no leak episodes No dysuria, postvoid fullness, constipation Three uncomplicated vaginal births; tubal ligation; Leep procedure 1993 Premenstrual syndrome dysphoria on fluoxetine Case One Denies tobacco or alcohol use; CNA Exam: NL cardiovascular, GI, Kidney. Genital: pelvic floor “prolapse to introitus”; negative UA & glucose; PVR: 100cc. Recommendations: Oxybutinin for “overactive bladder”? Pelvic Floor Physical Therapy Program? Referral to subspecialty? Case Two 76 y.o. woman with stress and urge incontinence, urinary leakage; nocturia 1-2x per night Urinary frequency, constipation, postvoid fullness G6P6; s/p oophorectomy, partial colectomy Depression, COPD, HTN, schizophrenia, anxiety Current smoker: 63 pack years; no alcohol; retired RN and widowed Case Two Albuterol, cogentin, valium, benadryl, depakote, advair, meclizine, zyprexa, piroxicam, quinine, risperidone, trazodone Exam: Stable cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA. PVR 60cc. Recommendations: Estrogen? Pelvic Floor Physical Therapy Program? Referral to subspecialty? Case Three 55 y.o. woman with stress incontinence when she coughs, laughs, or exercises No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation G0P0 Depression on Celexa Case Three Denies tobacco or alcohol use; Recently divorced Exam: NL cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA. PVR 60cc. Recommendations: Estrogens? Pessary? Pelvic Floor Physical Therapy Program? Referral to subspecialty? Case Four 44 y.o. woman with stress incontinence and urinary leakage, nocturia x2 at night No dribbling, urgency, frequency, dysuria, constipation Four vaginal, uneventful vaginal deliveries; hysterectomy and bladder suspension procedure 1990 HTN, fibromyalgia, GERD on ranitidine and atenolol Case Four Denies tobacco or alcohol use; CNA Exam: NL cardiovascular, GI, Kidney. Genital: atrophic vulva & pelvic floor laxity; negative UA. PVR 40cc. Has attempted Kegel exercises without improvement Recommendations: Medications? Pessary? Pelvic Floor Physical Therapy Program? Referral to subspecialty? Case Five 36 y.o. woman with stress incontinence recently exacerbated by URI symptoms No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation. G5P5, s/p C-section 1988 Intermittent asthma, neck pain Ortho evra patch, prn maxair, skelaxin Case Five Denies tobacco or alcohol use; Bus driver Exam: NL cardiovascular, GI, Kidney. Genital: grossly normal; negative UA. PVR 20cc Has attempted Kegel exercises without improvement Recommendations: Medications? Pessary? Pelvic Floor Physical Therapy Program? Referral to subspecialty?
