Female Urinary Incontinence
Dr Blayne Welk
Assistant Professor, Division of Urology, Western University
Disclosures Female Urinary Incontinence
Presenter Disclosure:
Dr Blayne Welk has no potential for conflict of interest with
this presentation (but has received funds from Astellas, Pfizer,
and Allergan).
Objectives
Review 3 key facts about urinary incontinence
Review 4 key things to do when evaluating a woman
with incontinence
Discuss the treatment options available to you as a family
physician
Review the treatment options available to specialists
Urinary Incontinence
Fact 1: Types of Urinary Dysfunction
22
American Urological Association
permanent catheter placements also should be followed regularly for symptom level, QoL and any complications. Patients who are using incontinence
pads, regardless of whether or how they are being treated, should be followed for appropriate skin care
and skin integrity.
Section 7: Research Needs and Future Directions
Better Stratification of OAB. OAB, because it is a
symptom complex, is primarily a diagnosis of exclusion.
Treatments are aimed at relieving symptoms and not
necessarily at reversing pathophysiologic abnormalities. Understanding the pathophysiology and the risk factors
for development of OAB is needed both to treat the syndrome as well as to prevent it. Future research will
need to address the entire spectrum of research
endeavors including epidemiology, QoL measurements, treatment modalities and basic bladder physiology
including sensory and motor signaling. Within the field of OAB, research sometimes is dichotomized between OAB/lower urinary tract symptoms or LUTS (e.g., OAB-
dry) versus OAB/urgency incontinence (OAB-wet).
However, this type of compartmentalization highlights our lack of understanding of OAB. In other words, are
OAB-dry and OAB-wet pathophysiologically related? Is
OAB-dry a milder manifestation of the OAB condition which progresses to OAB-wet over time? Or are OAB-
dry and OAB-wet two different conditions with different pathophysiologic mechanisms? How can we better
objectively measure bladder symptoms? In addition, particularly in females, stress urinary incontinence
(SUI) symptoms may exist concomitantly with OAB-symptoms (dry or wet). Further, isolated nocturia is a separate symptom entity, requiring different evaluation
and management strategies. This overlap in bladder
symptoms is captured in the Venn diagram below with
their potential to be concomitantly present. This Venn diagram will appear different based on the gender and age of the population depicted; the diagram included here is intended to provide a point of reference for
discussion. Therefore, the phenotype of bladder
symptoms should be carefully considered and declared
in all research to clarify the particular patient group being studied.
Epidemiology. Studies assessing how OAB develops
and its natural history and progression are required. The timing and circumstances around which OAB
develops and associated risk factors are not yet well-
u n d e r s t o o d .
While not specifically
targeting epidemiology of OAB, there are large community-based studies that assess prevalence of
lower urinary tract symptoms and urinary
incontinence.200, 201 By longitudinally studying these community cohorts, these investigators have developed
a new hypothesis that lower urinary tract symptoms are likely related to other systemic diseases/conditions.202,
203 Continuation of these types of studies could lead to potential preventive interventions for OAB symptoms
and/or utilization of treatments that target the
associated systemic conditions rather than the bladder. Epidemiologic studies provide a better cross sectional
estimation of the overall population impact of OAB-type symptoms.204
Clinical Research. As discussed previously, several validated OAB-symptom and OAB-symptom bother
tools have been developed. However, objective
measures of the “cornerstone” OAB-symptom of urgency205 remains poorly assessed. As defined by the
International Continence Society,27 “urgency is the
complaint of a sudden compelling desire to pass urine
which is difficult to defer.” Investigators have tested urgency questionnaires to assess for validity and
reliability;206-208 however, no single measure is used
consistently across trials, making it difficult to compare
findings.
Clinical studies should use validated standardized
measures to report subjective outcomes. Objective
outcomes should include frequency, nocturia, urgency, incontinence episode frequency and reporting of the variance for each of these measures. Furthermore, the
Overactive Bladder
OAB-dry
OAB-wet
SUI
Isolated nocturia
unrelated to OAB
Textured circles – incontinent subjects
Non-textured circles – continent subjects
Future Directions
Copyright © 2012 American Urological Association Education and Research, Inc.®
Nocturia Others:
• Fistula
• Overflow retention
10-40% of the
female
population
Fact 2: Why do women get
Incontinence?
Stress incontinence
Age
Ethnicity
Vaginal delivery
Genetics (40% of the
problem!)
Obesity
Smoking
Urgency Incontinence
Age
Ethnicity
Vaginal delivery
Genetics (only for Urgency
incontinence, not OAB!)
Obesity
Caffeine
Fact 3: Reversible causes of
Incontinence
Delirium or Drugs
Alcohol, Caffeine, Diuretics
Restricted mobility
Infection, impaction
Polyuria
Delirium
Infection
Atrophic
Pharmacologic
Psychological
Excess urine
Restricted Mobility
Stool Impaction
“DRIP” “DIAPERS”
Evaluating a woman for incontinence
Task 1: What kind of incontinence does
she PRIMARILY have?
Stress incontinence
Involuntary leakage on effort or exertion, such as sneezing or
coughing
Urgency incontinence
Involuntary leakage accompanied by or immediately
preceded by urinary urgency
The challenging ones…
“I leak all the time”
“I leak day and night”
“I have large volumes of incontinence”
Probably urgency incontinence
“I leak after I am done voiding”
Post void dribbling
ICIQ-UI Short Form
More questionnaires…
Task 2: Red Flags
Hematuria
Full bladder
Beware the radiologists PVR!
Other pelvic mass
Neurologic disease/symptoms
Back pain & lumbar disc disease
Recent urologic/gynecologic surgery
Urologist
Urologist
Gynecologist
Urologist/Neurologist
Neurosurgery
Followup Apt
Task 3: Examination
Palpable bladder
Screening neurologic exam of the lower limbs
Vaginal exam
Vaginal atrophy
Cystocele
Rectocele
Cough test
Bimanual
Task 4: Investigate
Urinalysis (+ Culture if suspicious)
Pelvic US with PVR (maybe)
Voiding diary
DAY 4 Date:
Time Amount Voided
(in ccs) Leak Volume (scale of 1-3*)
Activity during leak Was there an urge Fluide intake
(Amount in ounces/type)
Patient Name:
Instructions:
1. Choose 4 days (entire 24 hours) to complete this record – they do not have to be in a row. Pick days in which will be convenient for you to measure every void. 2. Begin recording when you wake up in the morning–continue for a full 24 hours. 3. Make a separate record for each time you void, leak, or have anything to drink. 4. Measure voids (using cc measurements) using the hat. 5. Measure fluid intake in ounces. 6. When recording a leak – please indicate the volume using a scale of 1-3 *(1=drops/damp, 2=wet -soaked, 3=bladder emptied), your activity during the leak, and if you had an urge (“yes” or “no”).
Normal voiding diary results
What to recommend for your patient
Option1: Behavioral/lifestyle changes
Conservative options
Reduce caffeine, fluid intake, or change the times they are taken
Review medications (ie diuretics)
Pessaries
Incontinence vs prolapse
Treat constipation
Quit smoking
Weight loss
NEJM RCT demonstrated that an 8% weight loss translated into a 47% reduction in incontinence
Bladder training: more frequent voiding
Bladder training
Schedule based on an interval the patient can manage
in daytime
Void at scheduled time even if urge not present; suppress
the urge if not time with Kegels
Increase voiding interval by 30 min each week until
continent for 3-4 hr
Option 2: Pelvic floor therapy
Pelvic floor muscle therapy
Primarily effective for both stress incontinence
Strengthening
Also effective for urgency incontinence
Urge suppression (10sec contraction, or 5 rapid contractions)
30% of women do Kegel’s wrong
Easy! Referral to a pelvic floor physiotherapist in London
Centric Health Physiotherapy and Wellness
www.lifemark.ca
Family Physiotherapy Centre of London
fpclondon.com
Option 3: Estrogen
Oral Estrogen
Not helpful!
Women's health initiative study (RCT, 23,000 women)
18% higher risk of incontinence (mostly stress
incontinence)
Vaginal estrogen
May improve incontinence, especially urgency
incontinence
Probably improves urgency and frequency
Probably works best if there is vaginal atrophy
Option 4: Oral medications
Only for mixed or urgency incontinence
Multiple approved medications available
All better than placebo
Modest effectiveness
Reduce urgency incontinence by 50%
Reduce frequency and urgency episodes by a few/day
Improved urinary quality of life
1-2/10 women become completely continent
Anticholinergics versus B3 agonists
The evidence based conclusions
about anticholinergics
Extended release oxybutnin has less dry mouth than IR
oxybutnin
Tolterodine is better tolerated than oxybutnin
Solifenacin has better cure/improvement than Tolterodine
Fesoterodine has better cure/improvement than Tolterodine
Solifenacin and Fesoterodine have titratable efficacy
Madhuvrata P, Cody JD, Ellis G, Herbison GP, Hay-Smith EJC. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database Syst Rev. 2012.
Specialist Management Stress Urinary incontinence
Bulking agents
Specialist Management Stress Urinary incontinence
Midurethral sling
Specialist Management Stress Urinary incontinence
Autologous fascial pubovaginal sling
Specialist Management Stress Urinary incontinence
The future
Intraurethral injection of autologous stem cells
Mini-slings
Specialist Management Urgency incontinence
Intravesical botox
Specialist Management Urgency incontinence
Neuromodulation
Specialist Management Urgency incontinence
The future
New drug targets in the bladder
Conclusions
Very few women with incontinence require an operation
Many women can be managed with reassurance and behavior modification
Pelvic floor muscle therapy is a good option for a motivated patient
A trial of anticholinergic medication is appropriate for patients with urgency or mixed incontinence
Multiple options are available for women if initial therapies aren’t effective, and they are bothered by their symptoms