Transcript The Diagnosis and Management of Incontinence
The Diagnosis and Management of Urinary Incontinence
Mr C Dawson MS FRCS Consultant Urologist
Edith Cavell Hospital, Peterborough Cromwell Clinic, Huntingdon
What this talk is about • Why Incontinence is an important problem • How to diagnose and manage most types of incontinence • Case presentations
Why Incontinence is important • Major health issue that affects an estimated 10 million women worldwide • Approximately 50% of all nursing home residents, and 15-30% of women over age 65 suffer from incontinence • 50% of all women over age 18 years have mild stress incontinence
Prevalence of Unstable Bladder • The average PCG (population ~ 100,000) will have over 5,600 people with urinary incontinence.
1 • One-third of residents in residential homes and two-thirds of residents in nursing homes suffer from urinary incontinence.
concealed by sufferers 2 • Exact prevalence not known because often 1 The Continence Foundation, Incontinence a Challenge & an Opportunity for Primary Care 2. DoH Guidelines, Good Practice in continence Services
Related health problems • Incontinence is a risk factor for: –falls (26% increased risk) and fractures (34% increased risk) –admission to hospital (1.3-1.5-fold risk) or nursing facility (2-3.2-fold risk)
Relationship to age • Risk of developing incontinence increases with age 1 –10% age 45-49 years –20% age 60-64 years –32% age 70-74 years 1. Sifo Research & Consulting, Pharmacia & Upjohn 1998
Prevalence of incontinence by age 18 16 14
15.4% 16.8% 13.3%
12 10 8 2 0 6 4
Men Women >60 1. Brocklehurst JC. Br Med J 1993;306:832-4 2. MORI Social Research Survey, August 1998
The Cost of Unstable Bladder • Diagnostic evaluation (blood tests/urodynamics/urine) • Treatment (e.g. drug therapy/bladder retraining) • Rehabilitation • Incontinence pads/catheters • Secondary consequences, e.g. skin irritation • Admission to residential/nursing home
Estimating the cost to the NHS
England only 1988
Drugs Appliances Containment products Staff costs and direct overheads* Surgery* MINIMUM TOTAL
Total cost £’ 000
22,732 58,612 69,000 189,926 13,325 353,595
*This estimate makes no allowance for overheads beyond direct employment costs e.g. for the appropriate shares of the cost of premises and of ancillary staff
The Continence Foundation. Making the Case for an Integrated Continence Service. 2000
Costs 1992 - 2001 £250 £200 £150 £100 £50 £0 1992 1996 2001 Estimated Euromonitor. World Survey of Incontinence Products 1997. Euromonitor. London
Impact of Urinary Incontinence on Quality of Life • Distress • Embarrassment • Inconvenience • Threat to self esteem • Loss of personal control • Desire for normalisation Kobelt G et al BJU International 1999; 83:583-90
Impact of Urinary Incontinence on Quality of Life • Introduction of coping techniques 1,2 –Avoiding social interaction –Toilet mapping –Carrying spare clothing –Avoiding long travel / journeys • Can lead to social exclusion 2 1. MORI Social Research Survey, August 1998 2. Brocklehurst JC, BMJ Vol 306 1993
Why you need to know about it • Patients often fail to seek help, and must therefore be supported when they do • Prevailing attitude from patients - “nothing can be done” • Many patients with mild symptoms can be greatly helped by simple investigations and treatment
How to diagnose and Manage Incontinence • Recognise opportunity for diagnosis • Take a full history • Full examination • Investigations • Management
Why screen in Primary Care?
• Why screen for patients with unstable bladder?
–Prevalence –Cost –Government Initiatives • •
Good Practice in Continence Services National Services Framework targets
Opportunities for screening • New Patient medical questionnaires • New Patient medical examinations • Routine cervical smears • Family planning / Menopause clinics • Patient leaflets / posters • Practice audit • Health visitors / District nurses / Practice nurses • Over 75 y.o. checks • Nursing homes
Examination in Primary Care • General - look for signs of systemic disease • Weight / BMI • Abdominal examination –Palpable abdominal or pelvic mass / bladder • Pelvic examination –Atrophic changes in vulva / vagina –Utero-vaginal prolapse –Demonstrable incontinence on coughing • Rectal examination –Tone of sphincter, exclude faecal impaction/prostatic • Brief neurological / mental state examination
Diagnosis in Primary Care • Other investigations may be possible in primary care (but are more likely to require referral): –Pad testing –Urodynamics –Measurement of urine flow –Residual volume –Subtracted cystometry –Videocystourethrography (VCU) –Cystoscopy
The Management of Incontinence • Types of Incontinence • Symptoms and Signs • Investigations • Management
Types of Incontinence • Anatomic or Genuine urinary stress incontinence • Urge Incontinence • Mixed • False (Overflow) Incontinence • Neuropathic Incontinence • Congenital • Post-traumatic or iatrogenic • Fistula
Types of Incontinence
‘Cough & Leak’ Small Volume Frequency Nocturia Urgency Stress and Urge Incontinence Frequency Urgency Nocturia Urge Incontinenc e Stress Mixed Urge Treat as detrusor instability (unstable bladder) (urinalysis & physical examination normal)
Adapted from: P Hilton, SL Stanton, BMJ, Vol 282, 1981
Incontinence in males
Stress 8% Mixed 19% Urge 73%
Hampel et al. Urology 1997; 50 (suppl 6A):4-14
Incontinence in females
Urge 22% Stress 49% Mixed 29%
Hampel et al. Urology 1997; 50 (suppl 6A):4-14
Genuine Stress Incontinence (GSI) • Cause • Hypermobility of the vesico-urethral junction owing to pelvic floor weakness • Symptoms and Signs • Leakage of urine in response to any physical activity - e.g. coughing, sneezing, bending down, exercise
Genuine Stress Incontinence (GSI) on examination. Urodynamics (VCMG) will confirm • Management • Pads • Weight Loss • Pelvic Floor Exercises • Surgery (Colposuspension, endoscopic bladder neck suspension)
• Cause Urge Incontinence (UI) • Detrusor instability with a normal sphincter, normal anatomy, and no neuropathy • Symptoms and Signs • Leakage occurs due to unstable bladder contraction (NB - can be precipitated by cough and therefore mimic GSI) • Usual symptoms of urgency, and frequency with or without urge incontinence
Unstable Bladder Symptoms • Frequency is defined as 8 or more voids in 24 hrs.
1 • Urgency is a sudden, strong desire to void.
2 • Urge incontinence is a wetting episode preceded by the sensation of urgency.
2 1. Fast Facts - Continence 2000, Shah & Leach 2. Hampel C et al, BJU International (1999), 83, Suppl . 2., 10-15.
Urge Incontinence (UI) • Management rule out other factors. Urodynamics (VCMG) will confirm • • Lifestyle changes Anticholinergic medication is first line therapy (NB warn patient about side effects) • Clam Ileocystoplasty
Modification of behaviour • Set realistic expectations for the outcome of treatment.
• Log improvement in a diary • Bladder retraining: – Re-educating the bladder to hold larger amounts of urine by gradually increasing the time between voids.
• Avoid caffeine and alcohol • Reduce fluid intake • Improve mobility and access to toilets Fast Facts, Urinary Continence,2000, Shah & Leach
Pharmacological treatment of unstable bladder includes: • Antimuscarinic drugs: –The most widely used in the U.K.
• Oxybutynin (Ditropan) • Tolterodine (Detrusitol) • Propiverine (Detrunorm) • Antispasmodic drugs: • Flavoxate • Tricyclic antidepressants • Oestrogens 1. British National Formulary No. 41. March 2001 2. Chapple et al, BJU 1990;66,491-494 3. MIMS August 2001
Surgery • Cystodistension • Clam ileocystoplasty • Suspension/sling techniques • Injectable therapy 1. Fast Facts, Urinary Continence, 2000, Shah & Leach 2. Bidmead J, Cardozo L. Lancet 2000;355:2183-4
Mixed Incontinence • Many women will have both GSI and UI • The management of these conditions is very different • Accurate Assessment is important
Aid to Diagnosis
Neuropathic Incontinence • Incontinence in the presence of a demonstrable neuropathy • Incontinence can be active (detrusor hyper reflexia), or passive (atony of sphincter), or a combination of the two
Congenital Incontinence • Ectopic ureters • Epispadias • Exstrophy • Cloacal malformation • Specialist Opinion will be required in all cases
Overflow Incontinence • Usually the result of obstructive or neuropathic lesion • Commonly seen in men with BPH • Often no preceding symptoms • Examination vital to detect over full bladder • Confirm with portable USS (large +++ residue) • Needs referral to Urologist
Traumatic Incontinence • Associated with – Pelvic Fracture – Sphincter damage post-TURP (note this is
GSI as sphincter is intact in GSI)
Fistula • Can be ureteral, vesical, or urethral • Usually iatrogenic, after pelvic or vaginal surgery • Needs specialist opinion and surgical repair
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