1/07/2014 HOW COMMON? FEMALE URINARY INCONTINENCE: OVERACTIVE BLADDER NORMAL BLADDER FUNCTION CAUSES OF URINARY INCONTINENCE HISTORY RISK FACTORS

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1 HOW COMMON? FEMALE URINARY INCONTINENCE: OVERACTIVE BLADDER Judith Goh AO MBBS(Qld) FRANZCOG CU PhD Urogynaecologist Griffith University Greenslopes Private Hospital, Brisbane Pindara Private Hospital, Gold Coast QEII Hospital 17% adult women complain of overactive bladder 40-50% women >75 years old complain of urinary incontinence Estimated that about 70% affected by urinary incontinence do not seek assistance NORMAL BLADDER FUNCTION 2 main functions: urine storage and expulsion at appropriate time Storage at low detrusor pressures Void up to 7 times a day Fluid intake l/day Each void > 250 mls CAUSES OF URINARY INCONTINENCE Urodynamic stress incontinence Detrusor overactivity Overflow incontinence Others Reversible UTI Fistula Cognitive RISK FACTORS Age Pregnancy 4D USS levator avulsion not associated with urinary incontinence Childhood urinary symptoms Others Neurological Obesity Caffeine Bad bladder habits HISTORY Activity related/stress leakage Involuntary leakage of urine on exertion/effort Urgency Urge incontinence Triggers Key in door, taps/water etc Frequency Nocturia Coital incontinence Penetration, orgasm Dysuria, bladder pain 1

2 HISTORY Voiding difficulty Straining, hesitancy Double voiding Voiding posture Haematuria, UTI Prolapse symptoms Anorectal symptoms constipation Previous surgery Medications EXAMINATION General, scars Labia Urine dermatitis/excoriation Labial fusion Urethra Mass, scar, mobility Leak coughing Vagina Prolapse, atrophy Prolapse generally does not cause urinary incontinence Pelvic mass INITIAL INVESTIGATIONS Depends on history, examination Pad test Residual volume MSU, cytology Voiding/urinary diary Blood sugar, renal function Imaging pelvis, renal tract URINARY DIARY 2 day diary adequate Type/amt fluid intake, time Time/volume of voids Associated symptoms eg urgency Leakage Related to activity, urgency Triggers Normally Each void > 250 mls If no nocturia, 1 st void in am is largest (>500 mls) URINARY DIARY URINARY DIARY Time volume comment urgency leakage intake 5.30 am 150 mls Wake up yes Yes 7.30 am 70 mls yes 2 cups tea 9 am 80 mls Going out yes yes 11 am 100 mls yes 1 cup tea pm 90 mls yes 250 water 2 pm 70 mls Come home yes yes 4pm 90 mls 1 cup tea 6 pm 65 mls shower yes yes 1 cup tea 7.10 pm 60 mls 9 pm 100 mls yes yes 9.30 pm 30 mls Going to bed yes 12 am 100 mls Yes 2 am 90 mls yes Time vol urgency leak intake mls Wake up yes Yes mls yes 2 tea mls Going out yes yes mls yes 1 tea mls yes 1 water mls home yes yes mls 1 tea mls shower yes yes 1 tea mls mls yes yes mls Bed yes mls Yes mls yes This diary Small voids Urge, urge incontinence Mainly caffeinated Nocturia small volumes 2

3 URINARY DIARY (2) NOCTURIA, STRESS LEAK Time volume comment urgency leakage intake 6 am 520 mls Wake up 1 cup coffee 7.30 am 250 mls 9 am cough yes 350 mls H20 11 am 200 mls pm 1 cup tea 2 pm 220 mls 200 mls H20 6 pm run yes 7.10 pm 250 mls 1 wine, 1 tea 8 pm 350 mls H pm 230 mls Bed 300 mls H pm 300 mls Wake up 2 am 400 mls FURTHER EVALUATION Uncertain diagnosis Failed initial therapy Surgery Other pathology FURTHER EVALUATION Urodynamics Uroflowmetry Cystometrogram Urethral closure pressure or leak point pressure MANAGEMENT OF OAB Imaging - Bladder neck mobility URODYNAMIC STRESS INCONTINENCE Diagnosis by symptom, sign and urodynamic investigations involves the finding of involuntary leakage, associated with increased intra-abdominal pressure, in the absence of a detrusor contraction. ICS/IUGA terminology URODYNAMIC STRESS INCONTINENCE Management Conservative Pelvic floor rehabilitation Vaginal devices Surgery 3

4 OVERACTIVE BLADDER Overactive bladder (OAB) is a syndrome characterised by urgency with or without urgency urinary incontinence (UUI), usually with frequency and nocturia (in the absence of proven infection or other obvious pathologies) IUGA/ICS 2010 terminology CONSERVATIVE MANAGEMENT Lifestyle, weight loss Fluid modification Pelvic floor rehabilitation Bladder retraining Pelvic floor exercises Voiding techniques Topical oestrogen improve irritative symptoms of urgency and frequency due to reversal of urogenital atrophy OTHER TREATMENT OPTIONS Medications Antimuscarinics Tricyclic antidepressants Beta3-adrenoreceptor agonist Surgery Botox SNS BEHAVIOURAL MODIFICATION Assess fluid intake Pelvic floor exercise Bladder retraining Deferring techniques Timed voiding Bladder diary Often with pharmacological agents Requires compliance and realistic expectations BAD BLADDER HABITS BLADDER TRAINING Bladder Training is a process to increase the functional capacity of the bladder and decrease the number of voids per day That is to pass more urine, less often. Continence Foundation of Australia Patient information pamphlets National Continence Helpline 4

5 BLADDER IRRITANTS ANTIMUSCARINIC MEDICATIONS Caffeine Alcohol Concentrated urine Infection Acetylcholine is the main contractile neurotransmitter of the detrusor muscle it stimulates the muscarinic receptors 5 subtypes of muscarinic receptors urinary smooth muscle and urothelium contain mainly M2 and M3 receptors M2, M3 also present in other tissues M2 in cardiac smooth muscle M3 in bowel, salivary glands, eye. M3 receptors primarily responsible for bladder contraction ANTIMUSCARINICS Reduce intravesical pressure Raise the volume threshold for voiding Reduce uninhibited contractions Up to 75% in reducing major symptoms SIDE-EFFECTS Central CNS effects Peripheral Dry mouth Constipation Tachycardia Narrow-angle glaucoma is a contraindication for all antimuscarinic medication. OXYBUTYNIN Oxybutynin IR (Ditropan) Anticholinergic, antispasmodic, local anaesthetic Greatest affinity for M1 and M2 receptors. More selective for salivary gland than bladder Dry mouth, constipation Most s/e caused by active metabolite from first pass mechanism in gut Well documented effectiveness 2.5-5mg up to 4 times/day TRANSDERMAL OXYBUTYNIN PATCH Oxytrol Change patch twice/week Releases oxybutynin 3.9mg/day No more systemic side-effects than placebo, with minimal discontinuation due to dry mouth Application site erythema 5

6 SOLIFENACIN (VESICARE) Blocks M1 and M3 receptors More selective for M3 receptors in bladder than salivary glands Low rates dry mouth Low discontinuation rate Well documented effectiveness Once daily oral dose : 5-10mg/day DARIFENACIN (ENABLEX) Relatively selective M3 receptor antagonist Low affinity for M1 and M2 therefore few effects on cognitive function or CVS Low discontinuation rates Well documented effectiveness Once daily oral dose: mg/day TOLTERODINE (DETRUSITOL) IR (twice/day) Nonselective muscarinic receptor antagonist More affinity for bladder than salivary gland Well documented effectiveness 1-2mg twice/day PROPANTHELINE (PROBANTHINE) Nonselective muscarinic receptor antagonist Poor GIT absorption Short half-life Poor side-effect profile Varying effectiveness TRICYCLIC ANTIDEPRESSANTS Systemic antimuscarinic actions, blockade of reuptake of serotonin and noradrenaline Use low dosage Beneficial for nocturnal enuresis and nocturia CARE WITH ANTICHOLINERGICS IN ELDERLY Drug distribution changes due to reduced muscle mass and renal impairment Consider overall antimuscarinic burden medications for Parkinson s disease and dementia Cognitive function - Impaired memory recall and immediate learning with oral oxybutynin 6

7 WHAT S NEW IN OAB BETA3-ADRENORECEPTOR AGONISTS Beta3-adrenoreceptor agonists Recently available in Australia Mirabegron Betmiga Detrusor relaxation and increased stability during bladder storage is achieved through direct activation of beta-adrenoreceptors All 3 subtypes (beta1, beta2, beta3) are found in human detrusor muscle and urothelium Beta3 subtype thought to be most important in mediating human detrusor relaxation MIRABEGRON Selective beta3-adrenoreceptor agonist Stimulation of these receptors relaxes detrusor smooth muscle, increases bladder capacity 25mg and 50mg doses MIRABEGRON Side-effect profile: dry mouth no different to placebo gastrointestinal disturbance; headache; hypertension Cardiovascular effects increase heart rate (1bpm) and blood pressure (1mmHg)? Clinically relevant However the effects not fully investigated include: Cardiovascular system Pharmacokinetic interactions with other drugs Long-term adverse events WHEN TO USE MIRABEGRON? Possible second-line treatment for OAB in patients who are poor responders or intolerant to anticholinergics??possible option of combination therapy with low dose anticholinergics and mirabegron Literature is still limited with no head-to-head comparative studies between anticholinergics and mirabegron; therefore no test of equivalence or superiority WHAT DOES IT MEAN? Medical therapies PBS listed: oral oxybutynin IR (Ditropan), propantheline (Pro- Banthine), imipramine (Tofranil), Second-line : oxybutynin transdermal patch (Oxytrol) Private script: tolteridine IR (Detrusitol), solifenacin (Vesicare), darifenacin (Enablex), oxybutynin transdermal patch (Oxytrol), mirabegron (Betmiga) 7

8 SURGERY FOR DETRUSOR OVERACTIVITY For intractable DO Botox (Botulinum toxin intravesicle injection therapy) Sacral Nerve Stimulation (sacral neuromodulation) BOTOX FOR DO Not yet approved in Australia for idiopathic DO (considered experimental) Success rates 60% Duration of clinical response 4 to 14 months (average 9-12 months) Complications Catheterization >10%; median 113 days While efficacy has been demonstrated, the significant risk of incomplete bladder emptying postoperatively, and subsequent need for some form of catheterisation, has limited its use. MANAGEMENT OAB Exclude pathology Pelvic floor rehabilitation Bladder training Fluids intake Caffeine Constipation Weight Medications CONCLUSION History and examination Investigate as appropriate Conservative management Bladder training Bladder diary Topical oestrogen Antimuscarinic New Beta3-adrenoreceptor agonist Surgery Intractable OAB Realistic expectations Urogynaecology Urogynaecology dept, can you hold? 8

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