Female Urinary Incontinence

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1 Female Urinary Incontinence Molly Heublein, MD Assistant Professor Clinical Medicine UCSF Women s Health Primary Care Disclosures I have nothing to disclose. 1

2 Objectives Review the problem Feel confident with office diagnosis of urge versus stress incontinence Feel confident with first line treatments Be aware of new developments/options for referral Female Urinary Incontinence An estimated 20 million American women struggle with urinary incontinence- around 50% of middle aged women, and 75% over the age of 75 1 Projected costs for urge incontinence alone: $76.2 billion in 2015 in the US 2 It leads to lower quality of life scores Urge incontinence increases risks for fractures and falls 3 It really is a primary care problem! 2

3 If we don t ask, they won t tell Do you have any bothersome leakage of urine? Asking about bothersome symptoms increases treatment rates 15% in the elderly 1 Female Urinary Incontinence Transient Chronic Urge Stress Mixed Overflow Functional 3

4 Urge Incontinence/Overactive Bladder (UI/OAB) Detrusor muscle contracts more frequently/ at lower stimulatory threshold and leakage occurs Women feel the urge to urinate, but lack control to hold it until the ideal time. Frequency and nocturia can occur Stress Incontinence (SUI) Sphincter/pelvic floor weakness gets overwhelmed by increased abdominal pressure and leakage occurs Symptoms occur with cough, sneeze, laugh, exercise, or change in position. Picture from: 4

5 Mixed Incontinence Both stress + urge Focus on treating the more bothersome symptoms Step 1: Differentiate stress vs urge incontinence Do you tend to leak urine with activities like coughing, sneezing, lifting, or jumping? Do you tend to feel a strong urge to urinate before you leak, or just don t make it to the bathroom on time? If both, which seems to happen more? 5

6 Feel confident in your office diagnosis! Basic questions have fair to good sensitivity and specificity in differentiating causes of incontinence Post void residual are not needed 7 Anal wink/neurologic testing add little in a relatively healthy outpatient without neurologic disease Urodynamic testing does not improve outcomes for conservative treatments (and it is controversial for surgical options) 8 Pelvic Floor Muscle Training Stress, urge and mixed all show >50% reduction in incontinence episodes compared to no treatment, number needed to treat 3 (NNT 6 for full continence) 1 Give a Kegels Prescription or refer to pelvic physical therapy 6

7 Lifestyle modifications - Fluid management - Consideration of dietary factors - Timed voids - Bladder diaries alone can improve symptoms significantly - Weight loss 7

8 Pharmacologic Options: Stress No FDA approved treatments - off label duloxetine showed trend toward improvement - off label vaginal estrogens show trend toward improvement But neither has proven statistical significance Anticholinergics for UI Side effects can be limiting Limited effectiveness- all seem to have similar effects, NNT 7-9 for improvement in UI NNH with side effects Continuation rates are only 12-40% at 1 year and 6-12% at 2 years across all drugs9 8

9 Mirabegron (Mybetriq) Novel class of treatment NNT 12 More favorable side effect profile Safe to combine with anticholinergics Next line therapies: Those who get inadequate benefit from lifestyle and pharmacologic options may benefit from urogynecology referral for: Percutaneous Tibial Nerve Stimulation (PTNS) for UI/OAB OnabotulinumToxinA injection (Botox) for UI/OAB Bulking agents for SUI Surgery for SUI 9

10 References 1. Qaseem et al. Nonsurgical Management of Urinary Incontinence in Women: A clinical Practice Guideline from the Amercian College of Physicians. Ann Internal Med. 2014; 161: Coyne KS, Wein A, Nicholson S, Kvasz M, Chen CI, Milsom I. Economic Burden of Urgency Urinary Incontinence in the United States: A Systematic Review. J Manag Care Pharm Feb;20(2): Brown et al. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc Jul;48(7): Khandelwal et al. Diagnosis of Urinary Incontinence. Am Fam Physician Apr 15;87(8): Shamliyan et al. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness. Comparative Effectiveness Reviews, No. 36. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Apr. Report No.: 11(12)-EHC074-EF 6. Huang AJ et al. Clinical Significance of Postvoid Residual Volume in Older Ambulatory Women. J Am Geriatr Soc Aug;59(8): doi: /j x. Epub 2011 Aug 1. References (cont) 7. Shamliyan et al. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness Comparative Effectiveness Reviews, No. 36 Minnesota Evidence-based Practice Center Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Apr. Report No.: 11(12)-EHC074-EF 8. Malone-Lee et al. Urodynamic verification of an overactive bladder is not a prerequisite for antimuscarinic treatment response. BJU Int Sep;92(4): Veenboer, et al. Long-Term Adherance to Antimuscarinic Therapy in Everyday Practice: A Systematic Review. Journal of Urology. Vol 191, , April Peters KML, et al. Percutaneous tibial nerve stimulation for the long-term treatment of overactive bladder: 3-year results of the STEP study. J Urol Jun;189(6): doi: /j.juro Epub 2012 Dec Nitti VW et al. OnabotulinumtoxinA for the treatment of patients with overactive bladder and urinary incontinence: results of a phase 3, randomized, placebo controlled trial.. J Urol Jun;189(6): doi: /j.juro Epub 2012 Dec Hellberg D, Holmgren C, Lanner L, Nilsson S. The very obese woman and the very old woman: tension-free vaginal tape for the treatment of stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:

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