UPDATE IN FEMALE URINARY INCONTINENCE Identifying Potential Urinary Incontinence In Women

Transcription

1 UPDATE IN FEMALE URINARY INCONTINENCE 2011 Identifying Potential Urinary Incontinence In Women DR IAN P TUCKER UROGYNAECOLOGIST

2 Update in Female Urinary Incontinence Identifying Potential Urinary Incontinence: ASK!! How questions are asked is important. Understanding normal bladder function is important. Understanding basic abnormal patterns is important. Much can be done at primary care level.

3 URINARY INCONTINENCE URINARY INCONTINENCE: The involuntary passage of urine [any amount].

4 URINARY INCONTINENCE INCONTINENCE IS AT BEST: EMBARRASSING. AT WORST: Totally disabling. One of the major factors for admission to high care residential facilities [Pearson Tucker Bolt et al].

5 PREVALENCE In 2010, nearly 4.8 million Australians were living with incontinence This figure included: 4.6 million community-dwelling Australians (aged 15 years or over) 128,500 people living in residential aged care (aged 60 years or over) Under-reported Study by Pearson, Tucker et al confirmed this and looked at reasons.

6 Prevalence of incontinence compared with other chronic conditions

7 COST OF INCONTINENCE IN 2010 In 2010, the total financial cost of incontinence was estimated to be $42.9 billion

8 MECHANISMS OF CONTINENCE To maintain continence the forces which tend to retain urine MUST exceed those forces which tend to expel urine. Even the slightest imbalance in any area may lead to incontinence. Combinations of problems are common.

9 MECHANISMS OF CONTINENCE There are many different causes of incontinence. Some are best controlled with: behavioral techniques. pelvic floor exercises medication. Some are treated surgically.

10 Mechanisms of Continence The control of Lower urinary tract function is an enigma. Dr Richard Turner-Warwick once likened the bladder to a bumble bee. - The bumble bee is curious. It is fat, round, has no aerodynamics and should not be able to fly. But the bumble bee doesn t know about aerodynamics so it flies anyway!

11 Complex Disorders of Bladder Function Physiology Physiology of Lower urinary tract Function: The bladder has its own autonomous contractility. Animation courtesy of Prof J Gillespie, Physiologist

12 Urogenital Tract Function: Physiology We are not born continent. The voluntary control of the bladder [ & bowel] is gained as higher centres and nerve pathways develop.

13 UROGYNAECOLOGY - UPDATE 2011 MECHANISMS OF CONTINENCE Mum, I need to do a wee Next: Perception of bladder filling [sensory nerve impulses travel up to the higher centres]. Still unable to inhibit bladder emptying [inhibitory nerve impulses still do not travel down the spinal cord]. Still incontinent.

14 UROGYNAECOLOGY - UPDATE 2011 MECHANISMS OF CONTINENCE Then: Inhibitory impulses travel down the spinal cord. Inhibition of voiding reflex. CONTINENCE

15 MECHANISMS OF CONTINENCE: Where can things go wrong? Interference at any level may cause incontinence. E.g. 1. Brain 2. Spinal cord 3. Peripheral nerves 4. Bladder 5. Urethra 6. Pelvic floor

16 CONTINENCE: IMPORTANT ASPECTS URINE PRODUCTION BLADDER STORAGE & EMPTYING URETHRAL COMPETENCE. ROTATIONAL URETHRAL DESCENT. FISTULA

17 MEDICATIONS & the Lower Urinary Tract URINE OUTPUT KIDNEYS & BLADDER APPROPRIATE URINE OUTPUT: The urine output should be 1.5 litres/24hrs. If it is excessive, consider: 1. Bad habit 2. Diabetes Excessive nocturnal volumes - common in the elderly. Diagnose with F/V chart.

18 UROGYNAECOLOGY - UPDATE 2011 EXCESSIVE URINE OUTPUT Management: Exclude &/or treat diabetes. Exclude large residual. Restore appropriate urine output. Correct bad habit.

19 UROGYNAECOLOGY - UPDATE 2011 EXCESSIVE URINE OUTPUT KIDNEYS & BLADDER X X Medical treatment: Diuretic in the afternoon if excess nocturnal volume. Minirin - anti-diuretic hormone [usually combine with a diuretic to prevent fluid overload and electrolyte imbalance]. NOT treated surgically.

20 INCONTINENCE - Excessive output Urinary diary Excessive output: Bad habit, Diabetes Correct bad habit Treat diabetes MSSU,? Cytology Exclude Residual Excessive residual: ISC

21 UROGYNAECOLOGY excessive urine output TAKE HOME MESSAGE: Always obtain urinary diary, Urine output should be 1.5L/24hrs, Check residual - be cautious of ultrasound residual, Exclude diabetes.

22 CONTINENCE: IMPORTANT ASPECTS URINE PRODUCTION. BLADDER STORAGE & EMPTYING URETHRAL COMPETENCE. ROTATIONAL URETHRAL DESCENT. FISTULA

23 CONTINENCE: Bladder Storage - OAB Bladder Storage: To allow the bladder to fill, the detrusor muscle must remain relaxed. One should NEVER HAVE to rush to the toilet! This muscle often becomes overactive causing urgency, urge incontinence nocturia & enuresis.

24 PATHOPHSIOLOGY OF INCONTINENCE: OVERACTIVE BLADDER SYMPTOMS: frequency, nocturia, urgency, urge incontinence CAUSES: Idiopathic - familial tendency genes on chromosomes 4, 8, 12, 13, 22. Onset at any age [e.g. Childhood]. Usually longer duration than first admitted. Males = Females. Neurological : 1. Sudden onset. 2. Often more severe. 3. neurological symptoms/signs.

25 CONTINENCE: Bladder Storage, OAB DIAGNOSED BY: History of frequency urgency urge incontinence. F/V Chart - Small frequent voids. Childhood enuresis or FH enuresis/urgency. Be aware of sudden onset of symptoms. MSSU for culture/cytology. Imaging & Urodynamic confirmation when appropriate.

26 OVERACTIVE BLADDER: MANAGEMENT TREATMENT: Behavioral modification. Pelvic floor muscle re-education. Medication. Surgery: Sacral Nerve Stimulation Botox injection

27 Lifestyle Changes Image002.gif 27

28 Influence ASCENDING PATHWAYS Pre-frontal cortex Pelvic Floor Exercises: Sensory pelvic floor relay sensations of bladder fullness. Periaqueductal grey Ascending fibres from the sacral spinal cord relay the information to the periaqueductal grey region. NEUROMODULATION Pontine micturition centre Pelvic floor Bladder External urethral sphincter 28

29 INFLUENCE DESCENDING PATHWAYS Alter Nerve-muscle transmission: Medication Botox Onuf s nucleus PMN Pontine micturition centre Bladder External urethral sphincter

30 How do medications work? MEDICATIONS & the Lower Urinary Tract Stop the release &/or uptake of Acetylcholine at the nerve muscle junction.

31 Dry out with drugs! Medications: [alone or in combination] Propantheline 15-30mg tds Tofranil 25-50mg nocte Ditropan 2.5-5mg bd-tds Oxytrol 1 patch twice a week Vesicare 5-10mg daily [or divided dose] Enablex mg daily [or divided dose] Detrusitol 1-2mg bd Fesoterodine [not yet available]

32 MEDICATIONS & the Lower Urinary Tract REMEMBER: Medications can also exacerbate incontinence Cholinergic agents Bowel stimulants incl maxolon Methotrexate SSRI antidepressants

33 Urinary diary INCONTINENCE Overactive detrusor Frequency urgency nocturia etc. Excessive output: Bad habit Diabetes Reduce intake to 1.5 L/24hrs Large Residual?ISC MSSU Cytology Organ Imaging Small frequent voids Lifestyle changes Pelvic floor physio Anticholinergics Refer if: Sudden onset Severe Failed response

34 OAB: Take Home Message Suspect from history and usually familial. Urine output chart. MSSU culture [& cytology if recent onset]. Exclude residual [caution with ultrasound report]. Begin treatment: Pelvic floor re-education, Lifestyle. Medication. Refer if not responding, severe or sudden onset.

35 MECHANISMS OF CONTINENCE: BLADDER EMPTYING BLADDER EMPTYING: Must be complete. 1. Normal detrusor contraction. 2. Sustained contraction. Retention of urine is not due to obstruction in the female.

36 BLADDER EMPTYING: INEFFICIENT BLADDER CONTRACTION TREATMENT: Medication: 1. Bethanechol 2. Phenoxybenzamine 3. Minipress Intermittent catheter?sacral Nerve Stimulation Avoid Urethrotomy, Urethral dilatation and hydrodilatation

37 CONTINENCE: IMPORTANT ASPECTS URINE PRODUCTION. BLADDER STORAGE & EMPTYING URETHRAL COMPETENCE. ROTATIONAL URETHRAL DESCENT. FISTULA

38 UROGYNAECOLOGY - UPDATE 2011 Urethral Sphincter deficiency Urethral Sphincter deficiency [ISD]. Unconscious dribbling Incontinence with exertion Often incontinence on standing

39 UROGYNAECOLOGY - UPDATE 2011 Urethral Sphincter deficiency URETHRAL CLOSURE: Normal urethra: 1. Adequate sphincter 2. Adequate length 3. Normal epithelium 4. Normal blood flow Poor urethral closure [USD]caused by: 1. Increased age 2. Oestrogen lack 3. Medications [minipress] 4. Surgery

40 UROGYNAECOLOGY - UPDATE 2011 POOR URETHRAL CLOSURE [ISD] TREATMENT: Medication: 1. Alpha agonists [phenylpropanolamine] 2.?Duloxetine 3. Local Oestrogen Peri-urethral bulking agents Pelvic floor physiotherapy

41 UROGYNAECOLOGY - UPDATE 2011 POOR URETHRAL CLOSURE [ISD] TAKE HOME MESSAGE: ISD increases with age, Suspected if unconscious dribbling, Diagnosed by Urodynamics [UPP s], Difficult to treat, Be aggressive with local oestrogens

42 CONTINENCE: IMPORTANT ASPECTS URINE PRODUCTION. BLADDER STORAGE & EMPTYING URETHRAL COMPETENCE. ROTATIONAL URETHRAL DESCENT. FISTULA

43 UROGYNAECOLOGY - UPDATE 2011 Stress urinary Incontinence STRESS INCONTINENCE: SYMPTOM SIGN CONDITION

44 UROGYNAECOLOGY - UPDATE 2011 STRESS INCONTINENCE PELVIC FLOOR MUSCLE GENUINE STRESS INCONTINENCE: Incontinence with exertion, not with urgency. Rotational urethral descent. 1. Disrupted retropubic supports [pubo-urethral ligament]. 2. Dysfunctional pelvic floor. 3. Separation of the levator ani muscle removes support for the ligament.

45 UROGYNAECOLOGY - UPDATE 2011 Mechanism of Stress Incontinence NORMAL Normal: Cough transmitted equally to bladder and proximal urethra Pressures cancel out. No incontinence with cough or exertion PELVIC FLOOR MUSCLE

46 UROGYNAECOLOGY - UPDATE 2011 Stress incontinence Stress Incontinence Urethra torn away from its retropubic supports. Cough transmitted only to bladder. Higher pressure in bladder than urethra. INCONTINENCE

47 STRESS INCONTINENCE: TREATMENT PELVIC FLOOR MUSCLE TREATMENT: Conservative: 1. Pelvic floor rehabilitation [physio]. 2. Local Oestrogens if post- menopausal. Surgery: Trans-vaginal Tape. Obturator Tape. NOT anterior repair.

48 STRESS INCONTINENCE: SURGICAL MANAGEMENT TREATMENT MUST: SUPPORT the urethra. Prevent rotational descent on exertion. Procedures with maximal success achieve both.

49 INCONTINENCE Stress Incontinence Urinary diary Exertional incontinence Small frequent voids Unconscious dribbling Conservative treatment Surgery for GSI Urodynamics Treat OAD also if present ISD: Local Oestrogens, Bulking agent

50 Stress Urinary Incontinence: Take home message Treat symptom conservatively but the only operate on the condition. Always obtain urine output chart. Conservative treatment first. Urodynamic evaluation a must before surgery. Procedures becoming less invasive.

51 CONTINENCE: IMPORTANT ASPECTS URINE PRODUCTION. BLADDER STORAGE & EMPTYING URETHRAL COMPETENCE. ROTATIONAL URETHRAL DESCENT. FISTULA

52 Urogynaecology Update: Summary Thorough History. Urine output chart [frequency/volume]. Examination as appropriate. Exclude residual. MSSU [+cytology if over 45 yrs].? Imaging

53 Urogynaecology Update: Summary Begin conservative treatment: Pelvic floor re-education Local oestrogens Anticholinergics

54 Urogynaecology Update: Summary Refer for urodynamics/specialist advice if: Failed conservative treatment. Sudden onset of symptoms. Moderate to severe symptoms. Surgery contemplated. You are concerned.

55 Incontinence: Case Studies 1 Mrs. LS Aet 38yrs G2P2 3-4 month history of frequency/urgency/urge incontinence. Sl anxiety. Some work stresses. PH: nil signif Medications: nil O/E pelvic findings normal,?sl Bell s palsy. Urine output chart:

56 Other investigations: Urinalysis: NAD Urodynamic studies OAD Incontinence: Case Studies 1 CT scan: Large frontal lobe tumour extending into corpus callosum. Neuological consult Neurosurgery Urgency controlled with Ditropan 5mg bd Survived 5 years

57 Incontinence: Case Studies 1 Important features: Sudden onset of severe symptoms Think of other causes: Infection, tumours Neurogenic tumours, MS etc.

58 Miss BC Aet. 23 G0P0 Incontinence: Case Studies 2 Lifelong history frequency, urgency, urge incontinence. No bowel symptoms. Enuresis as child occasionally now PH Anxiety, depression, neurofibromatosis previous medication for frequency urgency Medications: Yasmin Efexor O/E: Normal pelvic findings, no neurological deficits.

59 Incontinence: Case Studies 2 Investigations: Urinalysis NAD Urine output chart Urodynamics Overactive detrusor - familial OAD

60 Incontinence: Case Studies 2 Management: Anticholinergics Various combinations tried but either insufficient response or excessive side effects. Sacral Nerve Stimulation: After considerable discussion

61 Before Incontinence: Case Studies After

62 SACRAL NERVE STIMULATION: Gold standard for intractable OAB STIMULATION OF 3rd SACRAL NERVE IMPROVES: OVERACTIVE BLADDER. VOIDING DIFFICULTIES. [Detrusor/sphincter dyssinergia]. PELVIC PAIN [especially when associated with either of the above problems].

63 SACRAL NERVE STIMULATION Test Phase Needle inserted in 3 rd Sacral Foramen GA no paralysis X-ray imaging Levator and toe response Need 50% or more improvement

64 SACRAL NERVE STIMULATION Anchoring Tines NEW TINED LEAD DEVELOPED TO ALLOW: Minimally invasive technique. Percutaneous placement. Use as test lead and implanted lead. Quadripolar to ensure optimal contact with the nerve.

65 SACRAL NERVE STIMULATION TINED LEAD WITH PULSE GENERATOR

66 SACRAL NERVE STIMULATION Tined Lead in situ

67 Neuromodulation: Technique Easy as a Walk in the Park!

68 SACRAL NERVE STIMULATION VOIDED VOLUMES BEFORE & DURING PNE MLS AVG VOIDED VOLUME 1 AVG VOIDED VOL 2 PATIENTS

69 SACRAL NERVE STIMULATION VOIDED VOLUMES PRE & POST PNE AND POST IMPLANT MLS AVG VOIDED VOL 1 AVG VOIDED VOL 2 AVG VOIDED VOL 3 PATIENTS

70 SACRAL NERVE STIMULATION VOIDED VOLUMES PRE & POST IMPLANT MLS AVG VOIDED VOL 1 AVG VOIDED VOL 3 PATIENTS

71 SACRAL NERVE STIMULATION QUALITY OF LIFE DATA: Cappellano et al [Milan] Pre-implant Daily Incontinent Episodes Incontinent Episodes Post-implant Overactive bladder Hyperreflexia Incontinent Episodes

72 QUALITY OF LIFE DATA: Cappellano et al [Milan]. SACRAL NERVE STIMULATION Pre implant Quality of Life Quality of Life Post implant Quality of Life Overactive bladder Hyperreflexia

73 BOTOX Destroys Motor & Sensory Neuromuscular Junction 1. Synaptic binding of the toxin 3. Nerve sprouting 2. Internalisation of the toxin 4. Restoration of the neuromuscular junction

74 BOTOX Injection technique

75 Incontinence: Case Studies 3 Mrs. JA Aet. 68 G2P2 NVD s Aware of prolapse for years. Incontinence with exertion, No frequency or urgency No Bowel disturbance PH Nil Sig, No medications O/E Atrophic change, Gde 3 cystocele, No posterior descent, Good pelvic floor muscle tone

76 Investigations: Urine output chart Polyuria Urinalysis glycosuria GTT diabetic Incontinence: Case Studies 3

77 Incontinence : Case Studies 3 Further Investigations: Urodynamic studies ISD GSI

78 Management: Incontinence: Case Studies 3 Treat diabetes Reduce intake to ensure output 1.5L/24hrs Local Oestrogen Ovestin 3 x week? Conservative treatment Patient requested surgical repair of prolapse Anterior vaginal repair, Obturator tape procedure?? Trans urethral Macroplastique later for ISD

79 Incontinence: Case Studies 3 Important features: Urine output chart polyuria Cystocele does NOT cause incontinence Different causes of incontinence require different treatments.

80 UROGYNAECOLOGY - UPDATE 2011 INCONTINENCE - SURGERY Retro-pubic VAGINAL TAPE Procedures Modern form of sling procedure. Allows fixation NOT elevation. Works by obstructive effect. Long term results 10 yr data appears encouraging. Quick and easy but Reactions to tape. Obstructive problems still occur.

81 Transvesical mesh perforation

82 Transvesical mesh perforation

83 IVS Vaginal Erosion

84 Tape Erosion/Bladder Calculi

85 UROGYNAECOLOGY - UPDATE 2011 STRESS INCONTINENCE Obturator TVT: Are gradually replacing the retro-pubic approach. Less risk of bladder perforation. Less risk of haemorrhage. Probably less risk of obstruction. Seem to have equivalent success rates.

86 Surgery for Stress incontinence Obturator TVT AMS MONARC Procedure: Trans- Obturator Tape J & J Procedure TVT- O Now other clones

87 UROGYNAECOLOGY - UPDATE 2011 STRESS INCONTINENCE - Obturator TRANS-OBTURATOR TAPE - MONARC

88 Stress Incontinence More Recent Developments MORE RECENT: - Mini-slings MINI-ARC Precise [AMS] and several clones now appearing.

89 Mini-Arc Precise 8.5cm

90 UROGYNAECOLOGY - UPDATE 2011 STRESS INCONTINENCE - Obturator TRANS-OBTURATOR TAPE - MINIARC

91 Stress Incontinence More Recent Developments At this stage I have 3 years experience with the Mini-Arc/ Mini- Arc Precise. Advantages: ease, less invasive again but early days.

92 UROGYNAECOLOGY UPDATE 2011 Trans-urethral Macroplastique Injection - Multiple [3] Injection Sites 6 o clock Needle inserted 10 o clock at 6, 10 & 2 o clock 2 o clock position position position

93 ISD Macroplastique Needle insertion Sphincter incompetence Closure after 2 injections

94 UROGYNAECOLOGY - UPDATE 2011 Urinary incontinence Summary Incontinence management AIM: To Restore Continence Safely Effectively With Minimal or No Side Effects Careful Planning is Needed

95 UROGYNAECOLOGY - UPDATE 2011 STRESS INCONTINENCE The result of this careful planning will allow the bladder to fill.

96 UROGYNAECOLOGY - UPDATE 2011 STRESS INCONTINENCE It will allow normal voluntary voiding.

97 UROGYNAECOLOGY - UPDATE 2011 STRESS INCONTINENCE Stop the tap from leaking

98 UROGYNAECOLOGY - UPDATE 2011 STRESS INCONTINENCE Then No-one will get their feet wet!!!

99 Continence Foundation of Australia CFA SA Continence Resource Centre Blacks Road, Gilles Plains Tel: [SA & NT callers only] OR [08] SUPPORT THE CFA

100 UROGYNAECOLOGICAL SOCIETY OF AUSTRALASIA - UGSA Expanding the horizons in Female Health Care. Established by the UroGynaecologists of Australasia. Improve standards of care, improve teaching and training methods not only for Subspecial ists &. trainees but for other relevant medical and allied health care professionals