Urinary Incontinence in Women

Transcription

1 Urinary Incontinence in Women Raymond T. Foster, Sr., M.D., M.S., M.H.Sc. Assistant Professor of Obstetrics and Gynecology Director, Missouri Center for Female Continence and Advanced Pelvic Surgery University of Missouri School of Medicine Columbia, Missouri

2 Objectives Understand urinary continence in women Review anatomy of the lower urinary tract Discuss the magnitude of the problem Discuss evaluation by the primary care physician Consider initial treatment strategies Know when to ask for help Be aware of treatment options available

3 Urinary Continence in Women P u P V B Intrinsic Myogenic Neurogenic Extrinsic Idiopathic V R P u > P v P u P v P u and P v Continence Stress Urge Mixed

4 Anatomy of the Female Urethra The Anatomy Lesson of Professor Nicholaes Tulp, 1632 By Rembrandt

5 Neuroanatomoy of the Lower Urinary Tract

6 Epidemiology of Incontinence in Women Urinary incontinence affects 10% - 70% of women who live in a community setting One study (1659 subjects, men and women) reported that 77% of nursing home residents were incontinent and 25% of nursing effort was directly related to urinary incontinence Most women do not seek medical help Estimated annual direct cost for incontinence (in women) is $12.43 Billion in the U.S. Wilson L, et al., Annual Direct Cost of Urinary Incontinence, Obstet Gynecol, 98: , Hunskaar S, et al. Epidemiology and Natural History of Urinary Incontinence, Int Urogynecol J, 11: , 2000 ACOG Practice Bulletin 63, May 2005 Abrams P, et al., editors, Incontinence, 2 nd ed. Plymouth, UK: Health Publication Ltd.; Steel J, Fonda D. Minimising the cost of urinary incontinence in nursing homes. PharmacoEconomics, 7: , 1995.

7 Prevalence of Urinary Incontinence by Age Group and Severity 40% 10% 20y/o 85y/o

8 Prevalence of Urinary Incontinence by Age Group and Impact 40% 10% 20y/o 85y/o

9 Prevalence of Urinary Incontinence by Age Group and Significance 35% 10% 20y/o 85y/o

10 What can you do to evaluate the problem? ASK! Remember, about 30% - 40% of geriatric patients are incontinent Focused patient history What causes leakage (e.g. Key in the door, cough, laugh, etc.) Does incontinence limit your life style? Physical exam Urethral abnormalities Stress test Laboratory evaluation: Urine dipstick, UA, Urine C&S 24 hour pad weight 3 day voiding diary

11 24 Hour Pad Weight

12 Bladder Diary

13 What can you do? Dietary counseling Avoid alcohol and caffeine Urge control techniques Behavioral therapy Timed voiding Reduce liquids in the evening Pelvic floor exercises Treat urinary infections Correct urogenital atrophy

14 Should I refer my patient? Stress incontinence Refractory to pelvic floor exercises Refractory to behavioral modification Patient desires definitive surgical management Urge incontinence Refractory to behavioral modification, pelvic floor exercises and urge control techniques Refractory to pharmacologic therapy Incontinence associated with neurogenic bladder Other Incontinence associated with an anatomical problem (prolapse, diverticulum, fistula, etc) Incontinence associated with recurrent UTI

15 What can be done for a patient refractory to therapy? Evaluation Urodynamic studies Office cystourethroscopy POPQ Stress incontinence Pelvic floor rehabilitation with biofeedback Pessary Surgery Urge incontinence Sacral neuromodulation Botulinum toxin Other

16 Case 1 68 year old woman complains of daytime somnolence PHM: postmenopausal, osteoporosis, hypertension, chronic constipation PSH: BTL Fam Hx: noncontributory Meds: Fosomax, Premarin, HCTZ Soc Hx: Occasional EtOH, no tobacco or drugs, married, retired school teacher, walks for exercise Allergies: NKDA

17 Case 1 Exam Gen: Caucasian, healthy-appearing female HEENT: nml CV/lungs: nml Abd: nml Pelvic: moderate urogenital atrophy, otherwise nml Ext: nml

18 Case 1 3 day voiding diary: 90cc average voided volume 150cc functional capacity daytime voids 5-7 episodes of nocturia per night Leaks with change in position and sight/sound of running water 3-4 maxipads per day 24 hour pad weight: 225g

19 Case 1 Consider a different HTN medicine or move HCTZ dose to 1400 hours Behavior modification (gradually increasing voiding intervals) Urge control techniques/pelvic floor exercises Fix constipation Avoid caffeine/alcohol Vaginal Premarin Anticholinergic

20 Case 2 65 year old woman c/o urinary incontinence PMH: hypothyroid, postmenopausal, seasonal allergies PSH: TAH with BSO Fam Hx: noncontributory Meds: Synthroid and Premarin Soc Hx: Married, occasional EtOH, no tobacco or drugs, works as a senior executive with a financial brokerage Allergies: NKDA

21 Case 2 Exam Gen: Caucasian, healthy-appearing female HEENT: nml CV/lungs: mild expiratory wheezing, bronchospastic cough with deep inspiration Abd: nml Pelvic: uterus, tubes and ovaries surgically absent Ext: nml

22 Case 2 3 day voiding diary: 450cc average voided volume 750cc functional capacity 3-4 daytime voids Leaks with cough/sneeze/laugh 2-3 panty liners per day 24 hour pad weight: 50g

23 Case 2 Aggressive treatment of reactive airway/allergies Pelvic floor exercises Reduce voiding interval

24 Questions?