Ouzounoglou Urology consultant Urinary incontinence types and diagnosis in community Specialist approach and advanced management Urinary incontinence types and diagnosis in community Specialist approach and advanced management ID: 1009430
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1. Urology departmentMr Prodromos OuzounoglouUrology consultantUrinary incontinence types and diagnosis in community Specialist approach and advanced management
2. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementCommunity management
3. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementInitial clinical assessmentStress urinary incontinenceMixed urinary incontinenceUrge urinary incontinenceoveractive bladderPredominant symptom?
4. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementRelevant predisposing and precipitating factorsNumber or pregnanciesWeight of the babyNeurological diseases (MS, Parkinson’s disease)Body statusGynecological surgeriesVaginal prolapsDiscuss the benefit of non-surgical management and medicines before offering surgery.
5. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementTests and assessmentHistory and physical examinationPelvic floor muscle assessmentUrine testing (dipstick)Post voiding residual volume of urineBladder diary (input – output urine chart)Questionnaire (ICIQ, ICIQ-OAB)Baseline assessment before starting any type of treatment!
6. Urinary incontinence types and diagnosis in community – Specialist approach and advanced management1. Lifestyle interventions (50% improvement rate)Caffeine reduction Fluid managementLose weight (especially for BMI >30)2. Pelvic floor muscle training (50-60% success rate)Pelvic floor muscle training of at least 3 months (for stress or mixed urinary incontinence)Continue the exercise programme if pelvic floor muscle training is beneficial.3. Behavioural therapies (50-60% success rate)Bladder training lasting for a minimum of 6 weeks (for urge or mixed urinary incontinence) before consider medical treatment
7. Urinary incontinence types and diagnosis in community – Specialist approach and advanced management4a. Medicines for overactive bladderMedicine can be successful (60%)Side effects associated with the medicine 1. Dry mouth (20%) and constipation (10%) for Anticholinergic medicines 2. High blood pressure, abnormal heart rhythm (10%) for Beta-3 agonistTreatment at least 4 weeks Review contraindications (glaucoma, myasthenia gravis and dementia)4b. Medicines for stress incontinence (Duloxetine)Medicine can be successful up to 50%Side effects: nausea, dizziness, drowsiness
8. Urinary incontinence types and diagnosis in community – Specialist approach and advanced management5. Vaginal oestrogen (cream or pessary)Success rate approximately 50% for urge incontinenceMinor / local complicationsOnly suitable post menopauseContraindicated for breast cancer
9. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementSpecialist approach
10. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementTests and assessment UroflowUS urinary tract with post void residual volumeUrodynamic study (simple, video, ambulatory)Urethral pressure profilometryPad testFlexible / rigid cystoscopy +/- examination under aneasthesiaCystogram UrethrogramMRI pelvis
11. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementMedical treatementCombined medication: Anticolinergic + Beta-3 agonistCombined medical treatment with pelvic floor exercises and bladder trainingAny anatomical abnormality needs to be treated in advance in order to assessproperly the effect of behavioral therapy and medical treatment.Including treatment for :Urethral strictureVaginal prolapseCysto-vaginal fistulasBladder stonesPeriurethral cystsUrethral diverticula
12. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementPercutaneous posterior tibial nerve stimulation (PTNS)A procedure used to treat overactive bladder.Mild electric current is passed through a fine needle to stimulate a nerve in the leg which controls bladder function.Success rate: 53% good results - 31% fair resultsSide effects: gastrodynia and leg numbness for several hours, redness or inflammation around the needle insertion site
13. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementVaginal pessariesDevice made of latex or silicone and is inserted and left into the vagina to support the vaginal walls and pelvic organs.Used to ease the symptoms of moderate or severe prolapses.Vaginal pessaries come in different shapes and sizes. The most common is the ring pessary.Need to try a few different types and sizes to find the one that works best.It needs to be removed, cleaned and replaced regularly.Side effects of vaginal pessariesunpleasant smell of the vaginal discharge,some irritation and sores inside the vagina, and possibly bleedingstress incontinence urinary tract infectioninterference during intercourse
14. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementSurgical treatment for OABBotulinum toxin A (BOTOX) intravesical injectionsMinimally-invasive treatment - day-case procedurePerformed usually under local anaesthetic Success rate 80% report improvement Complications: Urinary infection (20%), difficulty passing urine with poor bladder emptying (10%) - requires clean intermittent self-catheterisationVery effective Local anaesthetic procedureRequires repeat injections every six months
15. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementSurgical treatment for OABSacral neuromodulationMinimally-invasive treatment that needs two separate proceduresUsually under general or spinal anaesthetic Success rate: 70% of patients report improvement Complications: Infection of the implanted stimulator (very rare)Requires two separate procedures usually within one month Patients unable to go in MRI scanner afterwards
16. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementSurgical treatment for OABAugmentation enterocystoplastyMajor operation with several days in hospital Success rate: 70% of patients report improvement Complications: 70% risk of needing CIC, mucus plugs in the urine and repeated infections Advantages: can be successful where other treatments have failed Disadvantages: Major surgery with significant long-term side-effects and a risk of CIC
17. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementSurgical treatment for OAB and stress urinary incontinenceIleal conduit urinary diversionMajor operation with several days in hospital Success rate: 100% resolution of incontinence Complications: Urine infections, poor kidney drainage and the need for a stoma (bag) Advantages: Last resort for severe, untreatable incontinence Disadvantages: Major surgery with a risk of complications, permanent stoma bag
18. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementSurgical treatment for stress incontinencePeriurethral bulking injectionsMinimally-invasive day-case procedureUsually performed under a general anaesthetic Success rate: 50 to 70% Complications: Incontinence may return; recurrence in 20% & slowing of your urinary flow in 10% Advantages: Can work well and avoids more invasive treatments Disadvantages: Less effective than other options, especially in the long term
19. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementSurgical treatment for stress incontinenceAutologous slingsOperation with an abdominal wound requiring a one to two-night stay in hospitalSuccess rate: 80-90% dry or significantly improved Complications: Urinary urgency (10%), difficulty passing urine (5-10%), damage to the urethra or bladder (5-10%), wound infection (5%) Advantages: Very effective; similar results to TVT and TOT but does not use synthetic mesh Disadvantages: Slightly more major procedure than TVT & TOT with an abdominal wound and longer hospital stay and recovery time
20. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementSurgical treatment for stress incontinenceColposuspensionOperation with an abdominal wound requiring a one to two-night stay in hospital Success rate 80-90% dry or significantly improved Complications: Vaginal prolapse (10-20%), urinary urgency (10%), minor damage to the bladder during surgery (5-10%), difficulty passing urine (20%), wound infection (5%) Advantages: Very effective; similar results to TVT and TOT but does not use synthetic mesh Disadvantages: Slightly more major procedure than TVT & TOT with an abdominal wound and longer hospital stay and recovery time
21. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementSurgical treatment for stress incontinenceArtificial urinary sphincter (AUS)Operation requiring one to two-night stay in hospital Success rate: More than 90% dry or significantly improved Complications: Device infection (2-10%), mechanical failure of the sphincter (2-10%), difficulty passing urine (5-10%) Advantages: May be successful where other treatments have failed Disadvantages: Need to squeeze a small pump, implanted into the labia every time you want to empty your bladder, a slightly more major procedure than TVT or TOT requiring longer hospital stay and recovery time
22. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementSurgical treatment for stress incontinenceSynthetic mid-urethral tapes (retropubic, transvaginal (TVT), transobturator (TOT)Minimally-invasive day-case procedure usually performed under a general anaesthetic Success rate: 80-90% dry or significantly improved Complications: Urinary urgency (10%), minor damage to the bladder during surgery (5-10%), migration of mesh into the vagina (2-5%), difficulty passing urine (2-5%), severe or long-standing pain (less than 1%), migration of mesh into the bladder, urethra or rectum (less than 2%) Advantages: Very effective; serious side-effects are uncommon Disadvantages: Although side-effects are uncommon, the synthetic mesh can cause major complications e.g. severe pain, mesh migration into the bladder, urethra or rectum, and vaginal erosion, which may require major surgical intervention
23. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementQuestions?
24. Urinary incontinence types and diagnosis in community – Specialist approach and advanced managementThank you