December 2017 Taken from NICE guidance 2015 Amy Micklethwaite GP Linthorpe surgery Learning Objectives T o have an approach to a patient presenting with urge incontinence in ID: 1040717
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1. Urinary Incontinence in WomenDecember 2017Taken from NICE guidance 2015Amy MicklethwaiteGP Linthorpe surgery
2. Learning ObjectivesTo have an approach to a patient presenting with urge incontinence in line with nice guidanceTo have an approach to a patient presenting with stress incontinence in line with nice guidanceTo have an approach to a patient presenting with mixed incontinence in line with nice guidanceTo know the 2 week rule criteria for referral in this presenting populationTo have an idea of what is likely to happen once a patient has been referred, in order to give the patient further information.
3. Plan for the sessionBoring slide bit- the NICE guidanceBreak into groups- approach to a patient presenting with incontinenceBack together to discuss thisCOFFEE aimed 3.10-3.30Cases & quizzes in groupsBack together to present our viewsFeedback Home 16.30
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5. Incontinence- involuntary leakage of urineTypes of incontinence
6. Bladder diaries3 daysSpecialist referralUrine testingDipstick & C&SSymptom scoring & QoL assessmentOAB/UUI only offer:Lifestyle adviceBladder trainingMixed incont:Lifestyle adviceBladder trainingPelvic floor muscle trainingSUI only offer:Lifestyle advicePelvic floor trainingOAB drug treatmentSecondary care incl urodynamic testingHistory & Examination
7. Specialist referral: 2 week ruleRenal tract Cancer>45yrs with frank haematuria without UTI>45yrs with frank haematuria which recurs after UTI treatment.>60yrs with microscopic haematuria AND EITHER dysuria or raised WBC.(Routine referral for >60yrs with recurrent UTIs)Ovarian cancerAscitesPelvic/abdominal massCheck urgent Ca125 (USS) especially if >50yrs if frequent/persistant:BloatingEarly satiety/loss of appetitePelvic/abdominal painIncreased urinary urge/frequencyNew IBSConsider if:Unexplained weight lossFatigueBowel changes
8. Specialist ReferralSymptomatic pelvic organ prolapse that is visible at or below the introitus. A palpable bladderPersistent bladder or urethral pain (refer urgently if cancer is suspected). A pelvic mass that is clinically benign, such as uterine fibroids. Associated faecal incontinence. Suspected or known neurological disease. A history of previous prolapse surgery, incontinence surgery, pelvic cancer surgery, or previous radiation therapy. Recurrent urinary tract infection. Microscopic (non-visible) haematuria in a woman who is <60 not fulfilling the 2wk rule. Refer to a renal physician if there is also proteinuria or raised serum creatinine levels. Refer non-urgently to a urologist if there is no proteinuria and serum creatinine level is normal. Suspected or known acute kidney injury (AKI) — refer to a nephrologist, urgent or same day referral may be required.
9. Bladder diaries3 daysSpecialist referralUrine testingDipstick & C&SSymptom scoring & QoL assessmentOAB/UUI only offer:Lifestyle adviceBladder trainingMixed incont:Lifestyle adviceBladder trainingPelvic floor muscle trainingSUI only offer:Lifestyle advicePelvic floor trainingOAB drug treatmentSecondary care incl urodynamic testingHistory & Examination
10. Bladder diaries3 daysSpecialist referralUrine testingDipstick & C&SSymptom scoring & QoL assessmentOAB/UUI only offer:Lifestyle adviceBladder trainingMixed incont:Lifestyle adviceBladder trainingPelvic floor muscle trainingSUI only offer:Lifestyle advicePelvic floor trainingOAB drug treatmentSecondary care incl urodynamic testingHistory & Examination
11. Bladder diaries3 daysSpecialist referralUrine testingDipstick & C&SSymptom scoring & QoL assessmentOAB/UUI only offer:Lifestyle adviceBladder trainingMixed incont:Lifestyle adviceBladder trainingPelvic floor muscle trainingSUI only offer:Lifestyle advicePelvic floor trainingOAB drug treatmentSecondary care incl urodynamic testingHistory & Examination
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13. Lifestyle advice Reversible causes or contributing factorsBladder training Minimum 6 weeks. Refer to incontinence service.OAB/UUI only offer:Lifestyle adviceBladder training
14. Condition Mechanism of effect Lower urinary tractUrinary tract infection May cause inflammation with activation of sensory afferent innervation. Obstruction May contribute to detrusor overactivity and urinary retention. Impaired bladder contractility Reduced functional bladder capacity and urinary retention can result. Bladder abnormalities causing inflammation (for example tumours, calculi, interstitial cystitis) May precipitate detrusor overactivity. Oestrogen deficiency Atrophic vaginitis and urethritis may contribute to symptoms. Sphincter weakness Leakage of urine into the proximal urethra may precipitate urgency. Ability to inhibit detrusor muscle by sphincter contraction may be diminished. Neurological Brain: stroke, dementia (including Alzheimer's disease), Parkinson's disease, multiple sclerosis Higher cortical inhibition of the bladder is impaired, causing detrusor overactivity of neurogenic origin. Spinal cord: multiple sclerosis, cervical or lumbar stenosis or disc herniation, spinal cord injury Neurogenic detrusor overactivity or urinary retention can result. Peripheral innervation: diabetic neuropathy, nerve injury Urinary retention and low functional bladder capacity can result. Systemic Congestive heart failure, venous insufficiency with oedema Volume overload can contribute to urinary frequency and nocturia when the person is lying down. Diabetes mellitus Poor blood glucose control can contribute to osmotic diuresis and polyuria. Hypercalcaemia Polyuria may result. Functional and behavioural disorders Excess intake of caffeine, alcohol, or fluids Polyuria and urinary frequency can result. Constipation Faecal impaction can contribute to symptoms. Impaired mobility or dexterity (for example joint disease or muscle weakness) Interferes with toileting ability and may precipitate urgency incontinence. Psychological conditions Chronic anxiety and learned voiding dysfunction can cause symptoms of overactive bladder.
15. Lifestyle adviceReducing caffeine intake — improve urgency and frequencyFluid intake — avoid drinking excessive amounts or reduced amounts The recommended daily intake is six to eight glasses of water. Avoiding alcohol, citrus drinks, fizzy drinks.Weight loss - if BMI >30 kg/m2Smoking if appropriate —chronic cough may contribute to stress urinary incontinence
16. Bladder diaries3 daysSpecialist referralUrine testingDipstick & C&SSymptom scoring & QoL assessmentOAB/UUI only offer:Lifestyle adviceBladder trainingMixed incont:Lifestyle adviceBladder trainingPelvic floor muscle trainingSUI only offer:Lifestyle advicePelvic floor trainingOAB drug treatmentSecondary care incl urodynamic testingHistory & Examination
17. OAB drug treatmentAnticholinergic (antimuscarinic) Oxybutynin (immediate release) Tolterodine (immediate release) Darifenacin (once daily preparation) can be used first-line.transdermal oxybutynin for women who are unable to take oral medicationDO NOT offer immediate release oxybutynin to frail older women due to the risk of impairment of daily functioning and delirium MirabegronAdd in topical vaginal oestrogen if atrophy presentConsider adding desmopressin if troublesome nocturia
18. OAB drug treatment continued…Counsel patientsTakes time to workSide effects- anticholinergic load, dry mouth, constipation, retention if poor bladder emptyingMay need to increase doseCan stay on longtermReview at 4weeks:If okay review at 12 weeks then annually (or 6m or elderlyIf not helping, try alternative antimuscarinic, consider mirabegron or referral
19. Bladder diaries3 daysSpecialist referralUrine testingDipstick & C&SSymptom scoring & QoL assessmentOAB/UUI only offer:Lifestyle adviceBladder trainingMixed incont:Lifestyle adviceBladder trainingPelvic floor muscle trainingSUI only offer:Lifestyle advicePelvic floor trainingOAB drug treatmentSecondary care incl urodynamic testingHistory & Examination
20. Secondary care incl urodynamic testingIf conservative treatments fail or if the woman wants further management, consider referring to urology/gynae for: Intermittant self catheterisationBotulinum toxin APercutaneous sacral nerve stimulationPercutaneous posterior tibial nerve stimulation if the woman does not want botulinum toxin A or sacral nerve stimulationAugmentation cystoplastyUrinary diversion
21. Bladder diaries3 daysSpecialist referralUrine testingDipstick & C&SSymptom scoring & QoL assessmentOAB/UUI only offer:Lifestyle adviceBladder trainingMixed incont:Lifestyle adviceBladder trainingPelvic floor muscle trainingSUI only offer:Lifestyle advicePelvic floor trainingOAB drug treatmentSecondary care incl urodynamic testingHistory & Examination
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23. SUI only offer:● Lifestyle advice● Pelvic floor training1. Lifestyle adviceCaffeineFluid intakeWeight loss Smoking if this is appropriate — eg chronic cough which may contribute to stress urinary incontinenceGive advice on reversible causes or contributing factors- as before
24. Lifestyle advice- self help infoNHS Choices provides online information for people with urinary incontinence. The Bladder and Bowel Foundation has a helpline (telephone 01536 533 255) and provides a range of resources on their website (www.bladderandbowelfoundation.org).
25. 2. Pelvic floor training Offer referral for a programme of supervised pelvic floor muscle training (PFMT) – continence nurses locallyShould last at least 3 months>8 pelvic floor muscle contractions >3x/day. Patient info at www.csp.org.uk (pdf)Pads & toileting aids should only be offered whilst awaiting treatment, if all treatment failed or severe cognitive or mobility impairment.
26. Bladder diaries3 daysSpecialist referralUrine testingDipstick & C&SSymptom scoring & QoL assessmentOAB/UUI only offer:Lifestyle adviceBladder trainingMixed incont:Lifestyle adviceBladder trainingPelvic floor muscle trainingSUI only offer:Lifestyle advicePelvic floor trainingOAB drug treatmentSecondary care incl urodynamic testingHistory & Examination
27. Secondary careIf conservative treatments fail or if the woman wants further management, consider: Referring to gynae/urology Treatment options in secondary care include synthetic mid-urethral tape, colposuspension, autologous rectus fascial sling, intramural urethral bulking agents, or an artificial urinary sphincter.Offer duloxetine as a second-line treatment, but only if the woman prefers drug to surgical treatment or is not suitable for surgical treatment.
28. Referenceshttp://cks.nice.org.uk/incontinence-urinary-in-women
29. Condition Mechanism of effect Lower urinary tractUrinary tract infection May cause inflammation with activation of sensory afferent innervation. Obstruction May contribute to detrusor overactivity and urinary retention. Impaired bladder contractility Reduced functional bladder capacity and urinary retention can result. Bladder abnormalities causing inflammation (for example tumours, calculi, interstitial cystitis) May precipitate detrusor overactivity. Oestrogen deficiency Atrophic vaginitis and urethritis may contribute to symptoms. Sphincter weakness Leakage of urine into the proximal urethra may precipitate urgency. Ability to inhibit detrusor muscle by sphincter contraction may be diminished. Neurological Brain: stroke, dementia (including Alzheimer's disease), Parkinson's disease, multiple sclerosis Higher cortical inhibition of the bladder is impaired, causing detrusor overactivity of neurogenic origin. Spinal cord: multiple sclerosis, cervical or lumbar stenosis or disc herniation, spinal cord injury Neurogenic detrusor overactivity or urinary retention can result. Peripheral innervation: diabetic neuropathy, nerve injury Urinary retention and low functional bladder capacity can result. Systemic Congestive heart failure, venous insufficiency with oedema Volume overload can contribute to urinary frequency and nocturia when the person is lying down. Diabetes mellitus Poor blood glucose control can contribute to osmotic diuresis and polyuria. Hypercalcaemia Polyuria may result. Functional and behavioural disorders Excess intake of caffeine, alcohol, or fluids Polyuria and urinary frequency can result. Constipation Faecal impaction can contribute to symptoms. Impaired mobility or dexterity (for example joint disease or muscle weakness) Interferes with toileting ability and may precipitate urgency incontinence. Psychological conditions Chronic anxiety and learned voiding dysfunction can cause symptoms of overactive bladder. Into pairs- Approach to a patient presenting with incontinence