A Review and Case Study of Urinary Incontinence

Section 1: Epidemiology and aetiology
Section ii: Making the diagnosis
Section 3: Managing the condition
Section four: Prognosis
Section 5: Case report
Section six: Testify base

Department one: Epidemiology and aetiology

Urinary incontinence (UI) is a symptom-based condition described every bit the 'complaint of involuntary loss of urine' as set out by the International Continence Society and the International Urogynecological Association. This commodity focuses on UI in women.

The number of patients experiencing UI is likely to exist under-reported and varies with sex, age grouping, parity and medication (meet box).

Associated drugs
Antipsychotics Antidepressants Alpha-adrenergic agonists Calcium-channel blockers Blastoff-antagonists Diuretics Sedative-hypnotics Medication for Parkinson's disease

UI is more mutual in women, with a prevalence of 17-40% in the Great britain.^1,2 UI is more than common in the elderly population and tin can take a significant impact on the psychological and social wellbeing of the person.³ Its aetiology is usually multifactorial and can include transient causes (see box).

Transient causes⁴
Delirium Infection Atrophic vaginitis Pharmaceutical agents Psychological disorders Backlog of urine output Restricted mobility Stool impaction

Classification

Stress UI: involuntary loss of urine occurs on effort or concrete exertion, related to an increase in intra-abdominal force per unit area. It tin can be associated with bladder-neck weakness, obesity, poor pelvic flooring muscle strength or nerve impairment
Urgency UI or overactive float (OAB): involuntary loss of urine occurs in association with urgency. This is typically caused by overactivity of the detrusor muscle and may be secondary to lesions affecting the motor or sensory pathways to the muscle. Causes include MS, neurological injury, diabetes, stroke, Alzheimer'south disease, Parkinson'sdisease and idiopathic causes
Mixed UI: a combination of stress UI and urgency UI.
Overflow incontinence: this can occur with float detrusor atony or float outlet obstruction secondary to a prolapsed uterus, previous surgery or incontinence process.
Functional incontinence: this occurs when the patient has difficulty reaching the toilet in fourth dimension, such as with restricted mobility or altered mental chapters.
Nocturnal enuresis: involuntary loss of urine occurs during slumber and is more common in children. Information technology can be due to a delay in evolution of bladder control, merely can also exist due to inadequate toilet training, urinary infections or emotional distress. There is a stiff genetic clan.
Continuous UI: an involuntary continuous loss of urine. This can be due to a fistula or distorted anatomy.

Several newer classifications have also been devised:

Postural UI: an involuntary loss of urine that occurs in association with a alter in body position.
Insensible UI: the patient is unaware of the occurrence and origin of the loss of urine.
Coital incontinence: an involuntary loss of urine with coitus that tin occur during penetration or with orgasm.

Important! UI is more mutual in women, with a prevalence of 17-forty% in the UK.

Section ii: Making the diagnosis

On average, a adult female will have experienced UI for 6 to ix years before seeking medical help.⁵ Diagnosis of UI is based on history, basic investigations and examination. Guidelines issued by Prissy highlight the importance of a adept history, including bladder diaries and routine digital pelvic floor cess, as well as beingness guided by the patient's symptoms and the effect on their quality of life.⁶

The emphasis is on treating the predominant symptom and the vast majority of patients will fall into iii categories; stress incontinence, urgency incontinence or mixed incontinence.

History

The points to elicit are the master urinary symptoms affecting the patient. This volition include UI associated with an increase in abdominal pressure (coughing, sneezing, physical action), or incontinence with urgency, frequency and nocturia.

The duration of symptoms and the touch on on the patient'due south quality of life and wellbeing should also exist recorded. Enquiries should as well be made regarding intake of caffeinated drinks, crimson vino and acidic or spicy nutrient.

If an acute onset of UI has occurred, a review of any new medications and a total neurological examination should be performed. Restricted mobility, cerebral harm and depression should also exist excluded equally causes for UI.

If symptoms of pain, poor urinary stream or hesitancy are present, a referral for specialist urogynaecology review should exist considered.

Examination

According to the NICE guideline,^{half dozen} in women with UI or OAB, a urine dipstick cess should exist performed to exclude a UTI and a specimen sent for microscopy and culture (MSSU) if aberrant.

The guidance suggests, in patients symptomatic of a UTI with a positive dipstick for leucocytes and/or nitrites, antibiotics may be commenced while waiting for the MSSU result. If the dipstick is negative, consideration may be given for antibiotics while awaiting the MSSU results.

In those asymptomatic of a UTI with a positive dipstick, the MSSU outcome should be awaited earlier starting antibiotics.⁶

If possible, it is optimal to examine the patient with a comfortably full bladder. This may aid confirmation of leakage of urine with a cough test during test. It is important to exclude whatever large pelvic or abdominal masses on abdominal exam.

Speculum and bimanual exam will be used to assess for atrophic vaginitis, prolapse and pelvic flooring musculus wrinkle using the Oxford calibration (1-5/v). Should a pelvic mass be found, a 2-week referral should exist organised. Ultrasound will exist needed but should not delay the referral.

A float diary should be completed for duration of at least three days, including a normal working day and a normal resting twenty-four hour period. This will allow a proficient assessment of functional bladder chapters.

Of import! In women with UI/OAB perform a urine dipstick assessment to exclude UTI.

When to refer

Urgent referral should exist considered (possibly via a fast-track pathway) in the following situations:

Microscopic haematuria in the absence of a UTI
Macroscopic haematuria
Pelvic pain
Pelvic or vaginal mass
Complex neurological symptoms
Women >40 years old with haematuria and recurrent UTIs

Routine referral should be considered in the post-obit cases:

History of previous pelvic surgery or radiations therapy
Suspected urogenital fistulae
Severe prolapse (grade 3 utero-vaginal prolapse)
Patients refractory to conservative handling
Sensory symptoms consistent with a change in normal sensation or function during float filling
Voiding and post-micturition symptoms such as hesitancy, ho-hum stream, intermittency, straining to void, spraying of urinary stream, feeling of incomplete float emptying, double voiding, mail service-micturition leakage, urinary memory and position-dependent micturition

Section three: Managing the condition

Management should involve the GP, community continence adviser, specialist physiotherapist and/or specialist nurse.

Sacral nerve stimulation tin can better symptoms (Photo: Zephyr/SPL)

Fluid intake should be approximately 1.5-2 litres per 24-hour interval.^half-dozen Weight reduction is appropriate for patients who have a BMI greater than 30.

Educational leaflets on pelvic floor muscle training (PFMT) should exist provided and supervised programmes should comprise at to the lowest degree viii contractions performed three times per day. Supervised PFMT should be undertaken for at to the lowest degree three months for women with stress or mixed UI.

Caffeinated beverages should exist restricted or stopped as caffeine is an irritant to the detrusor muscle, besides as a diuretic. In urgency or mixed UI, bladder retraining for a minimum of half dozen weeks and avoidance of drink four hours before slumber will help towards managing OAB symptoms.⁶

Management of other exacerbating conditions such as constipation and smoking abeyance (aiming to reduce cough) will besides help. In certain cases and in those with cognitive harm, timed voiding can be employed to reduce the number of episodes of UI.⁶

Important! Fluid intake should be 1.v-ii litres per day.

Stress incontinence

In cases with stress UI symptoms, where women can non contract their pelvic floor or standard PFMT has not given a satisfactory upshot, options to maximise pelvic floor contractility are:

Biofeedback PFMT: a device is used to convert the pelvic floor contraction into an auditory or visual response, thereby allowing objective observation of improvement
Electrical stimulation
Weighted vaginal cones

These therapies are mostly undertaken with the supervision of the community continence adviser, specialist nurse or physiotherapist.

Predominantly OAB

When bourgeois measures for OAB are unsuccessful, the next step is pharmacological handling. Whatsoever co-existing medical conditions should be reviewed, along with the concurrent use of other medications that could potentially touch on the full antimuscarinic load, and the chance of adverse effects considered.

Antimuscarinics are commonly used, with similar side-effects reported and variable tolerability between patients. Before commencing medication, the likelihood of success and associated side-effects should exist discussed. The patient should too be fabricated aware that some side-effects may indicate the treatment is starting to take effect, and that they may non see the full benefit until four weeks of medication.

Ii different antimuscarinics should be tried before referral to secondary care.

According to the NICE guideline, showtime-line drugs are oxybutynin (immediate-release), tolterodine (immediate-release) or darifenacin, and should be commenced at the lowest recommended dose.⁶ Oxybutynin immediate-release should not exist offered to frail older women.

Four weeks later commencing a new drug, a telephone or confront-to-face review should be offered to assess patient satisfaction, effectiveness and tolerability, the demand for a dosage increase if suboptimal result, or the need for a change to a 2d antimuscarinic if intolerable side-effects or no effect.

The patient should exist reviewed again after a farther four weeks. Choice of a second antimuscarinic should exist based on the everyman acquisition toll and transdermal medication should be offered if women are unable to tolerate oral medication.

Mirabegron, a beta-iii agonist, has a different safety contour and potential side-effects. It can be used when antimuscarinics are either contraindicated, have failed to reach satisfactory symptom relief or intolerable side-effects are reported. It is contraindicated in patients with severe hypertension and blood pressure should be monitored before and during handling.

Yearly review should be undertaken in patients on continued long term pharmacological treatment or six monthly in patients over 75. Encounter box below for a summary of common pharmacological treatments used.

With mixed UI, management should aim to treat the predominant symptoms. In cases where stress UI is the predominant symptom, benefits of conservative management including the utilize of OAB drugs should be discussed prior to offering surgery.

Secondary intendance

Patients should be referred if conservative measures have failed. Urodynamic studies (UDS) may aid management but should non exist undertaken prior to commencing conservative measures. UDS may non be required in patients who have pure stress UI based on history and exam, but the vast majority will have UDS performed prior to surgery. UDS should be undertaken in patients with OAB, symptoms suggestive of voiding dysfunction or patients who have had previous surgery for stress UI.

For cases of stress UI where conservative measures have failed, patients should exist offered synthetic mid-urethral slings (MUS), autologous rectus fascial slings or open colposuspension, and the risks and benefits of each choice should be discussed.The majority of procedures currently performed are synthetic MUS due to the lower complication rates in comparison to colposuspension.

Intramural bulking agents can also exist considered but patients should exist made aware that the effectiveness is greatly reduced compared to synthetic or autologous rectus fascial MUS, repeated injections may be required and efficacy diminishes with fourth dimension.

In cases where the patient is unfit to undergo surgery or would prefer a not-surgical treatment for stress UI, an alternative is duloxetine. This has a high risk of adverse effects and is therefore not mostly tolerated or prescribed.

For OAB, referral to secondary care should exist offered when the response to ii anticholinergics or mirabegron has not been satisfactory, or the patient wishes to discuss further options.

UDS should be performed to confirm detrusor overactivity is present and responsible for her OAB symptoms. Invasive treatment with intravesical injection of botulinum toxin A should then be offered.

Patients should be advised regards the likelihood of symptom reduction or resolution, the risk of adverse effects (e.g. potential need for clean cocky-catheterisation and increased risk of urinary tract infections), the paucity of show on long-term risks and the likelihood that repeated injections will be required.

Patients should be willing, trained and able to self-catheterise in order to accept the process. They should also be fabricated aware that this treatment does non currently have regulatory approval for idiopathic OAB.

An alternative for patients unresponsive to medical treatment, unwilling to attempt botulinum toxin A, or unable to self-catheterise is percutaneous sacral nerve stimulation.

This requires a multidisciplinary squad review (MDT) and discussion with the patient regarding the long-term implications, including probability of success (55-65% symptom improvement and improvements in bladder capacity), risk of failure and adverse effects, potential need for surgical revision and the long-term commitment required.Availability of this treatment is limited as at that place are few centres in the UK that offer it.

Transcutaneous sacral nerve stimulation and posterior tibial nervus stimulation are not currently offered due to limited bear witness. Percutaneous posterior tibial nerve stimulation should not exist offered unless there has been a MDT review, conservative measures have non been successful, and the patient does not want botulinum toxin A or percutaneous sacral nerve stimulation.

Uncommon procedures for astringent OAB refractory to medication and neuromodulation are augmentation cystoplasty or ureteric diversion and defunctioning of the bladder.

Important! Patients should be referred if bourgeois measures have failed.

Section 4: Prognosis

Prognosis depends on crusade, patient expectations and desired outcome. Multiple outcomes are used to allocate success – subjective, such as patient perception of improvement; or objective, such as urodynamic confirmation of resolution.

Stress UI

PFMT alone can better symptoms of stress incontinence by 56-75%, but appears to be less constructive in the long term and is dependent on compliance.⁷

Transurethral bulking agents can provide brusk-term improvement of 70-81%.^eight They tin be inserted under local anaesthetic, accept few complications and are a suitable alternative for patients medically unfit for more than complex surgery.

Burch colposuspension is known to have 53-94% continence rate during the showtime yr and 70-86% in the long-term,⁹ and is still considered start line for surgical treatment of stress incontinence. Withal, MUS has a comparable improvement in symptoms of 85-96% and has overtaken colposuspension due to lower morbidity and shorter hospital stays.¹⁰

Single-incision mini-slings take come into use, only brusk term efficacy is reduced compared to standard MUS and long term data is awaited.^xi

The effect of surgical treatment for stress incontinence on OAB symptoms is conflicting. Studies have shown a subtract in prevalence of OAB symptoms postoperatively, just likewise a persistence of symptoms in more than 1 third of patients. Development of de novo OAB symptoms appears to be low.^12,13

OAB

PFMT can meliorate OAB symptoms past up to 55%.^xiv Antimuscarinics have long-term symptom improvement of 60-70%,¹⁵ merely side-effects are common and can impact compliance. Intravesical botulinum toxin A has 66-96% symptom comeback,¹⁶ but injections need to be repeated as the outcome is reversible. Urinary retention secondary to detrusor hypotonia can also occur necessitating intermittent cocky-catheterisation until the effect wears off.

Neuromodulation techniques, such as sacral nerve stimulation, have shown curt to medium term symptom comeback of 65-70%.^17-xix OAB is generally a lifelong condition, but symptoms can exist controlled with a combination of lifestyle changes, medication and/or neuromodulation.

Sextion v: Case written report

A 45-twelvemonth-old woman presented with a five-year history of stress incontinence. Her symptoms had worsened recently, specially with coughing, sneezing and lifting. She experienced up to two episodes of incontinence per day and required the use of sanitary pads. The patient reported occasional coital incontinence that restricted the frequency of coitus.

Symptoms of urgency and frequency up to eight times per solar day were likewise reported.

The patient had a history of ii vaginal deliveries (forceps) and no other significant medical problems or current medications. She had a BMI of 35 and smoked x cigarettes per day.

Exam by her GP revealed a negative urine dipstick examination and first-caste uterine descent with a moderate inductive vaginal wall prolapse. Coughing test was negative, and a pelvic floor tone of 2/five in the Oxford scale.

After initial management involving lifestyle advice and referral to the continence adviser for PFMT and bladder retraining, the patient reported comeback of her stress incontinence symptoms and reduction in incontinent episodes to twice per week.

She withal required the daily use of pads and had become more than enlightened of urgency, despite completely abnegation from caffeinated beverages. An initial trial of oxybutynin immediate release (2.5mg twice a twenty-four hour period) was abandoned after two months due to intolerable side-furnishings of dry mouth and constipation.

A second-generation antimuscarinic was prescribed in combination with a laxative, giving a satisfactory reduction in frequency with tolerable side-effects. The patient continued to have small volume episodes of incontinence twice per week but felt this was manageable. She had managed to reduce her BMI to 33 but continued to smoke.

Twelve months afterward initial referral, the patient reported the urgency to be well controlled, but the stress incontinence had worsened.

Urogynaecology clinic

The patient was reviewed and referred for urodynamic assessment of the bladder. This confirmed both stress incontinence and detrusor overactivity. A day-example retropubic MUS procedure was accepted by the patient for further direction of her stress incontinence.

At the six-week postoperative review by the GP, the patient was very happy with the results. She connected on her antimuscarinic for handling of her OAB symptoms.

Section half-dozen: Evidence base

Clinical trials

Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev 2009 Oct 7; (4): CD006375. This supported the proffer that MUSs were as effective as traditional methods in the brusque term, with fewer complications.
Novara G, Artibani West, Barber MD et al. Updated systematic review and meta-assay of the comparative data on colposuspensions, pubovaginal slings and midurethral tapes in the surgical treatment of female stress urinary incontinence. Eur Urol 2010; 58(2): 218-38.
Anger JT, Weinburg A, Suttorp MJ et al. Outcomes of intravesical botulinum toxin for idiopathic overactive float symptoms: a systematic review of the literature. J Urol 2010; 183(6): 2258-64. This showed an improvement in idiopathic OAB refractory to medication, only a meaning increase in post-void residuals and urinary memory.

Guidelines

NICE. Clinical guidelines. Urinary incontinence in women (CG171). Publication date September 2013.

Online

NHS Choices. Urinary incontinence

This commodity was reviewed and updated past Dr Julian Spinks a GP in Kent. The original article was start published in May 2014 and the authors are:

Dr Alvaro Bedoya-Ronga, ST7, John Radcliffe Hospital, Oxford, UK
Miss Wing Han Cheung, Locum consultant, John Radcliffe Infirmary, Oxford, UK
Mr Ian Currie, Consultant in obstetrics and gynaecology, Stoke Mandeville Hospital, Buckinghamshire, United kingdom

Take a test on this article and claim your document on MIMS Learning

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