Female Incontinence

Patient Presentation

Patients usually present with the symptoms of leakage of urine that may be associated with urge (urge incontinence) or associated with situations like coughing, sneezing, effort and exertion (stress incontinence). Sometimes, both features may be present.

Prevalence and Impact of Female Incontinence

  • 12-22% of the population in Europe over the age of 40 (over 49 million people)
  • 16.5% in the USA (about 34 million people) suffer with OAB
  • 60% of patients seek help and 27% receive treatment
  • In 2000, the direct costs alone, in the USA, were about US $12.6 billion

Objectives of Management

  • Identify any serious conditions
  • Symptom Improvement and alleviate distress
  • Systematic approach to treatment in Primary care
  • Prompt referral to specialist when appropriate

Clinical Approach in Primary Care

History

A detailed history about the onset, duration, provoking factors, gynaecological and obstetric history

Symptom Assessment
  • Storage symptoms - Urgency, Frequency(daytime& night time) and incontinence
  • Voiding symptoms - Hesitancy, intermittency of stream, feeling of inadequate emptying and need to strain
  • Look for Red-flag symptoms - Haematuria, painful bladder, loss of weight and appetite
  • Clarify the type of incontinence

Bladder Diary: Very essential tool to objectively assess the symptoms and helpful to estimate the following parameters

  • Daytime and night time frequency
  • Volume of urine produced
  • Maximum and average bladder capacity
  • Quantify the beverage intake
Clinical Examination
  • Abdominal examination to feel any palpable bladder and Pelvic examination to assess for pelvic organ Prolapse and the strength of the pelvic floor.
Investigations
  • Urine Tests: helpful to rule out Haematuria, infection
  • Ultrasound scan: helpful to assess the bladder residuals and any other pelvic pathology
Red flag symptoms & signs

redflag

  • Haematuria
  • Palpable Bladder
  • Painful Bladder
  • Mass, suspected malignancy
  • Loss of weight or appetite

Any of these red-flags should trigger early referral to the urologist.

Differential Diagnosis
  • Over Active Bladder: This is a symptom complex that include the cardinal symptom of urgency with frequency and nocturia in the absence of any urethral or bladder pathology.

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  • Stress Incontinence: Typical leakage occurs during coughing, sneezing, effort and exertion. The patients tend to keep the bladder empty before embarking on the activities that is likely to cause leakage. The stress incontinence is caused by excessive movement of urethra (urethral hyper-mobility or urethral sphincter incontinence)

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  • Urinary Tract Infection:the symptoms will be of short duration and positive growth in culture and appropriate response to antibiotic treatment.
  • Painful Bladder: In this condition, the increased frequency is due to bladder pain during the full bladder. The patients visit the toilet frequently to alleviate the pain rather than the fear of leakage.
  • Polyuria: certain conditions liek diabetes could cause increased production of urine that may be causing the frequency.
  • Nocturnal Polyuria: Any condition that causes the swelling of legs like cardiac failure, renal failure may cause increased production of urine at night time due to the mobilisation of fluid from the legs into the circulation. Patients that suffer from sleep apnoea may also have over-production of urine at night time.

Conservative Treatment for Over Active Bladder

The non-pharmacological conservative treatment for incontinence can start from day 1 irrespective of type of incontinence.

Behavioural Approaches
  • Reduce or alter fluid intake : There is no short cut to cure if someone drinks excessive quantities of fluids and bladder stimulants. Tea, Coffee, Fiz etc.
  • Timed voiding : This is voiding by clock by pre-set achievable goals
  • Losing weight: is likely to improve both stress and urge incontinence
  • Smoking cessation
Bladder Retraining

Bladder retraining means to retrain the bladder to hold urine longer and longer to achieve an interval of at least three to four hours between the times of visiting the toilet.

After filling a bladder diary, patients will have a full idea of how frequently they are going to the toilet to urinate. From that interval, for example if they are going to the toilet every two hours, they need to increase the interval by one-half hour increments to achieve a maximum of three to four hours. This needs to be done in increments of one-half hour and once that goal is reached then move on to the next goal.

Pelvic floor Rehabilitation in women
Patients may be referred to a physiotherapist or an incontinence advisor to learn to do pelvic floor exercises. To do the pelvic floor muscle exercise properly, patients need to be taught to identify these muscles. These are the muscles that one would be contracting to stop breaking wind or stop urinating. They will need to contract those muscles in sets of 10 – 20, many times a day to achieve a total of 60 – 80 contractions per day. After mastering the ability to contract these muscles, at the voluntary control patients could contract the pelvic floor muscles before the situations of vulnerability like coughing, laughing and straining that could avoid the leakage. This is called KNACK manoeuvre.

Pharmacotherapy : Antimuscarinics

Antimuscarinics are the mainstay of drug treatment for women with over active bladder symptoms.

Choosing an Anti-muscarinic agent
The choice depends on ease of use, dose flexibility, efficacy and tolerability which varies from patient to patient. NICE guidelines (CG 40) on Incontinence in women recommends starting patients on short acting generic preparations of oxybutynin. It also recommends to counsel the patients about the side effects.
Available Antimuscarinics
  • Oxybutinin XL (Ditropan XL) 5-30 mg OD
  • Oxybutinin 2.5mg - 5mg TID
  • Oxybutinin Dermal – 3.9mg twice weekly
  • Trospium Chloride – 20mg bd – Half life 20 hours – Does not cross BBB
  • Tolterodine 1-2mg PO BID – Half life 10 hours
  • Fesoterodine 4mg, 8mg – Half life 8 hours
  • Solifenacin 5mg,10mg – Half life 50 hours
  • Darifenacin 7.5mg, 15mg – Half life 20 hours
Side Effects
  • Dryness of mouth and eyes: need to drink more fluids that could be counter-productive
  • Cardio-Vascular side effects
  • Gastrointestinal side effects – indigestion, constipation
  • Cognitive side effects : sedation and cognitive disturbances

Topical Oestrogen Treatment in Women

It is not clear, how the topical oestrogen help in incontinence. They are proven to improve urge incontinence. Risks: Though the systemic absorption is very small, patients should be informed about the uncertainty about the risks. This should be avoided in patients taking anti-oestrogen treatment for breast cancer.

How does it work?

The following mechanisms were postulated for the benefits from topical oestrogens.

  • Increased Urethral closing pressure
  • Raises sensory threshold in the bladder
  • Makes vaginal epithelium more Healthy & Defensive
  • Increases sensitivity and number of alpha receptors

Vildrup L et al, Current Med Res opin,19:485-490,2003

Specialist Management of Over Active Bladder in Secondary care

If patients do not get adequate benefit from conservative treatment or if there are any serious conditions or other curable urological conditions causing the symptoms, they will need referral to an urologist.

If the incontinence is accompanied by pelvic organ Prolapse, they will benefit from a referral to an urogynaecologist.

Specialist Assessment

Full conservative treatment: If patients have not received full counselling about life style changes and bladder retraining, they will go on to try these treatments under specialist’s care.

Diagnostic Cystoscopy : This may be necessary if there are any suspicion about bladder pathology.

Urodynamic Study: This test will be considered prior to any surgical intervention to assess the function of the bladder.

This involves passing a fine catheter into the bladder and another fine line through the anus into the lower part of the bowel. These fine lines will have electronic pressure sensors (transducers). When the bladder is filled with water, these fine lines will measure the pressures inside the bladder, as well as in the abdomen. During the bladder filling, any contraction of the bladder muscle (detrusor) if associated with symptoms of urgency, that will diagnose Detrusor Overactivity. It is also possible to demonstrate the stress leaks by making patients to cough and do valsalva manoeuvre, and the pressure in the abdomen at which the leakage occurs is measured. This test is a reliable way of differentiating different components of incontinence in women particularly when patients present with mixed symptoms. In men, Urodynamic study will be helpful to confirm or rule out Bladder outlet obstruction.

overactive_bladder

Surgical Treatment for Over Active Bladder (OAB)

Botox Injection into the Bladder:

Botox injection of the bladder is useful to treat overactive bladder (both idiopathic overactive bladder and overactive bladder secondary to other neurological diseases). Botox is a highly potent toxin known to man and is produced by a bacterium called Clostridium Botulinum. This is a very potent muscle relaxant and injecting this toxin in very minute quantities in the bladder muscle helps to relax to bladder muscle and increases the capacity to hold urine. When patients are diagnosed with bladder over activity, Botox injections do help and result a substantial improvement of their symptoms. The use of Botox for other conditions in cosmetic surgery and as well as in muscle spasms in the other parts of the body is well established. Botox works by blocking the nerve fibres in the muscle thereby preventing the muscle contractions in the part where the Botox is injected. Botox injection into the bladder is a fairly recent method of treatment and it has been in practice just over ten years. However when over activity of the bladder is treated with Botox injections the results are about 70-80% improvement in incontinence and reduction in the frequency. The improvement after the Botox injection lasts for about six months. After this the Botox effects do wear off and it is necessary to repeat the injections of Botox.

How is Botox injected into the bladder?

The Botox is a powder preparation which is reconstituted with by adding in fluid which is used as an injection. It is injected through a special needle which is passed down an instrument called a cystoscope. This can be done under either local anaesthetic or general anaesthetic. The entire procedure can take from 15 to 20 minutes.

borax

What are the long term effects of Botox?
Since the Botox treatment has been in practice for only the past ten years, it is difficult to predict the long term consequences of injecting Botox into the bladder. Therefore urologists are cautious about using this method of treatment for very young patients with a long life expectancy. Since Botox treatments need to be repeated on regular interval to achieve the ongoing control of the symptoms, it is a concern for urologists and patients alike with regard to long term effect on the bladder function. (HTML: Botox information sheet)

Sacral Neuro-Modulation

What is Sacral Neuro-modulation?
This is a special type of treatment which is useful to re-establish the normal bladder function. This is done by applying electrical stimulation to the nerves of the sacral spinal cord level that controls the bladder.
What conditions are treatable with Sacral Neuro-modulation?

Sacral Neuro-modulation is used to treat the following:

Non-obstructive urinary retention (female urinary retention). This is a condition where women find it impossible to pass urine due to blockage at the level of the urethra without any obvious blockage.

Overactive bladder with the typical symptoms of urgency and frequency with a bit of urge incontinence.

What is involved in this treatment?
The Sacral Neuro-modulation is done by a device called Intestim which generates a pulse. This is done in two phases. In the first phase, which is called test phase, a temporary electrode is inserted into the sacral spine touching the S2/S3 nerves. Then the electrodes are connected to a temporary nerve stimulator device. Patients will be assessed for a few weeks with this device to see if this enables them to better control their bladder or improves their urinary retention. If the temporary device is effective, then they would move onto the second phase of implanting the permanent device which would be implanted in the buttocks and connected to the electrodes. Recently the electrodes which are used for the test phase are permanent electrodes though they are connected to the temporary device. This avoids the insertion of the second electrode into the spinal canal.
How effective is this treatment?
This treatment is effective in the range of 70-80% of those treated for retention. More than 70% of the patients can be rendered catheter free or they can be made free of having to use self catheterisation. With regard to overactive bladder symptoms, the success rates are about 70%. This treatment is uniquely different from Botox or other treatment because this neural modulation treatment helps to re-establish the bladder function. This is an appropriate treatment method for a group of patients who respond favourably to the test phase treatment.

Posterior Tibial Nerve Stimulation

Posterior tibial nerve stimulation is a non-invasive method of achieving better bladder control. The nerve endings in the leg are stimulated by using the nerve stimulator which is a small gadget attached to very tiny needle electrodes that are inserted in the skin of the lower leg and in the hind foot. Stimulating the sensitive nerves in this area does give better control of the bladder by its action at the spinal root level. After placing the needle electrode through two pads which are applied just above the ankle and near the hind foot which is connected to the small gadget device (called a pulse generator), the entire treatment takes about 30 minutes. This treatment is repeated on a weekly basis for twelve weeks. PTNS does not have any significant side effects. It is a fairly less risky procedure. The minor side effects are irritation from the pads or from the needles. This may include minor skin irritation. There are a few studies which effectiveness of this treatment. Overall the results are broadly similar with 70-80% of patients showing some improvement in their overactive bladder symptoms.

Bladder Augmentation

This is offered for patients with extreme symptoms of overactive bladder with diminished bladder capacity. This involves taking a piece of small bowel and put it as a patch to increase the capacity of the bladder. This involves a major operation and the after effects may include the need to use self catheterisation and problems with mucous secretion from the bowel segment. Over the long term there is slightly increased risk of malignancy and therefore regular surveillance cystoscopy is necessary.

Surgical Treatment - Stress Incontinence

  • Colposuspension: In patients who are not suitable for vaginal tapes, this operation is a treatment of choice. This was the standard treatment for the surgical cure of stress urinary incontinence prior to the advent of vaginal tapes. This involves lifting the anterior wall of the vagina and fixing it behind the pubis that in turn support the urethra from hyper-mobility. This is done by an open operation or by laparosocopy.
  • Periurethral Injection of Bulking agents: This is the treatment of choice in patients who have stress urinary incontinence without urethral hyper-mobility or patients who do not wish to have Urethral slings. In patients with urethral hyper-mobility, the success rates from this procedure are only about 30-40%. Usually surgeons prefer this if patients had previous pelvic radio-therapy or multiple surgery.

Various bulking agents are available. They are injected at mid urethral level outside the urethra to achieve urethral compression and closure (co-optation) of the urethra.

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Role of Primary Care Professionals

Start Conservative Treatment from Day 1 after ruling out

  • Red flag signs and other correctable conditions

Secondary Care referral at appropriate stage

  • Any Red flag signs or other urological conditions – Urologist
  • Urge & Stress Incontinence – Urologist or Uro-gynaecologist
  • Associated pelvic Organ prolapse – Uro-gynaecologist

Periodic Follow up - Every 6 to 8 weeks

  • To Motivate
  • To change the drug treatment as necessary
  • Expedite Secondary Care Treatment

Proactive planning for

  • Treatment escalation
  • Onward referral to Urologist or Urogynaecologist as appropriate

Your role as Primary Healthcare Professionals is crucial in the management of Female Incontinence