GuidelinesOther guideline
Urinary Incontinence
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Organising urodynamic studies (UDS)
Management of genuine stress incontinuence (GSI)
Kegel's exercises in treatment of GSI
Management of Detrusor Instability (DI)
Management of mixed incontinence (GSI and DI)
Urinary tract infection must always be excluded in the incontinent patient – some require Stix testing, others formal MC&S.
Types
- Genuine stress incontinence (GSI) – weakness of the bladder neck
- Overactive bladder, formerly Detrusor instability (DI) – overactivity of the bladder muscle
- ‘Mixed’ incontinence – a combination of GSI & DI
- Overflow incontinence – following over-distension of the bladder
- Continuous incontinence – resulting from fistula
Important questions
- Duration of the problem
- Severity of the problem – how incapacitating it is
- Frequency of micturition (>7 times per day. Ask if the patient passes once an hour or so)
- Nocturia (>2 times per night)
- Dysuria – pain on passing urine
- Stress incontinence - with coughing, laughing, sneezing or movement/ always, sometimes or occasionally
- Urgency – a feeling of an urgent need to pass urine, Urge incontinence – patient doesn’t quite make it in time
- Smoking & chronic cough
- Previous medical problems, including diabetes mellitus, & medication (including diuretics)
- Previous cervical or genital tract cancer, or radiotherapy (incontinence)
- Previous gynaecological or urological surgery
- Outcome & mode of delivery of pregnancies
If the only significant symptom on history is stress incontinence, it is very likely (90%) that the cause of incontinence is GSI.
Physical examination
- General examination, & chest & neurological examination
- Chronic chest problems & obesity are associated with GSI
- Neurological problems may be associated with overflow or DI – the anal wink, and bulbocavernosus reflex (stroke side of labia majora – equivalent to cremasteric reflex
- Abdominal and pelvic examination
- Look for evidence of fistula if the history is suggestive
- Pelvic mass or prolapse may be associated with GSI & DI
- Trigonitis (tenderness in the upper anterior vaginal wall) may mimic DI
- Loss of urine with coughing or straining is suggestive of GSI
Investigations
- Urine MC&S – essential as urinary tract infection mimics GSI & DI
- Urinary calendar – ask the patient to record on a piece of paper: leaking, frequency, urgency, nocturia for 7 days
- Urodynamic studies – when GSI or DI or overflow are considered….BUT: Urodynamics has become more controversial, prone to false negatives
- Intravenous pyelogram – when fistula is considered particularly post- operative, to assess possible ureteric damage/effect
Organizing urodynamic studies (UDS)
- Contact Johannesburg Hospital Urology at 011-4883383/6
- An appointment date & time will be given
- Arrange a follow-up visit at which patient will present her UDS report
Interpretation of UDS reports
- Read the summary provided with the print-out
- Check if the investigation is described as ‘adequate’ or not
- Bladder capacity should be at least 400 mL
- Ensure the emptying flow rate is adequate (no obstruction)
- Look for the true detrusor pressure (PDet) line (intravesical pressure with rectal pressure subtracted)
- Spikes on the detrusor pressure line (>2 mL water) are suggestive of DI
- GSI is indicated by leakage on provocation, without spikes
- Leakage with and without spikes suggests mixed GSI & DI
Management of genuine stress incontinuence (GSI)
- Weight reduction, & treatment of chronic cough & stopping smoking
- Teach pelvic floor (Kegel’s) exercises particularly in the younger patient, especially post-partum (see below)
- There is limited experience with alpha-agonists (phenylpropanolamine)
- Estrogen replacement is of no value in post-menopausal patients
- Surgery is definitive, & necessary in many cases, & for almost all older patients
Kegel’s exercises in treatment of GSI
- These are tightening contractions of the perineal muscles, as in trying to hold urine or faeces, or squeezing the vagina
- Squeeze for 3 seconds & release for 10; repeat 10 times. This is done 10 times per day
- Compliance is essential, ask patients about this at follow-up
- These exercises are most beneficial in younger patients with mild GSI
Operations for GSI
Surgery is the standard management for many patients
- All patients must be fully assessed by a consultant
- Patients must understand that surgery may:
- Not be successful
- Need to be repeated
- Result in voiding difficulties occasionally necessitating intermittent catheterization
- Worsen DI in cases of mixed GSI & DI
- Cause damage to the lower urinary tract
- Tape erosion may result
- Obturator tape (Out-In, or In-Out) is now the gold standard. The Tension-free vaginal Tape (TVT), first published in 1995 is an alternative. They are both described as mid urethral tapes. Burch colposuspension, once the ‘gold standard’, is now almost of historical interest only
- In the presence of prolapse, consider vaginal hysterectomy with Kennedy-Kelly plication, or preferably combined with a tape procedure if available
Management of Detrusor Instability (DI) – Overactive bladder
Bladder drill is the mainstay of treatment, with drugs in the majority. Surgery (e.g. Clam cystoplasty, phenol injection in the trigone) is almost never indicated.
Bladder drill
- The patient should sit by the toilet when she gets an urge to urinate, and wait
- Each time she records how long she can wait before urinating
- She also records the frequency of micturition
- If possible, urine volumes should also be measured
- All these events are noted on a piece of paper, with dates and times
- Explain this thoroughly and ask the patient to explain it back
- Urinary volumes should increase, and frequency should decrease
- Usually, the condition improves a little, then worsens, then improves significantly
- Compliance is essential for best results
Medication
The intention is to inhibit muscarinic receptors preferably M2 receptors, but anti-cholinergic side-effects include blurred vision, constipation, confusion
- Oxybutinin (Ditropan) is the standard: give 2.5 mg orally twice daily, up to 5 mg 4 times daily. Warn about anticholinergic side-effects, e.g. dry mouth, blurred vision, constipation. Alternatives are listed below
- Propantheline (Probanthine): give 15 mg orally 3 times daily. Warn about anticholinergic side-effects
- Tolteridone (Detrusitol): give 1-2 mg orally twice daily
- Imipramine (Tofranil): give 25 mg orally at night, mainly for nocturnal enuresis, urgency or frequency
Management of mixed incontinence (GSI AND DI)
- Treat the DI first & assess the response. If limited response, surgery for GSI, and continue drug treatment if overactive bladder symptoms persist
- Kegel’s exercises may be attempted in younger patients
- The bladder neck should not be hitched too high at surgery, as this may worsen DI. This is the advantage of tension free(OT & TVT) procedures as this is far less common