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Female Urinary Incontinence I have nothing to disclose. Molly - - PowerPoint PPT Presentation

Apr 10, 2024 134 likes •275 views

6/24/2015 Disclosures Female Urinary Incontinence I have nothing to disclose. Molly Heublein, MD Assistant Professor Clinical Medicine UCSF Womens Health Primary Care Objectives Which is most true? Review the problem A. I have

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6/24/2015 1

  • Female Urinary

Incontinence

Molly Heublein, MD Assistant Professor Clinical Medicine UCSF Women’s Health Primary Care

Disclosures

I have nothing to disclose.

Objectives

Review the problem Feel confident with office diagnosis of urge

versus stress incontinence

Feel confident with first line treatments Be aware of new developments/options for

referral

Which is most true?

  • A. I have diagnosed and treated less than 5 patients

with incontinence

B.

I regularly diagnose and treat patients with incontinence but I feel unsure about my practice

  • C. I diagnose and treat regularly and feel confident

with my practice

I h a v e d i a g n

  • s

e d a n d t r . . . I r e g u l a r l y d i a g n

  • s

e a n d . . . I d i a g n

  • s

e a n d t r e a t r e g u . . .

32% 16% 52%

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6/24/2015 2

Female Urinary Incontinence

An estimated 20 million American women struggle with

urinary incontinence- around 50% of middle aged women, and 75% over the age of 751

Projected costs for urge incontinence alone: $76.2 billion

in 2015 in the US2

It leads to lower quality of life scores Urge incontinence increases risks for fractures and falls3 It really is a primary care problem!

If we don’t ask, they won’t tell

“Do you have any bothersome leakage of urine?” Asking about bothersome symptoms increases treatment

rates 15% in the elderly1

Female Urinary Incontinence

Transient Chronic

Urge Stress Mixed Overflow Functional

Female Urinary Incontinence

Transient Chronic

Urge Stress Mixed Overflow Functional

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6/24/2015 3

Urge Incontinence/Overactive Bladder (UI/OAB)

Detrusor muscle contracts more frequently/ at lower

stimulatory threshold and leakage occurs

Women feel the urge to urinate, but lack control to

hold it until the ideal time.

Frequency and nocturia can occur

Stress Incontinence (SUI)

Sphincter/pelvic floor

weakness gets

  • verwhelmed by

increased abdominal pressure and leakage

  • ccurs

Symptoms occur with

cough, sneeze, laugh, exercise, or change in position.

Picture from NIDDK: http://kidney.niddk.nih.gov/KUDiseases/pubs/uiwomen/index.aspx accessed 5/2015

Mixed Incontinence

Both stress + urge Focus on treating the more bothersome symptoms

The basics….

Jan is a 66 year old overweight female with hyperlipidemia and low back pain who complains of urinary leakage for several years, recently worsening. She leaks a few times per day and wears pads most of the

  • time. She’s pretty bothered by her symptoms and wants

to know what can be done to help.

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6/24/2015 4

Female Urinary Incontinence

Transient Chronic

Urge Stress Mixed Overflow Functional Jan reports that she usually leaks when she laughs or

  • coughs. She has cut back on aerobic exercise because

jogging makes her leak too. She gets up to urinate

  • nce per night, and in the day, goes every 2 hours.

Question: What is the next best step?

  • A. Refer Jan for post void residuals and

urodynamic testing to evaluate the cause

  • f her incontinence
  • B. Diagnose her with urge incontinence
  • C. Diagnose her with stress incontinence
  • D. Order an MRI of her back to make sure

her back pain and urinary incontinence is not cauda equina syndrome

Refer Jan for post void re... Diagnose her with urge i... Diagnose her with stress... Order an MRI of her back ..

15% 0% 79% 6%

Feel confident in your office diagnosis!

Basic questions have fair to good sensitivity and specificity

in differentiating causes of incontinence9

Post void residual are not needed7 Neurologic testing adds little in a relatively healthy

  • utpatient without known neurologic disease

Urodynamic testing does not improve outcomes for

conservative treatments (and it is controversial for surgical

  • ptions)8
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6/24/2015 5

Free copy available at: http://coe.ucsf.edu/wcc/3questions.pdf

The Sensitivity and Specificity of a Simple Test To Distinguish between Urge and Stress Urinary Incontinence9

UI SI Sensitivity (95% CI) 0.75 (0.68- 0.81) 0.86 (0.79- 0.90) Specificity (95% CI) 0.77 (0.69- 0.84) 0.60 (0.51- 0.68) + Likelyhood ratio (95% CI) 3.29 (2.39- 4.51) 2.13 (1.71- 2.66) Neg Likelyhood ratio (95% CI) 0.32 (0.24- 0.43) 0.24 (0.16- 0.35)

Audience Question:

Jan is diagnosed with stress incontinence, and treatment is

  • initiated. The most effective initial treatment based on high

quality evidence to suggest for her is:

  • A. A. Tolterodine (Detrol) once daily

B.

  • B. Mirabegron (Mybetriq) once daily
  • C. C. Pelvic floor muscle training
  • D. D. Intravesicular OnabotulinumtoxinA

(Botox) injections

A . T

  • l

t e r

  • d

i n e ( D e t r

  • l

)

  • .

. . B . M i r a b e g r

  • n

( M y b e t r i q . . . C . P e l v i c f l

  • r

m u s c l e t r a i . . . D . I n t r a v e s i c u l a r O n a b

  • t

. . .

5% 0% 93% 2%

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6/24/2015 6

Pelvic Floor Muscle Training

Stress, urge and mixed all show >50% reduction in

incontinence episodes compared to no treatment, number needed to treat 3 (NNT 6 for full continence)1

Give a “Kegels Prescription” or refer to pelvic physical

  • therapy. Handout available at:

http://campuslifeservices.ucsf.edu/dmx/PatientEd/SDOB G0030.pdf

Lifestyle modifications

  • Fluid management
  • Consideration of dietary factors
  • Timed voids
  • weight loss and exercise reduce incontinence episodes

in obese women (NNT 4)1

  • Bladder diaries alone can improve symptoms

significantly

Image from NIDDK: http://kidney.niddk.nih.gov/KUDiseases/pubs/diary/pages/page1.aspx (accessed 5/2015)

Pharmacologic Options: Stress

No FDA approved treatments

  • off label duloxetine showed trend toward

improvement

  • off label vaginal estrogens show trend toward

improvement But neither has proven statistical significance

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6/24/2015 7

Pharmacologic Options: Urge

Isabel is a healthy 70 year old woman. She had struggled with daily urge

  • incontinence. She complains that she gets little warning before she gets a strong

feeling of needing to pee, and sometimes can’t make it to the bathroom. Regular kegels, fluid management, and timed voids helped reduce her leakage to about 5 episodes/day. She is still bothered enough to want to try more

  • treatment. What is the next best choice for therapy?

A.

Darifenacin (enablex)

B.

Mirabegron (Mybetriq)

C.

Oxybutynin transdermal patch

D.

Any of the above

D a r i f e n a c i n ( e n a b l e x ) M i r a b e g r

  • n

( M y b e t r i q ) x y b u t y n i n t r a n s d e r m a l . . . A n y

  • f

t h e a b

  • v

e

0% 68% 32% 0%

Pharmacologic Options: Urge

Anticholinergics Beta-3 adrenergic agonists

Anticholinergics

Side effects can be limiting Limited effectiveness- all seem to have similar effects, NNT

7-9 for improvement in UI

NNH with side effects 7-127

Anticholinergics

darifenacin (Enablex) ($290 branded only) fesoterodine (Toviaz) ($250 branded only)

  • xybutynin (Ditropan) XL ($210 branded, $100 generic)

solifenacin (Vesicare) ($290 branded only) tolterodine (Detrol) ($240/mo generic, $320/mo branded) trospium (Sanctura) ($200/mo branded only)

Approximate monthly costs (data from uptodate.com 5/2015)

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6/24/2015 8

Effects of Fesoterodine in Vulnerable Elderly Subjects

De Beau, et al. Journal of Urology 2014

Anticholinergics

Continuation rates are only 12-40% at 1 year and 6-12% at 2

years across all drugs10

Mirabegron (Mybetriq)

Novel class of treatment NNT 12 More favorable side effect profile Safe to combine with anticholinergics Cost is about $300/mo

Next line therapies urge:

Jan has tried long acting oxybutynin but experienced excessive dry mouth. She tried tolterodine but did not experience significant benefit in her symptoms. How should we next best help her:

  • A. Recommend the best brand of incontinence

supplies

B.

Refer her for percutaneous tibial nerve stimulation

  • C. Refer her for incontinence surgery
  • D. Refer her for pessary fitting

R e c

  • m

m e n d t h e b e s t b r a . . R e f e r h e r f

  • r

p e r c u t a n e

  • .

. R e f e r h e r f

  • r

i n c

  • n

t i n e n c . . . R e f e r h e r f

  • r

p e s s a r y f i t t i n g

6% 23% 15% 56%

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6/24/2015 9

Next line therapies: UI

Neuromodulation:

Percutaneous Tibial Nerve Stimulators Sacral Nerve Stimulator

OnabotuliniumtoxinA injections Surgery is generally NOT an option for urge incontinence

Percutaneous Tibial Nerve Stimulation

Picture from: Uroplasty Device Manufacturer https://www.uroplasty.com/patients/urgentpc

SUmiT Trial

Peters et al. Journal of Urology 2010 Study of Urgent PC vs Sham Effectiveness in Treatment of

Overactive Bladder Symptoms

SUmiT Results11

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6/24/2015 10

STEP trial

50 participants who benefited from the active arm of

SUmiT

Prospective monitoring Tapered protocol to approximately once monthly PTNS

  • ver 3 years12

STEP Trial Sacral Nerve Stimulators

Picture from webmd: http://www.webmd.com/urinary-incontinence-oab/ss/slideshow-overactive-bladder

Results of Sacral Neuromodulation Therapy for Urinary Voiding Dysfunction: Outcomes of a Prospective, Worldwide Clinical Study

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6/24/2015 11

OnabotulinumtoxinA

Image from urology patient information: http://www.camurology.org.uk/incontinence-treatment/ (accessed 5/2015)

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6/24/2015 12

Next line options for Stress Incontinence

Urethral Bulking Agents Pessary Surgery

Uretheral Bulking Agents

Image from EAU Patient Information: http://patients.uroweb.org/ui/surgery-for-women-with-sui/bulking-agents/ accessed 5/2015

Pessary for SUI

Picture from Mayo Clinic: http://www.mayoclinic.org/dise ases-conditions/urinary- incontinence/multimedia/pessary

  • use/img-20006056 (accessed

5/2015)

Surgical Options for SUI

Surgical referral should be offered for fit patients with

bothersome stress incontinence

Cure rates of around 90% at 1 year Even in the elderly, cure rates of 55% at 5 years15

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6/24/2015 13

Image from Cleveland Clinic: http://my.clevelandclinic.org/services/ob-gyn-womens-health/diseases-conditions/urinary- incontinence (accessed 5/2015)

Image from the Mayo Clinic: http://www.mayoclinic.org/bladder-neck- suspension/img-20007033 (accessed 6/2015)

Long-Term Outcomes after Stress UI Surgery

Funk, et al. Obstetrics and Gynecology, 2012.

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In Summary

Urge and stress incontinence are easily differentiated in the

  • ffice with simple questions

First line therapy for both is pelvic floor muscle

strengthening and lifestyle measures

Pharmacologic options, PTNS, sacral nerve stimulators, or

botox are options for UI treatment

Consider bulking agents, pessary, or surgical referral for SUI

Questions? References

  • 1. Qaseem et al. Nonsurgical Management of Urinary Incontinence in Women: A clinical Practice Guideline from

the Amercian College of Physicians. Ann Internal Med. 2014; 161:429-444.

  • 2. Coyne KS, Wein A, Nicholson S, Kvasz M, Chen CI, Milsom I. Economic Burden of Urgency Urinary

Incontinence in the United States: A Systematic Review. J Manag Care Pharm. 2014 Feb;20(2):130-40.

  • 3. Brown et al. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures

Research Group. J Am Geriatr Soc. 2000 Jul;48(7):721-5.

  • 4. Khandelwal et al. Diagnosis of Urinary Incontinence. Am Fam Physician. 2013 Apr 15;87(8):543-550.
  • 5. Shamliyan et al. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative
  • Effectiveness. Comparative Effectiveness Reviews, No. 36. Rockville (MD): Agency for Healthcare Research and

Quality (US); 2012 Apr. Report No.: 11(12)-EHC074-EF

  • 6. Huang AJ et al. Clinical Significance of Postvoid Residual Volume in Older Ambulatory Women. J Am Geriatr
  • Soc. 2011 Aug;59(8):1452-8. doi: 10.1111/j.1532-5415.2011.03511.x. Epub 2011 Aug 1.
  • 7. Shamliyan et al. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative

Effectiveness Comparative Effectiveness Reviews, No. 36 Minnesota Evidence-based Practice Center Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Apr. Report No.: 11(12)-EHC074-EF

References (cont)

  • 8. Malone-Lee et al. Urodynamic verification of an overactive bladder is not a prerequisite for antimuscarinic treatment response. BJU Int. 2003

Sep;92(4):415-7.

  • 9. Brown JS, Bradley CS, Subak LL, et al. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann

Intern Med 2006;144:715–23. 3IQ questionaire, UCSF patient handouts: http://coe.ucsf.edu/wcc/3questions.pdf (accessed 6/2015)

  • 10. Veenboer, et al. Long-Term Adherance to Antimuscarinic Therapy in Everyday Practice: A Systematic Review. Journal of Urology. Vol 191, 1003-

1008, April 2014.

  • 11. Peters et al. Randomized Trial of Percutaneous Tibial Nerve Stimulation Versus Sham Efficacy in the Treatment of Overactive Bladder Syndrome:

Results from the SUmiT trial. Journal of Urology. 2010 April: 183 (4): 1438-43.

  • 12. Peters KML, et al. Percutaneous tibial nerve stimulation for the long-term treatment of overactive bladder: 3-year results of the STEP study. J Urol.

2013 Jun;189(6):2194-201. doi: 10.1016/j.juro.2012.11.175. Epub 2012 Dec 3.

  • 13. VanKerrebroeck et al. Results of Sacral Neuromodulation Therapy for Urinary Voiding Dysfunction: Outcomes of a Prospective, Worldwide Clinical
  • Study. Journal of Urology. 2007 November. V17(5): 2029-34.
  • 14. Chapple et al. OnabotulinumtoxinA 100 U Significantly Improves All Idiopathic Overactive Bladder Symptoms and Quality of Life in Patients with

Overactive Bladder and Urinary Incontinence: A Randomised, Double-Blind, Placebo-Controlled Trial. European Urology. 2013 August; V64(2):249- 256.

  • 15. Hellberg D, Holmgren C, Lanner L, Nilsson S. The very obese woman and the very old woman: tension-free vaginal tape for the treatment of stress

urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:423–429