Urge Incontinence in Women

Urinary incontinence is defined as any involuntary or uncontrolled loss of urine sufficient to cause a social or hygienic problem.
Urge urinary or “urge”—incontinence is the involuntary leakage accompanied or immediately preceded by a perceived strong imminent need to void

1. Urge Incontinence Presented by: Anish Dhakal (Aryan) 22 nd July, 2019

2. Introduction Urinary incontinence is defined as any involuntary or uncontrolled loss of urine sufficient to cause a social or hygienic problem Urge urinary or “urge”—incontinence is the involuntary leakage accompanied or immediately preceded by a perceived strong imminent need to void

3. Urge incontinence With urge urinary incontinence, women have difficulty postponing urination urges and generally must promptly empty their bladder on cue and without delay If urge urinary incontinence is objectively demonstrated during urodynamic testing with cystometric evaluation, the condition is termed detrusor overactivity (DO) , formerly known as detrusor instability.

4. Urge Incontinence Motor urge incontinence (overactive bladder) Admits strong desire to void, which if not complied with immediately leads to a more involuntary passage of urine It is due to detrusor instability (overactivity) Sensory urge incontinence Intense desire to void that is not associated with detrusor pressure

5. Causes of urge incontinence Idiopathic Genitourinary prolapse Pelvic mass (bladder mass) UTI Detrusor instability Diabetes, Neurological lesions (Alzheimer’s, Multiple sclerosis), Stroke Psychogenic It occurs following surgery for GSI if the bladder neck is placed too high and tightly sutured. It is seen in 1% of cases following anterior repair, 5.8% cases in endoscopic bladder neck suspension and 10% following colposuspension and sling operation

6. Overactive Bladder ( Detrusor instability) Urge incontinence (33%) due to detrusor overactivity is the 2 nd common cause of urinary incontinence in adult female Defined as The presence of “urinary urgency, usually accompanied by increased frequency and nocturia , with or without urge incontinence, in the absence of UTI or other metabolic pathologies” Bladder has tendency to contract spontaneously or on provocation during the filling phase while the patient is attempting to inhibit micturition

7. Pathophysiology Not clearly known Increased alpha-adrenergic and cholinergic activity causing increased detrusor contraction Causing increased detrusor contraction Incompetent bladder neck — urine in proximal urethra---detrusor over activity---incontinence Atherosclerosis or neuropathy Change in detrusor smooth muscle property

8. Clinical features Involuntary loss of urine with prior urge to urinate Urinary symptoms Urgency Frequency (>7 times/day) Nocturia (>once/night) Bed wetting Sexual intercourse, sounds of hand washing & water might trigger Loss of large volumes of urine

9. © Uptodate 2019

10. Stress Vs. Urge Incontinence: Clinical Features Symptom Urge incontinence Stress incontinence Urgency Yes No Frequency with urgency Yes No Urine leakage with increased abdominal pressure No Yes Amount of urinary leakage with each incontinence episode Large Small Ability to reach the toilet in time following an urge to void Often no Yes Waking at void at night Usually S eldom

11. Investigation Neurological examination especially in an old woman Perineal sensation Pelvic muscle tone Bulbocavernous reflex- labia majora is stroked with cotton swab--normally both labia equally contract bilaterally(S2-S4) Blood sugar Maintenance of urinary diary

12. Investigations Urinalysis and culture Sent at an initial visit In all women with urinary incontinence, infection must be excluded Postvoid residual volume Routinely measured during incontinence evaluation Handheld sonographic bladder scanner or transurethral catheterization Leiomyomatous uterus may be recorded as large PVR, so transurethral catheterization used to confirm residual bladder volume Large volume reflects; recurrent infection, urethral obstruction due to pelvic mass or neurologic deficit

13. Uroflowmetry : in idiopathic group, the flow rate is high and voiding time is short Cystometry Urge to pass urine is provoked at much lower bladder filling of 100-175ml of water Pressure rise during filling is >15 cm H2O and does not settle when filling ceases. Ultrasound shows a thick bladder wall more than 6 mm in detrusor instability, and residual urine, apart from urethrovesical angle posteriorly

14. Stress Vs. Urge Incontinence: Investigations Stress incontinence Overactive bladder Cystometry Leakage occurs as a result of coughing in the absence of a rise in detrusor pressure Pressure rise during filling > 15 cm H2O and does not settle when filling ceases Cystourethroscopy Normal Diminished bladder capacity Uroflowmetry Normal High in idiopathic cases

15. Management Approaches Behavioral therapy (e.g., bladder training, biofeedback, pelvic floor muscle therapy, and pelvic floor electrical stimulation) Pharmacologic therapy (e.g., anticholinergic/antimuscarinic agents) Surgical therapy (e.g., neuromodulation and augmentation cytoplasty

16. Management General measures Psychotherapy for psychosomatic problems Neurological problems and diabetes should be managed properly Behavioural therapy Limit the intake of fluid Reduce tea and coffee Drugs-diuretics may be stopped if possible Bladder retraining Pelvic Muscles Exercises

17. Bladder retraining Useful for idiopathic Detrusor instability Helps to hold urine for longer period Can be achieved by bladder drill, biofeedback or hypnotherapy Biofeedback Uses visual and auditory signals to demonstrate strength of detrusor activity Hypnotherapy In psychological women

18. Contd.. Bladder Drill with Bladder Training Instructions Instructed to void by the clock at progressively increasing intervals over 6 week Initial response is good but failure rate is high Simultaneous anticholinergic drug therapy improves the result Not useful in neurological disease for unstable bladder

19. Bladder Training Instructions: Start by going to the toilet and trying to urinate as often as your shortest voiding interval (the length of time between trips to the bathroom) based on your voiding diary. For example, go every hour if that is what your bladder diary indicates is the shortest interval of time between visits to urinate. Make these regular trips to the toilet while you are awake. You do not have to get up during the night ! You must try to urinate whether you feel the need or not. You must try to urinate even if you have just been incontinent. © Uptodate 2019

20. Bladder Training Instructions: If you get a strong urge to go to the bathroom before your scheduled time, use distraction or relaxation : Stop , do not run to the bathroom! Stand still or sit down if you can. RELAX. Take a deep breath and let it out slowly. Concentrate on making the urge decrease or even go away anyway you can (imagine the pressure becoming less and less). You can also try doing quick contractions of your pelvic floor muscles. DISTRACT yourself, for example by doing math problems in your head. When you feel IN CONTROL OF YOUR BLADDER, walk slowly to the bathroom, and then go. © Uptodate 2019

21. Bladder Training Instructions: Keep this schedule until you can go one day without urine leakage. Then, increase the time between scheduled trips to the toilet by 15 minutes. When you can go one day on this new schedule without urine leakage, extend the time between bathroom trips again by 15 minutes . Keep this up until you can go four hours between trips to the toilet (which is NORMAL), or until you are comfortable with a shorter time interval. This may take several weeks . DO NOT GET DISCOURAGED! Bladder training takes time and effort, but it is an effective way to get rid of incontinence without medication or surgery. © Uptodate 2019

22. Pelvic Muscles Exercises: First, you will need to learn which muscles to tighten. To do this, imagine you are sitting on a marble. Then tighten your pelvic muscles to lift that imaginary marble off the chair. After you learn which muscles to tighten, you can do the exercises in any position (sitting in a chair or lying down). Second , hold the pelvic muscle contraction approximately 8 to 10 seconds, and then relax the muscles; relaxing the muscles is as important as contracting. In the beginning, it may not be possible to hold the contraction for more than one second. Perform 8 to 12 exercises three times per day. Try to do this every day, but no less than three or four times a week. Continue this regimen for at least 15 to 20 weeks. © Uptodate 2019

23. Medical therapy Aim is to inhibit bladder contractility and increase bladder neck and urethral resistance Anticholinergic drugs Tolterodine and Solifenacin have detrusor selectivity R educe frequency and urgency Oestrogen cream Peri or Postmenopausal women

24. Pharmacologic treatment:

25. Drugs used in Incontinence © Uptodate 2019

26. Contd.. Imipramine (tricyclic antidepressant) 50 to 100 mg at night for 3 months For enuresis Desmopressin ( antidiuretic hormone) For nocturia Duloxetine  serotonin norepinephrine reuptake inhibitor Dose of 40-80 mg BD orally for 3 months improves the bladder capacity Injection of botulinum toxin A into the bladder wall may be used as a treatment for idiopathic detrusor overactivity

27. Contd.. Transvesical injection of phenol: A volume of 10 ml of 6% phenol injected into trigone, 60% benefit for a short period but at end of 1 year only 2% are relieved Augmentation 'Clam' cystoplasty involving augmentation of bladder capacity with a (25 cm length) segment of ileum  95% cure Detrusor myectomy creates a diverticulum and improves bladder capacity

28. Percutaneous tibial nerve stimulation  Percutaneous stimulation of the tibial nerve (PTNS), one type of electrical stimulation therapy, may have some benefit for women with detrusor overactivity. Methods include electrical stimulation administered for 30 minutes. These sessions occur once a week for 12 weeks followed by maintenance therapy of approximately once a month if the patient desires. A 2016 meta-analysis of multiple, non-implanted types of electrical stimulation for OAB concluded that electrical stimulation appeared to be more effective than either no treatment or drug treatment for OAB.

29. Sacral neuromodulation P ermanent lead wire is placed into one S3 foramen and tunneled under the skin to connect to a temporary stimulation device. Patients are asked to maintain voiding diaries to document their urinary urgency, frequency, and leakage severity at baseline for three days prior to the test phase and then daily during the two-week testing period . If greater than 50 percent improvement in any of these parameters is confirmed, the patient can elect permanent implantation with a pacemaker-like stimulator placed under the skin of the upper buttock. If the test phase is unsuccessful, then the lead is removed . A 2015 review of 16 studies concluded that there was evidence of benefit for SNM in some patients. Some have reported improvement rates of 60 to 90 percent and cure rates of 30 to 50 percent

30. Surgical Options Available Though the evidence is not very suggestive patients may consider surgical options. These may include augmentation cystoplasty , urinary diversion, or placement of a suprapubic catheter.

31. References Hoffman et al, Williams Gynecology , 2 nd edition S. Linda, Evaluation of women with incontinence, https:// www.uptodate.com/contents/evaluation-of-women-with-urinary-incontinence, Accessed on 20 th July, 2019 VG Padubidri et al, Howkins & Bourne Shaw’s Textbook of Gynecology, 15 th edition L. Emily, Treatment of Urgency Incontinence in women, https:// www.uptodate.com/contents/treatment-of-urgency-incontinence-overactive-bladder-in-women, Accessed on 21 st July, 2019 Gyanecology by Ten Teachers

32. 17 th -23 rd June, 2019 Thank you