urinary incontinence (ui) management in family practice references: can fam physician...

Urinary Incontinence (UI)

Management in Family Practice

References:Can Fam Physician 2003;49:611-618.Can Fam Physician 2003;49:602-610.SOGC Clinical Practice Guidelines. No. 127, April 2003.

To do:

Info Types of Incontinence What to do in office Treatment When to refer

Info

1.5 million Canadians 12% of women, 2% of men >55 Affects Quality of Life Majority can be managed by Family

Physician

Types of Incontinence

Stress Urge Mixed Overflow

Stress Incontinence

Most common Loss of urine on physical exertion or

increases in intra-abdominal pressure. Usually no nocturia (helps distinguish

from urge incontinence)

Urge Incontinence (overactive bladder)

Loss of urine with strong desire to void. Frequency and nocturia are common

Pure urge incontinence is least common (3% adult women)

Mixed UI (urge + stress)

Loss of urine with both urge and increases in abdominal stress.

Overflow

Associated with bladder distention or retention; poorly contractile detrusor or outlet obstruction

Chronic retention is usually painless Can be confused with stress

incontinence because leakage can occur with increase abdominal pressure

What to do in Office? Ask about it on annual precipitating factors,

amount, frequency, protective measures (pads, clothing changes), Quality of Life

Fluid Intake, caffeine, HS fluids?, previous surgeries, smoke, ? Sx of UTI, constipation

Meds: Ace (cough), diuretics, alpha-blockers

Causing retention: hypnotics, antipsychotics, narcotics, anticholinergics

Voiding diary

Basic Physical Exam/Labs Neurological exam Urinary Stress Test Speculum and

Bimanual Pelvic Urine Dip/R&M

Treatment

1. Lifestyle: fluid/caffeine, UTI, constipation, void regularly, lose weight, stop smoking

2. Pelvic Floor Strengthening: benefit urge, stress, and mixed UI. Success in 50-90% of patients

3. Bladder Training (Urge Suppression or scheduled voiding)

Kegel (Pelvic Floor Muscle) Exercises Squeeze (as if

stopping urination) Hold for 5s, relax for

10s. Repeat x10 TID. 15 contractions TID 20 contractions QID

+ 20 whenever

Specific Treatment for Stress Incontinence

Pessary: for Stress Incontinence +/- Prolapse

Specific Treatment for Mixed/Urge Muscarinic Receptor AntagonistsOXYBUTYNIN: Ditropan® XL 5 mgTransdermal: Adults: Apply one 3.9 mg/day patch twice weekly

(every 3-4 days) TOLTERODINE: Detrol® 2 mg BID or 4 mg Daily of Long

Acting (LA)

When to Refer No or partial response to conservative

measures Previous prolapse surgery Previous continence surgery that has failed Severe pelvic organ prolapse Voiding dysfunction with high postvoid

residual urine (with or without complications: recurrent UTI, hydronephrosis)