female urinary incontinence

1. Urinary Incontinence
Guides
Dr.Rachana Agrawal Dr.Ruchika Garg
Asst. professor Asst. professor
Dept of OBGY. Dept of OBGY.
S.N.M.C, Agra S.N.M.C, Agra
Presented By
Dr.Kokila. B.T.
Junior Resident
Dept. of OBGY,
SNMC , Agra

2. DEFINITION
• UI is defined by the International
Continence Society as 'the complaint of
any involuntary leakage of urine’ that is
objectively demonstrable and cause a social
or hygienic Inconvenience for day to day
activity

3. DEFINITIONS
• Urinary incontinence is defined as
involuntary leakage of urine.
• Urgency incontinence is involuntary
leakage accompanied by urgency. Urgency
is the complaint of a sudden and compelling
desire to pass urine that is difficult to defer.

4. Mechanism of continence in
women
4 factors contribute to female continence:
• Bladder compliance
• Efficient urethral sphincter
• Efficient urethral support
• Adequate urethral mucosal co-aption

6. NORMAL URETHRAL
CLOSURE
• Combination of intrinsic and extrinsic
factors.

7. EXTRINSIC FACTORS:
• levator ani
• endopelvic fascia
• and its attachments to pelvic
sidewalls and urethra

8. INTRINSIC FACTORS
• Striated muscle of urethral wall
• Vascular congestion of submucosal venous
plexus
• Smooth muscle of urethral wall and blood
vessels
• Epithelial coaptation of the folds of urethral
lining
• Urethral elasticity
• Tone of urethra- α- adnerergic receptors of
the sympathetic system

9. Normal Physiology

10. Urinary Incontinence
• Epidemiology
• Quality of Life
• Risk Factors and Causes
• Types of Urinary Incontinence
• Evaluation
• Treatment

11. Epidemiology

12. Urinary incontinence
Epidemiology
• Although the prevalence of UI increases
with age, UI should not be considered a
normal part of the aging process.

13. • Nearly 16 million women in india have UI.
• 9 million have urge incontinence or OAB.
• Remaining 7 million women need surgical
treatment..

14. Stress Urinary incontinence
• Prevalence of SUI increases with age
initially,
• peaks around the fourth or fifth decade,
• and then increases with increasing age.
• m/c in white than black.

15. Mixed and urge Urinary
incontinence
• Generally increases with age, eventually
overtake SUI, by sixth and seventh decade.
• UUI, more common in black women

16. Urinary incontinence
Epidemiology
• For non institutionalized persons older than
60 years of age, women have twice the
prevalence of men
• Whites > Blacks, Hispanics and Asians
• Family history -Mother +/- sister

17. Risk Factors and Causes

18. Urinary incontinence
Risk factors
• Immobility/chronic
degenerative disease
• Impaired cognition
• Medications
• Morbid obesity
• Diuretics
• Smoking
• Fecal impaction
• Delirium
• Environmental
barriers
• High-impact physical
activities
• Diabetes
• Stroke

19. Urinary incontinence
Risk factors-m/c in women
• Estrogen depletion-postmenopausal
women
• Pelvic muscle weakness-
Pregnancy/vaginal delivery/episiotomy
• Childhood nocturnal enuresis
• Race

20. Urinary incontinence
Causes
• Conditions affecting the lower urinary tract
• Drug side effects
• Increased urine production
• Impaired ability or willingness to reach a
toilet

21. Urinary incontinence
Conditions affecting the lower urinary
tract
• Urinary tract infection
• Atrophic vaginitis/urethritis
• Pregnancy/vaginal delivery/episiotomy
• Stool impaction

22. Urinary incontinence
Pharmacologic Causes
• sedatives
• loop diuretics
• alcohol
• caffeine
• cholinergics
(donepezil)
•  awareness, detrusor
activity Func & O UI
• Diuresis overwhelms bladder
capacity Urge & O UI
• Polyuria,  awareness 
Urge & Functional UI
• Polyuria,  detrusor activity
 Urge
•  detrusor activity  Urge
Culligan PJ Urinary Incontinence in women
Evaluation and Management AFP 12-1-01

23. Pharmacologic Causes,
Continued
alpha-agonists
  urethral sphincter
tone  retention and
Overflow
alpha-antagonists
 urethral sphincter
tone  Stress

25. Urinary incontinence
Increased urine production
• Metabolic (hyperglycemia, hypercalcemia)
• Excess fluid intake
• Volume overload
• Venous insufficiency with edema
• Congestive heart failure

26. Urinary incontinence
Impaired ability or willingness to reach a
toilet
• Delirium
• Chronic illness, injury, or restraint that
interferes with mobility
• Psychological

27. Quality of Life

28. Urinary incontinence
Quality of Life
• UI imposes a significant psychosocial
impact on individuals, their families, and
caregivers.
• UI results in a loss of self-esteem and a
decrease in ability to maintain an
independent lifestyle.
• Dependence on caregivers for activities of
daily life increases as incontinence worsens.

29. Urinary incontinence
Quality of Life
• UI is often undetected and underreported by
hospital and nursing home personnel.

30. Types of Urinary Incontinence
• Transient UI (Acute)
• Established UI (Chronic)
– Urge UI
– Stress UI
– Mixed UI
– Overflow UI

31. Causes of Transient (Acute)
Incontinence
• D Delirium
• I Infection
• A Atrophic Vulvovaginitis
• P Psychological
• P Pharmacologic agents
• E Endocrine, excessive UO
• R Restricted Mobility
• S Stool impaction

32. Classification of Urinary
Incontinence
Urethral
• GSI
• Detrusor overactivity
• Mixed (GSI and DO)
• Overflow incontinence
(acute and chronic)
• Functional and others
• Congenital(epispadius)
Extra urethral
• Acquired
1. Fistulae
2. Vesical
3. Urethral
4. Ureteral
• Congenital
1. Ectopic ureter and others

33. Classification of urinary
incontinence
• Stress urinary incontinence (SUI)
• Urge urinary incontinence (UUI)
• Mixed urinary incontinence
• Other
1. Transient causes (DIAPERS)
2. Urethral diverticulum
3. Vesico-vaginal fistula Ectopic urethrae

36. Urinary incontinence
Stress Incontinence (SUI)
ICS definitions (Abrams 2003)
• SUI is defined as involuntary urine loss
coincident with an increase in intra-
abdominal pressure (coughing, sneezing,
laughing, or other physical activities ), in
the absence of a detrusor contraction or an
overdistended bladder.

37. Stress urinary incontinence
• Urodynamic stress incontinence is noted
during urodynamic testing (filling
cystometry) and is defined as the
involuntary leakage of urine during
increases in abdominal pressure in the
absence of a detrusor contraction.

38. Theories of SUI development
(i) Urethral position theory (Kelly, Bonney,
Einhorning) – failed transmission of intra-
abdominal pressure to the urethra
(ii) Intrinsic sphincter deficiency (McGuire) –
poor periurethral support tissues
(iii) Hammock theory (DeLancey) – lax
pubococcygeus backplate
(iv) Integral theory (Petros and Ulmstein) –
weak pubourethral ligaments Probably
multifactorial, incorporating all features of
above.

39. Types of stress incontinence on
basis of supports:
1. Incontinence caused by anatomic
hypermobility of urethra (extrinsic)
2. Incontinence caused by intrinsic
sphincteric weakness or deficiency.

40. Urethral hypermobility
• Bladder base descent leads to urethra
exiting true pelvis.
• Thus raised intraabdominal pressure
unequally transmitted to bladder vs. urethra
and leakage occurs

41. • Risk factors for urethral hypermobility
1. Pregnancy (esp. prolonged labour)
2. Vaginal delivery (esp. instrumental)
3. Pelvic surgery ,Obesity,
4. Chronic cough ,Chronic consipation
5. Autonomic neuropathy (DM, MS, Shy-
Drager)

42. Sphincter deficiency without
descent (ISD)
• Bladder neck already open at rest;
• very low increase in intraabdominal
pressure results in urinary leakage
• Risk factors for pure ISD –
1. Neuropath
2. Trauma or
3. previous surgery
4. Radiation Poor oestrogenisation

43. Urinary incontinence
Stress Incontinence
• The most common cause in women is
intrinsic urethral sphincter deficiency which
may be due to congenital sphincter
weakness in patients with
myelomeningocele, epispadias, or pelvic
denervation.
• Another cause is urethral hypermobility, or
significant displacement of the urethra and
bladder neck during exertion (pressure)

44. • Originally believed that 2 types of stress
incontinence based on UDS findings:
Genuine stress incontinence (GSI) and
intrinsic sphincter deficiency (ISD)
• However, it is known that many women
with urethral hypermobility are not
incontinent, implying that a sphincter defect
present in all.
• SUI however may or may not be associated
with concomitant bladder base descent,
which may be important for subsequent
surgical treatment.

45. • Nowadays all patients considered to have
ISD, with varying degrees of urethral
hypermobility.

46. Classification of SUI (Blaivas
and Olson 1988)
• Based on position of bladder base in
relation to the inferior margin of the pubic
symphysis (IMPS), and whether or not the
Bladder neck is open at rest

48. Evaluation of Stress Urinary
Incontinence
• History
• Clinical examination
• Investigations
1. Basic investigations
2. Specialised investigations
• Management

49. HISTORY- detailed and accurate
1. Incontinent symptoms- how long,
frequency, severity, day or
night,precipitating factors, quality of life.
2. Other symptoms-frequency, nocturia,
urgency, enuresis, voiding difficulty,
dysuria, hematuria.
3. Any previous continence treatment
4. Gynecological- menopause, pelvic mass,
pelvic floor prolapse, bowel dysfuntion

50. 5. Medical- chronic cough, constipation,
diabetes mellitus or insipidus neurological
history, and its control
6. Surgical- previous pelvic surgery, continent
surgery, radical surgery for gynecological
malignancy, instrumental delivery.
7. Drugs- for constipation, diuretics,
sedatives, alcohol, anticholinergics, alpha
adrenergics, alpha adnergic blockers may be
causative.

51. Grade of GSI(Clinical)
• Grade I: Incontinence on cough or sneeze
• Grade II: With mild exercise
• Grade III: Even with change if posture

52. Physical examination
• General condition- mobility. Obesity, blood
pressure, cognitive status, edema etc
• Lungs- chronic bronchitis, asthmatics
• Abdominal- abdominal and pelvic mass,
scars, anal sphincter tone and fibroid.
• Pelvic- estrogenisation, vulval excoriations,
and …

53. • Stress test -Observation of leakage of urine
with valsalva or cough. Should be
performed in supine position; if no leak
repeat in standing position Usually
suggested by short time lag between cough
and leak
• Speculum examination -Ideally Simms
speculum in left lateral position; allows
identification of anterior and posterior
compartment prolapse

54. Vaginal examination
• Excludes obvious
vaginal,cervical or
adnexal masses
• Vaginal grip graded by
Oxford grading system
(Laycock 1992)
Whilst very limited
evidence that vaginal grip
predicts outcome of
PFMT, NICE expert
advice recommends grip
test

55. NO MORE RECOMMENDED
• Q-tip test -Lubricated ear bud in urethra.
Deviation > 30 degrees diagnostic.
Not recommended by NICE (NR)

57. Bonney’s test
• Without emptying the bladder
• Place 2-finger on each side of the urethra
and exert upward pressure against the
subpubic angle. Pt is requested to cough.
• If no urine escapes, operative correction can
be planned.
• Very difficult to do without compressing
urethra hence cannot diagnosis urethral
hypermobility
Not recommended by NICE (NR)

58. • Marshall test Equivalent to Bonney test
except clamp to avoid inadvertent
compression of urethra Impractical and
unneccesary
Not recommended by NICE

59. • Miyazaki’s modification of Bonney’s test
• anterior vaginal wall is streched
superiorlaterally till lateral pelvic wall by
ring forceps.
• Demonstration of leakage of urine with
coughing or vulsalva in lying down position
and may be even in standing.

60. Neurological examination
• Spina bifida occulta, lower limbs and skin
sensation and anal reflexes (S2-S4),
Multiple sclerosis, parkinson’s disease.
• Abbreviated neurological examination
1. Afferent = Perineal sensation,
bulbocavernosus (but absent in 30%)
2. Motor = Spreading of toes (S3)

61. Investigations
• Basic investigations
• Specialised investigations

62. Basic investigations
• Urinalysis- to rule out infection, glycosuria
and hematuria.
• Biochemical tests- RFT, RBS
• Post void residual urine- via catherterization
or ultrasound estimation post voiding.
normal- <50 ml,
high RU (>200 ml)- impaired detrusor
contractility – overflow incontinence

63. Post-Void Residual (PVR)
• Measure volume of urine left in bladder after
voiding by catheter or bladder scan
• < 50-100 Normal
• 100—400 Monitor until consistently less than
200cc.
• > 400cc—Insert Foley catheter

64. PAD TEST
• High false
negative rates;
better with
long-term
testing but no
relation to
outcome of Rx.
• Not
recommended
by NICE

66. Specialised investigations
• Uroflowmetry- objective assessment of
voiding function
- Bladder volume should be > 150 ml to
assess the flow rate.
- Flow rate should be > 20 ml per second in
normal women
• Filling and voiding cystometry
- measues the pressure- volume relationship
of bladder to diagnosis DI, GSI and voiding
disorders

67. • Urethral pressure profilometry (resting
and stress UPP)
- A UPP of <20 cm of H2O or a negative
pressure transmission ratio indicates
instrinsic sphincter deficiency as a cause of
GSI
• Valsalva Leak Point Pressure(VLPP)
Measures the urethral opening or leak point
pressure during vulsalva maneuver.
- <60 cm H2O indicates intrinsic sphincter
deficiency.

68. Urodynamics
• NICE recommendation that UDS not
required for straightforward ‘lone’ SUI
• Not recommended prior to commencincg
conservative therapy
• beneficial prior to surgery
• Multichannel recommended vs. single
channel

69. Indication for urodynamics
• Mixed symptoms (suspicion of OAB)
• Previous failed incontinence surgery
• Suspicion of neuropathic bladder or voiding
dysfunction

70. Differentiating ‘lone ISD’ from ISD with
hypermobility
• Urodynamic valsalva leak point pressure
(VLPP) < 60 cm water believed to be diagnostic [
60-90 equivocal; > 90 excludes diagnosis]
• Urethral pressure profile (Urethral pressure –
detrusor pressure) < 20cm water.
• Conflicting evidence that low VLPP or UPP
predicts failure following sling/tape procedures.
• Detrusor LPP (leakage of urine from bladder in
absence of abdominal contraction; DLPP > 40cm
water suggests possible urethral dilatation)

71. Ultrasound-
• detection of pelvic mass, structural
abnormalities (bladder diverticula,
hydronephrosis),
• estimation of residual urine.
• Transperineal USG – demonstrate urethral
hypermobility and descent of bladder neck
with vulsalva

72. • Videocystourethrography (VCU)-
- Cystometry and radiological imaging of
bladder/ urethra with contrast.
- Used in evaluating women with failed
continence surgery.
- Detects position and mobility of bladder
neck, ureteric reflux , incontinence

73. • Intravenous Pyelogram or micturiting
cystogram
- Demonstrate the presence of fistula and to
assess renal function.
• Cystourethroscopy- visualize disease at
bladder/ urethra (e,g. tumors, stone,
interstitial cystitis).
Not indicated in GSI

74. CYSTOSCOPY
• No evidence for routine cystoscopy, except
in the presence of dipstick haematuria .
• No evidence for the routine use of imaging,
except USG for the determination of PVR

75. • Pediatric foley’s Test- to see intrinsic
sphincter deficiency.
- No. 8 french is introduced in the urethra. The bulb
in inflated and try to remove the catheter.
- If it comes out, it confirm the diagnosis
• Carbon dioxide cystometry- not very
accurate
• Water cystometry- time consuming , but
more accurate
• Three swab test- to differentiate between
vesicovaginal fistula and uretrovaginal fistula

76. MANAGEMENT
• Life style changes
• Conservative management
• Pharmacotherapy
• Surgical treatment

77. Life style changes
• Use of incontinent pads and garments
• Caffeine withdrawal
• Stop smoking
• Restriction of fluid to one liter a day
• Treat cough ,constipation , weight
reduction.

78. • Pelvic floor exercises- during puerperium
• Estrogen replacement therapy in
postmenopausal women
• Bladder drill- (6 weeks course)asked to
urinate at designated intervals and resist the
urgency in between

79. Conservative management
Indicated-
• Pt refuses or undecided
• Pt is mentally or physically disabled
• Childbearing
• Uncontrolled detrusor instability or voiding
difficulty

80. Conservative treatment
• Pelvic floor muscle training (Kegel
exercises) Regular contractions of pelvic floor
muscles and stop the urinary stream in between for
few secs.
• 10-20 ten second contractions 3-4 times/day for
3 months+ (recommended by NICE)

82. Electrical stimulation
• Stimulation of pudendal nerve with
electrodes placed in the vagina or anus.
• Produces contraction of levator ani,
external urethral sphincter, and anal
sphincters
• Accompanied by a reflex inhibition of the
detrusor.
• Reduces detrusor overactivty and stress
incontinence in 50-70 %
• (E-Stim; requires vaginal probe) and
magnetic therapy (EM waves generated by
special chair – no vaginal probe required)

83. • Bladder retraining –
- gradual increase in voiding interval from 1-
3 hrs during day time.
- Supression of urge with distraction or
relaxation techniques (to prevent leakage).
- Avoidance of caffeinated beverages
• Acupuncture
• Hypnosis
• Weighed vaginal cones- of graded weight
placed inside vagina- pt attempts to keep the
cone falling out by squeezing the pelvic
floor. 10-20 minutes a day

84. • Devices-
1. Elevating devices- for mild
GSI,
- Reusuable foam, pessary or
prosthesis
- Elevate n support bladder neck
- S.E- UTI, Soreness of vaginal
mucosa.
2. Occlusive devices- occluding
both external and internal urethra
-for pt while awaiting surgery

85. Medical treatment
• Topical vaginal oestrogen Improves
‘hammock’ tone and urethral mucosal coaption
• Side-effects vaginal burn, itch, spotting Risks of
malignancy with long-term oestrogen treatment –
(BNF)

86. Pharmacologic treatment
Stress Incontinence: Urethral Sphincter
Insufficiency
• The rationale for pharmacologic therapy:
high concentration of -adrenergic
receptors in the bladder neck, bladder base,
and proximal urethra.
• Sympathomimetic drugs with alpha-
adrenergic agonist activity presumably
cause muscle contraction in these areas and
thereby increase bladder outlet resistance.

87. Pharmacologic treatment
Stress Incontinence: Urethral Sphincter
Insufficiency
• Pharmacotherapeutic strategies include:
– drugs with -adrenergic agonist activity,
– estrogen supplementation both for direct effect
on urethral mucosal and periurethral tissues and
for enhancement of  -adrenergic response
– -adrenergic-blocking drugs that may allow
unopposed stimulation of -receptor-mediated
contractile muscle responses.

88. Duloxetine
• Serotonin (5-HT) and NA reuptake inhibitor
(SNRI)
• Potentiates the physiological effects of
endogenous 5-HT and NA, enhancing the
CNS’s natural continence control
mechanism
• Acts chiefly in sacral spinal cord to increase
pudendal nerve activity – augmenting
urethral rhabdosphincter.
• 2 doses- 20mg and 40mg ( bd,tds)
• Not recommended as first or second-line treatment
by NICE: alternative in those unfit for surgery

89. Urge urinary incontinence
ICS definitions (Abrams 2003)
• The symptom is involuntary leakage of
urine accompanied by or immediately
preceded by urgency.

90. Urinary incontinence
Urge Incontinence
• It is usually associated with involuntary
detrusor contractions or detrusor instability
(DI).

91. DI- subdivided into
1. Primary (idiopathic)
2. Secondary to bladder outlet obstruction
3. Neuropathic or detrusor hyperreflexia

92. ETIOLOGY: -postjunctional
supersensitivity, -
- altered adrenoreceptor function,
- afferent nerve dysfuction,
- imbalance of neurotransmitters and
- primary or acquired myogenic deficit.
Co existing conditions-
pelvic organ prolapse, feces incontinence

93. Urinary incontinence
Urge Incontinence
• Elderly: detrusor hyperactivity with
impaired bladder contractility is common
(DHIC)
– involuntary detrusor contractions, yet must
strain to empty their bladders either
incompletely or completely.

94. Urinary incontinence
Urge Incontinence
• DHIC generally have symptoms of UI and
an elevated PVR, but they may also have
symptoms of obstruction, stress
incontinence, or overflow incontinence.

95. Urinary incontinence
Urge Incontinence
• When a causative neurologic lesion is
established, the DI is called detrusor
hyperreflexia (DH) .

96. Urinary incontinence
Urge Incontinence
• Stroke is associated with DH.
• Suprasacral spinal cord lesions/multiple
sclerosis: DH is commonly accompanied
by detrusor sphincter dyssynergia (DSD)
(inappropriate contraction of the external
sphincter with detrusor contraction).
• This can result in the development of
urinary retention, vesicoureteral reflux, and
subsequent renal damage

97. Urinary incontinence
Overflow Incontinence
• Involuntary loss of urine associated with
overdistension of the bladder
• It may have a variety of presentations,
including frequent or constant dribbling, or
urge or stress incontinence symptoms.
• Overflow UI may be caused by an
underactive or acontractile detrusor, or to
bladder outlet or urethral obstruction
leading to overdistension and overflow.

98. Urinary incontinence
Overflow Incontinence
• The bladder may be underactive or
acontractile secondary to drugs, neurologic
conditions such as diabetic neuropathy, low
spinal cord injury, or radical pelvic surgery
that interrupts the motor innervation of the
detrusor muscle.
• The detrusor muscle may also be
underactive from idiopathic causes.

99. Urinary incontinence
Overflow Incontinence
• Although an outlet obstruction is rare in
women, it can occur as a complication of an
anti-incontinence operation and because of
severe pelvic organ prolapse.

100. Urinary incontinence
Overflow Incontinence
• In patients with suprasacral spinal cord
injury or multiple sclerosis, DSD can cause
obstruction when the external sphincter
muscle inappropriately and involuntarily
contracts rather than relaxes at the same
time the detrusor contracts

101. Urinary incontinence
Functional Incontinence
• Urine loss may be caused by factors outside
the lower urinary tract such as chronic
impairment of physical or cognitive
functioning, or both.
• This diagnosis should be one of exclusion,
however, because some immobile and
cognitively impaired individuals have other
types and causes of UI that may respond to
specific therapies.

102. Urinary incontinence
Functional Incontinence
UI can often be improved or "cured" by
improving the patient's functional status,
1. treating other medical conditions,
2. discontinuing certain types of medication,
3. adjusting the hydration status,
even if a lower urinary tract abnormality is
present.

103. Overactive bladder (OAB) and
Urge urinary incontinence
• Overactive bladder (OAB) is defined as
urgency that occurs with or without urgency
UI and usually with frequency and nocturia.

104. Types of OAB
• OAB that occurs with incontinence is
known as 'OAB wet'.
• OAB that occurs without incontinence is
known as 'OAB dry'.

105. Mixed urinary incontinence
ICS definitions (Abrams 2003)
• The complaint of an involuntary leakage of
urine associated with urgency and also with
exertion, effort, sneezing, or coughing.

106. Evaluation
History
• Fluid intake
• Caffeine
• Smoking
• Diabetes
Examination
• Exclude demonstrable
stress incontinence
• Exclude palpable
bladder
Voiding diary
Post-micturition residual
Urinalysis
Urinary cytology (?)
Urodynamics

107. Lower Urinary Tract
Impairments of Function
Store Release
Bladder
Urethra
URGE
STRESS
OVERFLOW
OBSTRUCTIVE
PVR
PVR
0-100
PVR
> 200

108. Pharmacologic treatment
Urge Incontinence. Detrusor instability
• Anticholinergic agents: (First Line).
• Oxybutynin (2.5 mg bd- 5mg tds)is the
anticholinergic agent of choice.
• Anticholinergic agents block contraction of
the normal bladder and unstable bladder

109. Pharmacologic Treatment :
URGE
• Anticholinergic agents (first line)
– Darifenacin(7.5-10 mg OD)
– Oxybutinin(5mg tds)
– Solifenacin(5-10mg od)
– Tolterodine(4 mg od)
– Trospium (20mg bd)
• Variety of preparations: Immediate Release;
Extended Release; Transdermal
**ALL these drugs suppress the detrusor contractility and MAY
CAUSE URINARY RETENTION!!! ALWAYS CHECK PVR
PRIOR TO PRESCRIBING!!!

110. • Solifenacin may have better efficacy in urge
incontinence (Star trial)
• NICE recommend non-proprietary
immediate release (IR) oxybutynin first line
(>60 yrs 2.5mb bd; otherwise 5mg bd up to
qds)
• Propiverine(15mg BD), flavoxate(100-
200mg qid), propantheline and
imipramine(50mg at night) not
recommended by NICE

111. • If poorly tolerated then tolterodine,
solifenacin, darifenacin, trospium, or
transdermal oxybutynin.
• Tolterodine reserved for troublesome side-
effects
• trospium reserved for CNS side-effects, and
• solifenacin for treatment failures .

112. Contraindications
• Myasthenia gravis
• Narrow-angle glaucoma
• Toxic megacolon
• Bowel obstruction

113. Desmopressin
• Highly effective in reducing nocturia in
adults, with sustained long-term responses
• Side effects-Headache, nausea and daytime
urinary frequency
• Mild hyponatraemia more common in
elderly (post-Rx monitoring for 3 days
recommended if given to elderly pt)

114. Intravesical Botulinum toxin
• Binds to pre-synaptic nerve terminals,
leading to inhibition of ACh release and
failed neuromuscular transmission
• Specifically stops endovesicles fusing with
plasma membrane .
• Botulinum toxin A only recommended
(short duration of response with botulinum
toxin B)
• Typically 10IU/ml BoTox 20-30 injections
of 1 ml into detrusor..

115. Surgical treatment
• Surgery is recommended for stress
incontinence in men and women and may
be recommended as first-line treatment for
selected patients who are unable to comply
with other nonsurgical therapies.
• Surgery in the management of urge
incontinence is uncommon.
• Surgical treatment is considered only in
highly symptomatic patients in whom
nonoperative management has failed.

116. Surgical treatment
• Symptoms of overflow or incontinence
secondary to urethral obstruction can be
addressed with a surgical procedure to
relieve the obstruction.

117. Urinary Incontinence
Other measures
• Intermittent catheterization.
• Indwelling urethral catheterization.
• Suprapubic catheters.
• External collection systems. (external
female catheter)
• Pelvic organ support devices (pessaries)
• Absorbent pads or garments

118. Suprapubic catheters

119. External Catheter for Women

120. UI Summary
• Look for reversible causes and Rx
• Check PVR (>200 cc investigate further)
• Start with behavioral interventions before
medications
• Referral and urodynamic studies if no
response to usual measures
• Early referral if underlying GU tract
pathology present