HOW TO TREAT 31
ausdoc . com . au 13 SEPTEMBER 2024
HOW TO TREAT 31
Table 1 . Checklist for examination of a patient
Figure 1 . Normal vs overactive bladder .
Examination Abdominal
Gynaecological
Pelvic floor
BMI
Neurological
Detail
• Bladder retention on suprapubic palpation
• Abdominal distention / tenderness
• Striae and scars indicative of previous surgery
• Inspect the vulva for urogenital atrophy that causes skin pallor and loss of vulval architecture with labial shrinkage
• Inspect for vulvitis in a ‘ nappy rash ’ pattern indicative of pad use and incontinence
• Palpate for external genitalia tenderness
• Evaluate the urethral and pelvic organ descent at rest or with cough / Valsalva manoeuvre , consistent with SUI or POP ; note which vaginal compartment is prolapsing
• The Pelvic Organ Prolapse Quantification ( POP-Q ) System is the standardised system to describe POP 31
Note the speed , endurance and strength of pelvic floor contraction , which are often lowered in women with urinary incontinence , prolapse and vulvodynia If weak or tender , consider referral to pelvic floor physiotherapist
Elevated BMI is associated with both SUI and OAB ; weight loss improves both
Neurological referral ( or neuro-urological assessment ) may be indicated with new onset gait disturbance , sensory loss , severe poor warning OAB and bowel dysfunction
Box 5 . Symptoms and signs of LUTS
• Storage symptoms : — Stress incontinence . — Urge incontinence . — Urgency , the sudden desire to void from delayed awareness of filling . — Urinary frequency , more than eight voids / day . — I nsensible incontinence , ie , incontinence without awareness . — Nocturia , sleep interruption more than once / night because of the need to micturate .
• Voiding symptoms : — Urinary hesitancy , ie , delayed micturition initiation . — Straining , ie , increased effort to initiate or maintain stream . — Intermittency , ie , urine flow starting and stopping on more than one occasion during micturition . — Poor flow , ie , slow / interrupted flow compared with normal . — Terminal dribbling , ie , involuntary urine passage postmicturition . — Incomplete bladder emptying , ie , bladder does not feel empty postmicturition .
parasympathetic cholinergic muscarinic receptors that stimulate the bladder . The drug may take longer than four weeks to be effective . The anticholinergic drug may be M3 receptor selective ( for example , solifenacin , darifenacin ) or non-selective ( such as oxybutynin , tolterodine ).
Side effects of the anticholinergics include dry mouth , blurry vision / dry eyes , constipation , gastritis , urinary retention and confusion in elderly patients .
The contraindications include voiding dysfunction , urinary retention , narrow angle closure glaucoma , GI obstruction , dementia and increased risk of falls .
BETA 3 AGONISTS In OAB , beta 3 agonists ( such as mirabegron ) stimulate beta adrenergic receptors to inhibit bladder contraction .
These require a trial of at least four weeks . The recommended starting dose is 25mg / day with titration up to 50mg / day .
Side effects include nasopharyngitis , hypertensive effects in poorly controlled BP , tachycardia , urinary retention and constipation .
Contraindications include severe hypertension ( that is , greater than 180 / 110mmHg ) and renal or hepatic failure . Caution is advised in those with QT interval prolongation or on medications that can cause QT interval prolongation . 37
When prescribed with anticholinergics , mirabegron can contribute to anticholinergic effects .
Surgery
Surgical management is considered third line and is indicated when patients do not achieve adequate control with conservative management .
SURGERIES FOR SUI Bulking agents This involves the injection of hydrogel or silicone into the proximal urethral walls to improve mucosal coaptation . Repeat injections are often required ( see figure 4 ). This is useful for SUI where larger procedures are to be avoided and works best in those with a well-supported urethra .
A long-term success rate of 42-70 % has been reported , with a short-term success rate of 30-90 %. 38
Side effects include worsening UI , infection / abscess and urethral erosion , bulking agent extrusion , and de novo urgency in 12.5 % of patients . 39
Transvaginal mid-urethral mesh sling Synthetic polypropylene mesh is placed at the mid-urethral level via a small vaginal incision and the mesh exits through incisions in the suprapubic region . This applies pressure to prevent leakage from increased intra-abdominal
Box 6 . Points to cover on history
• LUTS severity and treatment to date :
— Explore the social , emotional and physical impact of these symptoms ( eg , does leakage prevent the patient from socialising or leaving home ?). Being housebound by incontinence is a severe disability that needs more urgent treatment than mild leakage that affects exercise choices .
— Explore current and attempted management methods ( eg , pad usage , medications , pelvic floor physiotherapy , vaginal oestrogen ).
— Ask about the presence of vaginal bulge , dragging discomfort or heaviness that is relieved on lying down ; pelvic organ prolapse can often co-exist and , in severe cases , contribute to urinary symptoms .
— Explore whether vaginal dryness is an issue , as this this may impact the infection risk . Vulvovaginal discomfort is easily rectified in a menopausal woman by using topical treatment . — Consider frequent UTIs and whether prevention is required . — Assess whether obstructive sleep apnoea is contributing to nocturnal enuresis or nocturia related to polyuria . — Questionnaires , such as the International Consultation on Incontinence Questionnaire , may be used to help understand the patient ’ s bladder and bowel symptoms ( see figure 2 ).
• Bowel symptoms : — Are these concomitant ? — If so , and they are severe and associated with new onset OAB , this may suggest a spinal disorder . However , pelvic floor muscle dysfunction may be associated with concomitant urinary and bowel symptoms . This may be associated with a childbirth injury or habit-based pelvic floor dysfunction and may respond to pelvic floor physiotherapy . — Treat constipation as this can worsen a patient ’ s urinary symptoms . 29
• Red flag symptoms : — Haematuria , especially in the absence of a UTI or in the presence of risk factors for urothelial carcinoma such as smoking , chemical exposures to aromatic amines and pelvic radiotherapy . This raises concern regarding urothelial carcinoma as a cause of the symptoms .
— Flank pain may occur as a result of unilateral or bilateral hydronephrosis in patients with severe urinary retention .
• Obstetric history : — Parity , instrumental delivery and high gestational birth weight are risk factors for SUI and POP . — LUT recovery following delivery may be partial . — Is the family complete ? Treatment may be considered even if the family is incomplete .
• Surgical and gynaecological history : — Hysterectomy +/ - oophorectomy may impact contractility , sphincter function and bladder compliance . — POP treatment and its success . — Surgical treatment ( s ) for incontinence and its success . — Whether mesh has been used as part of the repair ; a record of the operative procedure is required if this is unclear . — Other gynaecologic conditions and their treatment , eg , cancer , endometriosis . — Other abdominal surgery , because some bowel surgeries can damage the nerve supply to the LUT .
• Past medical history : — UTIs . — Diabetes mellitus may contribute to poor bladder emptying or chronic urinary infection that may complicate incontinence .
— Breast cancer , endometrial cancer and history of DVT or pulmonary embolus are relevant in the consideration of topical oestrogen ( which is still likely to be acceptable in risk / benefit profile even in oestrogen receptor positive tumours ). 30
— Conditions that may impact LUT function , such as neurological conditions , diabetes mellitus and ageing ( all may be associated with OAB and / or impaired contractility ). Impaired contractility is often called detrusor underactivity . — Consider respiratory status and chronic cough , which may impact on the potential value of SUI treatment .
• Current medications : — Diuretics ( including alcohol and caffeine ). — Anticholinergic drugs and calcium channel blockers that may promote constipation and poor bladder emptying . — Analgesics may cause constipation and decreased awareness of bladder filling .
• Pain associated with voiding is typically a feature of painful bladder syndrome . This condition is a differential diagnosis of OAB and is differentiated by discomfort or pain rather than leakage when voiding is deferred .