Australian Doctor 13th Sept Issue | Page 34

13 SEPTEMBER 2024 ausdoc . com . au

Table 5 . MSU results Aspect Urine specimen 1 Urine specimen 2

Chemistry pH : 7.0 Protein : Trace Glucose : Nil Blood : Nil

Microscopy Leucocytes : 11x10 6 / L ( normal less than 10 ) Erythrocytes : 30x10 6 / L ( normal less than 10 ) Epithelial cells : + pH : 6.0 Protein : Nil Glucose : Nil Blood : Nil

Leucocytes : 20x10 6 / L ( normal less than 10 ) Erythrocytes : 67x10 6 / L ( normal less than 10 )

in those with contraindications to , or deemed unsuitable for , onabotulinumtoxinA or sacral neuromodulation . Short-term success rates of 54-79 % are reported . 47

Contraindications include bleeding risk , pregnancy , presence of a pacemaker or defibrillator .

Transcutaneous tibial nerve stimulation This stimulates the posterior tibial nerve via a TENS machine with standard electrodes ( see figure 7 ), to inhibit reflex bladder contractions .

There is limited evidence regarding benefits , efficacy , the most effective stimulation dosage and treatment duration . 48

Augmentation cystoplasty and urinary diversion In very severe cases , bladder augmentation may be considered . This procedure involves ‘ patching ’ a piece of detubularised small bowel on to the bladder to surgically enlarge the bladder capacity . Urinary diversion with ileal conduit may be considered in suitable patients . These options require complex work-up and are rarely considered .

LONG-TERM IN-DWELLING CATHETER A long-term suprapubic catheter may be considered as a final treatment option . This will not improve urgency symptoms , although onabotulinum toxin may be used in refractory cases .

INDICATIONS FOR SPECIALIST REFERRAL

THESE are listed in box 7 .

PROGNOSIS

THERE is a surprising lack of robust long-term data on the probability of cure from effective treatment of allcause OAB . Onabotulinum toxin may be repeated in an ongoing fashion for refractory OAB . SNS is associated with long-term benefit . 49

Box 7 . Indications for specialist referral

• Failure of conservative treatment

• Severe UI of any type

• Red flag symptoms , eg , haematuria or pelvic pain

• Before surgery or other irreversible treatment

• Patient presenting with multiple or complex symptoms

• Concomitant high residual volumes or outright urinary retention

• For risk assessment for the upper urinary tract in spinal pathology

The most robust data on treatment of SUI comes from the SISTE-r trial and TOMUS studies of the Urinary

50 , 51

Incontinence Treatment Network . Five-year retreatment-free survival rates for Burch colposuspension , fascial sling , mesh transobturator and

URINARY INCONTINENCE IN WOMEN

GO ONLINE TO COMPLETE THE QUIZ ausdoc . com . au / how-to-treat mesh retropubic slings were 87 %, 96 %, 97 % and 99 %. 52

There is room for a robust , longterm real-world study of all-cause incontinence .

CASE STUDY

LINDA , a 54-year-old nulliparous woman , consults her GP about increasingly severe OAB . This started when she was aged 16 years . Aside from a history of a previous renal calculus , Linda is in good general health . She is an ex-smoker .

She has had three UTIs in the past six months . Linda reports that she sometimes has the sensation of needing to bear down during an episode of UTI .

Linda ’ s bedside examination is normal , with no pelvic masses or pelvic organ prolapse noted . The results of two consecutive MSU specimens appear in table 5 .

Linda is diagnosed with mixed UI . Multiple factors can contribute to mixed UI . Management starts with a history and physical examination , followed by simple tests such as voiding chart , urine culture and urinary tract ultrasound . Her voiding chart surprisingly demonstrates a very high urine output , which will make even a mild degree of leakage seem severe . Linda is advised to adjust her intake aiming for an output of 2L , at the upper end of the output range given her history of a renal calculus . The usual recommendation is 1.5 – 2L .

Pelvic floor physiotherapy is suggested , and topical oestrogens can be considered if urogenital atrophy is observed . This helps both the dryness and the tendency to recurrent UTI associated with urogenital atrophy .

Methamine hippurate 1g bd plus 1g vitamin C are prescribed to resolve the persistent UTI , and a follow-up urine specimen is planned to ensure the sterile pyuria has resolved . If this persists , a cystoscopy is indicated .

Oral medications are appropriate and the bladder-selective agents solifenacin and darifenacin , and the beta 3 agonist , mirabegron , have the fewest side effects . Low doses of oxybutynin ( 2.5mg bd ) or transdermal patches are often helpful and are cheaper options . Third-line options such as onabotulinumtoxin or SNM may be considered if the problem is refractory .

a Anticholinergic medications are commonly used as treatment for OAB . b Poor detrusor reflex emptying is not improved by pharmacology . c M2 receptors are the main receptors responsible for cholinergic contractions . d Activated α-adrenergic and β-adrenergic receptors lead to bladder relaxation .

4 . Which ONE is not part of the DIAPERS mnemonic for transient incontinence ? a Restricted mobility . b Stool impaction or faecal loading . c Dementia . d Infection ( chronic urinary tract infection ).

5 . Which THREE are risk factors for SUI ? a Pregnancy , vaginal delivery , hysterectomy . b Spinal pathology such as multiple sclerosis or spinal cord injury . c Obesity , smoking . d Strenuous activity , chronic cough , constipation .

6 . Which THREE in combination can result in a formulation and treatment regimen in most cases ? a History . b Examination . c Urodynamic studies . d MSU .

7 . Which THREE are appropriate to consider when assessing patients with UI ? a Bladder retention on suprapubic palpation . b Evaluation of the urethral and pelvic organ descent at rest or with cough / Valsalva manoeuvre . c Neurological referral in all cases of UI . d Urine dipstick and mid-stream urine test .

EARN CPD OR PDP POINTS

• Read this article and take the quiz via ausdoc . com . au / how-to-treat

• Each article has been allocated one hour by the RACGP and ACRRM .

• RACGP points are uploaded every six weeks and ACRRM points quarterly .

8 . Which TWO lifestyle changes are appropriate in the management of UI ? a Weight loss . b Increased fluid intake to prevent UTI . c Pelvic floor muscle training . d Reduce fibre in diet

9 . Which THREE statements regarding the management of urinary incontinence are correct ? a Topical hormone replacement therapy is indicated in all cases . b Anticholinergics and beta 3 agonists may take longer than four weeks to be effective c Surgical management is considered as third line . d A long-term suprapubic catheter may be considered as a final treatment option .

10 . Which THREE are indications for specialist referral ? a Failure of conservative treatment . b All UI . c Red flag symptoms , eg , haematuria or pelvic pain . d Before surgery or other irreversible treatment .

CONCLUSION

GPs have an important role in the diagnosis and management of UI . It is important to be aware of the resources available to help with the assessment and support of these patients . A multidisciplinary team of urologists , urogynecologists and geriatricians can provide more advanced diagnostic investigations and management .

RESOURCES

• Continence Foundation of Australia bit . ly / 3NYgCH5

• Continence Foundation of Australia Helpline 1800 33 00 66

• Australian Government : myagedcare : Caring for someone with incontinence bit . ly / 3HgedUG

• Health Pathways Melbourne ( requires sign in ) bit . ly / 3vCyhy1

• Australian Government Department of Health and Aged Care : Bladder and bowel bit . ly / 420D88e

• National Continence Program : The National Public Toilet Map bit . ly / 41ZOJo3

References Available on request from howtotreat @ adg . com . au