Diagnosis
- Initial assessment categorise as:
- Stress incontinence
- Urgency / Overactive Bladder (OAB)
- Mixed: if stress predominates discuss OAB drugs before surgery
- Urgent Referral:
- Microscopic haematuria in women aged 50 years and older
- Visible haematuria
- Recurrent or persisting UTI associated with haematuria in women > 40 years
- Suspected malignant mass arising from the urinary tract
- Refer if palpable bladder post void
- Consider referral: persisting bladder/urethral pain; clinically benign pelvic masses; faecal incontinence; suspected neurological disease; voiding difficulty; suspected urogenital fistulae; previous continence surgery; previous pelvic cancer surgery; previous pelvic radiation therapy
Investigation
- DRE to routinely confirm pelvic floor muscle contraction before supervised muscle training
- Prolapse: symptomatic and at or below vaginal interoitus refer to specialist
- Urine Dip: if UTI then culture and sensitivity and treat accordingly, if dip +ve leucocytes and nitrates do not offer Abx till culture and sensitivity
- Measure post-void residual volume by bladder scan (preferred) or catheterisation in women with symptoms suggestive of voiding dysfunction or recurrent UTI
- Cystometry (multichannel) filling and voiding, before surgery in women who have:
- Symptoms of storage dysfunction: OAB leading to a suspicion of detrusor over-activity
- Symptoms suggestive of voiding dysfunction or anterior compartment prolapse
- Previous surgery for stress incontinence
Management
Conservative
- Lifestyle interventions:
- Caffeine reduction in OAB
- Fluid intake modify if high or low
- BMI > 30 to lose weight
- Pelvic Floor Muscle Training: First line for 3 mths with stress or mixed UI (8 contractions 3 x day), and as preventative management for first pregnancy
- Electrical stimulation biofeedback considered to motivate if cannot actively contract pelvic floor
- Bladder training: if not satisfactory add an OAB drug
- Absorbent products only as coping strategy pending definitive treatment, and as an adjunct
Catheters
If persistent retention causing incontinence, symptomatic infections, renal dysfunction
- Intermittent urethral catheterisation if can be taught to self-catheterise
- Long-term indwelling urethral catheterisation: if can’t self catherise, other issues
- Indwelling suprapubic catheters considered as an alternative to long-term urethral catheters
Pharmacological Management
- Anti-muscarinic OAB drugs: discuss S/E, lowest effective dose, considering other co-morbidiites
- First Line: Oxybutynin (immediate release), Tolterodine (immediate release), Darifenacin (OD)
- If OAB not successful, discuss at MDT options for further management (non therapeutic / invasive)
- Desmopressin: specifically to reduce nocturia
- Oestrogens (Intravaginal) to treat OAB symptoms in postmenopausal women with vaginal atrophy
Invasive Procedures for OAB
- Botulinum toxin A: discuss intermittent catheterisation needed for variable lengths of time
- Neurostimulation: percutaneous posterior tibial nerve or percutaneous sacral stimulation only if conservative treatment ineffective and Botulism type A declined
- Augmentation cystoplasty: conservative failed and who are willing and able to self-catheterise
- Urinary Diversion: conservative, botulism, nerve stimulation failed
Surgical Approaches
If conservative management for SUI has failed, offer:
- Synthetic mid-urethral tape: transobturator approach, make aware of lack of long-term data
- Open colposuspension:
- Autologous rectus fascial sling