HOT TOPIC

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HOT TOPIC

• MANAGEMENT OF URINARY INCONTIENCE IN WOMEN

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CHOICE OF TOPIC

• COMMON
• NEW SIGN GUIDELINES 2004
• NICE GUIDELINES 0CT 2006
• RELEVENT TO GENERAL PRACTICE

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TOPICS COVERED

• TYPES OF INCONTINENCE
• ASSESSMENT AND IX IN PRIMARY CARE
• CONSERVATIVE MANAGEMENT
• SURGICAL MANAGEMENT
• RELATIONSHIP TO GUIDLINES

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WHY IS IT IMPORTANT

• COMMON
• INFLUENCES PHYSICAL, PSYCHOLOGICAL AND SOCIAL
  WELLBEING OF AFFECTED PATIENTS

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• 3 MILLION INCONTINENT WOMEN IN UK LESS THAN 20
  ARE INVESTIGATED OTHER THAN AN MSU
• ONLY SMALL PORPORTION GET HELP FROM SOCIAL
  SERVICES

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WHAT IS IT

• INVOLUNTARY LEAKAGE OF URINE
• STRESS INVOLUNTARY LEAKAGE OF URINE ON EXERTION
  / COUGHING
• URGE INVOLUNTARY LEAKAGE OF URINE PRECEEDED BY
  URGENCY
• MIXED SYMPTOMS OF BOTH

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INVESTIGATION

• GOOD HISTORY TO DETERMINE TYPE
• FREQ VOLUME CHART
• QUALITY OF LIFE QUESTIONNAIRE
• ABDO EXAM (RULE OUT MASS)
• PELVIC FLOOR ASSESSMENT
• PROLAPSE?
• URINALYSIS ?MSU

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WHAT OTHER INVESTIGATIONS?

• CYSTOSCOPY NOT RECOMMENDED IN PRESCENCE OF UI
  ALONE
• ULTRASOUND ONLY USEFUL IN ASSESSMENT OF RESIDUAL
  URINE VOLUME

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CONSERVATIVE TREATMENT

• DECREASE CAFFEINE
• MODIFY FLUID INTAKE
• LOOSE WEIGHT IF BMI gt30
• PELVIC FLOOR EXERCISES STRESS/MIXED INCONTINENCE
  CONTRACTIONS 3 TIMES DAILY FOR 3 MONTHS

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CONSERVATIVE MANAGEMENT

• BLADDER TRAINING FOR URGE INCONTINENCE MIN 6
  WEEKS
• OXYBUTYNIN IF BLADDER RETRAINING INEFFECTIVE MIN
  6 WEEKS
• ALT TX TOLTERIDONE/ TRANSDERMAL OXYBUTYNIN
  PERSIST FOR 6/12
• OXYBUTYNIN COST EFFECTIVE

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DRUG TX

• OXYBUTYNIN ANTIMUSCARINIC REDUCES CONTRACTIONS
• SIDE EFFECTS
• DRY MOUTH,DRY EYES ETC

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WHEN TO REFER

• UROLOGY
• MICROSCOPIC HAEMATURIA OVER 50
• VISIBLE HAEMATURIA
• RECURRENT UTI AGED OVER 40
• SUSPECTED MALIGNANT MASS
• GYNAE
• PROLAPSE
• CONSERVATIVE TREATMENT FAILURE

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WHAT HAPPENS IN SECONDARY CARE

• URODYNAMICS
• USED PRIOR TO SURGERY
• NOT NECESSARY TO REFER ROUTINELY
• EXPENSIVE,LONG WAITING TIME
• ?BENEFIT

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NORMAL BLADDER URODYNAMICS

• NORMAL BLADDER NO SENSATION OF URGENCY UP TO
  400ML
• VOIDING GOOD FLOW RATE
• EMPTIES BLADDER COMPLETELY

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URODYNAMICS

• URGENCY LEAKAGE OF URINE PRIOR TO NORMAL
  BLADDER CAPACITY
• BLADDER OUTFLOW OBSTRUCTION LOW FLOW AT HIGH
  PRESSURE
• STRESS- INCREASING INTRAABDOMINAL PRESSURECAUSES
  LEAK BUT DETRUSTOR PRESSURE NORMAL,

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SURGICAL MANAGEMENT

• SACRAL NERVE STIMULATION FOR URGE INCONTINENCE
• BOTULINUM TOXIN A URGE INCONTINENCE
• TVT STRESS INCONTINENCE

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TVT

• MINIMALLY INVASIVE
• STRESS INCONTINENCE
• DOCTOR APPLIED RIBBON LIKE STRIP WHICH SUPPORTS
  URETHRA
• 2 INCISIONS ABOVE PUBIC BONE SLING BETWEEN
• RESTORES CONTINENCE IN 80
• 94 SOME IMPROVEMENT

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OTHER OPTIONSSUGGESTED IN NICE

• DESMOPRESSIN NASAL SPRAY
• DULOXETINE FOR SI SRTI AND NORADRENALINE REUPTAKE
  INHIBITOR HELP BLADDER NECK MUSCLES ? INCREASE
  BLADDER CAPACITY
• INTRAVAGINAL OESTROGEN IS SUITABLE FOR PT WITH
  URGE SYMPTOMS AND ATROPHY
• CONTINENCE AIDS

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IN TAYSIDE

• UROGYNAE DR ALLEN PRI
• URODYNAMICS PRI

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REFERENCES

• (1) SIGN GUIDELINE NUMBER 79
• (2) rcog.org.uk/resources/Public/doc/stressin
  continence.doc
• (3) NICE GUIDELINE OCT 2006