Management of urinary incontinence

Urinary incontinence is a common problem affecting 25–45% women. Effective management can have a huge impact on a patient’s quality of life and many treatments are available. Management should be dictated by the degree of bother the symptoms are having, and vary depending on the type on incontinence. Conservative measures should always be initiated, including optimisation of body mass index and smoking cessation. Overactive bladder and urge urinary incontinence can be improved with bladder retraining and avoidance of bladder stimulants. Medical treatment then includes anticholinergic medications or Mirabegron. More invasive options include Botulinum Toxin A (Botox®) injections, sacral nerve stimulation or urological surgery. Stress urinary incontinence should be managed initially with pelvic floor exercises, and input from a specialist nurse or physiotherapist is beneficial. The surgical options for managing stress incontinence have changed considerably over the years, but include bladder neck injections, mid-urethral slings, colposuspension or autologous fascial slings. Mixed urinary incontinence is more challenging to manage, but all conservative measures should be started. Further treatment is directed towards the predominant symptom, but overactivity should be controlled before surgical measures for stress urinary incontinence are performed.

A randomised, double-blind, placebo-controlled clinical trial assessing the efficacy of bedtime buddy® for the treatment of nocturnal enuresis in children

Background Nocturnal enuresis (NE), or ‘bedwetting’, is a form of night-time urinary incontinence occurring in younger children. A diagnosis of NE can be socially disruptive and psychologically stressful for a child. The most common strategies used by parents to manage NE are waking the child during the night to use the bathroom and limiting the child’s water intake before going to bed. Behavioural or educational therapies for NE such as urotherapy or bladder retraining are widely accepted and considered as a mainstream treatment option for non-neurogenic lower urinary tract dysfunction in children. Pharmacotherapy also plays an ancillary role. However, there is no gold standard therapy or intervention to effectively manage NE. Methods This study aims to determine the efficacy of a herbal combination in the treatment of NE in children. The target population for this study is 80 children aged between 6 and 14 years old (males and females) who have primary nocturnal enuresis ≥3 per week (wet nights). The active group will receive one or two capsules per day containing 420 mg of a proprietary blend of Urox® (Seipel Group, Brisbane, Australia) containing Cratevox™ (Crataeva nurvala L; Capparidaceae; Varuna) stem bark extract standardised for 1.5% lupeol: non-standardised Equisetum arvense L. (Equisetaceae; Horsetail) stem extract; and, non-standardised Lindera aggregata Sims. The primary outcome for this study is the frequency of nocturia. Secondary outcomes include safety, quality of life, and daytime incontinence. Each participation will be involved in the trial for 32 weeks including contact with the research team every 2 weeks for the first 8 weeks and then every 8 weeks until trial completion. Discussion This study examines a novel treatment for an under-researched health condition affecting many children. Despite the availability of several therapies for NE, there is insufficient evidence to support the use of any one intervention and as such this randomised placebo-controlled phase II trial will be an important contribution to understanding potential new treatments for this condition. Trial registration Australian and New Zealand Clinical Trials Registration Number: 12618000288224. Protocol: 23 February 2018, version 1.1.

Multifaceted self-management interventions for older women with urinary incontinence: a systematic review and narrative synthesis

ObjectiveTo synthesise the evidence for the multifaceted self-management interventions for older women with urinary incontinence (UI) and to understand the outcomes associated with these interventions.DesignA systematic review and narrative synthesis to identify randomised controlled trials that investigated the effect of multifaceted self-management interventions for older women with UI.MethodsMEDLINE, PsycINFO, EMBASE, The Cochrane Library, CINAHL and Applied Social Sciences Index and Abstracts databases were searched (January 1990 to May 2019) using a systematic search strategy, complemented by manually screening the reference lists and citation indexes. Study selection, data extraction and risk of bias assessment were undertaken independently. A narrative synthesis was undertaken in which studies, interventions and outcomes were examined based on the intervention components. The effect size and 95% CI were estimated from each study.ResultsA total of 13 147 citations were identified and 16 studies were included. There was no study rated as of high quality. Three types of multifaceted interventions were found: those that had an element of pelvic floor muscle exercises (PFME), those with bladder retraining and some with combination behavioural interventions. Outcome measures varied across studies. A statistically significant improvement in incontinence symptoms was reported in the intervention group compared with the control in 15 studies.ConclusionMultifaceted interventions that included PFME, bladder retraining or combination behavioural techniques appear to be useful in some settings for UI management in older women, but the quality of the evidence was poor and unclear. There was insufficient evidence to determine whether any of the combination of components is superior to others in improving UI symptoms. There is a need for high-quality studies to confirm the effectiveness of these interventions and to identify comparative effectiveness.PROSPERO registration numberCRD42018104010.

EFFICACY OF ANTICHLONERGIC DRUGS IN IDIOPATHIC OVERACTIVE BLADDER.

Background: Symptoms of overactive bladder include urgency, frequency, and urge incontinence, with or without noctiuria. Symptoms are common in adults. The two main treatment options for overactive bladder syndrome are bladder retraining and anticholinergic drugs. Study Design: Cross sectional study. Setting: Urology Department, Kot Khawaja Saeed Hospital, Lahore. Period: January to June 2017. Methodology: Eighty patients were enrolled after informed consent. All patients were subjected to 5mg solifenacin succinate for three months. International Consultation on Incontinence Questionnaire-Urinary Incontinence (ICIQ-UI) was utilized to assess patient symptoms. Results: There 56 males (70%) and 24 female (30%) with mean age of 43 ± 1.6 years. Efficacy of solifenacin was found in 61 cases out of 80 patients. On first visit 19 (31%) patients were cured, 17 (28%) on second month follow up and 25 (41%) were cured on third month follow up. Conclusion: Solifenacin has significant role in managing patients with overactive bladder. It has a relatively safe side effect profile.

Urogynaecology and pelvic floor

This task assesses the following clinical skills: … ● Patient safety ● Communication with patients and their relatives ● Information gathering ● Applied clinical knowledge … You are a ST5 doctor in the urogynaecology clinic. You are asked to see Amanda Scott, who is a 64- year- old woman. She has been referred by her GP with mixed urinary incontinence which has not responded to supervized pelvic floor muscle training, bladder retraining and Tolterodine. She is para 2 with two spontaneous vaginal deliveries. She has no significant medical or surgical history. Previous examination did not reveal any pelvic organ prolapse. A urodynamic study was performed before her clinic appointment (see Fig 19.1). Amanda wishes to know more about the urodynamic findings and management options available to her. You will have ten minutes for the initial discussion. Once you have finished discussion with Amanda the assessor will ask you some questions. You have 10 minutes for this task (+ 2mins initial reading time). Please read instruction to candidate and actor. There are some marks on the process mark sheet for the actor to assign at the end of the station. Record your overall clinical impression of the candidate for each domain (i.e. should this performance be pass, borderline, or a fail). You are Amanda Scott, a 64- year- old mother of two. You have been experiencing a sudden, desperate need to pass urine and urine leakage if you don’t get to the toilet on time for the last three years. You also have episodes of unwanted loss of urine on coughing, laughing, physical exercise, and sexual intercourse. Your bowel function is normal and you are not aware of any vaginal ‘bulge’. You went through the ‘change’ (menopause) at the age of 52. You had two uneventful normal (vaginal) births. You are healthy without any previous operations. You have seen a physiotherapist for pelvic floor exercises and you have tried a drug for your bladder called Tolterodine (one 2mg tablet twice a day). Unfortunately, you haven’t seen any improvement of your symptoms.

Utility and cost-effectiveness of uroflowmetry in a busy pediatric urology practice

Introduction: Uroflowmetry (UF) is frequently employed in daily pediatric urology practice for diagnostic and follow-up purposes. We assess the utility and cost-effectiveness of UF in the management of patients seen at a tertiary care centre.Methods: We retrospectively reviewed the charts of consecutive patients who had a UF between January 1, 2010 and March 31, 2010. We collected data on demographics, diagnosis, UF parameters and the impact of the UF on management. The impact on management was defined as indication for surgery, introduction of new medications and bladder retraining based on clinical and UF findings.Results: In total, 524 patients were included in the study. In 63 (12%) patients, UF was performed as part of the evaluation at the first clinic appointment. The most common diagnoses were voiding dysfunction (VD) 41%, hypospadias 26%, vesicoureteric reflux (VUR) 16%, monosymptomatic nocturnal enuresis (NE) 8%, posterior urethral valves 5% and meatal stenosis (MS) 4%. In the VD group, UF contributed to a management decision in 25.2% of patients. In the MS group, surgical intervention was based on symptoms and supported by the UF in 41% of patients; in the PUV group, 50% of patients demonstrated high (>20 cc) post-void residual, which aided in management decisions. In contrast, there were virtually no changes in management supported by the UF in the NE, VUR and hypospadias groups. Overall, UF parameters had a direct influence in the management decisions in only 67 (12.8%) patients. Nonetheless, a repeat test was ordered for 44.5% of patients.Conclusions: In an era of financial restraints and in a busy tertiary pediatric urology practice, judicious use of UF for specific indications may translate into a more cost-effective use of time and resources. As expected, patients with VD were the ones that benefited most from the test, as did patients with symptomatic MS and PUV.

Systematic review of overactive bladder therapy in females

Although the prevalence of overactive bladder (OAB) is similarin both male and female populations, females have a greater tendencyto seek medical advice regarding their symptoms. A reviewof the evidence of therapy among women shows that a variety ofmodalities has been shown to be effective for symptom improvementin women with OAB. Bladder retraining/re-education shouldbe considered for all women with OAB. With respect to first-linepharmacotherapy with antimuscarinic agents, the development ofextended release preparations, bladder selective M3 antagonistsand alternative routes of delivery, have improved compliance andpersistence. Other pharmacotherapeutic options with potential forproviding benefit include antidepressants, vasopressin analogues,alpha-adrenoceptor antagonists and beta-adrenoceptor agonists.There are also a number of newer agents currently being investigated,including calcium channel blocking agents, potassium channelopening drugs, beta agonists and neurokinin receptor antagonists.Intravesical injections of botulinum toxin may be an alternative,while surgery can be considered for truly intractable cases.

Neurogenic Bladder

Congenital anomalies such as meningomyelocele and diseases/damage of the central, peripheral, or autonomic nervous systems may produce neurogenic bladder dysfunction, which untreated can result in progressive renal damage, adverse physical effects including decubiti and urinary tract infections, and psychological and social sequelae related to urinary incontinence. A comprehensive bladder-retraining program that incorporates appropriate education, training, medication, and surgical interventions can mitigate the adverse consequences of neurogenic bladder dysfunction and improve both quantity and quality of life. The goals of bladder retraining for neurogenic bladder dysfunction are prevention of urinary incontinence, urinary tract infections, detrusor overdistension, and progressive upper urinary tract damage due to chronic, excessive detrusor pressures. Understanding the physiology and pathophysiology of micturition is essential to select appropriate pharmacologic and surgical interventions to achieve these goals. Future perspectives on potential pharmacological, surgical, and regenerative medicine options for treating neurogenic bladder dysfunction are also presented.