Urinary incontinence

Island Docs are generalists.  We strive to maintain a breadth of knowledge rather than focus on a particular specialty field.  In our efforts to provide high quality patient care, we work hard to keep up to date with the latest evidence and guidelines.  We are lucky to receive regular visiting specialists, who continue to teach us and support us.  In this section, we go back to basics and present approaches to common conditions seen in rural general practice.  We’ll also try to include any hot tips and tricks from our visiting specialists.

GP Summary: Urinary Incontinence
FROGS Outreach Teaching 13/03/2018

Urinary incontinence in women is common and likely affects many women in the Torres Strait.  It can have a significant impact on quality of life and some women avoid seeking health care due to lack of knowledge, embarrassment or fear.  Health practitioners don’t always explore urinary symptoms opportunistically and this session has helped to reinforce the importance of asking and assessing women for urinary symptoms. 

Definition: involuntary loss of urine
Impact: QOL, sexual function, perineal infections, falls & fractures

1. Stress – effort, exertion eg. cough, sneeze
2. Urge – urgency
3. Mixed
4. Overflow – dribbling, hesitancy

Patient Questionnaires:
The 3 Incontinence Questions (3IQ)
Melbourne Bladder Clinic Urinary Incontinence Questions

Other history:
Age >65yo
Bladder diary for 3 days (eg. Continence Foundation Bladder diary)
Urinary: frequency, volume, nocturia
Fluid intake: volume, type
Precipitants: soft drinks, caffeine
Pads/pull ups (indicate severity)
Recurrent UTI or haematuria
Faecal incontinence
Vaginal atrophy or prolapse
Gynae hx
Obs hx: increased risk with multiparity
PMHx: diabetes, neurological disease, previous bladder/cervical cancer, cognitive impairment
Meds: opioids, antihypertensives, antidepressants, diuretics, anticholinergics, benzos
Lifestyle: obesity, very active (eg. running, jumping)

Abdominal exam
Bladder stress test – standing/lithotomy – monitor for urinary loss when coughing
Vaginal atrophy, prolapse
Pelvic floor muscles (PFM) – modified Oxford grading system 0-5

Modified Oxford Grading System (digital palpation of vagina PFM):
0 – no contraction
1 – flicker
2 – weak squeeze, no lift
3 – fair squeeze, no lift
4 – good squeeze with lift
5 – strong squeeze with a lift

MSU +/- cytology
Post-void urinary residual (<150ml is abnormal)
Urodynamics/cystoscopy/radiology – not usually required in first instance

Indications for referral:
Persisting pain
Pelvic mass -> obstruction
Palpable bladder post-void
Faecal incontinence
Neurological disease
Symptoms of voiding difficulty
Urogenital fistula
Previous continence surgery, cancer, radiotherapy
Prolapse beyond the hymen

Lifestyle modification:
Weight loss
Avoid alcohol, caffeine
Less fluid intake
Smoking cessation
Manage constipation

Stress incontinence:
Local oestrogen
Physio PFM exercises for 3/12 (8 contractions 3x daily)
Then refer for consideration of surgical management

Overactive bladder:
Lifestyle (as above)
Bladder training
Anti-muscarinics – oxybutynin 2.5mg BD -> 5mg QID (or patches)
Contraindications include MG, glaucoma, >70yo (relative), tachyarrhythmias
SEs – dry mouth, constipation, blurred vision, reduced cognition
Mirabegron – newer agent; less SEs; contraindicated in uncontrolled hypertension

Further reading:
AAFP: Diagnosis of urinary incontinence (2013)
AAFP: Clinical management of urniary incontinence in women (2013)