Incontinence management in primary care is often a difficult topic, as there seem to be a number of possible diagnoses and the assessment can take time.
This brief article aims to bring some clarity to the situation and provide a framework upon which to gather relevant information and begin the assessment and treatment process efficiently.
Firstly, the discussion will be around women, but many of the themes apply to men also. Initially consider the patient’s age, those in the geriatric group will potentially have a longer and more complicated history and there are more considerations, neatly summarized in the “DIAPPERS” pneumonic (see below).
For those younger patients, try and determine if the leakage relates to activity (stress urinary incontinence) or is associated with urgency, the desire to void that is difficult to defer. The latter patient will have trouble “holding on” and may have associated frequency and nocturia. This is in keeping with the clinical condition, overactive bladder.
Important discriminators between those with stress urinary incontinence or overactive bladder causing urge incontinence and those with complicated diagnoses or “don’t miss” conditions are the presence of any haematuria, recurrent UTI, neurological condition or new symptoms or previous surgery or radiotherapy. Look for these on history and examination and in all cases screen with a mid stream urine and renal tract ultrasound. These steps will lead to excluding most important issues such as those mentioned along with urinary tract malignancy. Certainly if they are normal, a trial of conservative therapy may begin.
Using a bladder diary and a tool like the Queensland Health Female Pelvic Floor Questionnaire covers many domains in an efficient, quantifiable way. The addition of a bladder diary will lead to a very comprehensive first line assessment and many issues of fluid intake and associated urinary frequency and volume and the presence and magnitude of nocturia can be assessed. These can be given to patients after an initial conversation about their symptoms, along with an MSU and a renal tract ultrasound request, and a follow up appointment can be made to discuss the outcome and the recommended treatment plan.
Most types of incontinence in women will benefit from input from a recognized pelvic floor physiotherapist. With a normal MSU and renal tract ultrasound, an initial appointment with the physiotherapist to teach bladder retraining in cases of overactive bladder along with comprehensive pelvic floor assessment, bowel management and fluid intake review is all that many patients will require. If medication is deemed necessary this can be used as an adjunct and the simplest anticholinergic is the Oxytrol patch, which is available on the PBS. A good summary of the management of overactive bladder is found in the new conjoint guidelines, recently published by the Urological Society of Australia and New Zealand and the Urogynaecological Society of Australia (website link).
Where conservative and medical management fails in overactive bladder, specialist urological assessment can be done with urodynamic studies with a view to further therapy with either injection of Botulinium Toxin A or Sacral Neuromodualtion, a type of “bladder pacemaker”.
For stress incontinence, starting with physiotherapy is also very worthwhile along with lifestyle changes such as weight loss and control of coughing (smoking cessation). Correction of vaginal atrophic changes with topical vaginal estrogen is also of benefit. Beyond this, referral for surgery is appropriate and most patients will know after about three visits to the physiotherapist, if they are happy with the outcome of their treatment or would like a urological opinion regarding possible surgery.
The commonest procedure for stress urinary incontinence is a mid urethral sling. These are synthetic and placed transvaginally, with an exit either suprapubic or in the inner thigh. There are other options including fascia instead of synthetic, injectable bulking agents which are helpful for older patients or multiply operated patients. A full discussion of the options can be done after specialist referral and after urodynamic studies have been performed.
Patients with mixed symptoms can still be referred to the physiotherapist and have a trial of medication for their urgency. If they do not make good progress further investigation and specialist urological assessment is warranted.
The management of incontinence should be comprehensive but take into account patient expectations and co-morbidities. There are many options available and good medical management and physiotherapy will often suffice. It is important to assess for associated issues in elderly patients that may impact.
Excellent patient information can be found on the IUGA website.
AUTHOR | Dr Caroline Dowling
Dr Caroline Dowling is a urologist with an interest in incontinence and prolapse. She has post fellowship training in neurourology and
urodynamics and also has a keen interest in general urology.
View profile on Epworth Find a Doctor
PH | 03 9188 3690 WEB | www.malvernhillconsulting.com.au