Storage disorders and incontinence

CHAPTER 5 Storage disorders and incontinence



INTRODUCTION


Storage disorders are common in both men and women and are often associated with urinary incontinence. Overactive bladder (OAB) syndrome affects approximately 12% of adult males and females in the population and the prevalence increases with age, whilst urinary incontinence affects millions of individuals worldwide, 85% of whom are women. More than one-third of healthy elderly women and approximately 50% of institutionalized females suffer from incontinence with estimates indicating that as many as one in four women experience urinary incontinence during their lifetime.


OAB and particularly urinary incontinence carry a considerable social stigma; many sufferers are unable to continue with their daily activities and many give up their employment. Not only are the symptoms troublesome but they are extremely embarrassing and can have a profound psychological as well as a social, sexual and hygienic impact. Many patients adopt elaborate coping mechanisms including voiding frequently, mapping out the location of toilets, drinking less or wearing dark clothing to mask incontinent episodes. Others resort to wearing incontinence pads or sanitary towels.


However, many successful treatments are available for these conditions; therefore it is important that sufferers are offered a suitable treatment and frequently urodynamics are required to determine the most appropriate management choice. A simple algorithm for the investigation of incontinence is shown in Figure 5.1.


image

Figure 5.1 Algorithm for the investigation of urinary incontinence. Initial investigations should focus on differentiating between detrusor overactivity and urodynamic stress incontinence, although the conditions frequently co-exist as mixed incontinence. CISC, clean intermittent self-catheterization; IVU, intravenous urogram.



OVERACTIVE BLADDER SYNDROME AND URGENCY INCONTINENCE


Overactive bladder (OAB) syndrome is defined as ‘urgency, with or without urgency incontinence, usually with frequency and nocturia’. OAB can only be diagnosed if infection or other obvious pathologies that may cause the symptoms are excluded. OAB is also known as urgency syndrome and urgency/frequency syndrome. These symptom combinations are frequently associated with demonstrable detrusor overactivity (DO) during the filling phase of pressure/flow cystometry.




CLINICAL NOTES: PATIENT EVALUATION OF STORAGE DISORDERS AND INCONTINENCE


History:


• Storage symptoms.

• Factors that induce leakage.

• Pad usage and volume leaked.

• Coping mechanisms.

• Obstetric history.

• Drug therapy including previous treatments.

• Surgical history.

Physical examination:


• A palpable enlargement of the bladder post-void residual (PVR) volume.

• Stress incontinence on coughing (preferably when the bladder is full).

• Pelvic organ prolapse (POP) on coughing/valsalva.

• Urethral mucosal prolapse.

• Introital atrophy.

• Pelvic floor muscle tone.

• Abnormal neurology.

Investigations:


• Urinalysis

• Post-void residual

• Pad testing

• Bladder diary

Must exclude:


• Urinary tract infections (UTI).

• Other significant lower urinary tract abnormalities such as bladder carcinoma or calculi. A urine sample should always be assessed for the presence of haematuria, pyuria or infection.

• Chronic retention with overflow incontinence.

OAB can be further categorized as:


• OAB-dry, where there is no associated urinary incontinence

• OAB-wet, where there is associated urgency urinary incontinence.

It is believed that the driving force within OAB is the symptom of urgency, defined as ‘the complaint of a sudden compelling desire to pass urine, which is difficult to deter’ (Figure 5.2). Urgency may compel the sufferer to void more frequently than normal and to wake from sleep to void. Increased frequency can also partly be a result of an adaptive or coping mechanism to suppress urgency. If urgency is severe and the patient has little warning or is not able to reach a toilet in time, then urgency incontinence may occur. Approximately 30% of patients with OAB have urgency incontinence, although the prevalence increases significantly in the elderly with multiple co-morbidities.


image

Figure 5.2 Urgency is the pivotal symptom of OAB/. Urgency drives the other storage symptoms.


As urgency is frequently associated with detrusor overactivity (DO) during cystometry, it had been previously hypothesized that the pathology was due to dysfunction in the efferent motor innervation of the bladder. However, significant emerging evidence suggests that the dysfunction (or its central nervous system interpretation) is at least partly (if not wholly) due to afferent sensory dysfunction and this would be in concordance with the pivotal symptom of urgency being an essentially sensory symptom (Figure 5.3). Though the majority of OAB and urgency incontinence patients are classified as ‘idiopathic’, a number of clinical causes should be considered:


• Intra-vesical, for instance infection, foreign body, bladder carcinoma.

• Neurogenic disease.

• Bladder outlet obstruction such as BOO in elderly men, urethral valves in boys, bladder neck dyssynergia in young men, pelvic floor dyssynergia and consequent upon obstructing cystourethropexy.

• Iatrogenic, for example following operative treatment of stress incontinence.

image

Figure 5.3 Overlap of OAB storage symptoms, urodynamic findings and other pathologies. Showing a large correlation of symptoms with urodynamic evidence of DO. However a small subset of these patients will also have other significant pathologies.


Frequently the symptoms are triggered by certain events such as running water, ‘key in the door’, ‘foot on the floor’, giggling, exertion or female orgasm.



Management of OAB and urgency incontinence


A large number of patients are treated empirically often by their primary care physician. If successfully managed and if important pathologies such as bladder carcinoma (Figure 5.4) and UTI have been excluded then there is often little need for further investigations. Frequently however the patient may have equivocal symptoms or the condition may not respond to initial therapy; in such circumstances the patient should be referred to secondary care for a more detailed evaluation and a greater range of management options. Successful management of OAB requires that the condition is accurately diagnosed and differentiated from other lower urinary disorders such as stress incontinence.


image

Figure 5.4 Other causes of storage symptoms. (a) A superficial transitional cell carcinoma of the bladder in a patient with predominant storage symptoms. (b) Cystoscopic evidence of a suture and bladder calculus in a patient with storage symptoms following an abdominal hysterectomy.


Available and emerging treatment choices include:


• Fluid intake advice (reduce volume, reduce tea/coffee/alcohol).

• Bladder training and bladder drill.

• Anticholinergic (antimuscarinic) therapy:
image Oxybutynin (oral and patches)

image Tolterodine (oral)

image Trospium chloride (oral)

image Solifenacin (oral)

image Fesoterodine (oral).

image Propiverine (oral)

image Darifenacin (oral)

• Tricyclic antidepressant therapy (particularly elderly with nocturia):
image Amitriptyline.

• Synthetic vasopressin analogue (particularly nocturia and nocturnal enuresis):
image Desmopressin.

• Intra-detrusor botulinum toxin injections:
image Type A

image Type B.

• Neuromodulation:
image Sacral neuromodulation (mechanism unknown but may act to stimulate the Aδ myelinated fibres, especially at the S3 level. Probably enhances sphincter/pelvic tone and may inhibit the detrusor reflex)

image Paraurethral stimulation

image Pudenal nerve stimulation

image Posterior tibial nerve stimulation.

• Surgery:
image Augmentation entero-cystoplasty

image Autoaugmentation (detrusor myectomy)

image Denervation (abandoned)

image Urinary diversion:
image ileal or colonic conduit

image continent diversion

image suprapubic catheter.


Urodynamics in OAB and urgency incontinence




Voiding diaries


Should be used during the initial evaluation and subsequent monitoring to give an estimate of the frequency and voided volumes. They are also be useful in ruling out suspected nocturnal polyuria. Prior to performing invasive urodynamics a voiding diary will give an estimate of the bladder capacity, and this information should be used to prevent overfilling during the assessment.



1-hour pad test


Useful in patients strongly suspected of urinary incontinence but who have failed to demonstrate any leakage on other investigations such as video urodynamic pressure/flow studies (Figure 5.5). Approximately 30% of patients with urgency incontinence have a normal pressure/flow study. The test also gives a quantification of the degree of incontinence, as patients are usually inaccurate when asked to quantify the leakage.


image

Figure 5.5 Possible video urodynamic findings during detrusor overactivity. MCC, maximum cystometric capacity; VUR, vesico-ureteric reflux.



Uroflowmetry


Not a particularly useful test in this condition, although may be beneficial in ruling out voiding dysfunction as a cause of the storage symptoms, such as in men with mixed LUTS. Should be performed prior to pressure/flow cystometry to give a more representative indication of the voiding pattern than is possible during invasive cystometry.



Pressure/flow cystometry


The gold standard test for detecting detrusor overactivity (DO) which is characterized by involuntary detrusor contractions (IDCs) during the filling phase. DO is thought to be the underlying cause for the symptom of urgency which drives the other symptoms in OAB and which may cause urgency incontinence. Pressure/flow cystometry should be used when a patient has been refractory to empirical therapy, to confirm the presence of DO before proceeding to further treatments. It is essential before considering any invasive treatments such as botulinum toxin therapy or surgery. In addition to clarifying the diagnosis it will help characterize other aspects of lower urinary tract function that may predict problems following an invasive procedure, for example a patient with concurrent voiding dysfunction may be more likely to require clean intermittent self-catheterization (CISC) following botulinum toxin therapy.


Cystometry is also valuable in determining the underlying diagnosis in patients with a mixture of storage and voiding symptoms such as men who may have OAB and also bladder outlet obstruction (BOO). Similarly, in women with a mixture of symptoms suggestive of both urgency incontinence and stress incontinence video cystometry is invaluable in determining if both conditions are present (mixed incontinence) and which is the predominant problem requiring focused treatment. Note that the presence of urgency (but not urgency incontinence) and stress incontinence is known as mixed symptoms.



Non-urodynamic tests


A number of validated questionnaires are available to determine the severity of the condition and the impact on the quality of life. These are useful both in the initial assessment of severity and also to monitor the impact of treatment. Common questionnaires include the King’s Health Questionnaire (KHQ), Patients Perception of Bladder Condition (PPBC), the International Consultation on Incontinence Modular Questionnaire (ICIQ) and the Short Form-36 (SF36) questionnaire.



Urodynamic findings in OAB and urgency incontinence Table 5.1)



Detrusor overactivity


The characteristic finding of DO during pressure/flow cystometry is shown in Figure 5.6. In patients with a known neurological cause for the lower urinary tract dysfunction this is described as neurogenic detrusor overactivity (NDO; see Chapter 9), whereas when the aetiology is unknown it is described as idiopathic detrusor overactivity (IDO). DO was previously called detrusor instability and NDO was previously called detrusor hyperreflexia.


Table 5.1 Possible findings during urodynamic testing of patients with OAB or urgency incontinence.








Possible findings during urodynamic testing of patients with OAB or urgency incontinence
Voiding diaries
• Increased daytime frequency, usually greater than 8 times daily
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Related posts:

Paediatric urodynamics Clinical evaluation of the lower urinary tract Urodynamic procedures Basic structure, function and control of the lower urinary tract Pressure/flow cystometry Sensory disorders

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Jul 20, 2016 | Posted by in UROLOGY | Comments Off on Storage disorders and incontinence

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