The two most common causes of urinary incontinence in women are stress incontinence and urge incontinence. Many women suffer from a combination or urge and stress incontinence.
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Stress incontinence
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- involuntary leakage of small amounts of urine with exertion such as coughing and sneezing, lifting or playing sport in the absence of any desire to go to the toilet
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Urge incontinence
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- is an urgent, sudden, overwhelming urge to pass urine and get to the toilet in time
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Diagnosis
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In most cases, a preliminary diagnosis of urinary incontinence can be made and treatment initiated based on findings of the medical history, physical examination and simple laboratory testing.
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Refer to Urodynamic assessment
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Predominantly stress incontinence
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1. History (key questions)
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2. Physical examination
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3. Dipstick urine and/or MSU
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5. Lifestyle interventions: decrease caffeine, weight and smoking
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6. Treat constipation
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7. Bladder retraining / pelvic floor muscle training for at least 12 weeks
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8. Provide advice on continence products
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9. Refer to Continence Physiotherapist or Continence Nurse Advisor for bladder retraining and pelvic floor exercises
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Post-menopausal women
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- topical vaginal oestrogen cream or vaginal oestrogen pessary 2-3 times a week (may take 6-8 weeks before any benefits noticed by patient)
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In elderly women remember the acronym "DIAPPERS " :
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- Delirium, Infection (UTI), Atrophic vaginitis, Pharmaceuticals, Psychological, Excess fluids, Restricted mobility, Stool constipation.
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- consider referral to Aged Care Unit for assessment
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Possible pharmacological causes
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- including diuretics, sedatives and alpha antagonists, consider prescribing alternative medications
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Predominantly stress incontinence with weak or no pelvic floor muscle contraction on vaginal examination
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- provide instruction on pelvic floor exercises or refer to Continence Physiotherapist or Continence Nurse Advisor
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Predominantly urge incontinence
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1. History (key questions)
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2. Physical examination
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3. Dipstick urine and/or MSU
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5. Lifestyle interventions: decrease caffeine, weight and smoking
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6. Treat constipation
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7. Bladder retraining / pelvic floor muscle training for at least 12 weeks
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8. Provide advice on continence products
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9. Refer to Continence Physiotherapist or Continence Nurse Advisor for bladder retraining and pelvic floor exercises
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Post-menopausal women:
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- topical vaginal oestrogen cream or vaginal oestrogen pessary 2-3 times a week (may take 6-8 weeks before any benefits noticed by patient)
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Overactive bladder syndrome:
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- trial of bladder relaxants: Oxybutynin (Ditropan) 2.5mg 2-3 times a day; Imipramine (Tofranil) 10mg twice a day and 25 mg at night; Tolterodine 2 mg twice a day (currently only available on special order from New Zealand)
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Indications for referral to a Specialist - stress or urge incontinence
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Failed conservative treatment
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- refer to Specialist (Gynaecologist, Urogynaecologist or Urologist specialising in Female Urology)
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Pain, haematuria, recurrent bladder infection, voiding difficulties, suspected fistulas, neuropathic bladder
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- refer to Specialist (Gynaecologist, Urogynaecologist or Urologist)
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Associated significant pelvic organ prolapse:
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- refer to Gynaecologist or Urogynaecologist
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History
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Key questions in evaluating patients for urinary incontinence
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- Do you leak urine when you cough, laugh, lift something or sneeze? How often? (Yes indicates diagnosis of stress incontinence).
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| - Do you ever leak urine when you have a strong urge on the way to the bathroom? How often ? (Yes indicates a diagnosis of overactive bladder syndrome).
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| - How frequently do you empty your bladder during the day?
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| - How many times do you get up to urinate after going to sleep? Is it the urge to urinate that wakes you?
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| - Do you wear pads that protect you from leaking urine? How often do you have to change them? (Indicates the severity of the incontinence).
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| - Do you ever find urine on your pads and clothes and were unaware of when the leakage occurred? (Indicates severity of incontinence).
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| - Does it hurt when you urinate? (May indicate UTI).
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| - Do you have a slow urinary stream or do you ever feel that you are unable to completely empty your bladder? (May indicate voiding difficulty).
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Links
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- Women's Health Information Centre (WHIC) Tel: 1800 442 007 or (03) 8345 3045
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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