This can be initiated in the primary care setting. It includes a combination of lifestyle interventions Table 4 , bladder training and behavioural modification. Antimuscarinic medications can be added if these measures fail to control symptoms. As behavioural treatments work gradually at first and rely on patient self management, it is important to follow patients regularly to see sustained behavioural changes.
Bladder training Table 6 has been found to reduce daily urinary frequency and lower daily urinary incontinence compared to antimuscarinics alone.
In women with cognitive impairment, prompted and timed voiding toileting programs are recommended. In the primary care setting, patients presenting with typical overactive bladder symptoms can be treated empirically with an antimuscarinic agent and obtain clinical benefit without the need for invasive urodynamic procedures 27 Table 7. Human bladder contraction is mediated mainly through stimulation of muscarinic receptors in the detrusor muscle by acetylcholine.
Controlled release compounds are generally better tolerated than immediate release formulations, with similar efficacy. The majority of adverse events associated with antimuscarinic agents are due to inhibition of muscarinic receptors in organs other than the bladder 7,28 Table 8.
If treatment with an antimuscarinic fails due to inadequate symptom control or unacceptable adverse effects, a second antimuscarinic or duloxetine can be trialled before considering second or third line therapies 23 and a urological opinion. Dry mouth and constipation should be managed before abandoning effective antimuscarinic therapy. A Cochrane review 29 evaluated anticholinergic medications versus nonpharmacologic treatment of OBS.
Symptomatic improvements were more common in patients on anticholinergic drugs compared with bladder training RR 0. There is no clear evidence that one anticholinergic is better than another for treatment of OBS. Cognitive dysfunction including memory loss and attention deficits are particular side effects in the elderly.
Antimuscarinic medications differ in their propensity to cause central nervous system adverse events due to differences in lipophilicity and crossing of the blood-brain barrier. Oxybutinin may be the most likely to cross the blood-brain barrier. The use of anticholinergics should be carefully weighed against the potential cognitive risks in the older adult population, 24 as long term exposure to anticholinergics may be associated with increased Alzheimer type pathology.
The newer antimuscarinics for OBS — darifenacin, solifenacin and tolterodine — have a significantly reduced impact on cognitition compared with traditional agents. Similarly, oxybutinin transdermal gel does not seem to adversely affect cognition. Oxybutinin can be started at 2. The morning dose can be increased or a lunchtime dose added depending on severity and timing of symptoms. The maximum dose is 5 mg three times per day. Duloxetine a serotonin noradrenaline reuptake inhibitor can be effective in both stress and mixed stress and urge incontinence.
In clinical practice, most women discontinue duloxetine within 4 weeks due to adverse effects Table 7. Failure of conservative and medical treatments warrants urology referral for further investigation with urodynamics, and more invasive therapies may be considered. The injections can be repeated. Sacral nerve stimulation involves an implantable electrode in the S3 foramen continuously stimulating the S3 nerve root, in order to stimulate the pudendal nerve. A temporary wire is initially placed under local anaesthetic for 5—7 days in both sides and a voiding diary is kept.
There is a potential benefit for up to 5 years in patients with OBS. Current indications for sacral nerve stimulation include refractory urge incontinence, refractory urgency and frequency, and idiopathic urinary retention. In augmentation cystoplasty, the bladder is enlarged by incorporating a variety of different patches into the native bladder, usually patches of bowel still attached to their mesentery ileum, caecum or sigmoid colon. Urinary diversion should be considered only when conservative treatments have failed, and if sacral nerve stimulation and augmentation cystoplasty are not appropriate or unacceptable to the patient.
Prem Rashid has been a visitor to the American Medical Systems AMS US manufacturing facility undertaking a cadaveric dissection clinic and observed operative procedures by high volume implant urologists affiliated with AMS during that time. No commercial organisation initiated or contributed to the writing of the article.
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Laparoscopic adjustable gastric banding Under-diagnosed late respiratory complications. Patients with colorectal cancer A qualitative study of referral pathways and continuing care. Wudinna Health Centre Improving access to primary care in a remote community. Gently grasp hold of the funnel to stabilise the catheter and prevent it from flicking out of the packet.
Slowly peel back the paper side of the packet and remove completely without touching the catheter. The catheter should remain in the clear packet. Drop lubricant onto the tip of the catheter and for about 5 cms along the tube. Without touching the catheter that is, grasp hold of it through the packet pick it up and hold it like a pen in your dominant hand and peel back the clear packet to reveal the tip of the catheter. With your other non-dominant hand grasp hold of your penis and hold it at an angle see figure 5.
Gently but firmly push the catheter into the penis 5 cms. Hold the shaft of the penis firmly so that the catheter does not fall out and peel back the paper to expose another 5 cms of catheter to be inserted.
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Continue to insert the catheter in this way. You may encounter some resistance at the point where the catheter reaches the prostate gland and the closed sphincter muscle. If it is stuck do not force the catheter but try coughing, bearing down as though you want to pass urine or deep breathing whilst keeping gentle pressure against the resistance.
You will then feel the catheter give and it can be pushed into the bladder. You can now remove the paper completely and wait for the urine flow. Return the penis to its natural position and hold onto the catheter until the flow of urine stops. Make sure you direct the flow of urine into the toilet or container. When the flow has stopped, have a cough and press gently over your bladder as more urine may flow out by doing this. Slowly pull out the catheter and place it in a bowl or dispose of it in the bin.
Replace your foreskin. Wash and dry yourself and then wash and dry your hands. Females Adjust your clothing. Get into a comfortable position. With your non-dominant hand, gently part the labia or lips of your vagina to expose the urethra the channel you normally urinate through. Gently insert the catheter into the urethra and continue to gently push it in until you drain urine.
If it is stuck do not force the catheter. Remove the catheter and try again later. Hold on to the catheter until the flow of urine stops.
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Where to get help See your doctor Visit a GP after hours Visit healthdirect external site or call Remember Clean intermittent self-catheterisation allows urine to drain freely and the bladder to be emptied. Will it be a bountiful evening, or will your hopes of fun and romance be squashed? Now that you've returned to Edgewater It's the night of your engagement ball at Edgewater Estate. Can you show your guests that you are the true heiress to Edgewater? It's the day of the hunt!
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