Improving the management of urinary incontinence.

Urinary incontinence (UI) is the complaint of any involuntary loss of urine and is a common condition that is likely to be under-reported. In the UK, the prevalence is estimated to be 17-40%, and rates are higher in the elderly. UI is more common in women than men. Its frequency increases with age, parity, high BMI, and associated comorbidities. The common types are stress UI, overactive bladder (OAB) or urge UI, and mixed UI a combination of the two. In stress UI there is involuntary loss of urine that occurs in association with an increase in intra-abdominal pressure. OAB is caused by overactivity of the detrusor muscle. This may be idiopathic or secondary to lesions affecting the motor or sensory pathways to the muscle. The history should include the circumstances in which the incontinence occurs, the duration and how it affects the patient's quality of life. The initial assessment should include enquiring for symptoms of urinary tract infection and carrying out a urine dipstick test. Abdominal examination should exclude a large pelvic-abdominal mass and a palpable bladder post micturition. Vulval-vaginal examination should assess for atrophic vaginitis and prolapse, masses and pelvic floor muscle contraction. Involving a skilled continence nurse or dedicated pelvic physiotherapist will improve care and can reduce referrals to secondary care. When conservative measures for OAB are unsuccessful, the next step is pharmacological treatment. Referral to secondary care should be offered when the response to two drugs has not been satisfactory. For stress UI, referral is indicated after failure of pelvic floor muscle training.

Which patients should be offered caesarean section?

Caesarean section (CS) rates have steadily risen from 10% of all deliveries in the 1980s to a current figure of around 23.8%. Approximately 75% of CS are emergency procedures and only 25% are elective planned deliveries. When deciding whether to offer CS, it is important to consider the psychological implications for the patient as well as the physical and mental sequelae in future pregnancies. Clinicians should provide pregnant women with evidence-based information and support. Information should include details about the true indication(s) for the CS and what it implies, including its risks and benefits. The updated NICE guideline does not advocate CS in uncomplicated pregnancies. However, it supports CS on maternal request when attempts to empower the mother to have a vaginal birth have not been successful. CS on maternal request only represented 1.4% of all CS in 2001. CS may reduce perineal and abdominal pain during birth and 3 days postpartum. It may also reduce injury to the vagina, early postpartum haemorrhage and obstetric shock. The following patients should be offered a planned elective CS: singleton breech presentation at term, after external cephalic version has failed, has been declined or is contraindicated; multiple pregnancies when the first twin is not cephalic; placenta praevia, minor or major, (close to or covering the os); HIV-positive women who are not on any antiretroviral therapy, have a high viral load or co-infection with hepatitis C irrespective of viral load; and women with primary genital herpes simplex virus infection occurring in the third trimester.