Urogynecology in EDS. Joan L. Blomquist, MD Greater Baltimore Medical Center August 2018

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1 Urogynecology in EDS Joan L. Blomquist, MD Greater Baltimore Medical Center August 2018

2 One in three like me

3 Voiding Issues Frequency/Urgency Urinary Incontinence neurogenic bladder

6 Neurologic supply of the bladder

7 Evaluation of Bladder Issues History Urinary Diary Physical examination Post void residual test Ultrasound or catheter Urodynamics

9 Symptoms Urinary hesitancy Slow stream Urinary frequency Bladder infections Kidney problems Causes Inadequate detrusor contraction Inadequate urethral relaxation High tone pelvic floor Pelvic organ prolapse Voiding Issues

10 Inadequate urethral sphincter relaxation Pelvic floor physical therapy Medications Cardura tamsolosin Self catheterization

11 High tone pelvic floor Pelvic floor physical therapy Relaxation techniques Muscle relaxants Vaginal suppositories

13 Urinary Frequency and Urgency Voiding dysfunction Overactive bladder Interstitial cystitis

14 Overactive Bladder

15 OAB treatment options Behavioral modifications -weight loss -avoidance of bladder irritants -fluid management

16 OAB - treatment Pelvic floor muscle exercises Physical therapy

17 OAB - treatment Medications anticholinergics oxybutynin tolterodine darifenicine solifenicine trospium Beta agonist mirabegron

18 Percutaneous Tibial Nerve Stimulation

19 Sacral Nerve Stimulation

20 Botox

21 Interstitial cystitis/painful bladder syndrome AUA (2011) unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes. ICS (2002) the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and night-time frequency, in the absence of proven urinary infection or other obvious pathology

22 Pathophysiology No recognized comprehensive pathophysiologic explanation Theories include Autoimmune Systemic disease Neurogenic inflammation Allergic/Mast cell activation Defective GAG layer ( leaky epithelium )

23 Pathophysiology Multifactorial Model Initiating event Vascular congestion and protein extravesation Change in urothelial function Mast cell activation Leaky Urothelium Release of substance P and inflammatory mediators Sensitization of peripheral nerves

appearance of Hunner s ulcer in an IC patient before bladder

24 Diagnosis Typical appearance of glomerulations after bladder distention in a patient with nonulcerative IC Typical appearance of Hunner s ulcer in an IC patient before bladder distention Walsh: Campbell's Urology, 8th ed., Copyright 2002 Elsevier

25 First Line Treatments General relaxation/stress management Pain management Calcium Glycerophosphate, phenazopyridine, aloe vera Pt education Behavioral modification Adequate water, dietary modifications

26 Second Line Treatments Appropriate manual physical therapy techniques Oral: amitriptyline, cimetidine, hydroxyzine, Pentosan polysulfate Intravesical: DMSO, heparin, lidocaine Pain managment

27 Physical Therapy for IC/PBS

28 Third Line therapies Cystoscopy under anesthesia with hydrodistention Neuromodulation Intravesical botox

29 Types of Urinary Incontinence Stress Incontinence Urge Incontinence Mixed Incontinence Functional Incontinence Overflow Incontinence Fistula

30 Stress Incontinence Leakage of urine during physical movement or activity Coughing, Laughing, Sneezing, Running, Exercising, Lifting, Straining Increases in abdominal pressure are transmitted to the bladder

32 Stress Incontinence

33 Treatment for Stress Incontinence Pelvic Floor Exercises Pessary/Impressa Surgery Urethral injections

34 Pelvic Floor Exercises

35 Pelvic Floor Muscle Therapy Kegel, 1948 Successful therapy of 64 patients with SUI

36 Electrical Stimulation

37 Pessary

38 Impressa

39 Transvaginal Sling

41 Unique aspects Involvement of pelvic floor muscles Tethered cord Mast cell activation POTS Multiple medications Recommendations Knowledgeable provider Conservative treatments Pelvic physical therapist

Objectives. Prevalence of Urinary Incontinence URINARY INCONTINENCE: EVALUATION AND CURRENT TREATMENT OPTIONS

Objectives. Prevalence of Urinary Incontinence URINARY INCONTINENCE: EVALUATION AND CURRENT TREATMENT OPTIONS URINARY INCONTINENCE: EVALUATION AND CURRENT TREATMENT OPTIONS Lisa S Pair, MSN, CRNP Division of Urogynecology and Pelvic Reconstructive Surgery Department of Obstetrics and Gynecology University of Alabama