INCONTINENCE: a Different Perspective as Applied to the Elderly.

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1 INCONTINENCE: a Different Perspective as Applied to the Elderly. Brian T. Geary, MD 7/27/2018 1

OBJECTIVES Provide you with a new appreciation for the role of the bladder in the spectrum of life. Leave here thinking about the bladder in a different way.

2 OBJECTIVES Provide you with a new appreciation for the role of the bladder in the spectrum of life. Leave here thinking about the bladder in a different way. Give you some ways to quickly address incontinence. (While you wait for the urologist s office to get back to you about an appointment.) Why it s only going to get worse. (No, this is not b/c of the forecasted shortage of urologist.) Disclaimer: This will not be your typical lecture except for maybe a slide or 2. 2

3 Bladder Bladder Sits ABOVE the prostate Sits ABOVE the vagina A QUICK LOOK: THE BLADDER A QUICK LOOK: THE BLADDER A muscle With a control valve Lined by a Hazmat suit 3

) INSENSATE Incontinence UNAWARE + UNAWARE No urge to void, doesn t recall voiding & did not know they were wet. ( I didn t know I d leaked until I went to check my pad.

4 A QUICK LOOK: THE BLADDER TYPES OF INCONTINENCE TYPES OF INCONTINENCE AWARE Aware of sensation, but can t control it. ( Gotta go RIGHT now! ) AWARE Aware of sensation, but unable/unwilling to act due to mental/physical limitations. Gotta go, but no sense in trying to get there. ( Aware can t get there. ) INSENSATE Incontinence UNAWARE + UNAWARE No urge to void, doesn t recall voiding & did not know they were wet. ( I didn t know I d leaked until I went to check my pad. ) AWARE + UNAWARE Literally a mix of symptoms.. ( I m just never sure! ) UNAWARE + Unable to control No urge, but after stress couldn t stop it. ( Cough/Laugh/Sneeze ) UNAWARE + Unable to control No urge to void, it s like a pop off valve that empties without warning, BUT once wet is aware of being wet. ( It just comes out whenever it s ready. ) 4

00 $ 4.00 $ 120.00 $ 1,440.00 $ 6.00 $ 180.00 $ 2,160.00 $ 8.00 $ 240.00 $ 2,880.

3 billion annually SIMILARITIES Peds GU is similar to Geriatrics PARENT The patient can t/won t: Tell you what s wrong.

CHILD SIMILARITIES A single male willing to inflict pain on another person for their own good.

NOT mentioned in the definition: Listening patiently Teasing out the information Using story telling in the treatment plan

5 THE NUMBERS Incontinence affects 28.8 million adults in the US $1 per diaper # of Pads/day Cost per DAY Cost per MONTH Cost per YEAR $ 2.00 $ $ $ 4.00 $ $ 1, $ 6.00 $ $ 2, $ 8.00 $ $ 2, Avg incontinence study inclusion criteria is 3 episodes per day So conservatively (2 pads/day) = $20.3 billion annually SIMILARITIES Peds GU is similar to Geriatrics PARENT The patient can t/won t: Tell you what s wrong. Cooperate with an exam. Swallow pills. Handle ADL without assistance. CHILD SIMILARITIES A single male willing to inflict pain on another person for their own good. Halsted s 1890 s definition of a surgery resident. NOT mentioned in the definition: Listening patiently Teasing out the information Using story telling in the treatment plan Repetitive reinforcement Most urology residents do NOT enjoy the peds rotation. 90% of clinic patients don t need an operation. So many things can go wrong and still be considered normal because of the anatomic variation of the GU system. Your grade is dependant on how much the patient and family like you. Mal-Rotated kidney Extra renal pelvis Horseshoe kidney Pelvic kidney UPJ-Obstruction Incomplete ureteral duplication Complete ureteral duplication Vesico-Ureteral Reflux Ureteroceles 5

6 #1. FAILURE TO POTTY TRAIN 5yo girl + a 1 st time mother Neither of them happy to be there. They ve been waiting, in the room for over 1 hr. She was potty trained, at 18 mo, but now she s wetting her pants. Boys >>> Girls labor intensive as far as Potty Training LABIA Secondary Sex Characteristics 6

7 SITTING STANDING FAILURE TO POTTY TRAIN DRY OVERNIGHT SIMILARITY Avg female urethral length is 4 CM Avg distance from meatus to outside of labia is approx 4 CM * 8 CM NIT & LEU (+) = 80% NIT (+) = 30% LEU (+) = 30% A (+).CC Urine Cx with NO symptoms = NO Abx * In Central Georgia 7

8 #2. INFREQUENT VOIDING #2. INFREQUENT VOIDING Given the Choice 8

9 THE BLADDER AS A SPECTRUM THE ELECTROMAGNETIC SPECTRUM THE BLADDER AS A SPECTRUM N.G.B. NORMAL O.A.B. NeuroGenic Bladder Over Active Bladder <4 5 to 7 <4 Bladder Capacity Post Void Residual Detrusor Pressure THE BLADDER AS A SPECTRUM N.G.B. NORMAL O.A.B. 9

10 THE BLADDER AS A SPECTRUM Hey, I m STARTING the pee pee dance protocol! Hey, you BETTER go pee! Hey, I m SERIOUS, you should go pee! Hey, you SHOULD go pee. Hey, you COULD go pee. Hey, FYI I m filling. 500 ml 250 ml THE BLADDER AS A SPECTRUM Hey, I m STARTING the pee pee dance protocol! Hey, you BETTER go pee! 800 ml Hey, you SHOULD go pee. Hey, you COULD go pee. 500 ml 250 ml THE BLADDER AS A SPECTRUM Hey, I m STARTING the pee pee dance protocol! Hey, you BETTER go pee! Hey, I m SERIOUS, you should go pee! Hey, you SHOULD go pee ml 800 ml 500 ml 250 ml 10

11 B L A D D E R ANALOGY: PAINT & DRY WALL 11

12 12

13 Donut Hole Pump 13

14 Donut Hole 2 pipe 2 pipe Pump 2 pipe 2 pipe BPH 1/4 pipe 1/4 pipe BPH 1/4 pipe 14

15 BLADDER PRESSURE (cmh 2 O) /2 1 1/2 1/ BLADDER PRESSURE (cmh 2 O) /2 1 1/2 1/ SURGICAL INTERVENTION TURP (TransUrethral Resection of the Prostate) Urology = Human Plumber 15

16 SURGICAL INTERVENTION Attempts to Improve on the TURP UroLume Stent SURGICAL INTERVENTION Attempts to Improve on the TURP UroLume Stent SURGICAL INTERVENTION Attempts to Improve on the TURP UroLume Stent 16

17 SURGICAL INTERVENTION Attempts to Improve on the TURP UroLume Stent TUMP TUNA GreenLight Laser SURGICAL INTERVENTION Attempts to Improve on the TURP UroLume Stent TUMP TUNA GreenLight Laser UroLift SURGICAL INTERVENTION Attempts to Improve on the TURP UroLume Stent TUMP TUNA GreenLight Laser UroLift 17

18 P E L V I C F L O O R P E L V I C F L O O R Hammock has 3 holes: 1. Urethra 2. Vagina 3. Rectum P E L V I C F L O O R Muscle is NOT evenly distributed Urethra Vaginal (Birth) Canal 18

19 MANAGEMENT Management is a BALANCE: Symptom Control + Bladder Health BOTH 19

Tools for Evaluation. Urodynamics Case Studies. Case 1. Evaluation. Case 1. Bladder Diary SUI 19/01/2018

Tools for Evaluation. Urodynamics Case Studies. Case 1. Evaluation. Case 1. Bladder Diary SUI 19/01/2018 Urodynamics Case Studies Christopher K. Payne, MD Vista Urology & Pelvic Pain Partners Emeritus Professor of Urology, Stanford University Tools for Evaluation Ears, Eyes, and Brain Bladder diary Stress