Taking Control of your Bladder, or. Don't make me laugh when laughter isn't the best medicine: a discussion on urinary incontinence

Transcription

1 Taking Control of your Bladder, or Don't make me laugh when laughter isn't the best medicine: a discussion on urinary incontinence Brett Vassallo, MD, FACOG, FAC Female Pelvic Medicine and Reconstructive urgery

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3 Objectives Anatomy/Physiology Epidemiology Define urinary incontinence Initial diagnosis and management Available resources

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5 Case presentation 45 y/o G2P2 w/ c/o leakage all the time Leaks w/ jumping Leaks before reaching the toilet Wears panty liners daily Notices pads sometimes damp

6 Normal Bladder Function Adequate compliance with appropriate sensation Outlet closed at rest and with increases in abdominal pressure Absence of involuntary bladder contractions

7 Normal Bladder Function Central Nervous ystem Elimination phase torage phase Bladder Contracts Urethral phincter opens Bladder relaxes Urethral sphincter contracts

8 torage Phase M2 M3 omatic Th10-L2 ympathetic Parasympathetic Rahn, DD, Roshanravan. Pathophysiology of Urinary Incontinence, Voiding Dysfunction, and Overactive BladderObstet Gynecol Clin N Am 2009;

9 Micturition Phase M2 M3 omatic Th10-L2 ympathetic Parasympathetic Rahn, DD, Roshanravan. Pathophysiology of Urinary Incontinence, Voiding Dysfunction, and Overactive BladderObstet Gynecol Clin N Am 2009;

10 Urinary Incontinence UI any involuntary loss of urine tress On effort or exertion, or on sneezing or coughing Urgency Mixed accompanied by or immediately preceded by urgency With urgency and also with exertion, effort, sneezing, or coughing Abrams P, Cardozo L, Fall M, et al. The standardization of terminology of lower urinary tract function: report from the standardization sub-committee of the International Continence ociety. Neurourol Urodyn. 2002;21:

11 UI is reported in half of the patients with urinary incontinence Urge Urinary Incontinence 22% Mixed Urinary Incontinence 29% tress Urinary Incontinence 49% 1. Hampel C, et al. Urology.1997;50(suppl 6A): Abrams P, et al. Urology. 2003;61:37-49.

12 Definitions URGENCY sudden, compelling desire to pass urine, which is difficult to defer FREQUENCY NOCTURIA 8 voids/24 hours waking up to void 1 time E. Ann Gormley et al. DIAGNOI AND TREATMENT OF OVERACTIVE BLADDER (Non-Neurogenic) IN ADULT: AUA/UFU GUIDELINE. 2012

13 Overactive bladder syndrome Urinary urgency +/- urgency urinary incontinence Usually with frequency and nocturia No UTI or other obvious pathology Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, Van Kerrebroeck P, Victor A, Wein A; tandardization ub-committee of the International Continence ociety. The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the International Continence ociety. Urology Jan;61(1):37-49.

14 Frequency Nocturia OVERACTIVE BLADDER Urgency incontinence Urgency

15 Detrusor over activity Urodynamic observation Involuntary detrusor contractions during the filling phase idiopathic neurogenic

16 Epidemiology UI highly prevalent 30% women worldwide Impacts Quality of Life Health Financial resources

17 Prevalence in Women UI Prevalence vs. other Chronic Diseases in Women 40% % 20% % 0% Obesity HTN Depression DM UI

18 UI & Quality of life Lower psychological well being Decreased participation in social activities Physical morbidity Loss of independence exual dysfunction Botlero R, Davis R, Urquhart DM, Bell RJ. Incidence and resolution rates of different types of urinary incontinence in women: findings from a cohort study. J Urol Apr;185(4):

19 OAB reduces QoL 0 Control Continent OAB Incontinent OAB -20 Liberman JN et al. Health-related quality of life among adults with symptoms of overactive bladder: results from a U.. community-based survey. Urology Jun;57(6):

20 UI & population UI more common in women than men U.. women with UI 18.3 million in million in 2050 UI prevalence increases with age Americans >65 y/o million million Abed H, Rogers RG. Urinary Incontinence and Pelvic Organ Prolapse: Diagnosis and Treatment for the Primary Care Physician. Med Clin N Am. 92 (2008): Wu JM, Hundley AF, Fulton RG, Myers ER. Forecasting the prevalence of pelvic floor disorders in U.. women Obstet Gynecol, 2009 Dec:114(6):

21 Prevalence of OAB ymptoms Milsom I, Abrams P, Cardoza L, et al. How widespread are the symptoms of overactive bladder and how are they managed? A population-based prevalence study. BJU Int. 2001;87:

22 Prevalence of OAB ymptoms Frequency 85 Urgency 54 UUI % of participants with OAB symptoms Milsom I, Abrams P, Cardoza L, et al. How widespread are the symptoms of overactive bladder and how are they managed? A population-based prevalence study. BJU Int. 2001;87:

23 Etiology of Urinary Incontinence GU conditions Non-GU conditions Filling & storage UI DO Fistula Bladder, urethral, ureters Other Common Causes Infection tones, Foreign Bodies, Tumors Previous Urologic urgery Congenital Ectopic ureter epispadias Functional Neurologic Cognitive Psychological Physical impairment Environmental Pharmacologic Metabolic

24 Etiology, cont d Reversible causes of UI Delirium Infection Atrophy Pharmacologic Psychological (esp. depression) Excessive UO (heart failure/diabetes insipidis) Restricted Mobility tool impaction/constipation

25 Diagnosis H&P Lab tests (UA, +/- ucx) Office evaluation Void & PVR Assess bladder capacity Cough stress test Urodynamic testing Cystoscopy

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28 Management First Line Behavioral Weight loss Bladder diet* Caffeine, alcohol, carbonation, acidic foods Bladder drill* Timed voids Pelvic floor PT Internal & external work pecify pelvic floor on referral

29 Medical management Estrogen-in patients with Atrophy Urethra & bladder contain rich supply of estrogen receptors Pharmacologic Anticholinergics, TCAs, and musculotropics Inhibit contractility of the bladder Address urgency, frequency, and UUI

30 Vaginal estrogen Estradiol vaginal cream, UP, 0.01% Estrace Conjugated estrogen vaginal cream Premarin Estradiol vaginal tablet, 10mcg Vagifem Estradiol vaginal ring, 2mg (7.5 mcg/24º) Estring

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32 Pharmacologic econd Line Anti-cholinergic/Anti-muscarinic therapy Oxybutynin Ditropan, Gelnique, Oxytrol Darifenacin Enablex Fesoterodine Toviaz olifenacin Vesicare Tolterodine Detrol Trospium anctura

33 Anti-cholinergics Most frequently prescribed medications for UUI Primarily bladder capacity and urgency Choice depends on cost dosing drug-drug interactions potential side effects co-morbid conditions Lack of response to one agent does not preclude response to another

34 Anti-cholinergic potential side effects Dry mouth (inhibit salivary secretion) Increased water intake may worsen UI May exacerbate dental caries, be careful Constipation (inhibit gut motility) May worsen LUT sx/complaints Blurry vision (blockade of ciliary muscles) Cognitive changes

35 Anti-cholinergic contraindications Delayed gastric motility Narrow angle glaucoma Monitor use in pts w/ Dementia Urinary retention

36 Alpha agonists timulate urethral smooth muscle contraction Imipramine (TCA) alpha agonist and anticholinergic activity mixed incontinence not recommended for older patients in whom anticholinergic adverse effects and orthostatic hypotension may be significant

37 Beta-3 adrenergic agonists Facilitate urine storage through bladder relaxation Mirabegron (Myrbetriq ) Approved by the U FDA in June 2012 The most common side effects reduced urinary frequency and wetting episodes increased blood pressure nasopharyngitis urinary tract infection constipation fatigue tachycardia abdominal pain NOT recommended for use in those with severe uncontrolled high blood pressure

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39 Other management options Third Line Neuromodulation acral nerve stimulation Posterior tibial nerve stimulation Botulinum toxin Augmentation cystoplasty

40 35 y/o G3P3 Leaks w/ laugh, cough, sneeze Unable to exercise due to leakage Limits her activities w/ kids given leakage

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42 Pathophysiology of tress Urinary Incontinence Urethral hypermobility Displacement of urethra during sudden increase in abdominal pressure Decreases pressure transmission to the urethra

43 tress UI Diagnosis: leak w/ cough or valsalva Management options Exp mgmt Pelvic Floor PT Pessary urgery Midurethral sling Periurethral injections/bulking Retropubic urethropexy Fascial pubovaginal sling

44 Complicated Incontinence Recurrent incontinence Continuous leakage Treatment failures

45 Consider referral Incontinence associated with Pain Hematuria Recurrent UTI s Retention Pelvic radiation Radical pelvic surgery uspected fistula Pelvic organ prolapse beyond the hymeneal ring Neurological disease or spinal cord injury

46 Resources: Patient info Nat l & Internat l Organization info ACOG: AUA: AUG: IUGA: IC:

47 Division of Female Pelvic Medicine and Reconstructive urgery Brett Vassallo Michael Noone

48 Virtual Pelvic Health Center Christine Rambke, RN, MBA, BN Patient Care Navigator

49 THANK YOU! Questions?