Management, Evaluation, and Treatment of Overactive Bladder and Urinary Incontinence

Transcription

1 Management, Evaluation, and Treatment of Overactive Bladder and Urinary Incontinence Arthur Mourtzinos, MD, MBA Co-Vice Chair, Institute of Urology Director, Continence Center Assistant Professor of Urology, Tufts University School of Medicine June 18, 2015 Disclosures American Medical Systems: Speaker, consultant, instructor, proctor Allergan: Speaker, proctor Astellas: Speaker Medtronic: Speaker, instructor Uroplasty: Speaker 1

2 Prevalence of Urinary Incontinence in Comparison to Other Chronic Conditions Millions National Center for Health Statistics. Vital Health Stat 10 (194) Fantl JA et al. AHCPR Publication No ;1996. Urinary Incontinence is an Underreported Condition Many patients do not seek help because they believe no effective treatment is available 73 percent of patients who seek treatment are currently not on medication Two of every three patients report that symptoms affect daily living Many patients self-manage urinary incontinence by voiding frequently, reducing fluid intake, and wearing pads Milsom I, et al. BJU Int. 2001;87:

3 Impact of Urinary Incontinence on Quality of Life Sexual Avoidance of sexual contact and intimacy Occupational Absence from work Limited productivity Physical Limitations of physical activities Domestic Quality of Life Requirements for specialized underwear, bedding Special attention to clothing Psychological Guilt/depression/denial Loss of self-respect and dignity Fear of being a burden; lack of bladder control; urine odor Social Reduction in social interaction Alteration of travel plans Risk of institutionalization of frail older persons 3

4 Urinary Incontinence Diagnosis and Approaches to Treatment Diagnosis Most cases can be diagnosed based on: Patient history Physical examination Urinalysis 4

5 History The Questions We Ask Beverage quantities Frequency Nocturnal incontinence Infections Pediatric voiding dysfunction Leakage with physical activity with urgency Physical Exam Weak sphincter muscle tone Abnormal neurologic exam of the pelvic floor Phimosis/paraphimosis 5

6 Male Pelvic Anatomy Stress Incontinence Leakage with increased abdominal pressure of laughing, coughing, sneezing, or exercise Anatomical due to malposition of a normal sphincteric unit 6

7 Urge Incontinence Urgent need to pass urine and difficulty getting to a toilet in time Reflexive/Involuntary contractions: phasic changes of bladder pressure unrelated to volume Laboratory Tests Urinalysis Rule out hematuria, pyuria, bacteriuria, glucosuria, proteinuria Blood work as appropriate (BUN, Cr) Serum glucose level Urine cytology Marchionni M, et al. J Reprod Med 1999;44:679. 7

8 Differential Diagnosis Neurogenic Fluid intake, urinary output disorders UTI Anatomic Malignancy Post-surgical Medication side effects AUA 2014 OAB Treatment Guidelines First line Second line Behavioral therapies for all patients May be combined with antimuscarinics Oral antimuscarinics or 3 agonists Transdermal preparations Dose modification or switch to different antimuscarinic if inadequate efficacy or poor tolerability Third line Sacral nerve stimulation PTNS Intradetrusor onabotulinumtoxina 8

9 Behavioral Therapy Fluid restriction (5 12 ounce glasses of fluid/24 hours) Bladder Retraining/Timed voiding (scheduling bathroom visits ~ 2-2 ½ hours as a goal) Dietary changes Avoid sipping throughout the day Limit caffeine, carbonated drinks, citrus, acidic foods and artificial sweeteners Stop drinking after supper time Voiding diary Pelvic Floor Exercise Able to suppress the voiding reflex Requires strong educational effort to recognize and isolate the pelvic musculature Try to contract muscles needed to start/stop urination Problems with patient compliance Probably not long-term cure in many patients 9

10 Medical Therapy Tolteridine Oxybutynin Oxybutynin chloride Oxybutynin Transdermal Darifenacin Solifenacin Trospium Chloride Fesoterodine Mirbegrone Undesired Effects of Anticholinergic Therapy Dry mouth (10-30%) Constipation (5-12%) Ocular effects (narrow angle glaucoma) CNS effects Cardiac effects Drug-drug interactions **Mirbegrone, as a β-3 agonist, has HTN as its major side effect 10

11 Anticholinergics and Incident Dementia Prospective, population-based cohort study Mean follow-up of 7.3 years 797 participants (23.2%) developed dementia 10-year cumulative dose-response relationship was observed for dementia and Alzheimer disease (test for trend, P <.001) Higher cumulative anticholinergic use is associated with an increased risk for dementia Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med Mar;175(3): Surgical therapy Urge Incontinence Sacral neuromodulation Botulinum toxin A injection Stress incontinence Transurethral bulking agents Perineal sling and artificial urinary sphincter (males) 11

12 Sacral Neuromodulation Minimally invasive procedure FDA approved in 1997 Two stage procedure 1-2 week test stage Implant stage Implantation of the Sacral Neuromodulation System Procedure done in operating room using conscious sedation Stimulator is implanted and connected to a lead that will stimulate your sacral nerve Stimulator is usually placed in upper buttock The entire system will reside under your skin Entire procedure takes minutes 12

13 Botulinum Toxin A (BoNTA) BoNTA protein produced by the anaerobic gram-positive bacteria, Clostridium botulinum. Mechanism of action Temporarily blocks release of acetylcholine at neuromuscular junction Inhibits release of other NTS Effect is reversed by neural regeneration BoNTA Treatment Protocol Minimally invasive procedure Office procedure under local anesthetic Flexible or rigid cystoscopy with an injection needle. BoNTA units dissolved in saline suburothelial or intradetrusor injections Post-operative care Follow-up to assess for bladder emptying in 2-6 weeks Retreatment in 6-12 months 6-20% urinary retention rate 13

14 Injection of transurethral bulking agent Minimally invasive Can be done in the office setting No restrictions Adverse events: -urinary tract infection -urinary retention (1%) Typically lasts 6-12 months Can be done multiple times Male Perineal Sling First retroluminal transobturator sling FDA approved in October 2007 Mechanism based on relocation of proximal urethral Sling exerts dorsal sphincter support 14

15 Artificial Urinary Sphincter (AUS) Cuff 4x 2cm up to 11x2 cm Balloon cm/h2o cm/h2o cm/h2o Pump with deactivation button AUS Mechanism Press the pump Resistor Slow fluid return 15

16 When to refer to Continence Center Incontinence/lower urinary tract symptoms that fail one medication Neurogenic patients with urinary symptoms (i.e. MS, Parkinson s, spinal cord injury) Failed prior anti-incontinence surgery Prolapse Incontinence after prostate cancer surgery or other pelvic surgery Lahey Hospital & Medical Center Continence Center Arthur Mourtzinos, MD, MBA Lara MacLachlan, MD Caitlin Koehler, NP Marybeth Singh, NP 16