Overactive Bladder. Learning Objectives

Transcription

1 Learning Objectives Describe neurophysiology of urinary storage and voiding and alterations that occur with pathology Define Overactive Bladder (OAB) and benign prostatic enlargement (BPE) and their impacts on urinary function Compare pharmacologic and minimally invasive treatment options for OAB/BPE Overactive Bladder Definition: Urgency, with or without urge urinary incontinence, usually with frequency and nocturia, in the absence of underlying pathology Abrams et al, Am J Obst Gyn, 2002 Bladder Muscle: Muscle is relaxed 99% of time to allow urine to flow into bladder Bladder Muscular tubes [Ureters] bring urine from Kidneys to bladder. Prostate->Donut-shaped muscle Around Urinary channel [Urethra] Circular muscle [sphincter] contracted 99% of time; Prevents urine leakage

2 Overactive Bladder Prevalence: NOBLE (National Overactive Bladder Evaluation, 2003) 16.5% of non-institutionalized American adults (33 million) >30% over 65 yrs old and comparable male and female EpiLUTS (Epidemiology of Lower Urinary Tract Symptoms, 2007) 18.5% Americans older than or equal to 40 (42.5 million) Powell et al, Neururol and Urodyn, 2018

3 Overactive Bladder Prevalence (cont.d) OAB-POLL (Overactive Bladder on Physical and Occupational Limitations, 2010) 23.2%, double prevalence in women than men Prevalence increases with age NOT a normal part of aging IS a chronic condition Overactive Bladder Cost of illness and economic modeling: 12.6 Billion Annually (2000) 65.9 Billion Annually (2007) >100 Billion Annually (2018) QoL impact: mental health (depression), sleep quality, complications such as UTI s, skin rashes/breakdown, falls, and inability to work Lowest health utility score (0.70) along with stroke (0.68)and Alzheimer's (0.58) Powell et al, Neururol and Urodyn, 2018 Hu et al, Urol 2004; Powell et al, Neuro & Urodyn 2018; Mittmann et al, Pharmacoecon 1999 Special Consideration: Male Population A. Median Lobe Enlargement, B. Bilobar Enlargement, C. Trilobar Enlargement, D. Median Bar

4 Incidence Rates of Acute Urinary Retention Cumulative Incidence of Acute Urinary Retention J Urol 1997;158: N Engl J Med 2003;349: Cumulative Incidence of Invasive Therapy (Surgery) Special Consideration: Elderly Population N Engl J Med 2003;349:

5 DO = Detrusor Overactivity OAB Diagnosis and Evaluation Resnick NM, Marcantonio ER: How should clinical care of the aged differ? Lancet 1997;350: ) Patient History Focus on GU symptoms, neurologic Intake-output Toileting Bladder/outlet Pelvic pathology Neurology General Health Voiding patterns and symptoms Voiding diary Symptom questionnaire Medications Functional and mental status Focused Physical Exam Abdominal/Back Females Pelvic Exam Males Genital Exam DRE Labs Urinalysis +/- Urine Culture PSA

6 Treatment

7 Delirium Transient Causes of Incontinence DIAPPERS Infection (urinary tract infection) Atrophic vaginitis/urethritis Psychological (e.g., severe depression, neurosis) Pharmacologic Excess urine production Restricted mobility Stool impaction From Resnick NM: Urinary incontinence in the elderly. Med Grand Rounds 1984;3: Oral Medications Antimuscarinic/anticholinergic Oxybutynin Tolterodine Solefenacin Trospium Darefenacin All Drugs Relax the Bladder Muscle & prevent Bladder Spasms!! The higher the dose the more effective Oral Medications Antimuscarinic/anticholinergic Oxybutynin Tolterodine Solefenacin Trospium Darefenacin All drugs create Dry Mouth and Constipation Stool Softeners & Laxative Reverse Constipation Hard candy Life-Savers, Lemon Drops, Peppermint, etc. reverse Dry Mouth!

8 New Pharmacologic Approach Mirabegron B-adrenergic agonist The use of AC medication was associated with increased brain atrophy and poorer short-term memory. Patient Roadmap to Better Bladder Control Case #1 51 year old male with nocturia 4-5x, frequency every 2 hours and urinary urgency. Pt with little improvement with alpha blockers and fluid management strategies. Sacral neuromodulation OnabotulinumtoxinA Peripheral nerve stimulation Percutaneous tibial nerve stimulation

9 Antimuscarinics Treatment Considerations in Men: OAB vs BPE B-adrenergic agonist Case #2 63 year old female with severe OAB symptoms including frequency every 1-2 hours, urinary urgency and urge incontinence 2-3x/day. Pt has tried behavioral therapy and anticholinergic medication but is bothered by dry mouth. Advanced OAB Treatment Options Percutaneous Tibial Nerve Stimulation (PTNS) h?v=o3clf8xbxg8

10 STEP Study 2 yr results Sacral Neuromodulation Sustainable improvements in OAB symptoms at 24 month followup with once a month maintenance therapy Peters et al, Neurourol & Urodyn, sm4hmqy Sacral Neuromodulation Implant Results Siegel et al, J Urol, 2018

11 Results InSite Trial 5 year follow-up 67% UI response rate, 38% completely continent, 57% frequency response rate Surgery for AE in 30% Explant rate 19% Biological Neuromodulation: OnabotulinumtoxinA Siegel et al, J Urol, 2018 Biological Neuromodulation: OnabotulinumtoxinA Biological Neuromodulation: OnabotulinumtoxinA

12 Cystoscopic Injection Cystoscopic Injection Results Results Nitti et al, J Urol, 2017 Nitti et al, J Urol, 2017

13 Key Learning Points Neurophysiology of Bladder storage and emptying is complex and regulated via the CNS Overactive Bladder is a chronic, highly prevalent and bothersome condition that can be impacted by male gender (BPE) and age (i.e. co-morbidities in elderly) Effective treatment requires commitment to a treatment algorythm consisting of behavioral modifications and oral medications followed by referral to a urologic specialist for minimally invasive advanced oab therapies when patients have an inadequate response. References Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Am J Obstet Gynecol Jul;187(1): Powell LC, Szabo SM, Walker D, Gooch K. The economic burden of overactive bladder in the United States: A systematic literature review. Neurourol Urodyn Jan 13. doi: /nau [Epub ahead of print] Hu TW, Wagner TH, Bentkover JD, Leblanc K, Zhou SZ, Hunt T. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. Urology Mar;63(3):461-5 Mittmann N, Trakas K, Risebrough N, Liu BA. Utility scores for chronic conditions in a community-dwelling population. Pharmacoeconomics Apr;15(4): Resnick NM: Urinary incontinence in the elderly. Med Grand Rounds 1984;3: Risacher SL, McDonald BC, Tallman EF, West JD, Farlow MR, Unverzagt FW, Gao S, Boustani M, Crane PK, Petersen RC, Jack CR Jr, Jagust WJ, Aisen PS, Weiner MW, Saykin AJ; Alzheimer s Disease Neuroimaging Initiative. Association Between Anticholinergic Medication Use and Cognition, Brain Metabolism, and Brain Atrophy in Cognitively Normal Older Adults. JAMA Neurol Jun 1;73(6): Peters KM, Carrico DJ, MacDiarmid SA, Wooldridge LS, Khan AU, McCoy CE, Franco N, Bennett JB. Sustained therapeutic effects of percutaneous tibial nerve stimulation: 24-month results of the STEP study. Neurourol Urodyn Jan;32(1):24-9. Siegel S, Noblett K, Mangel J, Bennett J, Griebling TL, Sutherland SE, Bird ET, Comiter C, Culkin D, Zylstra S, Kan F, Berg KC. Five-Year Followup Results of a Prospective, Multicenter Study of Patients with Overactive Bladder Treated with Sacral Neuromodulation. J Urol Jan;199(1): Nitti VW, Dmochowski R, Herschorn S, Sand P, Thompson C, Nardo C, Yan X, Haag-Molkenteller C; EMBARK Study Group. OnabotulinumtoxinA for the Treatment of Patients with Overactive Bladder and Urinary Incontinence: Results of a Phase 3, Randomized, Placebo Controlled Trial. J Urol Feb;197(2S):S216-S223.