R. Matthew Smith M.D. Stacy Pohlman, ARNP Jessica Gengler, PT, DPT Mercy Urology

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1 R. Matthew Smith M.D. Stacy Pohlman, ARNP Jessica Gengler, PT, DPT Mercy Urology

2 Disclosures Matt Smith None Stacy Pohlman None Jessica Gengler None

3 Topics Clinical Pathway Development Prostate Cancer Care Urinary Incontinence

4 Mercy Urology Third Anniversary 9/6/2019 Providers 3 MD 1 NP 1 PT Support Staff 6 Urology RN 2 MA 1 (1) Front Office 1 Surgery Scheduler

5 Clinic Volumes Last 3 Calendar Years Chart Title New Ptients Total Patients

6 Surgical Market Share Last 3 Fiscal Years MMC Surgical Market Share 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 84.60% 70.20% 67.94% 29.80% 32.06% 15.40% FY 17 FY 18 MMC Urology FY 19 Community

7 Plans for growth Continue to grow market share Maximize referrals from Mercy Care PCPs Outreach clinics Continue to identify underserved issues Moderate BPH Urolift Rezum Erectile Dysfunction Cheap Viagra Penile Prosthesis Clinical Pathways Streamline referrals Same day stone referrals Same day vasectomy

8 Clinical Pathways Standardize Care From PCP through specialty care Many urologic diseases are protocol driven Build on past success Hematuria evaluations Leverage shared medical record / Mercy resources When appropriate, develop smart sets for PCP use Develop Literature to help PCPs educate patients prior to and in anticipation of urologic referral. Perception of good care versus reality of good care

9 Clinical Pathways PSA/Prostate Cancer Female Voiding dysfunction Urgency, Incontinence, recurrent UTI BPH Hematuria / Bladder Cancer Renal stone disease Focus: Stone prevention......

10 Comprehensive Prostate Cancer Care Prostate Cancer is a longitudinal disease Prostate Cancer care can be managed by urology until late in disease course Provide known location / personnel for patients Currently all the pieces are in place Need for standardization Better understanding from patients on what to expect through the course of their disease

11 Detection Localized Cancer Care Surveillance Spectrum of prostate Cancer Castrate Sensitive Disease Castrate Resistant Disease Death from Prostate Cancer

12 Mortality Detection Localized Cancer Care Surveillance Castrate Sensitive Disease Castrate Resistant Disease Death from Prostate Cancer

13 Mortality Detection Localized Cancer Care Surveillance Non Cancer Mortality Castrate Sensitive Disease Castrate Resistant Disease Death from Prostate Cancer

14 Keeping Current Detection Localized Cancer Care Surveillance Castrate Sensitive Disease Castrate Resistant Disease Death from Prostate Cancer Fusion Biopsy / Genetic screens Updated technology Track Patients DEXA / Labs Offer All Adjuvant Tx

15 Quality of Life Detection Localized Cancer Care Surveillance Castrate Sensitive Disease Castrate Resistant Disease Death from Prostate Cancer Maximize Yield / Minimize SE Leakage / ED Manage Anxiety Manage SE from ADT SE from Adjuvant Tx / Prepare for EOL

16 Prostate Cancer detection Standard for 20+ years: Trans Rectal Ultrasound Guided prostate biopsy Real time procedure % false negative rate Infection risk Need for repeat biopsy Ultrasound good at visualizing prostate Not great at noting cancer random biopsy

17 Post Prostatectomy Incontinence Current paradigm: Discuss risks of Incontinence at diagnosis; need for pelvic floor strengthening post surgery Surgery, Catheter x 2 weeks Discuss kegel exercises at follow up, track incontinence with questionnaire s Problem with current paradigm: Confusion with what is a kegel No direct feedback of therapy Despite this, we still have good results

18 Post Prostatectomy Incontinence New Paradigm Discuss risks of incontinence at diagnosis Meet with PT prior to surgery, learn pelvic floor strengthening exercises Surgery, Catheter x 2 weeks Following catheter removal (1 2 weeks) Back with PT, stratify level of incontinence, review / reinforce pelvic floor strengthening Benefits: Minimize time to full continence Less confusion / frustration with return to continence Able to better track results

19 Patient E.O. 66 y.o. M Dx: 3/1/17: T1cN0M0; Intermediate risk CaP Prostatectomy: 7/18/17, Path: T2bN0Mx, 3+4=7 adenocarcinoma of the prostate All PSA post surgery <0.1 Persistent incontinence at every visit > 2 pads, but still in Depends feels more secure happy, no desire for intervention 11/19/18 visit: Referral to PT

20 Patient E.O. 12/10/18: PT Evaluation Initially leakage better, but plateaued Leakage with lifting heavy items, coughing, sneezing wears a depends all the time 2/18/19 PT Visit (5 th Treatment visit) good progress to goals improved hip and pelvic floor muscle strengthening still has a little leakage with heavy lifting and exertion Out of depends, wearing regular underwear with small liner Continues to benefit from treatment

21 Post Prostatectomy ED Varying level of importance to patients For some, it s the most important For others, it s not important at all But.... Not an unusual story: At initial diagnosis: Doc, I don t care about erections. Just get this cancer out One year after surgery, cancer free: Doc, am I ever going to get my erections back Varying level of pre existing erectile function Varying severity of cancer

22 Post Prostatectomy ED Current paradigm Discuss at initial diagnosis, identify and set expectations Explain nerve sparing and recovery of erectile function Surgery Review pathology, focus on continence Surveillance visits Discuss erections at each visit, usually after discussing cancer status and leakage

23 Post Prostatectomy ED New Paradigm At diagnosis: Formalize erection history (SHIM score), document patient desires for erections following surgery Prior to surgery (NP visit at time of pre surgery PT visit) Review expectations / desires VED prescription Viagra prescription Post surgery surveillance visits Track progress to goals Initiate injection Tx if desired Prepare for IPP if trajectory to goals not being met, and pt desires (12 18 months) If you want erections, we will get you erections

24 Summary Clinical Pathways Over next 6 12 months, develop and refine clinical pathways Work with marketing to develop tri folds / literature for PCP offices Visit PCP offices on a rotating basis Feedback Ideas for future collaboration Our goal: There is nowhere else I would want to go for my urologic care than Mercy Urology

25 What can we offer our patients?

26 Objectives To provide our primary care providers with the tools to assess and treat urinary incontinence To provide our primary care providers the knowledge of when to refer and what Mercy Urology can offer patients New services on the horizon.

27 Incontinence Urinary incontinence is a significant problem, affecting tens of millions of Americans. Urinary incontinence is not necessarily associated with increased mortality, but significantly affects quality of life.

28 Risk Factors Age Obesity Parity and Mode of delivery Family history Other Smoking Diabetes Injury or surgical intervention to low back Neurologic insults

29 Eitiology Urinary incontinence is generally the result of either bladder or urethral dysfunction

30 Evaluation Routine screening especially in High Risk populations Assess the impact on quality of life Assess for contributing factors Assess relevant urinary symptoms. May use standardized questionnaires. Inquire about frequency, volume, severity, hesitancy, precipitating triggers, nocturia, intermittent or slow stream, incomplete emptying, continuous urine leakage, and straining to void

31 Evaluation Physical Exam Pelvic exam Assess for prolapse Qtip test PVR Rule out UTI Neurologic deficits

32 Stress Incontinence Urine Test Cough stress test Do they leak during pelvic exam with Valsalva maneuvers? Urethral mobility Q Tip test

33 Prolapse

34 Classifying Incontinence Stress Urge Overflow Mixed

36 Classifying Incontinence Stress Incontinence: The loss of urine with increases in intraabdominal pressure, such as occurs with laughing, coughing, or sneezing. There is no urge to urinate prior to the leakage

37 Classifying Incontinence Urge Incontience: The urge to void immediately preceding or accompanied by involuntary leakage of urine. "Overactive bladder" urinary urgency with or without incontinence, which is often accompanied by nocturia and urinary frequency

38 Classifying Incontinence Overflow Incontinence Detrusor muscle underactivity :results in loss of urine with no warning or triggers. Urinary outlet obstruction associated with an intermittent or slow stream, hesitancy (difficulty getting urine stream started), and a sensation of incomplete emptying.

39 Treatment Stepwise Approach based on type of incontinence and affect on quality of life. Modify contributing factors Lifestyle modification Weight loss Diet changes Avoiding constipation/diarrhea Smoking cessation

sustained for 8 to 10 seconds each, three times a day.

40 Pelvic Floor (Kegel) exercises Useful for both Stress and Urge incontinence Initial regimen: Three sets of 8 to 12 contractions sustained for 8 to 10 seconds each, three times a day. Patients should try to do this every day and continue for at least 15 to 20 weeks

41 Medications for Urgency/OAB Anticholinergics Antimuscarinics/Smooth Muscle Relaxant oxybutynin ***Caution in elderly hyoscyamine (Levsin) Anticholinergics Antimuscarinics Nonselective for M3 Receptor Superior side effect profile to traditional anticholenergics Tolterodine (Detrol LA), Trospium (Sanctura), Solifenacin (Vesicare) Anticholinergics Antimuscarinics Selective for M3 Receptor darifenacin (Enablex) Beta 3 Adrenoceptor agonist Mirabergron (Myrbetriq) Decreased antimuscarinic type side effects but may increase blood pressure

42 When to refer: Failure to respond to medical therapy Presence of hematuria, recurrent infections or complicated incontinence. High risk patients Spinal cord injury / neurologic deficits Pyelonephritis / Hydronephrosis

43 What Mercy Urology can offer: Advanced evaluation and treatment Comprehensive patient centered care State of the art facility with convenient access Shared decision making in treatment planning to meet each patients unique and individual needs. Convenient and prompt scheduling

44 Advanced Evaluation Urodynamics testing by a certified personnel Ceiling lift to assist in evaluation of all patients Cystoscopy available as needed Built to incorporate fluoroscopy at a later date

45 Neuromodulation Percutaneous Tibial Nerve Stimulation (PTNS)

46 Interstim

47 Bladder Botox

48 Pelvic Floor Physical Therapy Jessica Gengler, PT, DPT

49 Pelvic Health Physical Therapy Bladder Dysfunction Urinary Incontinence: Stress, Urge, Mixed Urinary Urgency Urinary Frequency Sexual Dysfunction Dyspareunia Pelvic pain Pelvic Organ Prolapse Bowel Dysfunction Fecal Incontinence Constipation

50 PT Evaluation More than just kegels! Posture Breathing pattern LE and core strength Pelvic floor (PF) muscle awareness, strength, endurance, and coordination Pelvic floor muscle tone assessment/soft tissue restrictions

51 PT Treatment for Bladder Dysfunction Pelvic floor awareness and strengthening in isolation Biofeedback Slow twitch versus fast twitch fibers Progression to strengthening with functional movements Coordination of pelvic floor with diaphragm Core strengthening/diastasis recti

52 PT Treatment for Bladder Dysfunction Manual techniques for soft tissue restrictions Optimizing posture for good PF activation Downtraining of overactive PF muscles Movement strategies to control for increased IAP Education: urge suppression techniques, bladder diary, bladder irritants

53 How to refer to physical Therapy For Urologic Complaints Primary evaluation though urology, internal referral For GI complaints (Fecal Incontinence, Constipation) Typically after GI eval, but OK to inbox for chart review For OB/GYN complains (Postpartum pain, dyspareunia) Direct referral from PCP, or OB/GYN

54 Questions? For free up to date patient information visit:

Urinary Incontinence for the Primary Care Provider

Urinary Incontinence for the Primary Care Provider Diana J Scott FNP-BC https://youtu.be/gmzaue1ojn4 1 Assessment of Urinary Incontinence Urge Stress Mixed Other overflow, postural, continuous, insensible,