CLIMAtúria Alberto Silva - PowerPoint Presentation

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CLIMAtúria

Alberto SilvaHospital Prof Doutor Fernando Fonseca

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A

climatúria afeta a satisfação global da função sexual, visto estar associado a perda involuntária de urina relacionada temporalmente com o clímax / orgasmo, tendo impacto no paciente e na sua parceira.

  A incontinência, que pode ocorrer em pequenas quantidades durante as preliminares ou atividade sexual não relacionada ao orgasmo, tem o mesmo efeito.

  A perda de urina durante a atividade sexual após a RP é provavelmente subdiagnosticada na prática clínica, onde 221 (29,5%) dos 749 pacientes. Brant et al (Journal of Urology 2014) , Capogrosso et al (European Urology 2015)

Climatúria

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Climatúria

A disfunção sexual é comum em doentes submetidos a RP e RT pélvica

Além dos sintomas de

incontinência urinária e disfunção eréctil, vários outros problemas relacionados com a função sexual foram descritos após prostatectomia radical, no entanto, em números menos prevalentes. Entre eles, estão as transtorno do orgasmo, com impacto significativo na vida sexual dos doentesFrey AU, Sønksen J, Fode M. Neglected side effects after

radical prostatectomy: A

systematic

review

. J Sex Med. 2014;11(2):374–385.

Clavell-Hernández J, Martin C, Wang R. Orgasmic Dysfunction Following Radical Prostatectomy: Review of Current Literature. Sex Med Rev. 2018;6(1):124–134.

As alterações na função do orgasmo são experienciadas por cerca de 80% dos doentes após cirurgia. Entre as principais disfunções do orgosma estão: climatúria (incontinência associada ao orgasmo), percepção alterada do orgasmo, anorgasmia e disorgasmia .

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Climatúria

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Urinary

function

is the single strongest predictor of patient health-related quality of life (HRQoL) after RP, ranking above treatment modality and sexual function

. Although most patients (68%) become

completely

continent within 2 months, persistent urinary incontinence after RP is common and

affects 8% to 25% of patients. PREVALENCE OF PPI VARIES BY DEFINITION - PPI after RALP showed mean continence rates of 65%, 88%, 91%, and 95% at 3, 6, 12, and 24 to 36 months, respectively - outcomes after 1 year were fairly stable: at 18, 24, and 60 months after RP, 8.4%, 10%, and 14% reported incontinence - videourodynamics were used

, stress urinary incontinence (SUI) was noted in 95% of men at 4 years after RP , - At 5 years after RP, 14% of men report bother

due

to

urinary

incontinence

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ROLE OF PPI IN SEXUAL ACTIVITY

ED

secondary

RP problem affecting up to 77% to 88% of patient who do return to sexual activity, the problem of ED can be compounded by multiple factors:

orgasmic disturbances, penile

shortening

,

and

psychological impact of cancer treatment. Challenge “ PPI, incontinence

during sexual activity, during arousal (foreplay or masturbation), or during orgasmo” Climacturia, or leakage during orgasm, affected 28% to 44% of men who were sexually active after RP .93% when men were asked whether they experienced any incontinence

associated with orgasm, to any degree, at any time after RP.

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ROLE OF PPI IN SEXUAL ACTIVITY

Stratified

by frequency of climacturia:16% experienced leakage with every orgasm 77% replied “occasionally or rarely

“However, 10% to 37%

of

those

with NO SUI problem reported major bother from incontinence during sexual

activity A time-related improvement of symptomsdecrease in prevalence and major bother by 2 years

The degree of impact of climacturia on sexual activity is

unclear

.

- cause

avoidance

of

sexual

activity

and

decreased

sexual

satisfaction

by

the

patient

and

his

partner

-

other

studies

found

no

significant

impact

on

orgasmic

function

and

satisfaction

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Abordagem na consulta

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The

surgical

alterations of a RP result in:partial loss of the proximal intrinsic sphincter, the proximal urethral sphincter, and

the suspensory ligaments

,

resulting

in post-prostatectomy continence that is largely

dependent on the external sphincter Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE): - 372 men after prostatectomy, only 63% returned to their baseline continence EAU UI guideline review

, post-RP SUI rates ranged from 5% to 48.0%. Shown climacturia can occur in 20% to 64% of men

after

RP,

Fode

et

al, 2017

At

3m

pos-op

, 44%

reported

bother

from

incontinence

during

sexual

activity

,

which

decreased

to

36.1%

at

24m

.

This

bother

was

strongly

associated

with

SUI

at

all

times

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Climatúria

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Climacturia

in

men

can cause avoidance of sexual activity associated with depressed mood

, anxiety, and worse

QoL

Only 25% of

patients who self-report as having UI eventually seek care for their incontinence and only 33% of those diagnosed in a primary care setting received some form of

treatment

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Found

that

84% of men who emptied their bladder before sexual activity had limited accidents and 11% used condoms

Lee

et

al, 2006

Behavioral

interventions:patients emptying their bladder just before sexual activity;fluid and caffeine restriction in the time before suspected or planned

activity

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Supervised

pelvic

floor muscle training for at least three months has

been shown

to

produce

better outcomes than

unsupervised training. CLINICAL MESSAGES  PFMT augmented with biofeedback improves erectile function in men after RP, but

the evidence is limited. One study

found

PFMT

combined

with

electrical

stimulation

to

be

beneficial for

improving

RP

climacturia

.

However

,

electrical

stimulation

is

only

recommended

for

terminally

ill

patients

.

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Climatúria

Given

the limited options for these patients, which include the Urostop ( other similar devices), surgical options including

sling and AUS placement,

or

acceptance

of status quo and use of condoms to capture

the leak, There is a clinical need for a simpler, cost-effective and more user/ partner friendly option.

The use of a variable tension penile loop to compress the urethra

was

observed

to

decrease

the

frequency

and

volume

of

climacturia

.

Among

surgical

interventions

:

- arti

fi

cial

urinary

sphincters

and

urethral

slings

were

associated

with

improvements

in sexual

QoL

.

- In

the

largest

series to date

of

37

men

with

climacturia

after RP

transobturator sling placement resolved 83%

of SUI cases and 100% of climacturia

cases.

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ESTUDOS A DECORRER

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Informar os doentes

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The

study

group appears to have been carefully selected as being an ideal patient group by an exhaustive preoperative evaluation including routine endoscopy. As expected, the results demonstrate a cured/improved rate

of greater than

90%,

which

remained durable for 3 years.

- similar favorable outcomes with the traditional AdVance sling- precise sling placement, patient selection has emerged as an important

variable. - no longer perform slings in radiated men

or

those

with

more

severe

incontinence

.

-

Poor

candidates

with

heavy

leakage

are

guided

primarily

toward

artificial

urinary

sphincter

(AUS)

careful

patient

selection

yields

optimal

outcomes

Remains

a

subject

of

debate

(

patients

evaluated

)

Selected

,

the

cost- effectiveness of

various preoperative protocols.

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multicenter

study

of patients with post-RP erectile dysfunction and climacturia and/or mild urinary incontinence

( 2 pads/day [ppd

])

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Longer

follow-up

and

larger patient cohorts are needed to confirm the long-term safety and benefits of this intervention.

Furthermore

,

the

complication rate (13%) was comparable to

that reported in studies of urethral slings alone (12%)

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Not

enough

data exists regarding the optimal type of graft for use in the Mini-Jupette sling

Publications

have

questioned

the biocompatibility of implanted mesh

, with growing concerns regarding mesh contraction and extrusion Rectus fascia (3x4cm)Use of autologous fascia represents a safe and effective source for the Mini-Jupette graft, which

is cost efficient for the patient and is not subject to the controversy associated with synthetic mesh grafts.

Larger

cohorts

and

longer

follow-up

are

needed

before

recommending

widespread

adoption

of

this

technique

.

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Considerações Finais

UI

and

sexual dysfunction independently are key health factors :in QoL, social function, relationship stability, and perceived overall health. SI is a prevalent and underaddressed condition that embodies many of the negative impacts of

UI and sexual dysfunction on men and

women

.

There are a multitude of effective treatment options for men and women, which

should be discussed with patients who experience a significant degree of bother from their SI. Treatment interventions range from behavioral to surgical and should progress from least to most invasive

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Obrigado !