Joseph Costa DO FMPRS Associate Professor of Surgery Interim Chairman Department of Surgery University of Florida College of Medicine Jacksonville Learning objectives Distinguish unique characteristics of current medications for over active bladder ID: 577961
Download Presentation The PPT/PDF document "Contemporary Management of incontinence ..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Contemporary Management of incontinence and prolapse
Joseph Costa, DO, FM-PRS
Associate Professor of Surgery
Interim Chairman, Department of Surgery
University of Florida College of Medicine - JacksonvilleSlide2
Learning objectives
Distinguish
unique characteristics of current medications for over active bladder.
Identify
indication for surgical intervention for over active bladder.
Identify
interventions for pelvic organ prolapse. Slide3
Urinary incontinence
The involuntary loss of urine:
Immediate desire to urinate precedes involuntary loss =
URGE
Forceful pressure, (e.g. cough, sneeze, mad at husband) =
STRESS
Combination of the above types =
MIXED INCONTINENCESlide4
Urinary incontinence
Incontinence
Incontinence by type
Urge
Stress
Mixed
Prevalence
Gender/Ethnicity breakdown
Related Conditions
BPH , male
sypmtoms
AUA score / IPSS
Irritative
voiding symptoms
Female vaginal prolapse
UDI-6
IIQ-7Slide5
National Health and Nutrition Survey 20084,229 Women ÷ 33% = 1,396 of group surveyed
Incontinent
50% or above group pure stress incontinence
34% Mixed incontinence
16% Urge incontinence
SUI 2.5x higher risk in White or Mexican American women vs. Black
Women by AGE
Prevalence
of Incontinence
20-39 YRS
36%
40-59 YRS
28%60-AND OLDER YRS36%
Incontinence Gender breakdown
J
Urol
. 2008 Feb;179(2):656-61.
Epub
2007
Dec
21.
Urinary
incontinence
prevalence
:
results
from
the National
Health
and Nutrition
Examination
Survey.
Dooley Y1,
Kenton K,
Cao G,
Luke A,
Durazo-Arvizu R,
Kramer H,
Brubaker L.Slide6
Neurourol Urodyn. 2013 Mar;32(3):230-7.
The
prevalence
of
lower
urinary
tract
symptoms (LUTS) and overactive bladder (OAB) by racial/ethnic group and
age: results from OAB-POLL.
Coyne
KS1,
Sexton CC, Bell JA, Thompson CL, Dmochowski R, Bavendam T, Chen CI, Quentin Clemens J.10,000 men and women surveyed between age 18-70 yrsMen n = 4,977 ; Women n = 5,0232,000 African American ; 2,000 Hispanic ; 6,000 Caucasion
5,700 people respondedOveractive Bladder :
Men = 25%
Women = 50%
Urge Incontinent Often:
Men = 8%
Women = 30%
Ethnicity:
AA Men = 10% v. 6%
AA Women = 19% v. 16%Slide7
Pelvic organ prolapse
Prolapse Type
Anterior
Posterior compartment
TotalSlide8
Grades of Prolapse
Low Grade Stage I or II
High Grade Stage III or IVSlide9
Prevalence of pop, irish study
Int
Urogynecol J. 2014 Nov;25(11):1463-70
. 2014
Apr 16.
Prevalence, etiology and risk factors of pelvic organ prolapse in premenopausal
primiparous
women.
Durnea CM1,
Khashan AS, Kenny LC, Durnea UA, Smyth MM, O'Reilly BA
.
n = 202 Irish women > 1yr after delivery of first child
POP Q staging systemUterine = 89% Cystocele = 90% Rectocele = 70%65% Had at least POPQ Stage II DiseaseC Section protects for C ystocele and RectoceleSignificant Type III Collagen, varicose veins, asthma, hypermobile jointsSlide10
Risk of surgical repair for pop
Obstet Gynecol. 2010 Nov;116(5):1096-100.
Lifetime
risk of undergoing surgery for pelvic organ prolapse
.
Smith FJ1,
Holman CD,
Moorin RE,
Tsokos
N1981-2005 almost 45,000 surgical cases reviewedAge of risk calculated if life lived to 85
yrs
Risk of surgery for pelvic organ prolapse during female’s life =
19%Slide11
Pharmacologic intervention
Traditional anticholinergic
medications most likely to be generic
Later generation anticholinergic medications
Newer, selective medications
Botulinum
toxin
Traditional
Later Gen
Newer selective
Oxybutynin (IR and ER)
Solefenicin
Mirabegron
Hyoscyamine
Darefenicin
Botulinum
toxin A
Tolterodine
Fesoterodine
Trospium
ChlorideSlide12
Older generation agents
Higher side
effect
profile
Highest drop out rate. Oxybutynin IR 80% over one year
Most likely to be on best tear for patient insurance
Beware generic ER drugs that typically have engineered release capsulesSlide13
Second generation anti-muscarinics
More selective for bladder predominant receptors
Less Side Effects!!
More likely to have engineered capsules
Daily Dosing or Patch !!
Less likely to behave like generic form of medications
Technology Patents don’t expire like drug formulas !!Slide14
Modern anticholinergic therapy response
Significant decrease in number voids per day (1-3)
Significant increase in volume voided
Significant decrease in incontinent episodes , approximately 5 per week
Better response rate with
concommitent
pelvic floor exercises
Nabi
G, et al. (2006). Anticholinergic drugs versus
placebo for overactive bladder syndrome in adults. Cochrane Database of Systematic Reviews. Alhasso AA, et al. (2006).
Anticholinergic drugs versus non-drug active therapies for overactive bladder syndrome in adults. Cochrane Database of Systematic Reviews.Slide15
Newer agents for overactive bladder
Mirabegron
Metabolized by CYPD2D6
Beta 3 AGONIST
Increases bladder capacity
Should have less side effect profile due to non-muscarinic MOA
May cause or exacerbate Hypertension
Botulinum
Toxin A
200 Units1
Bladder volume 145mls at 4 weeks
Bladder volume 90mls at 12 weeks
Significant improvement in QOL1. Arun Sahai, Mohammad Shamim Khan, Prokar Dasgupta, GKT Botulinum Study GroupEfficacy of Botulinum Toxin-A for Treating Idiopathic Detrusor Overactivity
: Results From a Single Center,
Randomized
, Double-Blind, Placebo
Controlled
Trial
June 2007Volume 177, Issue 6, Pages 2231–2236Slide16
J Urol. 2006 Mar;175(3 Pt 1):999-1004;
.
Safety and tolerability of
tolterodine
for the treatment of overactive bladder in men with bladder outlet obstruction.
Abrams P1,
Kaplan S,
De Koning Gans HJ,
Millard R..
Men WITH obstruction ; > 40 yrs of age ; n=149
Tolterodine
BID ; n=70 placebo
Urodynamically demonstrated efficacy in Drug vs. Placebo p< 0.003Post void residual significantly greater Drug vs. Placebo +25 mls averageNo significant difference in adverse eventsSlide17
When medical management fails
Overactive Bladder
Botox
Injection
Neuromodulation
Obstruction
Prolapse
Prior Sling Surgery
Male:
Transurethral resectionSlide18
Botulinum toxin injectionSlide19
neuromodulationSlide20
Transurethral ablationSlide21
ProlapseWhen medical management fails
Incontinence
Pessary
Obstruction
Prolapse Repair
Sling SurgerySlide22
Prolapse repair - urethrolysisSlide23
Take home points
Generic agents for OAB have greater side effects therefore higher drop out rate
Patents for pill technology do NOT EXPIRE like those for drug formulation
Generic form not always going to behave the same if capsule is engineered
Men can be safely treated for OAB
33% of men may have OAB or incontinence of urine
19% of women have a lifetime risk of surgery for pelvic organ prolapse
There are interventions after failed medical intervention, encourage patients to see their Urologist Slide24
Thank you