FADE UP TO SET WITH TWO DOCTORS SEATED, FACING EACH OTHER AND ANGLED TOWARD THE CAMERA DR. ROMANZI: Hello, I m Dr. Romanzi with Weill Cornell

Transcription

1 FADE UP TO SET WITH TWO DOCTORS SEATED, FACING EACH OTHER AND ANGLED TOWARD THE CAMERA SUPER ROMANZI S CREDENTIALS DR. ROMANZI: Hello, I m Dr. Romanzi with Weill Cornell Medical Center at New York Presbyterian Hospital. SUPER ROVNER S CREDENTIALS DR. ROVNER: And I m Dr. Rovner with the University of Pennsylvania. DR. ROMANZI Overactive bladder is a widespread and under reported condition that affects the lives of millions of people. DR. ROVNER In this program, we will discuss the causes of overactive bladder and the symptoms that we should be sensitive to in patients who may be affected.

2 CUT TO DR. ROMANZI DR. ROMANZI In a normally functioning bladder, the detrusor muscle in the bladder wall relaxes as the bladder fills with urine and contracts when the bladder voids. The pressure in the bladder remains relatively constant during the storage phase as the detrusor relaxes to receive urine from the ureters. The first sensation of an urge to urinate occurs when about 200 ml of urine is stored in the bladder, although the average bladder can accommodate from 350 to 500 ml of urine. At the onset of the micturition reflex, the urethral sphincter relaxes and the detrusor contracts to expel urine from the bladder. 2

3 PULL OUT TO A TWO SHOT DR. ROVNER: In patients suffering from overactive bladder, the detrusor muscle contracts spontaneously in different regions of the bladder wall, often without any obvious reason, causing sensations of urgency or incontinence even when the bladder is not filled. DR. ROMANZI: The three most common types of incontinence are urge incontinence, stress incontinence and mixed incontinence. Overactive bladder, or OAB, is defined as urgency with or without urge incontinence, usually with frequency and nocturia. The key symptom of OAB is urgency and is defined as a sudden, compelling desire to void which is difficult to deter 1. 3

4 CUT TO DR. ROVNER: DR. ROVNER: Urge incontinence is involuntary leakage accompanied by or immediately preceded by urgency. 2 Many patients begin a cycle of frequent urination to avoid the problem which results in diminished bladder storage capacity over time as the bladder adjusts to voiding with smaller and smaller amounts of urine. Urge incontinence is caused by detrusor instability. Normally the detrusor doesn t contract until an appropriate time to void. However an unstable detrusor contracts involuntarily and spontaneously causing the sense of urgency and the need to urinate more frequently. 4

5 CUT TO DR. ROMANZI DR. ROMANZI: Stress incontinence is not OAB and should not be confused with OAB. With stress incontinence urine is lost when pressure in the bladder exceeds the pressure exerted by the sphincter muscles in the bladder neck. Normally an increase in pressure in the bladder is accompanied by a corresponding increase in pressure in the bladder neck. In patients suffering from stress incontinence, the pressure in the bladder neck is weakened, the sphincter is strained and urine escapes. Stress incontinence episodes can be triggered by exercise, coughing or sneezing. However, the most severely affected patients can lose urine by merely walking up stairs or picking up a heavy object. Stress incontinence is caused by weakness in the support tissues for the bladder or urethra, injury to the nerves that supply the urethra and weakness in the pelvic floor muscles. 5

6 DISSOLVE TO TWO SHOT DR. ROVNER: A third common type of incontinence is mixed incontinence in which patients exhibit symptoms of both urge and stress incontinence. An episode of urgency can be triggered by a cough or sneeze. Patients suffering from stress incontinence do not experience urgency before losing urine. Urge incontinence is the most bothersome and disruptive symptom and should be treated. 6

7 DR. ROMANZI: Over seventeen million Americans suffer from overactive bladder. It is most common in women and the incidence increases with age. However, overactive bladder can affect men and young people as well. It is estimated that twenty-five percent of women between the ages of thirty and fifty-nine suffer some degree of incontinence. Thirty percent of all people over 60 are incontinent. 3 Only a third CUT TO DR. ROVNER or fewer ever report symptoms to a physician. DR. ROVNER: The average patient waits seven years before reporting a bladder control problem to their physician. Some find it too embarrassing to talk about, others believe it is an inevitable consequence of aging, and most are unaware that most cases of overactive bladder can be successfully treated. This is particularly unfortunate because people resort to elaborate coping strategies that dramatically affect their lifestyles. 7

8 CUT TO DR. ROMANZI DR. ROMANZI: People suffering from overactive bladder often withdraw socially, limit travel and time with family and friends, and avoid intimacy. This can lead to depression and feelings of isolation. Urge incontinence has the most impact on a person s lifestyle since the episodes are unpredictable and a larger amount of urine is lost than in stress incontinence episodes, 4,5 which can be anticipated and to some extent avoided. People with urge incontinence report that it affects the quality of their lives more than stress incontinence, depression or diabetes. 4,5 8

9 CUT TO DR. ROVNER DR. ROVNER: Urinary urgency, urge incontinence, urinary frequency and nocturia are symptoms that may occur alone or in combination. A diagnosis of overactive bladder is usually made when a patient has urgency, with or without urge incontinence, and one of the other symptoms. 6 Urinary frequency is simply the need to urinate more often than normal. Normal differs among individuals, but frequency of urination increases significantly in patients suffering from overactive bladder. Urinary urgency is an intense feeling that urination is imminent and cannot be postponed. Urge incontinence is a sudden loss of urinary control accompanied by a sensation of urgency. Urgency is the key symptom of overactive bladder. 9

10 PULL OUT TO TWO SHOT DR. ROMANZI: There are several other types of incontinence, but the three most common types are: stress incontinence in which urine is lost when abdominal pressure on the bladder is increased by sneezing, laughing or exercising; urge incontinence, which is caused by spontaneous contractions of the detrusor; and mixed incontinence which has characteristics of each. DR. ROVNER: Let s look at how overactive bladder affects the lives of some typical patients. 10

11 Case Study A Overactive Bladder FADE UP TO SANDRA, WITH PATIENT IN A THERAPY SESSION. NARRATOR: Sandra is a forty-seven year old speech therapist. She has recently begun having episodes of incontinence. Her incontinence was causing her discomfort at work and problems with her job. She worried constantly about having accidents especially when dealing with her patients. The situation has driven Sandra to see her physician about the problem. CU DOCTOR ROMANZI, INSET IN BOTTOM RIGHT CORNER OF SCREEN DOCTOR ROMANZI: Less than a third of patients suffering from OAB discuss their symptoms with a physician FADE OUT FADE TO BLACK 11

12 FADE UP TO MS, A DOCTOR S EXAMINATION ROOM. SANDRA IS SITTING ON THE EXAM TABLE. THE DOCTOR ENTERS. Hello Sandra, we haven t seen you in a while. How are you doing today? SANDRA: Pretty well, generally. I, uh, I just seem to be having a problem recently. I see. What sort of problem? SANDRA: Well, I seem to have to go to the bathroom often. To urinate? SANDRA: Yes. 12

13 How often do you have to urinate during the day? SANDRA: I haven t counted, but it seems like a lot. It disrupts my work. DISISOLVE TO SANDRA S OFFICE. A PATIENT IS LEAVING. Well, normal is different for each person, but on average, adults urinate once every three to five hours. Do you think you are going more frequently than that? SANDRA LEAVES THE OFFICE SANDRA: Oh yes. It seems like every hour sometimes. I try to go between every patient, but sometimes I have to excuse myself. Does that seem to help? 13

14 DISSOLVE BACK TO MCU SANDRA SANDRA: It helps sometimes, but still during the middle of a session, I often feel like I just have to get up and go. But then, I m not able to urinate very much even though it felt so intense. Does this happen often? SANDRA: Yes, and it seems to be happening more frequently. And sometimes.... I don t quite make it. CUT TO MS, DOCTOR AND SANDRA You lose urine before you get to the bathroom. SANDRA: Yes. 14

15 Oh, I m sorry. I know that must be difficult to deal with. DISSOLVE TO SANDRA WITH PATIENT SANDRA: Yes it is. It s very embarrassing. And I m always worried that it will happen when I m with a patient. I m sure that must make work difficult since you are with patients most of your day. SANDRA: Yes it really does. DISSOLVE TO DOCTOR Do you lose a lot of urine when you don t make it to the bathroom? 15

16 SANDRA: It doesn t seem like a lot, but it is enough to make me very uncomfortable. I recently started leaving an extra pair of pants in my office, just in case. DISSOLVE TO SANDRA, JUGGLING WITH HER KEYS AT THE DOOR IN A RUSH TO GET INSIDE Is work the only place this occurs? SANDRA: Oh no, it can happen any time. Eating dinner, playing cards, running errands on the weekend. And often when I m coming home. Coming home? SANDRA: When I pull in the driveway, sometimes I have to rush inside. It just overwhelms me. 16

17 I see. DISSOLVE TO CU SANDRA SANDRA: Do you know what s wrong? Well, it could be a number of things. What I think we should do first is give you a routine checkup and run a urinalysis. That should give us an indication of what s going on. Let s see now, you are forty-seven? SANDRA: Yes. And you have two children..... FADE TO BLACK FADE OUT AUDIO 17

18 INTERACTIVE SCREEN Interactive Diagnosis Questions: 1. What seems to be Sandra s key symptom? A. Incontinence B. Nocturia C. Urgency Correct = C 2. Did you notice any secondary symptoms? A. Frequency B. Nocturia C. Incontinence Correct = A and C 3. What do these symptoms lead you to suspect as your initial diagnosis? A. Overactive bladder B. Stress incontinence C. Mixed incontinence Correct = A 18

19 Case Study B Mixed Incontinence FADE UP, EXTERIOR, WS JANICE POWER WALKING WITH A FRIEND Janice is a forty-five year old substitute teacher. She has always led an active lifestyle. She enjoys gardening and is a power walker who stays fit. DISSOLVE TO MS JANICE IN FRONT OF CLASS, WRITING ON BOARD Several years ago she began having episodes of intense urgency during class. As the frequency of the episodes increased, she began going to the bathroom between every class. She still had episodes of urgency, but frequent urination kept her from leaking. Later, she began to leak small amounts of urine without warning on energetic walks. She CUT TO MWS JANICE ON GARDEN WITH GLOVES AND A TROWEL, BENDS OVER AND PICKS UP A BAG OF POTTING SOIL thought she must just be getting older and began wearing a pad when she walked. Then she picked up a bag of potting soil one day and leaked. She began to leak regularly when lifting, so she began wearing a pad most of the time. 19

20 DISSOLVE TO JANICE WITH A HOSE, WATERING PLANTS IN GARDEN Janice was an avid gardener and nothing gave her more pleasure than getting out and working with her plants. Occasionally when watering her plants and she would be overcome with an intense urge to urinate and have to run to the house as quickly as she could. JANICE IN THE CLASSROOM, LECTURING, GLANCES AT THE CLOCK WITH A WORRIED LOOK ON HER FACE CUT TO CLOCK Janice s episodes of urgency in the classroom continued to increase in frequency and severity. When the school district announced that they were going to implement block scheduling the following semester, she decided to see her doctor about the problem. She didn t think she CUT BACK TO CU JANICE could make it through a ninety minute block. CU DOCTOR ROMANZI, INSET IN BOTTOM RIGHT CORNER OF SCREEN DOCTOR ROMANZI: Over seventeen million Americans suffer from overactive bladder FADE TO BLACK FADE OUT 20

21 FADE UP TO MS, A DOCTOR S EXAMINATION ROOM. JANICE IS SITTING ON THE EXAMINATION TABLE. THE DOCTOR ENTERS. Hello Janice. How are you this morning? JANICE: Pretty good overall. DOCTOR; Are you still walking regularly? JANICE: Yes, I walk almost every day. It s something I really look forward to. DOCTOR; That s great. You ve always stayed in shape. Are you having a problem? CUT TO CU JANICE, SHE IS UNCOMFORTABLE JANICE (HESITATES): Well..... yes I am, and I don t know quite what to do about it 21

22 Why don t you describe it for me and we ll see if it s something we can help with. JANICE It s my bladder. I ve been having just incredible CUT TO MS JANICE AND THE DOCTOR urges to go to the bathroom in the middle of class. Do you have to leave class to go to the bathroom. JANICE: No. But I make sure I go to the bathroom between every class. And does that help? JANICE: It keeps me from having to leave in the middle of class, but I still get the feeling of having to go real bad. And they are changing to block scheduling next semester. I could never make it through ninety minutes. 22

23 I see. Do you have the problem at any other time? DISSOLVE TO WS JANICE, AT SINK, WITH A DISH - PUTS HANDS IN WATER AND IMMEDIATELY SETS THE DISH DOWN AND EXITS THE FRAME. JANICE: Well it s similar. Sometimes I ll be watering my plants or put my hands in water at the sink and it makes me have to go right then. I actually didn t quite make it from the garden a couple of times. I know that must be disturbing. DISSOLVE TO MS JANICE AND THE DOCTOR JANICE: It is. It s embarrassing. Are there any other times or situations that you encounter this situation? 23

24 JANICE Sometimes it just happens without warning. CUT TO WS, EXTERIOR, JANICE WALKING WITH A FRIENC What do you mean? JANICE: When I m walking I usually leak a little so I wear a pad. Do you have a strong urge to go when you are walking? DISSOLVE TO MS JANICE INTERIOR. BENDS OVER AND PICKS UPS A MEDIUM SIZED BOX JANICE: No, it just happens. And if I pick up something heavy, like a bag of fertilizer or something, it will just happen without warning. And how long have you been experiencing these incidents? 24

25 DISSOLVE TO CU JANICE IN EXAMINATION ROOM JANICE: You know, I m really not sure. Several years at least. It didn t seem like such a big deal at first, but now I ve got to do something. I really enjoy teaching but I can t make it through a ninety minute block. I wish you had mentioned this earlier because the good news is that bladder control problems can almost always be treated successfully. JANICE: Oh really? That is good news. How do you treat it? 25

26 CUT TO MWS JANICE AND DOCTOR IN EXAM ROOM Bladder control can result from several causes. We will want to do a urinalysis just to make sure you don t have an infection, and a full pelvic exam. That should give us an idea of how to proceed. But I m sure that we can take care of this and get you ready for school! FADE TO BLACK FADE OUT 26

27 INTERACTIVE DIAGNOSIS SCREEN Interactive Diagnosis Questions: 4. What seems to be Janice s key symptom? A. Incontinence B. Nocturia C. Urgency Correct = C 5. Did you notice any secondary symptoms? A. Frequency B. Stress incontinence C. Nocturia Correct = A and B What do these symptoms lead you to suspect as your initial diagnosis? A. Overactive bladder B. Stress incontinence C. Mixed incontinence Correct = C 27

28 Case Study C Stress Incontinence FADU UP TO EXTERIOR MWS SHERRY AND A CHILD IN THE YARD Sherry is a fifty-five year old mother of three children. She is retired and has two grandchildren who she enjoys. She was diagnosed with hypercholesteremia two years ago and since she had a history of heart DISSOLVE TO MWS KITCHEN. SHERRY ENTERS FROM EXTERIOR DOOR IN SPANDEX AEROBICS OUTFIT. SHE TAKES A BOTTLE OF WATER FROM REFRIGERATOR, DRINKS AND EXITS THROUGH INTERIOR DOOR disease in her family, she took it seriously. She joined an aerobics class which she attends at least three days each week, and often more. She changed her diet from meat and potatoes fare to include whole grains and lots of fruits and vegetables. DISSOLVE BACK TO EXTERIORMWS OF SHERRY AND CHILD IN YARDAS THEY ARE PLAYING. SHE PICKS HIM UP Over the last several years she had also had isolated incidents of incontinence without any warning. She first noticed it one day when picking up her grandson. Then it happened occasionally when she sneezed or laughed really hard. 28

29 CUT TO MCU SHERRY, AND PARTNER DOING STEP AEROBICS (KEEP THE SHOT TIGHT TO IMPLY A LARGER CLASS) And she almost always lost some urine during her aerobics classes. When she first experienced it, she controlled it by wearing a pad. But now she was losing more urine than she can control with a pad that was small enough to exercise comfortably with. She finally decided to discuss it with her doctor. CU DOCTOR ROVNER, INSET IN BOTTOM RIGHT CORNER OF SCREEN DOCTOR ROVNER: The average patient waits seven years before discussing a bladder control problem with her physician. FADE UP TO MS, A DOCTOR S EXAMINATION ROOM. SANDRA IS SITTING AT A SMALL TABLE IN A CORNER OF THE ROOM. THE DOCTOR ENTERS. AND SITS ACROSS FROM HER. Hello Sherry, how are you today? 29

30 SHERRY (BRIGHTLY): Good, I hope! Why don t you tell me? Well your lipid profile came back excellent. You ve managed to get your total cholesterol down to 187, which is in the range we wanted to be. CUT TO DOCTOR SHERRY: That s great to hear. I ve really worked at it. And it has paid off for you. I m really impressed with the cholesterol ratio. Your bad cholesterol is at 128 and your good cholesterol is at 59 which gives you a ratio of just a little over three to one. That s excellent. And your triglycerides are at 148, which is good. SHERRY: That s good inspiration to keep at it. 30

31 You re still exercising regularly I assume CUT TO SHERRY SHERRY: Yes, I m in an aerobics class that I really enjoy, and I can tell that it s making me stronger. I get around better than I used too. Your general muscle tone seems to have improved. CUT TO MWS SHERRY AND DOCTOR SHERRY: Yes, and I m enjoying the lighter diet too. Let s see, you ve lost fourteen pounds in the last two years. Congratulations! SHERRY Thank you. I do feel better all around. DOCTOR Well then, if there s nothing else, all I can suggest is keep up the good work. 31

32 CUT TO CU SHERRY SHERRY (HESITATNLY, LOSING HER BRIGHT DEMEANOR): Well there is one thing.... Yes, what is it? SHERRY: Well.... I seem to leak sometimes. CUT TO MWS SHERRY AND DOCTOR DOCTOR You lose urine when you are not trying to urinate? SHERRY: Yes. Well, that s not uncommon. SHERRY(HOPEFUL): Really? 32

33 Not at all. When do you find that this is a problem? DISSOLVE TO SHOT OF SHERRY AND PARTNER DOING AEROBIC EXERCISES SHERRY: Well, I ve noticed it a lot at aerobics classes. I usually wear a pad, but it seems to be getting worse and the pad isn t really controlling it anymore. DISSOLVE TO SHOT OF SHERRY PICKING UP CHILD So have you been having this problem for some time? SHERRY: Well, I guess so, when I think about it. It happened a couple of years ago when I picked up my grandson. 33

34 DISSOLVE TO MS OF SHERRY AND DOCTOR I see. Can you think of other times when it happened? SHERRY: It s happened several times when I sneezed really hard. I see. CUT TO CU SHERRY SHERRY: I thought it was just part of getting older. But it can be embarrassing. And I really enjoy my aerobics classes so I need to do something about that. CUT TO CU DOCTOR Well, it is more common as people get older, but it s not an inevitable part of growing old. And it s almost always treatable. 34

35 CUT TO MS SHERRY AND DOCTOR SHERRY (RELIEVED): Really? That s wonderful! What will I have to do? Well, we will want to do a full pelvic exam to decide how to approach it. Bladder control problems can result from several causes, but I am sure that we can solve the problem for you. FADE AUDIO UNDER FADE TO BLACK 35

36 INTERACTIVE DIAGNOSIS SCREEN Interactive Diagnosis Questions: 6. What seems to be Sherry s key symptom? A. Incontinence B. Nocturia C. Urgency Correct = A 7. What were the key triggers for her incontinence? A. Urgency B. Physical activity C. Sneezing Correct = B and C What do these symptoms lead you to suspect as your initial diagnosis? A. Overactive bladder B. Stress incontinence C. Mixed incontinence Correct = B 36