7/21/2016. Purpose. Cases. Stress Incontinence: Not a normal part of aging!

Transcription

1 Stress Incontinence: Not a normal part of aging! Adam C. Steinberg, DO, FACOG, FACS Associate Chair FPMRS Fellowship Director Hartford Hospital Assistant Professor Department of OB/GYN Univ Connecticut School of Medicine Purpose Review stress incontinence Review non-surgical and surgical treatments options for stress incontinence Provide basic skills to identify stress incontinence in the office setting Use the evidence within the literature to successfully support above Cases 78 yo G3P3 presents with complaints of having to wear pads as she is leaking getting out of bed and while on walks 44 yo G3P3 that has leakage associated with doing burpees and squats while at her boot camp 22 yo G0 college runner who has noticed leakage on her long runs 1

2 Incontinence Under-diagnosed Condition patients are often embarrassed misconceptions about UI a normal part of being a woman, growing old, or giving birth unaware of effective non-surgical treatment strategies Who is affected? Median rate in community setting 58% (Offermans et al Neurourol Urodyn) 25-51% of women have at least one episode of leakage in the past year (buckley et al 2010 Urology) 85% of patients are women In people aged 15-64, affects: 1.5% - 5% of men 10-30% of women 2

3 Nursing Homes Prevalence Rate 60-78% of women have some form of incontinence (Sayhoun 2001 NCHS) 6-10% of nursing home admissions secondary to incontinence (Morrison 2006 Value Health) Cost Total urinary incontinence-related costs in the US were nearly $20 billion in 2000 (Hu 2004 Urology) In a study looking at cost of patients electing to proceed with SUI sugical treatment The annual mean cost of self expenditure for incontinence management was $751 accounting for almost 1% of the median annual household income (Subak 2008 Obstet Gynecol) Incontinence (urge and stress) Higher costs for urge Higher costs for African American than white women Annual costs with severe incontinence was $900 (Subak 2006 Obstet Gynecol) Risk Factors Established risk factors female gender: women 2x > men parity: 4 children age: > 50 bladder capacity and contractility involuntary detrusor contraction post-void residual volume in men and women Urethral sensation increases in women women - estrogen loss, UT tissue atrophy 3

4 Birth Trauma Urinary Incontinence during Exercise Highest prevalence of SUI = activities involving high impact (eg. Track and Field) (Bo et al,2001, Med Sci Sports Exerc) 26% of competitive track athletes had urinary incontinence while participating (Nygaard et al. 1994, Obstet Gynecol) 35% of female Olympic track athletes had urinary incontinence (Nygaard et al., 1997, Obstet Gynecol) 25% of high school and college women age 14-21yo had symptoms of either SUI or Urge incontinence while participating in high impact sports (Carls et al Urol Nurs) Incontinence in Pregnancy Affects 30-60% of pregnant women 6-35% of women in postpartum period report incontinence Leakage is mild in about half of women Resolution of symptoms in the postpartum period in 70% of those affected (Burgio 2003 Obstet Gynecol) 4

5 Office Work up History Validated Questionnaire Urine Analysis Vaginal exam Q-tip Cough Stress test Post void residual Simple cystometrics Complex cystometrics Validated Questionnaires Urogenital Distress Inventory (UDI) UDI-6 King s Health Questionnaire Incontinence Severity Index (women only) Incontinence Impact Questionnaire (IIQ, IIQ-7) (men and women) Pelvic Floor Distress Inventory Urodynamics 5

6 Complex Urodynamics Helpful or Not?? Pre-operative urodynamics failed to improve the rate of treatment success, as compared with the success rate associated with basic office eval. Nager et al NEJM Current recommendations: if patient with a positive cough stress test in the office no further work up is needed. Stress Incontinence Stress Incontinence loss of urine during activities that raise intra-abdominal pressure sneezing, coughing, laughing causes weakening in tissues surrounding bladder neck and urethra resulting in hyper-mobility intrinsic urethral sphincter deficiency 6

7 Stress Incontinence Treatment Expectant Management Medications Behavioral Pessary Impressa Surgical MMK/Burch Slings Bulking Agents Stress Incontinence Medication Alpha-adrenergic agonist medications Tricyclic antidepressants (imipramine)????duloxetine (cymbalta) Hormone Replacement Estrogen (oral or vaginal) A combination of both Stress Incontinence Behavioral Techniques (to teach you ways to control your bladder and sphincter muscles): Pelvic Muscle Exercises Kegels Cones Bladder Training Scheduled voiding Thinking of something else (Distraction) Biofeedback 7

8 PESSARY Pessary Hippocrates- pomegranate soaked in wine 50+ different kinds Frequency of cleaning not established 73% of patients successfully fitted 1 1. Clemons et al. Am J Obstet Gynecol 2004; 190(2): Ring Pessary 8

9 Pessary Requires manual dexterity for self-maintenance Removal for coitus Impressa Over the counter treatment Theory is it works like a pessary INTRINSIC SPHINCTER DEFICIENCY: Often times no urethral hypermobility Cystocele often times not present Leakage with minimal provocation 9

10 Stress Incontinence Bulking Agent Injection: A substance is injected around the urethra to help it remain closed. Collagen (no longer available) Fat Pyrolytic carbon-coated beads Submucosal Injection Technique Peri-urethral Injection Technique 10

11 Stress Incontinence Surgical Repairs Retropubic Urethropexy Two types: Marshall-Marchetti-Krantz (MMK) Burch Urethropexy Elevate UVJ and proximal urethra Approach: Abdominal, Laparoscopic, Vaginal, Robotic Marshall-Marchetti-Krantz One suture is placed bilateral at the level of the bladder neck and then into the periosteum of the pubic symphisis 11

12 Burch Urethropexy Different from MMK in that suture placed at Cooper s Ligament Suburethral Sling Procedures Mechanism of Action: All slings provide a backboard which stabilizes the urethra at rest and compresses it when intra-abdominal pressure increases. Tension free slings 1997 Gyencare launched TVT in the US Based on the intergal theory by Petros and Ulmstead Ward, Hilton et al, demonstrated in a randomized controlled trial that TVT was as efficacious as the prior gold standard, Burch colposuspension (2002 BMJ) Subsequently studies have demonstrated continued long term efficacy 12

13 Tension Free Slings TOT TVT TVT vs TOT Prospective randomized trial The tranobturator tape is not inferior to TVT for the treatment of stress urinary incontinence and results in fewer bladder perforations and less bleeding M Barber Obstetrics and Gynecology 11(3) 2008 TOT not as effective for ISD 13

14 MESH, MESH, MESH, MESH FDA Warning 10/2008 For the patient informing them, that there has been reports of complications (erosion, infection, pain, urinary problems, recurrence of prolapse) associated with vaginal mesh Make sure to ask your physician Why do you want to use mesh What is your experience If I have a complication related to mesh can it be removed and what are the consequences Ask for a copy of the information that comes with the mesh Details of FDA White paper Serious complications with transvaginal mesh are NOT rare (different from 2008) Not clear that transvaginal mesh is more effective than traditional repair B/w 2008 and 2010, 2874 reports of complications reported 1503 with POP repairs 1371 with SUI repairs (primarily a newer form of slings known as mini-slings introduced by multiple companies in 2007 and

15 Effects of Report Jan 2012: FDA sent letter to companies requiring that certain products needed post market studies and a response was needed by June with the intent of their plans. June 2012: multiple products pulled from market while others partaking in post market studies. Many slings were not part of this process. MESH Mesh Medical Device News Desk, January 2012, Mesh Makers who Received FDA Letters Requiring Postmarket Surveillance FDA Safety Communication: UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse, July s/ucm htm AUGS & SUFU Position Statement Nilsson, C.G., et al., Seventeen years follow-up of the tension-free vaginal tape procedure for female stress urinary incontinence. Int Urogynecol J, (8): p CG Nilsson, 11-year study on tape procedure for SUI, Intl Urogyn J. 2008, Cases 78 yo G3P3 presents with complaints of having to wear pads as she is leaking getting out of bed and while on walks 44 yo G3P3 that has leakage associated with doing burpees and squats while at her boot camp 22 yo G0 college runner who has noticed leakage on her long runs 15

16 QUESTIONS?????? Thank You 16