Treatment algorithm for urinary incontinence

Transcription

1 Treatment algorithm for urinary incontinence Post ICS-IUGA congress January 22nd 2016 Bunnik Prof. Dr. Gommert A. van Koeveringe MD,PhD Urologist and chairman dept. of Urology Maastricht University Medical Center, Netherlands

2 Urgency Incontinence Behavioural Physiotherapy Medication Combined behavioural and medication Botulinum toxin Neuromodulation Invasive surgical

3 Behavioural treatment and PFMT o Has proven to be beneficial and is often proposed as first line treatment. Van Kerrebroeck, Curr Urol Rep (2012) 13: Robinson and Cardozo. Maturitas 71 (2012) o Might prove to be more effective if the right patients are selected with biomarkers or predictive diagnostic tools. (personal opinion) obstruction induced DO! o Less effective than antimuscarincs alone. Rai et al. Cochrane reviews. 2012;vol 12.

4 Pharmacological treatment o o o Mainstay of therapy Many different drugs, ample RCT s High placebo response o o Mostly targeted at reduction of the afferent output of the bladder towards the central nervous system Andersson Can Urol Assoc J 2011;5(5Suppl2):S131-S133 Additional targets on autonomous bladder contractions? Rahnamai, van Koeveringe et al. J Urol 2010;183:

5 Pharmacological treatment

6 Combined pharmacological and behavioural treatment Whether drug and behavioral therapy are combined from the onset or used sequentially in a stepped program, the evidence from the present study is that two interventions combined have a greater potential to enhance outcome than could be achieved by either intervention alone. Burgio et al. J Am Geriatr Soc. 2000;48: Was partly confirmed in a recent cochrane review Rai et al. Cochrane reviews. 2012;vol 12.

7 Neuromodulation

8 Neuromodulation Test stimulation for neuromodulation: classical PNE: 50 % positive result i.e. more than 50 % reduction of urge episodes, number of incontinence episodes per 24 hours Tined lead 2 stage procedure: 80% positive results. Oerlemans, Weil et al. BJU int 2006

9 algorithm Source: P.Abrams et al. The Role of Neuromodulation in the Managerment of Urinary Urge Incontinence, BJU International 2003, 91, Abstract M Smits at al Maastricht ICS 2012 of Botulinum toxin

10 Surgical: augmentation of

11 Conclusions Urgency incontinence 1. Many different treatment options for the overactive bladder. 2. Pharmacological treatment nowadays mainly targeted at reducing afferent imput to the CNS. 3. High need for adequate patient and disease characterization: biomarkers. 4. Diagnostic and treatment algorithms need to be clarified. 5. Need for good quality trials on conservative therapy

12 Stress Incontinence Lifestyle Medication Physiotherapy Surgical: TOT/TVT Burch/Fascial sling Bulking / Balloons AMS sphincter Bladderneck closure/ Mitrofanoff/Ileal conduit

13 Lifestyle Obesity Stress incontinence occurs more frequently in obese women Int J of Obesity 2008, 32: 1415 Treatment of overweight (in morbidly and moderately obese women) decreases stress incontinence (Grade A evidence!) ICI reports Paris 2008 Neurourol urodyn, 2008, 27:749 N.Engl.J.Med, 2009, 360;5, 481 Obesity did not prove to affect long term surgical outcome of anti incontinence surgery. Am J O Gyn, 2007, 98 July 2007

14 Lifestyle Intoxications Reduction in caffeine use improves stress urinary incontinence (Grade B evidence) ICI reports Paris 2008 Severe stress incontinence is weakly associated with smoking. i.e. it seems only severe incontinence gets agravated by smoking or the related coughing BJOG, 2003, 110:247

15 Lifestyle Physical exercise Low or modarete physical exercise is beneficial to reduction of stress incontinence (Grade C evidence) ICI reports Paris 2008

16 Medication Duloxetine Serotonine nor adrenaline reuptake inhibitor In selected patients moderate effect even long term but very low long term adherence to therapy (Grade B evidence?) Imipramine Tricyclic antidepressant BJUI, 2008, 102: 214 Occasional positive effect on urgency- and stress incontinence Urol.Res. 2001, 29: 118

17 Medication Estrogen replacement therapy Local therapy occasionally effective Systemic therapy might agravate stress incontinence Cochrane review 2009, Cody et al.

18 signifcantly effective than no treatment signifcantly effective than placebo No complications Pelvic Physiotherapy Significance of effect should be offered as first line therapy subj/obj cure/improvement rates: 60-70% level 1, grade A ICI 2009

19 Conclusions on conservative therapy Grade A evidence for weight reduction to treat stress incontinence Grade A evidence for pelvic physiotherapy to treat stress incontinence The gain of these therapies is very much dependent upon motivation of the patient, referring physician and therapist.

20 Surgical approach Integral theory: Petros 1993, Ulmsten 1995 Creation of neoligaments with tapes Strengthening of pubo-urethral ligaments Mid-urethral placement of the tape

21 Surgical approach pubourethral ligament urethropelvic ligament Transobturator Sling Pubovaginal Sling m.d.a. P.Palma

22 Surgical approach The slings

23 Surgical classical approach Older surgical techniques: Stamey-Perreira, Raz, Marshall Marchetti Kranz (Old) Gold standard: Burch colposuspension Cr1y: 85-90%, Cr5y: 70% Classic sling: Suburethral proximal fascial sling Cr1y 73-95%,

24 Surgical approach Burch - TVT comparison (early): 2 years: TVT 63%, Burch: 51% dry (1hr pad) Complications: TVT: 9% bladder perforation, 7.5% sp pain, 0,4% tape erosion, (20% retentie) Burch: 7% wound infection en 32% UTI, Ward & Hilton, Am.J.Obstet.Gyn, 2004; 190:

25 Surgical approach De-novo urge incontinence: TVT (Abouassaly et al, BJU Int Jul;94(1): Seagal et.al. Obstet Gynecol Dec;104(6):1263-9) d-n urge incontinence: 15%, 9,1% 57% of oab symptoms before surgery is cured after. No urodynamics necessary (in primary cases)

26 Surgical approach TOT better short term in the long term (12m) no difference with TVT Also risk benefit comparable in the long term.

27 Surgical approach

28 If the tapes fail What next:

29 Evaluation of the patient Extended History taking Urge / stress differentiation. Previous surgery Neurogenic disease / Diabetes Psychogenic causes Sexual complaints (Dys-and His-pareunia)

30 Evaluation of the patient Vaginal examination + speculum and Qtip Leakage test: cough, strain, MMK Cystoscopy Flow and post void residual Multichannel urodynamics And optional: Video or ambulatory urodynamics Vaginal ultrasound

31 Evaluation of the patient Alway suspect erosion or wrong placement. In case of pain: always remove the tape Misrai et al. J urol :

32 What therapy should be selected A second tape: Attractive option: succes percentages 5 to 20 % less than primary. Second TVT 71% succes Second TOT 48% succes Prepare your patient for more complications: 30 % de novo urgency Old tape can stay Stav et al, Jurol 2010, 183,

33 What therapy should be selected If Intrinsic sphincter deficiency is suspected: If there is less urethral mobility: Retropubic sling is far more effective then Lim, Dwyer et al Curr opin obstet.gynecol (5), Consider an artificial urinary sphincter in women. Chartier Kastler et al. BJUint (10), Consider bulking agents Tamanini et al. J Endourol (9),

34 What therapy should be selected After tape removal: Retropubic Sling better than Burch Consider combination with Labial Fat Flap (Martius) Higher complication rate and erosion of perforation rate For this reason I personally prefer autologous fascia

35 Still not cured Bulking agent: Periurethral injection ACT placement AMS Sphincter Or.Do nothing

36 Artificial sphincter for female stress incontinence

37 Artificial sphincter for female stress incontinence

38 Conclusions Recurrent Stress incontinence Thorough Evaluation of the patient and the complaint If there is erosion pain or wrong placement remove the tape and come back a second time with sling or tape. Otherwise good results of a second tape, which should be a TVT and not TOT In ISD: consider bulking or AMS sphincter. Further reading: Comiter. Nat.clin.pract.urol (12):