Taking Control of Urinary Incontinence

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Dr. Slovick discusses common bladder problems and treatment options.

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  • Pelvic floor muscle exercises, a well-recognized technique, can strengthen the pelvic floor, thereby producing a more powerful inhibition of involuntary detrusor muscle contractions. Biofeedback may be a beneficial measure to enable patients to locate and train their pelvic floor in an effective manner. 1,2 Rovner ES, Gomes CM, Trigo-Rocha FE, Arap S, Wein AJ. Evaluation and treatment of the overactive bladder . Rev Hosp Clin Fac Med Sao Paulo . 2002;57(1):39-48. Wein AJ. Diagnosis and treatment of the overactive bladder. Urology . 2003;62(5 Suppl 2):20-27.
  • The etiology of OAB is not completely understood. However, evidence suggests that it can be caused by 1 or more factors. Neuronal pathways involved in bladder filling/storage may be damaged by or can malfunction because of neurologic conditions, such as stroke, multiple sclerosis, and Parkinson’s disease. The etiology also may be myogenic in nature, in that denervation or some other factor (eg, aging) can cause increased excitability between myocytes in the detrusor. Because so many components are interconnected and involved in bladder filling and storage, the cause may be a combination of the above, or causative factors may remain to be determined. Ouslander J. Management of overactive bladder. N Engl J Med . 2004;350(8):786-799.
  • Neurologic control of micturition occurs through the release of neurotransmitters. Numerous receptors for neurotransmitters have been identified in the bladder. The receptors for these transmitters are located in the detrusor muscle. Muscarinic and ß 3 -adrenergic receptors are located in the detrusor muscle. The muscarinic receptor has been the major peripheral target involved in pharmacological manipulation of OAB. Muscarinic receptors are located in various organs throughout the body. There are 5 known muscarinic receptor subtypes: M 1 to M 5 . The human detrusor contains M 2 and M 3 subtypes in a 2:1 ratio. When stimulated, M 3 receptors, although less abundant in the bladder than M 2 subtypes, directly evoke bladder smooth muscle contraction. M 2 receptors indirectly reverse sympathetically mediated smooth muscle relaxation. Recently, evidence has shown that more important functional roles of M 2 receptors emerge in aging and in pathologic states, such as outflow obstruction, neurogenic bladder, and diabetes. Andersson KE. Antimuscarinics for treatment of overactive bladder. L ancet Neurol . 2004;3(1):46-53. Braverman A, Ruggeri MR, Pontari MA. The M 2 muscarinic receptor subtype mediates cholinergic bladder contractions in patients with neurogenic bladder dysfunction. Urology . 2001;165(suppl):36. Braverman AS, Karlovsky M, Pontari MA, Ruggeri MR. Aging and hypertrophy change the muscarinic receptor subtype mediating bladder contraction from M 3 towards M 2 . Urology . 2002;167 (suppl):43. Key Messages: M 2 receptors are the most abundant muscarinic receptor in the detrusor and urothelium M 3 receptors are known to directly evoke bladder smooth muscle contraction New theories behind the etiology of urgency are exploring the role of the M 2 receptor in modulation of afferent signals potentially initiated by the urothelium
  • Bladder contraction is mediated by the release of acetylcholine (ACh) from parasympathetic nerve endings. ACh then interacts with muscarinic receptors on detrusor smooth muscle of the urinary bladder to initiate contraction. The effect of ACh on the detrusor muscle is modulated by the action of acetylcholinesterase (AChE) and may be blocked by atropine. Sellers DJ, Yamanishi T, Chapple CR, Couldwell C, Yasuda K, Chess-Williams R. M 3 muscarinic receptors but not M 2 mediate contraction of the porcine detrusor muscle in vitro. J Auton Pharmacol . 2000;20:171-176. Sjögren C, Andersson K-E, Husted S, Mattiasson A, Moller-Madsen B. Atropine resistance of transmurally stimulated isolated human bladder muscle. J Urol. 1982;128:1368-1371. Key Message: Contraction of the bladder smooth muscle involves both the M 3 and M 2 muscarinic receptor subtypes
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  • Taking Control of Urinary Incontinence

    1. 1. Taking Control of Urinary Incontinence Ronald W. Slovick MS, MD Affinity Medical Group Urologist
    2. 2. What are Bladder Control Problems? <ul><li>Broad range of symptoms </li></ul><ul><ul><li>May leak small or large amount of urine </li></ul></ul><ul><ul><li>May leak frequently </li></ul></ul><ul><ul><li>May be unable to completely empty the bladder, or may be unable to urinate at all </li></ul></ul><ul><li>Multiple causes </li></ul><ul><ul><li>Injury </li></ul></ul><ul><ul><li>Side effects from certain medications </li></ul></ul><ul><ul><li>Diseases </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Bearing children </li></ul></ul>
    3. 3. Urinary Control System
    4. 4. How the Urinary System Works Ureter Bladder Bladder neck Urinary sphincter Urethra Kidney
    5. 5. How Common are Bladder Control Problems? <ul><li>Over 33 million people suffer from bladder control problems in the United States alone! </li></ul><ul><li>May affect both women and men </li></ul><ul><li>It can affect people of any age – it is not just a normal part of aging </li></ul>
    6. 6. Types of Bladder Control Problems <ul><ul><li>Stress Incontinence </li></ul></ul><ul><ul><li>Urinary Retention </li></ul></ul><ul><li>Overactive Bladder </li></ul><ul><ul><li>Urge Incontinence </li></ul></ul><ul><ul><li>Urgency-Frequency </li></ul></ul>
    7. 7. Urinary Retention <ul><li>Occurs when you cannot fully empty your bladder. </li></ul><ul><li>Symptoms: </li></ul><ul><ul><li>Need a catheter to pass urine </li></ul></ul><ul><ul><li>Produce only a weak, dribbling stream of urine </li></ul></ul><ul><ul><li>Not have a sensation when your bladder is full </li></ul></ul><ul><ul><li>Store increasingly large volumes of urine </li></ul></ul>
    8. 8. Urge Incontinence <ul><li>A form of overactive bladder. </li></ul><ul><li>Symptoms: </li></ul><ul><ul><li>Lose urine as soon as you need to go to the bathroom </li></ul></ul><ul><ul><li>Leak urine when you drink even a small amount of liquid or when you hear or touch running water </li></ul></ul><ul><ul><li>Have frequent leaking episodes </li></ul></ul>
    9. 9. Urgency-Frequency <ul><li>Also a form of overactive bladder. </li></ul><ul><li>Symptoms: </li></ul><ul><ul><li>Have frequent, uncontrollable urges to urinate </li></ul></ul><ul><ul><li>Go to the bathroom more than seven times a day </li></ul></ul><ul><ul><li>Feel that your bladder is never completely empty </li></ul></ul>
    10. 10. Stress Incontinence <ul><li>Involuntary loss of urine resulting from </li></ul><ul><li>contraction of the abdominal muscles. </li></ul><ul><li>Symptoms: </li></ul><ul><ul><li>Leak urine when you sneeze, cough or laugh </li></ul></ul><ul><ul><li>Experience leakage when exercising, bending or lifting </li></ul></ul><ul><ul><li>Leak urine when climbing stairs or getting up from a chair </li></ul></ul><ul><ul><li>Go to the bathroom often to avoid accidents </li></ul></ul>
    11. 11. Wide Range of Treatment Options <ul><li>Diet modification </li></ul><ul><li>Pelvic Floor Exercises </li></ul><ul><li>Biofeedback </li></ul><ul><li>Medications </li></ul><ul><li>Catheterization </li></ul><ul><li>InterStim Therapy </li></ul><ul><li>Surgery </li></ul>
    12. 12. Diet Modification <ul><li>Fluid intake </li></ul><ul><ul><li>Base on recommended daily allowance: ½ ounce per pound (30 mL/kg) in ambulatory adult in moderate climate </li></ul></ul><ul><ul><li>Reduce fluids 2 hours before bedtime to reduce nocturia </li></ul></ul><ul><ul><li>Individualize timing of diuretic per patient need </li></ul></ul><ul><li>Reduce intake of bladder irritants such as: </li></ul><ul><ul><li>Caffeine </li></ul></ul><ul><ul><li>Alcohol (ETOH) </li></ul></ul><ul><ul><li>Nicotine </li></ul></ul><ul><ul><li>Cola </li></ul></ul>
    13. 13. Voiding Regimens <ul><li>Scheduled voiding </li></ul><ul><ul><li>Fixed voiding schedule, varies from 2 to 4 hours depending on results of voiding diary (bladder log) </li></ul></ul><ul><ul><li>Essential adjunct to pharmacotherapy </li></ul></ul><ul><li>Habit retraining </li></ul><ul><ul><li>Scheduled voiding that is adjusted based on patient’s voiding pattern </li></ul></ul><ul><ul><li>Requires significant patient motivation </li></ul></ul><ul><li>Bladder training </li></ul><ul><ul><li>Combination management strategy that combines education, scheduled voiding with adjustment, urge suppression maneuvers, and reinforcement </li></ul></ul>
    14. 14. Pelvic Muscle Rehabilitation <ul><li>Strategic use of pelvic floor muscles to maximize LUT function </li></ul><ul><li>Rehabilitation consists of 3 main components: </li></ul><ul><ul><li>Biofeedback to teach muscle identification and isolation for purposes of voluntary contraction and relaxation </li></ul></ul><ul><ul><li>Muscle training to improve function, tone, strength, and endurance </li></ul></ul><ul><ul><li>Neuromuscular reeducation (skill training) to promote continence, relief of bothersome urgency, and complete evacuation of bladder during micturition </li></ul></ul>
    15. 15. Overactive Bladder: Pharmacologic Options
    16. 16. Possible Etiology of Overactive Bladder Unknown Combination Ouslander J. N Engl J Med . 2004;350(8):786-799 Neurogenic Myogenic
    17. 17. Distribution of Cholinergic and Adrenergic Receptors <ul><li>Human bladder smooth muscle contains primarily M 2 (66%) and M 3 (33%) subtypes </li></ul><ul><li>Activation of M 3 receptors evokes direct smooth muscle contraction (primary stimulus for bladder contraction) </li></ul><ul><li>Stimulation of M 2 receptors may cause contractions </li></ul><ul><ul><li>Reverse sympathetically mediated smooth muscle relaxation </li></ul></ul><ul><li>M 2 receptors may have a more important functional role in the pathologic bladder </li></ul><ul><ul><li>Neurogenic bladders </li></ul></ul><ul><ul><li>Aging </li></ul></ul><ul><ul><li>Hypertropy </li></ul></ul>Andersson KE. Lancet Neurol . 2004;3:46-53. Braverman A et al. Urology . 2001;165:36. Braverman AS et al. Urology . 2002;167:43 . Bladder neck (  ) Urethra (  ) Trigone (  ) Pelvic floor (N) Detrusor muscle (M,  ) M = Muscarinic N = Nicotinic  =  1 - and  2 -Adrenergic  =  3 -Adrenergic
    18. 18. Bladder Contraction Is Mediated by M 2 and M 3 Receptors <ul><li>Release of ACh from cholinergic nerves </li></ul><ul><li>Stimulation of muscarinic receptors on the detrusor smooth muscle </li></ul><ul><li>ACh effects on the detrusor smooth muscle that may be blocked by atropine </li></ul>Andersson K-E. Lancet Neurol . 2004;3:46-53. Ouslander JG. N Engl J Med . 2004;350:786-799. Sellers DJ et al. J Auton Pharmacol . 2000;20:171-176. Sjögren C et al. J Urol. 1982;128:1368-1371. Bladder contraction is caused by: ACh = acetylcholine.
    19. 19. Commonly prescribed medications: <ul><li>Oxybutnin </li></ul><ul><li>Ditropan XL </li></ul><ul><li>Detrol LA </li></ul><ul><li>Vesicare </li></ul><ul><li>Enablex </li></ul><ul><li>Sanctura </li></ul><ul><li>Gelnique </li></ul><ul><li>Etc… </li></ul>
    20. 20. Medications do not work for everyone <ul><li>Voiding requires a coordinated activity between the nerves and the muscles that control voiding </li></ul><ul><li>While medications are thought to address the muscles, InterStim Therapy is thought to address the nerves. </li></ul><ul><li>If medications were not the answer for you, InterStim Therapy may provide relief. </li></ul>
    21. 21. InterStim Therapy for Urinary Control <ul><li>FDA-approved treatment for urinary control problems in people who have not had success with or could not tolerate more conventional treatments. </li></ul><ul><li>Over 60,000 patients implanted worldwide </li></ul>
    22. 22. How Does InterStim Therapy Work? <ul><li>A small stimulation system is implanted under the skin, usually in your upper buttock </li></ul><ul><li>The device provides stimulation of the sacral nerves to help restore more normal voiding function </li></ul><ul><li>This therapy is reversible at any time </li></ul>
    23. 23. Who Can Benefit from InterStim Therapy? <ul><li>People with non-obstructive urinary retention </li></ul><ul><li>People with symptoms of overactive bladder, including urinary urge incontinence and urgency-frequency </li></ul><ul><li>People whose symptoms did not improve with more conventional treatments, such as medications </li></ul><ul><li>People who cannot tolerate the side effects from medications </li></ul><ul><li>People who respond well to the test stimulation and can operate the system </li></ul>
    24. 24. Test Stimulation <ul><li>An office test is done to determine how you will respond to the implanted device </li></ul><ul><li>A thin wire (lead) is placed under the skin just above the tailbone </li></ul><ul><li>Lead is connected to an external device worn on your waistband for a period of 3-4 days </li></ul><ul><li>The decision for implantation of the device will be made based on your response to the test stimulation </li></ul>
    25. 25. Implantation of the InterStim System <ul><li>Procedure done at the hospital under local anesthesia </li></ul><ul><li>Stimulator is implanted and connected to a lead wire that will stimulate your sacral nerve </li></ul><ul><li>Stimulator is usually placed just under the skin in upper buttock </li></ul><ul><li>The InterStim System will reside under your skin </li></ul><ul><li>Entire procedure takes about 45-60 minutes </li></ul>
    26. 26. InterStim Patient Programmer <ul><li>You will be given a programmer to take home with you to control the stimulator </li></ul><ul><li>The programmer can turn the system on and off and adjust the level of stimulation </li></ul>
    27. 27. How effective is this therapy? <ul><li>Urge Incontinence (38 patients) </li></ul><ul><li>45% of patients completely dry </li></ul><ul><li>Further 34% had 50% or greater reduction in symptoms </li></ul><ul><li>Urgency-Frequency (33 patients) </li></ul><ul><li>31% back to normal (4-7 per day) </li></ul><ul><li>Additional 33% had a 50% or more reduction in number of urinations </li></ul><ul><li>Retention (38 patients) </li></ul><ul><li>61% stopped catherization </li></ul><ul><li>16% had > 50% reduction in the amount of urine emptied from the bladder by catheter </li></ul>Results 12 Months After Surgery Medtronic clinical study data on file
    28. 28. Potential Risks with InterStim Therapy <ul><li>As with other surgical procedures, there are risks: </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Transient stimulation discomfort </li></ul></ul><ul><ul><li>Lead migration </li></ul></ul><ul><ul><li>Adverse change in bowel function </li></ul></ul><ul><ul><li>Other* </li></ul></ul><ul><li>These complications were generally resolvable in the clinical study </li></ul><ul><li>*Types of risks that occurred less than 2% of the time </li></ul>
    29. 29. Does insurance pay for this? <ul><li>National Medicare coverage policy </li></ul><ul><li>Hundreds of insurance companies have paid for this procedure </li></ul><ul><li>Your doctor’s office will help you obtain coverage </li></ul>
    30. 30. Call us to make an appointment We’d be happy to help! <ul><li>Laurie Dietzen, RN </li></ul><ul><ul><li>Dr. R. Slovick’s nurse </li></ul></ul><ul><ul><li>Direct dial number: (920)730-4946 </li></ul></ul>
    31. 31. Sarah’s Story <ul><li>Being only 40 years old, I was self- conscious about the need to catheterize all the time. I am very active in sports, hiking, and taking long walks with my dog Randy – all of which I couldn’t do with a catheter. </li></ul><ul><li>InterStim Therapy has brought me back to normal activities with regard to urological function. It made such a difference in my life. I am thrilled to have my normal life back! </li></ul>
    32. 32. Jeannie’s Story <ul><li>My name is Jeannie. I’m a 50-year-old wife, mother, and a pre-op day surgery R.N. I’m also a patient who has struggled with urinary control problems for years until I found a treatment that completely changed my life. </li></ul><ul><li>Now I go every four hours during the day and I only get up once at night. I’m not sleep-deprived and I’ve begun working out again. My daughter and I love horseback riding and are taking hunt-seat jumping classes. I feel like I’ve been given my life back. </li></ul>
    33. 33. Brief Summary Disclosure for InterStim ® Therapy for Urinary Control InterStim ® Therapy for Urinary Control: Product technical manual must be reviewed prior to use for detailed disclosure.   Indications: InterStim Therapy for Urinary Control is indicated for the treatment of urinary retention and the symptoms of overactive bladder, including urinary urge incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatments. Contraindications: Patients are contraindicated for implant of the InterStim System if they have not demonstrated an appropriate response to test stimulation or are unable to operate the neurostimulator. Also, diathermy (e.g., shortwave diathermy, microwave diathermy or therapeutic ultrasound diathermy) is contraindicated because diathermy's energy can be transferred through the implanted system (or any of the separate implanted components), which can cause tissue damage and can result in severe injury or death. Diathermy can damage parts of the neurostimulation system. Precautions/Adverse Events: Warning : This therapy is not intended for patients with mechanical obstruction such as benign prostatic hypertrophy, cancer, or urethral stricture. Safety and effectiveness have not been established for: bilateral stimulation, patients with neurological disease origins such as multiple sclerosis, pregnancy and delivery, or for pediatric use under the age of 16. System may be affected by or adversely affect cardiac pacemakers or therapies, cardioverter defibrillators, electrocautery, external defibrillators, ultrasonic equipment, radiation therapy, magnetic resonance imaging (MRI), theft detectors and screening devices. Adverse events related to the therapy, device, or procedure can include: pain at the implant sites, lead migration, infection or skin irritation, technical or device problems, transient electric shock, adverse change in bowel or voiding function, numbness, nerve injury, seroma at the neurostimulator site, change in menstrual cycle, and undesirable stimulation or sensations. CAUTION: Federal law (USA) restricts this device to sale by or on the order of a physician.

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