URINARY TRACT INFECTIONS RISK FACTORS 	 URINARY TRACT INFECTIONS RISK FACTORS
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URINARY TRACT INFECTIONS RISK FACTORS URINARY TRACT INFECTIONS RISK FACTORS

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URINARY TRACT INFECTIONS RISK FACTORS 	 URINARY TRACT INFECTIONS RISK FACTORS URINARY TRACT INFECTIONS RISK FACTORS URINARY TRACT INFECTIONS RISK FACTORS Presentation Transcript

  • www.ucsf.edu/wcc
  • Mind Over Bladder: Everything you always wanted to know…. Jeanette S. Brown, MD Professor Obstetrics, Gynecology, & RS; Urology Epidemiology & Biostatistics University of California, San Francisco
  • Urinary Incontinence
    • Common
    • - 50% of women have incontinence
    • - It effects women of all ages
    • - Women suffer in silence
    • Chronic
    • Incontinence doesn’t kill you, it just takes away your life….
    • Profound effect on women’s lives
    • Limits exercise, travel, and social activities
    • Costly
        • $32 billion/year
        • Greater than the cost of all cancer care for women
    View slide
  • www.ucsf.edu/wcc View slide
  • UCSF Women’s Health: A New Vision
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  • UCSF WCC Mission
    • Clinical
    • Breaking the silence
    • Improving lives through education & treatment
    • Research
    • Preventing incontinence
    • Developing novel treatments
    • Training
    • Fellows, residents, students
    • Other healthcare providers
  • Current Clinical Innovations
    • Most comprehensive program
    • Multidisciplinary
    • - Urogynecologists, Urologists,
    • Colo-rectal surgeons
    • Extensive Pelvic Rehabilitation Program
    • - Continence Specialist, Physical Therapist
    • Community outreach
    • - Mind Over Bladder
  • Incontinence Definitions
    • Overactive Bladder (OAB)
    • - urgency, urinary frequency, getting up often at night, urge incontinence
    • Stress -coughing, sneezing, straining, exercise
    • Mixed - both urge and stress
  • Incontinence Treatment
    • Pelvic Floor Rehabilitation
    • - Pelvic Floor Exercises
    • - Bladder training
    • - Biofeedback
    • - Electrical Stimulation
    • Medications, devices
    • Surgery
  • Successful Pelvic Floor Exercises
    • Strengthen levator ani and sphincter
    • Two types: Rapid and Prolonged
    • Individualized Program
    • Coughing up
  • Bladder Training
    • Voluntary control
    • Scheduled voids
    • Bladder diary
    • Positive reinforcement
    • Goal = 3-4 hour voids
  • Additional Treatments
    • Timed voids to prevent full bladder
    • Fluid moderation
    • Urge UI: Urge suppression
      • - quick pelvic contractions
      • urge distraction
    • Prompted Voids
  • Plugs & Drugs
    • Pessary, Femsoft
    • Meds: Primarily Urge UI:
    • Oxybutynin (Ditropan, XL)
    • Tolterodine (Detrol, LA)
    • Stress UI: Duloxetine 2003?
  • Who should have surgery?
    • Patient driven
    • Failed conservative treatment
    • Stress UI primarily
    • Bladder neck mobility
    • Understands risks & benefits
  • How does it work?
    •  Urethral mobility
    • “ Backstop” for the urethra
    • Recreate “hammock”
    • Obstruction
  • What do we know?
    • 150 surgeries
    • Data limited on outcomes (Jarvis 1999)
    • Published surgical literature is of the lowest level of evidence and limited quality (Merlin 2001)
    • Lack of controlled trials, short follow-up
  • What else?
    • Overestimate success
    • Underestimate complications
    • First surgery: best surgery (Black 1996)
    • The more severe the UI, the better the outcome
    • Burch or Sling best choices
  • Urinary Incontinence Treatment Network
    • NIDDK supported; 9 centers
    • RCT of Burch vs. Sling
    • 2 to 4 year follow-up
    • Probable similar efficacy
    • - Difference in morbidity (Weber 2000)
  • Tension-free Vaginal Tape
    • Prolene tape, quick, easy, light anesthesia
    • Synthetic tape “well-tolerated”
    • - publication bias or short-term?
    • Outcomes:
    • - Short-term 90%; Long-term-no data
    • Reasonable choice with limited data
  • Long-term Outcomes
    • Average age at surgery: 54 yo
    • - Average life expectancy: 77 yo
    • At 4 years: 80-85% success (Leach 1997)
    • > 5 years: poor data and fall off
    • - 50-60% (Diokno 1989; Erikson 1990)
    • - 30% need re-operation (Stanton 1997 Erikson 1990)
  • Surgery Summary
    • SUI surgery is not an emergency!
    • More severe UI better outcome
    • First surgery most successful
    • New surgeries: RCT to standard
    • Long-term data lacking
  • www.ucsf.edu/scor
  • UCSF Specialized Center of Research (SCOR)
    • Only NIH designated center for:
    • Lower Urinary Tract Function in Women
    • Clinical and Basic Research
    • Multi-disciplinary Multi-Institutional
    • - Departments of: ObGyn, Urology, Family Medicine Geriatrics, Epi & Biostats
    • Translation of scientific results to improved care
  • UCSF Specialized Center of Research Basic Clinical Epidemiological Investigation New Treatments Database Analysis Improved Patient Care Economic Analysis Molecular Biology Training Prevention
  • Research
    • High quality research is necessary to identify:
    • Natural history and prognosis of disease
    • What happens to women with incontinence?
    • Risk factors for disease
    • Does having a hysterectomy increase risk for UI?
    • Effective, novel treatments
    • Does estrogen treat incontinence?
    • Does weight loss improve incontinence?
  • Think Outside the Bladder !
  • Falls & Fractures
    • In older women:
    • Falls: 20-40%
    • Hip fractures: 90% with fall
    • Incontinence: 50%
    • Association with OAB?
  • Falls and Fractures
    • 4 centers in US
      • 6049 women > 65 years of age
      • followed every 4 months for 3 years
    • Outcomes
    • 55% had falls
      • 8.5% had fractures
    Brown JAGS 2000
  • Multivariate Falls & Fractures Risk P Falls OAB 26% <0.0001 Stress 6% 0.3 Fractures OAB 34% <0.02 Stress 1% 0.09
  • Falls & Fractures Summary
    • Weekly OAB  Risk:
    • Falls 26%
    • Fracture 34%
    • Associated frequency & nocturia
    • Early diagnosis and treatment
    • Potential to prevent or  falls & fx
    • (Brown JAGS 2000)
  • Risk Factors for Daily UI
    • Risk Factor % Increased Risk
    • Oral HT 90
    • Stroke 80
    • Diabetes 70
    • Poor overall health 60
    • Obesity 50
    • Hysterectomy 40
    • COPD 40
    • Age (per 5 years) 30 (Brown 1996)
  • Hormone Therapy
    • Receptors in urethra, bladder
    • Clinical therapy
    • Limited trial data
  • Hormones & Incontinence
    • Randomized controlled trial
    • 1525 women with weekly incontinence
    • Hormone Therapy: Estrogen/ Progestin or Placebo
    • Followed 4.1 years
  • Hormones & Incontinence
    • Improved UI: 21% HT
      • 26% Placebo
    • Worsened UI: 39% HT
            • 27% Placebo P=0.001
    • Summary:
    • Oral HT not recommended for treatment
    • Prevention?
  • Weight and Incontinence
    • > 50% US women overweight or obese
    • Obese women: 4 fold  risk UI
    • Incontinent Women: 70% obese
    • Proposed Mechanism:  abdominal pressure, urethral mobility, damage supports
    • Can weight reduction improve or prevent UI?
  • Weight Reduction Studies
    • In women about 200 lbs:
      • Weight loss: > 5% or 30 lbs
    • > 50% Incontinence reduction
    • Effective therapy for UI
    • Public Health Implications
    • NIH Multi-centered trial funded
    • (Subak 2002)
  • Hysterectomy
    • United States
    • 600,000 per year
    • Average age: 44yo
    • By age 60, 37% of women
    • 90% for benign etiology
  • Hysterectomy & UI
    • Women > 60 yo with hysterectomy:
    • - 60%  Incontinence risk
    • Mechanism: Similar to childbirth
    • Damage to muscle/nerves
    • Clinically useful information
    • (Brown Lancet 2000)
  • Clinical Implications
    • Quality of life
    • Potential risks later
    • Patient preference
    • Alternatives to hysterectomy
  • Summary
    • Common
    • Make incontinence cocktail conversation!!
    • Important quality of life issue
    • Improving lives through education & treatment.
    • Innovative Research
    • Advancing treatment through research
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  • www.ucsf.edu/wcc