URINARY TRACT INFECTIONS RISK FACTORS URINARY TRACT INFECTIONS RISK FACTORS

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  • URINARY TRACT INFECTIONS RISK FACTORS URINARY TRACT INFECTIONS RISK FACTORS

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

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