Management of Overactive Bladder - medicine.utah.edu · Objectives •Review treatment options for...
Transcript of Management of Overactive Bladder - medicine.utah.edu · Objectives •Review treatment options for...
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Management of Overactive Bladder
Dee E. Fenner, M.D.Chair and Furlong Professor of Women’s HealthDept. of Obstetrics and GynecologyUniversity of Michigan
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Disclosures
• NONE
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Objectives
• Review treatment options for Urge Urinary Incontinence• Behavioral • Physical therapy of the pelvic floor• Medications• Procedures
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Stress urinary incontinence• “I leak when I laugh, cough,
or sneeze”• Definition: Loss of urine
involuntarily with effort or physical exertion
• Etiology thought to relate to urethral integrity• Does not result from a
cystocele
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All that leaks isn’t stress…• Overactive bladder syndrome: 17% women
• Frequency: micturition occurs more frequently during waking hours than previously deemed normal by the woman (>7 voids)
• Urgency: sudden, compelling desire to pass urine that is difficult to defer
• Urgency urinary incontinence – prevalence 7-33%• Complaint of involuntary loss of urine associated
with urgency• Women > men
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Bladder controlling
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UUI treatment overview• Behavioral changes
• Timed voiding ~3hrs• Decrease fluids and bladder irritants• Manage constipation
• Medications• Anticholinergics• Beta-3 blockers
• Pelvic floor physical therapy• Weight loss• Neuromodulation
• Interstim• PTNS• Traditional acupuncture
• Botox intra-detrusor injections
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Equilibration
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UUI practical tips• Use only incontinence pads, not menstrual
• Never Always®• Maybe cotton pads (available online/Amazon,
health stores)• If itching/pain/bleeding, needs pelvic exam
• Set an alarm in the middle of night before urgency wakes you
• Stop drinking ~7pm• Compression stockings/elevation in daytime
• If lower extremity edema and nocturia
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UUI practical tips• Vaginal estrogen
• Some evidence to suggest it treats OAB as well as Detrol
• Reduction of UTIs• Least systemic absorption: generic = Yuvafem• Least patient effort: Estring (no generic)
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“I don’t drink enough”• Numerous smart phone
apps exist to promote ‘hydration’• MyWater• Water Your Body• Water Tracker• Replenish Your Body• DrinkMore
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Lack of scientific support• No scientific studies support 8x8 (eight 8oz glasses of water a day)
• Other beverages (caffeinated, alcoholic) do count• Fluid is found in foods• Sophisticated osmoregulatory system maintains balance
• Encourage drinking:• People who exercise regularly• Warm, humid temperatures• Elderly (in moderation)• Certain medical conditions (ie, profuse diarrhea)
• We advise using urine color as assessment of hydration• Want a pale yellow color (not clear, not dark)
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Bladder irritants• Urgency and frequency symptoms are common• One treatment is modification of intake of
“potentially irritating beverages” (PIBs)• Anecdotally successful• Sparse evidence supporting
• Potentially Irritating Beverages (PIBs) defined as:
caffeinated artificially sweetened
citric/acidic juices
alcoholic
carbonated
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Bladder irritants• Copious recommendations in lay media encourage women to
reduce caffeinated, carbonated, acidic drinks and fluids in general
• In favor of:
• Show me the data … ?
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PIBs and real life• When women were asked to completely eliminate irritating
beverages (PIBs) without decreasing total intake volume:• Decreased overactive bladder symptoms • Variable volume of total beverage intake• Incomplete PIB elimination (some increase!)
• Key Question:
PIBs or Volume?
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Parallel-group RCT with three-period fixed sequence
Answered ad for symptoms of urgency/frequency
Screening: ≥16oz PIBs and ≥32oz total
Randomized n=61
Control (healthy diet guidelines)n=31
2 weeks later: 3-day voiding diary
2 months after baseline:3-day voiding diary
Baseline 3-day voiding diary
N=1 lost to follow-up
N=2 lost to follow-up
Leakage was not required
PIBs Educationn=30
PIB replacement and caffeine reduction
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Results• Despite detailed instruction to maintain fluid
intake volume, both groups reduced total beverage intake by about 7oz per day
• No significant difference between groups
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Results
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Results: Frequency
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Results: Bother
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Results: Effects of specific PIBs• Looking at bother score:
• Reduction in artificial sweeteners (p=0.04) and caffeinated beverages (p=0.004) predicted improvement in bother
• Looking at voids per day: • Reduction in alcoholic beverages (p=0.04) and caffeinated
beverages (trend only, p=0.06) predicted improvement in frequency
• J Urol Nov 2017 Systematic Review – sparse evidence• Association between increased fluid, caffeine and
urgency/frequency
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Conclusions & Take-aways• What’s new:
• SUI: non-collagen bulking injections, hypopressive PT• UUI: Botox, PTNS, mirabegron, hypopressive PT
• What’s old:• SUI: mesh slings, pessaries (oldies but goodies!)• UUI: anticholinergics, esp. short-acting (oldie but not-goodie)
• What’s fizzy:• SUI: Minislings (will fizz out…)• UUI: Stick with carbonated water flavored with fruit!
• Avoid caffeine, alcohol, and artificial sweeteners
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Pelvic Floor Physical Therapy• First line treatment• More effective for OAB than SUI• Graduated muscle training
• 3 sets of ten contractions a day• Short contraction (flicker) with increasing time of
contraction• Associate with activity – eating, TV news, stop light,
• Transfer ability to squeeze to activity – walking to toilet• Squeeze before standing to suppress urge
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Meds: Anticholinergics• Muscarinic receptor antagonists
• In US: oxybutynin, tolterodine, fesoterodine, trospium, solifenacin, and darifenacin
• Increase bladder capacity• Decrease urgency• Side effects: Dry eye, Dry mouth, Constipation
• Newer meds target M3 receptors “specific” to bladder to minimize • Not really successful
• Avoid if wide-angle glaucoma, frail elderly
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Meds: Anticholinergics• Muscarinic receptor antagonists
• ~40% better than placebo – but placebo ~30% better than nothing
• Use extended-release formulations rather than short-acting• OTC patch available now
• Expensive and rarely make you 100% dry• Most people are no longer on a drug past 1st
prescription, very few by 12mo later (as high as 90% discontinue)
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Cognitive side effects• Long known to be anticholinergic side effect, but thought to
be reversible/transient• Newer data show cumulative clinical decline, irreversible risk
of dementia and brain atrophy:• Compared to 350 patients not using anticholinergics, 52
anticholinergic-using patients (mean 73.3 yrs) showed: • Lower mean scores on Weschler Memory Scale-Revised Logical
Memory Immediate Recall • Lower mean scores on Trail Making Test Part B • Lower executive function composite score • Reduced total cortical volume and temporal lobe cortical thickness • Greater lateral ventricle and inferior lateral ventricle volumes
• 1. Gray et al. JAMA Intern Med. 2015 Mar;175(3):401-7.• 2. Risacher SL et al. JAMA Neurol. 2016 Jun;73(6):721-32.
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• Behavioral therapies first• Providers should counsel on the associated risk of cognitive
impairment, dementia, and Alzheimer disease, prescribe the lowest effective dose, and consider alternative medications in patients at risk
• Be aware of other anticholinergics patients are also using• Refer for Botox or neuromodulation
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Meds: Newest option• ß-3-adrenoreceptor agonists (mirabegron)
• 1st new option in 30 yrs• Enhancing storage function and relaxing the
urinary bladder – ß3 receptors play a role in detrusor relaxation• Effective vs placebo in studies• Improves daily incontinence episodes, nocturia,
number of daily voids, and urine volume per void
• Caution in patients with uncontrolled hypertension, frail elderly
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Obesity and UI
• Each 5-unit increase in body mass index above normal weight is associated with a 40% to 70% increased odds of prevalent incontinence and a 30% to 60% increased risk of incident incontinence
• The prevalence of incontinence has been reported to be as high as 60% to 70% among severely obese women.
Brown JS, Obstet Gynecol. 1996;:715–721. Burgio KL.. Obstet Gynecol. 2007; 110(5):1034–1040.
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Weight loss and OAB• 338 women randomized for a 6 month trial
• Mean BMI 36• 24±18 (case) and 24±16 (control) UI episodes/week• mean weight loss of 8.0% (7.8 kg) case vs. 1.6% (1.5
kg) control • 47% vs. 28% reduction in UI episodes • 70% of women in control group saw clinical relevant
reduction in UI
Subak N Engl J Med. 2009; 29; 360(5): 481–490
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Urinary Incontinence before and after Bariatric Surgery
Subak JAMA Intern Med. 2015; 175(8): 1378–1387
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Posterior Tibial Nerve Stimulation (PTNS)
• Initially discovered as part of transcutaneous patch tibial nerve stimulation (McGuire et al, J Urol 121:78-9, 1983)
• Stoller investigated direct stimulation since it is a terminal projection of S3
• Technique involves 34 G needle placement in office 3-4 cm above medial malleolus and ground pad on same foot near arch
• Connect lead to stimulator
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PTNS• Spleen-6 acupuncture
point
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Posterior Tibial Nerve Stimulation (PTNS)• Stimulator has adjustable pulse intensity (0-9mA)• Fixed pulse width of 200 ųs• Frequency of 20 Hz• Amplitude slowly increased till large toe curls• 12 weekly sessions for 30 min each• Responses usually in 5-6 sessions and if improved
after 12 sessions, begin chronic rx
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Neuromodulation: PTNS• 12 weekly visits about 30 min each then monthly maintenance• Acupuncture-style needle placed posterior to medial malleolus
• Stimulate posterior tibial nerve peripherally • Modulate sacral nerve plexus through S2-4 nerves
• RCT: 80% patients improved/cured vs. 55% patients on Detrol • More efficacious than pelvic floor muscle training exercises
and behavioral therapy for improving: urgency, urinary incontinence episodes, daily voids, volume per void, and QOL
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Neuromodulation: Interstim• Electrode placed at S3 nerve foramen
• Two-step surgical procedure• Battery lasts 5 yrs
• Systematic review: 67-80% patients achieve continence or >50% improvement
• Now also indicated for fecal incontinence• Cannot have MRIs afterward
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Interstim
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Sacral Neuromodulation• May help OAB based on “reprogramming” of
sacral afferent fibers• FDA approved in 1997• Indications:
• Refractory urge-frequency• Urge incontinence• Idiopathic non obstructive urinary retention
• 2 stage procedure or PNE
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Idiopathic Sacral Neuromodulation Data
Study Study Design
Sample Size
Follow Up(months)
Success%
Weil, Eur Urol2000
RCT 21 6 56%
Schmidt, J Urol 1999
RCT 34 6 75%
Bosch, J Urol 2000
Open label 40 47 60%
Hassouna J Urol 2000
RCT 25 6 56%
Amundsen Am J Obst
Open label 12 7 100%
Van Voskullen BJU int 2007
Open label 31 15.5 90%
Greonendijk BJU int 2008
Open label 67 6 61%
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Botox• FDA approved for urgency UI/OAB in
Jan 2013• Injected into detrusor at bladder
base during cystoscopy, relaxes muscle
• Systematic review of 23 trials: 3.9 fewer leaks per day
• Significant QOL improvements• Risks:
• Retention – temporary (risk ~9% with 100U injection)
• UTIs• Presently third-line treatment• Ideal dosing still being defined
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Botulinum ToxinContraindications
Infection at injection siteHypersensitivity
Issues:Complex with human albuminInteraction with aminoglycosides
Immunogenicity: 2 % of patients develop antibodies to botulinum
Complications:Localized pain, tenderness, or bruising at inj. siteWeakness of adjacent muscle due to spread of toxinNo reported complications with GU applications
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Botox A for Idiopathic OABStudy Design Sample
SizeSuccess Success
%Kessler,
NUU 2005Open label 11 3 months 91%
Popat, J Urol 2005
Open label 44 4 months 57%
WernerAm J Obst,
2005
Open label 26 9 months 65%
BrubakerJ Urol 2008
RCT 43 (28 botox, 15 placebo)
373 days 60% PGII
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Botox or drugs?• ABC trial (Visco et al)
• Blinded RCT of women with idiopathic urgency urinary incontinence• Daily solifenacin 5-10mg or trospium XR 60mg + placebo injection• One injection of 100U onabotulinumtoxin A + placebo pills
• Successful treatment• Baseline 5.0 leaks/day to 3.4/day in med group vs 3.3 in Botox (NS)• Resolution of incontinence in 13% med group vs 27% Botox (p =
0.003)• QOL improved equally
• Side effects: • Med group had more dry mouth• Botox group more catheterization (5% at 2mo) and UTIs (33%)
• Systematic review of Botox vs any drug (BJU July 2107)• Botox patients had greatest reductions in leaks, urgency, and frequency
• Botox vs Interstim: same symptom relief, pts. preferred Botox• Higher rate UTIs with Botox
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UUI treatment overview• Behavioral changes
• Timed voiding ~3hrs• Decrease fluids and bladder irritants• Manage constipation
• Medications• Anticholinergics• Beta-3 blockers
• Pelvic floor physical therapy• Weight loss• Neuromodulation
• Interstim• PTNS• Traditional acupuncture
• Botox intra-detrusor injections
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Need some patient information?• www.voicesforpfd.org
• Includes patient factsheets• https://www.augs.org/patient-services/patient-fact-sheets/
• YouTube channel: search “Voices for PFD”• https://www.augs.org/patient-services/healthcare-providers/• Or, google “AUGS Patient information”