overactive bladder: diagnosis and treatment chase kenyon sovell, md urology associates may 30 th,...
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![Page 1: Overactive Bladder: Diagnosis and Treatment Chase Kenyon Sovell, MD Urology Associates May 30 th, 2007 Pearls of Plumbing Seminar](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649d3f5503460f94a1833c/html5/thumbnails/1.jpg)
Overactive Bladder:Diagnosis and TreatmentChase Kenyon Sovell, MDUrology Associates
May 30th, 2007Pearls of Plumbing Seminar
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Overview of Bladder Problems
• Can’t void
• Void too often
• Urinary leakage
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Bladder Function
• Storage phase– Actively relaxes to store urine.– Majority of time spent in this phase.
• Emptying phase– Coordinated sphincter relaxation and
bladder contraction.
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A Spectrum of Symptoms
z
• FrequencyFrequency• UrgencyUrgency
StressStressIncont.Incont. MixedMixed
Incont.Incont.
UrgeUrgeIncont.Incont.
Overactive BladderOveractive Bladder
Minimally Minimally Invasive Invasive SurgerySurgery
IncontinenceIncontinence
Medications & Medications & NeuromodulationNeuromodulation
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What is Overactive Bladder (OAB)?
– Defined as a compelling desire to void that is difficult to deter.
• >8 times per day, >2 times per night
– A third of the patients with OAB will also have urge urinary incontinence.
– Absence of urinary tract infection or neurological condition (Multiple Sclerosis, Parkinson’s Disease).
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Prevalence of O
AB
increases w
ith age
Men
Women
N = 5,204
0 5 10 15 20 25 30 35 40
18-24
25-34
35-44
45-54
55-64
65-74
75+
Ag
e (y
ears
)
Prevalence (%)
Prevalence of OAB in the United States:Estimated to Impact ~33 Million Americans
National Center for Health Statistics. Vital Health Stat. 2002;10:209.Stewart W et al. World J Urol. 2003;20:327-336.
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Diagnostic Evaluation
• Medical History– Hematuria, pelvic surgery or radiation, infections
• Physical Exam– Office cystoscopy to exclude malignancy or
stones.
• Office tests– Urine Analysis, post void residual urine
assessment, Uro-flow and PSA (in men)
– Urodynamic testing
• A 48 hour Voiding Diary• Questionnaire
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Treatment Options for OAB
• Dietary– Reducing bladder irritants such as caffeine,
alcohol, nicotine.
• Behavioral Modification– Review of the Voiding Diary, biofeedback.
• Pharmacotherapy: anticholinergics– Ditropan, Detrol, Enablex, Sanctura, Vesicare.
• Minimally Invasive Treatments– Botox– Neuromodulation (InterStim)
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Medicines: Anticholinergics
• Heavily marketed medicines– Detrol – Vesicare– Enablex– Sanctura– Oxytrol– Ditropan
• These medicines help relax the bladder.
• They work by blocking receptors in the bladder.
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Adverse Reactions to Medications
• Dry mouth or eyes (20%-45%)
• Constipation (6%-21%)
• Headache (4%-8%)
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Drug Therapy Persistence is Poor Among OAB Patients
100%
88%
15%28%
34%44%
Initial Rx 1st Refill 2nd Refill 3rd Refill 4th Refill 11th Refill
20%
40%
60%
80%
100%Prescription persistency rates of OAB
medications among patients new to market (n=21,362)
Source: The 2002 Gallup Study of the Market for Prescription Incontinence Medication. Princeton, NJ: Multi-Sponsor Surveys, Inc 2002
This data is dated from 2002 and current numbers would likely be better, but only marginally.
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InterStim Therapy for Urinary Control
• FDA-approved treatment for urinary control problems in people who have not had success with behavioral modification or medications.
• Over 30,000 patients implanted worldwide
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Test Stimulation
• A test is done to determine the respond to the stimulus.
• Performed in the office (20 minutes).
• A lead is placed under the skin just above the tailbone
• Lead is connected to an external device (size of a pager) for a period of 2-3 days.
• The decision for implantation of the permanent device will be made based on the response to the test stimulation
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Implantation of the InterStim System
• Procedure done in operating room using a light anesthesia on a same day surgery basis.
• Stimulator is usually placed in upper buttock
• The entire InterStim System will reside under the skin
• Entire procedure takes less than one hour
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How effective is this therapy?
• Urge Incontinence • 45% of patients completely dry• Further 34% had 50% or greater reduction in
symptoms
• Urgency-Frequency• 31% back to normal (4-7 per day)• Additional 33% had a 50% or more
reduction in number of urinations
• Retention• 61% stopped catherization• 16% had > 50% reduction in the amount of
urine emptied from the bladder by catheter
Results 12 Months After Surgery
Medtronic clinical study data on file
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Potential Risks with InterStim Therapy
As with other surgical procedures, there are risks:– Pain– Infection – Transient electrical shock– Lead migration
• These complications were generally resolvable in the clinical study
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Does insurance pay for this?
• National Medicare coverage policy.
• Local coverage in the Twin Cities is excellent.
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Pearls
• Trans-obturator taping for stress incontinence: – Highly effective, same day surgery.
• InterStim for frequency and urge incontinence:– Office procedure, well tolerated.
• Medications are rarely the cure for incontinence.
• Careful evaluation for an accurate diagnosis– Voiding diary, urodynamics.
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Thank YouChase Kenyon Sovell, MD
Urology Associates, Ltd
(952) 925-0473