Management of Urinary Incontinence and Overactive Bladder Syndrome

1

Management

of Urinary Incontinence and Overactive Bladder Syndrome

Ja-Hong Kim, MD, FACS *

Associate Clinical Professor

Division of Female Pelvic Medicine & Reconstructive Surgery Center for Women’s Pelvic Health

Department of Urology

* NO FINANCIAL DISCLOSURES

Learning Objectives:

Incontinence & OAB

• BACKGROUND

• EVALUATION

• TREATMENT

• MANAGEMENT ALGORITHM

2

3

BACKGROUND

• Terminology

• Etiology

• Epidemiology

TERMINOLOGY of LOWER URINARY TRACT SYMPTOMS (LUTS) *

• Urgency:

• Sudden compelling desire to pass urine which is difficult to defer

• Frequency:

• Complaint by patient who considers that he/she voids too often by day

• Urination greater than 8 times/ 24 hours

• Nocturia:

• Interruption of sleep to urinate, each void is preceded and followed by sleep

• Complaint that the individual has to wake at night one or more times to void.

• Urinary Incontinence:

• Involuntary loss of urine

* International Continence Society https://www.ics.org/terminology/17

TYPES of INCONTINENCE*

• Stress Urinary Incontinence (SUI): Involuntary leakage of urine on effort or exertion, such as coughing and sneezing

• Urge urinary incontinence (UUI): involuntary leakage accompanied or immediately preceded by urgency

• Mixed Urinary incontinence (MUI): loss of urine associated with urgency and also with effort or physical exertion, or on sneezing or coughing

* International Continence Society https://www.ics.org/terminology/17

STRESS vs. URGE

• Unpredictable Leakage

• Frequency and urgency to void

• Inability to make it to the

bathroom: patient leaks on the way

• Nocturnal incontinence

• Bladder leakage

• Leakage with activity

• History of Vaginal Delivery or prostate surgery

• Daytime incontinence

• Gravitational Incontinence

• Urethra leakage

Mixed Incontinence

• Leakage due to both stress and urge

• Many patients have elements of both

• May need dual treatment

• Older patients, usually after menopause

What is Overactive Bladder (OAB)?

• Overactive bladder is a clinical SYNDROME characterized by the presence of bothersome urinary symptoms:

•Symptoms of frequency and urgency, with or without urgency incontinence, self-reported as bothersome

(AUA guideline on OAB, 2015)

•“Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary

incontinence, in the absence of UTI or other obvious pathology” (International Continence Society)

What Isn’t OAB?

• Urinary urgency or

frequency associated with large volume voids and large fluid intake

(polydipsia)

• Urinary urgency or

frequency explained by metabolic or local

pathological factors (e.g.

UTI, atrophic vaginitis, OSA, DI, etc.)

What causes OAB?

• Precise mechanism of OAB not fully understood

• Theories of Detrusor overactivity:

• Neurogenic:

• Detrusor overactivity arises from generalized, nerve-mediated excitation of detrusor muscle

• Reduced inhibition of voiding reflexes due to brain or spinal cord injury

• Synaptic plasticity and reorganization of C-fiber activity

• Increased sensitization of bladder nerve endings

• Myogenic:

• Fundamental change in detrusor myocytes

• Increased probability of spontaneous contraction and/or propagation of activity between muscle cells

• Denervated smooth muscle = increased surface expression of receptors

• Altered basal membrane potential

• Increased possibility spontaneous contraction

Prevalence of OAB and Urge Incontinence

• 7 to 27% of men

• 9 to 43% of women

• No difference between North American and other

populations

• Urgency incontinence more common in women

• OAB prevalence and severity increases with age

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INCONTINENCE has HUGE IMPACT

• 200 million people in world with incontinence ¹

• 17 million in US alone

• 50 % women > 20 y.o. have incontinence ²

• 50% SUI, 16 % UUI, 34% mixed

• Annual cost 32 billion ³

• Quality of life – social and hygienic problem

• Depression, anxiety

1.Norton and Brubaker. Lancet 2006 2. Dooley et al. J Urol 2008.

3. Levy and Muller. Adv Ther 2006

US Prevalence of Overactive Bladder

OAB

US Population ≈ 200 million adults

33.3 Million US Adults with OAB

Overactive Bladder affects 16% of US adult population!!

OAB and Urinary Incontinence

37% Incontinent

63% Continent

12.2 million (6.1% of the population)

21.2 million (10.5% of the adult population) OAB

NHANES Survey: Incontinence among

Noninstitutionalized Adults 65 and Over *

None¹ Urinary or bowel leakage²

Urinary

leakage only³

Urinary and bowel leakage⁴

Bowel leakage only⁵

All Men Women

Percent (age-adjusted)

* Age-adjusted incontinence among noninstitutionalized persons aged 65 and over, by type of incontinence and sex: National Health and Nutrition Examination Survey, 2007–

2010 0

10 20 30 40 50 60 70

Direct Costs of Incontinence

• Diagnostic

• Laboratory

• Consultation visit

• UDS eval

• Treatment

• Medication

• Surgery

• Behavioral Therapy

• Devices

• Routine Care

•Pads

•Laundry, dry cleaning

•Catheters

•Furniture cleaning

• Consequence

•Treatment for falls

•Treatment for UTI

•Skin infection

•Lengthened hospital stay

•Nursing home admission

Costs of Urinary Incontinence

Indirect Costs

3% Diagnostic Costs

1%

Consequence Costs

50%

Routine Costs

43%

Treatment Costs

3%

3,600 Annually Per Person Aged > 65 Years

Wagner TH, Hu T-W. Urology. 1998;51:355-361.

Hampel C, et al. Urology. 1997;50(suppl 6A):4-14.

Total Costs in 1995 US > $26 Billion

Journal of Managed Care Pharmacy JMCP February 2014 Vol. 20, No. 2 www.amcp.org

0 5 10 15 20

USDBillion

≥85

Adapted from Ganz et al., Economic costs of overactive bladder in the United States.²⁰ USD= U.S. dollars; UUI= urgency urinary incontinence^.

F I G U R E 2

Projected Total Annual National Costs of OAB or UUI from 2007 to 2020 in US

25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84

2007 2015 2020

More than $65 Billion dollars by 2020

Huge impact on Psychosocial Function and Quality of Life

• Interferences in daily activities

• Negative impact on sexual

function and marital satisfaction

• Linked with depression and anxiety

• Lack of sleep can impact work performance

• Financial burden due to management

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EVALUATION

• History & Physical

• Initial office tests

URINARY INCONTINENCE is HIDDEN CONDITION!

• Most patients do not mention the problem to their doctor, some wait 3 years

•Self-manage

•59% of patients do not seek help because they believe no effective treatment is available

•73% of patients who seek treatment are currently not on medication

• Most patients do not mention the problem to their friends

• Most people think incontinence is part of normal aging

Milsom I et al. BJU Int. 2001;87:760-766.

A Practical Approach to Bladder Problems

 Many patients can be evaluated based on history, physical examination, and urinalysis

 Specialized tests are not normally required to be part of the basic evaluation

 urodynamics

 cystoscopy

 imaging

INITIAL VISIT

 Patient history

 Review voiding patterns and symptoms

 3 day voiding diary

 Review medications

 Physical Exam

 Simple laboratory tests

 URINALYSIS

 POST VOID RESIDUAL (bladder scan or simple catheterization)

Fantl JA et al. Agency for Healthcare Policy and Research;

1996; AHCPR Publication No. 96-0686.

DETAILED & FOCUSED HISTORY

• Voiding pattern: Frequency, timing, number of continence voids and incontinence episodes, quality of stream (can get from Diary)

• Precipitants of incontinence – differentiate stress vs urge vs both

• Fluid intake history – total volume intake; caffeine and alcohol

• Previous Surgery (pelvic surgery), prior radiation

• Alterations in bowel habits or sexual function; recent weight gain

• Neurologic history

•Back pain, back surgery

•CVA, MS, diabetes, parkinson’s disease

•Numbness, weakness, balance problems

• OB/GYN history, estrogen status, prolapse, UTIs, pelvic cancer

• Mental status, social/environment

• Degree of bother

Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.

Wyman JF, et al. Obstet Gynecol. 1988;71:812-817.

Medications That May

Influence Bladder Function

 Diuretics

 Antidepressants

 Antihypertensives

 Hypnotics

 Analgesics

 Steroids

 Narcotics

 Sedatives

 Chemotherapy

 OTC sleep aids and cold remedies

 Antipsychotics

 Herbal remedies

Voiding Diary

• More Accurate documentation of voiding pattern

• Foundation for therapy

• Track progress

• Consists of:

• Voided volume

• Time of void

• Incontinence episodes

• Taken over 3 days

• Note precipitating factors

• Phone Apps

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Physical Examination

• Evaluate for prolapse

• Vaginal atrophy

• Cough/valsalva stress test (200cc in bladder)

• Look for urethral hypermobility

• Evaluate the integrity of the pelvic musculature

• Neurological exam – gait disturbances, abnormal speech pattern

• Lower extremity swelling

• Cognitive function (may affect toilet access)

Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.

Laboratory Tests

 Urinalysis

 to rule out blood in the urine, kidney problems, urinary tract infections

 Post void residual urine

 Important to rule out obstructive symptoms

 Bladder scan or catheter insertion

 PVR > 150 cc imply bladder outlet obstruction

 Blood work as appropriate

Fantl JA et al. Agency for Healthcare Policy and Research;

1996; AHCPR Publication No. 96-0686.

Other Specialized Testing

• Additional Tests useful if conservative therapy fails or those with prior surgery or mixed symptoms

• Refer to Urology or Urogynecology

• Urodynamics

• Cystoscopy

• Imaging Studies

VCUG (Voiding cystourethrogram)

MRI

CT scan

Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.

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TREATMENT

• Anatomy and Physiology of Micturition

• First line treatment

• Second line treatment

• Tertiary treatmen for refractory conditions

Micturition Cycle

Storage Emptying

Incontinence and OAB is STORAGE PROBLEM

Bladder Functional Anatomy

Beta-Adrenergic

Alpha-Adrenergic

“Smooth Sphincter”

(BN/ Prox Urethra)

“Striated”

Sphincter”

Pelvic Floor

Body

Base

Muscarinic Ach

Outlet

Neural Control of Micturition

• Conscious control over autonomic reflexes

• 3 sets of nerves innervate the lower urinary tract:

• Pelvic Parasympathetic nerves (autonomic)

• Detrusor contraction

• Basis for antimuscarinic therapy for OAB

• Lumbar Sympathetic nerves (autonomic)

• Detrusor relaxation (Beta receptors in bladder dome)

• Bladder neck contraction (Alpha receptors in BN)

• Basis for Beta 3 agonist therapy for OAB

• Pudendal nerve (somatic)

• Reflexively relax and contract external sphincter as part of voiding reflex

• Consciously will contract / relax external sphincter

• Basis for pelvic floor (Kegel) exercises

First Line Treatment

• Behavioral therapy

• Medication

• Combined therapy

1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.

Behavioral Treatment for

Overactive Bladder Control

• Patient Education

• Normal and abnormal bladder function

• “normal” fluid intake - Drink less than 4 glasses/day (32 oz)

• Stop drinking after dinner

• Eliminate irritants (caffeine, alcohol, nicotine)

• Modify voiding habits (keep voiding diary)

• Time voiding

• Bladder training, delayed voiding

• Pelvic floor muscle training (biofeedback)

• Weight loss

Fluid Management

• Daily fluid intake < 4 glasses of 8 oz in 24 hours

• reduce nighttime fluids to manage nocturia

• Check color of urine

• Eliminate bladder irritants such as:

• Caffeine, alcohol, Nicotine

• Evaluate and modify bowel habits as appropriate

• add fiber to diet to avoid constipation

Pelvic Floor Muscle Training

• Help strengthen the muscles of the pelvic floor – improve bladder stability

• Help suppress the voiding reflex

• Sometimes difficult to isolate the

muscle which needs to be contracted

• Decreased incontinence and increased bladder capacity

• Higher patient reported satisfaction

Contraction

Bladder Relaxation

Weight loss

• Can improve urge incontinence episodes

• BMI > 30 independent risk factor for OAB

• One study showed that 8% weight loss in obese women resulted in reduction of urge incontinence episodes *

• 42% in weight loss group

• 26% in control group

* Subak LL, et al: Weight loss to treat urinary incontinence in overweight 38

and obese women. NEJM 2009; 360: 481

Pharmacological Treatment

• Anticholinergics/antimuscarinics

• Beta 3 agonists

• Antidepressants

• Other

ANTIMUSCARINICS/ ANTICHOLINERGICS

• Targets Bladder contraction

•Acetylcholine stimulation of muscarinic receptors in detrusor and elsewhere in bladder

• Muscarinic receptors (M₀-M₅)

•M2 most prevalent in bladder

•M3 most significant for contraction

•Present on detrusor muscle, interstitial cells, urothelium, suburothelial nerves

•Also in salivary glands, parotid gland, brain, eye, heart

Antimuscarinics

• In US 6 are approved: darifenicin, oxybutynin, solifenacin, tolterodine, trospium, fesoterodine

• All have similar efficacy 70 to 75% for decreasing UI episodes

• Side effects:

• Dry mouth, constipation, blurry vision, stomach upset, impaired cognitive function (MEMORY LOSS)

• Contraindications:

• Narrow angle glaucoma

• Use with caution for impaired gastric emptying, urinary retention

Anticholinergics and Dementia

June 24, 2019

Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-

Control Study

Carol A. C. Coupland, PhD1; Trevor Hill, MSc1; Tom Dening, MD2; et al Richard Morriss, MD2; Michael Moore, MSc3; Julia Hippisley-Cox, MD1,4. JAMA Intern Med. 2019;179(8):1084-1093.

doi:10.1001/jamainternmed.2019.0677

• Known short term effects on cognitive impairment

• Long term effects can last 20 years

• Risk-benefit analysis

OXYBUTYNIN (Ditropan)

• Oxybutynin

• Poorly selective for M1 and M3 over M2.

• Best insurance coverage

• Caution with elderly

• Dosage:

• Immediate release: 5 mg twice daily, titrate to TID

• ER: 5, 10, 15 mg daily, maximum 30 mg/ day

• Oxy-Gel (Gelnique)

• Topical satchets, 1 g/ packet apply to skin daily (change location)

• Oxytrol patch

• Apply 3.9 mg patch every 3 to 4 days.

• Chronic use associated with memory loss *

* Kay G, Crook T, Rekeda L, et al. Differential effects of the antimuscarinic agents darifenacin and oxybutynin ER on memory in older subjects. Eur Urol. 2006 Apr 19;

TOLTERODINE (DETROL)

•Tolterodine (Detrol)

• Low incidence of CNS effect compared with oxybutynin

• Non-selective antimuscarinic

• Dosage:

• Immediate release: 1 to 2 mg tablets taken BID

• Extended release (Detrol LA): 2 or 4 mg once daily

FESOTERODINE (TOVIAZ)

•Fesoterodine (Toviaz)

• Non-selective

• Metabolized to 5-hydroxymethyltolterodine, same as Detrol

• Hepatic metabolism

• Cytochrome P450

• Extended release only

• Dosage:

• 4 mg daily

• Titrate to 8 mg

SOLIFENACIN (VESICARE)

•Solifenacin (VESIcare)

• Modestly selective for M3

• Extended release only

• Renal Excretion

• Dosage:

• 5 mg or 10 mg QD

• With or without food

Greater efficacy than tolterodine head to head, but greater side effects of dry mouth and constipation*

* Chapple CR, et al. Treatment outcomes in the STAR study: a subanalysis of solifenacin 5 mg and tolterodine ER 4 mg. Eur Urol.2007 Oct;52(4):1195-203. Epub 2007 Jun 6.

DARIFENACIN (ENABLEX)

•Darifenacin (Enablex)

• Relatively selective for M3 subtype

• Few CNS side effects (equal to placebo in some studies)

• Extended Release form only

• Dosage:

•7.5 mg or 15 mg daily with or without food

TROSPIUM CHLORIDE (SANCTURA)

•Trospium (Sanctura)

• Quaternary amine – no CNS side effect

• Does not cross blood brain barrier

• Non-selective antimuscarinic

• Renal Excretion

• Dosage:

• 20 mg po BID, titrate to once daily for elderly

• Sanctura XR 60 mg daily, avoid in patients with renal impairment

• Taken with water on empty stomach one hour before meal

Beta 3 adrenergic Agonists

• Mirabegron (Myrbetriq) approved by FDA in 2012

• No difference in dry mouth, HTN

• Mechanism of Action

• Activates beta3 adrenergic receptors in the detrusor for bladder relaxation

• Beta3 accounts for 97% of adrenergic beta receptor subtypes in bladder.

• Side effects:

• Nausea, High blood pressure, nasopharyngitis, UTI, dry mouth, headache

• Drug interaction:

• Digoxin and Warfarin (CYP2D6 metabolism)

• Contraindication:

• Uncontrolled high blood pressure

• Dosage:

• 25 or 50 mg once daily with or without food

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Antidepressants to treat incontinence?

• Imipramine – tricyclic antidepressant

• Direct relaxation of bladder muscle & improve bladder neck function (beta and alpha agonist)

• Used for childhood bedwetting

• Great for mixed incontinence

• Side effects:

• Sedation, dizziness, nausea/ vomiting

• Contraindication:

• MAO inhibitors

• Dosage:

• 25 mg QHS, titrate up to 75 mg as tolerated

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Other RX: ESTROGEN

• Evidence was generally of poor to moderate quality

• Postoperative vaginal estrogen after sling:

• decreased urinary frequency and urgency.

• Vaginal Estrogen and SUI:

• Mild improvement

• Vaginal estrogen and immediate-release oxybutynin:

• similar in improvement of urinary urgency, frequency, and urgency urinary incontinence, but oxybutynin had higher rates of side effects and

discontinuation.

• Vaginal estrogen to immediate or extended-release tolterodine:

• did not improve urinary symptoms more than tolterodine alone.

• Use with caution in women with breast cancer

Rahn DD, et al.; Society of Gynecologic Surgeons Systematic Review Group. Vaginal estrogen use in postmenopausal women with pelvic floor disorders: systematic review and practice guidelines. Int Urogyneco J. 2015 Jan;26(1):3-13. doi: 10.1007/s00192-014-2554-z..

MEDICAL TREATMENT

• All have similar efficacy 70 to 75% for decreasing UI episodes

• Unwanted side effects in 10-30% of patients:

• Dry mouth

• Constipation

• Fatigue

• Confusion

• No correlation between clinical improvement and cystometric changes

• Placebo effect: 15-25%

• Medication alone rarely cures the problem and must be used with other techniques

Combined Therapy is Most Effective

• Numerous studies support combined behavioral therapy and pharmacotherapy

•Improves objective outcomes

•Improves patient satisfaction

• 57% behavior therapy alone vs 88.5% added drug therapy (p= 0.0034)

• 72% drug therapy alone vs. 84% when behavioral therapy added (p=.001)

Burgio KL et al. Ann Intern Med. 2008, 149: 161-9.

Klutke CG et al. J Urol. 2009, 181: 2599-2607.

Song C et al. J Korean Med Sci. 2006, 21: 1060-1063 Burgio KL et al. J Am Geriatr Soc. 2000, 48: 370-4.

Mattiason et al., BJU Int. 2003, 91: 54- 60.

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Management options for Refractory Overactive Bladder and Incontinence

 Minimally invasive procedure

 Surgery

What if First Line Treatment fails?

• Minimally invasive procedures

• Botox (botulinum toxin A) injection therapy (OAB, UUI)

• Percutaneous tibial nerve stimulation (OAB, UUI)

• Sacral neuromodulation (OAB, UUI)

• Bulking agents (SUI, mixed incontinence)

• Surgery

• Sling (SUI, mixed incontinence)

• Prolapse surgery (OAB associated with incomplete emptying)

• Bladder augmentation

• urinary diversion

Botulinum A Toxin (Botox)

• Works by chemodenervation of bladder muscle and decreasing its contractility

• Success rate 60 to 90% (66% continent)

• Can be done in office with local anesthetic

• 100 to 300 units, immediate improvement

• Lasts 6 to 12 months, must be repeated

• Covered by insurance

• Side effects:

• Urinary retention requiring intermittent catheterization 5 to 43%

• UTI 20 – 40%

PERCUTANEOUS TIBIAL NERVE Stimulation (PTNS)

• Tibial nerve 5 cm cephalad medial malleolus

• Acupuncture needle or patch

• Electrical impulses travel from ankle to sacral nerves

• Protocol: 12 weekly sessions of 30 min

• Maintenance therapy tailored for patient

• Meta-Analysis 37 to 82%, with no

difference with antimuscarinic therapy and less SE*

* Burton C et al. Effectiveness of percutaneous posterior tibial nerve stimulation for overactive bladder: a systematic review and meta-analysis. Neurourol Urodyn 2012 Nov;31(8):1206-16.

SACRAL NEUROMODULATION

• Stimulation of the sacral nerves to modulate the neural reflexes that influence the bladder, sphincter and pelvic floor.

• FDA approved 1997 - Interstim by Medtronic

• Electrode floats close to sacral nerve – S3

• Done in two stages, under local and light sedation

•First stage: placement of electrodes, followed by 1-2 wk trial period with temporary device

•Second stage: Implant of permanent pacemaker/

battery

First Stage: Placement of Electrodes for Sacral Neuromodulation

59

Sciatic notch

After needle reposition test stimulation

using spring loaded electrode

Second Stage: Implant of Interstim Battery (pacemaker)

• If there is > 50% reduction in

symptoms, proceed to Stage 2 or electrodes are removed

• Both staged procedures last 30 minutes, minimal anesthesia

• Good cognitive function

Results of Sacral Neuromodulation

• Overactive bladder: >70% improved, partial success

• Adverse events:

• Wound infection

• Need for revision 3 to 16%

• Contraindications:

• Unstable neurogenic conditions

• Certain types of cardiac pacemaker

Newer generation of sacral neuromodulators

• MRI compatible

• Rechargeable

• Smaller

AXONIC sacral neuromodulation

Pezzela A, et al: Two-year outcomes of the ARTISAN-SNM study for the treatment of urinary urgency incontinence using the Axonics rechargeable sacral neuromodulation system

Neurourol Urodyn. 2021 Feb;40(2):714-721. doi: 10.1002/nau.24615. Epub 2021 Jan 28.

•121 of the 129 participants completed the 2-year visit

•Sustained high efficacy at 93%

•82% of the participants had a >75% reduction in symptoms

•37% dry rate

•Reduction in UUI episodes at 2 years was from 5.6 at baseline to 1 at 2 years

•94% overall satisfaction with the therapy

•94% satisfaction with charging

ROSETTA TRIAL:

Botox vs. Neuromodulation

• 386 women

• Mean age 63 years

• Mean BMI 32 m/kg²

• > 80% “severely” or “very severely” incontinent on Sandvik quesitonnaire

• 1 month post op 83 v 84% had clinical response greater than 50%

improvement

• 6 month intention-to-treat change in mean number of daily urge incontinent episodes -3.9 in botox, -3. 3/day in neuromodulation; P=0.01.

• Complete symptom resolution at 6 months: 20% v 4%; P<0.0001 favoring botox

• Reduction of at least 75% in daily episodes at 6 months: 46% v 26%

favoring botox

• OAB symptom bother scores -46 v -38; P=0.002 favoring botox

• Treatment satisfaction greater, as was endorsement in and for botox

ROSETTA TRIAL

• UTI at 6 months: 35% in botox, 11% in neuromodulation;

P<0.0001

• Intermittent catheterization 8% at 1 month, 2% at 6 months in botox

• 3% of neuromodulation required surgical revision or removal by 6 months

• Cost-effectiveness analysis Botox < SNS

• Only women were in the trial

• No placebo group

Surgical options for Stress Incontinence

• Important to consider frailty in elderly population

• Paucity of data assessing outcomes

• Sling

• Bladder neck suspensions

• Bulking Agents

• AUA updated guidelines

• http://auanet.org/Documents/education/clinical-guidance/SUI- Plenary-Slides.pdf

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MID-URETHRAL SLING (MUS)

• Gold Standard

• Retropubic vs. transobturator approach

• For urethral hypermobility correction to treat SUI

• Outpatient

• Mesh vs. Autologous fascia sling

• Due to aging population and improved functional independence, these procedures are being performed increasingly in the elderly.

• Most sling outcomes data focus on the middle-aged women

• Elderly defined as > 75 years

• Australian Study compared outcomes of elderly women (>80) to younger women (<80). (1)

• No difference in subjective cure between two groups (elderly 81% vs. younger 85%, p=0.35)

• Longer hospital stay (1.6 days in elderly vs. 0.7 days in younger)

• Higher incidence of short term voiding dysfunction (initial retention in 37% in elderly vs.

9% in younger)

• No difference in long term voiding dysfunction (elderly 8% vs. younger 6%)

Sling surgery in the Elderly

1. Stav K, Dwyer P, Rosamilia A, Schierlitz L, Lim YN, Lee J (2010). Midurethral sling procedures for stress urinary incontinence in women over 80 years. Neurourol Urodyn 29:1262–12660

• British study evaluated short term subjective outcomes of midurethral slings in 4256 cases, of which 452 were > 70 years ⁽¹⁾

• FU range between 6 weeks to 12 months

• Significant difference in subjective improvement using patient Global Impression of Improvement: 70% in > 80 years, 85% in 70 – 79, and 93% in < 50)

• No difference in complications, voiding dysfunction, urgency incontinence

Sling surgery in the Elderly

1. Robinson, D, Castro-Diaz D, Giarenis I, Toozs-Hobson P, Anding R, Burton C, Cardozo L (2015). What is the best surgical intervention for stress urinary incontinence in the very young and very old? An international Consultation on Incontinence Research Society update. Int Urogynecol J 26:1599-1604

• Recent Norwegian study looked at their Female Incontinence Registry on 21 832 women with SUI or MUI who underwent MUS from 1998 to 2016. Primary

outcomes were treatment satisfaction and absence of objective stress leakage at 6-12 mos FU. Secondary outcomes were increase in urgency incontinence

symptoms and surgical complications.

• Women in sixth decade and older had more objective post op SUI

• Women in seventh decade and older were less satisfied

• Urgency incontinence (persistent and de novo) after surgery increased with age

• Intermittent catheterization higher in seventh decade

• Bladder perforation higher in seventh and eighth decades

Sling surgery in the Elderly

1. Engen M, Svenningsen R, Schiotz H, Kulseng-Hanssen S (2018). Mid-urethral slings in young, middle- aged, and older women. Neurourology and Urodynamics Sep 2018, ePub, ahead of print.

BULKING AGENTS

• Injection of nondegradable synthetic products

• Carbon coated zirconium beads in beta-glucan gel (Durasphere)

• Calcium hydroxylapatite (Coaptite)

• mooth hydrogel that consists of 97.5% water and 2.5% polyacrylamide (Bulkamid)

• Indication: lack of urethral coaptation due to instrinsic sphincter deficiency associated with age or those who cannot or will not tolerate surgery

• Overall cure rate: 48% at 12 -23 mos, 32% 24 to 47 months, and 30% at > 48 mos

• Repeat injections may be required

• Success after 2 or 3 injections is unlikely

• Urgency incontinence:

• De novo 13%, unspecified 8%

Other Surgical Options: Urinary Diversion

• Bladder augmentation

• Continent catheteriazable stoma

• Ileal conduit

• Pelvic floor reconstruction

• Permanent suprapubic tube (SPT) or indwelling catheter

• Can improve quality of life for bed-bound patients

• Severe dementia

• Prefer SPT

• Changed once a month

• Daily maintenance with irrigation can minimize UTI

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MANAGEMENT ALGORITHMS

• Clinical care pathway for clinicians

• Patient education materials

Updated AUA/SUFU Clinical Care Pathway for OAB*

*https://www.urotoday.com/categories-media/1627-urology-tube-video-channels/oab-treatment- vl/2137-the-oab-clinical-care-pathway-mobile-app-stephen-kraus.html

Patient Care Pathway

SUMMARY

• OAB and Urinary Incontinence are prevalent in the aging population and have significant financial, social impact

• Evaluation can be done in office without invasive tests

• Various treatment options available

• Goal of therapy tailored to the individual patient to maximize success and improve quality of life with minimal morbidity

• Success depends on patient engagement and education

jhkim@mednet.ucla.edu 77