Overactive Bladder: Diagnosis and Treatment

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Overactive BladderDiagnosis and Treatment Chase
Kenyon Sovell, MD Urology Associates May 30th,
2007 Pearls of Plumbing Seminar
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Overview of Bladder Problems

• Cant 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
Overactive Bladder

• Frequency
• Urgency

z
Incontinence
Stress Incont.
UrgeIncont.
Mixed Incont.
Minimally Invasive Surgery
Medications Neuromodulation
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What is Overactive Bladder (OAB)?

• Defined as a compelling desire to void that is
  difficult to deter.
• gt8 times per day, gt2 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,
  Parkinsons Disease).

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Prevalence of OAB in the United StatesEstimated
to Impact 33 Million Americans
75
65-74
55-64
Age (years)
45-54
35-44
Men
25-34
Women
N 5,204
18-24
0
5
10
15
20
25
30
35
40
Prevalence ()
National Center for Health Statistics. Vital
Health Stat. 200210209.Stewart W et al. World
J Urol. 200320327-336.
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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
Prescription persistency rates of OAB medications
among patients new to market (n21,362)
This data is dated from 2002 and current numbers
would likely be better, but only marginally.
Source The 2002 Gallup Study of the Market for
Prescription Incontinence Medication. Princeton,
NJ Multi-Sponsor Surveys, Inc 2002
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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?
Results 12 Months After Surgery

• 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 gt 50 reduction in the amount of urine
  emptied from the bladder by catheter

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 You Chase Kenyon Sovell, MD Urology
Associates, Ltd [phone]