Transcript Document

Overactive Bladder:
Diagnosis and
Treatment
Chase Kenyon Sovell, MD
Urology Associates
May 30th, 2007
Pearls of Plumbing Seminar
Overview of Bladder Problems
• Can’t void
• Void too often
• Urinary leakage
Bladder Function
• Storage phase
– Actively relaxes to store urine.
– Majority of time spent in this phase.
• Emptying phase
– Coordinated sphincter relaxation and
bladder contraction.
A Spectrum of Symptoms
Overactive Bladder
• Frequency
• Urgency
Incontinence
Stress
Incont.
Minimally
Invasive
Surgery
z
Mixed
Incont.
Urge
Incont.
Medications &
Neuromodulation
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).
Prevalence of OAB in the United States:
Estimated to Impact ~33 Million Americans
75+
Age (years)
65-74
55-64
45-54
35-44
Men
25-34
Women
N = 5,204
18-24
0
5
10
15
20
25
30
35
Prevalence (%)
National Center for Health Statistics. Vital Health Stat. 2002;10:209.
Stewart W et al. World J Urol. 2003;20:327-336.
40
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
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)
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.
Adverse Reactions to Medications
• Dry mouth or eyes (20%-45%)
• Constipation (6%-21%)
• Headache (4%-8%)
Drug Therapy Persistence is Poor Among
OAB Patients
100%
100%
88%
Prescription persistency rates of OAB
medications among patients new to
market (n=21,362)
80%
60%
44%
40%
34%
28%
15%
20%
Initial Rx
1st Refill
2nd Refill
3rd Refill
4th Refill
11th Refill
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
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
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
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
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 > 50% reduction in the amount of
urine emptied from the bladder by catheter
Medtronic clinical study data on file
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
Does insurance pay for this?
• National Medicare
coverage policy.
• Local coverage in
the Twin Cities is
excellent.
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.
Thank You
Chase Kenyon Sovell, MD
Urology Associates, Ltd
(952) 925-0473