incontinence: evaluation and management bernard d. morris, jr, md, facs killeen hemingway clinics...

Incontinence:Evaluation and Management

Bernard D. Morris, Jr, MD, FACS

Killeen Hemingway ClinicsScott&White

Prevalence of Incontinence

• Women 30-60 years of age• 30% have some type of urinary

incontinence• Increasing population of active,

healthy women over 60• Decreasing morbidity of Rx options

Incontinence Underreported

• Embarrassment• Misunderstanding of causes• Low expectation of benefits from

treatments• Never asked by provider• Patient does not want to “bother”

provider

Incontinence- Cost

• Financial • Physical • Psychological• Indirect costs of consequences• Loss of independence

Types of Incontinence

• Stress Urinary Incontinence• Urge Incontinence• Mixed Urinary Incontinence• Stress-induced Urge Incontinence• Overflow Incontinence• Cognitive/awareness issues

Evaluation of Incontinence

• Focused history• Focused physical examination• Objective demonstration of SUI• Post-void residual

Indications for Urologic Evaluation

• Hematuria• Large post-void residual• Abnormal urine cytology• Refractory symptoms after failed

aggressive rx• Neurologic diagnosis

Urge Incontinence

• Medical management• Improvement in molecular

characteristics• Improvement in delivery systems

Urge Incontinence

• Physical therapy• Biofeedback• Peripheral nerve stimulators

Urge Incontinece

• Surgical options - rare• Interstim• Botox injections• Bladder augmentation

Other diagnostic testing (prn)

• Voiding diary• Urodynamic evaluation• Cystoscopy• Imaging studies

Indications for diagnostic tests

• Diagnosis unclear• Mixed incontinence• Prior pelvic floor surgery• Neurogenic diagnoses• Hematuria/pyuria• Large post-void residual• Grade 3-4 prolapse• Dysfunctional voiding

Stress IncontinenceNon-surgical Rx

• Physical therapy• Biofeedback• Acupuncture• Nerve stimulatorsAppropriate patient selection and

expectations

Stress IncontineceSurgical Rx

• Retropubic suspensions• Slings• Injectable agents• Artificial Urinary Sphincter

Retropubic Suspensions

• Gold standard for long-term results• 75-85% at 48 months• Retention 15%• Post-operative complications

involving intestines/ureters• Invasive

Slings

• Continuous evolution of materials and techniques

• Autologous vs synthetic• Bladder neck vs mid-urethra• Retropubic vs trans-obturator vs

needleless• Adjustable sling

Slings

• Retention 3-8%• Erosion/infection <5%• 85% success at 48 months• Decreased morbidity has led to

expanded population of appropriate candidates

Injectable Agents

• Sub-mucosal bulking agents for intrinsic sphincteric deficiency (type 3) incontinence

• Lack of the ideal bulking agent• Minimally invasive, local anesthetic

Injectable Agents

• Teflon• Autologous fat• Collagen• Calcium hydroxy-apatite (Coaptite)• Inert synthetic agents (Durasphere)

Artificial Urinary Sphincter

• Limited indications in women

Stress IncontinenceManagement

• Patient selection• Patient expectations• Patient preferences