kuang percifull - male incontinence...• mild incontinence! • 24 hour pad test
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4/24/15!
1!
Male Incontinence: !Beyond Anti-Cholinergics!
!Wayne Kuang MD!
Candace Percifull NP!
Disclosures!
• Wayne Kuang MD!
• MenMD | Theralogix | United Therapies!
• Candace Percifull NP!
• None!
Big Thanks!!!!
• NM Nurse Practitioner Council!
• Rachel Bevan RN!
• Candace Percifull NP!
• You all!!!
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2!
No-Needle No-Scalpel!Vasectomy!
• Minimally invasive!
• Single 30 minute appt!
• Anesthetic spray!
Erectile Dysfunction!
• Beyond pills!
• Penile injection therapy!
• Penile doppler ultrasound!
• Vacuum erection pumps!
• Inflatable penile implants!
Prostate Health!
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3!
Low T & Me!
Men's Health!
Bladder Health!
astellas.com!
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4!
Incontinence!
• Involuntary loss of urine!
• Urge leakage / Overactive bladder (OAB)!
• Stress leakage!
• Mixed (Stress & Urge)!
• Overflow!
Causes in Men!
• Prostate cancer therapy!
• Prostatectomy & Radiation!
• Neurogenic!
• DM, MS, Parkinsons, CVA!
• BPH!
• Bladder cancer!
• Foreign bodies!
• UTI!
• Undiagnosed diabetes!
• Medications (Diuretics)!
History!• Strong & sudden urge!
• Laugh, cough, sneeze!
• Frequency!
• Nocturia!
• Pads or Depends!
• BPH or Prostate cancer!
• QOL (sex, work, life, sleep)! Adopsinsider.com!
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Physical!
• Suprapubic fullness!
• Abdominal/perineal scars!
• Urethral palpation!
• Meatal stenosis!
• Cough in standing position!
productive-cough.com!
Evaluation!• 24 hour pad test!
• Voiding diary!
• UA !
• Cytology!
• Post void residual (overflow)!
• Renal bladder ultrasound !
• Urodynamics!
Evaluation!
• Cystoscopy !
• tumor!
• stricture!
• bph!
• stone!
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Urge Incontinence!OAB!
2014 !OAB Guidelines!
• American Urological Association!• First Line Rx: Behavioral Modifications!• Second Line Rx: Oral or Transdermal Agents!• Third Line Rx: !
• Neuromodulation (SNS & PTNS)!• Intradetrusor botulinum toxin injections!• Invasive surgeries (Augmentation / Diversion)!
May 2014 AUA/SUFU OAB Guidelines: 1-57!
Primary OAB Rx!
• Behavioral modification!
• Timed voiding!
• Decrease stimulants!
• Fluid restriction!
• Pelvic floor exercises/Biofeedback!
• Anti-Cholinergics!
• Balancing efficacy with side effects!
• 50% will not reach their treatment goals!!!!
Int J Clin Pract 2011; 65: 567!
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Refractory OAB!
• "Failure of appropriate behavioral therapy of sufficient length and a trial of at least one antimuscarinic medication administered for 6-12 weeks."!
J Urol 2012; 188: 2455!
Real World!
• Can't afford it!
• Can't tolerate the side effects | Contraindications!
• Desire to have a "chemical-free" life!
• No or insufficient response!
The White Flag!
• Most with Refractory OAB "simply give up", believe they are beyond help.!
• They simply surrender...!
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There is Hope!
• Beta-3 Agonist - Mirabegron!
• Neuromodulation!
• Posterior Tibial Nerve Stimulation (15,000 in 2012)!
• Sacral Nerve Stimulation (25,000 in 2012)!
• Onabotulinumtoxin A (35,000 in 2012)!
Urology Times Feb 2015: 12!
Myrbetriq!• Beta 3 adrenergic agonist.!
• It relaxes the detrusor muscle of the bladder during the filling phase of the fill/void cycle. It increases bladder capacity by activating the beta 3 receptor pathway. !
Myrbetriq!• Side effects:!
• Nasopharyngitis!
• UTI!
• Constipation!
• Headache!
• Elevated blood pressure. Periodic monitoring of blood pressures is recommended in HTN patients.!
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Myrbetriq!
• Contraindicated:!
• Severe renal impairment!
• Severe hepatic impairment!
• Uncontrolled, severe HTN. Systolic BP >180 and/or Diastolic BP >110. !
OAB Medications!
• Unfortunately there is a 92% failure rate after 2 years. !
What is Neuromodulation?!
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Neuromodulation!
• There are nerves that pass through the L4-S3 spinal roots.!
• Electrical stimulation of these nerves inhibits bladder activity by activating large-diameter somatic afferent fibers which will then triggers a central inhibition of the micturition reflex in the spinal cord (Pontine Micturition Center)!
Tai 2011 Am J Physiol Ren Physiol 300(2): F385!
Neuromodulation!
nature.com!
Posterior Tibial Nerve Stimulation (PTNS)!
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PTNS!
• Neuromodulation!
• Posterior Tibial Nerve!
• 3rd Line Rx!
studyblue.com!
PTNS!
• Inductions: Weekly for 30 minutes x 12 wks!
• Maintenance: q 3-6 wks!
2010 SUmiT Trial!• Multicenter double-blind
randomized controlled trial!
• 220 patients!
• PTNS vs Sham therapy!
• 54% of PTNS group demonstrated moderate -marked improvement vs 21% in Sham group!
Peters 2010 J Urol 183: 1438!
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PTNS at 13 Weeks!
12
3
8
3
11
35
1
10
24
00
3.5
7
10.5
14
Freq Nocturia Urgency Urge Leakage
Baseline Sham PTNS
*!
* Baseline in the Sham group was 1.8!
80% 80%71% 71% 67% 67% 64% 60%
0%
20%
40%
60%
80%
100%
Peters Govier Klingler Vandoninck
Up to 80% Improve!
Botox!
• Indicated for OAB and neurogenic bladder. It is not indicated for stress incontinence.!
• 2nd line of treatment after anticholinergics have failed.!
• The medication is applied directly to the bladder wall under local anesthesia using a cystoscope.!
• It decreases the hyperactivity of the detrusor muscle leading to decreased symptoms of urinary frequency, urgency, and UI. !
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Botox!• No sedation is required. It is an in-office procedure.!
• 50 cc of liquid 2% lidocaine is injected into the bladder for local anesthesia.!
• A total of 20 injections are given across the bladder wall. !
• Patients with OAB are given 100 units and patients with a neurogenic bladder are given a total of 200 units. !
Botox-Efficacy!• 1,105 patients studied in a randomized, multicenter,
double-blind clinical trial.!
• Symptoms are decreased in 2 weeks with the height of efficacy reached in 6 weeks.!
• Patients are asymptomatic or will have a significant decrease in symptoms for 4-6 months with the 100 unit dose. The patients given the 200 unit dose will experience relief for 8-12 months.!
• Up to 35% of patients can have complete resolution of symptoms.!
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Botox!
• RTC in 2 weeks for review of urinary symptoms.!
• May reinject if symptomatic in 3-4 months.!
Botox!• Cannot have another injection 360 units in a 90 day period.!
• Side effects:!
• Urinary retention. In patients receiving 100 unit dose chance of retention is 6%. Receiving the 200 unit dose it is 18%. Retention is transient and it is recommended that patients know how to perform self caths if necessary. !
Botox!Contraindications!
• UTI: UAC must be performed 1 week before the procedure and UA must be done on the day of the procedure.!
• Patients who are susceptible to UTI's. Prophylactic abxs may be given 1-2 days before and after the procedure.!
• D/C antiplatelet therapy 3 days before the procedure.!
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Interstim!
• To understand how this device works, it is important to understand the pathophysiology of the urological system.!
• The bladder is controlled with the neurological pathways of the brain, spinal cord, peripheral/sacral nerves. Together these systems regulate urine storage and voiding.!
Interstim!• It is an implantable device that generates mild
electrical impulses from a lead that is placed near the sacral nerve to the bladder. This alters the neural activity and begins sending appropriate signals to the brain.!
• It involves a 2 step approach. The patient is given a test stimulator. The device is worn on the outside of the body and the patient keeps a journal of their urinary symptoms for 5-7 days. If symptoms decrease, the device can be implanted permanently.!
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Interstim!• Contraindications:!
• Urethral stricture, cancer, and/or benign prostatic hypertrophy.!
• Risks: Infection, bleeding, bruising.!
• Depending on the type of device implanted MRIs may be contraindicated.!
• Efficacy is 60-70%.!
• FDA approved for fecal incontinence.!
Stress Incontinence!Male Sling!
!Artificial Urinary Sphincter!
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Male Sling!
• "Hammock" to provide urethral support!
• Mild incontinence!
• 24 Hour Pad Test
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Male Sling!• Risks: pain, mesh erosion, retention, infection!
• Success Rates: >60-70%!
• Contraindications: UTI, immunocompromised!
• Does NOT preclude doing a sphincter later on!
• Higher pre-op pad counts & radiation are negative prognisticators.. !
Rehder 2012 Eur Urol 62: 140!Zuckerman 2014 Urology 83: 939!
Artificial Urinary Sphincter!
• Moderate - Severe Incontinence!
• >400-500g!
• Active coaptation of urethra!
• 3 Parts: urethral cuff, resevoir, pump!
Artificial Urinary Sphincter!
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Artificial Urinary Spincter!
• Retrospective cohort in 2008 of 40 men followed for 4+ yr!
• 90% success rate of cure or improvment!
• From 4.0 to 0.6 pads per day!
Rocha 2008 Urol 71(1): 85!
Artificial Urinary Spincter!
• Retrospective cohort of 218 men followed for 3yr!
• RRP XRT (60), RRP (116), NGB (11), REDO (31)!
• Complications:!
• Infection 5.5%, Erosion 6.0%, Atrophy 9.6%, Mechanical failure 6.0%!
• Revision/removal 27%!Lai 2007 J Urol 177 (3): 1021!
Artificial Urinary Spincter!
• Risks: mechanical failure, erosion, infection, fluid loss!
• Medical Alert necklace or bracelet!
• Success rates: >90%!
• Contraindications: poor manual dexterity, radiation!
Arai 2009 Intl J Urol 16(1): 101!
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Take Away!
• Do not surrender. There is hope!!
• Urodynamics: UNM, Presbyterian, AUA!
• Candace Percifull NP Rio Grande FP!
• Your NP community!
Thank You!!!!Wayne Kuang MD !
(505) 510-1675!!
Candace Percifull NP!(870) 239-1282!
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