Overactive Bladder: Diagnosis and Treatment Chase Kenyon Sovell, MD Urology Associates May 30 th, 2007 Pearls of Plumbing Seminar.

Overactive Bladder:Diagnosis and TreatmentChase Kenyon Sovell, MDUrology Associates

May 30th, 2007Pearls 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

z

• FrequencyFrequency• UrgencyUrgency

StressStressIncont.Incont. MixedMixed

Incont.Incont.

UrgeUrgeIncont.Incont.

Overactive BladderOveractive Bladder

Minimally Minimally Invasive Invasive SurgerySurgery

IncontinenceIncontinence

Medications & Medications & NeuromodulationNeuromodulation

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 O

AB

increases w

ith age

Men

Women

N = 5,204

0 5 10 15 20 25 30 35 40

18-24

25-34

35-44

45-54

55-64

65-74

75+

Ag

e (y

ears

)

Prevalence (%)

Prevalence of OAB in the United States:Estimated to Impact ~33 Million Americans

National Center for Health Statistics. Vital Health Stat. 2002;10:209.Stewart W et al. World J Urol. 2003;20:327-336.

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%

88%

15%28%

34%44%

Initial Rx 1st Refill 2nd Refill 3rd Refill 4th Refill 11th Refill

20%

40%

60%

80%

100%Prescription persistency rates of OAB

medications among patients new to market (n=21,362)

Source: The 2002 Gallup Study of the Market for Prescription Incontinence Medication. Princeton, NJ: Multi-Sponsor Surveys, Inc 2002

This data is dated from 2002 and current numbers would likely be better, but only marginally.

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?

• 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

Results 12 Months After Surgery

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 YouChase Kenyon Sovell, MD

Urology Associates, Ltd

(952) 925-0473