Incontinence: Evaluation and Management
description
Transcript of Incontinence: Evaluation and Management
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