Incontinence: Evaluation and Management Bernard D. Morris, Jr, MD, FACS Killeen Hemingway Clinics Scott&White

Prevalence of Incontinence Women years of ageWomen years of age 30% have some type of urinary incontinence30% have some type of urinary incontinence Increasing population of active, healthy women over 60Increasing population of active, healthy women over 60 Decreasing morbidity of Rx optionsDecreasing morbidity of Rx options

Incontinence Underreported EmbarrassmentEmbarrassment Misunderstanding of causesMisunderstanding of causes Low expectation of benefits from treatmentsLow expectation of benefits from treatments Never asked by providerNever asked by provider Patient does not want to bother providerPatient does not want to bother provider

Incontinence- Cost FinancialFinancial PhysicalPhysical PsychologicalPsychological Indirect costs of consequencesIndirect costs of consequences Loss of independenceLoss of independence

Types of Incontinence Stress Urinary IncontinenceStress Urinary Incontinence Urge IncontinenceUrge Incontinence Mixed Urinary IncontinenceMixed Urinary Incontinence Stress-induced Urge IncontinenceStress-induced Urge Incontinence Overflow IncontinenceOverflow Incontinence Cognitive/awareness issuesCognitive/awareness issues

Evaluation of Incontinence Focused historyFocused history Focused physical examinationFocused physical examination Objective demonstration of SUIObjective demonstration of SUI Post-void residualPost-void residual

Indications for Urologic Evaluation HematuriaHematuria Large post-void residualLarge post-void residual Abnormal urine cytologyAbnormal urine cytology Refractory symptoms after failed aggressive rxRefractory symptoms after failed aggressive rx Neurologic diagnosisNeurologic diagnosis

Urge Incontinence Medical managementMedical management Improvement in molecular characteristicsImprovement in molecular characteristics Improvement in delivery systemsImprovement in delivery systems

Urge Incontinence Physical therapyPhysical therapy BiofeedbackBiofeedback Peripheral nerve stimulatorsPeripheral nerve stimulators

Urge Incontinece Surgical options - rareSurgical options - rare InterstimInterstim Botox injectionsBotox injections Bladder augmentationBladder augmentation

Other diagnostic testing (prn) Voiding diaryVoiding diary Urodynamic evaluationUrodynamic evaluation CystoscopyCystoscopy Imaging studiesImaging studies

Indications for diagnostic tests Diagnosis unclearDiagnosis unclear Mixed incontinenceMixed incontinence Prior pelvic floor surgeryPrior pelvic floor surgery Neurogenic diagnosesNeurogenic diagnoses Hematuria/pyuriaHematuria/pyuria Large post-void residualLarge post-void residual Grade 3-4 prolapseGrade 3-4 prolapse Dysfunctional voidingDysfunctional voiding

Stress Incontinence Non-surgical Rx Physical therapyPhysical therapy BiofeedbackBiofeedback AcupunctureAcupuncture Nerve stimulatorsNerve stimulators Appropriate patient selection and expectations

Stress Incontinece Surgical Rx Retropubic suspensionsRetropubic suspensions SlingsSlings Injectable agentsInjectable agents Artificial Urinary SphincterArtificial Urinary Sphincter

Retropubic Suspensions Gold standard for long-term resultsGold standard for long-term results 75-85% at 48 months75-85% at 48 months Retention 15%Retention 15% Post-operative complications involving intestines/uretersPost-operative complications involving intestines/ureters InvasiveInvasive

Slings Continuous evolution of materials and techniquesContinuous evolution of materials and techniques Autologous vs syntheticAutologous vs synthetic Bladder neck vs mid-urethraBladder neck vs mid-urethra Retropubic vs trans-obturator vs needlelessRetropubic vs trans-obturator vs needleless Adjustable slingAdjustable sling

Slings Retention 3-8%Retention 3-8% Erosion/infection <5%Erosion/infection <5% 85% success at 48 months85% success at 48 months Decreased morbidity has led to expanded population of appropriate candidatesDecreased morbidity has led to expanded population of appropriate candidates

Injectable Agents Sub-mucosal bulking agents for intrinsic sphincteric deficiency (type 3) incontinenceSub-mucosal bulking agents for intrinsic sphincteric deficiency (type 3) incontinence Lack of the ideal bulking agentLack of the ideal bulking agent Minimally invasive, local anestheticMinimally invasive, local anesthetic

Injectable Agents TeflonTeflon Autologous fatAutologous fat CollagenCollagen Calcium hydroxy-apatite (Coaptite)Calcium hydroxy-apatite (Coaptite) Inert synthetic agents (Durasphere)Inert synthetic agents (Durasphere)

Artificial Urinary Sphincter Limited indications in womenLimited indications in women

Stress Incontinence Management Patient selectionPatient selection Patient expectationsPatient expectations Patient preferencesPatient preferences