1. Controlling Urine Leakage What You Need To Know David Spellberg MD,FACS Controlling Urine Leakage What You Need To Know David Spellberg MD,FACS

4. Urinary incontinence affects over 13 million Americans, 85% of whom are women. With new treatment options available for incontinence, women can now restore and may improve their active lifestyle. The Facts

5.  Normal part of aging  Nothing can be done  Surgical treatment is invasive  Catheters and daily management products are the best solutions Incontinence Myths

6.  Urge incontinence: involuntary leakage with antecedent urgency  Urgency: the sudden compelling desire to void, which is difficult to defer  Frequency: the patient that complains of urinating to frequently  Nocturia: urinating at night 1 or more times

7. Incontinence Stress incontinence: leakage associated with exertion, coughing sneezing or laughing Urge incontinence: leakage with antecedent urgency Mixed incontinence: leakage associated with both symptoms

8. Overactive bladder (OAB): International continence society replaced terms Detrusor hyperreflexia Unstable bladder OAB: Non-neurogenic OAB Neurogenic OAB: MS, spinal cord injury, spina bifida, neurologic disease or injury

9. Prevalence in women Stress : 49% Urge : 22% Mixed : 29%

10.  Child birth  Aging  Weak pelvic floor muscles  Previous pelvic surgery What Causes Stress Incontinence?

11. Risk factors  Age  Female  Obesity  Vaginal delivery 10% versus 3% - 1 yr post delivery  Menopause? HERS, WHI - systemic estrogen replacement doesn’t help

12. Anatomy Striated sphincter is a horseshoe configuration

13. Urethral sphincter – 2 components striated and smooth muscle

14. Urethral hypermobility Valsalva

15. ISD Open and “pipe’ like urethra

16.  Physical exam: rule out pelvic organ prolapse or vaginal atrophy  UA: rule out infection or hematuria  Direct observation: demonstration of stress incontinence with valsalva or cough

17.  Behavior Modification Techniques  Drug Therapy  Injectable Agents  Catheters/Absorbent Products/Mechanical Devices  Surgery  Suspension  Sling  Artificial Sphincter Treatments for Incontinence

18.  Nonsurgical  Pelvic floor muscle training (Kegel’s)  Biofeedback  Electrical stimulation  Pessaries  Surgical : recreating urethral support  Abdominal  Contemporary

20. Kegel Increasing the muscle bulk of the levator ani and pelvic floor 50% of pt’s can’t complete with simple instructions 25% of pt’s promote incontinence by improper performance

21. Dr. Kegel’s perineometer

22. Biofeedback “training a patient to control their bodily function by providing them information about the function”

23. Vaginal cones

24. Stimulation to the pelvic floor

25. A vaginal insert for pelvic organ prolapse that may also work for stress urinary incontinence

27.  Modest improvements  Pt’s with a small amount of leakage  Pt’s who want a conservative trial  Pt’s with significant comorbidities

28.  Surgical : recreating urethral support allowing for coaptation of the urethra during increased abdominal pressures  Abdominal approaches  Open retropubic colposuspension  Burch  Marshall-Marchetti-Krantz (MMK)  Contemporary  Pubo-vaginal sling  Tension free vaginal tape (TVT)

29. Abdominal approaches :Open retropubic colposuspension : Burch or MMK

30. Contemporary approaches : pubovaginal sling A strip of rectus fascia, or cadeveric fascia is placed under the urethra and brought through the abdominal fascia

31. Contemporary approaches : Tension free vaginal tape