2. Gotta Go? Gotta Go! Gotta GO!!! Discussion of Urinary and Fecal Urgency, Frequency, and Incontinence Elizabeth Babin, MD Female Pelvic Medicine and Reconstructive Surgeon Director, Athena Women’s Institute for Pelvic Health Professor Drexel University Department of Urogynecology

3. Select the most appropriate subtitle for this talk A: Bladders gone wild! B: There’s no such thing as bad bladders, they just do bad things… C: Your system software has been corrupted. Do you have the right driver installed for that bladder? D: I’m going to go crazy if I have to find another potty

4. Learning Objectives  Review definition, causes, and treatments for:  urinary urgency, frequency, and urinary incontinence  recurrent urinary tract infections  fecal incontinence

5. General Definitions  Urgency: sudden compelling sensation to pass urine or feces which is difficult to defer “Gotta Go” “Gotta Go” Primary symptom of overactive bladder or bowel Primary symptom of overactive bladder or bowel  Frequency: excessive number of voids or movements over a 24 hour period  Urinary Incontinence: involuntary loss of urine  Fecal Incontinence: involuntary loss of gas or feces  Recurrent Urinary Tract Infections (UTIs): >2 bladder infections proven by urine culture in a 6 months period

6. Incontinence is a Common Problem 1:3 women over age 45 Which is over 13 million women 1:2 women over age 65

7. Anatomy Review  Bladder: stores urine  Urethra: tube that allows urine to pass  Urethral sphincter: muscle surrounding the urethra that hold the urine  Brain signals are key to coordinating the function of these anatomical structures

8. Anatomy Review

9. What is Overactive Bladder?  It is a combination of symptoms that may or may not include involuntary loss of urine that are the result of the brain miscommunicating with the bladder (nerve inputs leading to abnormal sensations and/or muscle reactions)  Urgency  Frequency  Leakage  “I get an urge to urinate that causes me to frequently search for the bathroom and sometimes I don’t make it!” Gotta go!!

10. OAB Treatments  Behavioral Modification Lifestyle changes, dietary avoidance, timed voiding Lifestyle changes, dietary avoidance, timed voiding  Biofeedback/Pelvic Floor Rehabilitation  Medications  Neural stimulation  Botox

11. Interstim Nerve Stimulator

12. What is Stress Incontinence?  Loss of urine with anything that increases the pressure on the bladder that overcomes the urethral sphincter Cough Sneeze Exercise Laugh

13. What Causes Female SUI Hypermobile urethra – descent Hypermobile urethra – descent Inadequate urethral sphincter Inadequate urethral sphincter These are resulting from Birth, trauma, surgery, radiation, hormonal changes, muscle deterioration

15. SUI Treatments  Goal: To strengthen or support the damaged pelvic floor muscles  Pelvic floor excercises  Pessaries or Urethral Plugs  Bulking agents  Minimally Invasive Surgery  *There are no medications at this point

16. FemSoft Insert Function  Disposable, Single-Use Device  Placed in a Woman’s Urethra to Prevent Accidental Leakage  Soft Sleeve Conforms to the Urethra and Bladder Neck

17. Bulking Agents

18. Slings  90% success rate  Minimally invasive  Outpatient  Quick recovery 3-4 days

19. What is Mixed Incontinence?  The combination of both stress and urge incontinence.  Therapy focuses on the most bothersome symptom and usually requires both nonsurgical and surgical treatment.

20. Recurrent UTIs  20% of women who have a UTI will have another  30% if you have had 2  80% if you have had >2  Defined as at least 2 culture documented infections in 6 months or 3 in 12 months

21. Why do I always get bladder infections?  Hormone deficiency  Diabetes  Incomplete bladder emptying either from weak bladder muscle or partial obstruction from prolapse  Bladder stones or masses  Incomplete initial treatment or bacterial resistance  Intercourse

22. How do I get rid of the darn things?  Always get a urine culture and antibiotic sensitivity when symptoms occur  Have a physical exam and cystoscopy to ensure no anatomical reasons  Treatments: Low dose daily antibiotic for at least 6 months Low dose daily antibiotic for at least 6 months Single antibiotic dose with each intercourse Single antibiotic dose with each intercourse Hormone supplementation Hormone supplementation

23. Recurrent UTI prevention  Drink plenty of water to avoid concentrating any small bacteria in urine  Wipe front to back to avoid anal bacterial contamination  Take showers instead of baths  Cleanse genital area after intercourse  Avoid douches and feminine hygiene spray  Drink Cranberry Juice

24. Fecal Incontinence  Inability to control your bowels  Either leakage with urge or unexpected  6.5 million Americans  Not a normal part of Aging

25. Anatomy Rectum and Anus

26. What causes Fecal Incontinence?  Childbirth/trauma/surg ery may damage the sphincter or the nerve innervation  Loss of storage capacity in the rectum  Diarrhea or loss of bulking  Pelvic floor dysfunction

27. Non-surgical management Dietary changes Dietary changes Fiber supplementation Fiber supplementation Drink lots of water Drink lots of water Avoid foods which exacerbate IBS or diarrhea states Avoid foods which exacerbate IBS or diarrhea states Caffeine, spice, cured meat, grease, artificial sweetnersCaffeine, spice, cured meat, grease, artificial sweetners Bowel management Bowel management Planned defectation (timing, use of gastrocolic reflex) Planned defectation (timing, use of gastrocolic reflex) Enemas Enemas

28. Non-surgical management Pharmacologic interventions Pharmacologic interventions Steroids and sulfasalazine for UC Steroids and sulfasalazine for UC Steroid enemas for radiation proctitis Steroid enemas for radiation proctitis Cholestyramine for diarrhea from malabsorption of bile salts Cholestyramine for diarrhea from malabsorption of bile salts Motility agents: Motility agents: Loperamide (Imodium) Loperamide (Imodium) Lomotil (atropine/diphenoxylate) Lomotil (atropine/diphenoxylate)

29. Non-surgical management Perineal exercises to strengthen muscles Perineal exercises to strengthen muscles Anal Plug Anal Plug Biofeedback Biofeedback Sensory training Sensory training Muscle training Muscle training Cure or improvement in 70-80% Cure or improvement in 70-80% Results tend to be long-lasting Results tend to be long-lasting

30. Surgical Procedures Sphincteroplasty Sphincteroplasty Prolapse Repair Prolapse Repair Artificial Anal Sphincter Artificial Anal Sphincter Bulking agent Bulking agent Radio-Frequency Radio-Frequency Sacral Nerve Stimulation Sacral Nerve Stimulation Colostomy Colostomy

31. Conclusion  Bladder and Fecal Incontinence can rob you of your life. Let us help you get your LIFE BACK!!