1. Incontinence and Erectile Dysfunction
Male Incontinence
Female Incontinence
Male Erectile Dysfunction
What the urologist can do for your patient

2. Male Incontinence There are essentially 4 types of Incontinence
Overflow
Urge
Neurogenic
Stress

3. Overflow Incontinence
Bladder overfilling and subsequent leakage- Dx by residual urine
Treatment
Catheterization intermittent or continuous
Eliminate drugs that cause poor bladder contraction : anticholinergics
Interstim therapy

4. Overflow Incontinence
BPH is the most common cause
Treatment
Alpha blockers: Flomax, Uroxatral, Rapaflo,Cardura and Hytrin
TUR Prostate
Green Light Laser Prostatectomy
Microwave thermotherapy

5. BPH treatment TUR Prostate is has been a gold standard for years
Complications:
Bleeding and Blood loss
Fluid absorption during the procedure
Rare incontinence

6. Green Light laser Prostatectomy
Becoming the new standard
Becoming more common that TURP
The operation is the removal of the same tissue (Prostate Adenoma) by vaporization rather than cutting it out.
Almost no bleeding
No fluid absorption
Can be done with sedation (even in office)

7. Green Light laser Prostatectomy
Advantages of office procedure
Less stressful for patient
Less cost for the patient and the health care system

10. Microwave Thermotherapy
A catheter is placed in the urethra and microwave heat is applied to the prostate
Results:
Minimally invasive office procedure for poor surgical risk patients
Other patients may request it

11. Urgency Incontinence
Inability to control an unstable bladder contraction
Etiology: MS, CVA, and idiopathic, BPH
Diagnosis: Urodynamic studies
Treatment: If secondary to obstruction e.g. BPH, treat BPH first

12. Urgency Incontinence
Anticholinergic medications: Detrol, Enablex, Vesicare, Sanctura, Oxybutinin, Oxytrol patch, Gelnique
Botox injection
Behavioral Therapy
Interstim therapy
Percutaneous Tibial Nerve Stimulation

13. Botox injection I have been doing this for 4 years Office procedure
Units ( 10 units per CC) of Botox A injected submucosally in the bladder
90 % patients respond; usual response is within 8 days and lasts 6month to two years
Complication: retention

14. Interstim Therapy Neuromodulation of S3 or S4 nerve root
Why it works is unknown
50 % response rate
Staged procedure:
Place electrode and stimulate as outpatient; if successful implant batter stimulator and attach electrode

15. Interstim Therapy
Single Stage procedure in OR
Two Stage Procedure

16. PTNS Weekly tibial nerve stimulation
Office procedure that lasts one hour
Needs 12 treatments
Lasts 12 months
50 % improvement in nocturia, incontinence, episodes, and OAB score

17. PTNS

18. Neurogenic Incontinence
Spinal cord injury
Retention
Spastic Bladder

19. Neurogenic Bladder
Etiology is spinal cord lesion and trauma most common
Most patients will have spinal shock and be in retention and best handled by intermittent catheterization
Follow up Urodynamic studies

20. Retention
Usually motor neuron lesion and will require intermittent catheterization for life
Can construct a continent suprapubic stoma (appendix) if urethral catheterization not acceptable or possible
Occasionally due to spastic sphincter and treatment of choice is Botox injection of the external sphincter

21. Spastic Bladder Usually secondary to Upper spinal cord lesion
Treatment with imipramine, anticholinergic and alpha blocker together
If no results, then Botox
If no results then diversion or bladder augmentation and IC

22. Stress incontinence
Etiology is usually surgery and usually radical prostatectomy for cancer
This is manifest with urinary leakage with cough or abdominal straining
Treatment: Advance Sling or AMS 800 urinary sphincter

23. Advance Sling
Used when there only stress incontinence and there is mobility of the urethra
Outpatient procedure
Success of 90%
Risk of early retention

24. Mechanism of Action for AdVance Sling
Image: Peter Rehder

25. AdVance Transobterator Male Sling
Introduced to the market in 2007

26. AMS 800 Urinary Sphincter Can be used for stress in all circumstances
Usually used for stress incontinence when there is no urethral mobility
Used for total incontinence
Success rate 95%
Risk: infection; retention and erosion

27. AMS Sphincter

28. AMS Sphincter Artificial Sphincter-over 65,000 procedures
The Gold Standard for treatment of moderate to severe incontinence
Minimally invasive
Outpatient procedure
92% of patients would have the AMS 800 placed again
96% of patients would recommend it to a friend
33 years on the market

29. Female Incontinence
Overflow
Urgency
Neurogenic
Stress

30. Female Overflow Incontinence
Diabetic neuropathy
Lumbar Disc disease
Herpes Simple or Zoster
Post-op especially gyn surgery
Anticholinergic agents
Rare urethral or bladder cancer

31. Overflow Incontinence RX
Intermittent Catheterization
Interstim therapy
Alpha blockade

32. Urgency Incontinence Overactive Bladder R/O <Multiple sclerosis CVA
Interstitial cystitis
Acute urgency: cystitis, lower stone

33. Rx urge incontinence Anticholinergics Botox Interstim PTNS
Behavior therapy

34. Neurogenic incontinence
Convert to a hypotonic bladder
Botox
Augmentation
Anticholinergics
Then start intermittent catheterization

35. Female Stress Incontinence
Inability to control leakage with
Cough
Strain
Sneeze
Valsalva

36. Female Stress Incontinence
This is an anatomic problem which is corrected anatomically
Type 2 Hypermobile urethra
Type 3 rigid urethra

37. RX of Type 2 and Type 3
Slings
Transobturator
Retropubic

38. Slings for Stress Incontinence
Considered minimally invasive surgery
First developed in mid 1990’s
A sling or hammock shape material is placed below the urethra
Incisions are very small
Long term data shows success of over 80%*
* Long-Term Results of the Tension-Free Vaginal Tape (TVT) Procedure for Surgical Treatment of Female Stress Urinary Incontinence, Nilsson et. al, International Urology Journal, 2001.

39. Stress Incontinence Solutions
Sling or Hammock
Incisions are very small
Procedure pain is minimal*
Recovery time is less than half the time of Burch procedure*
Patient usually goes home the same day
Products like SPARC™, TVT™, or Monarc™ Subfascial Hammock
Will play animation here
* Burch Colposuspension and Tension-Free Vaginal Tape in the Management of Stress Urinary Incontinence in Women, Liapis et. al, European Urology, 2002,

40. Urethral Implant
Collagen
Macroplastique
Durasphere

41.                                                                                                                                                                             
    
Product Photo Library
Contigen® Implant Syringe
Open Bladder Neck
Transurethral Technique Step 1
Transurethral Technique Step 2
Periurethral Technique Step 1
Periurethral Technique Step 2
Periurethral Technique Tip 1
Periurethral Technique Tip 2
Periurethral Technique Tip 3
                                                                                                                 
Pass the needle through the cystoscope sheath Place the needle into the side of the urethra beneath the mucosa proximal to the external sphincter (i.e., towards the bladder neck) No injection should take place either in the external sphincter or around the bulbous urethra
                           
   

42. Erectile Dysfunction
Inability to obtain or maintain an erection satisfying for intercourse

43. Physical Causes of ED • Diabetes • Heart disease
• Surgery (Prostate, Bladder, Colon, Rectal)
• Medications
• Spinal injury
• Hormone imbalance

44. Available treatments PDE- Inhibitors
Prostaglandin and papavarine injection
Testosterone for hypogonadism
Vacuum Pump
Penile Implants

45. Oral Therapies: Work only in response to sexual stimulation
Must take Viagra and Levitra at least ½ hour before anticipated sexual activity. They remains effective for up to 4 hours after are they taken
Cialis can last as long as 36 hours

46. Vacuum Erection Device:
Externally applied device mechanically effects penile blood engorgement
Cylinder/pump placed over penis creates closed chamber; pump creates vacuum, drawing blood into corpora cavernosa
Constrictive elastic ring then placed at base of penis to restrict flow of suctioned blood
VED: Basic Principles
VEDs are a useful noninvasive treatment for ED. They involve a cylindrical device that is placed over the penis. Many types of VEDs are now available, and it is recommended that only those available by prescription should be used.1,2 A VED, which mechanically creates penile blood engorgement, consists of a vacuum chamber or cylinder, a pump to produce negative pressure, and constriction rings.3
VEDs can be used to treat organic or psychogenic ED. Current reviews report successful results in men with a variety of organic etiologies, including spinal cord injuries, postprostatectomy, diabetes, and arterial insufficiency.3
After the penis and constriction rings are coated with water-soluble lubricant and the rings are loaded onto the cylinder base, the cylinder is placed over the penis with the base held firmly against the pubis to maintain a seal. The pump is then activated to slowly create negative pressure, or a vacuum, inside the cylinder, which draws blood into the corpora cavernosa, producing an erection.1,3
Once the penis is engorged, the constriction band is pulled from the cylinder onto the base of the penis. The negative pressure is released through a valve, and the cylinder is removed. It takes an average of 2 to 2½ minutes to create an erection through this procedure, according to recent reviews.3
The erectile state produced by VEDs differs from a normal erection: penile skin temperature is lower, the veins of the penis appear distended, and penile circumference is increased. In addition, the penis may pivot at the base, requiring the patient to stabilize the penis during intercourse.1
Montague DK, et al, for the AUA Guidelines Panel on Erectile Dysfunction. J Urol. 1996;156:
Donatucci CF. In: Mulcahy JJ, ed. Male Sexual Function. Totowa, NJ: Humana Press Inc; 2001:
Levine LA, Dimitriou RJ. Urol Clin North Am. 2001;28:
Levine LA, Dimitriou RJ. Urol Clin North Am. 2001;28:
Montague DK, et al, for the AUA Clinical Guidelines Panel on Erectile Dysfunction. J Urol. 1996;156:

47. Transurethral Medication: MUSE

48. Transurethral Medication: MUSE

49. Injection Therapy Diabetic needle and syringe
Drug dosage - 1 cc or less
5-15 minute response time
30 minute to 2 hour duration
Possible side effects
Pain on administration
Prolonged erections
Scarring

50. Penile Injection Therapy:
Smooth muscle – relaxing medication injected directly into the penis

51. Penile Implants vs. Other Treatment Options
Overall Patient Satisfaction with ED Treatments1
0% 20% 40% 60% 80% 100%
Penile
Implant
Oral
Medication
Injection
93%
51%
40%
Percentage Satisfied
1 Rajpurkar A, Dhabuwala CB. Comparison of satisfaction rates and erectile function in patients treated with sildenafil, intracavernous prostaglandin E1 and penile implant surgery for erectile dysfunction in urology practice. J Urol Jul 2003 v.170(1)p

52. Penile Implants Ideal for men who have tried other
treatments without success
• On the market for over 30 years
• 25,000 penile implants per year
• High patient and partner satisfaction

53. Three – Piece Inflatable Penile Implant
Acts and feels more like a natural erection
Expands the girth of the penis
More firm and full than other implants
Feels softer and more flaccid when deflated

54. How does it work?
Fluid flows from the small reservoir in the abdomen into the cylinders of the penis when the pump is squeezed until there is a firm erection.
Once the erection is not needed you squeeze the pump which allows the fluid to return to the reservoir.

55. Implants are Highly Recommended
100%
95%
90%
85%
80%
92%
would
recommend
to others3
90% partners would recommend to other couples4
Levine LA, Estrada CR, Morgentaler A. Mechanical reliability and safety of, and patient satisfaction with the Ambicor inflatable penile prosthesis; results of a 2 center study. J Urol Sep; 166 (3) :932-7

56. Q & A