www.ucsf.edu/wcc

Mind Over Bladder:Mind Over Bladder:Everything you always wanted to Everything you always wanted to

know….know….

Jeanette S. Brown, MDJeanette S. Brown, MDProfessor Professor

Obstetrics, Gynecology, & RS; UrologyObstetrics, Gynecology, & RS; Urology

Epidemiology & BiostatisticsEpidemiology & Biostatistics

University of California, San FranciscoUniversity of California, San Francisco

Urinary IncontinenceUrinary Incontinence CommonCommon

- 50% of women have incontinence- 50% of women have incontinence- It effects women of - It effects women of allall ages ages- Women suffer in silence- Women suffer in silence

ChronicChronicIncontinence doesn’t kill you, it just takes away your life….Incontinence doesn’t kill you, it just takes away your life….Profound effect on women’s livesProfound effect on women’s livesLimits exercise, travel, and social activitiesLimits exercise, travel, and social activities

CostlyCostly$32 billion/year$32 billion/yearGreater than the cost of all cancer care for womenGreater than the cost of all cancer care for women

www.ucsf.edu/wcc

UCSF Women’s Health: UCSF Women’s Health: A New Vision A New Vision

UCSF WCC MissionUCSF WCC MissionClinicalClinical Breaking the silenceBreaking the silence Improving lives through education & treatmentImproving lives through education & treatmentResearchResearch Preventing incontinencePreventing incontinence Developing novel treatmentsDeveloping novel treatmentsTrainingTraining Fellows, residents, students Fellows, residents, students Other healthcare providersOther healthcare providers

Current Clinical InnovationsCurrent Clinical Innovations

Most comprehensive programMost comprehensive program MultidisciplinaryMultidisciplinary

- Urogynecologists, Urologists, - Urogynecologists, Urologists, Colo-rectal surgeonsColo-rectal surgeons

Extensive Pelvic Rehabilitation ProgramExtensive Pelvic Rehabilitation Program- Continence Specialist, Physical Therapist- Continence Specialist, Physical Therapist

Community outreachCommunity outreach- Mind Over Bladder- Mind Over Bladder

Incontinence DefinitionsIncontinence Definitions

Overactive Bladder (OAB)Overactive Bladder (OAB) - urgency, urinary frequency, getting up - urgency, urinary frequency, getting up often at night, urge incontinence often at night, urge incontinence

StressStress -coughing, sneezing, straining, -coughing, sneezing, straining, exerciseexercise

MixedMixed - both urge and stress - both urge and stress

Incontinence TreatmentIncontinence Treatment

Pelvic Floor RehabilitationPelvic Floor Rehabilitation- Pelvic Floor Exercises- Pelvic Floor Exercises

- Bladder training- Bladder training- Biofeedback- Biofeedback- Electrical Stimulation- Electrical Stimulation

Medications, devicesMedications, devices SurgerySurgery

Successful Pelvic Floor ExercisesSuccessful Pelvic Floor Exercises

Strengthen levator ani and sphincter Strengthen levator ani and sphincter Two types: Rapid and ProlongedTwo types: Rapid and Prolonged Individualized ProgramIndividualized Program Coughing upCoughing up

Bladder TrainingBladder Training

Voluntary controlVoluntary control Scheduled voids Scheduled voids Bladder diaryBladder diary Positive reinforcementPositive reinforcement Goal = 3-4 hour voidsGoal = 3-4 hour voids

Additional TreatmentsAdditional Treatments Timed voids to prevent full bladderTimed voids to prevent full bladder Fluid moderationFluid moderation Urge UI: Urge suppressionUrge UI: Urge suppression

- quick pelvic contractions- quick pelvic contractions- urge distractionurge distraction

Prompted VoidsPrompted Voids

Plugs & DrugsPlugs & Drugs Pessary, FemsoftPessary, Femsoft

Meds: Primarily Urge UI: Meds: Primarily Urge UI: Oxybutynin (Ditropan, XL)Oxybutynin (Ditropan, XL) Tolterodine (Detrol, LA)Tolterodine (Detrol, LA)

Stress UI: Duloxetine 2003? Stress UI: Duloxetine 2003?

Who should have surgery?Who should have surgery?

Patient drivenPatient driven Failed conservative treatmentFailed conservative treatment Stress UI primarilyStress UI primarily Bladder neck mobilityBladder neck mobility Understands risks & benefitsUnderstands risks & benefits

How does it work?How does it work?

Urethral mobilityUrethral mobility ““Backstop” for the urethraBackstop” for the urethra Recreate “hammock”Recreate “hammock” ObstructionObstruction

What do we know?What do we know?

150 surgeries150 surgeries Data limited on outcomes Data limited on outcomes (Jarvis 1999)(Jarvis 1999)

Published surgical literature is of the Published surgical literature is of the lowestlowest level of evidence and limited quality level of evidence and limited quality (Merlin (Merlin 2001)2001)

Lack of controlled trials, Lack of controlled trials, short follow-upshort follow-up

What else?What else?

Overestimate successOverestimate success Underestimate complicationsUnderestimate complications First surgery: best surgery First surgery: best surgery (Black 1996)(Black 1996)

The more severe the UI, the better the The more severe the UI, the better the outcomeoutcome

Burch or Sling best choices Burch or Sling best choices

Urinary Incontinence Treatment Urinary Incontinence Treatment NetworkNetwork

NIDDK supported; 9 centersNIDDK supported; 9 centers RCT of Burch vs. SlingRCT of Burch vs. Sling 2 to 4 year follow-up2 to 4 year follow-up Probable similar efficacyProbable similar efficacy

- Difference in morbidity- Difference in morbidity (Weber 2000)(Weber 2000)

Tension-free Vaginal TapeTension-free Vaginal Tape

Prolene tape, quick, easy, light anesthesiaProlene tape, quick, easy, light anesthesia Synthetic tape “well-tolerated”Synthetic tape “well-tolerated”

- publication bias or short-term?- publication bias or short-term? Outcomes:Outcomes:

- Short-term 90%; Long-term-no data- Short-term 90%; Long-term-no data Reasonable choice with limited dataReasonable choice with limited data

Long-term OutcomesLong-term Outcomes

Average age at surgery: 54 yo Average age at surgery: 54 yo - Average life expectancy: 77 yo- Average life expectancy: 77 yo

At 4 years: 80-85% success At 4 years: 80-85% success (Leach 1997)(Leach 1997)

> 5 years: poor data and fall off> 5 years: poor data and fall off- 50-60% - 50-60% (Diokno 1989; Erikson 1990)(Diokno 1989; Erikson 1990)

- 30% need re-operation - 30% need re-operation (Stanton 1997 Erikson (Stanton 1997 Erikson 1990)1990)

Surgery SummarySurgery Summary

SUI surgery is not an emergency!SUI surgery is not an emergency! More severe UI better outcomeMore severe UI better outcome First surgery most successfulFirst surgery most successful New surgeries: RCT to standardNew surgeries: RCT to standard Long-term data lackingLong-term data lacking

www.ucsf.edu/scor

UCSF Specialized Center of Research UCSF Specialized Center of Research (SCOR)(SCOR)

Only NIH designated center for:Only NIH designated center for:Lower Urinary Tract Function in WomenLower Urinary Tract Function in Women

Clinical and Basic ResearchClinical and Basic Research Multi-disciplinary Multi-InstitutionalMulti-disciplinary Multi-Institutional

- Departments of: ObGyn, Urology, Family - Departments of: ObGyn, Urology, Family Medicine Geriatrics, Epi & Biostats Medicine Geriatrics, Epi & Biostats

Translation of scientific results to improved careTranslation of scientific results to improved care

UCSF Specialized Center of Research UCSF Specialized Center of Research

BasicBasic ClinicalClinical

EpidemiologicalEpidemiologicalInvestigationInvestigation

New TreatmentsNew Treatments

DatabaseDatabaseAnalysisAnalysis

ImprovedImprovedPatient CarePatient Care

EconomicEconomicAnalysisAnalysis

Molecular Molecular BiologyBiology

TrainingTrainingPreventionPrevention

ResearchResearchHigh quality research is necessary to identify:High quality research is necessary to identify: Natural history and prognosis of diseaseNatural history and prognosis of diseaseWhat happens to women with incontinence?What happens to women with incontinence? Risk factors for diseaseRisk factors for diseaseDoes having a hysterectomy increase risk for UI?Does having a hysterectomy increase risk for UI? Effective, novel treatmentsEffective, novel treatmentsDoes estrogen treat incontinence?Does estrogen treat incontinence?Does weight loss improve incontinence?Does weight loss improve incontinence?

Think Outside the Think Outside the Bladder Bladder !!

Falls & FracturesFalls & Fractures

In older women:In older women:

Falls: 20-40%Falls: 20-40% Hip fractures: 90% with fallHip fractures: 90% with fall Incontinence: 50%Incontinence: 50% Association with OAB?Association with OAB?

Falls and FracturesFalls and Fractures 4 centers in US4 centers in US

6049 women > 65 years of age6049 women > 65 years of age

followed every 4 months for 3 yearsfollowed every 4 months for 3 years OutcomesOutcomes

55% had falls55% had falls

8.5% had fractures8.5% had fracturesBrown Brown JAGS JAGS 20002000

Multivariate Falls & FracturesMultivariate Falls & Fractures RiskRisk PP

FallsFallsOABOAB 26% <0.0001 26% <0.0001StressStress 6% 6% 0.30.3

FracturesFracturesOABOAB 34%34% <0.02 <0.02StressStress 1% 1% 0.090.09

Falls & Fractures SummaryFalls & Fractures Summary Weekly OAB Weekly OAB Risk: Risk:

Falls 26%Falls 26%

Fracture 34%Fracture 34% Associated frequency & nocturiaAssociated frequency & nocturia Early diagnosis and treatmentEarly diagnosis and treatment Potential to prevent or Potential to prevent or falls & fx falls & fx

(Brown (Brown JAGSJAGS 2000) 2000)

Risk Factors for Daily UIRisk Factors for Daily UIRisk FactorRisk Factor % Increased Risk% Increased RiskOral HTOral HT 9090StrokeStroke 8080DiabetesDiabetes 7070Poor overall healthPoor overall health 6060ObesityObesity 5050HysterectomyHysterectomy 4040COPDCOPD 4040Age (per 5 years)Age (per 5 years) 3030 (Brown 1996)(Brown 1996)

Hormone TherapyHormone Therapy

Receptors in urethra, bladderReceptors in urethra, bladder Clinical therapyClinical therapy Limited trial dataLimited trial data

Hormones & IncontinenceHormones & Incontinence

Randomized controlled trialRandomized controlled trial 1525 women with weekly incontinence1525 women with weekly incontinence Hormone Therapy: Estrogen/ Progestin Hormone Therapy: Estrogen/ Progestin

or Placeboor Placebo Followed 4.1 yearsFollowed 4.1 years

Hormones & IncontinenceHormones & Incontinence

ImprovedImproved UI: UI: 21% HT21% HT26% Placebo26% Placebo

WorsenedWorsened UI: UI: 39% HT39% HT 27% Placebo 27% Placebo

P=0.001P=0.001

Summary:Summary: Oral HT not recommended for treatmentOral HT not recommended for treatment Prevention?Prevention?

Weight and IncontinenceWeight and Incontinence

> 50% US women overweight or obese> 50% US women overweight or obese Obese women: 4 fold Obese women: 4 fold risk UI risk UI Incontinent Women: 70% obeseIncontinent Women: 70% obese Proposed Mechanism:Proposed Mechanism: abdominal pressure, abdominal pressure,

urethral mobility, damage supportsurethral mobility, damage supports

Can weight reduction improve or prevent UI?Can weight reduction improve or prevent UI?

Weight Reduction StudiesWeight Reduction Studies

In women about 200 lbs:In women about 200 lbs:Weight loss: > 5% or 30 lbs Weight loss: > 5% or 30 lbs

> 50% Incontinence reduction> 50% Incontinence reduction Effective therapy for UIEffective therapy for UI Public Health ImplicationsPublic Health Implications NIH Multi-centered trial fundedNIH Multi-centered trial funded

(Subak 2002)(Subak 2002)

HysterectomyHysterectomy

United StatesUnited States 600,000 per year600,000 per year Average age: 44yoAverage age: 44yo By age 60, 37% of womenBy age 60, 37% of women 90% for benign etiology90% for benign etiology

Hysterectomy & UIHysterectomy & UI

Women > 60 yo with hysterectomy: Women > 60 yo with hysterectomy: - 60% - 60% Incontinence risk Incontinence risk

Mechanism: Similar to childbirthMechanism: Similar to childbirthDamage to muscle/nervesDamage to muscle/nerves

Clinically useful informationClinically useful information(Brown (Brown LancetLancet 2000) 2000)

Clinical ImplicationsClinical Implications

Quality of lifeQuality of life Potential risks laterPotential risks later Patient preferencePatient preference Alternatives to hysterectomyAlternatives to hysterectomy

SummarySummary

CommonCommon

Make incontinence Make incontinence cocktail conversation!!cocktail conversation!! Important quality of life issueImportant quality of life issue

Improving lives through education & Improving lives through education & treatment.treatment.

Innovative ResearchInnovative Research

Advancing treatment through researchAdvancing treatment through research

www.ucsf.edu/wcc