2. Mind Over Bladder: Everything you always wanted to know. Jeanette S. Brown, MD ProfessorObstetrics, Gynecology, & RS; Urology Epidemiology & Biostatistics University of California, San Francisco 3. Urinary Incontinence
- - 50% of women have incontinence
- - It effects women ofallages
- - Women suffer in silence
- Incontinence doesnt kill you, it just takes away your life.
- Profound effect on womens lives
- Limits exercise, travel, and social activities
- Greater than the cost of all cancer care for women
4. www.ucsf.edu/wcc 5. UCSF Womens Health: A New Vision 6. 7. 8. 9. 10. UCSF WCC Mission
- Improving lives through education & treatment
- Developing novel treatments
- Fellows, residents, students
- Other healthcare providers
11. Current Clinical Innovations
- Most comprehensive program
- - Urogynecologists, Urologists,
- Extensive Pelvic Rehabilitation Program
- - Continence Specialist, Physical Therapist
12. Incontinence Definitions
- - urgency, urinary frequency, getting upoften at night, urge incontinence
- Stress-coughing, sneezing, straining, exercise
- Mixed- both urge and stress
13. Incontinence Treatment
- Pelvic Floor Rehabilitation
14. Successful PelvicFloor Exercises
- Strengthen levator ani and sphincter
- Two types: Rapid and Prolonged
15. Bladder Training
16. Additional Treatments
- Timed voids to prevent full bladder
- Urge UI: Urge suppression
- - quick pelvic contractions
17. Plugs & Drugs
- Oxybutynin (Ditropan, XL)
- Stress UI: Duloxetine 2003?
18. Who should have surgery?
- Failed conservative treatment
- Understands risks & benefits
19. How does it work?
20. What do we know?
- Data limited on outcomes(Jarvis 1999)
- Published surgical literature is of thelowest level of evidence and limited quality(Merlin 2001)
- Lack of controlled trials,short follow-up
21. What else?
- Underestimate complications
- First surgery: best surgery(Black 1996)
- The more severe the UI, the better the outcome
- Burch or Sling best choices
22. Urinary Incontinence Treatment Network
- NIDDK supported; 9 centers
- Probable similar efficacy
- - Difference in morbidity (Weber 2000)
23. Tension-free Vaginal Tape
- Prolene tape, quick, easy, light anesthesia
- Synthetic tape well-tolerated
- - publication bias or short-term?
- - Short-term 90%; Long-term-no data
- Reasonable choice with limited data
24. Long-term Outcomes
- Average age at surgery: 54 yo
- - Average life expectancy: 77 yo
- At 4 years: 80-85% success(Leach 1997)
- > 5 years: poor data and fall off
- - 50-60%(Diokno 1989; Erikson 1990)
- - 30% need re-operation(Stanton 1997 Erikson 1990)
25. Surgery Summary
- SUI surgery is not an emergency!
- More severe UI better outcome
- First surgery most successful
- New surgeries: RCT to standard
26. www.ucsf.edu/scor 27. UCSF Specialized Center of Research (SCOR)
- Only NIH designated center for:
- Lower Urinary Tract Function in Women
- Clinical and Basic Research
- Multi-disciplinary Multi-Institutional
- -Departments of:ObGyn, Urology, Family Medicine Geriatrics, Epi & Biostats
- Translation of scientific results to improved care
28. UCSF Specialized Center of ResearchBasic Clinical Epidemiological Investigation New Treatments Database Analysis Improved Patient Care Economic Analysis MolecularBiology Training Prevention 29. Research
- High quality research is necessary to identify:
- Natural history and prognosis of disease
- What happens to women with incontinence?
- Does having a hysterectomy increase risk for UI?
- Effective, noveltreatments
- Does estrogen treat incontinence?
- Does weight loss improve incontinence?
30. Think Outside theBladder! 31. Falls & Fractures
- Hip fractures: 90% with fall
32. Falls and Fractures
- 6049women > 65 years of age
- followed every 4 months for 3 years
BrownJAGS2000 33. Multivariate Falls & Fractures Risk P Falls OAB 26% 5% or 30 lbs
- > 50% Incontinence reduction
- Public Health Implications
- NIH Multi-centered trial funded
42. Hysterectomy & UI
- Women > 60 yo with hysterectomy:
- Mechanism: Similar to childbirth
- Clinically useful information
43. Clinical Implications
- Alternatives to hysterectomy
- Make incontinencecocktail conversation!!
- Important quality of life issue
- Improving lives through education & treatment.
- Advancing treatment through research
45. 46. www.ucsf.edu/wcc