URINARY TRACT INFECTIONS RISK FACTORS URINARY TRACT INFECTIONS RISK FACTORS

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  • 1. www.ucsf.edu/wcc

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

  • Common
  • - 50% of women have incontinence
  • - It effects women ofallages
  • - Women suffer in silence
  • Chronic
  • Incontinence doesnt kill you, it just takes away your life.
  • Profound effect on womens lives
  • Limits exercise, travel, and social activities
  • Costly
      • $32 billion/year
      • 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

  • Clinical
  • Breaking the silence
  • Improving lives through education & treatment
  • Research
  • Preventing incontinence
  • Developing novel treatments
  • Training
  • Fellows, residents, students
  • Other healthcare providers

11. Current Clinical Innovations

  • Most comprehensive program
  • Multidisciplinary
  • - Urogynecologists, Urologists,
  • Colo-rectal surgeons
  • Extensive Pelvic Rehabilitation Program
  • - Continence Specialist, Physical Therapist
  • Community outreach
  • - Mind Over Bladder

12. Incontinence Definitions

  • Overactive Bladder (OAB)
  • - 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
  • - Pelvic Floor Exercises
  • - Bladder training
  • - Biofeedback
  • - Electrical Stimulation
  • Medications, devices
  • Surgery

14. Successful PelvicFloor Exercises

  • Strengthen levator ani and sphincter
  • Two types: Rapid and Prolonged
  • Individualized Program
  • Coughing up

15. Bladder Training

  • Voluntary control
  • Scheduled voids
  • Bladder diary
  • Positive reinforcement
  • Goal = 3-4 hour voids

16. Additional Treatments

  • Timed voids to prevent full bladder
  • Fluid moderation
  • Urge UI: Urge suppression
    • - quick pelvic contractions
    • urge distraction
  • Prompted Voids

17. Plugs & Drugs

  • Pessary, Femsoft
  • Meds: Primarily Urge UI:
  • Oxybutynin (Ditropan, XL)
  • Tolterodine (Detrol, LA)
  • Stress UI: Duloxetine 2003?

18. Who should have surgery?

  • Patient driven
  • Failed conservative treatment
  • Stress UI primarily
  • Bladder neck mobility
  • Understands risks & benefits

19. How does it work?

  • Urethral mobility
  • Backstop for the urethra
  • Recreate hammock
  • Obstruction

20. What do we know?

  • 150 surgeries
  • 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?

  • Overestimate success
  • 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
  • RCT of Burch vs. Sling
  • 2 to 4 year follow-up
  • 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?
  • Outcomes:
  • - 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
  • Long-term data lacking

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?
  • Risk factors for disease
  • 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

  • In older women:
  • Falls: 20-40%
  • Hip fractures: 90% with fall
  • Incontinence: 50%
  • Association with OAB?

32. Falls and Fractures

  • 4 centers in US
    • 6049women > 65 years of age
    • followed every 4 months for 3 years
  • Outcomes
  • 55% had falls
    • 8.5% had fractures

BrownJAGS2000 33. Multivariate Falls & Fractures Risk P Falls OAB 26% 5% or 30 lbs

  • > 50% Incontinence reduction
  • Effective therapy for UI
  • Public Health Implications
  • NIH Multi-centered trial funded
  • (Subak 2002)

41. Hysterectomy

  • United States
  • 600,000 per year
  • Average age: 44yo
  • By age 60, 37% of women
  • 90% for benign etiology

42. Hysterectomy & UI

  • Women > 60 yo with hysterectomy:
  • - 60%Incontinence risk
  • Mechanism: Similar to childbirth
  • Damage to muscle/nerves
  • Clinically useful information
  • (BrownLancet2000)

43. Clinical Implications

  • Quality of life
  • Potential risks later
  • Patient preference
  • Alternatives to hysterectomy

44. Summary

  • Common
  • Make incontinencecocktail conversation!!
  • Important quality of life issue
  • Improving lives through education & treatment.
  • Innovative Research
  • Advancing treatment through research

45. 46. www.ucsf.edu/wcc