Topic: Incontinence

Overactive Bladder vs. Interstitial Cystitis: Overlapping Conditions?

John Thomas Stoffel, MD, Associate Professor of Urology and Chief of the Division of Neurourology and Pelvic Reconstruction within the University of Michigan Department of Urology in Ann Arbor, Michigan, discusses how to differentiate overactive bladder (OAB) from interstitial cystitis (IC), as well as how to appropriately treat both conditions. He begins with some background, explaining that OAB is common and affects 30 to 50 million women worldwide. IC is also common, and may affect between 2 and 17% of US adults. Dr. Stoffel argues that despite this prevalence, clinicians do not understand the depth of these conditions nor how to differentiate them. He then defines OAB as “[urinary] urgency, with or without urgency incontinence, usually with increased daytime frequency and nocturia,” whereas IC is an unpleasant sensation (pain, pressure, discomfort) perceived to be related in the urinary bladder, associated with LUTS, of greater than 6 weeks duration in the absence of infection. Dr. Stoffel posits that IC is more associated with sensory symptoms while OAB more associated with motor symptoms. He then discusses the work-up for OAB and IC, explaining that the work-up for the former should include a physical exam, urine analysis, and a voiding diary, while the work-up for the latter should feature a physical exam, a history of symptoms, urinalysis, urine culture, and urine cytology. Dr. Stoffel moves on to treatment strategies, describing the treatment of OAB as like a ladder, moving sequentially from behavioral therapy to medications to neuromodulation/onabotulinum toxin. He recommends tracking outcomes for OAB with patient reported outcome measures (PROMS), and highlights the effectiveness of behavioral therapies such as timed voiding/fluid management, weight loss, and biofeedback. Dr. Stoffel also notes that there are no clear winners among OAB medications, and he emphasizes the need to define patients’ expectations. He describes the treatment strategy for IC as less like a ladder than a grab bag, explaining that “initial treatment type and level should depend on symptom severity, clinician judgment, and patient preferences.” Dr. Stoffel briefly considers the evidence for neuromodulation and onabotulinum toxin, concluding that they are effective for OAB, but there is little extended data in IC.

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Current Diagnosis and Management of Female Stress Incontinence

Alexander Gomelsky, MD, FACS, B.E. Trichel Professor and Chair in the Department of Urology at LSU Health Shreveport, discusses current guidance regarding the diagnosis and surgical management of female stress incontinence (SUI). He frames his presentation around the 2017 AUA/SUFU Guidelines which, while based on more high-level evidence than prior guidelines, still use an index patient who does not match the majority of women urologists are likely to see for SUI. Dr. Gomelsky particularly focuses on this limitation, noting for instance that doing urodynamic testing, which does not appear to be useful for index patients, can help urologists meet the particular needs of non-index patients (e.g., women of advanced age, women with high BMIs, women suffering from recurrent/persistent SUI, women who have had prior surgery for SUI, etc.). He further discusses both the benefits and adverse events associated with different available surgical therapies for treating SUI, emphasizing that while mesh for transvaginal repair of pelvic organ prolapse has been banned, evidence still supports mesh placed abdominally for pelvic organ prolapse, as well as midurethral slings for SUI.

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Innovation in the Treatment of Male Urinary Incontinence

Culley C. Carson III, MD, Emeritus Rhodes Distinguished Professor in the Department of Urology at the University of North Carolina School of Medicine, discusses innovations in the treatment of male urinary incontinence. He outlines different treatments and their various pros and cons, including some cutting-edge technology that is not yet available in the US. He also goes over innovations, which still need to be made in order to further improve certain technologies like the artificial urinary sphincter. He highlights how important it is to come up with a more cost-effective model because, currently, artificial urinary sphincters are extremely expensive. There are also several significant causes of revision surgery for artificial urinary sphincters, demonstrating the need for further innovation. Dr. Carson also emphasizes the importance of customizing the pumps to individual patients, and goes over current research intended to improve patient outcomes.

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Stress Urinary Incontinence: Non-Mesh Alternatives

Una Lee, MD, FPMRS, urologist and researcher at Virginia Mason Medical Center, reviews the evidence on non-mesh alternatives for stress urinary incontinence (SUI). She provides an overview of the causes of female SUI, presents an effective treatment tree addressing both overactive bladder and stress incontinence, and discusses treatment options. Dr. Lee encourages physicians to consider how they present treatment decisions in order to allow patients to make the choice that fits best for them. In addition to covering all possible risks and benefits, she advises physicians to also educate patients on their condition and help manage their expectations for treatment outcomes.

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Geriatric Considerations in Urinary Incontinence and Overactive Bladder (OAB)

Una Lee, MD, FPMRS, a urologist at the Virginia Mason Medical Center, discusses concepts physicians should consider when managing urinary incontinence and overactive bladder (OAB) in geriatric populations. First, Dr. Lee reviews the “5 M’s”: mind, mobility, medications, multi-complexity, and what matters most to the patient, or care goals/preferences. Additionally, she addresses the role of frailty in older adults, which is associated with increased risk of poor health outcomes. Lastly, she reviews data about the association of anticholinergic medication use and dementia.

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HIFU is not Ready for Prime Time

Erik P. Castle, MD, argues that using high intensity focused ultrasound (HIFU) to treat prostate cancer, as the technology stands today, results in too many negative quality of life outcomes for patients. Therefore, HIFU is not ready to be a standard of care in urological practices.

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