Taking Control of Urinary Incontinence

Ronald W. Slovick MS, MDAffinity Medical Group

Urologist

What are Bladder Control Problems?

• Broad range of symptoms– May leak small or large amount of urine– May leak frequently– May be unable to completely empty the bladder, or may be

unable to urinate at all

• Multiple causes– Injury– Side effects from certain medications– Diseases– Infection– Bearing children

Urinary Control System

How the Urinary System Works

Ureter

Bladder

Bladderneck

Urinarysphincter

Urethra

Kidney

How Common are Bladder Control Problems?

• Over 33 million people suffer from bladder control problems in the United States alone!

• May affect both women and men

• It can affect people of any age – it is not just a normal part of aging

Types of Bladder Control Problems

• Stress Incontinence

• Urinary Retention

• Overactive Bladder– Urge Incontinence– Urgency-Frequency

Urinary Retention

Occurs when you cannot fully empty your bladder.

Symptoms:– Need a catheter to pass urine

– Produce only a weak, dribbling stream of urine

– Not have a sensation when your bladder is full

– Store increasingly large volumes of urine

Urge Incontinence

A form of overactive bladder.

Symptoms:– Lose urine as soon as you need to go to the

bathroom

– Leak urine when you drink even a small amount of liquid or when you hear or touch running water

– Have frequent leaking episodes

Urgency-Frequency

Also a form of overactive bladder.

Symptoms:– Have frequent, uncontrollable urges to urinate– Go to the bathroom more than seven times a

day– Feel that your bladder is never completely

empty

Stress Incontinence

Involuntary loss of urine resulting fromcontraction of the abdominal muscles.

Symptoms:– Leak urine when you sneeze, cough or laugh– Experience leakage when exercising, bending or

lifting– Leak urine when climbing stairs or getting up from a

chair– Go to the bathroom often to avoid accidents

Wide Range of Treatment Options

• Diet modification

• Pelvic Floor Exercises

• Biofeedback

• Medications

• Catheterization

• InterStim Therapy

• Surgery

Diet Modification

• Fluid intake – Base on recommended daily allowance: ½ ounce per pound (30

mL/kg) in ambulatory adult in moderate climate – Reduce fluids 2 hours before bedtime to reduce nocturia– Individualize timing of diuretic per patient need

• Reduce intake of bladder irritants such as:– Caffeine– Alcohol (ETOH)– Nicotine– Cola

Voiding Regimens

• Scheduled voiding– Fixed voiding schedule, varies from 2 to 4 hours depending on

results of voiding diary (bladder log)– Essential adjunct to pharmacotherapy

• Habit retraining– Scheduled voiding that is adjusted based on patient’s voiding

pattern– Requires significant patient motivation

• Bladder training– Combination management strategy that combines education,

scheduled voiding with adjustment, urge suppression maneuvers, and reinforcement

Pelvic Muscle Rehabilitation

• Strategic use of pelvic floor muscles to maximize LUT function

• Rehabilitation consists of 3 main components:– Biofeedback to teach muscle identification and

isolation for purposes of voluntary contraction and relaxation

– Muscle training to improve function, tone, strength, and endurance

– Neuromuscular reeducation (skill training) to promote continence, relief of bothersome urgency, and complete evacuation of bladder during micturition

Overactive Bladder: Pharmacologic Options

Possible Etiology of Overactive Bladder

Neurogenic

Myogenic

Unknown

Combination

Ouslander J. N Engl J Med. 2004;350(8):786-799

Distribution of Cholinergic and Adrenergic Receptors

• Human bladder smooth muscle contains primarily M2 (66%) and M3 (33%) subtypes

• Activation of M3 receptors evokes direct smooth muscle contraction (primary stimulus for bladder contraction)

• Stimulation of M2 receptors may cause contractions

– Reverse sympathetically mediated smooth muscle relaxation

• M2 receptors may have a more important functional role in the pathologic bladder

– Neurogenic bladders – Aging– Hypertropy

Bladder neck ()

Urethra ()

Trigone ()Pelvic floor (N)

Detrusor muscle (M, )

M = MuscarinicN = Nicotinic = 1- and 2-Adrenergic = 3-Adrenergic

Andersson KE. Lancet Neurol. 2004;3:46-53.Braverman A et al. Urology. 2001;165:36.

Braverman AS et al. Urology. 2002;167:43.

Bladder Contraction Is Mediated by M2 and M3 Receptors

• Release of ACh from cholinergic nerves

• Stimulation of muscarinic receptors on the detrusor smooth muscle

• ACh effects on the detrusor smooth muscle that may be blocked by atropine Andersson K-E. Lancet Neurol. 2004;3:46-53.

Ouslander JG. N Engl J Med. 2004;350:786-799.Sellers DJ et al. J Auton Pharmacol. 2000;20:171-176.

Sjögren C et al. J Urol. 1982;128:1368-1371.

Bladder contractionis caused by:

ACh = acetylcholine.

Commonly prescribed medications:

• Oxybutnin• Ditropan XL• Detrol LA• Vesicare• Enablex• Sanctura• Gelnique• Etc…

Medications do not work for everyone

• Voiding requires a coordinated activity between the nerves and the muscles that control voiding

• While medications are thought to address the muscles, InterStim Therapy is thought to address the nerves.

• If medications were not the answer for you, InterStim Therapy may provide relief.

InterStim Therapy for Urinary Control

• FDA-approved treatment for urinary control problems in people who have not had success with or could not tolerate more conventional treatments.

• Over 60,000 patients implanted worldwide

How Does InterStim Therapy Work?• A small stimulation system

is implanted under the skin, usually in your upper buttock

• The device provides stimulation of the sacral nerves to help restore more normal voiding function

• This therapy is reversible at any time

Who Can Benefit from InterStim Therapy?

• People with non-obstructive urinary retention • People with symptoms of overactive bladder, including

urinary urge incontinence and urgency-frequency• People whose symptoms did not improve with more

conventional treatments, such as medications• People who cannot tolerate the side effects from

medications• People who respond well to the test stimulation and can

operate the system

Test Stimulation• An office test is done to

determine how you will respond to the implanted device

• A thin wire (lead) is placed under the skin just above the tailbone

• Lead is connected to an external device worn on your waistband for a period of 3-4 days

• The decision for implantation of the device will be made based on your response to the test stimulation

Implantation of the InterStim System

• Procedure done at the hospital under local anesthesia

• Stimulator is implanted and connected to a lead wire that will stimulate your sacral nerve

• Stimulator is usually placed just under the skin in upper buttock

• The InterStim System will reside under your skin

• Entire procedure takes about 45-60 minutes

InterStim Patient Programmer

• You will be given a programmer to take home with you to control the stimulator

• The programmer can turn the system on and off and adjust the level of stimulation

How effective is this therapy?

• Urge Incontinence (38 patients)• 45% of patients completely dry• Further 34% had 50% or greater

reduction in symptoms

• Urgency-Frequency (33 patients)• 31% back to normal (4-7 per day)• Additional 33% had a 50% or more

reduction in number of urinations

• Retention (38 patients)• 61% stopped catherization• 16% had > 50% reduction in the amount

of urine emptied from the bladder by catheter

Results 12 Months After Surgery

Medtronic clinical study data on file

Potential Risks with InterStim Therapy

As with other surgical procedures, there are risks:– Pain– Infection – Transient stimulation discomfort– Lead migration– Adverse change in bowel function– Other*

• These complications were generally resolvable in the clinical study

*Types of risks that occurred less than 2% of the time

Does insurance pay for this?

• National Medicare coverage policy

• Hundreds of insurance companies have paid for this procedure

• Your doctor’s office will help you obtain coverage

Call us to make an appointmentWe’d be happy to help!

• Laurie Dietzen, RN– Dr. R. Slovick’s nurse– Direct dial number: (920)730-4946

Sarah’s Story

Being only 40 years old, I was self- conscious about the need to catheterize all the time. I am very active in sports, hiking, and taking long walks with my dog Randy – all of which I couldn’t do with a catheter.

InterStim Therapy has brought me back to normal activities with regard to urological function. It made such a difference in my life. I am thrilled to have my normal life back!

Jeannie’s StoryMy name is Jeannie. I’m a 50-year-old wife, mother, and a pre-op day surgery R.N. I’m also a patient who has struggled with urinary control problems for years until I found a treatment that completely changed my life.

Now I go every four hours during the day and I only get up once at night. I’m not sleep-deprived and I’ve begun working out again. My daughter and I love horseback riding and are taking hunt-seat jumping classes. I feel like I’ve been given my life back.

Brief Summary Disclosure for InterStim® Therapy for Urinary Control InterStim® Therapy for Urinary Control: Product technical manual must be reviewed prior to use for detailed disclosure.

 Indications:

InterStim Therapy for Urinary Control is indicated for the treatment of urinary retention and the symptoms of overactive bladder, including urinary urge incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatments.

Contraindications:

Patients are contraindicated for implant of the InterStim System if they have not demonstrated an appropriate response to test stimulation or are unable to operate the neurostimulator. Also, diathermy (e.g., shortwave diathermy, microwave diathermy or therapeutic ultrasound diathermy) is contraindicated because diathermy's energy can be transferred through the implanted system (or any of the separate implanted components), which can cause tissue damage and can result in severe injury or death. Diathermy can damage parts of the neurostimulation system.

Precautions/Adverse Events:

Warning: This therapy is not intended for patients with mechanical obstruction such as benign prostatic hypertrophy, cancer, or urethral stricture.

Safety and effectiveness have not been established for: bilateral stimulation, patients with neurological disease origins such as multiple sclerosis, pregnancy and delivery, or for pediatric use under the age of 16. System may be affected by or adversely affect cardiac pacemakers or therapies, cardioverter defibrillators, electrocautery, external defibrillators, ultrasonic equipment, radiation therapy, magnetic resonance imaging (MRI), theft detectors and screening devices. Adverse events related to the therapy, device, or procedure can include: pain at the implant sites, lead migration, infection or skin irritation, technical or device problems, transient electric shock, adverse change in bowel or voiding function, numbness, nerve injury, seroma at the neurostimulator site, change in menstrual cycle, and undesirable stimulation or sensations.

CAUTION: Federal law (USA) restricts this device to sale by or on the order of a physician.