incontinence and erectile dysfunction male incontinence male incontinence female incontinence female...

Incontinence andIncontinence and Erectile Dysfunction Erectile Dysfunction

• Male IncontinenceMale Incontinence

• Female IncontinenceFemale Incontinence

• Male Erectile DysfunctionMale Erectile Dysfunction

• What the urologist can do for your What the urologist can do for your patientpatient

Male IncontinenceMale Incontinence

• There are essentially 4 types of There are essentially 4 types of IncontinenceIncontinence

– Overflow Overflow – UrgeUrge– NeurogenicNeurogenic– StressStress

Overflow IncontinenceOverflow Incontinence

• Bladder overfilling and subsequent Bladder overfilling and subsequent leakage- Dx by residual urineleakage- Dx by residual urine

• TreatmentTreatment– Catheterization intermittent or Catheterization intermittent or

continuouscontinuous– Eliminate drugs that cause poor bladder Eliminate drugs that cause poor bladder

contraction : anticholinergicscontraction : anticholinergics– Interstim therapyInterstim therapy

Overflow IncontinenceOverflow Incontinence

• BPH is the most common causeBPH is the most common cause

• TreatmentTreatment– Alpha blockers: Flomax, Uroxatral, Alpha blockers: Flomax, Uroxatral,

Rapaflo,Cardura and HytrinRapaflo,Cardura and Hytrin– TUR ProstateTUR Prostate– Green Light Laser ProstatectomyGreen Light Laser Prostatectomy– Microwave thermotherapyMicrowave thermotherapy

BPH treatmentBPH treatment

• TUR Prostate is has been a gold TUR Prostate is has been a gold standard for yearsstandard for years

• Complications: Complications: – Bleeding and Blood lossBleeding and Blood loss– Fluid absorption during the procedureFluid absorption during the procedure– Rare incontinenceRare incontinence

Green Light laser Green Light laser ProstatectomyProstatectomy• Becoming the new standard Becoming the new standard • Becoming more common that TURPBecoming more common that TURP• The operation is the removal of the The operation is the removal of the

same tissue (Prostate Adenoma) by same tissue (Prostate Adenoma) by vaporization rather than cutting it out.vaporization rather than cutting it out.– Almost no bleedingAlmost no bleeding– No fluid absorptionNo fluid absorption– Can be done with sedation (even in office)Can be done with sedation (even in office)

Green Light laser Green Light laser ProstatectomyProstatectomy

• Advantages of office procedureAdvantages of office procedure– Less stressful for patientLess stressful for patient– Less cost for the patient and the health Less cost for the patient and the health

care systemcare system

Microwave ThermotherapyMicrowave Thermotherapy

• A catheter is placed in the urethra and A catheter is placed in the urethra and microwave heat is applied to the microwave heat is applied to the prostateprostate

• Results:Results:

• Minimally invasive office procedure for Minimally invasive office procedure for poor surgical risk patientspoor surgical risk patients

• Other patients may request itOther patients may request it

Urgency IncontinenceUrgency Incontinence

• Inability to control an unstable Inability to control an unstable bladder contractionbladder contraction

• Etiology: MS, CVA, and idiopathic, Etiology: MS, CVA, and idiopathic, BPHBPH

• Diagnosis: Urodynamic studiesDiagnosis: Urodynamic studies

• Treatment: If secondary to Treatment: If secondary to obstruction e.g. BPH, treat BPH firstobstruction e.g. BPH, treat BPH first

Urgency IncontinenceUrgency Incontinence

• Anticholinergic medications: Detrol, Anticholinergic medications: Detrol, Enablex, Vesicare, Sanctura, Enablex, Vesicare, Sanctura, Oxybutinin, Oxytrol patch, GelniqueOxybutinin, Oxytrol patch, Gelnique

• Botox injectionBotox injection

• Behavioral TherapyBehavioral Therapy

• Interstim therapyInterstim therapy

• Percutaneous Tibial Nerve StimulationPercutaneous Tibial Nerve Stimulation

Botox injectionBotox injection

• I have been doing this for 4 yearsI have been doing this for 4 years• Office procedureOffice procedure• 100-200 Units ( 10 units per CC) of 100-200 Units ( 10 units per CC) of

Botox A injected submucosally in the Botox A injected submucosally in the bladderbladder

• 90 % patients respond; usual response 90 % patients respond; usual response is within 8 days and lasts 6month to is within 8 days and lasts 6month to two yearstwo years

• Complication: retentionComplication: retention

Interstim TherapyInterstim Therapy

• Neuromodulation of S3 or S4 nerve Neuromodulation of S3 or S4 nerve rootroot

• Why it works is unknownWhy it works is unknown

• 50 % response rate50 % response rate

• Staged procedure: Staged procedure: – Place electrode and stimulate as Place electrode and stimulate as

outpatient; if successful implant batter outpatient; if successful implant batter stimulator and attach electrodestimulator and attach electrode

Interstim TherapyInterstim Therapy

• Single Stage procedure in ORSingle Stage procedure in OR

• Two Stage ProcedureTwo Stage Procedure

PTNSPTNS

• Weekly tibial nerve stimulationWeekly tibial nerve stimulation

• Office procedure that lasts one hourOffice procedure that lasts one hour

• Needs 12 treatments Needs 12 treatments

• Lasts 12 monthsLasts 12 months

• 50 % improvement in nocturia, 50 % improvement in nocturia, incontinence, episodes, and OAB incontinence, episodes, and OAB scorescore

PTNSPTNS

Neurogenic IncontinenceNeurogenic Incontinence

• Spinal cord injurySpinal cord injury

• RetentionRetention

• Spastic BladderSpastic Bladder

Neurogenic BladderNeurogenic Bladder

• Etiology is spinal cord lesion and Etiology is spinal cord lesion and trauma most commontrauma most common

• Most patients will have spinal shock Most patients will have spinal shock and be in retention and best handled and be in retention and best handled by intermittent catheterizationby intermittent catheterization

• Follow up Urodynamic studiesFollow up Urodynamic studies

Retention Retention

• Usually motor neuron lesion and will Usually motor neuron lesion and will require intermittent catheterization for require intermittent catheterization for lifelife

• Can construct a continent suprapubic Can construct a continent suprapubic stoma (appendix) if urethral stoma (appendix) if urethral catheterization not acceptable or catheterization not acceptable or possiblepossible

• Occasionally due to spastic sphincter and Occasionally due to spastic sphincter and treatment of choice is Botox injection of treatment of choice is Botox injection of the external sphincterthe external sphincter

Spastic BladderSpastic Bladder

• Usually secondary to Upper spinal Usually secondary to Upper spinal cord lesioncord lesion

• Treatment with imipramine, Treatment with imipramine, anticholinergic and alpha blocker anticholinergic and alpha blocker togethertogether

• If no results, then BotoxIf no results, then Botox

• If no results then diversion or bladder If no results then diversion or bladder augmentation and ICaugmentation and IC

Stress incontinenceStress incontinence

• Etiology is usually surgery and Etiology is usually surgery and usually radical prostatectomy for usually radical prostatectomy for cancercancer

• This is manifest with urinary leakage This is manifest with urinary leakage with cough or abdominal strainingwith cough or abdominal straining

• Treatment: Advance Sling or AMS Treatment: Advance Sling or AMS 800 urinary sphincter800 urinary sphincter

Advance SlingAdvance Sling

• Used when there only stress Used when there only stress incontinence and there is mobility of incontinence and there is mobility of the urethrathe urethra

• Outpatient procedureOutpatient procedure

• Success of 90%Success of 90%

• Risk of early retentionRisk of early retention

Image: Peter Rehder

Mechanism Mechanism of Action of Action for for AdVance AdVance SlingSling

AdVance AdVance Transobterator Transobterator

Male SlingMale SlingIntroduced to the market in 2007

AMS 800 Urinary SphincterAMS 800 Urinary Sphincter

• Can be used for stress in all Can be used for stress in all circumstancescircumstances

• Usually used for stress incontinence Usually used for stress incontinence when there is no urethral mobilitywhen there is no urethral mobility

• Used for total incontinenceUsed for total incontinence

• Success rate 95%Success rate 95%

• Risk: infection; retention and erosionRisk: infection; retention and erosion

AMS SphincterAMS Sphincter

AMS SphincterAMS Sphincter

• Artificial Sphincter-over 65,000Artificial Sphincter-over 65,000 procedures procedures

• The Gold Standard for treatment of moderate to severe The Gold Standard for treatment of moderate to severe incontinenceincontinence

• Minimally invasiveMinimally invasive

• Outpatient procedureOutpatient procedure

• 92% of patients would have the AMS 800 placed again92% of patients would have the AMS 800 placed again

• 96% of patients would recommend it to a friend96% of patients would recommend it to a friend

• 33 years on the market33 years on the market

Female IncontinenceFemale Incontinence

• OverflowOverflow

• Urgency Urgency

• NeurogenicNeurogenic

• StressStress

Female Overflow Female Overflow IncontinenceIncontinence

• Diabetic neuropathyDiabetic neuropathy

• Lumbar Disc diseaseLumbar Disc disease

• Herpes Simple or ZosterHerpes Simple or Zoster

• Post-op especially gyn surgeryPost-op especially gyn surgery

• Anticholinergic agentsAnticholinergic agents

• Rare urethral or bladder cancerRare urethral or bladder cancer

Overflow Incontinence RXOverflow Incontinence RX

• Intermittent CatheterizationIntermittent Catheterization

• Interstim therapyInterstim therapy

• Alpha blockadeAlpha blockade

Urgency IncontinenceUrgency Incontinence

• Overactive BladderOveractive Bladder

• R/O <Multiple sclerosisR/O <Multiple sclerosis

• CVACVA

• Interstitial cystitisInterstitial cystitis

• Acute urgency: cystitis, lower stoneAcute urgency: cystitis, lower stone

Rx urge incontinenceRx urge incontinence

•AnticholinergicsAnticholinergics

•BotoxBotox

• InterstimInterstim

•PTNSPTNS

•Behavior therapyBehavior therapy

NeurogenicNeurogenic incontinence incontinence

•Convert to a hypotonic bladderConvert to a hypotonic bladder– BotoxBotox– AugmentationAugmentation– AnticholinergicsAnticholinergics

Then start intermittent Then start intermittent catheterizationcatheterization

Female Stress IncontinenceFemale Stress Incontinence

• Inability to control leakage with Inability to control leakage with – CoughCough– StrainStrain– SneezeSneeze– ValsalvaValsalva

Female Stress IncontinenceFemale Stress Incontinence

• This is an anatomic problem which is This is an anatomic problem which is corrected anatomicallycorrected anatomically

• Type 2 Hypermobile urethraType 2 Hypermobile urethra

• Type 3 rigid urethraType 3 rigid urethra

RX of Type 2 and Type 3RX of Type 2 and Type 3

•SlingsSlings– TransobturatorTransobturator

– RetropubicRetropubic

Slings for Stress Slings for Stress IncontinenceIncontinence

• Considered minimally Considered minimally invasive surgeryinvasive surgery

• First developed in mid First developed in mid 1990’s1990’s

• A sling or hammock shape A sling or hammock shape material is placed below material is placed below the urethrathe urethra

• Incisions are very smallIncisions are very small

• Long term data shows Long term data shows success of over 80%* success of over 80%*

* Long-Term Results of the Tension-Free Vaginal Tape (TVT) Procedure for Surgical Treatment of Female Stress Urinary Incontinence, Nilsson et. al, International Urology Journal, 2001.

Stress Incontinence Stress Incontinence SolutionsSolutions• Sling or Hammock Sling or Hammock

– Incisions are very Incisions are very small small

– Procedure pain is Procedure pain is minimal*minimal*

– Recovery time is less Recovery time is less than half the time of than half the time of Burch procedure*Burch procedure*

– Patient usually goes Patient usually goes home the same dayhome the same day

– Products like SPARCProducts like SPARC™™, , TVTTVT™™,, or Monarc or Monarc™™

Subfascial Hammock Subfascial Hammock

* Burch Colposuspension and Tension-Free Vaginal Tape in the Management of Stress Urinary Incontinence in Women, Liapis et. al, European Urology, 2002, 41 469-73.

Urethral ImplantUrethral Implant

•CollagenCollagen

•MacroplastiqueMacroplastique

•DurasphereDurasphere

Product Photo Library Contigen® Implant Syringe Open Bladder Neck Transurethral Technique Step 1 Transurethral Technique Step 2 Periurethral Technique Step 1 Periurethral Technique Step 2 Periurethral Technique Tip 1 Periurethral Technique Tip 2 Periurethral Technique Tip 3

Pass the needle through the cystoscope sheath Place the needle into the side of the urethra beneath the mucosa proximal to the external sphincter (i.e., towards the bladder neck) No injection should take place either in the external sphincter or around the bulbous urethra

Erectile DysfunctionErectile Dysfunction

• Inability to obtain or maintain an Inability to obtain or maintain an erection satisfying for erection satisfying for intercourseintercourse

Physical Causes of EDPhysical Causes of ED

••• DiabetesDiabetes

••• Heart diseaseHeart disease

••• Surgery (Prostate, Bladder, Colon, Rectal)Surgery (Prostate, Bladder, Colon, Rectal)

••• MedicationsMedications

••• Spinal injurySpinal injury

••• Hormone imbalanceHormone imbalance

Available treatmentsAvailable treatments

•PDE- InhibitorsPDE- Inhibitors

•Prostaglandin and papavarine Prostaglandin and papavarine injectioninjection

•Testosterone for hypogonadismTestosterone for hypogonadism

•Vacuum PumpVacuum Pump

•Penile ImplantsPenile Implants

Oral Therapies:Oral Therapies:

•Work only in response to sexual stimulationWork only in response to sexual stimulation

•Must take Viagra and Levitra at least ½ hour Must take Viagra and Levitra at least ½ hour before anticipated sexual activity. They before anticipated sexual activity. They remains effective for up to 4 hours after are remains effective for up to 4 hours after are they takenthey taken

•Cialis can last as long as 36 hoursCialis can last as long as 36 hours

Vacuum Erection Device:Vacuum Erection Device:• Externally applied device Externally applied device

mechanically effects penile mechanically effects penile blood engorgementblood engorgement

• Cylinder/pump placed over Cylinder/pump placed over penis creates closed chamber; penis creates closed chamber; pump creates vacuum, pump creates vacuum, drawing blood into corpora drawing blood into corpora cavernosacavernosa

• Constrictive elastic ring then Constrictive elastic ring then placed at base of penis to placed at base of penis to restrict flow of suctioned restrict flow of suctioned bloodblood

Levine LA, Dimitriou RJ. Urol Clin North Am. 2001;28:335-341.Montague DK, et al, for the AUA Clinical Guidelines Panel on Erectile Dysfunction. J Urol. 1996;156:2007-2011.

Transurethral Transurethral Medication:Medication:MUSEMUSE

Transurethral Transurethral Medication:Medication:MUSEMUSE

Injection TherapyInjection Therapy

• Diabetic needle and syringeDiabetic needle and syringe

• Drug dosage - 1 cc or lessDrug dosage - 1 cc or less

• 5-15 minute response time5-15 minute response time

• 30 minute to 2 hour duration30 minute to 2 hour duration

• Possible side effectsPossible side effects– Pain on administrationPain on administration– Prolonged erectionsProlonged erections– ScarringScarring

Smooth muscle – relaxing medication injected directly into the penis

Penile Injection Penile Injection Therapy:Therapy:

Penile Implants vs. Penile Implants vs. Other Treatment OptionsOther Treatment Options

•Overall Patient Satisfaction with ED Overall Patient Satisfaction with ED TreatmentsTreatments11•0%0% 20%20% 40%40% 60%60% 80%80% 100%100%

PercentagPercentage Satisfiede Satisfied

• Penile Penile • ImplantImplant

• OralOral• MedicationMedication

• Penile Penile • InjectionInjection

•51%51%

•93%93%

•40%40%

1 Rajpurkar A, Dhabuwala CB. Comparison of satisfaction rates and erectile function in patients treated with sildenafil, intracavernous prostaglandin E1 and penile implant surgery for erectile dysfunction in urology practice. J Urol Jul 2003 v.170(1)p.159-63.

Penile ImplantsPenile Implants

•Ideal for men who have tried other Ideal for men who have tried other •treatments without successtreatments without success

••• On the market for over 30 yearsOn the market for over 30 years

••• 25,000 penile implants per year25,000 penile implants per year

•• • High patient and partner High patient and partner satisfactionsatisfaction

Three – Piece Three – Piece Inflatable Inflatable Penile ImplantPenile Implant

•Acts and feels more Acts and feels more like a like a natural erectionnatural erection

•Expands the girth of Expands the girth of the penisthe penis

•More firm and full More firm and full than other implantsthan other implants

•Feels softer and more Feels softer and more flaccid when deflatedflaccid when deflated

How does it work?How does it work?

• Fluid flows from the small Fluid flows from the small

reservoir in the abdomen reservoir in the abdomen

into the cylinders of the into the cylinders of the

penis when the pump is penis when the pump is

squeezed until there is a squeezed until there is a

firm erection.firm erection.

• Once the erection is not Once the erection is not

needed you squeeze the needed you squeeze the

pump which allows the fluid pump which allows the fluid

to return to the reservoir.to return to the reservoir.

Implants are Highly Implants are Highly RecommendedRecommended

Levine LA, Estrada CR, Morgentaler A. Mechanical reliability and safety of, and patient satisfaction with the Ambicor inflatable penile prosthesis; results of a 2 center study. J Urol. 2001 Sep; 166 (3) :932-7

•100%100%

•95%95%

•90%90%

•85%85%

•80%80%

•92% 92% •would would

•recommerecommend nd •to to

othersothers33

• 90% 90% partners partners

would would recommend recommend

to other to other couplescouples44

• Q & AQ & A