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Male Incontinence: !Beyond Anti-Cholinergics!

!Wayne Kuang MD!

Candace Percifull NP!

Disclosures!

•  Wayne Kuang MD!

•  MenMD | Theralogix | United Therapies!

•  Candace Percifull NP!

•  None!

Big Thanks!!!!

•  NM Nurse Practitioner Council!

•  Rachel Bevan RN!

•  Candace Percifull NP!

•  You all!!!

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No-Needle No-Scalpel!Vasectomy!

•  Minimally invasive!

•  Single 30 minute appt!

•  Anesthetic spray!

Erectile Dysfunction!

•  Beyond pills!

•  Penile injection therapy!

•  Penile doppler ultrasound!

•  Vacuum erection pumps!

•  Inflatable penile implants!

Prostate Health!

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Low T & Me!

Men's Health!

Bladder Health!

astellas.com!

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Incontinence!

•  Involuntary loss of urine!

•  Urge leakage / Overactive bladder (OAB)!

•  Stress leakage!

•  Mixed (Stress & Urge)!

•  Overflow!

Causes in Men!

•  Prostate cancer therapy!

•  Prostatectomy & Radiation!

•  Neurogenic!

•  DM, MS, Parkinsons, CVA!

•  BPH!

•  Bladder cancer!

•  Foreign bodies!

•  UTI!

•  Undiagnosed diabetes!

•  Medications (Diuretics)!

History!•  Strong & sudden urge!

•  Laugh, cough, sneeze!

•  Frequency!

•  Nocturia!

•  Pads or Depends!

•  BPH or Prostate cancer!

•  QOL (sex, work, life, sleep)! Adopsinsider.com!

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Physical!

•  Suprapubic fullness!

•  Abdominal/perineal scars!

•  Urethral palpation!

•  Meatal stenosis!

•  Cough in standing position!

productive-cough.com!

Evaluation!•  24 hour pad test!

•  Voiding diary!

•  UA !

•  Cytology!

•  Post void residual (overflow)!

•  Renal bladder ultrasound !

•  Urodynamics!

Evaluation!

•  Cystoscopy !

•  tumor!

•  stricture!

•  bph!

•  stone!

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Urge Incontinence!OAB!

2014 !OAB Guidelines!

• American Urological Association!• First Line Rx: Behavioral Modifications!• Second Line Rx: Oral or Transdermal Agents!• Third Line Rx: !

• Neuromodulation (SNS & PTNS)!•  Intradetrusor botulinum toxin injections!•  Invasive surgeries (Augmentation / Diversion)!

May 2014 AUA/SUFU OAB Guidelines: 1-57!

Primary OAB Rx!

•  Behavioral modification!

•  Timed voiding!

•  Decrease stimulants!

•  Fluid restriction!

•  Pelvic floor exercises/Biofeedback!

•  Anti-Cholinergics!

•  Balancing efficacy with side effects!

•  50% will not reach their treatment goals!!!!

Int J Clin Pract 2011; 65: 567!

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Refractory OAB!

•  "Failure of appropriate behavioral therapy of sufficient length and a trial of at least one antimuscarinic medication administered for 6-12 weeks."!

J Urol 2012; 188: 2455!

Real World!

•  Can't afford it!

•  Can't tolerate the side effects | Contraindications!

•  Desire to have a "chemical-free" life!

•  No or insufficient response!

The White Flag!

•  Most with Refractory OAB "simply give up", believe they are beyond help.!

•  They simply surrender...!

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There is Hope!

•  Beta-3 Agonist - Mirabegron!

•  Neuromodulation!

•  Posterior Tibial Nerve Stimulation (15,000 in 2012)!

•  Sacral Nerve Stimulation (25,000 in 2012)!

•  Onabotulinumtoxin A (35,000 in 2012)!

Urology Times Feb 2015: 12!

Myrbetriq!•  Beta 3 adrenergic agonist.!

•  It relaxes the detrusor muscle of the bladder during the filling phase of the fill/void cycle. It increases bladder capacity by activating the beta 3 receptor pathway. !

Myrbetriq!•  Side effects:!

•  Nasopharyngitis!

•  UTI!

•  Constipation!

•  Headache!

•  Elevated blood pressure. Periodic monitoring of blood pressures is recommended in HTN patients.!

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Myrbetriq!

•  Contraindicated:!

•  Severe renal impairment!

•  Severe hepatic impairment!

•  Uncontrolled, severe HTN. Systolic BP >180 and/or Diastolic BP >110. !

OAB Medications!

•  Unfortunately there is a 92% failure rate after 2 years. !

What is Neuromodulation?!

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Neuromodulation!

•  There are nerves that pass through the L4-S3 spinal roots.!

•  Electrical stimulation of these nerves inhibits bladder activity by activating large-diameter somatic afferent fibers which will then triggers a central inhibition of the micturition reflex in the spinal cord (Pontine Micturition Center)!

Tai 2011 Am J Physiol Ren Physiol 300(2): F385!

Neuromodulation!

nature.com!

Posterior Tibial Nerve Stimulation (PTNS)!

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PTNS!

•  Neuromodulation!

•  Posterior Tibial Nerve!

•  3rd Line Rx!

studyblue.com!

PTNS!

•  Inductions: Weekly for 30 minutes x 12 wks!

•  Maintenance: q 3-6 wks!

2010 SUmiT Trial!•  Multicenter double-blind

randomized controlled trial!

•  220 patients!

•  PTNS vs Sham therapy!

•  54% of PTNS group demonstrated moderate -marked improvement vs 21% in Sham group!

Peters 2010 J Urol 183: 1438!

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PTNS at 13 Weeks!

12

3

8

3

11

35

1

10

24

00

3.5

7

10.5

14

Freq Nocturia Urgency Urge Leakage

Baseline Sham PTNS

*!

* Baseline in the Sham group was 1.8!

80% 80%71% 71% 67% 67% 64% 60%

0%

20%

40%

60%

80%

100%

Peters Govier Klingler Vandoninck

Up to 80% Improve!

Botox!

•  Indicated for OAB and neurogenic bladder. It is not indicated for stress incontinence.!

•  2nd line of treatment after anticholinergics have failed.!

•  The medication is applied directly to the bladder wall under local anesthesia using a cystoscope.!

•  It decreases the hyperactivity of the detrusor muscle leading to decreased symptoms of urinary frequency, urgency, and UI. !

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Botox!•  No sedation is required. It is an in-office procedure.!

•  50 cc of liquid 2% lidocaine is injected into the bladder for local anesthesia.!

•  A total of 20 injections are given across the bladder wall. !

•  Patients with OAB are given 100 units and patients with a neurogenic bladder are given a total of 200 units. !

Botox-Efficacy!•  1,105 patients studied in a randomized, multicenter,

double-blind clinical trial.!

•  Symptoms are decreased in 2 weeks with the height of efficacy reached in 6 weeks.!

•  Patients are asymptomatic or will have a significant decrease in symptoms for 4-6 months with the 100 unit dose. The patients given the 200 unit dose will experience relief for 8-12 months.!

•  Up to 35% of patients can have complete resolution of symptoms.!

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Botox!

•  RTC in 2 weeks for review of urinary symptoms.!

•  May reinject if symptomatic in 3-4 months.!

Botox!•  Cannot have another injection 360 units in a 90 day period.!

•  Side effects:!

•  Urinary retention. In patients receiving 100 unit dose chance of retention is 6%. Receiving the 200 unit dose it is 18%. Retention is transient and it is recommended that patients know how to perform self caths if necessary. !

Botox!Contraindications!

•  UTI: UAC must be performed 1 week before the procedure and UA must be done on the day of the procedure.!

•  Patients who are susceptible to UTI's. Prophylactic abxs may be given 1-2 days before and after the procedure.!

•  D/C antiplatelet therapy 3 days before the procedure.!

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Interstim!

•  To understand how this device works, it is important to understand the pathophysiology of the urological system.!

•  The bladder is controlled with the neurological pathways of the brain, spinal cord, peripheral/sacral nerves. Together these systems regulate urine storage and voiding.!

Interstim!•  It is an implantable device that generates mild

electrical impulses from a lead that is placed near the sacral nerve to the bladder. This alters the neural activity and begins sending appropriate signals to the brain.!

•  It involves a 2 step approach. The patient is given a test stimulator. The device is worn on the outside of the body and the patient keeps a journal of their urinary symptoms for 5-7 days. If symptoms decrease, the device can be implanted permanently.!

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Interstim!•  Contraindications:!

•  Urethral stricture, cancer, and/or benign prostatic hypertrophy.!

•  Risks: Infection, bleeding, bruising.!

•  Depending on the type of device implanted MRIs may be contraindicated.!

•  Efficacy is 60-70%.!

•  FDA approved for fecal incontinence.!

Stress Incontinence!Male Sling!

!Artificial Urinary Sphincter!

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Male Sling!

•  "Hammock" to provide urethral support!

•  Mild incontinence!

•  24 Hour Pad Test

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Male Sling!•  Risks: pain, mesh erosion, retention, infection!

•  Success Rates: >60-70%!

•  Contraindications: UTI, immunocompromised!

•  Does NOT preclude doing a sphincter later on!

•  Higher pre-op pad counts & radiation are negative prognisticators.. !

Rehder 2012 Eur Urol 62: 140!Zuckerman 2014 Urology 83: 939!

Artificial Urinary Sphincter!

•  Moderate - Severe Incontinence!

•  >400-500g!

•  Active coaptation of urethra!

•  3 Parts: urethral cuff, resevoir, pump!

Artificial Urinary Sphincter!

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Artificial Urinary Spincter!

•  Retrospective cohort in 2008 of 40 men followed for 4+ yr!

•  90% success rate of cure or improvment!

•  From 4.0 to 0.6 pads per day!

Rocha 2008 Urol 71(1): 85!

Artificial Urinary Spincter!

•  Retrospective cohort of 218 men followed for 3yr!

•  RRP XRT (60), RRP (116), NGB (11), REDO (31)!

•  Complications:!

•  Infection 5.5%, Erosion 6.0%, Atrophy 9.6%, Mechanical failure 6.0%!

•  Revision/removal 27%!Lai 2007 J Urol 177 (3): 1021!

Artificial Urinary Spincter!

•  Risks: mechanical failure, erosion, infection, fluid loss!

•  Medical Alert necklace or bracelet!

•  Success rates: >90%!

•  Contraindications: poor manual dexterity, radiation!

Arai 2009 Intl J Urol 16(1): 101!

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Take Away!

•  Do not surrender. There is hope!!

•  Urodynamics: UNM, Presbyterian, AUA!

•  Candace Percifull NP Rio Grande FP!

•  Your NP community!

Thank You!!!!Wayne Kuang MD !

(505) 510-1675!!

Candace Percifull NP!(870) 239-1282!