how to treat stress urin inary ry in incontinence
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How to treat Stress Urin inary ry In Incontinence in in patie - PowerPoint PPT Presentation

How to treat Stress Urin inary ry In Incontinence in in patie ients wit ith Underactiv ive Bla ladder Ass. Prof Ilan Gruenwald Neuro-urology unit Rambam Medical Center, Haifa, Israel Underactive bla ladder Reduced strength of


  1. How to treat Stress Urin inary ry In Incontinence in in patie ients wit ith Underactiv ive Bla ladder Ass. Prof Ilan Gruenwald Neuro-urology unit Rambam Medical Center, Haifa, Israel

  2. Underactive bla ladder • Reduced strength of detrusor contraction resulting in prolonged bladder emptying or in a PVR • Often linked to sensory dysfunction : diminished sensitivity to bladder volumes, hypotonicity • It is described by symptoms of hesitancy, poor or intermittent stream, or incomplete bladder emptying. Failure to void

  3. UAB may overlap with BOO, OAB, or SUI • Age-related symptoms such as urinary retention, weak stream, and/or incontinence have been attributed to UAB and suggest that Detrusor Underactivity has age-associated prevalence. Half of elderly men and ¾ of elderly women With Detrusor Underactivity have other urologic conditions such as OAB, BOO, or SUI.

  4. Failure to void (UAB) with failure to store (SUI) • UAB is associated with voiding LUTS, particularly poor flow. • SUI is associated with storage LUTS, particularly “ superflow ” • A state of Bladder underactivity with Urethral sphincter underactivity • The combination of SUI with UAB is clinically beneficial for UAB symptoms. • Theoretically, treating SUI could interfere with bladder emptying and could result in severe voiding difficulty and urinary retention.

  5. Management of f SUI I in in patients wit ith UAB • Treatment should be stepwise and tailored according to basic UAB and SUI severity: • If UAB is severe and the patient is already treated by CIC- treat SUI as Genuine SUI. In the rare case of a successful Sacral neuromodulation therapy - treat SUI as Genuine SUI. • If UAB is mild/moderate , applyng the crede maneuver with/without medications (alpha blockers/cholinergics/combination) could alleviate bladder emptying . SUI could then be treated by pelvic floor rehabilitation (contraction and relaxation).

  6. Management of f SUI I in in patients wit ith UAB • If results are unsatisfactory, and SUI is mild to moderate, introducing a vaginal insert is appropriate (Impresa, Diveen, Nolix)

  7. Su Surgical in interventions for the treatment of SU SUI wit ith UAB • Basically , several studies have shown that lower Qmax before surgery (which is consistent with DU) and patient age are unfavorable predictors for an unfavorable outcome after MUS. • Some studies show that the continence rate after MUS in patients with DU was lower than in patients with normal detrusor function, and was associated with 36% voiding difficulty and significantly Increased PVR.

  8. Should we treat these UAB + SUI patie ients wit ith a mid id urethral l slin ling? • The problematics- applying the sling too loose - persistent SUI, and applying normal tension may cause postoperative voiding difficulty • Tension- free aims to enhance the support of the urethra , as opposed to the sling procedure (which aims to compress the urethra or raise urethral resistance) • TVT and urethral resistance (R = P/Q 2 )

  9. Alternatives to TVT • Bulking agents, laser therapy • An adjustable sling could be a reasonable option- allows control over tension according to the postoperative urine leak or voiding difficulty. • Some studies show high objective and subjective cure rates with adjustable slings, prospective long-term follow-up RCT data are still needed. T. Gateau et al: Clinical and Urodynamic Repercussions after TVT and How to Diminish Patient Complaints. European Urology ,44 (3), 372-376, 2003

  10. Take home messages • UDS should be performed to confirm the presence of DU • UDS may demonstrate false-positive underactivity and may falsely prevent the patient from undergoing MUS. Consider obstructing the bladder outlet to demonstrate true bladder contractility • Better patient preparation, detailed explanation and meeting expectations regarding lower success rate of MUS should be done. • Treatment should be tailored to each patient's main symptom. • Pelvic floor exercise, proper medication and intra vaginal anti SUI devices are all valid optional treatments. • The risk of voiding difficulty after surgery suggests that the use of an adjustable sling should be considered.

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