TREATMENT OPTIONS FOR OVERACTIVE BLADDER Leslee L. Subak, MD Professor Obstetrics, Gynecology & RS Epidemiology, Urology University of California, San Francisco No Conflicts of Interest Types of Urinary Incontinence Chronic Conditions The Problem Stress Urine loss with increased intraabdominal pressure, like with coughing, sneezing, lifting, exercising Urinary Incontinence: Urgency Urine loss associated with a sudden, strong desire to urinate. Occurs with muscle contractions/instability. High prevalence, Mixed Stress and urge incontinence together High cost, Functional Loss of bladder control due to factors not related to Low the urinary tract, like physical disability, external obstacles, or problems in thinking or communicating intervention rate ��� Overflow Dribbling or continuous leaks due to urinary retention Kaiser Family Foundation, 2008
Overactive Bladder (OAB) Stress vs. Urgency Incontinence Characteristic Stress UI OAB/Urge UI � Support Etiology OAB/DI Precipitant activity urgency Timing immediate delayed Amount small-mod large Frequency rare common Nocturia rare common Overactive Bladder (OAB) UI: Who is at Risk? � Risk Risk Factor Prevalence: 8-31% of women Age (per 5 years) 30% • Frequency: >8 voids per day Live birth 30% Modifiable or Preventable • Urgency: sudden compelling desire Oral estrogen 90% to void; difficult to defer Stroke 90% • Nocturia: >2 voids per night Diabetes 70% BMI (per 5 units) 60% • Urgency urinary incontinence (UUI) Poor overall health 60% Hysterectomy 40% COPD 40% Abrams P et al. Neuourol Urodyn. 2002;21:167 Sampselle 2002; Jackson 2004; Hannestad 2003; Waetjen 2006; Melville 2005; Danforth 2006; Ebbesen 2006; Wetle 1995; Brown 1996
Modifiable Contributing Factors for UI • Obesity < 1/3 • Diabetes • Oral estrogen seek treatment • UTI • Constipation • Mobility impairment • Liquids, caffeine, EtOH • Drugs: diuretics, ACE inhibitors, sedatives, hypnotics Don’t tell : Patients • Few women seek care: 20-30% < 1/3 • Not discussed with other women seek treatment • Treatments: lack knowledge, fear of surgery • Failed communication with provider Incontinence is embarrassing! Shaw 2001; Roe 1999; Seim 1995; Mitteness 1995; Burgio 1994
Diagnostic Aspects of Incontinence Don’t ask: PCC Study (DAISy) • Multi-center study (N=301) Practice Guidelines: • 3 Incontinence Questions (3 IQ) vs. History, diary, pelvic exam, stress cough test, Extended Evaluation post void residual (PVR), U/A, 24 hr pad test • U.S. PCC reality check : − US, UK, WHO: Clinical Practice Guidelines − Extensive History − 15 minute appointments − Exam: Neuro S2-S4, Pelvic exam − no pelvic exam tables − Tests: PVR, Cough Stress Test, UA − 3-Day Diary − PVR not possible Too cumbersome for US primary care Brown JS et al. Annals Internal Med 2006;144:715 Accuracy of 3 IQ Compared to 3 Incontinence Questions (3 IQ) Extended Evaluatio n 1. During the last 3 months, have you leaked urine, even a small amount? No � Questionnaire Completed. � Yes � 2. During the last 3 months, did you leak urine: ( Check ALL that apply. ) ����������� ����������� ��� ��� � When you were performing some physical activity such as coughing, sneezing, lifting or exercise? ������� ���� ���� ���� ���� � When you had the urge or the feeling that you needed to empty your bladder but you could not get to the toilet fast enough? ��������� ���� ���� ���� ���� � Without physical activity and without a sense of urgency? 3. During the last 3 months, did you leak urine most often: (Check only ONE) � When you were performing some physical activity such as coughing, sneezing, lifting or > Similar to other diagnostic tests exercise? [ STRESS ] � When you had the urge or the feeling that you needed to empty your bladder but you could not get to the toilet fast enough? [ URGENCY ] � Without physical activity and without a sense of urgency? [ OTHER ] Brown JS. Annals 2006 � About equally as often with physical activity as with a sense of urgency? [ MIXED ]
VALIDATION OF 3IQ 3 IQ in Action • 3IQ: simple, inexpensive, feasible • Ms. I. Gotta Go is a 60 yo teacher G0P0: − Reproducible (kappa 70% for urge and stress) − Acceptable accuracy for classification of incontinence • “ I have a hard time waiting until the end a class type to go to the bathroom and usually have to run to • Include a urinalysis (UA) in the evaluation get there. Almost every day I leak on the way to • Take Home Message the bathroom. When I have a severe cough, I − 3IQ is a good test for type of UI in women may leak also but that occurs rarely. ” − With 3IQ + UA, the risk of missed Dx and Rx is low Brown JS et al. Ann Intern Med. 2006;144:715 3 Incontinence Questions (3 IQ) And the diagnosis is? 1. During the last 3 months, have you leaked urine, even a small amount? X No � Questionnaire Completed. � Yes � Stress UI 1. 2. During the last 3 months, did you leak urine: ( Check ALL that apply. ) X � When you were performing some physical activity such as coughing, sneezing, lifting or Urgency UI 80% 2. exercise? X � When you had the urge or the feeling that you needed to empty your bladder but you Mixed UI 3. could not get to the toilet fast enough? � Without physical activity and without a sense of urgency? Other UI 4. 3. During the last 3 months, did you leak urine most often: (Check only ONE) � When you were performing some physical activity such as coughing, sneezing, lifting or 16% exercise? X � When you had the urge or the feeling that you needed to empty your bladder but you 2% 2% could not get to the toilet fast enough? I I I I U U U U s y d r s c e e � Without physical activity and without a sense of urgency? e n x h r e i t S t g M O U r � About equally as often with physical activity as with a sense of urgency?
3 Incontinence Questions (3 IQ) 3 IQ in Action 1. During the last 3 months, have you leaked urine, even a small amount? X No � Questionnaire Completed. � Yes � • Ms. Stressed is a 54 yo Techie G2P2: 2. During the last 3 months, did you leak urine: ( Check ALL that apply. ) X � When you were performing some physical activity such as coughing, sneezing, lifting or • “ Ever since my first birth, when I am physically exercise? � When you had the urge or the feeling that you needed to empty your bladder but you active - I leak urine. Recently, almost every day could not get to the toilet fast enough? � Without physical activity and without a sense of urgency? I leak with a cough or when I lift something 3. During the last 3 months, did you leak urine most often: (Check only ONE) heavy. Playing tennis is really a problem – I leak X � When you were performing some physical activity such as coughing, sneezing, lifting or exercise? when I hit the ball – so I pretty much stopped � When you had the urge or the feeling that you needed to empty your bladder but you playing ” could not get to the toilet fast enough? � Without physical activity and without a sense of urgency? � About equally as often with physical activity as with a sense of urgency? Initial Visit & Therapy for UI And the diagnosis is? Stress UI 1. 1. History, Simple Diagnosis - 3 IQ 98% Urgency UI 2. UA 2. Mixed UI 3. Voiding diary 3. Other UI 4. Patient information 4. Educate and Empower (self-help) − 5. Treat modifiable factors 2% 0% 0% 6. Reasonable expectations Mixed UI Stress UI Urgency UI Other UI Ask patient what she wants! −
Urinary Diary • Simple form for recording voids, incontinent episodes, fluid intake • Excellent education & intervention! − � UI episodes by 25-45% • Very useful in planning therapy − fluid adjustment − timing and type of medications National Association For Behavioral Treatment for UI Continence: Patient Resources • Web site: www.nafc.org Phone: 1-800-BLADDER Lifestyle changes • Diagnostic quiz 1. Fluids management • Disease state and treatment information 2. Avoid Caffeine, carbonated beverages, alcohol, acidic foods/beverages • FAQs • Q&A forum 3. Bedside commode, night light 4. Weight loss, diabetes control
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