Transcript Incontinence and Erectile Dysfunction

Incontinence and
Erectile Dysfunction
• Male Incontinence
• Female Incontinence
• Male Erectile Dysfunction
• What the urologist can do for your patient
Male Incontinence
• There are essentially 4 types of Incontinence
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Overflow
Urge
Neurogenic
Stress
Overflow Incontinence
• Bladder overfilling and subsequent
leakage- Dx by residual urine
• Treatment
– Catheterization intermittent or continuous
– Eliminate drugs that cause poor bladder
contraction : anticholinergics
– Interstim therapy
Overflow Incontinence
• BPH is the most common cause
• Treatment
– Alpha blockers: Flomax, Uroxatral,
Rapaflo,Cardura and Hytrin
– TUR Prostate
– Green Light Laser Prostatectomy
– Microwave thermotherapy
BPH treatment
• TUR Prostate is has been a gold standard
for years
• Complications:
– Bleeding and Blood loss
– Fluid absorption during the procedure
– Rare incontinence
Green Light laser Prostatectomy
• Becoming the new standard
• Becoming more common that TURP
• The operation is the removal of the same
tissue (Prostate Adenoma) by vaporization
rather than cutting it out.
– Almost no bleeding
– No fluid absorption
– Can be done with sedation (even in office)
Green Light laser Prostatectomy
• Advantages of office procedure
– Less stressful for patient
– Less cost for the patient and the health care
system
Microwave Thermotherapy
• A catheter is placed in the urethra and
microwave heat is applied to the prostate
• Results:
• Minimally invasive office procedure for
poor surgical risk patients
• Other patients may request it
Urgency Incontinence
• Inability to control an unstable bladder
contraction
• Etiology: MS, CVA, and idiopathic, BPH
• Diagnosis: Urodynamic studies
• Treatment: If secondary to obstruction
e.g. BPH, treat BPH first
Urgency Incontinence
• Anticholinergic medications: Detrol,
Enablex, Vesicare, Sanctura, Oxybutinin,
Oxytrol patch, Gelnique
• Botox injection
• Behavioral Therapy
• Interstim therapy
• Percutaneous Tibial Nerve Stimulation
Botox injection
• I have been doing this for 4 years
• Office procedure
• 100-200 Units ( 10 units per CC) of Botox
A injected submucosally in the bladder
• 90 % patients respond; usual response is
within 8 days and lasts 6month to two
years
• Complication: retention
Interstim Therapy
• Neuromodulation of S3 or S4 nerve root
• Why it works is unknown
• 50 % response rate
• Staged procedure:
– Place electrode and stimulate as outpatient; if
successful implant batter stimulator and
attach electrode
Interstim Therapy
• Single Stage procedure in OR
• Two Stage Procedure
PTNS
• Weekly tibial nerve stimulation
• Office procedure that lasts one hour
• Needs 12 treatments
• Lasts 12 months
• 50 % improvement in nocturia,
incontinence, episodes, and OAB score
PTNS
Neurogenic Incontinence
• Spinal cord injury
• Retention
• Spastic Bladder
Neurogenic Bladder
• Etiology is spinal cord lesion and trauma
most common
• Most patients will have spinal shock and
be in retention and best handled by
intermittent catheterization
• Follow up Urodynamic studies
Retention
• Usually motor neuron lesion and will
require intermittent catheterization for life
• Can construct a continent suprapubic
stoma (appendix) if urethral
catheterization not acceptable or possible
• Occasionally due to spastic sphincter and
treatment of choice is Botox injection of
the external sphincter
Spastic Bladder
• Usually secondary to Upper spinal cord
lesion
• Treatment with imipramine, anticholinergic
and alpha blocker together
• If no results, then Botox
• If no results then diversion or bladder
augmentation and IC
Stress incontinence
• Etiology is usually surgery and usually
radical prostatectomy for cancer
• This is manifest with urinary leakage with
cough or abdominal straining
• Treatment: Advance Sling or AMS 800
urinary sphincter
Advance Sling
• Used when there only stress incontinence
and there is mobility of the urethra
• Outpatient procedure
• Success of 90%
• Risk of early retention
of Action for
AdVance
Sling
Image: Peter Rehder
AdVance
Transobterator
Male Sling
Introduced to the market in 2007
AMS 800 Urinary Sphincter
• Can be used for stress in all circumstances
• Usually used for stress incontinence when
there is no urethral mobility
• Used for total incontinence
• Success rate 95%
• Risk: infection; retention and erosion
AMS Sphincter
AMS Sphincter
• Artificial Sphincter-over 65,000
procedures
• The Gold Standard for treatment of moderate to severe
incontinence
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Minimally invasive
Outpatient procedure
92% of patients would have the AMS 800 placed again
96% of patients would recommend it to a friend
33 years on the market
Female Incontinence
• Overflow
• Urgency
• Neurogenic
• Stress
Female Overflow Incontinence
• Diabetic neuropathy
• Lumbar Disc disease
• Herpes Simple or Zoster
• Post-op especially gyn surgery
• Anticholinergic agents
• Rare urethral or bladder cancer
Overflow Incontinence RX
• Intermittent Catheterization
• Interstim therapy
• Alpha blockade
Urgency Incontinence
• Overactive Bladder
• R/O <Multiple sclerosis
• CVA
• Interstitial cystitis
• Acute urgency: cystitis, lower stone
Rx urge incontinence
• Anticholinergics
• Botox
• Interstim
• PTNS
• Behavior therapy
Neurogenic incontinence
• Convert to a hypotonic bladder
– Botox
– Augmentation
– Anticholinergics
Then start intermittent catheterization
Female Stress Incontinence
• Inability to control leakage with
– Cough
– Strain
– Sneeze
– Valsalva
Female Stress Incontinence
• This is an anatomic problem which is
corrected anatomically
• Type 2 Hypermobile urethra
• Type 3 rigid urethra
RX of Type 2 and Type 3
• Slings
– Transobturator
– Retropubic
Slings for Stress Incontinence
• Considered minimally invasive
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•
•
•
surgery
First developed in mid 1990’s
A sling or hammock shape
material is placed below the
urethra
Incisions are very small
Long term data shows 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 Solutions
• Sling or Hammock
– Incisions are very
small
– Procedure pain is
minimal*
– Recovery time is less
than half the time of
Burch procedure*
– Patient usually goes
home the same day
– Products like SPARC™,
TVT™, or Monarc™
Subfascial Hammock
* Burch Colposuspension and Tension-Free Vaginal Tape in the Management of Stress Urinary Incontinence in Women, Liapis et. al, European Urology,
Urethral Implant
• Collagen
• Macroplastique
• Durasphere
Product
Photo
Library
Contigen®
Implant
Syringe
Open
Bladder
Neck
Transureth
ral
Technique
Step 1
Transureth
ral
Technique
Step 2
Periurethr
al
Technique
Step 1
Periurethr
al
Technique
Step 2
Periurethr
al
Technique
Tip 1
Periurethr
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 Dysfunction
• Inability to obtain or maintain an
erection satisfying for intercourse
Physical Causes of ED
••
Diabetes
••
Heart disease
••
Surgery (Prostate, Bladder, Colon,
Rectal)
••
Medications
••
Spinal injury
••
Hormone imbalance
Available treatments
• PDE- Inhibitors
• Prostaglandin and papavarine
injection
• Testosterone for hypogonadism
• Vacuum Pump
• Penile Implants
Oral Therapies:
• Work only in response to sexual
stimulation
• Must take Viagra and Levitra at least
½ hour before anticipated sexual
activity. They remains effective for up
to 4 hours after are they taken
Vacuum Erection Device:
• Externally applied device
mechanically effects penile
blood engorgement
• Cylinder/pump placed
over penis creates closed
chamber; pump creates
vacuum, drawing blood
into corpora cavernosa
• Constrictive elastic ring
then placed at base of
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 Medication:
MUSE
Transurethral
Medication:
MUSE
Injection Therapy
• Diabetic needle and syringe
• Drug dosage - 1 cc or less
• 5-15 minute response time
• 30 minute to 2 hour duration
• Possible side effects
– Pain on administration
– Prolonged erections
– Scarring
Penile Injection
Smooth
muscle – relaxing medication
Therapy:
injected directly into the penis
Penile Implants vs.
Other Treatment Options
•Overall Patient Satisfaction with ED
•0%
Treatments
1
20%
40%
60%
•Penile
•93
•Implant
%
•51
•Oral
%
•Medication
•Penile
•Injection
80%
•40
%
Percentage
Satisfied
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.
100%
Penile Implants
•Ideal for men who have tried other
•treatments without success
••
On the market for over 30 years
••
25,000 penile implants per year
••
High patient and partner
satisfaction
Three – Piece
Inflatable
Penile Implant
• Acts and feels more
like a
natural erection
• Expands the girth of
the penis
• More firm and full
than other implants
• Feels softer and more
flaccid when deflated
How does it work?
• Fluid flows from the
small reservoir in the
abdomen into the
cylinders of the penis
when the pump is
squeezed until there is a
firm erection.
• Once the erection is not
Implants are Highly
Recommended
•100%
•95%
•90%
•85%
•80%
•92%
•would
•recommen
d
•to others3
•90%
partners
would
recomme
nd to
other
couples4
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
• Q&A