This presentation from urologist Michelle Van Kuiken, MD, clearly defines overactive bladder and types of urinary incontinence, then walks through the pros and cons of treatment options – from physical therapy and meds to nerve stimulation and surgery. She clarifies which methods make sense for which patients and when to refer. Bonus: Hear the benefits of vaginal estrogen.
I'm honored to get to talk about a topic that's very near and dear to my heart and something that I you know careful on a daily basis. And this is preliminary management of overactive bladder and urinary incontinence. So before I get started I just wanna preface with most of the items that I'll be talking about today. Um Both overactive bladder um and stress urinary incontinence. There are guidelines available on the U. S. Website that are geared towards both um urologist but also primary care providers and anyone who's treating patients with overactive bladder and incontinence. There's also guidelines as you can see here and updated. Want a microscopic materia on the current urinary tract infections, Bph etcetera. And all of these are free and available to use. Here's the website up here. So we're going to start talking about overactive bladder and urge urinary incontinence. And these two things are often grouped together. Um And so overactive bladder by definition is the presence of urinary urgency which is the hallmark symptom of overactive bladder, but it can also be accompanied by urinary frequency and bacteria with or without urgency urinary incontinence, also known as you know i in the absence of a urinary tract infection or other obvious pathology. And this is the official definition of directive ladder by the international Euro gynecologic association and the international continent society. And so essentially overactive bladder consists of these four key components, urgency being the main component of overactive bladder, but frequency knocked urea and urgency and continents are also important components that may be present. So overactive bladder is very, very common and prevalence rates range from 7-27 in men and 9-43 in women. So again very common. However, we know that urge urinary incontinence is more common in women than in men. And a lot of this accounts for the inherent and atomic differences between men and women. The way the symptom prevalence and severity also tend to increase with age and all patients. And this is important who present with new overactive bladder symptoms, particularly if they're acute, should get a or urine culture as part of their workout. It's important to rule out any component of infection that may be contributing to their symptoms, but also to rule out any underlying Hugh materia. Occasionally, a new urologic malignancy can present as new type of overactive or irritated lower urinary tract symptoms. So we want to make sure that there's not something else we need to be worried about In terms of overactive bladder ideologies, there are a wide array of things that can contribute to these issues in different patients. So issues with fluid metabolism, um, worse than his patients age, we know that there's decreased 88 production and patients as they get older particularly at night and this can lead um two knocked urea a number of co morbid conditions, common ones being diabetes, which ended up itself can induce policy area diabetes can also cause changes to the bladder wall that can cause issues with over activity and inability to store your uncomfortably obesity and back and spine issues can play a role. A number of neurologic conditions are known to play a role in overactive bladder such as stroke, Parkinson's disease and M. S. Just to name a few, there's a wide array of medications that can also cause overactive bladder. Obviously diuretics which will increase volume of urine production, but also lesser known medications. Some calcium channel blockers such as nifedipine can actually cause increased fluid retention and can predispose some patients to really bother some knocked urea. So looking at our patients medications is important and also bowel dysfunction. This is often under appreciated when we're caring for patients with overactive flatter. However, I always screen patients for bowel dysfunction and treat constipation and present. There was also general aging factors that can contribute to overactive bladder, such as an atomic factors. So in men we know the prostate can enlarge with age and prolonged obstruction can lead to blatter instability and urgency, frequency and urge urinary incontinence. In women, there is components of pelvic organ prolapse and laxity of the pelvic floor that can also lead particularly to stress incontinence. There's also hormonal factors. We know that there are hormonal receptors in the urethra and bladder in both genders. Um and that the decrease in hormone over time can cause atrophy of these tissues, weakening of the urethral structures and also instability of the bladder and finally mobility issues. Common cause of overactive bladder and particularly urinary incontinence can be of patients simply can't get to the restroom when they have the urge to go. So when it comes to treating overactive bladder, there's a really great tiered approach that we use when seeing these patients. And this is the tiered approach that's supported by the american urologic association guideline. So our first line in any patient who are treating for overactive bladder urge incontinence is behavioral modification, which kind of involved things like color floor muscle exercises or color color physical therapy and fluid management and time voiding. Second line or are pharmacologic therapies and third liner procedural intervention. And I'll talk more specifically about each of these interventions. So first line therapy um fluid management. Um it's very often that I see patients who present with overactive bladder and urgent continents who are oftentimes drinking what I believe to be um over abundance of fluid, especially for their metabolic needs. And oftentimes are drinking fluids that may be irritating to their bladder. So I try to get a sense of how much fluid is a patient drinking in a given day. Um You know how many ounces are leaders and I sometimes we'll try to assess why patients are drinking a certain amount of fluid. Um, Some patients you read that they're supposed to be drinking a certain amount of fluid or maybe they have another health condition where they need to be drinking that much, in which case that's less modifiable. But for some patients, as truly as a behavioral um, intervention that can easily be made if there's no medical reason why they need to be drinking as much as they are. Types of fluids are really important. Um, so we know that caffeinated beverages and alcohol can be diuretics. So patients are drinking a lot of caffeine or alcohol. Um they're going to produce more urine. Um There is a number of fluids and foods that can be irritating to the bladder. So things like juices which are high in acid carbonated beverages can be particularly irritating to the bladder. And some patients caffeine. Again not only as a diuretic but can also be a bladder irritant and even certain herbal teas which are sometimes accepted in a number of the bladder guidelines that are given. But I have seen even herbal teas be irritating and a number of patients. And so I try to ask patients to sort of keep track of, you know, the types of fluids that they're drinking. And do they notice that their symptoms worsen with certain types of beverages? And in general, I advise patients to limit most of the beverages listed here. and I also ask about the timing of fluid intake, which is particularly important if patients have bacteria. So I'll ask patients, you know what time they go to bed and how soon before bed did they stop drinking these fluids? Um if a patient is bothered by significant knocked Urea, I'll often advise them to stop drinking fluids usually after dinner and at least 3-4 hours before bedtime. And if a patient is on diuretics, sometimes I'll consult with their PCP to see is there a way that we can adjust the timing of the diuretics? Um to help reduce the amount of bacteria that the patient is experiencing. Another way to help kind of assess fluid intake into eight and behavioral modifications is considered the use of avoiding diary. So this is a way that patients can monitor their ins and outs at home. Um And the benefit of a bladder avoiding diary is that it offers both a diagnostic and therapeutic benefit. I'll use this to help determine as a patient actually experiencing bacteria insofar as they're just having urges to avoid overnight. Or do they have actual physiologic nocturnal policy area where they're making more than a third of their urine volume overnight. It also helps patients and need to see how much they're actually consuming in a given day. You know, some patients who are complaining about frequent urination, um maybe it may be helpful for them to see if they're drinking three liters of fluid a day and they're avoiding three leaders. If you're in a day, you know what's coming in is going out and some patients just need help making that connection. And finally, it also helps when I perform this, I'll actually give patients and urinal to avoid in the hat. I can assess what the volume of each individual void is. And again, that helps me to determine. Is this more a bladder storage problem? Is the patient having frequent small volume voids or is this more of a volume of production problem? You know? Are they avoiding 4 to 500 CCs at a time? But just frequently because they have high fluid intake um or some other cause of their diaries is so this can be really helpful. Pelvic floor muscle exercises can either be done alone or with a physical therapist. And if you have any doubts about this, you can always consider referring to a physical therapist. I use their services very liberally in these patients and a little bit more about public physical therapy. Is that public for physical therapists engage patients in many different ways outside of just pelvic floor exercises. They also work with patients and will oftentimes help them perform their avoiding diaries as instructed here and counsel patients and fluid and dietary modifications that may help with their overactive bladder. Physical therapist will also work with patients um to teach them some sort of behavioral and cognitive techniques to help with urge suppression, particularly with things like locking key syndrome. When the patient says, oh, as soon as I get to my house and I opened, you know, and I opened the door, I immediately have to go to the bathroom, so teaching them some kind of mental techniques as well to help with that. And a good physical therapists can not only help with physical component, but also with the behavioral and cognitive components that can play into overactive bladder. So when in doubt, I'd say um public floor physical therapy is a really useful tool in these patients. So if you've already canceled your patients on behavioral modifications um and considered um referral to public or physical therapy and they're still significantly bothered. Or if you see a patient who the initial visit is just terribly bothered by their symptoms, you can consider pharmacologic therapy. Um So there's two different classes of pharmacologic therapy that are available for treatment of overactive bladder and urge urinary incontinence. So the first or anti coal energy picks on which have been on the market the longest. And essentially these are mustering receptor blockers, um the target, the bladder wall and they help with relaxation. So the most common side effects that are almost ubiquitous. Um with the anti Coal Energy and the council, every patient on when I prescribe them is a risk of constipation and dry mouth. There's also been a lot of questions lately about the risk of long term cognitive side effects with the use of these medications. A lot of people have been looking at this um you know, and a lot of the risk factors for cognitive issues and dementia are also the same patients who are at risk for overactive bladder. So the question of whether or not these medications are causing these side effects or whether or not there's just a correlation between patients who require overactive bladder management and cognitive side effects is still a little bit unclear. An absolute contra indication for um anti coal energy is narrow angle glaucoma and it should be used with caution in patients with a history of delayed gastric emptying. I also avoided in patients who have a history of very severe constipation due to risk of making it worse. And also in patients with a history of urinary retention. In general, anti Coal Energy won't cause urinary retention and a patient who isn't otherwise susceptible. Um but it definitely can and people who have difficulties with bladder emptying or a history of urinary retention. So something to screen for. So there are six different anti coal energies that are available on the market. Um None has really been shown to be superior to another in terms of efficacy, but there is definitely a difference um in some side effect profile and cost of these medications. Um So the oldest and best known um anti full allergic on the market is oxytocin and also known as Detroit pan. Um This comes in both short acting and long released forms. Um and this is a medication that is almost ubiquitously covered by patients insurance. Um other medications told parroting vesta vessel charity and also known as Tobias and solar venison, which is best care. These are all tertiary amines. And so these four medications are thought to have a little bit increased risk of both constipation and cognitive side effects due to increased um risk of crossing the blood brain barrier. So if I need to prescribe an anti equal and urgent to an elderly patient where I am a little bit more concerned about cognitive side effects, I'll try to use either trotsky um which is known as Centura or dara venison enable X. I have a lot of difficulty. Dara venison often isn't covered. Um Trust PM at least the 20 mg twice daily dose is generic now, so it is easier to get covered in some patients when it comes to choosing between these four medications up here, um defecit charity and Her Toby Oz. Um It's generally the most expensive and least often covered. However, it has less side effect and dry mouth profiles and does tend to be um fairly efficacious. So if I can prescribe it, I'll choose it. Um But ultimately what happens is when I'm choosing an anti Colin ergic, I'm often times um forced to choose by what the patient can afford and what insurance is willing to cover, which oftentimes is either oxygen or told charity, and also the side effect profile, which I think is particularly um notable and elderly patients or patients with severe constipation issues. Um So that's just a little bit about how I make my choice. But usually unfortunately it's oftentimes driven by what insurance will pay for our other um medication on the market. And there's about to be a second one, a little bit more on that are our beta three agonists. So the mechanism of action is that it acts on the beta three, a drone ergic receptor in the bladder wall to promote bladder relaxation. So mere background or mere patrick is currently the only medication on the market in this category. It comes in two different dose availability is 25 or 50 mg. Um Generally I start patients on the higher dose. Um I find with Patrick it really works better when you use 15 mg. Um And the nice thing about your metric is that it's generally really well tolerated and you avoid a lot of those side effects that you have with anti Colin ergic medication, you have no dry mouth, you have no constipation, There's no concern for any cognitive side effects. Headache is probably the most commonly reported concern. Um And there is in the study has reported a risk of hypertension and tachycardia and patients who are susceptible. So patients with a really strong cardiac history oftentimes consider avoiding this medication. Um and there are some recommendations to repeat a blood pressure check within four weeks. I can tell you in my experience. Um and patients who are not otherwise susceptible to severe hypertension or or don't have poorly controlled hypertension, This is rarely if ever seen. The medication is also very effective. So patients insurance will cover near Petrich mere baghran. Um It's usually my go to and what I'll prescribe. But I would say that only in a minority of patients this is what I'm able to start with. Um so this may be changing soon. So there is a second beta three agonist called by Big Ron Argenti Pizza. Um that has been FDA approved and is due to launch um in april um it comes in a single dose 75 mg daily. And the perceived advantage of by Bergeron over mere baghran is that in the studies there was even a lesser risk of both hypertension and tachycardia. Um So this is how they are positioning themselves in regards to nearby ground is that there was a little bit less cardiovascular side effects risk profile with this. Again very effective for helping overactive bladder and urgent continents in the studies. Um So look for that sometime this month. Again, I expected to be expensive and probably not often covered. So when it comes to the principles of prescribing these medications, especially with anti coal energy mix um when you're able to use an extended release version, so if a patient you can only give oxygen into that patient always use an extended release version. It increases your chance of medication compliance. But it also has been shown to decrease the risk of the constipation, dry mouth and cognitive side effects when you use a long acting version. So side effects such as dry mouth and constipation should be managed if the medication is otherwise working well. And this is considered one of the principles in the EU eight guidelines. The issue is you may switch the medication to another one because of these side effects and the patient may still experience these side effects In terms of how long should we try the medication on trial? Of about 4-8 weeks um is what's recommended before considering the medication of failure. And again, if there's, if there's minimal efficacy or the side effect profile is not tolerated, it is acceptable to switch to another medication. And one of the newer changes overactive bladder guidelines is that you can consider a combination of both an anti colon ergic and a beta three agonists in patients who are not receiving adequate benefit from either medication alone. Again, sometimes this takes a little bit of battling with insurances and the often reference this guideline that says this is now a recommendation for patients who are not having adequate benefit from a single medication. Um So again here's just um what the Eu a guidelines looks like. There's a treatment algorithm that goes through the location, education, behavioral treatments, pharmacologic management and then it talks about you know, when to reassess or refer to a urologist if they've been refractory to some of these initial measures. So at what point should patients be referred? Um So really at any point if the patient is really bothered by their symptoms or um you feel like they need additional input from a urologist or if they failed the second line therapies and we're now moving on to our procedural therapies. So these come in two different flavors. So the first is on a botulinum toxin. It's an injection more Botox, which is a procedure that we can perform in the office. So what we do is we insert the system scope and we inject Botox into the lining of the bladder. Um Well usually instill local lidocaine into the bladder to provide some local anesthesia prior to the procedure. So Botox usually lasts about 6-9 months. One of the disadvantages of this procedure is that if the patient has good efficacy, they will require repeat treatments um For the foreseeable future. And oftentimes patients will undergo many multiple treatments. As long as they're effective. The most common risks of Botox or urinary tract infection rates as high of about 25 in some of the studies and urinary retention, which six either indwelling catheter at least temporarily or learn or be willing to learn how to self categorize. This can be a really um scary concern for some patients and we'll turn them off to this treatment. Um But otherwise Botox is a really great option for patients who have been refractory to medications as it does have very good efficacy and can really improve quality of life for patients. So are other um basket of treatments are neuromodulation. So the first of these is another office treatment that we can offer. And this is called posterior tibial nerve stimulation. This was actually developed with one of the urologists in our department here at UCSF. Um And this is a in office therapy where we insert a small uh needle into the the posterior tibial nerve just behind the medial Valueless. It's the size of an acupuncture needles will often tell patients it's sort of like an acupuncture treatment. We insert the needle on them, we stimulate the posterior tibial nerve for 30 minutes for a total of 12 sessions, usually on a weekly basis. So the advantages of this treatment or that there's there's virtually minimal to no risk of the procedure. It can cause some discomfort at the site of the needle, but other than that there's really no long term more serious adverse events reported with this treatment. The disadvantages are that it can often be time consuming for patients. They have to come out to the office park, sit for a 30 minute session and come in 12 weeks in a row. Which can often be prohibitive for young patients or patients who have transportation issues. There really are no home versions of P. T. N. S. Currently available on the other issue is that occasionally will have issues with insurance approving this. There are some implantable P. T. N. S. Devices that are becoming available. Um And I've seen a number of institutions have been studying these. Um So basically we would implant a device right at the level of the posterior tibial nerve and the patient could stimulate at home. So that's something that is potentially forthcoming and may be able to be offered soon. So finally we have sacral neuromodulation. Um And so this is a therapy that's been FDA approved for over 20 years again also developed um here at UCSF by Dr Tina Go. And so the premise of this is that it's we're stimulating the S. three nerve root directly um using a small lead that we place in the operating room. We do this under flores, coptic guidance. So the advantages of sacral neuromodulation or that it provides a constant stimulation. So the patient isn't having to come in for routine treatments and it's there all the time but also allows for adjustment of the setting so patients can increase or decrease their stimulation um to help with their symptoms. Some of the disadvantages of this procedure are that used to not be MRI compatible. So for patients that had these devices implanted prior to about a year ago I'm in order to have an MRI below the head and neck. The device had to be completely X. Planted. So that's really prohibited are use in patients for example with M. S. Who may need frequent mris. However um there are two companies that make these devices and they are now both MRI compatible. So that's no longer a disadvantage of this procedure and the battery oftentimes needs to be changed. So I'll tell patients depending on how much stimulation they're using. They may need a repeat trip though are every 3 to 5 years for a battery replacement. There are actually now both companies who make this device to make a rechargeable device that is quite small Um and it can last up to 15 years. However the patient has to charge the device on a weekly weekly basis and for many patients they don't want to have to intervene or be involved managing up therapy so they will opt for the more permanent implant. The success rates of this procedure are about 70 to 80 percent. It doesn't work in everyone. So we usually perform it as a two stage procedure where we implant the lead in one setting we let the patient go out with a test simulator for either a week or two. Um if they have at least 50 improvement with their symptoms, we proceed with permanent implant. Um So this can be a really life changing procedure for patients who really are suffering from overactive bladder and urgent continents. So we'll move on to stress urinary incontinence. So stress urinary incontinence is the most common type of incontinence in women that affects up to 49 of women, depending on what definition is used with about a 14 risk of a woman needing a procedure to correct stress urinary incontinence in her lifetime and stress urinary incontinence as opposed to urgent continence, is loss of urine with activities that increase intra abdominal pressure. So these are patients who complete complain of leaking with things like coughing, sneezing, laughing, exercising or jumping, or sometimes with position changes rising from sitting to stand. Or sometimes patients will complain of stress incontinence when they get out of bed, that position shift. So in terms of what puts patients at risk of this, you know, vaginal childbirth and increasing parody, especially if there's been used of forceps or there was a difficult delivery. These patients are at increased risk patients who have a history of smoking or chronic cough um And patients with a history of pelvic floor dysfunction, either high or low tone will sometimes paradoxically see stress incontinence and young. The Liberace women who have really high pelvic tone due to an inability to really contract the center at the time of a stress maneuver. Um And the diagnosis of stress incontinence really quite straightforward. There are not really any significant tests that need to be performed. All it is is the objective demonstration of stress urinary incontinence on physical exam by any means. So with the patient um in the supine position or standing position with a comfortably full bladder, you can ask the patient to cough bear down. Um really, any way you can get the patient to demonstrate stress incontinence is the right way. So, in terms of what we can do to treat stress incontinence, it's entirely patient driven. Um So unlike overactive bladder urgent continence, there's a little bit less of a tiered approach. So stress and continents will assess how severe is their incontinence and the number one most important factor is what is the degree of bother for this patient and what are their treatment goals? We can offer patients conservative or nonsurgical therapies or surgical therapies to help correct their incontinence. Right. In terms of conservative therapies and things that can be offered by any provider again, behavioral management. So for patients with more mild forms of stress incontinence, pelvic floor muscle exercises. So kegels that they can do on their own or referral to pelvic floor. Physical therapists may confer some benefit for these women. Um This works well and women where their incontinence again is more mild and patients should be counseled that they'll likely need to keep up with these exercises over time in order to maintain the efficacy. So if they stop doing exercises they may lose the benefit. Um For all forms of incontinence. I think monitoring fluid and take is again important and encouraging patients to use the bathroom. Um A lot of times if they say, you know I leak when my bladder is full, making sure they don't allow their bladder to get two full. There are also intra vaginal devices that are available that provide an extrinsic compression of the urethra, and these can be inserted and removed by the patient as needed to help with their incontinence. They come in two varieties. There are disposable intra vaginal devices um and then there are reusable international devices that come in the form of accessory which can be fit in clinic and the patient can take it out, wash it and reuse it and use it as needed in terms of disposable intra vaginal devices. This is something that the patient can obtain on their own or can be recommended by a primary care provider. So these are really good for patients that have light, more predictable leakage. So for example, your female patient that says I really only leak when I exercise and I don't really have bothersome because at other times this can be really helpful because they can insert it when needed. Good for a patient who's hesitant about surgery and it's good for a patient who doesn't mind using a vaginal device. The cons with a disposable devices that it can only be worn up to 12 hours at a time. So much like a tampon, it can't be left for a prolonged period of time for a member of our post menopausal women. These devices can cause a significant amount of discomfort at their a trophic, especially if they're not using estrogen and if it's an immense treating patients, these are not absorptive so it can't be used during onesies. Um Despite the fact that they look somewhat like a tampon. One particular brand that I'm familiar with is the poison Press a brand. It comes in three different sizes and it actually has an initial sizing kit. So if you have a patient and you don't know what size to recommend, you can tell them to purchase the sizing kit they can go home, try the different sizes, see what's most comfortable and works for them and then they can purchase that particular size. Yeah so surgical or procedural interventions. We offer urethral bulking injections. So this is one of the advantages of this is that it's an in office procedure and this is generally good for women who have mild to moderate incontinence. What we do is we insert our system scope and with a needle on the end we essentially inject um a bulking material. There's a number of different agents on the market. Um The sort of this purpose basically to provide co adaptation of the urethra. Again it's good for women with more mild to moderate incontinence. The disadvantages are that bulking agents don't work well in women with more severe incontinence and they only last for about 6 to 12 months. So most women will need to have a repeat injection um of the bulking agent usually by 12 months as well, notice that the the material starts to wear off. Another advantage is that it's really minimal risk to this procedure. Patients may have some temporary um bleeding or discomfort with urination, low risk of urinary tract infection and very low risk of urinary retention. Again as I mentioned, it's less efficacious than surgery. So if we're more definitive management of stress urinary incontinence really our gold standard procedure is placement of a sling slings come in two different varieties. So the original sling um was the pew Bow vaginal sling, also known as an autologous Paschall sling. This procedure has been around for many years and it involves using um a strip of the patient's own tissue. Um It can either come from a strip of the rectus fascia or fashion lotta. Also known as the I. T. Band from the leg. We can fashion on the strip of fashion um into a sling that can then be placed sub, you're literally in a retro pubic fashion um to help with incontinence. Um the use of the pubic vaginal or autologous sling has been largely supplanted by the use of the mid urethral sling um which was first introduced in 1996. These things are made out of polypropylene mesh and they can either be placed retro pubic lee or in a trans operator fashion. Um And there are risks and benefits to all these different procedures. Um In terms of the mesh use. So the F. D. A. The american urologic association along with the american Euro gynecologic association, all still support the use of polypropylene mesh for mid urethral sling. As the safety and efficacy data have really been proven out in numerous studies. However, the pupil vaginal sling still remains a good operation um that we offer to patients, particularly in patients who are still very concerned about mashed complications or who have had a previous issue with mesh complications. So it is still a surgery in our armamentarium that we offer to patients really anyone who's interested and in terms of efficacy, there there's not one that's been shown to be better than another, improving stress urinary incontinence. Yeah. So finally we have mixed urinary incontinence. And so really this is, you know, the combination of both stress and urgent continents. And this is estimated to affect about 20-25 of women who have incontinence. And this can be a little bit tricky to treat because it's sometimes hard to tell which is worse. I'll try to ask patients which type of incontinence is more bothersome to them. Is that the leakage with cost sneeze, laugh, exercise or is it the fact that they can't make it to the bathroom on time? They have that strong urge and can't make it there. And the physical exam is really very pivotal and determining what's more severe in these patients. If I see a patient that has horrible mixed incontinence and clearly has stress incontinence, I may think about treating the stress component first. However, if their diagnosis is unclear or the patient is a poor historian or I just want more information to adequately be able to counsel that patient all. Oftentimes proceed with your dynamic testing which we can do in the O. R. To really get a better sense of what's going on with the bladder and urethra. Um Really again for those diagnostic and counseling purposes so we can decide what's the best plan of action for this patient. So finally to summarize um overactive bladder and incontinence, I think there is really um you know this kind of nice tiered approach for any patient with incontinence. You know, I think things like fluid management, time voiding and pelvic floor muscle exercises plus or minus a referral to pelvic floor. Physical therapy can be helpful for patients with stress incontinence, urge incontinence or mixed incontinence. Um consider vaginal estrogen if the patient has attribute present. I'm going to talk about this just briefly before we finish our talk today um particularly in women if they have a history of recurrent urinary tract infections. And of course we talked about you need to rule out a urinary tract infection or Hugh materia to make sure that that's not a positive ideology of these new symptoms. Second line therapies again for overactive bladder or urgent continents are either are anti coal energy X and we're beta three agonists and sometimes in combination. And then consider referral for really any patient who has bothered some incontinence, who is either refractory to conservative therapies or desires any type of uh further intervention. There's no reason why a patient with stress incontinence has to try on conservative therapies. First. If there were significantly bothered, we can get them seeing treated right away. So finally, before I end today, I just want to talk a little bit about vaginal estrogen. And the reason why it wasn't mentioned in my talk earlier is it's not formally part of any of the guidelines for treatment of either stress or urge urinary incontinence. But there is some data to support its use in this area. So, vaginal estrogen really is the go to treatment for genital urinary syndrome of menopause, also known as vaginal atrophy. But the reason why the name was changed, this is a little bit more inclusive of all of the symptoms of post menopausal women may experience, which can be vaginal dryness and despair ania. But these women may also have urinary symptoms like the syria, microscopic materia and recurrent U. T. I. The data on whether or not vaginal estrogen helps with overactive bladder symptoms and mild incontinence is a little bit mixed. Um But I think the problem in a lot of these studies is when you use vaginal estrogen in a patient with more severe incontinence, it's less likely to be efficacious. So if I see a woman who presents that has overactive bladder symptoms may be very mild stress or urge incontinence and significant atrophy. In exam, I'll consider putting this patient on vaginal estrogen. Again, I always consider putting them on vaginal estrogen if they have any of the other above symptoms. So they have to syria in the absence of um positive US or culture. They have pain with intercourse or if they have recurrent UTI. S. So the Eu a guidelines for recurrent urinary tract infections do recommend the use the vaginal estrogen and any postmenopausal patients suffering from a current U. T. S. So I prescribed vaginal estrogen very liberally to patients particularly who will post menopause for any of these indications fragile estrogen is very safe. Um There's minimal systemic absorption. And so the key is is that it's safe to use in women that even have a history of breast cancer and gynecologic malignancies. And its use is supported by many societies who treat women for these conditions and there is no increased risk of blood clots or cardiovascular concerns when vaginal estrogen is just used alone. And so unfortunately women, they get prescribed this medication, they go home, they read the label um and it will tell them that there is an increased risk of breast cancer, uterine cancer, blood clots, cardiovascular concerns. And all of this came from the trials when they were looking at systemic estrogen and have never been proven to cause any risk um when only being used for as vaginal. And finally, how do I use vaginal estrogen? So it comes in three different preparations of cream and depositories in the ring. Um Again, sometimes what I choose to prescribe is a little bit dependent on the patient's insurance for medication that I deem absolutely necessary and many women and can be significantly improve their quality of life insurance. Um Oftentimes chooses not to cover it or will have some patients will deal with high co pays. Um Usually I'll, cream is the first one that I'll use, The way that I prescribe it is that I recommend. Women apply a fingertip size amount at bedtime every night for two weeks and transition to 23 nights weekly. A lot of women find the applicator to become bothersome and burdensome and so they will not use the estrogen because of this. So I tell them don't use the applicator. You can just use your finger. It's really simplifies things and about a fingertip size amount, which is somewhere between a half a gram and gram. Mhm. If they're using the suppository same thing I'll do a loading dose where I'll have them use it um you know every night for 14 days and then transition to two nights a week. And if you have a patient who is using the ring um This is one ring every three months. Usually it's exchanged by the provider. The benefit of the ring. I really only use this in women who are more elderly um who may have difficulties either applying the cream or using a suppository. The ring is nice. You can place that you can leave it. The patient doesn't have, there's nothing that patient has to do except come in and have the ring exchanged on every three month intervals similar to accessory. Mhm. Um So again that concludes my talk today. Um So this is a shout out to the EU guidelines again that has great guidelines for many of the urologic conditions that you may see in your patients, the book, overactive bladder and urinary incontinence, um stress urinary incontinence that we talked about today, but also things like micro materia Bph and recurrent urinary tract infections. So I encourage all of you to references at any time you have questions. So a brief overview of our team. So I'm part of the Urology faculty practice here at UCSF. And within our neurology faculty practice um we have developed a new women's center for bladder and pelvic health and this is our team. So myself and my partner dr anne Suskind, we're both urologists have completed fellowship training and female public medicine and reconstructive surgery. We have an outstanding there's practitioner who is part of our team by the name of Leslie martin. Um and we also I wanted to include Janice Earl, who's our administrative director and she's just been pivotal and really helping us to develop and establish our clinic and it's really a front um sort of our point of contact between us and um referring providers and it's very helpful um getting patients in to be seen. So again, just a quick overview of what we see and treat in our clinic. So today we talked about overactive bladder and urinary incontinence. We also see patients with pelvic organ prolapse, urinary tract fistula. So physical vaginal fistula, your reader, a vaginal fistula. I also see patients with recto, vaginal fistula or obstetric injury, urinary retention, vaginal mesh complications, fecal incontinence, urethral disorders, recurrent UTI. Is bladder pain syndrome and any neurologic condition affecting the lower urinary tract. We have our in office procedure center were able to perform many of the treatments that I talked about today. So we're able to perform diagnostic testing such as this to Skopje. Advanced video Euro dynamic testing for counseling um for diagnosis and counselling purposes. And we can also do a variety of different flores, coptic studies in terms of therapeutic procedures. We offer bladder Botox for bulking injections and P. T. N. S, all of which I spoke about today. We offer our also offer a bladder installations for bladder pain. Um We do pass a refitting in maintenance for pelvic organ prolapse in pelvic floor, trigger point injections for patients with pelvic pain.