While stress incontinence and overactive bladder may not be life-threatening, they can be life-diminishing. Yet, with the stepped care approach presented by urologic surgeon Anne M. Suskind, MD, MS, FACS, clinicians can find a remedy to help almost any patient. She details a wealth of options, from physical therapy to in-clinic nerve stimulation to surgery; describes how she counsels patients to optimize outcomes; and explains recent options, such as an injection that works for up to seven years
So today I'm going to talk about updates in female public medicine for primary care. And just these are my disclosures. I have some NIH funding in the form of an R. 01 for grants and I work on an arc um grant as an expert consultant. And then here are my disclosures that don't have anything to do with the topic I'm discussing today. So I want to start off by just letting you know about our Women's center for bladder and pelvic health. This is in the department of Urology at UCSF and we formed the center about a year and a half ago and I'm really excited about this um as a holistic center where we are women serving women with pelvic health conditions and this is our team that's me in the middle um ancestor kind and then on the left is Michelle Van Kick in. She joined us a couple of years ago and um is also subspecialty trained in what we call female public medicine reconstructive surgery or F. P. M. R. S. Um And on the right is Leslie martin Mel parnell who is a nurse practitioner who works very closely with us. So three of us worked closely together in the center and as Christine mentioned before, we specialize in seeing women with pelvic floor conditions. So these are kind of our bread and butter urinary incontinence, overactive bladder pelvic organ prolapse neurogenesis, bladder urinary officials mesh complications and things that are a little less common like urethral diverticular female urethral stricture disease. Female and continents bladder pain syndrome and urinary tract infections. And we have a great in office procedure center where we're able to do all sorts of diagnostic and therapeutic procedures such as video Euro dynamics. Sista ska p intra chooser Botox injections. I'll talk a little bit more about that. Urethral injections for stress and continence. I'll talk some about that today. Other flores, topic diagnostic procedures, per cutaneous tibial nerve stimulation will go into that. And we also do pelvic floor injections for pelvic pain, bladder installations for pain um and pastoral fitting fittings and maintenance. And of course as surgeons we do operate and these are some of the things that we take care of. So we do mesh and non mesh slings for stress urinary incontinence, vaginal robotic surgery for pelvic organ prolapse including uterine sparing approaches which are becoming more popular. We do complex pelvic reconstructive surgery um including vesco, vaginal officially repairs you Rachel, diverticular mesh complications and of course sacral neuromodulation and Botox. So today I'm going to talk about updates and stress urinary incontinence and overactive bladder. So just starting off kind of broad strokes. Big pictures. Um it's what we do is actually really quite simple. So I think about all these conditions in terms of the bladder and the outlet. Okay and so during normal bladder filling, what we want is a bladder which is a reservoir that accommodates urine increase in volume in urine at low pressures. Okay. And then we also want an outlet that's closed of course and we want to increase urethral resistance to prevent any leakage and that's caused by various various different mechanisms such as urethral support urethral co optation and the urethral sphincter. Okay, so that's normal. Normal emptying. We want a coordinated contraction of the bladder and decreased resistance of the outlet so that the bladder can empty completely. Now we know it's not always that simple. Right? And and here's our just another cartoon drawing of the bladder and the outlet. And there's a lot of things that can impact both the bladder and the outlet. So in the real world, we have to consider all these different things like the brain and spinal cord. So, any neurologic conditions that affect the bladder. Co morbid conditions such as diabetes and a whole host of other conditions. Normal aging can affect the bladder and the outlet. Of course, pelvic birth and uh pelvic floor at the pelvic floor. Childbirth and hormones. So changes in hormones is um uh we go through different life stages, cancer, pelvic cancer, and radiation to the pelvis certainly can have an effect any prior surgery in the area and the bowels. I'm always asking patients about their bowel function because it's all very related. So this is more like real world. What we see. I'm gonna start off with a case. So, so this is a 45 year old female with complaints of leakage with coughing laughing, sneezing. She wears two pads per day and began leaking after delivery of her second child who was £9. She's been told to do kegel exercises and does these on her own. She denies any straining to urinate or urinary urgency frequency. So didn't exam. Um Everything was pretty normal, public exam, normal external genitalia and vaginal tissue looked okay. No tenderness, no prolapse. Um And then she did have a leakage with a cough. So I always do this in the sodomy. Make sure that the patient has um some urine or fluid in the ladder and just look for the kind of visually inspect for for leakage which she had. So by the international continent society definition this is stress urinary incontinence pretty straightforward. So this is a complaint of involuntary leakage, on effort or exertion or on sneezing or coughing. So very simple. This is our normal um urinary tract during filling. And what happens is we have just this increased abdominal track pressure, exerting pressure on the bladder and that pressure ingredient is higher than the outlet which is the urethra. And of course you get leakage, simple plumbing problem. Right? So unfortunately this is a very common problem in women, it greatly impacts as I'm sure you all know in here, health-related quality of life and we are most recent estimates that it costs over $26 billion 28 million women in 2010 and projected to be over 43 million women in 2050. So certainly common. And this is a slide that I find helpful and this shows the prevalence of stress incontinence and the prevalence of urgency urinary incontinence which we'll talk about in a little bit over an older adults. And so you can see kind of the age distribution. So stress incontinence actually goes down with age. Um an urgent continence goes up with age and the mixed incontinence are either type of incontinence. Just any incontinence, overall prevalence goes up with increasing age. So the path of physiology of stress and continence and women. So to be honest, we don't completely understand it but we have a lot of different theories as to what we think causes it. And it probably doesn't result from any single factor but rather a combination of factors and to have normal functioning in the normal function of the peripheral and central nervous systems, the bladder wall, that the cruiser muscle, the urethra, pelvic floor musculature. And here are we do have guidelines on stress urinary incontinence in women. And these are put out by our professional organizations, the American Urologic Association and stuff which is the Society of Euro dynamics. Female urology, Euro, General reconstruction, it's kind of a mouthful to say. So I'll just say sue from here on. And And these were put forth in 2017 but nothing. Not much has changed. And so the initial evaluation for stress incontinence is of course a history of physical exam. We need to see a demonstration of stress urinary incontinence in order to move on to more invasive treatments. Okay, we don't need it for less invasive treatments. But for considering surgery, that's a requirement. It's recommended that we get a post void residual. So just a measure of how well the bladder is emptying. Um and your analysis to rule out any other pathology and and more invasive to test like Sista ska P and Euro dynamics are generally not indicated. Um So in terms of treatment, um we kind of think about it as non surgical and these are all things that you're probably very familiar with and probably may do in your own practices and and surgical. So starting with nonsurgical things such as continents possessory vaginal inserts, public floor muscle exercises. I decide on these will go into these in more detail and surgically. And speaking with things such this bulking agents which are actually growing in popularity. Mid urethral slings, which you probably have some experience with. And we've certainly heard a lot about autologous pupil vaginal slings which are done with pasha and then the last one vertical suspension. That's rarely done. It's an open abdominal procedure. So it's there for purposes of being complete. But you probably aren't seeing a whole lot of those done anymore. So starting with the nonsurgical treatment. So these actually can work very well in in certain women and I always try to start everybody with pelvic floor physical therapy because there's really little downside their public floor physical therapists all over, you know, you do don't have to do it in any one place. And I have a whole list of people to refer to organize based on area. So I think the most important thing is that the woman sees someone who's local to them and convenience and I try to do whatever I can to help facilitate that um public floor physical therapy works pretty well. Um and then some women, it cures them and that's all that they need. Um Usually techniques such as biofeedback are incorporated, which I think can be really, really beneficial. And like I said, the only downside is the time and effort put into doing it, but it's a great place to start and it's something I offer to every single woman who's come through my door. Um and I'm a big proponent of okay pass arrays um are, can be great for uh for the right woman. And we think of passageways often for public organ prolapse, which is the majority of their uses, but they can also be used for stress urinary incontinence. And there's a certain mastery that's a ring with a continent's knob you can see here, it's just this knob on the side and it extra, it kind of just compresses the urethra at the bladder neck and that compression can prevent leakage. So in someone who's not sexually active or someone who's interested in this option, it can be a really great option and it may be all that they need. Um And if someone doesn't want surgery, this this is a great thing to offer them. And then I just want to mention down here the vaginal inserts. So this one is made by poise. It's um it's actually the only one I'm familiar with. Um And this is a great option for some women. So you can buy this in the drugstore. Um There's actually it comes in a sizing kit. So it comes with three different sizes. So I tell people to buy the sizing kit determine which size they are. Um And then um and then they can buy the proper size and it comes in this little applicator, just like a tampon. And then there's these kind of little silicone prongs underneath this paper like product and it just fits into the vagina. Um Similarly to pass ary and just compresses the urethra. So this doesn't work for everyone. Um But it's worth a shot. It's low investment in terms of time and cost to try out. And I found just in my own experience that the women who this works best for our women who say I only leak when I do X activity like I go for a jog and the rest of the time they're fine. This is a great thing to try when you're going for that job, right? So it's only to be left in for a few hours. Kind of think of it similarly to a tampon but there's a certain activity that someone's avoiding because of the stress incontinence. This is a great thing to try. Okay, urethral injection. So these have gone through different variations and an evolution over time. They're minimally. They said they can be done in the office or in the operating room. Um The latest one on the market is this um poly acrylamide hydrogel. The brand name is bowl common. It's been in europe for several for over 10 years but it's just come to the United States in the last year and the benefit of it is it's supposed to last a little bit longer. So we're telling people 3 to 7 years whereas the other injections last maybe six months to two years. So they're a nice more temporary fix, minimally invasive. Um and they work reasonably well. Um So they may or may not provide a cure but they may get provide levels of improvement. And I actually have been having really good success particularly with the the newer the newer agents. So this is a great thing to consider um for patients who may not want more invasive surgery. And this is just another picture. So we talked about co optation of the urethra is one of the mechanisms to prevent incontinence. So basically you go we go in through the urethra with a camera and a little needle and we just inject the agent and you can see it in front of your eyes. Kind of plump up the mucosa of the urethra comes together and co aps okay. And then this is just sort of a live picture of of what it would look like. Endoscopic lee. So the mid urethral sling. So this is the gold standard treatment for treatment of stress urinary incontinence in women. And it uses synthetic polypropylene mesh and cure rates are quite high. And I have to say these are women who have these slings are among my happiest patients. Um They really do quite well. Overall comp Applications are rare of course. What's on everybody's mind are complications associated with Mash which are about 2-3%. So you know when they happen they you know we do hear a lot about them but they are in the minority of patients and I think in well trained hands this incidents and these problems are quite low. Um They can't always tell women it can change kind of how the sensational avoiding. So some women tell me they have to push their strain a little bit to avoid afterwards. Um But generally and people are very happy with us. And this is just kind of a picture showing where the sling is. So there's a small incision underneath the urethra to tiny little incisions either up here behind the pubic bone or we all also can place it through the operator frame. And so in the other incision would be in the groins and then there's this piece of mesh and it serves as sort of a backboard for the urethra. So this is the urethra here and there's urethral mobility when someone has stressed. So cough laugh sneeze basically the sling just provides a backboard for that or sort of the other way it's described as a hammock to help prevent the leakage works really well. Um and just to kind of mention the mesh positions. These are perfect subspecialty professional societies both from urology and from gynecology. And they put out many sort of statements regarding the use of static mesh and um they still stand by the use and mesh for stress urinary incontinence is as the gold standard treatment. So um I do you know, talk to all women who I consider putting mission about mesh about the problems associated with mesh, about the real life risks associated with mesh and make sure that they are fully informed. But I do think it is very safe. And finally, there are women who either don't want nash but would like a stronger surgical procedure or in women who have kind of really bad stress urinary incontinence. Um The cuba vaginal sling using rectus fascia is a great alternative. So this is a more invasive surgery. Um it involves a fan and steal incision here where we actually harvest a piece of match. So if someone's had like a C. Section or a fan and steals decision. For another reason we can go in through the same incision. I use like an eight centimeter incision. So it's pretty small. We harvest this piece of mesh and then we just fashion it into a sling and actually use this mesh to pull up on the bladder neck. So it's a stronger sling. It's directly sitting on the bladder neck. And it's it's pulling up so it's tenting it up a little bit. So it's a stronger sling. Okay. Alright so that's the part on stress urinary incontinence. So now I'm gonna move to a second patient scenario. So this is a 67 year old female presenting with urinary urgency frequency and urgency urinary incontinence for several years. And she leaks urine. Uh If she does not get to the bathroom in time, she was prescribed oxy beat in five mg to take three times a day but only takes it once at night. And she thinks it may be helpful. She drinks mainly water but has a cup of coffee every day and has a history of diabetes type two and hypertension. So these are the questions I ask that every patient visit of all my patients. So she avoids every 1 to 2 hours during the day, gets up 3 to 4 times at night. Um Has a leakage with urgency urgency and continents. But is not wearing any pads had one U. T. I. In the last year and has three bowel movements a day. So on the evaluation with the Ui that was negative. A post void residual 54. So pretty minimal, nothing too concerning. And pelvic exams should vaginal atrophy otherwise normal. No prolapse, no leakage and supine empty stress test and a week Kagel of one out of five. So um she has overactive bladder and this is basically the way I think about it is the bladder is a muscle and the purpose of the muscles to contract or squeeze when you want to urinate and in this case the bladder muscles squeezing when the patient doesn't want to urinate and that spasm or squeeze is causing that sense of urgency and also can be associated with leakage. So overactive bladder is really more of a clinical diagnosis that's defined defined by the presence of bothersome symptoms. And um per our guidelines it's the presence of urinary urgency. Usually accompanied by frequency and knocked area with or without urgency urinary incontinence in the absence of a U. T. I. Or other obvious pathology um and therefore components. So one is urgency to his frequency three knocked Korea which is two or more times a night. And for urgency and comments and I put this up here because we often think about overactive bladder symptoms in women. Um but there's a great missed opportunity because the prevalence in men is felt to be just fairly equivalent to that in women I think we just miss it a lot because we, when men have these problems, we think of the prostate and we assume it's BPH and we maybe go down that pathway, but oftentimes it's there's actually a bladder component. And so it's really important to consider these symptoms and treatment of these symptoms in both men and women. And of course the prevalence increases and with age in both genders. So the degree of bother um of that's caused by sometimes directly a fax care seeking behavior, treatment, intensity and satisfaction with treatment. So this is usually not a date life threatening conditions. So we really want to treat based on the level of bother. Okay, And everybody is different. Um and I'm always surprised by what I think might be bothersome may be very different than what the patient in front of me might think. So it's really important to understand your their preferences and how bothered they are and ask those questions. Um so we know that this condition can, while it may not be life threatening, it can really impact health related quality of life. A lot of people restrict their activities. Um they there's an unwillingness to be exposed to environments where access to the bathroom may be difficult. A lot of people don't want to leave the house um or only want to go to places where they know they can have access to a bathroom, like really can negatively impact sexual function, marital satisfaction. And it's often associated with depression and anxiety. And we also know that the majority of patients don't seek treatment. So um you know as primary care doctors I know you guys have a lot to to focus on in your very short visits. Um But this is the kind of thing that often times if we don't ask about it we don't learn about it and there's so much that we can do to help people um That I really do think it is it is worth going into. Um so we also have a way seafood guidelines and originally created in 2012 updated in 2019. And now there's a call for new guideline committee. So new guidelines will be coming out shortly but the standard approaches the stepped approach to care and I think that this this is gonna change a little bit in the next set of the guidelines. But the way it's presented in the guidelines now is 1st, 2nd and 3rd line care and the idea being that you kind of go in this this graduated fashion. So sign care includes pelvic floor physical therapy, behavioral modifications will go into this in more detail. Uh Second line would be anti colony six and beta three agonists. And certainly in recent years there's more of a push towards beta three agonists and away from anti Colin urge IX and and third line treatments include perky tania's tibial nerve stimulation P. T. N. S. And tried to choose or Botox or on a batch line of toxin. A injections and sacral neuromodulation will go into each of these and this is what the kind of clinical pathway uh in the guidelines look like it's a really busy slide but basically it's saying the same thing. So consider behavioral treatments as step one pharmacologic management is step two and then the third line or more advanced treatments is step through. So in this uh we always want to start with excluding other conditions. So doing a history, physical exam, your analysis. Um Again it's not a life threatening condition. So no treatment is always an option and um always discussed with, I always discuss that with patients um and it's really we should be providing education normal urinary tract function. What's known about maybe benefits and risks of certain treatments and acceptable. Um Symptom control may try, may require trial multiple options before it's achieved and I think this is so important because oftentimes we may try a medication um you know it may not work or the patient may have side effects and they may not come back to see us because it didn't work and they think there isn't anything more. So I really make a point of kind of laying out that this is a journey. We may not fix this in one visit. We may have to try different things but let them know that there are a lot of different options that we can try. Um You can always even talk about some of these things in terms of referral to to us if you need our help if some of the more simple things aren't working. Um but I think it also gives patients hope um and just a better understanding and better expectations. Um I also try to keep in pretty close contact with people who I start on this pathway because if things fail, I want to make sure that I know um so that they're not waiting around in despair and then I can move them along to another treatment that might be more helpful. So I think kind of having these broad discussions upfront is really helpful. Um So in terms of first lines of lifestyle modifications um I always talk about limiting bladder irritants and this is my personal list um that I put in my after visit summary and hand out to patients and um you know I always ask patients what kind of things are they drinking? The patient in this case I think was drinking coffee, right? But there's so many things beyond coffee that most people aren't aware of. So fruits, alcohol of course juices, carbonated beverages um and a little vinegar, different condiments and a little education goes a really long way because a lot of people just aren't aware of all the things on this list and it can be expensive um and it can also be overwhelming. So I try not to overwhelm people um you know, there's different approaches based on kind of the individual scenario um you can just do an elimination diet where you remove things from the diet but um sometimes that's overwhelming for people and sometimes I just say take a look at this list, kind of get familiarize yourself with it and then start to build an awareness. So if your bladder, if you sometimes are worse ask ask yourself, did I just eat any of those things and then try to make connections in your own life? Everybody's responds very definitely to each of these. Um Sometimes we use bladder diaries. Double voiding or delayed voiding. Um So basically this is when someone is um it feels like they're going right back to the bathroom after they urinate and like they feel like they're not emptying. Um so I tell people to urinate, um maybe stand up, walk around, come back and try again. Let's double voiding, timed urination, click, quick flick or kegel exercises as many of you may know and actually doing a kegel sends a feedback mechanism to the brain for urge, depression of the bladder. Um So that's something that, you know, most people know do your kegels, but they don't know when you have the urge that's when you need to do the kegel for it to work in the setting and of course biofeedback um there are patient handouts um on the seafood website and they go over things like five changes you can make to improve bladder problems. These are for patients. So tracking the amount of liquid you put into your body, what you eat, reaching and staying at a healthy weight, keeping healthy bowel habits, stopping smoking. There's a handout on changes you can make to improve bladder problems, such as controlling urges and a guide to pelvic floor, muscle training and healthy bladder habits. So I just put these in here is some tips and tricks that you can give your patients. So second line treatments or medications. I'm sure many of you prescribe many of these medications. They're all listed here as anti columnar chicks or beta three agonists. There are six anti colon ergic. They've all been around a long time. I I don't need to tell you about them. Um You know, there are side effects associated with them. Um You know, dry mouth constipation, difficulty emptying the bladder, delayed gastric emptying and cognitive changes, particularly in older adults. Um And the and the list goes on and on. Right. Um and then there are beta three agonists. Mirror background has been around since I believe 2012 by Bergeron is the newer one that came out in the last year. Um they it's not as covered by insurance, so I haven't used it as much. Um but the way that they are marketing it is that it has less of an effect or really no effect on things like heart rate and blood pressure which is what we weren't worried about with beta three agonists. I can't tell you I don't have a whole lot of experience with prescribing it just because of difficulties with insurance but um that's what the party line is. So um some kind of details from the guidelines in terms of prescribing. Um So of course you can prescribe either an anti Masonic or beta three agonists. Of course extended release formulations are preferred over any immediate release formulation and if a patient experiences inadequate symptom control or unaccepted side effects with one medication then you can always do dose modification or try a different medication. Um And of course avoid use of anti mascara knicks with narrow angle glaucoma and use concussion with impaired gastric emptying or bladder emptying um managing constipation and dry mouth. Um And using caution and prescribing anti mask clinics and patients using other medications with Colin ergic properties and there are a lot of them um And use caution in prescribing when frail older patients and for fracturing the medications that's a good time to refer to a specialist. Um And per our guideline clinicians should discuss the patient's expectations from treatment and their willingness to participate in therapies other than pharma co therapy. If a patient would not consider invasive treatment options or referral to specialists may not be warranted. So that's always a good thing to ask before sending them our way. Um So that we um kind of understand their expectations. Um So back to this patient. 6 67 year old female with urgency frequency, urgency incontinence on oxy Vietnam once a day. Um Start with patient education discussing healthy bladder habits, reviewing normal bladder function, discussing uh fluid intake um and what's normal versus abnormal then starting with behavior and lifestyle modification. So practices for urged suppression. Like we talked about pelvic physical therapy, bladder training, dietary modification and then if they're interested pharma co therapy so we know they're taking the exhibition but it's immediately released just once a day and they have abated. The patient has hypertension. So probably not the best um option having a beta three agonist. Um It's not an absolute contra indication. I actually rarely see um problems with blood pressure. But if someone does have high blood pressure that might be a time where I would get you guys involved or make sure that the patients communicating closely with their primary care. Physicians are monitoring their blood pressure that everybody kind of knows what's going on. Uh so this particular patient was interested in dietary changes in physical therapy. And then we also switched the exhibition in um to try spm which 20 mg which is the lower dose but an extended release formulation and we'll have them follow up in two months. So if this patient came back in two months and you know wasn't doing better. We could just escalate from there. We could switch to a different medication. Or we could talk about third line therapies at that point. All right. Um So this is another patient. Um And this is a 40 year old with urgency frequency for many years. They started recently having urgency incontinence. They had tried P. T. N. S. For several years. That's the perk cutaneous tibial nerve stimulation. I'll go over to that in more detail which was helpful but it's no longer working now. Um So they avoid every hour during the day. So quite a bit and only once at night. Um Recently started having a little bit of urgency incontinence. Not wearing any pads. No U. T. I. History daily bowel movements. So that's good. They had previously tried gel nique which is the oxy button in gel formulation but that cause dry mouth they have no PVR which is good and a normal your analysis. Um So what's next in terms of treatment options? So they've tried the P. T. N. S. And a medication. So always starting with patient education. I don't care where they come from or what they've tried before. There's always a role for that. Again some of the things that we talk about previously talking about behavioral lifestyle modification. Same thing as with the other patient pharma co therapy. And they've already tried an anti Colin arctic. Um We could try beta three agonists and then the third line treatments would be another option. So they ended up choosing mira baghran at the full dose, which is 50 mg. Followed up two months later without significant improvement. Um So what would we do now? So for me, this patient's already tried and failed all the kind of simpler 1st and 2nd line treatments. We can play around with medications a little bit more. But I think it's time to consider third line treatments and the more invasive treatments. So for me, in my practice, whenever I decide to do a slightly more invasive treatment, I'd like to do bladder testing to make sure we're not missing anything else. And also to confirm the diagnosis. So this is a Euro dynamics. This is what we do in our office quite regularly. Uh And this is a catheter based study. Um And there's this tiny catheter that goes in the bladder, a tiny catheter in the rectum and we slowly fill the flu the bladder fluid, take some pressure measurements, try to reproduce the symptoms the individuals having at home and then have them urinate. So we're trying to kind of take them through the normal um filling and avoiding uh phases. And do a full functional assessment of the urinary track. So this green line here is a calculated pressure of the D true sir, the bladder. And you can see we're filling as we're moving across the page, there's a nice pretty steady line here. Um And then as we get here we start seeing these bumps. These are bladder contractions and their associates with and that kind of feeling of urgency. Here's you can see here that there's these bumps again and the patient has a strong desire. So those that's the trees are over activity or overactive bladder basically. And you can see here that they urinated. This is a perfect voiding curve. So no problems with urination. So there we go to choose our contraction. So in terms of the third line treatments and there's P. T. N. S. Which she's already tried sacral neuromodulation and intend to choose her own a botulinum toxin a or Botox injections. So I'm just gonna go through each of these uh to give you a little bit more information. P. T. N. S. Is a really nice therapy. It's performed in the office and their 30 minute session. So what we do is we put a little um an acupuncture needle into this area here which is the per cutaneous tibial nerve. It's just on the inside of the ankle. Um It doesn't hurt it just feels like a little acupuncture needle and we hook it up to a little pulse generator here and so there's a little stimulation or buzzing feeling in the foot. I've tried it on myself because I wanted to know how it felt. It's totally not a big deal. It just feels like a little buzzing in your foot. Um So basically what that does is it sends an electrical stimulation up that nerve which is a peripheral nerve that goes back to the bladder and so indirectly sends a signal to the bladder. Um and gets it to behave differently. Um It was actually developed in our department here at UCSF many years ago um Based on Chinese acupuncture points. Uh the sessions last 30 minutes and it's FADA approved for treatment of these symptoms um in 30 minute once a week sessions for 12 weeks in a row. So it is a lot of visits to the office um and a commitment of time but other than that it's very low risk. Um And this is kind of saying what I said before. So it's a mixed sensory and motor nerve containing fibers from the spinal rates L. Four to S. Three. And it's based on traditional chinese acupuncture points and FDA approved. So that's that's what she had already tried. Then there's a sacral neuromodulation. So this neuromodulation idea, it's the same idea but this is working more centrally and it's there's an electorate that's placed directly onto the S. Three frame. And so this is done typically in the operating room. The mechanism isn't fully understood. It's FDA approved for frequency urgency urgency incontinence androgenic retention. And also it actually works really well for fecal incontinence. So do keep that in mind as well. And you can see here there's a little timed leave that gets placed through the S. Three for Raymond. So that these leads here are right on kind of sit right directly on the S. Three nerve root. And the downside of this treatment is we can't it doesn't work on everyone and we can't predict who it's going to work in and who it isn't gonna work in. And so we do it in a staged approach. Okay so it's two outpatient procedures done in the operating room under either sedation or general anesthesia, up to the patient what they prefer. And the first phase and I do them and most people do them two weeks apart. So the first phase we call it the test phase or stage one I mean plant the lead and then we give them some kind of external piece. They take it home for two weeks and I could tell them they give it a test drive. They see how well it works if it helps their symptoms and we're looking for at least a 50% improvement in their symptoms. So if someone's going every hour then we'd hope they'd be going every two hours. Or if they're using £4 a day we hope we go down to two or something like that. And then if it works in two weeks they come back and we implant a battery which is called the I. P. G. Um And it's an implantable pulse generator and it looks just like this. It's um made by the same company that makes pacemakers. So it's exactly the same technology and battery that you would see in a pacemaker. Um If it doesn't work I should say we still bring them back to O. R. To remove the lead that we play. So either way it's two trips that are and these are just some we use Flora Skopje to get the optimal lead location. And we also do some inter operative nerve testing testing. Excuse me. But here you can see just to give you an idea what it looks like. So here's the lead sitting on the S. Three nerve root. This is a cross sectional View, a lateral view. You can see it's right over we know we're in the right place because we're right over this hill here. Um and then this is the interior view um and S3 usually kind of lines up with this this kind of notch level here on the issue of spine. So then there's on a botulinum toxin. A and otherwise known as Botox. Um As you know we use Botox for all sorts of conditions. It works really well in the bladder. Um And the mechanism of Botox is it just basically prevents the release of acetylcholine from the pre synaptic nerve terminal shown here so that the acetylcholine isn't available to the muscle to contract. Um Now Botox works great, it lasts 3 to 12 months wears off and then people need repeat injections. I'd say I do about 95% of Botox injections in the office. So people tolerate it very well. We bring them in, we put some lidocaine in the bladder and for about 20 or 30 minutes and then I come in with the camera, do the little injections really quick. It takes about two minutes. Um And and it's Over the downside. Is that with kind of the starting dose I'd say about 10% of women and about 20% of men have difficulty emptying their bladder afterwards and temporarily need to potentially need to categorize. That's something I talk about with everyone. Um and in my hands people have to be willing to to learn or to try that if and if they want to undergo Botox. But that's a minority of patients. Um And generally speaking it works really well and patients are generally very very happy. Oh here we go. So it's FDA approved for idiopathic O. A. B neurogenesis. Overactive bladder. Success rates are very high and last through 12 months and urinary retention. This is just an endoscopic picture of Botox going into the bladder. Um So and follow up for this patient. They chose to undergo Botox at 100 units which is kind of the lower dose with the starting dose. Um I bring all my patients back in after the first Botox injection in two weeks to do a PVR there's those 52. They did great. They noted 70% improvement in their symptoms. Um And we continued doing it every three months and then she noted it wasn't working as well. Um And at that point this is you know, five years later we ended up increasing the dose. Um And her PVR was 1 54. So you go up on the dose. People do tend to have more trouble emptying. When she avoided again it was 1 22 but she felt like her symptoms were improved and she was happy with the outcome. She was doing well. So I didn't feel she needed to characterize um And I she continues to get Botox at this dose and continues to be very happy. Um So I hope I've given you some ideas of all the different things that we can do for stress incontinence and overactive bladder. There's really a lot out there and I just want to leave you with the impression that you know, if we try one thing and it doesn't work, then there's lots of other things that we can try. And there's almost always something that we can do to make quality of life better, even if we can't cure the condition which often times we can I don't want to give you that impression. But even if we can't cure it and there almost always is something we can do to make quality of life better. So I think that that's really important and just to kind of reiterate, this is our team um from our clinic and I will leave you with my contact info.