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 gonna talk about updates in female pelvic medicine for primary care. And just uh these are my disclosures. I have some NIH funding in the form of an RO1 um for grants and I work on an arc, um uh grant as an expert consultant and then here are my disclosures that don't have anything to do with, uh, the topic I'm discussing today. So I wanna 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 just a holistic center where we are, um, women serving women, uh, with pelvic uh, health conditions. And this is our team, that's me in the middle, um, Anskind, and then on the left is Michelle Van Keyn. Uh, she joined us a couple of years ago and, um, is also subspecialty trained in what we call female Pelvic medicine reconstructive Surgery or FPMRS, um, and on the right is Leslie, uh, Martin, now Parnell, who is a nurse practitioner who works very closely with us. So the three of us work closely together in this 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, neurogenic bladder, urinary fistulas, mesh complications, um, things that are a little less common like urethral diverticula, female urethral stricture disease, female incontinence, 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 um diagnostic and therapeutic procedures such as video urodynamics, cystoscopy, uh, intratrusal Botox injections. I'll talk a little bit more about that, urethral injections for stress incontinence. I'll talk some about that today. Other fluoroscopic diagnostic procedures, percutaneous tibial nerve stimulation, I'll go into that. Uh, we also do pelvic floor injections for pelvic pain, bladder installations for pain, um, and pessary 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. Uh, we do complex, uh, pelvic reconstructive surgery, um, including vasov vaginal fistula repairs, urethral diverticulectomy, mesh complications, and of course sacral neuromodulation and Botox. So today, I'm gonna talk about updates in stress urinary incontinence and overactive bladder. So just starting off kind of broad strokes, big picture, and it's all what we do is actually really quite simple. So I think about um all these conditions in terms of the bladder and the outlet, OK? And so during normal bladder filling, what we want is a bladder which is a reservoir that accommodates urine and increase in volume in urine at low pressures, OK. And then we also want an outlet that's closed, of course, and we want to increase urethral resi resistance uh to prevent any leakage and that's caused by various, uh, various different mechanisms such as urethral support, urethral coaptation, and the urethral sphincter. OK, so that's normal. Normal emptying, we want a coordinated contraction of the bladder and decrease resistance of the outlet so that the, 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. Uh, comorbid conditions such as, um, diabetes and a whole host of other, uh, conditions. Normal aging can affect the bladder and the outlet. Of course, pelvic birth and, uh, pelvic floor, and the pelvic floor, childbirth, and hormones. So changes in hormones is Um, uh, uh, we go through, uh, different life stages. 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 cause it's all very related. So this is more like real world what we see. I'm gonna start off with a case. So, uh, 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 is 9 pounds. Uh, 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, did an exam, um, everything was pretty normal. Um, pelvic exam normal, external genitalia, vaginal tissue looked OK, no tenderness, no prolapse, um, and then she did have, um, leakage with a cough, so I always do this in lithotomy, make sure that the patient has, um, some urine or fluid in the bladder and just look for 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 tract pressure exerting pressure on the bladder and that pressure gradient 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 and hear, um, health-related quality of life. And we, our most recent estimates are it costs over $26 billion a year in the United States to treat this condition. It affected 28 million women in 2010 and it's projected to be over 43 million women in 2050. So certainly common. And this is a um a slide that I, 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 in older adults. And so you can see kind of the age distribution. So stress incontinence actually goes down with age, um, and urge incontinence goes up with age, and the mixed incontinence or either type of incontinence, just any incontinence overall prevalence goes up with increasing age. So the pathophysiology of stress incontinence in 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 it to have normal functioning, you need normal function of, uh, the peripheral and central nervous systems, the bladder wall, the detrusor muscle, the urethra, pelvic floor musculature. Um, and here are, we do have um guidelines on stress urinary incontinence in women, and these are put out by our professional organizations, the American Urologic Association and SUFU, which is the Society of, um, Urodynamics, Female, uh, Urology, urogenital Reconstruction. Uh, it's kind of a mouthful to say, so I'll just say SUFU from here on. Um. And these were um put forth in 2017, but nothing real, not too much has changed. And so the initial evaluation for stress incontinence is of course a history of physical exam. We need to see demonstration of stress urinary incontinence in order to move on to more invasive treatments, OK? We don't need it for less invasive treatments, but we're considering surgery, that's a requirement. Uh, it's recommended that we get a post-void residual, so just a measure of how well the bladder is emptying. Um, and a urinalysis to rule out, um, any other pathology and, and more invasive tests like cystoscopy and urodynamics 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, um, and surgical. So starting with non-surgical, um, things such as, uh, continence pessary, vaginal inserts, uh, pelvic floor muscle exercises. I have a slide on these, so I'll go into these in more detail. And surgically, and speaking with have things such As bulking agents which are actually growing in popularity, uh, midurethral slings, which you probably have some experience with and we certainly heard a lot about, um, autologous pubal vaginal slings which are done with fascia, um, and then the last one, birchopal suspension, that's rarely done. It's an, an open abdominal procedure. So, um, it, 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 non-surgical treatment, so, um, this actually can work very well in, in certain women and I always try to start everybody with pelvic floor physical therapy because um there's really little downside. There are pelvic floor physical therapists all over, you know, you don't You don't have to do it in any one place and I have a whole list of um people to refer to organize based on area. So I think the most important thing is that uh the woman sees someone who's local to them and convenient and I, you know, try to do whatever I can to help facilitate that. Um, pelvic floor physical therapy works pretty well, um, and in some women it cures them, and that's all that they need. Um, usually, uh, techniques such as biofeedback are incorporated, which I think can be really, uh, really beneficial, and, uh, like I said, the only downside is the time and, and effort put into, to doing it, but, um, it's a great place to start, and it's something I offer to every single woman who Come through my door, um, and, um, I'm a big proponent of, OK? Um, pessaries, um, are, uh, can be great for, uh, for the right woman, and we think of pessaries often for pelvic organ prolapse which is, um, the majority of their uses, but they can also be used for stress urinary incontinence, and there's a certain pessary, uh, that's a ring with a continence knob, you can see here, it's just This knob on the side and it it kind of just compresses the uh urethra at the bladder neck and that compression can prevent leakage. So in someone who's not sexually active um or um 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 wanna mention um down here the vaginal insert. So this one is made by poise. It's um it's actually the only one I'm um 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 3 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, the proper size and it comes in this little applicator just like a tampon and then there's this kind of little silicone prongs underneath this, um, paper-like product and it just fits into the vagina, um, similarly to a pessary and just compresses the urethra. So this doesn't work for everyone, um, but it's worth a shot. It's a low investment in terms of time and cost to try it out, and I found just in my own experience that, uh, the women who this works best for are 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 jog, 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 um of the stress incontinence, this is a great thing to try. OK? Urethral injections. So, um, these have gone through different, um, variations in in evolution over time. They're minimally invasive. They can be done in the office or in the operating room. Um, the latest one on the market is this, um, polyacrylamide hydrogel. The brand name is Volamin. It's been in Europe for, um, several, uh, 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, uh, whereas the other injections last maybe 6 months to 2 years. So they're a nice more temporary fix, um, minimally invasive, um, and they, they work reasonably well. Um, so they may or may not provide a cure, but they may get, uh, provide levels of improvement and I actually have been having really good success particularly with the, the newer, um, the newer agents. So this is a great thing to consider. Um, uh, for patients who may not want more invasive surgery, and this is just another picture, so we talked about coactation of the urethra is one of the mechanisms to prevent incontinence. So basically you go, we go in through the urethra, um, 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 so the mucosa of the urethra comes together and collapse. OK. Uh, and then this is just sort of a live picture of, of what it would look like endoscopically. 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, uh, women who have these slings are among my happiest patients. Um, they really do quite well overall. Complications are rare. Of course, what's on everybody's mind are complications associated with MASH, which are about 2 to 3%. Um, so, you know, when they happen, they, uh, you know, we, we do hear a lot about them, but they are in the minority of, of patients and I think in well-trained hands, this incident and, uh, these problems are quite low. Um, they, they can, I always tell them they can change kind of, um, how the sensation of voiding. So some women tell me they have to push or strain a little bit to void afterwards. Um, but generally, um, people are very happy with this, and this is just kind of a picture showing where the sling is. So there's a small incision underneath the urethra, two tiny little incisions either up here, um, behind the pubic bone, um, or we all Also can place it through the operator frame and so in the other incision would be in the groin. So then there's this piece of mesh and it serves as sort of a, a backboard for uh the urethra. So this is the urethra here and there's urethral mobility when um someone has stress, or cough, laugh, sneeze, um, basically the, 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, um, mention the, the mesh positions, these are our profess subspecialty professional societies both from urology and from gynecology, and, um, they put out many sort of statements regarding the use of mesh, and, um, they still stand by the use. And mesh for stress urinary incontinence is as um the gold standard treatment. So, um, I do, um, you know, talk to all women who I consider putting mesh in about mesh, about the problems associated with mesh, about the real-life risks associated with mesh and make sure that they um are fully informed, but I do think it is very safe. And finally, there are, uh, women who either don't want mesh, um, but would like a, a stronger surgical procedure or in women who have kind of really bad stress urinary incontinence, um, the pubov vaginal sling using, uh, rectus fascia is a great alternative. So this is a more Invasive surgery. Um, it involves a fan and steel incision here where we actually harvest, uh, a piece of mesh. So if someone's had like a C-section or a Fan and steel incision for another reason, we can go in through the same incision. Uh, I use like an 8 centimeter incision, so it's pretty small. Um, 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 tending it up a little bit. So it's a stronger sling. OK. All right, so that's um the, the part on uh stress urinary incontinence. So now I'm gonna move to a second um patient scenario. So this is a 67 year old female uh 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 oxybutynin 5 mg to take 3 times a day, but only takes it once at night, and she thinks it may be helpful. Uh, she drinks mainly water but has a cup of coffee, uh, every day and has a history of diabetes type 2 and hypertension. So, um, these are the questions I ask at every patient visit of all my patients. So she voids every 1 to 2 hours during the day, gets up 3 to 4 times at night. Um, has, uh, leakage with urgency, so urgency incontinence, but is not wearing any pads, and had one UTI in the last year and has 3 bowel movements a day. So on exam, uh, evaluation, we had a UA that was negative, a post-void residual 54, so pretty minimal, nothing too concerning, and pelvic exam showed vaginal atrophy, otherwise normal. Uh, no prolapse, no leakage on supine empty stress test, and a weak kegel of 1 out of 5. So, um, she has overactive bladder and this is basically the, the way I think about it is the bladder is a muscle and the purpose of the muscle is to contract or squeeze when you want to urinate and in this case, the bladder muscles squeezing when, um, the patient doesn't want to urinate and that spasm or squeeze is, um, cau 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 um by the presence of bothersome symptoms and, um, per our guidelines, it's the presence of urinary urgency, usually accompanied by frequency and nocturia with or without urgency, urinary incontinence in the absence of a UTI or other obvious pathology. Um, and there are 4 components. So one is urgency, 2 is frequency. Uh, 3 nocturia, which is 2 or more times a night, and 4 urgency incontinence. 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, uh, fairly equivalent to that in women. I think we just miss it a lot, and, because we, when, uh, 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, uh, consider these symptoms and treatment of these symptoms in both men and women. And of course the, the prevalence uh increases um in with age in both genders. So, um, the degree of bother, um, of, uh, that's caused by symptoms directly affects care seeking, um, behavior, treatment intensity, and satisfaction with treatment. So this is, um, usually not a danger. Dangerous or life-threatening conditions, so we really wanna treat based on the um the level of bother, OK? And everybody is different, um, and I'm always surprised um by what I think might be bothersome, maybe very different than what the uh patient in front of me might think. Um, 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, uh, well it may not be life-threatening, it can really impact health-related quality of life. Um, 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 wanna go to places where they know they can have access to a bathroom. Um, it really can negatively impact sexual function, marital satisfaction, and it's often associated with depression and anxiety. Um, and we also know that the majority of patients don't seek treatment. So, um, you know, as primary care doctors, I, I know. You guys have a lot to, to focus on in your very short visits, um, but uh this is the kind of thing that oftentimes 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, um, I really do think it is, it is worth going into. Um, so we also have AUAC food guidelines, um, originally created in 2012, updated in 2019, and now there's a call for new guideline committees, so new guidelines will be coming out shortly. Um, but the standard approach is the stepped approach to care, and I think that this, uh, uh, 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, second, and third-line care. And the idea being that you kind of go in this, this, uh, gradiated fashion. So first, First line care includes um pelvic floor physical therapy, behavioral modifications. I'll go into this in more detail. Uh, second line would be anticholinergics and beta 3 agonists, and certainly in recent years, there's more of a push towards beta-3 agonists and away from anticholinergics. Um, and third line treatments include percutaneous tibial nerve stimulation, PTNS, intradetrusal Botox, or on a botulin and toxin A injections, and sacral neuromodulation. I'll go into each of these. And this is what the, 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, uh, the third line or more advanced treatments is step 3. So in this, uh, we uh always wanna start with excluding other conditions. So doing a history, physical exam, urinalysis. Um, again, it's not a life-threatening condition, so no treatment is always an option and um always discussed with, uh, I always discuss that with patients. Um, and it's really, we should be providing education on, uh, normal urinary tract function, what's known about OAB benefits and risks of certain treatments and acceptable, um, symptom control may try, may require a trial of 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, um, 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, um, even talk about some of these things in terms of referral to, to us if you need, um, our help with some of the more simple things aren't working. Um, but I think it also gives patients hope, um, and just a understanding and better expectations. Um, you know, I also try to keep in pretty close contact with people who I start on this pathway because if things fail, I wanna make sure that I know, um, so that I, they're not waiting around in despair and that I can move them along to, um, another treatment that might be more helpful. So I think, um, 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, uh, limiting bladder irritants, and this is my personal list, um, that I, you know, put in my after visit summary and hand out to patients, and, um, you know, I, I always ask patients what kind of things. Are they drinking? The, the patient in this case, I think was drinking coffee, right? Um, but there's so many things beyond coffee that, uh, most people aren't aware of. So fruits, um, alcohol, of course, juices, um, carbonated beverages, um, and a little vinegar, different condiments, uh, and a little education goes a really long way cause 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, I, I, 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, You know, take a look at this list, kind of get familiarize yourself with it, and then start to build an awareness. So, um, if your bladder, if your symptoms are worse, ask, ask yourself, do I just eat any of those things and then try to make connections in your own life. Everybody's, uh, responds very differently to each of these. Um, sometimes we use bladder diaries, um, double voiding or delayed voiding. Um, so basically, um, this is when someone is, um, Uh, 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. That's double voiding, uh, timed urination, quick, quick flick or Kegel exercises. So, as many of you may know, um, actually doing a Kegel sends a feedback mechanism to the brain for urge suppression 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, uh, for it to work in this setting, and of course biofeedback. And there are patient handouts, um, on the Sufu website, and they go over things like 5 changes you can make to improve bladder problems. These are for patients, uh, so tracking the amount of liquid you put into your body, what you eat, uh, reaching and staying at a healthy weight. Keeping uh 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 as some uh tips and, and tricks that you can give your patients. So, um, second line treatments or medications. I'm sure many of you prescribe many of these medications. Um, they're all listed here as anticholinergics or beta 3 agonists. Um, there are 6 anticholinergics. They've all been around a long time. I, I don't need to tell you about them. Um, you know, there are, uh, side effects associated with them, um, you know, dry mouth, constipation, difficulty emptying the bladder, delayed gastric emptying, cognitive changes, particularly in older adults, um, and the, and the list goes on and on, right? Um, and then there are beta 3 agonists. Um, Mirbegron has been around for, uh, since I believe 2012. Bibegron is the newer one that came out, um, in the last year. Um, they, uh, 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, um, It has less of an effect or really no effect on, um, uh, things like heart rate and blood pressure, which is what we weren't uh worry about with beta 3 agonists. Um, 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, but that, that's what, uh, the, the party line is. So, um, Some kind of details from the uh guidelines in terms of prescribing, um, so of course you can prescribe either an antimuscarinic or beta 3 agonist. Um, of course, extended release formulations are preferred over any immediate release formulation and if a patient experiences inadequate symptom control or unacceptable. Side effects with one medication, uh, then you can always do dose modification or try a different medication. Um, and of course avoid use of anti uh muscarinics with narrow angle glaucoma, uh, and use caution with impaired, uh, gastric emptying or bladder emptying. Um, managing constipation and dry mouth, um, and using caution and prescribing antimuscarinics in patients using other medications with cholinergic properties, and there are a lot of them, um, and use, uh, caution in prescribing with frail older patients and if refractory to medications, that's a good time to refer to a specialist. Um, and per our guideline, uh, clinicians should discuss the patient's expectations from treatment and their willingness to participate in therapies other than pharmacotherapy. If a patient would not consider invasive, uh, treatment options, a referral to a specialist may not be warranted. So that's always, uh, a good thing to ask before sending them our way, um, so that we, um, kind of, uh, understand their expectations. Um, so back to this patient, uh, 667 year old female with urgency, frequency, urgency incontinence on oxybutynin once a day. Um, let's 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 me and practices for urge suppression like we talked about, um, pelvic. For physical therapy, bladder training, dietary modification, and then if they're interested, uh, pharmacotherapy, so we know they're taking the oxybutynin but it's immediate release just once a day and, um, uh, they have a bed there, um, the patient has hypertension, so probably not the best, um. Uh, option, uh, having a beta-3 agonist, um, it's not an absolute contraindication. 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, um, the patient's communicating closely with their primary care physicians or monitoring their blood pressure that everybody kind of knows what's going on. Uh, so this particular patient was interested in dietary changes and physical therapy and then we also switched the oxybutynin, um, to trospium which, uh, 20 mg, which is the lower dose, um, but in extended release formulation. And I'll have them follow up in 2 months. So if this patient came back in 2 months and, you know, wasn't doing better, we can just escalate from there. Uh, we could switch to a different medication or we could talk about third line, uh, therapies at that point. All right. Um, so this is another patient, um, and this is a 40 year old, uh, with urgency frequency for many years. They started recently having urgency incontinence. They had tried PTNS for several, several years, that's the percutaneous tibial nerve stimulation. Uh, I'll go over that in more detail, which was helpful, um, but it's no longer working now. Um, so they void 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 UTI history, daily bowel movements, so that's good. They'd previously tried Gelnique, which is the oxybutynin gel formulation, but that caused dry mouth. Uh, they have no PVR, which is good, and a normal urinalysis. Um, so what's next in terms of treatment options? So they've tried the PTNS and, uh, a medication. So always starting with patient education. I don't care where they come, um, from or what they've tried before, there's always a role for that. Um, again, some of the things that we talked. about previously, talking about behavioral lifestyle modification, same thing as with the other patient, pharmacotherapy, and they've already tried an anticholinergic. Um, we, um, could try beta 3 agonist, and then the third line treatments would be another option. So they ended up choosing Mirabberon at the full dose, which is 50 mg, followed up two months later without significant improvement. Um, so what would we do now? Um, so for me, this patient's already tried and failed all the kind of simpler, uh, 1st and 2nd line treatments. Uh, we could play around with medications a little bit more, but I think it's time to, 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 urodynamics. 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 fluid, uh, the bladder with 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 voiding. Uh, phases and do a full functional assessment of the urinary tract. So this green line here is a calculated pressure of the detrusor or the bladder, and you can see we're feeling as we're moving across the page. There's a nice, pretty, uh, steady line here, um, and then as we get here we start seeing these bumps. These are bladder contractions and they're associated with um that kind of feeling of urgency. Here's, um, you can see here the there's these bumps again and, and the patient has a strong desire. So those, that's to choose their overactivity or, um, uh, overactive bladder basically. And you can see here that they urinated and they, this is a perfect voiding curve, so no problems with urination. So, oh, there we go, detrusor contraction. So, um, in terms of the third line treatments, um, there's PTNS which she's already tried, sacral neuromodulation, and intradetrusar onobotulinoxin A or Botox injections. So I'm just gonna go through each of these, uh, to give you a little bit more information. PTNS is, uh, a really nice therapy. It's performed in the office and they're 30 minute sessions. So what we do is we put a little, um, Uh, acupuncture needle into this area here, which is the, um, percutaneous 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 cause I wanted to know how it felt. It's totally not a big deal. Uh, 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, uh, and so it indirectly sends a signal to the bladder, um, and gets it to behave differently. Um, it was actually developed, um, in our department here at UCSF many years ago, um, based on, uh, Chinese acupuncture points. Uh, the sessions last 30 minutes and it's FDA approved, um, for treatment of these symptoms, um, in 30-minute, once a week sessions for 12 weeks in a row. So it is, uh, a lot of visits to the office, um, and, um, 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, um, containing fibers from, um, the spinal roots L4 to S3, 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 uh sacral neuromodulation. So this neuromodulation idea, it's the same idea, but this is working more centrally and it's, there's an electrode that's placed directly onto the S3 foramen. So this is done typically in the operating room. Uh, the mechanism isn't fully understood. It's FDA approved for frequency, urgency, urgency incontinence, neurogenic 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 tiny lead that gets placed uh through the Sary foramen so that these uh leads here are right on, kind of sit right directly on the S3 nerve root. And the downside of this treatment is we can't, it doesn't work in everyone and we can't predict who it's gonna work in and who it isn't gonna work in. And so we do it in a staged approach, OK? So it's two outpatient procedures, uh, done in the operating room under either sedation or general anesthesia up to the patient what they prefer. And, um, the, the first phase, and I, I do them, and most people do them two weeks apart. So the first phase we call it the test phase or stage one, and we implant the lead and then we give them some kind of external piece. They take it home for Two weeks and I 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 2 hours. Or if they're using 4 pads a day, we'd hope they go down to 2 or something like that. Um, and then if it works in 2 weeks, they come back and we implant a battery which is called the IPG. 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 him back to the OR to remove the lead that we placed. So either way, it's two trips to the OR. And these are just some we use fluoroscopy to get the optimal lead location and we also do some intraoperative nerve testing, testing, excuse me, but here you can see, um, just to give you an idea what it looks like. So here's the lead, um, sitting on the S3 nerve root. Um, this is a, um, cross-sectional view, a lateral view. You can see it's right over it, we know we're in the right place cause we're right over this hillock here. Um, and then this is the anterior view, um, and S3 usually kind of lines up with, um, this, this kind of notch um level here on the, uh, ischial spine. So then there's ona 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 presynaptic nerve terminal shown here, so that 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, numb it up for about 20 or 30 minutes, and then I come in with the camera and do the little injections. It's really quick. It takes about 2 minutes, um, and, and it's Over. Uh, the downside is that, um, with the 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, uh, potentially need to catheterize. That's something I talk about with everyone, um, and in my hands, people have to be willing, uh, to, to learn or to try that if Um, if they wanna undergo Botox, um, 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 OAB, neurogenic overactive bladder. Success rates are very high, and lasts 3 to 12 months, and urinary retention. This is just an endoscopic picture of Botox going into the bladder. Um, so in follow-up for this patient, uh, they chose to undergo Botox at 100 units, which is kind of the lower dose or the starting dose. Um, I bring all my patients back in after the first Botox injection in 2 weeks to do a PVR. Theirs was 52. They did great. They noted 70% improvement in their symptoms, um, and we continued doing it every 3 months. Um, and then she noted it wasn't working as well, um, and at that point, this is, you know, 5 years later, um, we She ended up increasing the dose, um, and her PDR was 154, so you go up on the dose, people do tend to have more trouble emptying. When she voided again, it was 122, but she felt like her symptoms were improved and she was happy with the outcome. She was doing well, so, um, I didn't feel she needed to catheterize, um, and, um, I, uh, 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 Um, I, I just wanna leave you with the impression that, uh, you know, if we, 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, uh, the condition, which oftentimes we can. Uh, I don't wanna give you that impression, but even if we can't cure it, and there almost always is something we can do to make, uh, quality of life better, so I think that that's really important. Um, and just to kind of reiterate, this is our team, um, from our, our clinic, and I will leave you with my uh contact info.
