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Incontinence and Erectile Dysfunction • Male Incontinence • Female Incontinence • Male Erectile Dysfunction • What the urologist can do for your patient Male Incontinence • There are essentially 4 types of Incontinence – – – – Overflow Urge Neurogenic Stress Overflow Incontinence • Bladder overfilling and subsequent leakage- Dx by residual urine • Treatment – Catheterization intermittent or continuous – Eliminate drugs that cause poor bladder contraction : anticholinergics – Interstim therapy Overflow Incontinence • BPH is the most common cause • Treatment – Alpha blockers: Flomax, Uroxatral, Rapaflo,Cardura and Hytrin – TUR Prostate – Green Light Laser Prostatectomy – Microwave thermotherapy BPH treatment • TUR Prostate is has been a gold standard for years • Complications: – Bleeding and Blood loss – Fluid absorption during the procedure – Rare incontinence Green Light laser Prostatectomy • Becoming the new standard • Becoming more common that TURP • The operation is the removal of the same tissue (Prostate Adenoma) by vaporization rather than cutting it out. – Almost no bleeding – No fluid absorption – Can be done with sedation (even in office) Green Light laser Prostatectomy • Advantages of office procedure – Less stressful for patient – Less cost for the patient and the health care system Microwave Thermotherapy • A catheter is placed in the urethra and microwave heat is applied to the prostate • Results: • Minimally invasive office procedure for poor surgical risk patients • Other patients may request it Urgency Incontinence • Inability to control an unstable bladder contraction • Etiology: MS, CVA, and idiopathic, BPH • Diagnosis: Urodynamic studies • Treatment: If secondary to obstruction e.g. BPH, treat BPH first Urgency Incontinence • Anticholinergic medications: Detrol, Enablex, Vesicare, Sanctura, Oxybutinin, Oxytrol patch, Gelnique • Botox injection • Behavioral Therapy • Interstim therapy • Percutaneous Tibial Nerve Stimulation Botox injection • I have been doing this for 4 years • Office procedure • 100-200 Units ( 10 units per CC) of Botox A injected submucosally in the bladder • 90 % patients respond; usual response is within 8 days and lasts 6month to two years • Complication: retention Interstim Therapy • Neuromodulation of S3 or S4 nerve root • Why it works is unknown • 50 % response rate • Staged procedure: – Place electrode and stimulate as outpatient; if successful implant batter stimulator and attach electrode Interstim Therapy • Single Stage procedure in OR • Two Stage Procedure PTNS • Weekly tibial nerve stimulation • Office procedure that lasts one hour • Needs 12 treatments • Lasts 12 months • 50 % improvement in nocturia, incontinence, episodes, and OAB score PTNS Neurogenic Incontinence • Spinal cord injury • Retention • Spastic Bladder Neurogenic Bladder • Etiology is spinal cord lesion and trauma most common • Most patients will have spinal shock and be in retention and best handled by intermittent catheterization • Follow up Urodynamic studies Retention • Usually motor neuron lesion and will require intermittent catheterization for life • Can construct a continent suprapubic stoma (appendix) if urethral catheterization not acceptable or possible • Occasionally due to spastic sphincter and treatment of choice is Botox injection of the external sphincter Spastic Bladder • Usually secondary to Upper spinal cord lesion • Treatment with imipramine, anticholinergic and alpha blocker together • If no results, then Botox • If no results then diversion or bladder augmentation and IC Stress incontinence • Etiology is usually surgery and usually radical prostatectomy for cancer • This is manifest with urinary leakage with cough or abdominal straining • Treatment: Advance Sling or AMS 800 urinary sphincter Advance Sling • Used when there only stress incontinence and there is mobility of the urethra • Outpatient procedure • Success of 90% • Risk of early retention of Action for AdVance Sling Image: Peter Rehder AdVance Transobterator Male Sling Introduced to the market in 2007 AMS 800 Urinary Sphincter • Can be used for stress in all circumstances • Usually used for stress incontinence when there is no urethral mobility • Used for total incontinence • Success rate 95% • Risk: infection; retention and erosion AMS Sphincter AMS Sphincter • Artificial Sphincter-over 65,000 procedures • The Gold Standard for treatment of moderate to severe incontinence • • • • • Minimally invasive Outpatient procedure 92% of patients would have the AMS 800 placed again 96% of patients would recommend it to a friend 33 years on the market Female Incontinence • Overflow • Urgency • Neurogenic • Stress Female Overflow Incontinence • Diabetic neuropathy • Lumbar Disc disease • Herpes Simple or Zoster • Post-op especially gyn surgery • Anticholinergic agents • Rare urethral or bladder cancer Overflow Incontinence RX • Intermittent Catheterization • Interstim therapy • Alpha blockade Urgency Incontinence • Overactive Bladder • R/O <Multiple sclerosis • CVA • Interstitial cystitis • Acute urgency: cystitis, lower stone Rx urge incontinence • Anticholinergics • Botox • Interstim • PTNS • Behavior therapy Neurogenic incontinence • Convert to a hypotonic bladder – Botox – Augmentation – Anticholinergics Then start intermittent catheterization Female Stress Incontinence • Inability to control leakage with – Cough – Strain – Sneeze – Valsalva Female Stress Incontinence • This is an anatomic problem which is corrected anatomically • Type 2 Hypermobile urethra • Type 3 rigid urethra RX of Type 2 and Type 3 • Slings – Transobturator – Retropubic Slings for Stress Incontinence • Considered minimally invasive • • • • surgery First developed in mid 1990’s A sling or hammock shape material is placed below the urethra Incisions are very small Long term data shows success of over 80%* * Long-Term Results of the Tension-Free Vaginal Tape (TVT) Procedure for Surgical Treatment of Female Stress Urinary Incontinence, Nilsson et. al, International Urology Journal, 2001. Stress Incontinence Solutions • Sling or Hammock – Incisions are very small – Procedure pain is minimal* – Recovery time is less than half the time of Burch procedure* – Patient usually goes home the same day – Products like SPARC™, TVT™, or Monarc™ Subfascial Hammock * Burch Colposuspension and Tension-Free Vaginal Tape in the Management of Stress Urinary Incontinence in Women, Liapis et. al, European Urology, Urethral Implant • Collagen • Macroplastique • Durasphere Product Photo Library Contigen® Implant Syringe Open Bladder Neck Transureth ral Technique Step 1 Transureth ral Technique Step 2 Periurethr al Technique Step 1 Periurethr al Technique Step 2 Periurethr al Technique Tip 1 Periurethr Pass the needle through the cystoscope sheath Place the needle into the side of the urethra beneath the mucosa proximal to the external sphincter (i.e., towards the bladder neck) No injection should take place either in the external sphincter or around the bulbous urethra Erectile Dysfunction • Inability to obtain or maintain an erection satisfying for intercourse Physical Causes of ED •• Diabetes •• Heart disease •• Surgery (Prostate, Bladder, Colon, Rectal) •• Medications •• Spinal injury •• Hormone imbalance Available treatments • PDE- Inhibitors • Prostaglandin and papavarine injection • Testosterone for hypogonadism • Vacuum Pump • Penile Implants Oral Therapies: • Work only in response to sexual stimulation • Must take Viagra and Levitra at least ½ hour before anticipated sexual activity. They remains effective for up to 4 hours after are they taken Vacuum Erection Device: • Externally applied device mechanically effects penile blood engorgement • Cylinder/pump placed over penis creates closed chamber; pump creates vacuum, drawing blood into corpora cavernosa • Constrictive elastic ring then placed at base of Levine LA, Dimitriou RJ. Urol Clin North Am. 2001;28:335-341. Montague DK, et al, for the AUA Clinical Guidelines Panel on Erectile Dysfunction. J Urol. 1996;156:2007-2011. Transurethral Medication: MUSE Transurethral Medication: MUSE Injection Therapy • Diabetic needle and syringe • Drug dosage - 1 cc or less • 5-15 minute response time • 30 minute to 2 hour duration • Possible side effects – Pain on administration – Prolonged erections – Scarring Penile Injection Smooth muscle – relaxing medication Therapy: injected directly into the penis Penile Implants vs. Other Treatment Options •Overall Patient Satisfaction with ED •0% Treatments 1 20% 40% 60% •Penile •93 •Implant % •51 •Oral % •Medication •Penile •Injection 80% •40 % Percentage Satisfied 1 Rajpurkar A, Dhabuwala CB. Comparison of satisfaction rates and erectile function in patients treated with sildenafil, intracavernous prostaglandin E1 and penile implant surgery for erectile dysfunction in urology practice. J Urol Jul 2003 v.170(1)p.159-63. 100% Penile Implants •Ideal for men who have tried other •treatments without success •• On the market for over 30 years •• 25,000 penile implants per year •• High patient and partner satisfaction Three – Piece Inflatable Penile Implant • Acts and feels more like a natural erection • Expands the girth of the penis • More firm and full than other implants • Feels softer and more flaccid when deflated How does it work? • Fluid flows from the small reservoir in the abdomen into the cylinders of the penis when the pump is squeezed until there is a firm erection. • Once the erection is not Implants are Highly Recommended •100% •95% •90% •85% •80% •92% •would •recommen d •to others3 •90% partners would recomme nd to other couples4 Levine LA, Estrada CR, Morgentaler A. Mechanical reliability and safety of, and patient satisfaction with the Ambicor inflatable penile prosthesis; results of a 2 center study. J Urol. 2001 Sep; 166 (3) :932-7 • Q&A