So, the webinar tonight is urinary incontinence essentials for primary care and again I'm just going to introduce myself briefly. My name is Kate Bradley, I am a urogynecologist at the University of Iowa, and I happen to be the current president of the American Urogynecologic Society or AUGS. You know part of our mission, of course, is education. We spend a lot of time educating our members and other trainees, particularly subspecialists interested in urogynecology, but we also are committed to educating our patients and other colleagues and healthcare providers about pelvic floor problems in women and tonight I'm going to focus on urinary incontinence. And I should just say there's a chat function if you have any technical problems and a Q&A kind of box that you are welcome to add questions. I'm going to try and present for about 45 minutes with some slides and then I'm happy to answer questions that are sent in through the Q&A. I don't have any disclosures relevant to products or devices I'm going to discuss today. And our objectives are that after the presentation you should be able to understand common types of urinary incontinence that you would see in primary care practice. We'll go over the initial evaluation, diagnosis, and treatments that you can start. And then we feel like it's important that you can, that you're aware of advanced treatment options and some resources to support patients who maybe don't improve in initial therapy. So why, you know, are we talking about urinary incontinence? This is probably preaching to the choir as you are people who are committing some time to learning more about this, but we think this is really important. We know that incontinence is really common, it impacts quality of life and there are important associated risks and costs that I'll show you. So in the next just couple of slides, I have this kind of background information about incontinence and then we'll get into the meat of how do we diagnose and treat it in our practice. So urinary incontinence is really common in women. We're most interested in women who have bothersome incontinence, so they are interested in seeking treatment and that we would qualify often as kind of moderate to severe incontinence. And if you look at all US women across all age groups, it's about 16% of women have bothersome urinary incontinence or about one in six women. But of course this, you know, prevalence changes with age and it increases with age, which is probably the biggest risk factor. So not only does the prevalence increase with age, but severity. So as women get older, those who have incontinence tend to have more severe incontinence. So when you look into the elderly group, almost 50% of women have some urinary incontinence symptoms and here about 15% or one in six has daily incontinence, at least daily, and certainly are going to have a lot more impact from that. This slide just has, I love this figure. It's from an older study that was one of the first kind of well done population based studies asking women in a, and this was a County in Norway about urinary incontinence symptoms. And you can see, you know, it just illustrates really nicely how the prevalence increases from women in their twenties over here in the left side of the slide over to women in their eighties on the right. And not only the prevalence increases, but these, you know, darker color bands, which has the women with more severe incontinence is clearly increasing, but even women in their twenties, almost 5% have bothersome incontinence, which may be, you know, higher than we might expect. When you get up to women in their eighties, it's a third or more, and these prevalence rates probably are less than what we would see in our current U S based population, because these are Scandinavian. They're going to women who are probably on average, a little healthier and of lower body mass index. And we know that BMIs are increasing and that's also a big risk factor for urinary incontinence. Okay. So incontinence has a big economic impact on our on the U S healthcare budget, not only for medical care, but also for all of the incontinence products that patients purchase. And for most women, this is an out of pocket cost. So this is really expensive for our patients. And we know from many well done studies that urinary incontinence has a negative impact on all aspects of health-related quality of life, ranging from physical function to, you know, social functions to emotional and mental health. And as, as the slide mentions also sexual wellbeing, some studies have shown that populations or groups of women with incontinence are at higher risk for hospitalization. They're at higher risk for actually falls and fractures. We think this is because particularly at getting up at night to use the bathroom or because of nocturia or because of nighttime incontinence symptoms. We know women who had urinary incontinence are 40 to 80% more likely to have mental health comorbidities like depression and anxiety. So this is a higher risk group that we would be seeing with these symptoms. So when we talk about urinary incontinence, that's actually a very fairly generic description. We're not really talking about a specific condition. It's just a non-specific symptom and women with incontinence might have several reasons for that underlying conditions, but the greatest, the great majority of them over 90% of those patients you would see presenting to your office and even to a specialist office are going to have stress incontinence, urgency incontinence, or some combination of that, which we call mixed incontinence. So most of our job as a clinician and talking to patients is to really listen to their symptoms and try to figure out, do we think this is more stress incontinence? Do we think this is more urgency-based incontinence? Now there are some other types. Overflow incontinence means that they're not emptying their bladder, so they may have urinary retention and then just be leaking urine and those symptoms are actually really difficult to figure out. They can sound a little bit like stress incontinence and urge incontinence, they just kind of maybe leak all the time. It's actually not very common in women though. It's more common that men have overflow incontinence because of obstructive problems from the prostate. Functional incontinence, I'll mention on another slide, meaning something else changes in their health that makes it difficult for them to get to the bathroom potentially and worsen splatter control. And then extra urethral incontinence is very rare overall, and that would mean something like some kind of fistula or maybe a congenital problem like an ectopic ureter resulting in more continuous urine leakage. So those are rarely seen. So the next two slides really just kind of define both stress incontinence and then urgency incontinence. Those are the two conditions we're going to really focus on in terms of our evaluation and treatment options. So stress incontinence or stress urinary incontinence is manifested by urine leakage occurring with physical exertion or activity or urine that leaks because of increased intra-abdominal pressures. And so we would have women report leaking with coughing or sneezing or sudden physical movements like jumping or lifting, often maybe with exercise. This is caused, we believe, by a couple of conditions. One is more of a loss of anatomic support underneath the proximal urethra, the bladder neck. We call that urethral hypermobility. Or some people we think have just a deficiency of the sphincter mechanism around the urethra, neurologic problem leading to this or muscular problem like atrophy or injury, and sometimes a combination of these. Now, this is different from prolapse and this, I don't have this on the slide, but I think it's important to understand that vaginal prolapse, another really common pelvic floor disorder that we see and that you will see as primary care providers, does not cause stress incontinence. These are actually two different conditions and women who have prolapse of the anterior or front vaginal wall under the bladder, we sometimes call this a cysticeal, about half of them also have stress incontinence, but about half don't. And they're really kind of two separate conditions. So prolapse surgery doesn't fix stress incontinence for sure. So when we see women with urinary incontinence, the most common type in younger women is stress incontinence. These are women of reproductive age. And the main risk factors are pregnancy, delivery, particularly difficult, more difficult vaginal childbirth, like long labors, lots of pushing or traumatic deliveries, operative deliveries, bigger babies. And obesity, as I mentioned, is also a major risk factor for stress incontinence. Now urgency urinary incontinence is different. This is involuntary urine leakage that happens with this sense of having to empty the bladder or getting this sudden sense of urgency, this gotta go, gotta go sensation, and I can't get to the bathroom before I leak, or I suddenly need to pee and I leak a little bit. So in the great majority of people, this is not associated with any known neurologic condition, but some women who have a neurologic problem will have this, this symptom. And that would be things like multiple sclerosis, Parkinson's disease, spinal cord problems, stroke. And then we would consider this kind of a neurologic associated your bladder problem. But the most common, you know, thing is just to have idiopathic urgency incontinence. This is the most common type of urine incontinence in older women. And it's associated not only with age, but also diabetes and history of urinary tract infection is another risk factor. And I just wanted to define overactive bladder. So this is a really common term that's used. It's a diagnosis that's really just based on symptoms, not specifically on kind of the underlying pathology. And it's defined as urgency with or without the urgency incontinence. And usually people who have overactive bladder or urgency incontinence also described frequency, urgency and maybe nighttime frequency or nocturia. And I often use the terms overactive bladder and urge, excuse me, urgency or urgency incontinence kind of as synonymously, although they're not exactly the same, but they certainly overlap. And then, as I mentioned, because both of these conditions, stress and urgency comments are common. A lot of women have both. And so 20 to 40% of women presenting with urinary incontinence have mixed incontinence or both stress and urgency. And our job is to try to figure out maybe which one seems to be more bothersome or the real problem and focus our treatments there, at least initially, and also starting with start with conservative therapies, as we would usually do anyway. And then this slide just illustrates how it can be a little complicated. But there are a lot of these symptoms that overlap, conditions that overlap when we're seeing women with stress and urgency urinary incontinence. So there are a few what we would consider reversible causes of incontinence, and these are different pelvic conditions. So things like urinary tract infection can cause frequency, urgency, and some women definitely feel like they have incontinence as part of their UTI symptoms. Significant atrophy can cause some symptoms that overlap with incontinence. Pregnancy is a reversible cause of incontinence, and severe constipation can worsen a lot of bladder symptoms, including cause incontinence. Different medications can result in different urinary symptoms, and I have a slide about that we'll go through. And then medical conditions that increase urine production certainly can exacerbate or cause kind of new or newly bothersome urinary symptoms. And I mentioned functional urinary incontinence as one type of incontinence, and this might be this last category where there's an impaired ability to reach the toilet or impaired willingness. So sometimes patients with severe psychiatric illness or with dementia just don't realize they need to go to the toilet, and it may be almost more of a functional problem related to their mental faculties. But often something that is not uncommon would be to see a patient who reports that they suddenly have bladder control problems after a knee replacement or after a hip fracture or something where their mobility suddenly changed, a back injury or something, and now they just can't get to the bathroom quickly enough, and they leak urine. Maybe before this problem, they just voided fairly frequently and kept their bladder volume low, and they were able to manage some potential incontinence that way. So that would be an example of functional incontinence. Okay, so moving into how we need to diagnose incontinence. First of all, the most important thing is just to screen patients, and we know that women are embarrassed about these symptoms. Some women believe that urinary incontinence may just be a function of getting older and not something that they can get treatment for. They may not know treatment's available. And so we know that if we actually screen women for incontinence and just ask them if they have urinary leakage, that we will identify more patients that wouldn't bring it up to us initially. And I'll go through a couple of, there's some questionnaires that you can use, or you can just add a simple question about having urine leakage to, for instance, a review of systems type questionnaire. And then you can, just through a clinical evaluation in outpatient office, get a presumptive diagnosis of incontinence and initiate treatment based on this evaluation, which should include a good history, a physical exam, and a urinalysis. So some of the first research I did in my career was, I was really interested in a tool to help identify different types of incontinence, which there was many fewer kind of questionnaires and tools available at this point over 20 years ago. And so I developed and validated a diagnostic incontinence questionnaire for women and found that these six questions were kind of the most helpful in differentiating stress and urgency incontinence. So these are just nice examples of how we would ask women about leakage. If they report leakage, we want to know, do you leak urine when you cough or sneeze? Do you leak urine with lifting? Do you leak urine with exercise? So very simple stress incontinence questions. And urgency incontinence, do you leak or have incontinence or wet yourself because you suddenly feel like you need to empty your bladder and you can't hold it? Or do you leak because you're hurrying to the bathroom and you are leaking before you can get your pants down or underwear off? Do you have accidents or incontinence while you're rushing to the bathroom? Those are urgency related questions. And I was involved in another group that created this three IQ screener that was actually particularly tested and developed for use in more of a primary care setting with the idea that you could just use these simple questions and then do a simple evaluation before, for instance, starting a patient on a medication for urgency related incontinence or overactive bladder. And so there's just three questions that ask if there are incontinence happening and then when does it usually happen and maybe if it does, what is the most frequent type of incontinence? So these are just examples of questionnaires that you can use. When we find a patient who has incontinence or they bring it up to us, part of the evaluation would be, of course, a patient history and we want to focus on their symptoms. So their urinary symptoms, these different incontinence questions that I've just been going over, asking patients about, do they have frequency? Do they wake up at night to urinate and how often? Do they feel like they have any difficulty emptying their bladder? And then in terms of past history, focusing on past medical history, but specifically neurologic problems, genitourinary histories, any past treatment of these, of a urologic problem and potentially past pelvic surgery would be relevant. We need to review their medications. A diary can be helpful, but certainly is not required. And a bladder diary can be anywhere from extremely complex, where like if I do a bladder diary, I often require patients to, we give them a hat and we ask them to measure their voided volumes and record these and then measure how much fluid they're taking in when and what type of fluids and when they're leaking and what's making them leak. So that's very complex, but you can just do, there's some very simple ones available, just single day, maybe like kind of screening diaries where people just make check marks when they had to urinate and if they leaked and maybe what, you know, did they cough or was it on the way to the bathroom, for instance. So a variety of diaries are available and they can be helpful. This is a slide that just shows some of the kind of urinary or urologic side effects that may be associated with different medications. So of course, diuretics are going to increase the urine volume so they can result in polyuria, frequency and urgency symptoms. I basically tell my patients that if you have overactive bladder, you know, those things are, it's going to be worse when when you're making more urine. So there's a whole group of these medications, antihistamines, anticholinergics, alpha agonists, beta agonists, calcium channel blockers that can make it a little more difficult to empty the bladder. So it can cause retention or overflow incontinence, for instance. Alpha blockers can cause stress incontinence and alcohol can have several effects and it can worsen frequency, urgency and incontinence. It can also, of course, it's sometimes associated with enuresis or nighttime incontinence. So after the history, we would do a physical exam. And in a woman or a female patient, at least once they should have a pelvic exam when you're evaluating or treating urinary incontinence. Men or male patients really need, you know, a prostate exam. So in general, our physical exam, we're just assessing mental status. We're thinking about mobility, any mobility issues. An abdominal exam to kind of rule out a pelvic mass makes sense. Or if somebody really has urinary retention, you may be able to palpate the bladder as a mass in the pelvis. Leg edema, you know, may be relevant in a patient who has a lot of nocturia or nighttime symptoms. And then on the pelvic exam, basically we're looking for significant skin problems or atrophy. And then we're looking for pelvic organ prolapse or vaginal wall prolapse. And when I say this, I'm really, in terms of the relevance to our diagnostic process for incontinence and treatments, I'm really just worried about incontinence that's more in the moderate to severe range. So are they feeling symptoms of prolapse, like a bulge in the vaginal area? And can you see prolapse at the hymen or coming out at the vaginal entroitis with straining? If, you know, if it's very mild prolapse, it's like inside the vagina, that's really not very relevant. That should not really be associated with urinary symptoms. Treating their prolapse probably isn't going to change their urinary symptoms. So we're really talking about more moderate, severe prolapse, because at that point it could be causing some obstructive symptoms and is more likely to be associated with frequency urgency, for instance. A rectal exam might be helpful, particularly if you're worried about neurologic status or constipation, for instance, or masses, I suppose. And then just a very general and not, it doesn't have to be a really detailed neurologic assessment. I'm interested just very grossly, do they have normal lower extremity motor function or close to normal, any sensory changes? Of course, patients who have like a neurologic history or other symptoms, you're going to focus in more and do a more careful neurologic exam. I tend to just check gross motor function, sensation of kind of the inner thighs and perineum. And then I check for sacral reflexes by looking for a lobar cavernosus reflex or an anal wink when I just, I touch the perineum or just lateral to the perineum or perianal area with a Q-tip. I think the exam for that, that it's not very sensitive. So patients who don't have any other suggestion of a neurologic problem, I think that's probably not critical. Okay. And then tests, like what tests do we have to do in the office? And I would say, really, you need to do your analysis. And that is the one really, you know, clearly required test. We need to make sure the patient doesn't have real cystitis or bacteria that's symptomatic. If patients have bacteria, and I'm not really sure if it's symptomatic or related to their lower urinary tract symptoms, I might treat them the first time I see them and tell them to, you know, keep track of their symptoms. Do they change at all? If they don't change, I won't treat that patient again. And that's considered asymptomatic bacteria. Clearly, we need to identify hematuria, though. We do not want to miss a patient with hematuria that could be caused by bladder cancer in situ or even, you know, bladder cancer that occasionally, you know, can present with frequency urgency type symptoms, sometimes tend to have more pain and painful urgency. And so we screen for that with urine analysis looking for any hematuria. When I do a pelvic exam for incontinence, I do ask the patient to cough. As long as I'm doing a pelvic exam, I look at the urethra while they cough or bear down to see if I see urine leakage that is, you know, going to corroborate their symptoms. And that would be the symptom of stress incontinence. And then PVR. And I'm going to just go to the next slide here. I think there's good evidence that not everyone needs a PVR before starting initial non-invasive treatment. But patients at higher risk, meaning those who actually say, I don't think I'm emptying, or have difficulty emptying their bladder, have hesitancy, weak stream, or intermittent stream, they need a PVR or a postwar residual check. And you can do that either with a bladder scanner, or you can do a straight catheterization. But obviously, this takes time and really slows down a busy clinic. And so if people don't have those symptoms, if they don't have other reasons that might increase the risk of retention, like moderate to severe prolapse, or a history of incontinence surgery, or a neurologic diagnosis, those are the people that really need to be screened with a postwar residual volume, either by you, or you should refer those patients where they can get a more thorough evaluation. But people who don't have these symptoms, I don't think need a PVR before starting initial treatment. And typically, a residual volume, we're really not that concerned unless that's more than 200, maybe more than 150. There's a big variability in post-void volume, depending on the voided volume, for one thing. And sometimes people just feel uncomfortable, or they're not relaxing and really emptying when they're in the doctor's office or provider's office. So we tend to not consider it too abnormal unless it's over 150 to 200. And urodynamic testing is not necessary in the initial workup of uncomplicated urinary incontinence. So it is recommended when we don't have a clear diagnosis after basic evaluation, or when symptoms really don't correlate with objective findings. Or I would say importantly, if we treat patients and they don't get better, that would be a reason for needing further evaluation or potentially just referral to a specialist. People who have had prior incontinence surgery or significant pelvic floor surgery, they probably need a little more evaluation. And those with complex comorbidities like neurologic diseases that can really affect the bladder, like multiple sclerosis, like Parkinson's, I think those people need further evaluation and potentially referral. And this slide really focuses in on the referral question. Who needs referral? There's a kind of list here of people who have complicated incontinence, those who have an abnormal evaluation, like they aren't emptying their bladder, they have significant prolapse or a mass or something like that, or those who have treatment failure. So you have tried to treat them with non-invasive treatments that we're going to go through next and just haven't had success. And they've had a couple of months, you know, then potentially refer those people for further evaluation. Okay. And I'm going to now talk about treatments. And we're going to go through each of these types of treatments on future slides. This slide just summarizes those, and you can see they're a little different for whether we're treating someone with stress incontinence or urgency incontinence. However, you can also see that these first couple of treatments really work for both. And so sometimes if we're unsure about the diagnosis, or it seems like they have maybe some mixed incontinence, it is reasonable if they're not, they don't have other complicating factors to start with these initial non-invasive low risk treatments and give the patient six to eight weeks and see if they improve. So going first talking about lifestyle kind of modifications, behavioral therapies. We talk to our patients about fluid management, potentially reducing nighttime fluids for nighttime symptoms, or reducing overall fluid intake. If that seems excessive, you probably do need to talk to the patient about what they're drinking and how much, or do a diary that where they would document that. You, we think it's very important to add, talk to patients about reducing bladder irritants. Some people are very sensitive to this and I'll have great results by doing this. Others won't, but reducing caffeine, carbonated beverages, maybe potentially alcohol, those, those changes can actually significantly improve symptoms, particularly urgency related symptoms. Timed or scheduled voiding, just asking a patient to empty their bladder by the clock on a regular basis can really help both types of incontinence by keeping the volume of urine lower in the bladder. Weight loss has been shown to significantly improve stress incontinence in particular. And I try to mention this to all of my patients and really talk to those who are overweight or obese about that. And finally constipation is like a constant player. I think it, it worsens symptoms. And so getting people on a, on a regular bowel regimen can be helpful. So the next, and all of those things, I, I tend to talk to both patients with stress and urgency focused incontinence with. So pelvic floor muscle training or exercises also help all types of incontinence. And this can be just simply asking a patient to Kegel exercises at home, perhaps giving them a handout about how this can be done. Some patients really can't find a way to do this Some patients really can't find those muscles or don't feel like they're really contracting the muscles correctly. Or unfortunately there's been, you know, studies that show if you just tell people to do Kegels or hand them a handout, something like 50% of women are doing them wrong or actually are, are bearing down or doing Valsalva instead of contracting, which is counterproductive. So I, you know, as in, in my practice, when I do a pelvic exam on this patient, the first time I see them, I assess the muscles to make sure they're not tender. And I ask them to try to do a Kegel. If they really can't do a Kegel, or if it's really weak, I'm not going to just send them off to do Kegels. I'm going to recommend that they see a work with a physical therapist or another therapist. Biofeedback is just an adjunct that biofeedback and electrical stimulation, I should say, are just adjunct, adjunctive therapies that go along with pelvic floor strengthening. They may help particular patients when they have trouble finding those, those muscles, but there's, there's no, the evidence doesn't suggest that, that outcomes are any better by adding that really to just good pelvic floor physical therapy. And I, I kept, I put this picture here just to remind you all about the pelvic floor. When we say pelvic floor muscles are really talking about the levator muscle and the deeper coccygeus muscle. And the levator muscle is this one here you can see with three, three sections, the puborectalis, which is kind of closest to the vagina, the pubococcygeus and iliococcygeus. This is a picture of, for instance, of a patient if they're in lithotomy position. And when I am assessing them to see if they can Kegel, I just put one, you know, one or two fingers in kind of the more distal part of the vagina, not deep, and just ask them to try to contract their pelvic floor or do a Kegel or squeeze the muscles around my finger or contract the muscles that you would contract if you're trying to hold in gas or trying to slow your urine stream. Those are different kind of coaching phrases I use. And then I kind of, I should feel the pelvic floor lifting a little bit under my finger or even, you know, squeezing around my finger or gripping in somebody who's really strong, you'll actually feel circumferential squeeze and your finger will get pulled inward toward their belly button. Okay. So when, you know, pelvic floor training, and in the slide before I really was talking about strengthening, so doing exercises every day that strengthen these muscles that will help stress and urge incontinence, but the best help for urgency incontinence is then to learn how to use the muscles to suppress urgency. Some people call this just urgency suppression techniques. We call it here at Iowa, the reason squeeze technique. And we give people a handout with these kind of pointers. So when you get the urgency, stop what you're doing, relax all your muscles, but do several quick, strong Kegels or squeezes of the pelvic floor. So quicker than you would do if you were strengthening usually. So squeeze, squeeze, squeeze, squeeze four to six times. Again, take some deep breaths, relax the rest of the body. You should feel the urgency start to subside a little bit, and then you can walk to the bathroom and hopefully get there to empty the bladder without leaking. That's my little coaching spiel for patients. And this really works in people, you know, who have some control over their pelvic floor. And as they get stronger with contractions, this will work even better. So patients are often pleasantly surprised that this works. Okay. I'm going to, bladder training is something that works better if you can really be in contact with the patient and give them a lot of education. So it's even difficult to do from our office, but we basically find a shorter avoiding interval where they seem to be able to maintain control and not leak. And then ask them to empty at that interval all day for two or three days. And if they're able to get to the bathroom and not leak at that interval, say they're avoiding every hour on the hour for that period of time or every 90 minutes, for instance, then they slowly increase that interval over time. And it kind of trains the bladder to hold more urine. I tend to do more timed or scheduled voiding instead and just recommend people avoid every say two hours during the day or two hours in the morning. And every three hours in the afternoon is a common kind of schedule I'll recommend for patients. And then the last couple of big topics here. So for stress incontinence, the other non-invasive therapy after behavioral things and pelvic muscle strengthening are vaginal devices. So either incontinence pessaries, which typically we get in the office. So some primary care providers, family medicine providers, definitely general OBGYNs will provide pessaries in their office. They have to be fit for the pessary and given instructions on how to kind of maintain it. Most of our patients actually, especially with incontinence pessaries will remove the pessary themselves once or twice a week at night, leave it out overnight, put it back in the next morning. Some patients take it every night. Some just wear it for the activities that make them leak when they're using it for stress incontinence. We have some patients with incontinence who aren't able to maintain the pessary themselves or remove it. And they might come to the office just like they do for some prolapse pessaries for changing. There are also over the counter vaginal inserts. The one here to the far right is the Impressa that is shaped a little more like a tampon as they're inserted that way. And then it opens up and kind of lifts under the urethra. And then this one is called Revive. You can get it on Amazon. It is a disposable insert that is a little bit more like a pessary. It's a ring. It is inserted though a little bit like a tampon with this applicator in this middle picture. And the patients can use it for up to a month on a daily basis. You can leave it in a little longer and then you dispose of it and put in a new one. The Impressa you just use one day and then throw it away. So it can get expensive if you have to keep buying more. All right. So I'm going to focus several minutes on urgency incontinence and overactive bladder medications because this is a really common treatment option for patients in more of a primary care setting as well as when they come to see a specialist. These are for urgency incontinence and overactive bladder. There are no medications that we use typically for stress incontinence. There are certainly none that are FDA approved for stress incontinence. And you can see there are now a lot of these medications. The most common one that people are familiar with often is oxybutynin and that is immediate release or extended release. And that is one of the most common ones used because it is often available as a generic drug and it's inexpensive and insurance will cover it. But it tends to have more side effects. And some of the newer anti-muscarinic medications here in the bottom are more daily and they tend to have somewhat fewer side effects. The efficacy is pretty similar across the board. So just going to my next slide, these I've divided it up. So these in blue are kind of all the different anti-muscarinics or anti-cholinergics. And in the green at the bottom are our newest class of medications for overactive bladder. And those are the beta-3 agonists. And these generally have a pretty equivalent efficacy to anti-muscarinics. They do not have the side effects that go along with anti-muscarinics or anti-cholinergics. Some of the mild side effects that you might see would be headache or navel congestion, but they're actually really well tolerated. Mirabagiron may increase blood pressure a little bit. And so we don't prescribe it in patients who have uncontrolled hypertension. And in people with hypertension, you might just need to monitor that a little bit. And the newest in this class is called Vibagiron. This has been approved for two to three years now, I think. And it's slowly getting on more plans in terms of coverage. It doesn't have, it only has a single dose and it doesn't have the hypertension side effects, which is nice for some patients. Now, the biggest change in terms, I've been giving this talk a long time as kind of like a visiting professor in the state of Iowa, we go out to community family medicine programs. And so this is a common talk I give to these programs. And things haven't changed that much, but the next couple of slides are important. So we now know that there is increasing evidence for an association between anticholinergic drugs and cognitive impairment and dementia. And this extends to those anticholinergics, anti-muscarinics we use for overactive bladder or urgent continence. There is now a lot of this mostly epidemiologic data, but there are systematic reviews putting them all together. And there definitely appears to be an association despite some limitations to these data in that mostly they're observational. The risk may be small for the risk of dementia, but maybe not so small. You know, dementia is something that all our patients are concerned about. We don't have the best treatments for once people have it. And so probably prevention of dementia is imperative. You know, that's something that we need to do. And, you know, one big systematic review calculated that the number needed to harm was 37, although there's pretty wide confidence intervals of 20 to 100. But meaning, you know, if we prescribe oxybutyn an immediate release to 37 individuals, trying to remember that particular study, whether it was over three months or over a year, that there's one increased case of new dementia. So not so small to, you know, in my mind. It's possible that some of the newer anti-Muscarinics have lower risk and we just don't know for sure yet because most of the data, long-term data was from oxybutynin. And there is some evidence though that specifically looks at the risks in populations of people getting treated for overactive bladder and those getting an anticholinergic compared to these beta-3 agonists did have the higher risk. So this has led to a big change in our practice in the last five to 10 years, especially in the last two to three, I'd say. And there are now some new expert recommendations and the overactive bladder guidelines are gonna be, from the AUA are gonna be revised in the next year, probably published in 2024. And I think that we'll see some big changes. The expert recommendations from some of the people who helped make the guidelines, and this is not yet at the guidelines, you know, strength of evidence or strength of recommendations, but it's more expert recommendations that when we start drug therapy for overactive bladder or urgency urinary incontinence, a trial of the beta-3 agonist is preferred before using an anticholinergic or anti-muscarinic. This is a change. This is saying we should be using mirabegrin or viabegrin before starting one of the other drugs. And the second guideline that was most applicable for this talk is that when we use anticholinergics for overactive bladder, we should avoid immediate release oxybutynin and try to use alternatives with more favorable neuropharmacological profiles like extended release drugs at a minimum, or potentially those extended release drugs that may be safer. And this is based on different pharmacologic properties of these molecules and different data that are out there and potentially trospium, which doesn't appear to cross the blood-brain barrier. Maybe derefinitin and vegetaranin might be the safest among these newer anti-muscarinics. The data is still, I think it's a little weak though to know for sure. So what should our approach be for overactive bladder and urgency incontinence? And here's what we're recommending. We are really using these much less frequently in our older adults, although potentially the risk goes for younger people as well because it increases with duration of use. And this is a condition that it can come and go, but if somebody starts it at a younger age, there is some likelihood that they're gonna need it off and on as they age. We do more individualized counseling about the risks. We look at their other medications and think about overall burden of anticholinergics. And we really talk to people about balancing the risk and benefits. If they really, if we think this will make a big quality of life difference for them, they may consider that this potential small risk of future cognitive dysfunction or even maldementia is worth it. People who are on a lot of medications are already worried about their memory, or they are not a good candidate for anti-muscarinic therapy. And we're not using these drugs in them very often. If we feel like it's worth something, trying something because of their, the severity of their symptoms, it's really impairing their quality of life. I would, I often would start with like those meds that may be safer like Trospium. We try to use Mirabagron and Vibagron, but a lot of our patients, this is not yet covered and they just financially cannot pay for these. Sometimes we can get them covered by filling out like PA, you know, the prior off forms and things. And maybe importantly in patients who are at risk and we don't think they're a good candidate for anticholinergics, we can offer them some advanced therapies earlier in the treatment algorithm. And I'm going to bring those up at the end. So I'm actually going to, I'm going to fast forward because those were kind of repeat slides. So just as a reminder, here's our treatment algorithm. We're going to evaluate patients with a history, a physical exam, including one, at least one pelvic exam and a urinalysis. We're going to help, we're going to use those data to try to get a clinical diagnosis of stress or urgency incontinence, or maybe both mixed incontinence. Generally starting by, you know, reminding them about lifestyle modifications like reducing caffeine and carbonated beverages, reducing excessive fluid intake, talking about controlling constipation and weight loss. And then when we are focused more on stress incontinence, we would offer pelvic floor muscle exercises, potentially physical therapy and or vaginal pessaries or inserts, these devices. And then for urgency incontinence, when that's the predominant symptom, we will offer the same pelvic floor strengthening and PT, maybe also giving them some education about urgency suppression with their muscles and then offer them potentially medications. So that is a quick summary of all of the kind of noninvasive options and the initial things that we would typically recommend. Now, if those things aren't successful, aren't successful, then we should potentially either reassess and try something different, or I would say consider referral or in those patients who are more complicated to start, it may be that referral is reasonable from the beginning. Okay, so if you refer a patient, what might we offer them? Because, and that could be referring to a urogynecologist, to a urologist who, you know, takes care of women with incontinence problems. And some patients and some providers just aren't really aware that there are other things to do. I mean, I often see women who have had urgency incontinence for some time, and they've been on and off meds, and they've tried PT and changing their behaviors. And they say, you know, I just didn't really think there was anything else out there. So we need to educate patients. And so I'm trying to educate you all that there are other things that we can do. Most people know there are more for stress incontinence, but not everybody for urge incontinence. So for stress incontinence, if those initial things aren't working, we can offer procedures or surgery. Urethral bulking injections we can do in the office under local. Sometimes we don't have to, patients on anticoagulation don't have to stop that. So that's kind of a nice, less invasive and less risky procedure. And then there's surgery. The most common surgery we offer are midurethral slings. We have great evidence to support their use and the duration of their success rates. And they have a pretty long durability. There are single incision slings. There's non-mesh or autologous fascial slings. And then there is the Burch's procedure, which we use not as often, but has less risks without any mesh implantation. It also is, success rate is not as durable. We know that, it's a good procedure for some patients. And then we have the urgency incontinence treatments. Those who are unable to get improvement with all their behavioral therapies, PT, exercises, lifestyle modifications and medications. We have other neurostimulation therapies available ranging from office-based Botox injections. Again, we do it under, we do them in our office under local and peripheral tibial nerve stimulation. There's what's been around for a long time as percutaneous, which is more of an office-based therapy, very low risk, but requires more office visits. And now just recently, there is a small implantable device that's implanted over the tibial nerve in the ankle area and can do stimulation then at home. And then of course we have sacral neuromodulation, which is more surgery, minor two-stage surgery to help patients with refractory urgency incontinence and overactive bladder. So just in my conclusions, then we'll get to some questions. Incontinence is common and bothersome. Our job as clinicians to try to identify if women have stress urgency or mixed incontinence and do this basic treatment, basic evaluation, and then offer non-invasive treatments. Most patients can get improvement from behavioral and or pharmacologic treatments. So, you know, it makes sense to offer these things in the primary care setting. And if patients are more complicated or they don't get better, those are the patients that should be referred or reassessed. I do wanna just say that the American Ergonomic Logic Society or AUGS, we do have some resources and we have some QR codes here. We have our Voices for PFD website, which is our patient-facing website, which offers a lot of education and some community kind of groups that they can get on and get questions answered. And then we have a relatively new book that's Pelvic Floor Health for women who are pregnant or postpartum. It's kind of like the pregnancy book, focusing on the pelvic floor. This is something that you can tell patients about. It's available on Amazon. It's not too expensive. And then we have provider resources also. We're increasing our resources for primary care providers on our website. We have handouts, patient education sheets that you can print about incontinence, about different treatments. Yeah, and I just wanna say that we have our big annual meeting coming up in October, which I'm very excited about in Portland. It's also available virtually. So if you have an interest in incontinence and prolapse, you can look at the schedule, see if it looks interesting to you and register on our website. And we, oh, of course I've gone a little longer than I meant to, but I'm gonna go to the Q&A section here. And if people have more questions, feel free to add a few more. Okay, so... Actualized cost data according to current inflation rates. You know, I can't do that in my head. I'm sure it is much higher than I had on that slide. The 25 million was impacting the economy, and that was published near the end of the 2000s. And I honestly couldn't find one the last time I looked that was a little newer. So I don't have that data. Will the hard copy be made available to us, please? I'm happy to share my slides in a PDF, but I don't know the mechanism of how that happens behind the scenes. But it looks like somebody is helping me with an answer. And the question has been answered live. Let's see. Can Botox injections help with stress urinary incontinence? No. So Botox, well, so you may be thinking about a couple of different Botox injections. So for urgency urinary incontinence, we do Botox injections in the actual muscle of the bladder wall. So we put a scope into the bladder and inject the muscle, which is really the lining of the bladder. It doesn't help stress incontinence at all. There is some evidence to support the use of Botox in the pelvic floor, not in the bladder or urethra, but in the pelvic floor muscles. And that's actually done for chronic pelvic pain or severe high tone pelvic floor muscle dysfunction that is sometimes associated with difficulty emptying the bladder or the bowels or with painful sex. And it can be helpful for that. Although while there's some evidence that supports it, it's not yet approved. It doesn't have, there's no FDA indication for this, and it's generally not paid for very much, too much by insurance companies. Starting to get a little paid for that, but not for stress incontinence. And then what do you think of PRP injection? I will say that I'm not very hopeful that we're going to see a real improvement. There was, there's been one center in Europe that's had success with this, I think, and they've published some small case series mostly. I think there was just a recent randomized trial that was published. And we actually, I worked with a couple of urologists here at Iowa who just did a randomized trial and we haven't published it yet. It only, it was three month outcomes and it was a small trial, but we didn't see any improvement. So, so far don't see too much help from that. Maybe in the future, you know, different treatment protocols might be helpful. The implantable PTNS, there are several devices in the works. Right now there's one that the FDA approved. It's called E-Coin and it is a, it is a kind of minor office procedure to implant this over the tibial nerve in the ankle. And then it heals and then it stimulates that nerve and it has kind of a preset stimulation pattern. It's very new. So I know that there are like, we have, one of my partners is just getting trained on this. So I don't have a lot of information yet about, like we don't yet have good studies that show us like which patients are going to respond the best to this or we don't have a lot of information on real long-term outcomes. And I have no practical information about in whom it's covered because it's so new, but it is exciting to have that to offer. And there's another implantable device that is undergoing, you know, good trials right now that it sounds like may also be approved within the next year or so. Bariatric surgery before, this is a great question. Before or after ante-incontinence surgery. So I've had both kind of followed both approaches with patients and it depends a little on the patient. We have some evidence that the success rate for a sling is not quite as high in obese patients as in non-obese patients. But we also know that the complication rates are not any higher in obese women. So I sometimes counsel patients and I usually recommend the bariatric surgery first if they're at the place where they could get that surgery, they're already looking into it with the idea that it may be less technically challenging based on their BMI to place the sling really well in the future if they still need it. Many may still need the sling. I've had some patients that really feel like they can't even exercise at all because of severe stress incontinence and they need to start exercising and lose some weight before they kind of go to bariatric surgery. And I will offer those patients a sling in that setting. But we don't have, other than knowing that the success rate overall is a little bit lower, we don't have other evidence that really suggests one pathway is better than another, I'd say that's probably a patient independent. So I really appreciate everybody joining. I think that's the end of the questions that were submitted. I really appreciate your interest in treating this important problem and pelvic floor problems in our patients. So thank you very much. This concludes the webinar.

webinar

Urinary Incontinence Essentials for Primary Care

Dr. Kate Bradley

urogynecologist

University of Iowa

American Urogynecologic Society

urinary incontinence

types

evaluation

non-invasive treatment options