Underdiagnosed and undertreated, loss of bladder control is a common issue that both embarrassed patients and time-pressed clinicians often hesitate to mention. Yet pelvic floor disorders, such as stress urinary incontinence and fecal incontinence, take a toll on psychosocial well-being and have a range of effective treatments available. In this talk for PCPs, urogynecologist Olga Ramm, MD, MS, offers simple, quick ways to assess older patients for these issues; presents success rates and complications of various therapies, ranging from pessary use to injections to surgery; and discusses how to match the treatment option to the individual’s condition and preferences. Learn why subspecialty care pays off in the long run and how UCSF experts approach advanced techniques, such as sacral neuromodulation, to boost patient satisfaction.
I was tasked to talk today about disorders of the lower urinary tract, um, so the bladder and the pelvic floor, since oftentimes they're connected and give a general, um, clinical overview. And so we've all kind of heard of the pelvic floor, but, um, for, for a lot of um Practitioners, I think it is sort of mystical entity. So I've, I've tried to include a picture here, and it basically shows the bony pelvis, um, and you can see that the entire base of the bowl here is made entirely of muscle. Um, and that muscle connects to each other, to the connective tissue, to the bones themselves, and also acts as the conduit through which, um, not only blood vessels, but nerves and pretty sizable nerve fibers run. Um, and the pelvis itself houses um the, the organs that are affected by pelvic floor disorders, so specifically the bladder, the uterus, if the patient has one, and, uh, the, the rectum and large bowel. Uh, so then what are pelvic floor disorders? Well, the most common pelvic floor disorders that we see in the geriatric population are really a continuation of neuromuscular disorders, and those are urinary incontinence, anal incontinence, and pelvic organ prolapse. So you can see that by far the most prevalent pelvic floor disorder is urinary incontinence and um I don't know if you guys kind of see this and are able to appreciate it in your practice, but, um, lots and lots of women, um, suffer from urinary incontinence. But you may hear less about, but it's actually second most common in prevalence is fecal incontinence. And there's just so much shame um around talking about it, and there's also a a kind of a lack of expectation of treatment around it. Um, so this doesn't get mentioned nearly as much. And then pelvic organ prolapse is essentially a herniation, so let me just kind of show. Um, so you can see that the, the general shape of this pelvic floor muscles roughly, um, resembles a U shape, like a horseshoe going from one side of the pubic bone around all these organs, the urethra, the vagina, the rectum, to the other side. And so with pregnancy delivery, genetics, menopause, aging, living life in general, the arms Of those, of those U-shaped muscles tend to sag and separate, allowing for herniation of the organs through this supportive shelf, and that, um, results in pelvic organ prolapse. And that's obviously a much higher level of nerve and muscle dysfunction that actually shows up as an anatomic rather than just a functional limitation. So it's a bit less common. Um, So the prevalence of pelvic floor disorders uh increases with age, and uh by the time they're in their 8th decade, about 1 in 8 women, um, has had surgical treatment of, uh, a pelvic for a pelvic floor disorder. Most commonly. Prolapse or urinary incontinence. And that's obviously just the iceberg above the water that we can see is the surgical treatment. And then there are all the people that are maybe either, um, too frail, ineligible, don't have access to, aren't aware of treatment, that are, that are not getting treated. But just, um, Just that above water tip of the iceberg represents about 250,000 operations annually in the United States, and um the unfortunate piece of it is that there's about a 30% reoperation rate. And so when that data was published, both the American Board of OBGYNs and American Board of Urology, which are the, the governing boards that um certify clinicians and surgeons in our specialty. Um, pushed to create subspecialty certification in neuro gynecology and reconstructive pelvic surgery to kind of make sure that the patients are actually ushered to the appropriate correct procedure that is most likely to yield the outcomes that minimize complications and recurrences. Um, so what causes pelvic floor disorders? Well, there are some predisposing factors which are basically the genetics you're born with, right? Like people with Ehlers-Danlos syndrome or other collagen disorders, um, or people with, um, spinal cord dysfunction, spina bifida, you know, are, are obviously at greater risk. And then probably the unifying factor for women is childbirth, which results in tissue damage and nerve injury. Uh, roughly 84% of women in the United States have carried a pregnancy and given birth, so this is a fairly ubiquitous risk factor, and then Aging and specific promoting factors, some of which are modifiable, like smoking and weight, and others that are not, again, like, uh, genetics, um, and, and comorbidities, diabetes, other things that affect the, the peripheral nerves will further modulate this. Tissue damage, the muscle tissue damage and nerve injury to then eventually surpass the threshold at which normal function is expected and cause symptoms of pelvic floor disorders. So, urinary incontinence is at least as prevalent as some other conditions that probably receive a lot more um airtime. Um, you can see it here roughly 30%, and it's expensive to boot. These are the direct and indirect costs, and this is in um $2001 so we've had quite a bit of inflation since then. So it's probably now pushing well over $35 billion if I had to guess. Um, so, urinary incontinence is common, expensive, underdiagnosed, and undertreated. What we know based on population-wide, uh, questionnaire-based studies is that 1 in 3 American adults is living with the loss of bladder control. Of those, 87% are undiagnosed, probably because they don't self-report or they're not asked. Um, if we look at community dwelling women, which, um, Uh, you know, again, I don't know if that's entirely your practice population, but 16% of those suffer from, uh, urinary incontinence that's bothersome. Um, that number goes up to about 20 to 40% of women in midlife and beyond, and upwards of 50% of women who, um, are, uh, in, in some kind of assisted living or institutionalized setting. Um, So fewer than 50% of people with bladder control problems reported to their healthcare provider, and the reasons are individual and multifactorial, and there's obviously the influence of culture and access to healthcare as well, but a lot of common themes that emerge are that people are embarrassed to bring it up without being asked. Um, that they have low expectations of benefit from reporting that they or their community and or their community have normalized these symptoms, and they have a lack of information regarding management options or their success rates. Um, a lot of people use the availability of absorbent products like pads or diapers as a crutch rather than kind of trying to Um, resolve the underlying issue, and they're not queried about it, they're not asked about it at their visits, which is again understandable given that there, there's so many pressures, um, and so many check boxes to check off during a visit. Um, the individual consequences of urinary incontinence have been well described. Um, in addition to kind of lack of attention to, to personal hygiene, a lot, and, and sexual difficulties, a lot of them are actually psychosocial. So there's a loss of loss of self-confidence and self-esteem, which leads to, uh, self-isolation, reduction in social Activities, which oftentimes leads to both psychological, but also neurological decline and functional decline. And, uh, in women, um, urinary incontinence, um, is, is a, is a risk factor that increases the risk of institutionalization twofold. Um, so as your gynecologist, the myths that we typically try to dispel about urinary incontinence is that it, it's, it shouldn't be considered a normal part of aging, even though it is common. It's not strictly a female problem. Successful treatments are available and they can be successful in the long term. Um, so the most common type of urinary incontinence is stress urinary incontinence. This is defined as leakage with exertion, such as coughing, sneezing, jumping, running, other exercise, or even lifting and bending. And the etiology is that there's a weakness either in the small urethral sphincter muscle at the bladder outlet or the nerve that supplies that muscle. So essentially what I tell patients is like, if you have a water balloon with a spigot and a knot on the end, if The, if the knot is loose and you start mashing on the balloon, there's gonna be leakage. There's a very reliable, simple, one question, validated questionnaire that can be, uh, you know, orally administered to the patient. And you basically say, in the last 3 months, have you leaked urine when you cough, sneeze, laugh, um, jump, or exercise? And if they say yes, then you can get a sense of whether it bothers them. And does this bother you? And if it does, then, you know, they're they're probably somebody who Can either be counseled about or referred to your gynecology for management. So OK, there we go. So, management, um, Ranges from very conservative to more invasive. Um, you know, part of it is healthy, good, clean living is what I, what I call it to patients. So, uh, we were actually a site that that published the study about the impact of weight loss. Even a 10% reduction in, um, total body weight can, can lead to almost a 50% improvement in incontinence symptoms. The caveat is that this is for obese or morbid. Obese patients, not for those of normal weight. Um, pelvic floor muscle strengthening with or without individual one on one work with pelvic floor physical therapy. And then, um, more immediate relief for those who are seeking it with pessary, which is an intravaginal device that's placed and has this sort of condensed knob that sits under the urethra, acting as a speed bump and preventing, um, leakage. Um, surgical options exist as well, and the gold standard first line surgical approach for women who don't have contraindications to it, like, uh, a kidney transplant or or pelvic radiation are minimally invasive mid-urethral slings. The one that I've shown here is a retropubic approach. They're different. Approaches that can be used. And in short, they take about 20 minutes of surgical time. It's a same day procedure, and the success rate is quoted at around 80 to 85% objectively, while the subjective satisfaction rate is in the 92% to 95% range. Um, it seems that the best predictor of success is baseline neuromuscular function. So the, the healthier you are, the better you'll do. Um, but it is, it is definitely a treatment option that has been widely studied even in elderly populations, so, um, defined as folks 70 and higher and, um, and still has excellent subjective satisfaction rates, albeit lower objective cure rates. Um, we also pride ourselves on being a center that's able to offer non-mesh surgical options to patients who are not candidates for mesh or maybe have misgivings about it. Um, and then for, for those patients who are too frail, even for the minimally invasive, you know, sling operation which still does require most often, um, general anesthesia. Um, albeit brief, uh, we can, we can still help them with an in-office procedure called urethral bulking. So we basically inject the hydrogel under the urethral mucosa to kind of help co-opt it. It doesn't seem to have the same, um, long-term durability, uh, but has excellent satisfaction rates. OK, so I'm switching gears a little bit. So we talked about stress incontinence, which is super common. The second most common type of incontinence, and this becomes increasingly common with age, right? Like stress incontinence, you're probably gonna have people in their 40s, 50s, 60s, 70s complaining of it. As people start to slow down and expect. Less of their bodies, stress incontinence becomes kind of less of an issue, right? Like I just this morning spoke to a patient who, um, has some, some other issues, but was kind of saying, oh yeah, I had really bothersome stress incontinence. But then I had a back surgery and a discectomy, and now I have too much pain to exercise. So my stress incontinence isn't an issue, right? Um, and so oftentimes aging and frailty will kind of gradually take stress incontinence out of the picture and bring urgency incontinence and overactive bladder to the forefront. I put this in here, um, for, for those of you that are able to see the screen, um, just to, um, illustrate all the different levels of neurologic. Um, control that go into adequate bladder control, right? So there's, um, there's bladder storage, and there's bladder emptying, and storage has to happen in a way that is sort of this gradual crescendo that doesn't actually cause sensations when your bladder isn't full, but does cross the threshold at an appropriate time to give you out What time to triage and react to that, to those symptoms of bladder fullness, and then to actually initiate, uh, matuition at the appropriate time. And so, urgency incontinence, by and large, most commonly is idiopathic, but it is also a primary presenting symptom of almost every neurologic disorder, from MS to Parkinson's to, um, um, Spinal cord injury to stroke. Um, so before we delve into kind of idiopathic urgency incontinence, um, especially in the frail elderly population, it's, it's, it probably is important to rule out non-idiopathic causes of urgency incontinence, and this is You know, some of the work that we do in that initial evaluation with patients. So, you know, we wanna make sure that they're not delirious and I should probably add dementia to this as well, cause people sometimes just forget to go to the bathroom. Um, or are, are not cognitively intact enough to, to realize that the urgency symptoms they're getting requires some kind of action on their part, in which case, you know, it takes the caregiver just taking them to the bathroom every X many hours in order to empty on a time schedule. Um, infection, like a UTI or any kind of, you know, irritative bladder, um, issues such as stone or even bladder cancer. Less common in women, but also diagnosed at much later stages because people have a lower index of suspicion. Um, atrophic vaginitis, probably very common in your patient population, the female patient population. Um, pharmaceuticals specific ones are, are likely to cause, um, polyuria and urgency incontinence, um, psychiatric and neurologic disorders, um, as well as things like excess urine production. So that can be due to diuretics or it can be due to endogenous causes like sleep apnea as. One of the most common causes of nocturnal polyuria. And then depending on the patient's cognitive and functional status, that can be either nocturia, like nighttime frequency, which obviously is disruptive and annoying, or it can be bedwetting, which is more often disruptive and annoying to the, to the caregiver than to the patient, him or herself. Restricted mobility, like functional incontinence and uh stool impaction um and including just, you know, constipation does not have to be the kind of impaction that lands the patient in the ER. If they're constipated, likely their urgency incontinence is gonna get worse. And then if you didn't catch it, the spells diapers with two P's. So, um, the single question to ask when diagnosing urgency incontinence is in the past 3 months, have you leaked urine when you had the urge or the feeling that you needed to empty your bladder but couldn't get to the toilet fast enough? And if they say yes, then does this bother you? Um, my caveat to that is that, you know, this is the way I explain this to patients is that there's an aberration, like a lack of crispness in the communication, in the nerve communication between the bladder and the brain. And sometimes those, those two are so um kind of Disconnected, that the patient doesn't feel a sensation of urgency, in which case they report like, oh, I just stand up from sitting at my computer for a few hours and your urine just pours out. Again, that's most likely urgency incontinence that they're they're just not actually registering the urge. So again, urgency incontinence treatments range from conservative to to less so, depending on the degree of bother. The first line modifications are kind of healthy bladder behaviors that we recommend to everybody, including adequate, not excessive fluid intake, which is about 50 ounces for 24 hours, and in our really frail patients with um lower lean. Body mass, we even recommend 40 ounces. Avoiding bladder irritants like caffeine and alcohol, um, stopping food and fluid intake 2 to 3 hours before bedtime, depending on the patient's age. The older they are, the, the earlier. Um, treating or preventing constipation, you know, polyethylene glycol or MiraLax is, is my favorite agent for that cause it's so well tolerated, so patients tend to adhere to it. And then bladder training basically time voiding every 1.5 to 2 hours, and you can look at their fluid intake and their kidney function to kind of guesstimate um how often they should go in order to prevent um a leak. And so Laura, this kind of um uh dovetails into your questions. So then, 2nd and 3rd line treatments, we're actually moving away from that. Like recently our society came out with guidelines saying that we shouldn't really think about them as 2nd and 3rd line treatments, and rather what is best for that individual patient and meets their goals, right? So in the frail and elderly antimuscarinics are probably not the best um option, um, as they are increasingly associated with dementia and we're, you know, gonna actually um Hopefully very soon publish a study specific to dementia in patients with overactive bladder, um, because the bugaboo around this from the internal medicine journals has been, well, overactive bladder is an early symptom of neurocognitive decline. So is it the chicken or the egg, like did they Did they get dementia cause they had overactive bladder and we're probably gonna get it anyway, or did they get dementia because we treated their overactive bladder with antimuscarinics? Well, our patient population for this study, actually everyone has overactive bladder, so that kind of nullifies that question. And yet, patients who used antimuscarinics had a significantly higher odds over twofold of um dementia and cognitive decline, and there was a clear dose response in terms of duration of use and all of that. Um, so lots of folks are, are, uh, switching to beta 3, some pathomimetics like Mirobagron, um, as the, the preferred treatment of choice. Those are pretty well tolerated, but there's about a 5%, um, incidence of uncontrolled hypertension. So for folks that already have, um, hypertension, that's maybe difficult to control or on multiple agents, it's not the best, um, first line therapy. Um, For people who are looking for a very quick, um, fix in the sense that, you know, they don't wanna wait for the medication onset, etc. They just wanna be better within a day or two. There's intradetrusor Botox injections, which we do in the office under cystoscopic guidance. Um, the, uh, this is the, the treatment that is most likely to cure urgency incontinence rather than reducing the severity or the frequency of episodes. Um, and again, it is covered by insurance. The side effects are urinary tract infection cause it's an invasive procedure, and also urinary retention. Urinary retention rates range from as low as 2% to as high as, you know, approaching 10%. And again, you know, to your point, the, the, the differentiator there is age. So the more frail someone is, the less, um, Neuromuscular reserve they have, the more likely they are to go into retention. So we counsel patients about that, we check for it, etc. Nevertheless, 90+% of people never have urinary retention after Botox injection. So it is, it is definitely um You know, a treatment that that we discuss even with our octogenarians and and beyond. Um, for those people who are kind of, uh, into minimal invasivity and minimal risk, we offer peripheral nerve stimulation. Um, it's, it's kind of interesting actually, the, the bladder meridian in, in acupuncture and traditional Chinese medicine runs along the course in the ankle of the tibial nerve. And um in the late 70s at UCSF um the The tibial nerve was stimulated with electrical uh signals to to help patients with um both voiding and uh bladder control difficulties, and that's how peripheral nerve stimulation was born. And it has about a similar success rate as antimuscarinic medications. Again, no risk, all just kind of a time investment on the patient's part. Um, and this is, these are treatments that are done in the office. And if someone is too frail to come to the office, then we actually now, this was, uh, because of COVID, um, we started using electrode patches rather than um acupuncture needles in order to access the, uh, tibial nerve, and the data should be published soon that they're actually it's actually not inferior. So then we just have the patient come into the office. Our nurse practitioners teach them where and how to apply the patch, and then they can go home and do it anywhere from 3 times a week to even daily. And then sacral neuromodulation is um a treatment that that's used not only for urgency incontinence, it's also used for anal incontinence, and so it's, it's really highest yield in patients with dual incontinence. I showed you that Venn diagram. Um, it's very common for people who have urinary incontinence to also have fecal incontinence and vice versa. So it can take, it can improve symptoms in both, um, as well as idiopathic urinary retention. Um, and so Laura, for sacral neuromodulation, the way that we do it is we actually do a very simple in-office, what we call peripheral nerve evaluation. So with a little bit of local anesthesia applied kind of over the, the skin overlying the sacral bone, um, we place a very, very thin, tiny wire. And the patient wears that connected to a neurostimulator for a week, and they, you know, they've got diaries that they keep and validated questionnaires that they answer to help them assess at the end of the week, if their symptoms are at least 50% better or whatever threshold they choose to call it a success. Um, and so then if they're better, then we move on to the permanent implant, which is, um, done in the operating room, generally, um, under, under, um, uh. General anesthesia, we place the perman lead into the sacral third sacral forter into the S3 nerve root, and then we just kind of bury the little battery stimulator just above um the the buttocks and that little fat pad, the love handles that that that most folks have, um. And uh the battery life has actually been phenomenal. Now they can last 15 to 20 years and they're actually rechargeable batteries as well, um, probably, you know, less of a draw in, in the old population, cause then you do have to be a little bit tech savvy and recharge it, but only twice a year actually. Um, so, so either one's a good choice and um. The success rate of that approaches that of intradetrus or Botox injections. Um, so if somebody isn't able to tolerate intraditruse or Botox injections in the office, or they've had untoward reactions to Botox, or they have urinary retention or frequent UTIs as already. Um, then sacral neuromodulation is a better option for them. So irritative lower urinary tract symptoms, these kind of UTI symptoms and the absence of positive urine cultures, urgency frequency, etc. I think that I'm, I actually need to change, I'm, I'm, I'm not gonna follow this slide. Um, I'll just go back to this so you can look at the picture of the pretty chameleon. And the point of the chameleon is to say that there are lots of different conditions that can camouflage as or present themselves as irritative lower urinary tract symptoms or recurrent UTI symptoms. Um, and those range from atrophic vaginitis, vulva vaginal atrophy, which is super common in patients who are hypo. estrogenic to patients who have myofascial pain in their pelvic floor, which interfaces with the low back, the hips, um, hip flexors, like the whole hip girdle and anterior abdominal wall. And so by the time patients are 70s and 80s, etc. they've accumulated enough orthopedic problems. Problems that these oftentimes impact the function of the pelvic floor muscles, which are called upon then to compensate and do more than they're able to do. And these pelvics become tight and tense, uh, in part because they're called upon to do more, in part as a response to pain, right? The normal natural response of muscle to pain is to tense up. And then these muscles squeeze the little nerves and capillaries that run through them, which can cause these sensations of pelvic heaviness, urgency, frequency, not full, like the need to pee that's not fully relieved or comes back 5 minutes after voiding. Um, for patients who are sexually active, oftentimes these symptoms are worse following uh receptive intercourse again, because the muscles are stretched. Um, and there, you know, the treatment essentially reflects the underlying causes. So if there's significant myofascial pain, then we work with pelvic floor PT for deep myofascial release, core stabilization. If there's, you know, significant hip problems like PT to stabilize, change gait, maybe they need some kind of orthopedic device, etc. and then for uh atrophic vaginitis, we treat that, etc. etc.
