1. Incontinence:Evaluation and Management Bernard D. Morris, Jr, MD, FACS Killeen Hemingway Clinics Scott&White

2. Prevalence of Incontinence • Women 30-60 years of age • 30% have some type of urinary incontinence • Increasing population of active, healthy women over 60 • Decreasing morbidity of Rx options

3. Incontinence Underreported • Embarrassment • Misunderstanding of causes • Low expectation of benefits from treatments • Never asked by provider • Patient does not want to “bother” provider

4. Incontinence- Cost • Financial • Physical • Psychological • Indirect costs of consequences • Loss of independence

5. Types of Incontinence • Stress Urinary Incontinence • Urge Incontinence • Mixed Urinary Incontinence • Stress-induced Urge Incontinence • Overflow Incontinence • Cognitive/awareness issues

6. Evaluation of Incontinence • Focused history • Focused physical examination • Objective demonstration of SUI • Post-void residual

7. Indications for Urologic Evaluation • Hematuria • Large post-void residual • Abnormal urine cytology • Refractory symptoms after failed aggressive rx • Neurologic diagnosis

8. Urge Incontinence • Medical management • Improvement in molecular characteristics • Improvement in delivery systems

9. Urge Incontinence • Physical therapy • Biofeedback • Peripheral nerve stimulators

10. Urge Incontinece • Surgical options - rare • Interstim • Botox injections • Bladder augmentation

11. Other diagnostic testing (prn) • Voiding diary • Urodynamic evaluation • Cystoscopy • Imaging studies

12. Indications for diagnostic tests • Diagnosis unclear • Mixed incontinence • Prior pelvic floor surgery • Neurogenic diagnoses • Hematuria/pyuria • Large post-void residual • Grade 3-4 prolapse • Dysfunctional voiding

13. Stress IncontinenceNon-surgical Rx • Physical therapy • Biofeedback • Acupuncture • Nerve stimulators Appropriate patient selection and expectations

14. Stress IncontineceSurgical Rx • Retropubic suspensions • Slings • Injectable agents • Artificial Urinary Sphincter

15. Retropubic Suspensions • Gold standard for long-term results • 75-85% at 48 months • Retention 15% • Post-operative complications involving intestines/ureters • Invasive

16. Slings • Continuous evolution of materials and techniques • Autologous vs synthetic • Bladder neck vs mid-urethra • Retropubic vs trans-obturator vs needleless • Adjustable sling

17. Slings • Retention 3-8% • Erosion/infection <5% • 85% success at 48 months • Decreased morbidity has led to expanded population of appropriate candidates

18. Injectable Agents • Sub-mucosal bulking agents for intrinsic sphincteric deficiency (type 3) incontinence • Lack of the ideal bulking agent • Minimally invasive, local anesthetic

19. Injectable Agents • Teflon • Autologous fat • Collagen • Calcium hydroxy-apatite (Coaptite) • Inert synthetic agents (Durasphere)

20. Artificial Urinary Sphincter • Limited indications in women

21. Stress IncontinenceManagement • Patient selection • Patient expectations • Patient preferences