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Management of Post-Prostatectomy Incontinence (PPI) Primary Care Conference 2/25/04

Management of Post-Prostatectomy Incontinence (PPI) Primary Care Conference 2/25/04. MARY JO WILLIS, MS, APRN-BC CLINICAL ASSOCIATE PROFESSOR NURSE PRACTITIONER, USIM. OBJECTIVES. Discuss the incidence of incontinence in males post radical prostatectomy for Prostate cancer

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Management of Post-Prostatectomy Incontinence (PPI) Primary Care Conference 2/25/04

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  1. Management of Post-Prostatectomy Incontinence (PPI)Primary Care Conference2/25/04 MARY JO WILLIS, MS, APRN-BC CLINICAL ASSOCIATE PROFESSOR NURSE PRACTITIONER, USIM

  2. OBJECTIVES • Discuss the incidence of incontinence in males post radical prostatectomy for Prostate cancer • Address the common causes of the incontinence post prostatectomy • Describe which conservative treatments offer benefit • Describe the surgical options for treatment

  3. CONFLICTS OF INTEREST • I have not received compensation for this presentation • I have a personal interest in understanding what options for treatment exist and what works. • I wish to thank Dr Wade Bushman for his assistance with this presentation

  4. CASE STUDY • Patient is a 69 y/o w/m who underwent retropubic radical prostatectomy for prostate cancer 4/02. • Prostate cancer was a moderately aggressive Gleason 7 found on biopsy after patient had increased problem with nocturia, frequency and inability to completely empty bladder. No incontinence • PSA history 4.4 in 10/2000, 4.5 in 10/2001, and 5.0 at the time of diagnosis 4/02

  5. RISKS OF RADICAL PROSTATECTOMY COMPLICATIONS • Multi-center study of over 1069 men provided self reported incidence of incontinence, impotence, and bladder neck contracture /stricture revealed the following results: • Incontinence=65% • Impotence=88.4% • Bladder neck contracture/stricture=20.5% • Even though complications of post radical prostatectomy are common and affects overall quality of life, most patients would elect the same treatment again. Journal of Urology 163,858-864, March 2000

  6. GENERAL MALE POPULATION URINARY INCONTINENCE • Community population rate on incontinence in persons over 60 is 15-30%; 10-15% in women; 50% in institutionalized elderly • Prevalence rate on incontinence in men >60 in Michigan study in 1998 was 19% with • 34.9% had urge incontinence • 7.9% had stress incontinence • 28.9 had mixed • 28.3% had other • Ostomy/Wound Management 44(6), 54-59, (1998)

  7. GENERAL MALE POPULATION URINARY INCONTINENCE • Study conducted by questionnaire in one county in Minnesota assessing UI in men >50 in previous 12 months found a prevalence rate of 23% with: • 24.9% with stress and urge incontinence • 40.8% had only urge incontinence • 30.88% had neither stress or urge incontinence • 77.8% rated it as mild and 22.2% moderate to severe

  8. RISKS FOR PPI • Age • Size and configuration of the prostate • Size and location of tumor • Presence and degree of bladder outlet obstruction and detrusor muscle dysfunction preoperatively • Surgical technique and skill of surgeon: resection of neurovascular bundles, bladder neck preservation/reconstruction • Other studies found no association based upon the above variables nor cancer stage, tumor grade

  9. CAUSES OF PPI Injury to bladder • Bladder instability • Trigonal denervation (reduced sensitivity in the trigone with altered voiding sensation) • Bladder wall damage from longstanding outlet obstruction or decreased bladder wall compliance • Bladder outlet obstruction (BOO) causing overflow incontinence is rare

  10. CAUSES OF PPI Injury to the sphincter with • Difficulty emptying the urethra leading to post void dribble • Intrinsic sphincter deficiency/weakness is most common cause Sphinter injury, pudendal nerve injury Ischemia and immobilization by scar, atrophy Shortening of the urethra below critical functional length of 2.8 cm

  11. ANATOMY • There are 2 separate continence zones: • Proximal urethral sphincter (PUS) includes • The bladder neck, prostate and prostatic urethra to veru montanum • Distal urethral sphincter –DUS extending from the veru montanum to the bulbar urethra • Includes slow twitch intrinsic rhabdosphincter fibers that sustain urethral lumen tone • Fast twitch fibers of the periurethral extrinsic skeletal muscle layer that supplement the activity of slow twitch fibers • Intrinsic smooth muscle layer that is a continuation of the superficial layer of the detrusor muscle lining the posterior prostatic urethra

  12. POINTS OF DAMAGE POST OP • Either the PUS or DUS must be intact to maintain continence • After prostatectomy the PUS is destroyed and continence relies totally upon an intact DUS • During a radical prostatectomy, the proximal portion of the DUS is also removed • Continence therefore is dependent on an intact distal sphincter as well as normal bladder function (capacity and compliance without detrusor instability) • Any bladder dysfunction resulting in an intravesical pressure that exceeds that of the distal urethral spincter resistence leads to PPI • Urodynamically based studies point out that sphincter weakness with secondary detrusor weakness based upon reduced maximum urethral closure pressure, low leak point pressure and shortened urethral length lead to incontinence

  13. ANATOMY

  14. PROBLEMS DEFINING INCONTINENCE RATES • Krane(2000) and Parekh(2003) found incidence post op to range from2.5-87 % depending on definition, method and time of data collection • Centers of excellence research indicate overall rates from 6-20%;70-90% were dry at 1 year • Reported incontinence rates were influenced by the • Lack of consensus of definition • Optimal time to assess continence • Methodology • Inclusion of pts incontinent prior to surgery • Variations of operative technique

  15. PPI • Multicenter study: 1990-97 • Immediately after surgery: 81.5% • 6 months post op status=65.6%) • 53.9% <15ml • 23.2% notice leakage once or less daily • 44% used protection with 27% using pads • Most commonly used Rx was pelvic exercise (34%)

  16. PPI • Study by Gomha and Boone(2003) found • 100% of patients with stress incontinence • 48% with urgency and urge incontinence • 42% had delayed first sensation • Study by Chao and Mayo (1995) found • 57% reported sphincter weakness • 39% had detrusor dysfunction • 50% had combined causes

  17. PPI • Findings of Eastham et. al. from Baylor College of Medicine and The Methodist Hospital • Continence returned at a median of 1.5 months in pts treated since 1990 and 95% eventually regained control • Patient’s age (less than 70) and technical features of the surgery significantly improved recovery of continence (e.g wide resection of 1 bundle substantially decreased recovery), and increase in functional length of the urethra improved continence • Incontinence was largely refractory toconservative measures

  18. CONSERVATIVE TREATMENT • Urodynamic Testing • Role of Pelvic Floor Exercises • Commonly recommended • May be effective when employed in an intensive, supervised program • Improved continence at 3 mo (88% vs 56%). Difference diminished at 1 year (14%). [Van Kampen et al., Lancet 2000 355(9198):98-102] • Benefit of office based instruction is questionable • Sueppel et.al (2001) found that starting PFM exercises prior to surgery improved outcomes

  19. CONSERVATIVE TREATMENT INSTRUCTIONS: DIETARY IRRITANTS TO THE URINARY TRACT If your bladder symptoms are related to dietary factors, strict adherence to a diet which eliminates certain food products should bring significant relief in 10 days. The proof is resuming your old dietary habits followed by the return of your symptom complex. Once you are feeling better, you can begin to add these things back into your diet, one item at the time. This way, if something really does cause you symptoms, you will be able to identify what it is. When you do begin to add foods back into your diet, it is crucial that you maintain a significant water intake. Water should be the majority of what you drink everyday (approximately 1-2 quarts a day).  Mayo Clinic Urology Clinic 11/02

  20. CONSERVATIVE TREATMENT FOODS TO BE AVOIDED: **All alcoholic beverages *Chocolate *Apples, apple juice Grapes *NutraSweet Guava Cantaloupe Vitamin E if powered *Carbonated beverages Peaches, pineapple, plums *Chiles/spicy foods *Citrus foods incl lemons **Coffee, tea, (incl decaf) Tomatoes Strawberries, cranberries Onions Vinegar Vitamin B complex(B6 okay)

  21. CONSERVATIVE TREATMENT DAILY DIET SUBSTITUTIONS: 1. Coffee-acid removed: Kava, cold brewed coffee 2. Weak or Herbal teas-if free of large amounts of citrus. dunk a tea bag in water 4 times quickly to color the water. Sun-brewed tea 3. Carob for chocolate; Ovaltine instead of chocolate drinks • 4. Fruit juices: apricot, nectar, pear nectar, papaya, watermelon • 5. Late harvest dessert wines • 6. Fructose, as in Superose instead of NutraSweet or saccharin • 7. Orange or lime peel without white part of rind • 8. Pine nuts in place of other types of nuts • 9. Consider wheat allergy: breads made of potato, soya, rice flour • 10. Vitamins: Vit. C in calcium ascorbate co-buffered with calcium carbon

  22. CONSERVATIVE TREATMENT • Electomyography (EMG) can be used as an adjunct when teaching the PFM exercises to provide visual and audible assessment of the pelvic floor. • Low EMG profile is an identifiable risk factor for incontinence. Can be done preoperatively to establish risk

  23. CONSERVATIVE TREATMENT • Bladder retraining • Helpful if detrusor dysfunction is present, especially with adjunctive anticholinergics • Useful for urinary urge and frequency • Patient needs to keep a bladder diary with information on voiding pattern, frequency and voided volumes

  24. MEDICAL AND SURGICAL TREATMENT OPTIONS • Medical: In addition to conservative measures: • Anticholinergics for detrusor instability • Surgical: • Bulbourethral Sling • Artificial Urinary Sphincter

  25. BULBOURETHRAL SLlNG Northwestern technique – bulbourethral sling Recent interest in male sling procedures for post-radical prostatectomy incontinence • preserve volitional voiding • quick, simple to perform

  26. PRE-OPERATIVE URODYNAMIC EVALUATION • Confirm Sphincter deficiency • R/O detrusor instability as cause of leakage • R/O diminished bladder compliance

  27. BACKGROUND • Northwestern technique (bulbourethral sling) • Gore-tex bolsters placed beneath bulbar urethra, suspended from rectus fascia • Intraoperative urodynamics • Goal = analogous procedure to pubovaginal sling

  28. BACKGROUND Previous analysis with 12-month follow-up: • 91% cured or improved • 85% 0-2 pads per day • 6% removal rate for infection, erosion The purpose of this study was to review the long-term outcomes of the first 95 patients (10/94 to 6/00) who underwent the bulbourethral sling procedure at Northwestern.

  29. STUDY MATERIALS AND METHODS • 95 patients from 10/94 to 6/00 • 8 patients deceased at time of questionnaire • 71/87 patients completed survey (82% contact rate) • Mean follow-up interval 4.0 years (0.27-6.55) • Mean age at time of surgery: 69 years (55-81) • Preoperative adjuvant radiation therapy: 9 (13%)

  30. PREOPERATIVE INCONTINENCE *Median duration of incontinence: 68 month (range 14-198)

  31. RESULTS AT 4 YEARS

  32. POSTOPERATIVE CONTINENCE STATUS: Non-radiated Patients U >2 C 0 I 1-2

  33. POSTOPERATIVE CONTINENCE STATUS: Radiated Patients C 0 I >2 1-2 U

  34. PATIENT SATISFACTION: Non-radiated Patients N Y

  35. PATIENT SATISFACTION: Radiated Patients Y N

  36. POST-OPERATIVE PAIN

  37. INCONTINENCE QUALITY OF LIFE Questionnaire

  38. SLING COMPLICATIONS no. (%) Retightening 15 (21) Sling removal 7 (10) - infection 6 (8) -urethral erosion 1 (1)

  39. Follow-up Duration 12 months4 years Cured/Improved 91% 81% 2 or less pads 85% 69% No perineal numbness/pain 47.5% 82% Moderate/severe pain 26% 12% Bolster removal 6% 10% COMPARISON TO SHORT TERM Follow-up

  40. COMPLICATIONS SUMMARY • Infection/erosion rate=10% • AUS 6.8% • Barrett 2000 • Revision rate = 21% • XRT 66%; no XRT 15 % • AUS 20-40% • Light 1989; Barrett 1989; Montague 1992; Webster 1992; Singh 1996; Herschorn 1996; Castro Diaz 1997

  41. CONCLUSIONS • Bulbourethral Sling is effective for post-radical prostatectomy incontinence • Radiation significantly reduced efficacy • Post-operative discomfort resolved in most patients

  42. ARTIFICIAL URINARY SPHINCTER • Gold standard for surgical treatment of PPI • First developed in 1947 by Foley; refined in the 1970s. AMS 800 developed in 1983 • AUS implantation usually delayed for 12 months after RP • Men usually seeking this option have significant incontinence

  43. ARTIFICIAL URINARY SPHINCTER DATA Gousse et al1 : mean follow-up 7.7 years 0 pads: 27% very satisfied: 58% >3 pads: 25% satisfied: 19% 16% revision rate unsatisfied: 23% Montague et al2: mean follow-up 73 months 0-1 pads: 64% very satisfied: 28% 2+ pads: 35% satisfied: 45% 12% revision rate dissatisfied/ very dissatisfied: 10%

  44. ARTIFICIAL URINARY SPHINCTER DATA Elliot and Barrett3: 245 of 271 pts (90%) had functioning AUS at 5 years Complications: Mean follow-up 68.8 months (narrow-backed cuff data) 17% (31 of 184) required a first re-operation 7 required 2nd re-operation 1 required 3rd operation 7% Infection/erosion rate 7.6% Mechanical failure Quality of Life: Several recent studies have found patient satisfaction with the AUS in PPI is 85-95% even in the face of revisions and complications • 1. Gousse, A.E., Madjar S., Lambert, M-M, Fishman: Artificial urinary sphincter for post-radical prostatectomy urinary incontinence: long-term subjective results. J. Urol 166: 1755, 2001. • 2. Montague, D.K, Angermeier, K.W., and Paolone, D.R: Long-term continence and patient satisfaction after artificial sphincter implantation for urinary incontinence after prostatectomy. J Urol 166: 547, 2001. • 3. Elliot, D.S., and Barrett, D.M.: Mayo Clinic long-term analysis of the functional durability of the AMS 800 artificial urinary sphincter: a review of 323 cases J. Urol 159: 1206, 1998. • 4. Tse,Vand Stone,A.R. Incontinence after prostatectomy: the AUS. BJU 92(9),2003.

  45. CONCLUSIONS: • Pelvic floor exercises are not helpful for patients with established SUI • Medical therapy is of limited value • Urodynamic testing is useful to R/O detrusor instability or diminished compliance • Artificial Sphincter and BUS show similar efficacy. • Artificial sphincter is preferred in patients with history of radiation and in post-TUPR incontinence.

  46. CASE STUDY OUTCOME • Initial reaction to incontinence • Patient uses <2 pads per day • Stress incontinence continues to limited patient’s hobbies such as golf, tennis and landscaping • Has limited social events to avoid embarrassment • PFM exercises were never really beneficial in fact it worsened the problem after 6 months • Will not consider further surgery unless the PPI gets worse.

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