THE BLADDER MATTERS!

1. THE BLADDER MATTERS! Lindsey A Kerr MD Associate Professor of Urology Co-Director, Center for Pelvic Floor Disorders University of Utah

2. THE BLADDER MATTERS! • Pelvic Floor Disorders are Common • Bladder Dysfunction including Pain Disorders and Incontinence disproportionately impact Women • These are Expensive, Debilitating but Treatable Entities

3. Bladder Matters and Urinary Incontinence • Incontinence: The unexpected and unwanted leakage of urine • Uromythology: • Uncommon • Natural part of aging • Nuisance but not a health issue • Not cost effective to treat

4. Senate Special Committee on Aging • Alzheimer’s • Loss of Vision • Osteoporosis • Urinary Incontinence Determined four health problems affecting quality of life for seniors:

5. Urinary Incontinence • Affects as many as 30+ million Americans • Three quarters are women • Half of nursing home residents are incontinent • Associated with other disease processes and the treatment of those diseases

6. Conservative Estimates... • 1996 AHCPR Urinary Incontinence Guidelines estimates 15% to 30% of community-dwelling adults • 5% to 10% of all Americans are affected by periodic or chronic urinary incontinence • More Common than Asthma and Heart Disease

7. Costs of UI to Older People(65+ in the United States) (T.W. Hu, 1997)

8. The Bladder Matters! • Patients with incontinence also complain of • Decreased sexual function • Sleep disturbances • Decrease in normal activities • Fear of stigmatization Roe B et al. J Adv Nurs. 1999;30:573-579. Abrams P et al. Am J Manag Care. 2000;6(suppl):S580-590. Lenderking WR et al. Phamacoeconomics. 1996; 9:11-23.

9. The Bladder Matters! • Patients with incontinence are at increased risk for falls and fractures • More urinary tract infections and skin infections • More likely to need treatment for depression Wagner TH et al. Am J Manag Care. 2002;8:S598-607., Brown JS et al. Am J Manag Care. 2000;6:S574-579. Fonda D et al. Aust Clin Rev. 1988;8:102-107., Stewart WF et al. Eur Urol. 2003;20:327-336.

10. Bladder Matters: Urinary Incontinence • A valid predictor of heavy nursing home use • Nursing home costs are between $39,000 and $43,000 per year • Two-thirds paid by Medicare and Medicaid

11. Urinary Incontinence: Terminology • Stress incontinence – Leakage that occurs with “stress maneuvers” coughing, running • Urge incontinence – Leakage associated with the “urge” to void, cannot make it to the bathroom on time. • Functional incontinence – inability to get to the bathroom • Overflow incontinence – bladder is overly full, does not empty on its own

12. 2001 ICS Terminology Urge incontinence now included in the definition of Overactive Bladder Overactive bladder is an empiric diagnosis Patients can be wet or dry Used as the basis for initial management Abrams P et al. Urology. 2003;61:37-49.

13. Multiple Types of Coping Behaviors Used in Attempt to Regain Control Empty Bladder Frequently, Even Without Urge 53% Learn in Advance Where Bathrooms Are 45% Limit Intake of Fluids 44% Use Panty Liners 42% Use Incontinence Pads 32% Do Pelvic Floor Exercises 29% Avoid Going Where I Don’t KnowLocation of Bathroom 29% Limit Activities That Are Not Close to a Bathroom 28% Use Pads/Sanitary Napkins 28% Take a Prescription Medication 17% Lifestyle Voiding/Mapping Exercises Fluid Intake Rx Therapy Pads/Undergarments Source: Consumer Segmentation Study (2002).

15. Options for Incontinence • Improved Understanding • Better Pharmaceuticals • New Devices • Novel approaches

16. Options for Incontinence • Improved Understanding – Research • Requires commitment and funding • UITN Network NIH funded www.UTIN.net • PFDN Network • HR 4979 support these , but no funding for these initiatives

17. Options for Incontinence • Improved Understanding – Research • TRU Act -Training and Research in Urology Act of 2003 • Establishes a Division of Urology at NIDDK • Stimulates intra- and interagency research in incontinence • Establish O’Brien Research Centers with emphasis on women’s urologic issues –incontinence and IC

18. Duloxetine Solifenacin Darifenacin, Trospium Tolterodine ER Oxybutynin 2004 2000 1965 1998 2003 Tolterodine IR, Oxybutynin ER Oxybutynin TDS Better Pharmacologic Options for Incontinence

19. Iris/ciliary body Blurred vision CNS Lacrimal gland Dry eyes Salivary glands Dry mouth • Dizziness • Somnolence • Cognitive deficits Tachycardia Heart Stomach and esophagus Dyspepsia Constipation Colon Bladder (detrusor muscle) Muscarinic Receptor Distribution Abrams P, Wein AJ. The Overactive Bladder: A Widespread but Treatable Condition.Stockholm, Sweden: Erik Sparre Medical AB;1998.

20. Incontinence: Better devices • Novel approaches • Implantable stimulators • Botox for the bladder • Radiofrequency modification of tissues Graphics complements of Pfizer

21. Incontinence: Biofeedback and Electrical Stimulation

22. Incontinence: Urethral Devices RochesterMedical Uromed

23. Incontinence: Better devices • Improved Surgical Devices • Better conservative management • Cutting edge minimally invasive procedures Graphics complements of Pfizer

24. The Bladder Matters • Incontinence is prevalent • It is very treatable • Better therapies are needed • More investment in research and better diagnostic tools • Support is needed at every level • Ask your urologist

25. A significant health issue The importance of adding life to years Reimbursement scrutiny Women’s health issue- Education of professionals and patients Public health directives Help is available New options Key Global Messages

26. The Bladder Matters! • www.womenshealthresearch.org • www.urologyhealth.org • www.UITN.net • National Association for Continence • 1-800-BLADDER