Title: Management of Post-Prostatectomy Incontinence (PPI) Primary Care Conference 2/25/04
1Management of Post-Prostatectomy Incontinence
(PPI)Primary Care Conference2/25/04
- MARY JO WILLIS, MS, APRN-BC
- CLINICAL ASSOCIATE PROFESSOR
- NURSE PRACTITIONER, USIM
2OBJECTIVES
- 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
3CONFLICTS 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
4CASE 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
5RISKS 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 - Incontinence65
- Impotence88.4
- Bladder neck contracture/stricture20.5
- 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
6GENERAL 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 gt60 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)
7GENERAL MALE POPULATION URINARY INCONTINENCE
- Study conducted by questionnaire in one county in
Minnesota assessing UI in men gt50 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
8RISKS 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
9CAUSES 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
10CAUSES 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
11ANATOMY
- 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
12POINTS 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
13ANATOMY
14PROBLEMS 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 6-2070-90 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
15PPI
- Multicenter study 1990-97
- Immediately after surgery 81.5
- 6 months post op status65.6)
- 53.9 lt15ml
- 23.2 notice leakage once or less daily
- 44 used protection with 27 using pads
- Most commonly used Rx was pelvic exercise (34)
16PPI
- 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
17PPI
- 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 - Patients 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 to
conservative measures
18CONSERVATIVE 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
19CONSERVATIVE 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
20CONSERVATIVE 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)
21CONSERVATIVE 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
22CONSERVATIVE 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
23CONSERVATIVE 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
24MEDICAL AND SURGICAL TREATMENT OPTIONS
- Medical In addition to conservative measures
-
- Anticholinergics for detrusor instability
- Surgical
- Bulbourethral Sling
- Artificial Urinary Sphincter
-
25BULBOURETHRAL SLlNG
- Northwestern technique bulbourethral sling
- Recent interest in male sling procedures for
post-radical prostatectomy incontinence - preserve volitional voiding
- quick, simple to perform
26PRE-OPERATIVE URODYNAMIC EVALUATION
- Confirm Sphincter deficiency
- R/O detrusor instability as cause of leakage
- R/O diminished bladder compliance
27BACKGROUND
- Northwestern technique (bulbourethral sling)
- Gore-tex bolsters placed beneath bulbar urethra,
suspended from rectus fascia - Intraoperative urodynamics
- Goal analogous procedure to pubovaginal sling
28BACKGROUND
- 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.
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31STUDY 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)
32PREOPERATIVE INCONTINENCE
()
Complete 20
gt 5 pads 40
gt 2 pads 98
Median duration of incontinence 68 month
(range 14-198)
33RESULTS AT 4 YEARS
Overall Sling Intact
Total patients 71 64
Cured (n25) 35 39
Cured/ Improved (n52) 73 81
0 pads (n23) 32 36
lt2 pads per day (n44) 62 69
34POSTOPERATIVE CONTINENCE STATUS Non-radiated
Patients
U
gt2
C
0
I
1-2
35POSTOPERATIVE CONTINENCE STATUS Radiated Patients
C
0
I
gt2
1-2
U
36PATIENT SATISFACTION Non-radiated Patients
N
Y
37PATIENT SATISFACTION Radiated Patients
Y
N
38POST-OPERATIVE PAIN
39INCONTINENCE QUALITY OF LIFE Questionnaire
40SLING COMPLICATIONS
- no. ()
- Retightening 15 (21)
- Sling removal 7 (10)
- - infection 6 (8)
- -urethral erosion 1 (1)
41COMPARISON TO SHORT TERM Follow-up
- Follow-up Duration
- 12 months 4 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
42COMPLICATIONS SUMMARY
- Infection/erosion rate10
- 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
43CONCLUSIONS
- Bulbourethral Sling is effective for post-radical
prostatectomy incontinence - Radiation significantly reduced efficacy
- Post-operative discomfort resolved in most
patients
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45ARTIFICIAL 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
46ARTIFICIAL URINARY SPHINCTER DATA
- Gousse et al1 mean follow-up 7.7 years
- 0 pads 27 very satisfied 58
- gt3 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
47ARTIFICIAL 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.
48CONCLUSIONS
- 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.
49CASE STUDY OUTCOME
- Initial reaction to incontinence
- Patient uses lt2 pads per day
- Stress incontinence continues to limited
patients 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.