URINARY TRACT INFECTIONS RISK FACTORS

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www.ucsf.edu/wcc
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Mind Over BladderEverything you always wanted
to know.

• Jeanette S. Brown, MD
• Professor
• Obstetrics, Gynecology, RS Urology
• Epidemiology Biostatistics
• University of California, San Francisco

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Urinary Incontinence

• Common
• - 50 of women have incontinence
• - It effects women of all ages
• - Women suffer in silence
• Chronic
• Incontinence doesnt kill you, it just takes
  away your life.
• Profound effect on womens lives
• Limits exercise, travel, and social activities
• Costly
• 32 billion/year
• Greater than the cost of all cancer care for
  women

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www.ucsf.edu/wcc
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UCSF Womens Health A New Vision
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UCSF WCC Mission

• Clinical
• Breaking the silence
• Improving lives through education treatment
• Research
• Preventing incontinence
• Developing novel treatments
• Training
• Fellows, residents, students
• Other healthcare providers

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Current Clinical Innovations

• Most comprehensive program
• Multidisciplinary
• - Urogynecologists, Urologists,
• Colo-rectal surgeons
• Extensive Pelvic Rehabilitation Program
• - Continence Specialist, Physical Therapist
• Community outreach
• - Mind Over Bladder

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Incontinence Definitions

• Overactive Bladder (OAB)
• - urgency, urinary frequency, getting up often
  at night, urge incontinence
• Stress -coughing, sneezing, straining, exercise
• Mixed - both urge and stress

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Incontinence Treatment

• Pelvic Floor Rehabilitation
• - Pelvic Floor Exercises
• - Bladder training
• - Biofeedback
• - Electrical Stimulation
• Medications, devices
• Surgery

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Successful Pelvic Floor Exercises

• Strengthen levator ani and sphincter
• Two types Rapid and Prolonged
• Individualized Program
• Coughing up

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Bladder Training

• Voluntary control
• Scheduled voids
• Bladder diary
• Positive reinforcement
• Goal 3-4 hour voids

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Additional Treatments

• Timed voids to prevent full bladder
• Fluid moderation
• Urge UI Urge suppression
• - quick pelvic contractions
• urge distraction
• Prompted Voids

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Plugs Drugs

• Pessary, Femsoft
• Meds Primarily Urge UI
• Oxybutynin (Ditropan, XL)
• Tolterodine (Detrol, LA)
• Stress UI Duloxetine 2003?

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Who should have surgery?

• Patient driven
• Failed conservative treatment
• Stress UI primarily
• Bladder neck mobility
• Understands risks benefits

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How does it work?

• ? Urethral mobility
• Backstop for the urethra
• Recreate hammock
• Obstruction

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What do we know?

• 150 surgeries
• Data limited on outcomes (Jarvis 1999)
• Published surgical literature is of the lowest
  level of evidence and limited quality (Merlin
  2001)
• Lack of controlled trials, short follow-up

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What else?

• Overestimate success
• Underestimate complications
• First surgery best surgery (Black 1996)
• The more severe the UI, the better the outcome
• Burch or Sling best choices

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Urinary Incontinence Treatment Network

• NIDDK supported 9 centers
• RCT of Burch vs. Sling
• 2 to 4 year follow-up
• Probable similar efficacy
• - Difference in morbidity (Weber 2000)

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Tension-free Vaginal Tape

• Prolene tape, quick, easy, light anesthesia
• Synthetic tape well-tolerated
• - publication bias or short-term?
• Outcomes
• - Short-term 90 Long-term-no data
• Reasonable choice with limited data

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Long-term Outcomes

• Average age at surgery 54 yo
• - Average life expectancy 77 yo
• At 4 years 80-85 success (Leach 1997)
• gt 5 years poor data and fall off
• - 50-60 (Diokno 1989 Erikson 1990)
• - 30 need re-operation (Stanton 1997 Erikson
  1990)

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Surgery Summary

• SUI surgery is not an emergency!
• More severe UI better outcome
• First surgery most successful
• New surgeries RCT to standard
• Long-term data lacking

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www.ucsf.edu/scor
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UCSF Specialized Center of Research (SCOR)

• Only NIH designated center for
• Lower Urinary Tract Function in Women
• Clinical and Basic Research
• Multi-disciplinary Multi-Institutional
• - Departments of ObGyn, Urology, Family
  Medicine Geriatrics, Epi Biostats
• Translation of scientific results to improved
  care

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UCSF Specialized Center of Research
Database Analysis
Epidemiological Investigation
Economic Analysis
Molecular Biology
New Treatments
Basic Clinical
Improved Patient Care
Prevention
Training
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Research

• High quality research is necessary to identify
• Natural history and prognosis of disease
• What happens to women with incontinence?
• Risk factors for disease
• Does having a hysterectomy increase risk for UI?
• Effective, novel treatments
• Does estrogen treat incontinence?
• Does weight loss improve incontinence?

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Think Outside the Bladder !
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Falls Fractures

• In older women
• Falls 20-40
• Hip fractures 90 with fall
• Incontinence 50
• Association with OAB?

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Falls and Fractures

• 4 centers in US
• 6049 women gt 65 years of age
• followed every 4 months for 3 years
• Outcomes
• 55 had falls
• 8.5 had fractures

Brown JAGS 2000
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Multivariate Falls Fractures
Risk P
Falls OAB 26
lt0.0001 Stress 6 0.3 Fractures OAB
34 lt0.02 Stress 1 0.09
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Falls Fractures Summary

• Weekly OAB ? Risk
• Falls 26
• Fracture 34
• Associated frequency nocturia
• Early diagnosis and treatment
• Potential to prevent or ? falls fx
  
• (Brown JAGS 2000)

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Risk Factors for Daily UI

• Risk Factor Increased Risk
• Oral HT 90
• Stroke 80
• Diabetes 70
• Poor overall health 60
• Obesity 50
• Hysterectomy 40
• COPD 40
• Age (per 5 years) 30 (Brown 1996)

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Hormone Therapy

• Receptors in urethra, bladder
• Clinical therapy
• Limited trial data

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Hormones Incontinence

• Randomized controlled trial
• 1525 women with weekly incontinence
• Hormone Therapy Estrogen/ Progestin or Placebo
• Followed 4.1 years

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Hormones Incontinence

• Improved UI 21 HT
• 26 Placebo
• Worsened UI 39 HT
• 27 Placebo P0.001
• Summary
• Oral HT not recommended for treatment
• Prevention?

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Weight and Incontinence

• gt 50 US women overweight or obese
• Obese women 4 fold ? risk UI
• Incontinent Women 70 obese
• Proposed Mechanism? abdominal pressure, urethral
  mobility, damage supports
• Can weight reduction improve or prevent UI?

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Weight Reduction Studies

• In women about 200 lbs
• Weight loss gt 5 or 30 lbs
• gt 50 Incontinence reduction
• Effective therapy for UI
• Public Health Implications
• NIH Multi-centered trial funded
• (Subak 2002)

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Hysterectomy

• United States
• 600,000 per year
• Average age 44yo
• By age 60, 37 of women
• 90 for benign etiology

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Hysterectomy UI

• Women gt 60 yo with hysterectomy
• - 60 ? Incontinence risk
• Mechanism Similar to childbirth
• Damage to muscle/nerves
• Clinically useful information
• (Brown Lancet 2000)

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Clinical Implications

• Quality of life
• Potential risks later
• Patient preference
• Alternatives to hysterectomy

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Summary

• Common
• Make incontinence cocktail conversation!!
• Important quality of life issue
• Improving lives through education treatment.
• Innovative Research
• Advancing treatment through research

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www.ucsf.edu/wcc