Challenges in Managing Urge Incontinence/OAB in the Elderly Patient: Introduction and Overview of...
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Challenges in Managing Challenges in Managing Urge Incontinence/OAB Urge Incontinence/OAB in the Elderly in the Elderly Patient: Introduction Patient: Introduction and Overview of OAB and Overview of OAB
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Transcript of Challenges in Managing Urge Incontinence/OAB in the Elderly Patient: Introduction and Overview of...
Challenges in Managing Challenges in Managing Urge Incontinence/OAB Urge Incontinence/OAB
in the Elderly Patient: in the Elderly Patient: Introduction and Overview Introduction and Overview
of OABof OAB
Demographics and Demographics and ClassificationClassification
OAB - DemographicsOAB - Demographics
► 23 - 35 million sufferers in the US23 - 35 million sufferers in the US
- Fewer than half seek medical treatment- Fewer than half seek medical treatment
- Prevalence increases with age- Prevalence increases with age
- Patients often on multiple medications- Patients often on multiple medications
► Over $1.1 billion in sales-2003 USOver $1.1 billion in sales-2003 US
► Patients over 60 years of age comprise a Patients over 60 years of age comprise a
significant share of the OAB populationsignificant share of the OAB population
► Treatment rates are lower than for other age groupsTreatment rates are lower than for other age groups
► Patient population is unsatisfied with current treatmentPatient population is unsatisfied with current treatment
- Utilization rates of only 50%- Utilization rates of only 50%
- Low refill rates among all drugs- Low refill rates among all drugs
Prevalence of OAB Prevalence of OAB Age and GenderAge and Gender
Stewart WF, et al. World J Urol. 2003;20:327-336.
0
5
10
15
20
25
30
35
40
<25 25-34 35-44 45-54 55-64 65-74 75+
Age (years)
Pre
va
len
ce
(%
)
Men
Women
Prevalence of OAB• Men: 16.0%• Women: 16.9%
OAB Treatment Rates by Age GroupOAB Treatment Rates by Age Group
9.30%
18.40%19.60%
8.70%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
60-64 65-74 75-84 85+Age
Source: IMS Retail Perspective
Patient Persistency is PoorPatient Persistency is Poor
35.2 million35.2 million Prevalent patient pop., 2004 (NOBLE)Prevalent patient pop., 2004 (NOBLE)
7.5 million7.5 million
21% consult physicians21% consult physicians
1.9 million1.9 million Total patient population, 2004Total patient population, 2004
1.24 million1.24 million
35% dropout rate35% dropout rate
25% consult physicians25% consult physicians
Actively treated patient population, 2004Actively treated patient population, 2004
0.83 million0.83 million
33% compliance rate33% compliance rate
Persistant patient population, 2004Persistant patient population, 2004
OAB Population - ConsiderationsOAB Population - Considerations
► Data presented here may be conservative – Data presented here may be conservative –
estimates exist noting the OAB population in estimates exist noting the OAB population in
the U.S. is 50% larger than the data presentedthe U.S. is 50% larger than the data presented
► The elderly population will continue to The elderly population will continue to
increase at a greater rate than the general increase at a greater rate than the general
populationpopulation
► The 2006 Medicare Modernization Act may The 2006 Medicare Modernization Act may
increase the availability of drugs to all increase the availability of drugs to all
Medicare patientsMedicare patients
DEFINITIONS
EPIDEMIOLOGY
CLASSIFICATION
PHYSIOLOGY
OAB Symptom DefinitionsOAB Symptom Definitions
►Urgency: a sudden compelling desire to pass Urgency: a sudden compelling desire to pass
urine that is difficult to deferurine that is difficult to defer
►Urgency Urinary Inc. (UUI): involuntary leakage Urgency Urinary Inc. (UUI): involuntary leakage
accompanied by or immediately preceded by accompanied by or immediately preceded by
urgencyurgency
►Frequency: 8 voids / day = “normal”Frequency: 8 voids / day = “normal”
►Nocturia: patient wakes one or more times at Nocturia: patient wakes one or more times at
night to void (sleep “before” and “after”)night to void (sleep “before” and “after”)
Abrams P, et al. Urology. 2003;61:37-49.
OAB Symptom DefinitionsOAB Symptom Definitions
►Urinary Stress Incontinence (USI): urinary loss Urinary Stress Incontinence (USI): urinary loss
with “effort”with “effort”
►Overflow Incontinence: urinary leakage with Overflow Incontinence: urinary leakage with
retentionretention
►OAB – WET: urgency, frequency, incontinenceOAB – WET: urgency, frequency, incontinence
►OAB – DRY: no urinary incontinenceOAB – DRY: no urinary incontinence
Abrams P, et al. Urology. 2003;61:37-49.
Types of Incontinence/EtiologyTypes of Incontinence/Etiology
UrgeUrge StressStress OverflowOverflow TransientTransient
Damage to Damage to bladder nerves bladder nerves
Spinal cordSpinal cord
Bladder CaBladder Ca
Multiple Multiple sclerosissclerosis
Parkinson’sParkinson’s
Alzheimer’sAlzheimer’s
Stroke Stroke
BPHBPH
OABOAB
Weak pelvic Weak pelvic floor musclefloor muscle
Multiple Multiple pregnancy pregnancy
Pelvic prolapsePelvic prolapse
Weak bladder Weak bladder musclesmuscles
DiabetesDiabetes
Bladder tumorsBladder tumors
Urinary stonesUrinary stones
DDeliriumelirium
IInfectionnfection
AAtrophic urethritistrophic urethritis
PPharmacologic/ harmacologic/ psychologicalpsychological
EEndocrine disordersndocrine disorders
RRestricted mobilityestricted mobility
SStool impactiontool impaction
Steers WD, et al. In: Adult and Pediatric Urology. 4th Ed. 2002:1115-1216.Available at: http://kidney.niddk.nih.gov/kudiseases/pubs/uiwomen. Accessed 2/1/06.
What Is Overactive Bladder?What Is Overactive Bladder?
Symptom Spectrum of OABSymptom Spectrum of OAB
STORAGE
STORAGE EMPTYING
STORAGE EMPTYING
BLADDER
STORAGE EMPTYING
BLADDER
OUTLET
STORAGE EMPTYING
BLADDER
OUTLET
OVERACTIVE UNDERACTIVE
UNDERACTIVE OVERACTIVE
“URGE” “RETENTION”
“STRESS” “OBSTRUCTION”
PRESSURE‘TOO MUCH’
PRESSURE‘TOO LITTLE’
RESISTANCE‘TOO LITTLE’
RESISTANCE‘TOO MUCH’
STORAGE EMPTYING
BLADDER
OUTLET
OVERACTIVE
UNDERACTIVE
UNDERACTIVE OVERACTIVE
“URGE”
“RETENTION”
“STRESS” “OBSTRUCTION”
PRESSURE= ‘TOO MUCH’ PRESSURE= ‘TOO LITTLE’
RESISTANCE= ‘TOO LITTLE’ RESISTANCE= ‘TOO MUCH’
SYMPTOMS:frequency, urge,
nocturia,urge incontinence
SYMPTOMS:hesitancy, nocturia, straining, overflow
incontinence
SYMPTOMS:cough, laugh, sneezestress incontinence
SYMPTOMS:hesitancy, straining, incomplete emptying,
nocturiaoverflow incontinence
STORAGE EMPTYING
BLADDER
OUTLET
OVERACTIVEUNDERACTIVE“URGE”
“RETENTION”
PRESSURE= ‘TOO MUCH’ PRESSURE= ‘TOO LITTLE’
UNDERACTIVE“STRESS”
RESISTANCE= ‘TOO LITTLE’
OVERACTIVE“OBSTRUCTION”
RESISTANCE= ‘TOO MUCH’
CAUSES:1) idiopathic 2) neurogenic (central)3) obstruction
CAUSES:1) medication–distention2) neurogenic–peripheral3) muscular
CAUSES:1) anatomic hypermobility2) ISD
CAUSES:1) iatrogenic -surgery2) neurogenic3) anatomic atrophy-stenosis
OVERACTIVE
UNDERACTIVE
UNDERACTIVE OVERACTIVE
“URGE”
“RETENTION”
“STRESS” “OBSTRUCTION”
PRESSURE= ‘TOO MUCH’ PRESSURE= ‘TOO LITTLE’
RESISTANCE= ‘TOO LITTLE’ RESISTANCE= ‘TOO MUCH’
MEDICAL TREATMENT anticholinergics
estrogens BEHAVIORAL THERAPY
MEDICAL TREATMENT cholinergics(?)
CIC
MEDICAL TREATMENT alpha agonists
estrogens
MEDICAL TREATMENTalpha blockers
STORAGE EMPTYING
BLADDER
OUTLET
OVERACTIVEUNDERACTIVE
UNDERACTIVE OVERACTIVE
“URGE”“RETENTION”
“STRESS” “OBSTRUCTION”
PRESSURE= ‘TOO MUCH’ PRESSURE= ‘TOO LITTLE’
RESISTANCE= ‘TOO LITTLE’ RESISTANCE= ‘TOO MUCH’
SURGICAL TREATMENT sacral nerve stimulator bladder augmentation
SURGICAL TREATMENT sacral nerve stimulator
SURGICAL TREATMENT pubovaginal sling
bladder neck suspension collagen injection
SURGICAL TREATMENTexcision of lesion
urethrolysis
STORAGE EMPTYING
BLADDER
OUTLET
Storage and Voiding SymptomsStorage and Voiding Symptoms
StorageStorage VoidingVoiding Postmicturition Postmicturition
UrgencyUrgency HesitancyHesitancy Terminal dribbleTerminal dribble
FrequencyFrequency Poor flowPoor flow Postvoid dribblePostvoid dribble
NocturiaNocturia IntermittencyIntermittency Sense of Sense of incomplete emptyingincomplete emptying
UrgencyUrgencyincontinenceincontinence StrainingStraining
Stress incontinenceStress incontinence DysuriaDysuria
Symptoms Often Relate to Bladder and ProstateSymptoms Often Relate to Bladder and Prostate
Abrams P et al. Neuro Urodyn. 2002;21:167-178.
Storage and Voiding SymptomsStorage and Voiding Symptoms
StorageStorage VoidingVoiding Postmicturition Postmicturition
UrgencyUrgency HesitancyHesitancy Terminal dribbleTerminal dribble
FrequencyFrequency Poor flowPoor flow Postvoid dribblePostvoid dribble
NocturiaNocturia IntermittencyIntermittency Sense of Sense of incomplete emptyingincomplete emptying
UrgencyUrgencyincontinenceincontinence StrainingStraining
Stress incontinenceStress incontinence DysuriaDysuria
Abrams P et al. Neuro Urodyn. 2002;21:167-178.
Symptoms Often Relate to Bladder and ProstateSymptoms Often Relate to Bladder and Prostate
Why Do We Treat Men Differently Why Do We Treat Men Differently Than Women When It Comes to Bladder Symptoms?Than Women When It Comes to Bladder Symptoms?
FemaleFemale MaleMale
ProstateProstate
• OAB OAB symptomssymptoms are the same; anatomy is are the same; anatomy is differentdifferent
• In men, LUTS are often considered relatedIn men, LUTS are often considered relatedto the prostateto the prostate
Wein, Exp. Opin. Invest. Drugs 10(1): 65-83, 2001
Atropa belladonna
L-type Ca 2+ channel
