4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 must be held in the peri-operative setting. Patients should also be advised that the device will require battery replacement for the generator over time. OnabotulinumtoxinA (BTX-A) was first FDA approved for neurogenic OAB in 2011. 34 Following successful Phase 2 and 3 clinical trials, BTX-A was FDA approved in 2013 for idiopathic OAB at a recommended dose of 100 units. 35-37 Its mechanism of action is inhibiting acetylcholine release from pre-synaptic cholinergic junctions which results in chemodenervation and reduced muscle contractility and possibly reduced afferent input. 38 Treatment can be performed in the office with local anesthesia or in the operating roomwith sedation with either a flexible or rigid cystoscope. 39 AUAshould be performed prior to procedure to rule out UTI. Patients should also have a baseline PVR and be followed up with a PVR after procedure to check on incomplete bladder emptying. The treatment effects usually last for 6 months before requiring retreatment. Complications of the procedure include UTI, hematuria, urinary retention, and systemic weakness. In the case of urinary retention, patients should be advised about the possibility of requiring clean intermittent catheterization (CIC) if they are unable to void following the procedure. If the patient has failed the first three lines of therapy, the guidelines allow for augmentation cystoplasty and urinary diversion as a last resort. 16,17 The goal of treatment is to disrupt coordinated detrusor contractions, increase bladder capacity, and create a low-pressure urinary storage system. Patients undergoing the procedure must also be willing to do CIC. However, with the advent of neuromodulation and BTX-A treatments, augmentation cystoplasty has become less frequently utilized. 40 Complications include revision, metabolic acidosis (from use of ileum), stone formation, and UTI. SUI treatment When starting treatment for SUI, non-surgical options should be considered before more aggressive interventions where it is appropriate. In general, SUI can be managed in a graded approach that includes measures such as lifestyle modifications and vaginal inserts before progressing tourethral bulking agents and then surgicalmeasures such as the syntheticmidurethral sling (MUS) or the autologous fascial pubovaginal sling. Lifestyle modifications As with UUI, lifestyle modifications are often an effective first line treatment in the management of SUI. These include behavioral therapy and pelvic floor muscle therapy (PFMT), and weight loss. PFMT is considered a mainstay of treatment for SUI, in some cases showing up to 70% improvement in symptoms across all age groups. 41 Ameta-analysis conducted by Dumoulin et al demonstrated that PFMT can improve symptoms of SUI, reducing the frequency of leakage and the amount of urine voided. Moreover, it is a cost- effective treatment with a low risk for adverse effects, making PFMT an attractive first line therapy for the motivated SUI patient. 42 Vaginal devices Another non-surgical treatment for SUI entails introducing devices into the vaginal canal which exert a mechanical force on the urethra, in turn increasing urethral outlet resistance. This includes continence pessaries, vaginal inserts, and urethral plugs. The few studies which describe these interventions suggest they are an effectivemeans ofmaintainingurinary continence, though their effectiveness can be reduced by previous UI surgery or anatomic variations among patients such as wide urethra or decreased bladder capacity. 43,44 Bulking agents Bulking agents are a form of injection treatment which combat SUI through improved coaptation of the proximal urethra, thus increasing outlet resistance. These are an effective treatment, though long term data for their effectiveness is scant. 14 The most common site of injection for bulking agents is the submucosa of the proximal urethra through either the periurethral or transurethral approach. The two classes of bulking agents are particulate agents (solid microparticles in a liquid or gel carrier), and non- particulate agents (homogenous gel). The composition of the microparticulate material in such agents includes polyacrylamide, calcium hydroxylapatite, polydimethylsiloxane, and carbon coated zirconium beads. 45 Bulking agents may represent an appropriate treatment in patients who have restricted surgical options, however, they are associated with a high rate of treatment failure andmay therefore requiremultiple administrations to maintain symptom relief. 46,47 Mid-urethral sling (MUS) MUS is a surgical procedure for SUI with either a retropubic or transobturator approach. The retropubic approach features the insertion of two needles which are passed through the retropubic space fromthe vagina Denisenko ET AL. 30