Doctors share ways to improve treatment for incontinent patients at experts’ forum
Declaring that it’s time to replace adult diapers and social withdrawal with more liberating long-term options, a recent forum of the nation’s top surgeons looked at how to improve patient and physician education regarding more effective therapies for incontinence.
“It makes me want to educate my patients and other providers that there is hope,” said Dr. Richard Farnam after returning from last month’s Medtronic Second Annual Pelvic Floor Forum in Las Colinas, Texas. The two-day forum is an invitation-only conference of 100 leading urogynecologists, urologists and colorectal surgeons who are experts in minimally invasive and robotic surgery. Dr. Farnam, of the El Paso Urogynecology and Laser Surgery Center, was the only El Paso physician selected to attend.
The conference focused on improving understanding of sacral neuromodulation therapy using the InterStim System, an implantable nuerostimulator with a high success rate of resolving bladder problems as well as issues of fecal incontinence. But some patients don’t realize the difference the therapy can make in their lives.
“They see the lack of success that they’ve had with pills and they just assume that they won’t get a whole lot better with an implant,” Farnam said.
But the procedure, which is 100 percent reversible, can make a dramatic difference in a patient’s quality of life. Overactive bladder symptoms can get severe enough that people with the condition need to go to the bathroom every 20 minutes. It can be debilitating when they don’t feel that they can leave their house for fear of having an “accident.”
Therapies for urinary incontinence
The American Urologic Association provides guidelines for three lines of treatment for urinary incontinence:
- First line of treatment - Behavioral therapies such as diet, biofeedback and pelvic exercises.
- Second line of treatment – Medication therapies
- Third line of treatment - Neuromodulation therapies, including Interstim
The main therapy for decades has been medications known as anticholinergics. They are effective, but the side effects – constipation, dry mouth and memory issues - prevent many people from having meaningful improvement and they may discontinue using the pills. A newer drug in a different class, Myrbetriq, was approved by the FDA in 2012 and is showing some benefit without those side effects, but it remains to be seen how useful it is going to be over the long term. Reported side effects of Myrbetriq include nausea, dizziness, fast heartbeat or headaches.
When medication isn’t the answer, patients may opt to pursue the third line of treatment and choose one of a variety of procedures. One therapy is Botox, which is used to freeze the nerves in the bladder and prevent the muscle from contracting. But there is a risk when the bladder doesn’t contract that a patient may need to use a catheter. Some clinicians may offer a third line treatment called peripheral tibial nerve stimulation (PTNS). The nerve stimulating device InterStim is also a third line therapy. AUA guidelines state that Botox and PTNS are options, but the InterStim system is recommended.
“The best available data shows that Botox is as good as pills. It shows that PTNS is as good as pills. InterStim is the only therapy that has data that shows that it is better than pills,” Farnam said.
Success with InterStim
The bladder is supposed to fill to capacity and then notify the brain that fullness has occurred. Emptying should occur at an appropriate time without creating an excessive urge to void. A coordinated muscular contraction should allow for the complete emptying of the bladder in a continuous fashion. And then the process starts over again.
But an overactive bladder - that may only be 20 to 50 percent full - inappropriately sends a message to the brain that it is 110 percent full and creates an urgent need to void immediately.
Behavioral therapies, such as diet, biofeedback and pelvic exercises can help improve symptoms, but they are a lot of work and most people don’t put in the work to be successful.
InterStim is a small implant that shuts down the inappropriate signal at the bladder before it is sent to the brain. Not only does it more effectively manage an overactive bladder, it also corrects a bladder that doesn’t empty completely. InterStim resets the signal to normal in both instances.
Currently only patients with the most severe bladder control issues are selected for third line treatment after failing the other two levels of therapy. Among these most extreme cases InterStim has a 79 percent success rate of alleviating symptoms.
InterStim was also recently approved by the FDA for the treatment of fecal incontinence, a socially crippling condition that occurs when sphincter muscles don’t tighten enough. This can be caused by obstetrical muscle tears during child bearing. For years the treatment was to either add bulking regimen to the diet or undergo surgery for sphincter repair or sphincter replacement, which have low success rates. Another option is to implant an artificial sphincter, which is virtually impossible to keep sterile and has infection rates of 70 percent. The final option is colostomy. However, now InterStim offers a minimally invasive option with a lower risk of infection and an 80 percent long-term success rate.
“This is a therapy that could be used for different urogynecological indications and it is more successful than conservative therapy or, in the case of fecal incontinence, more successful than open surgery,” Farnam explained.
Best outcomes when the surgeon has the right expertise
Presenters at the Medtronic Pelvic Floor Forum are innovators in the field who encouraged physicians to be champions for their patients to get the best possible outcomes. This includes being highly selective in determining which patients are candidates for the procedure and making sure they are fully informed about the therapy.
“They want to make sure that when a patient opts for this therapy that it’s done by high volume physicians that are going to commit to excellence and top performance every time. Not someone who is only going to do one or two a year and never gets through the learning curve,” Farnam said.
One seminar, by Dr. Steven W. Siegel , director of the Metro Urology Centers for Female Urology and Continence Care in Minnesota, showed the latest technique on how to get a perfect placement to maximize effectiveness and minimize risks when the surgeon is committed to excellence in mastering the procedure.
"It’s such a great therapy. It can have such a great outcome,” said Farnam, who is noted for making El Paso a regional center of excellence.
It starts with a test
Patients who meet the criteria and opt for the InterStim system can try the therapy before undergoing the implant procedure. It doesn’t require an incision, just a 20-minute office procedure involving a small acupuncture-style needle to place an electrode next to the bladder nerve.
If after about a week patients show at least a 50 percent improvement the InterStim can be implanted. The procedure is done in the operating room using a local anesthetic.