Belastungsinkontinenz-“Al les Schlinge“

Belastungsinkontinenz-“Al
les Schlinge“-Neue Daten
G. Häusler Definition (ICS)
……..involuntary leakage of urine that occurs with effort, exer<on, sneezing, coughing, laughing, or any<me an increase in intraabdominal pressure exceeds urethral sphincter closure mechanisms, in the absence of urinary tract infec<on…. Belastungsinkontinenz
Prävalenz
Risikofaktoren
•  Partus •  BMI •  Niko<n •  Tee •  Opera<onen im kleinen Becken •  DM •  Systemische HRT Diagnostik
•  Anamnese •  Combur/Uricult •  Klinischer Stresstest •  Urodynamik Therapie
Therapie-Risikoverminderung
•  Partus •  BMI •  Niko<n •  Tee •  Opera<onen im kleinen Becken •  DM •  Systemische HRT Therapie-Risikoverminderung
•  Partus •  BMI •  Niko<n •  Tee •  Opera<onen im kleinen Becken •  DM •  Systemische HRT Epincont
Prevalence of Nulliparous (%) Cesarean sec5on (%) Vaginal delivery (%) Any incon<nence 10.1 15.9 (OR 1,5) 21.0 (OR 2.3/1.7) Moderate or severe 3.7 incon<nence Stress incon<nence 4.7 6.2 (OR 1.4) 8.7 (OR 2.6/2.2) 6.9 (OR 1.4) 12.2 (OR 3.0/2.4) Urge incon<nence 1.6 2.2 (OR 1.4) 1.8 (OR 1.2/0.9) Mixed incon<nence 3.1 5.3 (OR 1.7) 6.1 (OR 2.1/1.3) „These results suggest that the mechanical strain during labour may add to the risk associated with pregnancy itself“ Epincont
•  No associa<on between parity and incon<nence a_er 65 years of age. •  The mode of delivery is of minimal importance in elderly women, who have the highest prevalence of both any incon<nence and moderate or severe incon<nence. nntp: 7-­‐15 Therapie-Risikoverminderung
•  Partus •  BMI •  Niko<n •  Tee •  Opera<onen im kleinen Becken •  DM •  Systemische HRT Obstet Gynecol. 2008 Aug;112(2 Pt 1):341-9.
Obesity and pelvic floor disorders: a
systematic review.
Greer WJ, Richter HE, Bartolucci AA, Burgio KL
CONCLUSION: There is good evidence that surgery for stress UI in obese women is as safe as in their nonobese counterparts, but cure rates may be lower in the obese pa<ent. Weight loss studies indicate that both bariatric and nonsurgical weight loss lead to significant improvements in pelvic floor disorder symptoms. Urology. 2013 Sep;82(3):547-51.
Does bariatric surgery affect urinary
incontinence?
Knoepp LR, Semins Mj, Wright EJ, Steele K, Shore AD, Clark JM, Makary MA, Matlaga
BR, Chen CC
CONCLUSION: Pa<ents who undergo bariatric surgery are more likely to lose a previous diagnosis of UI than are obese pa<ents not treated with bariatric surgery. This supports the fact that bariatric surgery may have other indirect benefits to the obese popula<on. 62.4% Therapie-Risikoverminderung
•  Partus •  BMI •  Niko<n •  Tee •  Opera<onen im kleinen Becken •  DM •  Systemische HRT Therapie-Risikoverminderung
•  Partus •  BMI •  Niko<n •  Tee •  Opera<onen im kleinen Becken •  DM •  Systemische HRT Therapie-Risikoverminderung
•  Partus •  BMI •  Niko<n •  Tee •  Opera<onen im kleinen Becken •  DM •  Systemische HRT Therapie
•  BBT •  Opera<on Therapie
•  BBT •  Opera<on Was ist Beckenbodentraining?
Das Beckenbodentraining, nach seinem Erfinder Dr. Arnold H. Kegel (1894–1981) auch Kegelübung genannt, dient dazu, die Muskulatur des Beckenbodens zu trainieren. Dies ist wie bei jeder anderen Muskelgruppe möglich. Allerdings ist ein gezieltes Training der Beckenbodenmuskulatur für viele Menschen schwierig, weil es sich dabei um „unsichtbare“, im Körperinneren verborgene Muskeln handelt. Pelvic floor muscle training versus no
treatment, or inactive control treatments,
for urinary incontinence in women: A
short version Cochrane systematic review
with meta-analysis.
Dumoulin C, Hay-Smith J, Habée-Seguin GM, Mercier J
Neurourol Urodyn. 2014 Nov
•  CONCLUSIONS: •  The addi<on of seven new trials did not change the essen<al findings of the earlier version of this review. In this itera<on, using the GRADE quality criteria strengthened the recommenda<ons for PFMT and a wider range of secondary outcomes (also generally in favor of PFMT) were reported. Neurourol. Urodynam. © 2014 Wiley Periodicals, Inc. [Intervention Review]
Weighted vaginal cones for urinary incontinence
Harninkon<nenz G Peter Herbison1, Nicola Dean2
Editorial group: Cochrane Incontinence Group.
Publication status and date: Edited (no change to conclusions), published in Issue 2, 2009.
Review content assessed as up-to-date: 24 June 2007.
Cones were bener than no ac<ve treatment (RR for failure to cure incon<nence 0.88, 95% CI 0.79 to 0.98). There was linle evidence of difference between cones and PFMT (RR 1.00, 95% CI 0.91 to 1.11), or electros<mula<on (RR 1.00, 95% CI 0.86 to 1.13), but the confidence intervals were wide. There was not enough evidence to show that cones plus PFMT was different to either cones alone or PFMT alone. Only three studies used a quality of life measure and no study looked at economic outcomes. Maturitas. 2010 Sep 7. [Epub ahead of print]
Pelvic floor exercise for urinary incontinence: A
systematic literature review.
Harninkon<nenz Price N, Dawood R, Jackson SR.
There is evidence that women perform bener with exercise regimes supervised by specialist physiotherapists or con<nence nurses, as opposed to unsupervised or leaflet-­‐based care. There is evidence for the widespread recommenda<on that pelvic floor muscle exercise helps women with all types of urinary incon<nence. However, the treatment is most beneficial in women with stress urinary incon<nence alone, and who par<cipate in a supervised pelvic floor muscle training programme for at least three months. [Intervention Review]
Schwangerscha_ Pelvic floor muscle training for prevention and
treatment of
urinary and faecal incontinence in antenatal and
postnatal
women
Jean Hay-Smith1, Siv Mørkved2, Kate A Fairbrother3, G Peter
Herbison4
Editorial group: Cochrane Incontinence Group.
Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 22 April 2008.
•  There is some evidence that PFMT in women having their first baby can prevent urinary incon<nence in le
ate pregnancy and postpartum. There was not nough evidence about long-­‐term •  There is support the widespread recommenda<on that PFMT is an effects for for either urinary or faecal incon<nence appropriate treatment for women with persistent postpartum urinary incon<nence. •  It is possible that the effects of PFMT might be greater with targeted rather than popula<on-­‐based approaches and in certain groups of women. •  At 12 months a_er delivery: women receiving PFMT were about half as likely to report faecal incon<nence. BJOG. 2008 Jul;115(8):985-90.
Schwangerscha_ The long-term effectiveness of antenatal pelvic floor
muscle training: eight-year follow up of a randomised
controlled trial.
Agur WI, Steggles P, Waterfield M, Freeman RM.
CONCLUSION: The ini<ally beneficial effect of supervised antenatal PFMT on SUI did not con<nue for a long term despite the majority claiming to s<ll perform PFMT. These findings are in keeping with those of other studies and raise concerns about the long-­‐term efficacy of PFMT. Strategies to improve compliance with PFMT are required. Am J Obstet Gynecol. 2004 Oct;191(4):1152-7.
Who will benefit from pelvic floor muscle training for
stress urinary incontinence?
Grenzen Cammu H, Van Nylen M, Blockeel C, Kaufman L, Amy JJ.
Three independent predictors of treatment failure were > or =2 leakages per day before treatment ( P < .0001), the chronic use of psychotropic medica<on ( P = .002), and a baseline posi<ve stress test result at first cough ( P = .042). The odds were only 15% for an individual pa<ent to be treated successfully when these 3 predictors were present. Health Educ Res. 2001 Apr;16(2):173-86.
Predictors of intention to adhere to physiotherapy
among women with urinary incontinence.
Grenzen Alewijnse D, Mesters I, Metsemakers J, Adriaans J, van den Borne B.
Significant predictors of the inten<on to adhere to PFME therapy were the amount to urinary loss per wet episode and women's percep<on of their ability to do the exercises as recommended under various circumstances. Surgery versus
Physiotherapy for Stress
Urinary Incontinence
Julien Labrie, M.D., Bary L.C.M. Berghmans, Ph.D., Kathelijn Fischer, M.D., Ph.D., Alfredo L. Milani, M.D., Ph.D., Ileana van der Wijk, M.D., Dina J.C. Smalbraak, M.D., Astrid Vollebregt, M.D., Ph.D., René P. Schellart, M.D., Giuseppe C.M. Graziosi, M.D., Ph.D., J. Marinus van der Ploeg, M.D., Joseph F.G.M. Brouns, M.D., Ph.D., E. Stella M. Tiersma, M.D., Ph.D., Annene G. Groenendijk, M.D., Ph.D., Piet Scholten, M.D., Ph.D., Ben Willem Mol, M.D., Ph.D., Elisabeth E. Blokhuis, M.D., Albert H. Adriaanse, M.D., Ph.D., Aaltje Schram, M.D., Ph.D., Jan-­‐Paul W.R. Roovers, M.D., Ph.D., Antoine L.M. Lagro-­‐Janssen, M.D., Ph.D., and Carl H. van der Vaart, M.D., Ph.D. N Engl J Med 2013; 369:1124-­‐1133September 19, 2013DOI: 10.1056/NEJMoa1210627 Studienpopulation
460 Frauen eingeschlossen 35-­‐80a Moderate oder schwere SUI MUI, wenn SUI dominat Bisher keine Therapie Keine Physiotherapie in den letzten 6 Monaten Ausschluss bei POP> 2 und vorhergegangener Op Cross-over
Op PHT PHT 11,2% (22) Op 49,0% (99) Ergebnisse (Intention to treat)
•  Subjek<ve Verbesserung OP 90,8% vs PHT 64,4% Diff.: 26,4% •  Subjek<ve Heilung OP 85,2% vs PHT 53,4% Diff.: 31,8% •  Objek<ve Heilung OP 76,5% vs PHT 58,8% Diff.: 17,8% Per-Protocol Analysis
•  Subjek<ve Verbesserung OP 90,8 (93,5)% vs PHT 31,7% (26/82) •  Subjek<ve Heilung OP 85,2 (87,0)% vs PHT 15,9% (13/82) •  Objek<ve Heilung OP 76,5 (71,8)% vs PHT 44,0% (33/75) Therapie
•  BBT •  Opera<on Seventeen years' follow-up of the tensionfree vaginal tape procedure for female
stress urinary incontinence.
Nilsson CG, Palva K, Aarnio R, Morcos E, Falconer C
Int Urogynecol J. 2013 Aug
CONCLUSION: The TVT opera<on is durable for 17 years, with a high sa<sfac<on rate and no serious long-­‐term tape-­‐induced adverse effects. Over 90 % of the women were objec<vely con<nent. Eighty-­‐seven per cent were subjec<vely cured or significantly improved. Retropubic vs. transobturator tension-free
vaginal tape for female stress urinary
incontinence: 3-month results of a
randomized controlled trial.
Aigmüller T, Tammaa A, Tamussino K, Hanzal E, Umek W, Kölle D, Kropshofer S,
Bjelic-Radisic V, Haas J, Giuliani A, Lang PF, Preyer O, Peschers U, Jundt K, Ralph G,
Dungl A, Riss PA; Austrian TVT vs. TVT-O Study Group.
Int Urogynecol J. 2014 Aug;25(8):1023-30
•  CONCLUSIONS: •  Results of this trial demonstrate noninferiority between TVT and TVT-­‐
O with regard to postopera<ve con<nence and QoL and suggest linle difference in periopera<ve problems Alternativen zu TVT/TVT-O
•  Kurzarmschlingen •  Bulkamid •  Inkon<nenzpessare Alternativen zu TVT/TVT-O
•  Kurzarmschlingen •  Bulkamid •  Inkon<nenzpessare Prog Urol. 2013 Sep;23(11):917-25.
[Mini-sling for management of stress
urinary incontinence in women: a
literature review].
Lizée D, Cornu JN, Peyrat L, Ciofu C, Beley S, Haab F.
RESULTS: Ajust™ and Mini-­‐Arc™ were the two main SIMS evaluated in the literature. Studies about Mini-­‐Arc™ generated heterogeneous results, with a success rate between 44% and 91% a_er 1 year. Ajust™ was the most promising device with 80% efficacy a_er mid-­‐term follow-­‐
up. All evaluated SIMS had a low rate of immediate complica<ons. CONCLUSION: Due to short follow-­‐up, limited evidence and heterogeneous data, SIMS are not yet standard of care and further research is warranted. TVT-­‐Secur™ was excluded because this device is not anymore marketed. Alternativen zu TVT/TVT-O
•  Kurzarmschlingen •  Bulkamid •  Inkon<nenzpessare Urethral Injection Therapy (Cochrane Review)
•  14 randomisierte Studien
•  n = 2004 Patientinnen, 7 Produkte
•  Kleine Fallzahlen
•  Moderate Studienqualität
•  Für Metaanalyse unzureichend
•  Kein Fett verwenden (Embolierisiko)
Kirchin V. et al. Cochrane Database 2012 www.cochrane.org
Periurethral Injection Therapy (Cochrane Review)
… cannot be recommended as alternative for women fit for other
surgical procedures…
Kirchin V. et al. Cochrane Database 2012 www.cochrane.org
CONTIP-01
Leakage/24h
- 93%
Incontinence episodes/24h
- 87%
Subjective response:
81% of patients dry or
improved after 12 months
based on
Stamey score
Lose et al. BJU Int 2006
Bulkamid Results N = 129
N
Recovere
Unchange
Improved
Worse
d
d
6 Mo
43
49%
44%
7%
0%
12 Mo
38
32%
55%
8%
5%
18 Mo
22
32%
50%
18%
0
24 Mo
12
50%
50%
0
0
30 Mo
14
50%
43%
7%
0
Reinjektionsrate: 76 %
Lobodasch, Chemnitz 2008
CONSUIRT-DK02
Patient Zufriedenheit
JA
NEIN
•  Sind Sie mit dem Eingriff zufrieden?
45 (75%)
15 (25%)
•  Würden Sie den Eingriff anderen
48 (79%)
13 (21%)
empfehlen ?
Note: Missing answers are accounted as ‘No’
Sørensen et al. IUGJ 2007;18 (suppl 1):S190-1
J of Urology, September 2014
Einfach-verblindet, randomisiert, 33 Zentren, 12 Monate Nachsorge
229 Pat mit Bulkamid® versus 116 mit Kollagen (Contigen®)
53 % versus 55 % mit ≥ 50% Reduktion der Inkontinenzepisoden
77%…zwei Injektionen; 36%…drei Injektionen mit Bulkamid®
66%…zwei Injektionen; 26%…drei Injektionen mit Contigen®
Kein Veränderung oder schlechter: 27 und 30 %
Sicherheitsaspekte
COLLAGEN
Contigen®
Migration
NEIN
Granulom
Sterile Abszeß
CARBONCOATED
BEADS
CALCIUM
Durasphere®
Coaptite®
HYDROXYLAPATITE
JA
?
3%
JA
EVHO
SILICONE
ELASTOMER
DEXTRANOMER/
HYALURONIC
ACID
POLYACRYLAMID
HYDROGEL
Macroplasty®
Zuidex®
Bulkamid®
Oryx®
Tegress®
NEIN
JA
NEIN
NEIN
(JA)
JA
NEIN
10%
NEIN
Yes
NEIN
JA
(Pseudocyste)
Erosion
JA
Calcification
JA
Allergie
JA
16%
JA
NEIN
NEIN
Nebenwirkungen
(für Bulkamid)
•  12% HWI
•  48% lokale, vorübergehende Schmerzen
•  17% Harnverhalt (vorübergehend)
•  3% Drangbeschwerden
•  1 % Verschlechterung der HI
95% der NW wurden als „mild“ oder „moderat“ klassifiziert
Zweite Schlingen-OP versus Bulking
bei Rezidiv-Belastungsinkontinenz
Gaddi A et al. Obs Gyn 2014
•  Retrospek<ve Kohortenstudie •  165 Reopera<onen nach 6914 midurethralen Schlingen (2.4%) •  60% erneute midurethrale Schlingen vs •  40% bulking agents (Con<gen®, Macroplast®, Coap<te®) •  Bulking eher bei älteren, dickeren, prämenopausalen •  11% Versager nach einem Jahr…Re-­‐Schlinge •  39% Versager nach einem Jahr…bulking agents OR: 3.5
Subjektive Ansprechrate
(Geheilt/gebessert)
Belastungsinkontinenz
70% (26/37)
Mischinkontinenz
50% (11/22)
Dranginkontinenz
0/2
Sørensen et al. IUGJ 2007;18 (suppl 1):S190-1
Alternativen zu TVT/TVT-O
•  Kurzarmschlingen •  Bulkamid •  Inkon<nenzpessare Cochrane Database Syst Rev. 2014 Dec 17;12
Mechanical devices for urinary
incontinence in women.
Lipp A, Shaw C, Glavind K.
AUTHORS' CONCLUSIONS: The place of mechanical devices in the management of urinary incon<nence remains in ques<on. Currently there is linle evidence from controlled trials on which to judge whether their use is bener than no treatment and large well-­‐conducted trials are required for clarifica<on. There was also insufficient evidence in favour of one device over another and linle evidence to compare mechanical devices with other forms of treatment. Obstet Gynecol. 2010 Mar;115(3):609-17.
Continence pessary compared with
behavioral therapy or combined therapy
for stress incontinence: a randomized
controlled trial.
Richter HE et al., Pelvic Floor Disorders Network.
CONCLUSION: Behavioral therapy resulted in greater pa<ent sa<sfac<on and fewer bothersome incon<nence symptoms than pessary at 3 months, but differences did not persist to 12 months. Combina<on therapy was not superior to single-­‐modality therapy. Zusammenfassung
•  Belastungsinkon<nenz ist die häufigste Inkon<nenzform bei Frauen •  Sie trin am häufigsten in der Lebensmine auf •  Reduk<on der Risikofaktoren! •  BBT kann in 16-­‐44% eine Op vermeiden •  TVT/TVT-­‐O dzt. Therapie der Wahl „Fast alles Schlinge………!“