Jovi:
Welcome everyone to tonight’s webinar “Advancements in Prostate Cancer, Diagnoses and Treatment and Understanding Evaluation and Management of Urinary Incontinence in Women” My name is Jovi, and I am your host for this evening.
Before we get started, I would like to make an acknowledgment of country. We recognise the traditional custodians of the land and sea on which we live, and work and we pay our respects to elders past, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online tonight.
I would like to formally introduce to you our presenters for this evening. We have got Dr Jinna Yao, who underwent a six-year Advanced Surgical Training for Urology NSW and was accepted as a fellow of the Royal Australasian College of Surgeons in 2019. Dr Yao went on to complete her post fellowship training in kidney and pancreas transplantation where she gained skills in complex open and laparoscopic kidney surgery. She then completed a Robotic Urological Oncology fellowship at Macquarie University Hospital where she underwent rigorous training in robotic surgery for kidney and prostate cancers.
Our second speaker, we have got Dr Amanda Chung is a urological surgeon and is skilled in urogenital reconstructive surgery, functional urology and urology. She operates at Macquarie University Hospital, North Shore Private Hospital, Royal North Shore Hospital, Northern Beaches and the Sydney Adventist Hospital. Amanda became a fellow of the Royal Australasian College of Surgeons in 2016. She then completed a fellowship of the Society of Genitourinary Reconstructive Surgeons in 2017. Amanda combines her clinical work with research and submitted her PhD on lower urinary tract dysfunction the University of Sydney in 2023 and last but not least we have got Dr Tim Senior.
Tim is a GP at Dharawal Aboriginal Corporation in Southwestern Sydney. Tim is also an RACGP medical advisor for the National Faculty of Aboriginal and TSI Health and senior lecturer in general practice. As well as indigenous health at USW and RACGP medical educator.
Welcome to all of our speakers for tonight. I would like to hand you over to Tim who will go over the learning objectives. Thank you, Tim.
Dr Tim Senior:
Thank you very much. Good evening, everyone. I am sorry I think I just unmuted as my cat did something bad in the corner of the room.
Good evening, everyone. It is lovely to have you here. There is another event happening later on tonight so, it is really excellent to have you here. Anyone watching this on catch-up afterwards. This is the night of the England-Australia World Cup Semifinal, and you will already know the result, but we do not, and we are terribly excited about it.
These are our learning objectives for tonight. So, this is education speak for what we hope to get out of the evening. So that by the end of this online CPD activity we should all be able to discuss the latest diagnostic techniques for prostate cancer including PSA testing and imaging modalities and their role in the early detection and accurate assessment of patient risk.
We should all be able to discuss the current treatment options available for prostate cancer such as surgery, radiation therapy, and targeted therapies and know when to refer to a specialist. We should have increased confidence in performing evaluation and initiating treatments for urinary incontinence in women and we should have an improved understanding of advanced treatment options for urinary incontinence and know when to refer to a specialist. So, I shall pass us straight back onto Dr Yao to start us. Thank you very much.
Dr Yao:
Yes, thank you very much Tim and Jovi for that kind introduction. So, I am just going to just share my screen. Okay. Alright, so thank you for joining us even though it is a very important night for Australia. So, I am going to be talking about advancements in prostate cancer screening, diagnosis and treatment.
So, prostate cancer. Why are we talking about it? Because it is very common. 1 in 5 men develop prostate cancer by age 85. It is the most commonly diagnosed cancer in Australia and lifetime risk of dying from prostate cancer is 3%. It is the second most common cause of cancer deaths in Australian males last year.
Risk factors: age is by far the most important risk factor. The risk increases from age 50 and then it is family history, so one first-degree relative diagnosed with prostate cancer increases your risk by up to 3 x the average person. If you have two first-degree relatives that goes up to 6 x. If you have three first-degree relatives, then that goes up to 10 x and if you have hereditary prostate cancer then the diagnosis becomes 6-7 years earlier.
Race: African descent is also risk factor. So most prostate cancers do not cause any symptoms; however, many men do have urinary symptoms due to BPH. So, symptoms typically show up when disease is advanced, so there are local symptoms versus distant metastatic symptoms. So, local symptoms are for example, urinary frequency and urgency. So, storage lower urinary tract symptoms. When the prostate cancer blocks off the bladder neck you get bladder outlet obstruction symptoms like weak flow, sense of incomplete emptying, dysuria and also it can also cause haematuria and haematospermia. When it metastasises and causes sclerotic bony lesions then you can get lower back pain, bone pain. You can have weight loss and B symptoms and also one of the emergencies is cord compression or cauda equina where you get metastatic lesions to the bone and causes compression of the spinal cord and so these patients need to be admitted. They need to have some steroids, LHRH antagonists and involvement of the radiation and medical oncologists.
So, first of all we will talk about prostate cancer screening. Screening has been a very controversial topic. So, it involves PSA and DRE. So, 15% of cancers have normal PSA but abnormal DRE. So, there is a lot of talk about whether or not we should do a DRE or not. So, my personal opinion as a urologist is that I should but also when your PSA is low then the yield from a DRE is quite low but when you PSA is high then that yield increases obviously.
So, the data from the two largest trials have become more mature. So, now we know that both the European and US trials show that PSA screening reduced prostate cancer mortality by 30%. The balance of benefits and harms of screening improves with time. And so, at the moment the ERSPC number needed to treat is at 18 and that is below the level that is the number needed to treat for breast cancer. So, we know that the earlier you start screening men then the more benefits you have in terms of reducing prostate cancer-related mortality, but it is the striking that balance between overdiagnosis and overtreatment. So, from this study we know that starting screening before the age of 55 halved your risk of prostate cancer compared to starting PSA screening at aged 60.
So, perhaps we should not throw out the baby with the bath water as suggested by the US Preventative Services Taskforce. Even though the PSA screening can lead to harms of overdiagnosis and overtreatment, perhaps it can increase harms from other causes.
So, this is the graph of incidence of prostate cancer compared to other cancers. So you can see that with the other cancers; it is a nice gradual kind-of graphs, whereas with prostate cancer it goes into this spasm, so when PSA screening was first adopted in the late 1980s there was a big uptake corresponding with an increase in incidence of prostate cancer but then when the US PSTF recommended to stop PSA screening then the incidence went down. So, this had several effects, So, the first effect which is good whereas that you reduce the incidence of detection of very low-risk prostate cancer which is the green part of the graph, so the Gleason 6s, but what is worrying is that in recent times there is an increase in the prevalence of Gleason 8s and 9s. We are also now seeing a definitive and sustained increase in prostate cancer metastasis consistent with decreases in PSA screening and also death rate from prostate cancer which was declining from the mid 90s through to the 2010s has stabilised in the recent years. So, I think it is about using PSA in a more wise manner. So, this study shows the PSA level in midlife stratifies long-term risk of metastasis or death from prostate cancer and if we performed a PSA at 60 it is a powerful predicter of the 25-year risk of lethal prostate cancer. So, 90% of cancer deaths occurred in men with PSA > 2 when they were 60 years old, and if you are 60 years old and your PSA was < than the median, so < 1 then you are very unlikely to die from prostate cancer.
So, we should be discussing these benefits versus harms of prostate cancer screening. So, one the potential benefits being earlier detection, it improves survival, and the test is easy to administer, and the potential harms are the false positives are common, there is over treatment and many prostate cancers may not cause issues in their lifetime.
So, who should be screened? So first of all, you would need to have a life expectancy of > 10 years in the American guidelines they recommend 15 years. Men at higher risk of prostate cancer, so the family history like we spoke about before, but also that includes family history of not just prostate cancer but also breast cancer, ovarian cancer, things that are linked with other syndromes as well like Lynch syndrome. African ancestry, germline mutations and they need to be well-informed men and they need to be informed of the limitations of the PSA test.
So, what do our guidelines say? So, they recommend that for men at average risk of prostate cancer that we should offer PSA testing every two years from age 50-69 and if the PSA is > 3, then to offer further investigation. If you have 1 father or brother, then that recommendation becomes earlier to age 45 if you have father or two or more brothers then that reduced down to 40 years.
So, prostate cancer diagnosis. So, you have a patient with a one-off reading of a raised PSA. So, what do we do? We all know that we need to repeat your PSA and that is because there is a very high fluctuation of PSA readings and this is a nice study by James Eastham in Memorial Sloan Kettering that shows that if you do a repeat PSA then the probability that your PSA will return back to normal is about 40%.
So, we look at the age-specific PSA range as well and the age-specific median. So, for example, in patients who are in their 50s then the median is 1.1. So, in recent years there has been a widespread use and uptake of multiparametric prostate MRI, and this is a nice table that I like to use in my clinical practice. So the column on the left here is the grading of the lesions based on their MRI images, so it goes from PI-RADS 1 which is very unlikely but there is prostate cancer to PI-RADS 5 which is very likely that the patient has prostate cancer and then they correlate that with your PSA density.
So now what if we decide to go ahead and biopsy the patient because they have a raised PSA or abnormal prostate MRI finding? So, prostate biopsies, you can either do transperineal or transrectal, so the difference is that both of them involve having an ultrasound probe in the rectum in order to visualise the prostate. In transperineal prostate biopsy the needle goes in through the skin here between the scrotum and the back passage whereas the needle for transrectal prostate biopsies goes through the rectum, so in Australia we mostly do transperineal now but I know that in the US I think, if I remember correctly that it is still 50/50.
So, the advantages of transperineal prostate biopsy is that there is low risk of sepsis of < 0.1% and also, they have a higher risk of urinary retention of 5%. We can also do MRI fusion prostate biopsies as well and this machine the Biobot is available at Macquarie University Hospital where we can plan on the MRI and then the robot will actually take the biopsies.
So, once we get the biopsy results then the pathologists grade the prostate cancer. So, this is what a typical pathology report looks like. So, the things that I look for on the pathology report is obviously the Gleason score. The Gleason score is a combination of the primary and secondary and sometimes the tertiary score and then I would look at the percentage of high-grade prostate cancer which is grades 4 and 5 and also, I look at the number of cores that are involved in order to inform me how big the cancer is. If it is a small-volume or a high-volume prostate cancer and also things like intraductal carcinoma, perineural invasion and vascular invasion and extrastatic extension is also relevant when I am trying to decide whether or not this patient is for active treatment or for active surveillance or is they need surgery or should I refer them on to my radiation oncology colleagues.
So, once we have got the diagnosis then we stage. So traditionally the staging for prostate cancer involves a CT chest, abdomen and pelvis and bone scan. These days there is the PSMA and that is widely available in Australia now and this can be used in initial staging of the disease to allow us to see if there are any distant metastatic sites or in recurrent disease. Also it can be used in primary diagnosis for example, I have had a patient who had rising PSA but repeated negative biopsies and so after the second negative biopsy I said to him “Look we will monitor you PSA, if it increases still then the next step will be, let’s do a PSMA test to see if your prostate lights up. If it does, then that gives us a good idea that he may have prostate cancer that we have missed on the biopsy”.
So prostate cancer treatment. We can treat prostate cancer with just active surveillance, radical prostatectomy, radiation therapy, focal therapy and watchful waiting. So, this is the ProtecT trial that is widely known. You have probably heard about this. So, this one was the 15-year update that was published just very recently, earlier this year. So, basically it was done in the UK 1999-2009. It was a randomised control trial. They offered 82,000 men PSA testing. They diagnosed 3.2% of patients with prostate cancer. So, in the end 1643 patients were eligible for the study and they were randomised to active monitoring versus radiotherapy versus surgery. So, the end result was that they found active monitoring was just as effective as active treatment, but active monitoring had an increased risk of metastatic progression, 9% compared to 5%. That was in comparison to active treatment which includes radiation or surgery, but since then the approach to prostate cancer has changes dramatically. So, 10 years ago we had the PSA test, we would do a TRUS biopsy, and then we would stage the patient with staging CT and bone scan and then we would offer them treatment; either surgery or radiation therapy. Now a days we have a PSA and then they may get genomic testing. There is MRI, transperineal prostate biopsies. They can get stage with PSMA PET CT and then they get treatment.
Also, if you look at the patient group; the patient characteristics, 77 were in the Grade Group 1 disease, so that means these patients for patients who have Gleason 6 then the standard of care is actually do nothing: active surveillance. Also, active monitoring in the ProtecT trial is somewhere between active surveillance and watchful waiting and it is not really what we do today. So, really the result of the trial should probably be only applicable to men with low-risk prostate cancer. So, management of low-risk disease, this is taken from the EAU Guidelines (European Urology Association Guidelines 2023). So, active surveillance or watchful waiting is standard of care based on life expectancy or active treatment options present a risk of over-treatment in low-risk disease so that is patients with Gleason 6. So, this just shows that there is a steady uptake of active surveillance amongst men with low-risk prostate cancer.
What is active surveillance? It is a method of delayed curative treatment. It is for men with > 10-year life expectancy and the aim is to limit the adverse effects of treatment but survival is unchanged and that is different from watchful waiting where you intend to give palliative therapy if the patient cancer progresses. In watchful waiting there is not routine follow-up and testing, and it is for men who have < 10-year life expectancy. For active surveillance follow-up of these men is mandatory. So, they need to have regular PSA, DRE plus/minus an MRI and they need to have a confirmatory biopsy within 1-2 years because there is a risk of upstaging these men.
So, what is the risk for someone who is on active surveillance? So, the risk of death over 10 years and the risk of metastasis is about 1%, so also they know that about 1/4 of men at 5 years and 1/3 of men at 10 years drop off from that active surveillance program and that is because they develop higher risk disease or increase in cancer volume or abnormal MRI findings. This advantage of active surveillance is it causes anxiety and also you need to repeat biopsies and you need to have someone who will come back to you for follow-up.
This is what we do, so, radical prostatectomy; it involves the removal of prostate, seminal vesicles, pelvic lymph nodes, robotic versus open, so, about these days 90-95% of prostates are done robotically. There is less blood loss, shorter length of possible stay and lower pain scores. There is three days of hospital stay usually and seven days for catheterisation and this is just a picture to say that the vision for robotic surgery is much superior to open surgery and we can actually visualise the neurovascular bundle which is very difficult to do in open surgery.
Side effects: Urinary incontinence, the risk of severe incontinence is 5% which will necessitate further surgery. Erectile dysfunction, bladder neck contractures, penile length shortening about 1 cm, aspermia, rectal injury, bleeding and infection.
Radiation therapy. So, radiation therapy is divided into external beam radiation or internal with brachytherapy. So note that I think for most centres they use VMAT: volumated metric modulated arc therapy these days and also when you do radiation therapy for intermediate to high-risk disease then they need to be on 1-3 years of ADT, so hormonal therapy which has added risks to cardiovascular and bone health.
Radiation side effects include genitourinary and GI side effects, erectile dysfunction, urinary incontinence, bowel incontinence. I just read a paper that was the “Functional and Quality of Life Outcomes of the ProtecT trials” so that was the 12-year update that was just published in NEJM early this year and that actually showed that faecal incontinence rate in radiation after 12 years was 12% which was actually quite surprising to me.
Also causes bladder irritation, rectal irritation, urinary retention, decreased ejaculatory volume, haemorrhagic cystitis which is something that the patient comes into ED and then we have to manage, and they are very refractory to treatment in a lot of cases. Urethral strictures and secondary malignancy.
Focal therapy is largely experimental at this stage, but a lot of my colleagues do offer this across Sydney. So, the decision between surgery versus radiation is complex. So, there is no level 1 evidence that shows that there is any oncological benefit of one over the other. So, our information comes from mostly pooled data from observational studies. So, this study that was published last year was in men with higher risk and very high-risk prostate cancer. They looked at cancer specific mortality amongst patients undergoing surgery versus radiation therapy and looked at the SEER database it was propensity score matching and so for those people who say that well, radiation therapy you treat mostly older men with more comorbidities well then this study is propensity matched so it matches patients in he same cohort like age and comorbidities. So, basically is showed that if you were treated with radiation therapy then you had a higher risk of death, hazard ratios show what is 0.68 favouring radiation for high-risk and 0.58 for very high-risk. This was one of the more well-known meta-analysis comparing surgery versus radiotherapy for clinically localised prostate cancer and if you look forest plot here this side favours surgery, this side favours radiotherapy and this is in favour of surgery. So, patients treated with surgery had a lower risk of death, that is overall mortality and prostate cancer-specific mortality. We know that we are getting better at doing surgery, so there is declining positive margin rate over the last decade, so we are leaving less cancer behind. This was local data, this was done by the Victorians, so you can see that the blue line is robotic prostatectomy, and the red line is open, and you can see that the line is decreasing.
So, why surgery? I think in my opinion it is a relatively low morbidity procedure done in the right patient. Patient goes home on day 3. It facilitates lower pain scores, less blood loss, faster recovery. There is fewer local complications at progression and I think that is very important because a lot of these men who progress later on when they became castrate-resistant have these problems, so you see the prostate cancer invading into the trigone of the bladder causing haematuria, bladder outlet, obstruction, acute urinary retention and also it causes bilateral hydronephrosis sometimes when it blocks off the ureteric orifice or the lymph nodes block off the ureters. I think in my mind the continence risk is the main differentiating factor, so there is a higher risk of continence the older the get and if they have bulky apical disease then I am less likely to offer surgery because then that is encroaching on the urinary sphincter here.
Also, that if cancer progresses after surgery, you can offer radiation, but if cancer progresses after radiation and you do surgery it is very difficult and not many men get that. So, I think surgery should be offered to younger men with higher-risk disease. So, you should only do it if you can have a continent patient at the end of it and you are confident you can remove all of the disease.
Thank you.
Dr Tim Senior:
Wonderful. Thank you very much. So, there is a summary up there. We will switch over to Dr Chung. There are quite a few questions that have come through and Dr Yao may well get to answer some of those while Dr Chung is talking. Thank you very much.
Dr Amanda Chung:
Thank you so much for the warm invitation to join you all tonight. I will be speaking about the evaluation and management of urinary incontinence in women. I trust that you can see the screen okay.
Jovi:
Yes
Dr Tim Senior:
Yep. It is perfect. Not on presentation.. we can see there that is right.
Dr Amanda Chung:
It is in presentation mode. Yep.
Jovi:
Perfect.
Dr Amanda Chung:
So, these are my disclosures.
So, what is urinary incontinence? Well quite frankly it is a failure of the bladder to store the urine. By definition it is the complaint by the patient of any involuntary leakage of urine. There are different kinds of urinary incontinence. Generally speaking, there are three categories. There is stress urinary incontinence and we don’t mean psychological stress when we talk about stress urinary incontinence, although it can be very distressing. What we mean is that there is leakage on effort or exertion such as sneezing, coughing, lifting something heavy, going for a run, jumping on a trampoline. Urinary urgency incontinence is the other main kind of incontinence which is where there is leakage accompanied by or immediately preceded by urgency. So the patient might describe feeling like they really need to go to the toilet right now and before they can get there is in time they might start to leak urine and there are some people who have a combination of the two where they have got some leakage with the urgency but also with the exertion.
Incontinence in Australia is unfortunately a really big problem. So, 1 in 4 Australians are actually incontinent so that means over 5, 000,000 Australians. In Australian men it affects up to 13% of Australian men and up to 37% of Australian women. In fact, in your waiting rooms surveys have shown that 65% of women sitting in your waiting rooms have urinary incontinence and 30% of men sitting in your waiting rooms have urinary incontinence. Yet only a third of these persons report having sought help from a healthcare professional and why is it that therefore about 70% of people have this problem yet don’t seek advice and treatment for it? Well, I think there is a number of reasons for that. I think a lot of times people are embarrassed. Sometimes they think it is a normal part of aging and surveys have also shown that patients actually prefer their healthcare providers to ask them about some of these issues rather than them having to drum up the courage to speak up about it and so I think the first steps in helping these patients is firstly to identify them and I think that as primary care providers you are in a very unique position in order to do this and then to empower the patients to know that even though it may be common it is not normal. They do not have to live with it.
There are treatments available and actually a lot of those treatments are actually relatively simple, and they do not necessarily require any major surgery and so tonight I would like to present a systematic approach to evaluating and starting treatments for lower urinary tract symptoms and urinary incontinence. Of course, starting with history and examination but before we launch into that let’s get into our minds a framework as to how we are going to structure the history and examination.
So, let’s take a moment to think about the causes of urinary incontinence. There are basically two main causes. If people are incontinent, it is usually either the outlet, so as you can see in this diagram here that could be bladder neck, the prostate, the urethra, the rest of the urethra, or in women the bladder neck and the urethra is not holding tight enough. It is too loose and so when they do cough, sneeze, go from lying to standing up first thing in the morning the urine basically just drops out with gravity. The other reason for incontinence is actually because of the bladder. If the bladder is hypersensitive. If it is a bit tense or stiff or if even has the ball of muscle that is the bladder, spasms, then it does not stretch or relax to accommodate urine as it fills and it might push it out or even spasm and squeeze it out accidentally and so therefore there are these two aspects to it.
One which is the bladder factor. We call overactive bladder or overactive bladder incontinence and usually that is associated with the urgency incontinence-type symptoms that patients would describe or the sphincter factors which is a deficient sphincter or weak pelvic floor muscles and that is associated with the stress urinary incontinence or the kind of incontinence when you cough, sneeze, laugh, do star jumps on that aspect of things. So therefore when I do take a history and exam a patient and decide on investigations I have got those things in mind because I am really trying to work out what kind of incontinence it is, so that we can start the right initial treatments but also keep in mind the red flags as well. So in the history in trying to work out what kind of incontinence I would ask in which situations it happens and whether there are any other associated urinary symptoms, like for example, is there urinary frequency, urgency, nocturia that goes along with that incontinence, because that tends to suggest that it is probably more overactive bladder incontinence as opposed to the stress urinary incontinence which is the one that happens with exertion. If someone says they don’t have to wake up at all during the night and when they are sleeping at night they don’t have any leakage at all but it is on the more active days that they have the urinary leakage, even if they can’t tell you that they cough or they sneeze or something like that, then that is more likely to be the stress urinary incontinence; basically the outlet not holding tightly enough. Ask them how long it has been for, how severe it is, how many pads do they wear, does it bother them, do they want to make this better, if possible, are there any easily reversible causes. So, if they say “look it has only been for a week that I have had this frequency, the urgency, this incontinence and can’t get to the toilet in time”, Well then you are thinking things more like a urinary tract infection as opposed to a longer standing overactive bladder syndrome and also I will ask if there is any red flags such as neurological symptoms for example.
Other specifics like their personal other general health. Previous surgeries, pelvic cancer history like it if is on a background of having pelvic cancer resection or radiotherapy, whether there is any other neurological symptoms that might be relevant and whether or not they have faecal incontinence because they can sometimes go hand in hand.
On physical examination we want to see that they don’t have a palpable bladder because the other rarer type of urinary incontinence is actually overflowing incontinence when paradoxically they are too full, they can’t empty their bladder out and it is just spilling out or overflowing from that point of view and I would have the patient as an adjunct to the physical examination complete a bladder diary as well, so I can get a bit of a picture of how severe this is and how bad it is because sometimes patients aren’t very good at remembering what is like because sometimes they have just lived with it so long and got used to it and they might say actually it is not that bad but when they give you their bladder diary, you think “Wow this is really not normal”.
In terms of investigations, I would usually start with an MSU, consider a urine cytology creatinine and an ultrasound of their urinary tract. So, in terms of initial management this is how I would structure is. First let them know there are treatments available. History examination: the investigations and then talk about some strategies and therapies, so for example, some simple things to do is the fluid management. They could link in with a pelvic floor physio and do pelvic floor exercises and bladder retraining. There is not much downside to that. If you think it sounds like it might be an overactive bladder syndrome then you could start a trial of overactive bladder medications and I will go a little bit more into details about that later, but if you are not getting any joy or adequate improvement with that then do consider referral to a urologist for further testing, further investigation and discussion of other definitive treatments.
So, this is the diagram that I have got in my mind when I talk to patients with urinary tract symptoms. So, really at the moment we are talking about what is in this red box, red circle here, “Storage symptoms” and it could be a bladder factor or an outlet factor causing it, so a storage problem caused by bladder factor is an overactive bladder (OAB). A storage problem caused by an outlet factor is ISD, so that is stress urinary incontinence or intrinsic sphincter deficiency. This is a Venn diagram of overactive bladder constellation of symptoms. So, the patient may have nocturia, urinary urgency incontinence, detrusor overactivity but as you can see on this Venn diagram not every patient with overactive bladder syndrome necessarily has all the features of an overactive bladder syndrome. Some of these symptoms can overlap. So, if you think it might be an overactive bladder, first exclude other causes of similar symptoms such as urinary tract infection and this is a picture of the E. coli bacterium and bladder malignancy. This is a cystoscopic picture of what a papillary, urothelial bladder cancer looks like when we have a look in on a cystoscope and that can cause bladder irritability which can present as an overactive bladder.
This on the side here on the side of the page is an overactive bladder care pathway, which is what I find very useful to talk to patients about the algorithm and the journey that they might take in terms of how to evaluate and treat their overactive bladder. So often I will give this to patients that I am very happy to share it if you think it would be useful for you in your conversations with patients a well. Basically, it lays out how we approach an overactive bladder. From less invasive options, medications, and then if patients need to there are advanced therapies down blow as well. In terms of the conservative therapies dietary modifications may be about limiting irritants in the diet so things like caffeine, carbonated drinks including sparkling water and spicy foods, that can make a bladder more irritable if it is already prone to being overactive and they could see a pelvic floor physio to help with bladder retraining and pelvic floor exercises.
Fluid management refers a little bit more to patients who have nocturia as a big feature of their overactive bladder. They might restrict the amount of fluid they would drink at night to help prevent them getting up so many times. In terms of other lifestyle modifications and time voiding, there are some patients where their bladder does not tell them that it is full until it is really full and then it is really urgent, and they would have incontinence.
So, for example if that would happen at around the 4 or 5 hour mark it might be reasonable to say well let’s pre-empt that. Even if you do not feel like you need to toilet yet, why don’t you try to go to the toilet around the clock about every three hours, of course not when you’re sleeping, to see if you can pre-empt that really urgent period and incontinence episode. So, they could try that for maybe a month or so and see how they go. Usually by the time patients have seen me they have done all these things already with you, and their GPs or even a pelvic floor physio and they are really ready to try something a little bit more, so the next thing that you could offer them would be a medication if they are open to it.
There are two classes of medication that can treat an overactive bladder. An anticholinergic class of which there are multiple options including oxybutynin patches or other oral agents such as solifenacin and oxybutynin as well as a beta-3 agonists class of medication called mirabegron and there is only one choice in that class in Australia at the moment. I would usually advise them regarding the common side effects and I have put that on the side of my care pathway there and the common ones to look out for and there are some subtleties in terms of which one you might like to choose first depending on their age, what sort of side effects they are very keen to prevent. So, for example, the anticholinergics can sometimes cause a patient some dry mouth, constipation, dry eyes and there is also a concern about cognitive side effects so I am very weary of prescribing it in someone over 70 years of age and I will ask them if they do suffer from any of those things already and if they say “Look I have already got dry eyes or I am already struggling with constipation” then I will say “Alright, no problem, how about this other one , the mirabegron one, maybe that would suit you better but most patients to do not get side effects with it. Some patients though however can get some hypertension, so I usually would advise them to check with their GP, their blood pressure, usually about two weeks after starting it and watch out for any headaches or cardiac palpitations and if they experience any of that then to stop it and let me know.
So, if you have started a patient on these medications when would you consider referring them to a urologist? Well I think that if they have failed the initial therapies of pelvic floor exercises and they have given these pelvic floor exercises a good 6-8 weeks but they are not getting improvement I think it is unlikely that they would get improvement beyond that and so then it would be reasonable to start them on a medication or refer them on, but it depends a bit on the patient, so for example, if the incontinence is very severe and they are very distressed by it then it is probably unlikely that just pelvic floor exercises are going to fix the problem. It might lessen it. So, maybe they will go from 8 pads down to maybe 7 or 6 pads a day, but it is really unlikely to get them dry and that is even more the case especially if they are quite elderly. It can be a bit overlofty ambition to think that their pelvic floor exercises may be able to fix them completely.
So, when you do refer them to a urologist and the urologist is likely to then do further evaluation or talk to the patient about that if the medications haven’t helped them already and this is to help determine the exact cause of the incontinence. Is it a sphincter problem or a bladder problem or both and that can help to decide whether what advanced treatments would be most suitable for them.
So urodynamic study takes about half an hour. It is done in the office, and it is basically a urologist version of an ECG. It gives us a tracing of what the bladder activity is like. Are there actual bladder spasms which are pushing the urine out? Or is it stress urinary incontinence? Or is it a mixture of both and other features like how they empty, and their leak point pressures which helps me to tailor the treatment options to the patient. The advanced therapies that we have listed below at the bottom of the page here are threefold. So, there is sacral neuromodulation which is essentially a pacemaker for the bladder.
There is onabotulinumtoxin injections into the bladder which is applied via a cystoscope or there is percutaneous tibial nerve stimulation which essentially looks a bit like an acupuncture needle connected to an electrical device to stimulate that nerve. The onabotulinumtoxin injections into the bladder is a day stay surgery that takes about 15 minutes under a short anaesthetic, or it can even be done under a local anaesthetic. Patients go home the same day, and it takes about two weeks to kick in. On average it will last about 6-9 months for the patient and so if they do feel that it wears off after some time but they had a good response then they would come back for a top-up injection about every 6-9 months on average, because some patients are lucky and they get a year out of it. It has a 90% success rate.
Sacral neuromodulation is the one that is a pacemaker for the bladder, but it does not go into the bladder itself, it goes into the lower back. There is a little wire that is placed into the S3 foramen connected to a little battery which is implanted in the upper buttock. Before we do the real implant through, we would usually do the evaluation trial first, which is just two little wires down into the S3 foramen bilaterally as a day stay procedure that takes about 30 minutes to do. When they wake up from that they have a sticky dressing over it. It is connected to a little plastic battery, and they wear a waistband for a week to two weeks to see if it works for them. If it works for them then we would implant the real things which is about a 45-minute day stay procedure as well. The battery is MRI eligible since the 1 July 2021 which is great, and it does come with a rechargeable option or a recharge-free option and also has a 90% success rate.
PTNS: percutaneous tibial nerve stimulation is essentially like an acupuncture needle into the ankle near the tibial nerve and this electrical stimulation runs up that nerve to the S1-S3 nerve roots, so it is the S3 nerve root that is shared with the bladder. It is a half hour stimulation just in the clinic, no anaesthetic required, once a week for 12 weeks its success rate is about 60-80%. If it works well after 12 weeks then we do a tapering course, so we spread that apart two-weekly, three-weekly, four-weekly and then the maintenance is once per month.
So that was then talking about the overactive bladder treatment pathway. So, let’s change tune a little bit now and talk about the stress urinary incontinence side of things. So that is if there is intrinsic sphincter deficiency. So, this is leakage when you cough, sneeze and so forth. So, the treatment options from less invasive to more involved include continence pessaries which can be fitted by a pelvic floor physio. Essentially a rubber insert that goes up into the vagina, pushes on the back of the urethra and bladder neck in order to improve its coaptation. This one has become very popular these days. The female urethral bulking agent injections for example, Bulkamid. So, it is suitable for mild and some moderate incontinence. It is a very minimally invasive procedure. It takes less than 30 minutes and there is a cystoscope placed in the urethra, injecting essentially a gel to help to coat or squeeze the urethra a little bit more tightly. For patients it is a day stay procedure and their recovery is very quick and they can return to their activities within 24 hours. It has about a 70% success rate with the durability up to 7 years and it can be topped up if need be. For patients that have more moderate to severe incontinence then a sling is more definitive and is a stronger sort of support to the urethra. You might have heard a bit about the mesh issues and concern about that and so these days we offer to use natural tissue and repairs and so the most popular type of sling that I am doing at the moment is the rectus fascia tissue repair. So what that is is that we borrow a little strip of tissue, a little 8 x 1 cm strip from the rectus fascia through a little transverse incision at the lower abdomen, usually at the bikini line area and we put two sutures on either end and it is inserted behind the urethra, a bit like a U-shaped hammock in order to support it.
So that when the patient does cough, sneeze with something heavy rather than that bladder neck descending and opening up and letting urine escape it just helps to support it so that urine does not escape and it had about a success rate over 90%.
The artificial urinary sphincter can also be used but it is less common and quite rare. It is essentially a silicone device that is like a cuff around the urethra. For the patient to urinate they would need to reach down and press on that cuff on the labial pump in order to release the cuff so that the patient can void.
So, take home message. I would like to encourage you to teach your patients and educate your patients that there are treatments available for everyone for their urinary incontinence. Although urinary incontinence is very common especially in women, it is not normal, and they do not have to live with it. Start by using the history, examination and investigations to try and distinguish the incontinence type and to rule out any red flags with an MSU for example, a urine cytology, creatinine and an ultrasound of the urinary tract.
I hope that you feel confident to start and initiate management strategies and therapies such as fluid management, physio, pelvic floor exercises. If it is complicated with complex background or severe red flags, then feel free to refer early as well. If you think it might be an overactive bladder, I hope that you feel confident starting a trial of overactive bladder medications or more confident now after this webinar and also consider using a care pathway to help empower the patient in their own journey for the treatment as well as to engage them in their journey. So, I am happy to also provide copies of that if you think if would be useful for you. If the urinary incontinence has not resolved though within about 6-12 weeks, then I would encourage you to refer to a urologist for further testing and discussion of other definitive forms of treatment.
Thank you so much for your attention.
Dr Tim Senior:
Thank you very much. That’s great. We have hit 8:24 and we do have just time for a few questions if I can ask you those on behalf of people if that is alright Dr Chung?
Dr Amanda Chung:
Yes. Absolutely.
Dr Tim Senior:
So, one of them is “What is the best way of diagnosing overactive bladder?”
Dr Amanda Chung:
Great question. So, I think that the diagnosis can first be done just by talking to the patient about the history. So if they say “I feel I need to go to the toilet frequently or urgently and I can’t get there in time and before I get there I would start leaking or I get up multiple times a night”, then that tells me that it is probably an overactive bladder syndrome. If you wanted to get technical then it would require a urodynamic study to see that for sure, but I would be comfortable starting the initial conservative therapies as well as medication trials based even just on the story alone.
Dr Tim Senior:
Lovely. Thank you.
There is a question about medications on the PBS. “Oxybutynin is not on the PBS but are any others on the PBS?”
Dr Amanda Chung:
No unfortunately, not the Mirabegron which is beta-3 agonist is not yet on the PBS, so it is a bit more expensive for patients at the moment.
Dr Tim Senior:
Thank you. “How long do pelvic floor exercises need to be done to get some benefit in controlling your continence?”
Dr Amanda Chung:
So, I do think that they need to be done for a good 6-8 weeks. If you think about training other muscle groups in the body I think that it is not reasonable to think that after a week or two weeks that there would be great results, so I think it is important to ask the patient to persist for a good 6-8 weeks but I think that if it has been 2-3 months already and they have been trying, it is really unlikely that they are going to get more benefit from that and especially it they’re elderly and they’ve got poor muscle mass and things like that then I think that it is also a bit too lofty an ambition to think that they can necessarily build up their pelvic floor so well that they would get dry again, depending on their degree of incontinence.
Dr Tim Senior:
Thank you. This is an interesting one from an incontinence point of view. “Do you think caesarean section is better than a normal vaginal birth?”
Dr Amanda Chung:
That is a very good question. So, the data is that actually it does not make much difference to the incontinence whichever way the delivery occurs. The carrying of a baby on the pelvic floor and all the stretch that happens is enough to cause the urinary incontinence or to increase the risk of that; however, when it comes to what is more of a risk factor for vaginal prolapse then vaginal deliveries have increased risk of vaginal prolapse compared to caesarean but for stress urinary continence is about equal.
Dr Tim Senior:
Lovely. Does Betmiga cause arrhythmia like IF.
Dr Amanda Chung:
It can. Yes. So, it can cause some palpitations. So, if the patient tells me that they have palpitations or they have got a history of arrhythmia I usually clear the use of it with their cardiologist or their GP first.
Dr Tim Senior:
Yeah, and among Betmiga and Vesicare which one is superior in terms of efficacy and side effects?
Dr Amanda Chung:
The same. So, in terms of efficacy it is equal. In terms of side effects, they have different side effect profiles. It seems a little bit more common for patients to have side effects from an anticholinergic so Vesicare or solifenacin compared to the Betmiga or the mirabegron, but the side effect profile is quite different. There is also studies that show you can take both in combination. So, if you took 5 of solifenacin plus 25 or 50 of mirabegron together you would get better resolution of the overactive bladder symptoms and less side effect profile compared to if you took solifenacin and doubled that dose to 10 mg a day.
Dr Tim Senior:
That is helpful and I think our final question to round us off which is a good teamwork between GPs and urologist question, I think. “If we do a GP management plant, that sort of item for urinary incontinence do we involve urologists in the initial phase when creating a plan, so that would involve a team care arrangement for involving physio as well in the first 6-8 weeks?” Have you got experience of being involved in GP management plans?
Dr Amanda Chung:
Absolutely. I have been involved in a lot of those team care plan arrangements and yeah very happy to be involved. I think that is a great idea.
Dr Tim Senior:
Lovely. We have had a few requests for the recording and Jovi will tell us about how to access that because it will be recorded as I suspect a lot of people will be watching but thank you very much Dr Chung and Dr Yao. We have had lots of appreciative comments coming through. People have really appreciated what you have had to teach us this evening, so thank you very much indeed.
Dr Amanda Chung:
My absolute pleasure.
Dr Yao:
Thank you very much.
Jovi:
Thank you. So, I would also like to extend my thanks to Jinna, Amanda and Tim for presenting tonight’s session and also to everyone who has joined us online. We hope you enjoyed the session and also the rest of you you’re evening. It is just a friendly reminder that this is a CPD accredited activity. You will receive your CPD hour on completion of the survey following this webinar. If you have missed any parts of tonight’s session it is recorded and will be uploaded on the RACGP website within the next week. That does bring us to the end of our session. So, thank you everyone and goodnight.
Dr Yao:
Goodbye. Thank you again