LINDA HARDER | PHOTOGRAPHY TRACEY BROWN
While American society has become more open about health issues, many of your patients may still be reluctant to mention that they have incontinence or erectile dysfunction. That’s why our experts advise that physicians ask about these common disorders.
The prevalence of incontinence increases with age. In a large U.S. survey of non-pregnant women, moderate or severe urinary incontinence was reported to affect 7% of women ages 20 to 39, 17% ages 40 to 59, 23% ages 60 to 79, and 32% over 80 years. Stress and urge incontinence are the most common types in females. While age, menopause, weight, number of children and prior pelvic surgery or radiation are risk factors, studies have shown that even college athletes can suffer from one or both of these types of incontinence.
Despite the growing acceptance of countless formerly taboo topics in our culture, many patients remain reluctant to tell their physicians about incontinence. Jennifer Bepple, M.D., a urologist with Central Maryland Urology Associates, says, “There’s still an unfortunate stigma associated with incontinence. Primary care physicians should be sure to ask every patient, whether via the health survey or during the visit, about this issue. And they should educate patients that it’s not a normal part of aging, and there are multiple treatment options available.”
Stress incontinence refers to the inability to prevent leakage of urine when stress is placed on the abdominal muscles. Caused by weakened pelvic muscles or a deficient urethral sphincter, stress incontinence has two main types – urethral hypermobility and intrinsic sphincter deficiency. “When assessing patients and determining their options, we are sure to identify which type they have,” Dr. Bepple reports. “We do this based upon their physical exam and urodynamic studies.”
Anything that increases intra-abdominal pressure, such as smoking, a chronic cough, obesity or constipation, can worsen stress incontinence. Because it is essentially an anatomical issue, no medications are indicated. The first line of treatment is conservative. Dr. Bepple recommends referring patients to a qualified pelvic floor physical therapist who can provide biofeedback and a personalized exercise regimen. Home biofeedback devices can also be useful to ensure that patients are performing the exercises correctly.
Surprisingly, Dr. Bepple notes that many people do the wrong variety of exercises or perform them incorrectly. She says, “It’s like the gym. If you haven’t worked out in five years, you can’t just go and bench press 150 pounds immediately. And you need a guide as to what exercises are appropriate.”
She adds, “I’m a strong advocate for women to try these conservative approaches because there are no side effects.”
If these conservative approaches fail, women may need one of two surgical options. The first option is a mid-urethral sling, performed as an outpatient procedure under sedation to address urethral hypermobility issues.
While it enjoys a success rate greater than 80%, many women continue to mistakenly believe that the polypropylene mesh used in the sling procedure is what the FDA once cautioned users about, despite clarifications issued in 2011 and 2013. “The FDA warning excludes mid-urethral slings, but many women are still nervous about this procedure,” Dr. Bepple comments. “The American Urogynecologic Society issued a position statement supporting the sling as the worldwide standard of care. However, it’s contraindicated for women who are, or are considering becoming, pregnant, and those with compromised immune systems, bleeding or some pelvic disorders.”
The second surgical option involves the injection of a urethral bulking agent to address intrinsic sphincter deficiency (ISD). This procedure is performed on an outpatient procedure under mild sedation. While it’s a viable option for those who can’t tolerate a sling or who only need their sphincter deficiency addressed, it has the drawback that some 30% of patients may need a repeat injection.
The bulking agents, which can be injected via a transurethral or periurethral approach, can be made of synthetics, bovine collagen or autologous substances. Stem cells also show promise as future bulking agents. They work by coapting the submucosal tissues of the bladder neck and urethral wall and resisting urinary flow.
Urge incontinence, or overactive bladder (OAB), is the need to urinate urgently and often. While more common in women, especially in older women, it is also seen in men. “What patients eat and drink influences this condition,” Dr. Bepple states. “Coffee, teas, sodas, acidic fruit such as tomatoes or oranges, alcohol and spicy food contribute to the problem. Even decaffeinated products can worsens symptoms because it’s the acidity, in addition to the caffeine, that contributes.”
Even when patients follow a strict diet, they may still need medications. Anticholinergics, such as Ditropan or Vesicare, are the oldest class of these medications. Their potential side effects, including dry eyes, dry mouth and constipation, can dissuade patients from using them, and they’re contraindicated in those with narrow-angle glaucoma, urinary retention and some gastrointestinal diseases.
The tricyclic antidepressant imipramine hydrochloride may be used to relax the smooth muscle of the bladder, and may also contract the muscles at the bladder neck. A newer class of drugs, the beta 3-adrenoceptor agonists such as Myrbetriq (mirabegron), targets beta-3 receptors, decreasing the frequency of rhythmic bladder contractions during the filling phase. This increases bladder capacity and improves symptoms in patients with OAB. It is contraindicated in those with poorly controlled hypertension.
Dr. Bepple says, “Many primary care physicians have a ‘go-to’ medication. If that medication fails, they often refer to a urologist, where further evaluation can be performed. We make sure patients are emptying their bladders well by checking a post-void residual, and can perform cystoscopies, urodynamic studies, uroflow evaluations and a urine culture or microscopic analysis as indicated. We also sometimes ask patients to keep a voiding diary that records what and how much they drank, and when and how much they voided.
“When patients fail medications, we may use medications in combination,” she continues. “Other options include BOTOX®, initially approved for the neurogenic bladder, but now FDA-approved for idiopathic overactive bladder. Side effects may include infection or retention, however, and it must be repeated every six to 10 months.”
Second-line treatments also include InterStim®, a sacral neuromodulator – essentially a bladder pacemaker. It treats urinary frequency, urgency and non-obstructive urinary retention by regulating the signals the sacral nerves send to the brain. Percutaneous tibial nerve stimulation employs a similar concept, involving the placement of a tiny needle behind the ankle to stimulate the nerves that control pelvic floor function. Patients initially have weekly treatments in the urology office for 12 weeks, then every two weeks thereafter, trying to then stretch this to monthly treatments.
“Thankfully, it’s rare today to have patients need bladder augments or open procedures,” Dr. Bepple concludes.
Erectile Dysfunction, Not Impotence
Andrew Kramer, M.D., associate professor of Surgery/Urology at University of Maryland Medical School, and director of Sexual Medicine at the medical center, often hears his patients with erectile dysfunction (ED) say, “I don’t know how to say this… I’m embarrassed.”
He says, “I reassure them that sex is a basic human right, and that ED is just a medical condition like any other. The term I don’t like to use is impotence. That implies weakness or powerlessness – and it’s not. ED affects about half of men over age 50 in some form – not getting an erection, not sustaining it, etc.
“ED is a window into a man’s health,” Dr. Kramer continues. “Men may not seek help for a health condition until they get ED, which mimics the degree of many medical problems, including hypertension, heart disease and endothelial dysfunction. If a patient has vessel disease or diabetes, their physician should ask if they’re experiencing ED.”
Dr. Kramer urges primary care physicians to ask their male patients if they have any erectile issues. “If they indicate any problems, you can either suggest medication, or tell them you can refer them to an expert who can help,” he says. “We’re capturing so little ED now – only about 5% of what’s out there. It’s good to address the other medical issues, but not fair to expect patients to wait to address their ED.
“The key to a diagnosis is putting together the picture from the history and symptoms,” Dr. Kramer explains. “I find out whether the man can experience orgasm, has sensation or has issues with firmness. I also ask about morning erections. I don’t typically need an EKG or angiography. There’s not much benefit to digging into the causes – it’s almost always a combination of age, small-vessel disease and nerve disease. Many men can get an erection when they masturbate – it’s only the stress of performing that gives rise to ED. I tell them the brain is the biggest sex organ. Emotional attachment is important.”
He continues, “Age is an independent risk factor – some men mistakenly expect their performance to be the same at 50 as it was at 18. Other risk factors are blood-vessel disease and anything that affects on-demand blood flow. Smoking causes vasospasms and small-vessel disease. Exercise and big fatty meals also affect blood flow. For an erection, you need rapid, on-demand diversion of blood flow within 30 seconds.”
Treatment has changed dramatically since 1997, when medications to treat ED came onto the scene. Sildenafil (Viagra), vardenafil (Levitra or Staxyn) and tadalafil (Cialis) reverse erectile dysfunction by increasing nitric oxide, which opens and relaxes blood vessels in the penis, helping men get and keep an erection.
“The medications are similar, except that Cialis is long-acting and Viagra and Levitra are short-acting,” Dr. Kramer comments.”Each is vasoactive and about 92 – 93% effective, though it should be noted that placebos are over 40% effective. All of them may cause a stuffy nose or other minor side effects. Contraindications include those taking nitrates or anticoagulants, those with hyper- or hypotension, heart or liver disease or prior stroke.”
Even at about $10 a pill, Dr. Kramer feels that insurance coverage is appropriate, stating, “Sexuality is a normal human function, not involving vanity or greed.”
If pills don’t work, the next step is often injections of alprostadil (Caverject or Trimix). These also are vasoactive, drawing blood into the penis. Men inject the medication into the penis about five minutes before sex, and they work regardless of mental stimuli. While the injections involve essentially no pain, many men are queasy about injecting themselves, and the drop-out rate is high.
Inserting suppositories like MUSE into the urethra have an effect similar to the injections, though their use has decreased since Viagra was introduced. Vacuum devices are a fourth option.
Dr. Kramer notes, “Vacuum devices, which trap blood in the penis, have been around for 100 years. Today, we use a vacuum erection device with a hand-powered or battery-powered pump to create a vacuum that pulls blood into the penis. After getting an erection, patients slip a tension ring around the base of the penis to keep it firm.”
When less-invasive methods fail, penile implants are a viable option. “Costing about $12,000 and covered by most insurances, implants provide a terrific cost-benefit ratio, with little risk of infection or injury,” Dr. Kramer exclaims. “In a 30-minute outpatient procedure involving general anesthesia, the surgeon inserts a pump in the scrotum and a cylinder in the penis. The sensation and orgasm are the same as a natural erection. It’s very effective. Even men who have not had an erection for 10 years can quickly return to erections following an implant.”
Jennifer Bepple, M.D., urologist at Central Maryland Urology Associates
Andrew Kramer, M.D., associate professor of Surgery/Urology at University of Maryland Medical School, and director of Sexual Medicine at University of Maryland Medical Center