The American Urological Association (AUA) released a guideline update on the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome with 26 updated guideline statements on diagnosis and approach to management.  Evidence levels assigned included a strength rating of A (high), B (moderate), or C (low) but many recommendations were based on Clinical Principles and Expert Opinion when insufficient evidence existed.

For the past 30 years, I have treated men referred because of the adverse effects of prostate cancer (PCa) treatments. These patient complaints include lower urinary tract symptoms of incontinence, urgency, frequency, and sexual complaints such as erectile dysfunction and loss of libido. I have heard comments from these men such as “I wish I never had the surgery” and “I never thought I would not be able to swing a golf club without wetting myself” and “I can’t get an erection anymore- I didn’t expect that”.  Thus, I was not surprised by the findings of a population-based, prospective cohort study by Wallis and colleagues (2021). 

The International Continence Society (ICS) 2020 online meeting opened with a presentation by Dr. Alan Wein, previous Chief of Urology at the University of Pennsylvania, now Director of the Penn Urology Residency Training Program. Dr. Wein presented an informative lecture on the effectiveness of the “placebo” in clinical research. He reviewed the results of the proof of concept study of stress urinary incontinence (SUI) in post-menopausal women with an enobosarm (GTX-024), a synthetic androgen receptor analog, presented previously at the 2017 International Continence Society (ICS) and the 2018 American Urological Association (AUA) annual meetings.

To start off Bladder Health month, I thought a discussion about urinary incontinence, a bladder concern of many women, especially those who have undergone pregnancy, would be appropriate. Pregnancy and childbirth are known risk factors for urinary incontinence (unintentional and involuntary loss of urine). But despite the fact that more than one-third of women experience urinary incontinence in the second and third trimesters of pregnancy and about one-third leak urine in the first three months after giving birth, the topic is widely avoided.

I recently saw a 77 year-old Latina woman with complaints of strong urinary urgency resulting in incontinence, frequency every 2 hours with nocturia x4.  She described urgency as “pressure in my bladder.” She reported that her symptoms were “terrible.” Her symptoms were longstanding but appeared to be worsening. She had undergone lumbar spinal fusion 18 months ago, her third back surgery. This was about the time symptoms worsened.

A major part of my practice is treating men with prostate cancer (PCa) who are experiencing stress urinary incontinence (SUI), urine leakage with effort, when laughing, coughing, exercising, etc. SUI following PCa surgery (robotic or open prostatectomy) is a complication seen in a subset of men.

I see many young and older men with complaints of overactive symptoms of urgency and frequency. The older men may have benign prostatic hyperplasia (BPH) and the younger men seem to have no underlying pathology. Whatever the cause, these are distressing symptoms that affect the quality of life for all of these men. Drug therapy is usually recommended at first with behavioral therapy added usually as an afterthought. But based on a recently published research in JAMA by Burgio and colleagues, clinicians should consider a more effective stepped approach to combination overactive bladder (OAB) therapy by first recommending behavioral therapy.1

The New York Time’s (NYT) Twitter resident gynecologist, Dr. Jen Gunter, had an excellent response to a 63-year old woman who asked if wearing pads for urine leakage was the fate of all women her age and older.1

Urination is not part of daily conversations, especially for girls and women. A skit performed on SNL (Saturday Night Live) on the 7th of July, 2019, revolved around the problem of nocturia in men. It presented the “PottyPM” device that allows for uninterrupted sleep for men. The device looked antiquated, like an external male “Texas” catheter. 

I found a recent article in the New York Times (NYTs) about resistant UTIs1 to be timely and disturbing. It noted the New York City (NYC) Department of Health’s concern about drug-resistant UTIs and a new mobile phone app that gives prescribers access to a list of UTIs organisms and which drugs they are resistant to.  
“I am up all night” is a complaint voiced by many of my patients, both male and female patients.  But when I hear this, I know that they are not saying they are continuously awake all night but that they are up enough times to make it feel like they never got to sleep at all.  When asked why, this complaint usually translates to a prevalent symptom, nocturia, when you get up more than two times per night to urinate. 
I have been struck by the results of a recent Harris Poll national online survey of 2,040 U.S. adults, on the effect of nocturia, awakening one or more at night to urinate.  Their data shows that nocturia is not only a nighttime problem. 61% of nocturia sufferers noted that daytime activity and function were negatively impacted by their lack of sleep as 42% of sufferers feel drowsy, 21% site irritability, 17% are unable to perform or function and 15% report inability to concentrate. 
After reading a front-page article, How Profiteers Coax Women Into Surgery, in the New York Times, I knew I had to write this blog. The article describes the business case for exploiting women who have had a mesh implant for surgical treatment of pelvic floor disorders, e.g. pelvic organ prolapse, urinary incontinence. The author notes “Litigation against implants’ manufacturers has involved more than 100,000 plaintiffs in federal court alone.”   But we know that not all women who undergo mesh-implant surgery have mesh-related post-operative complications.

The article is an exposé on the practice of marketing unnecessary mesh-implant removal to women who may or may not have mesh-related complications from the surgery.  Through some unexplained access, marketing firms are able to obtain lists of women who have undergone pelvic surgery and who have received mesh implants. They randomly contact these women to encourage removal of the mesh. The women are lead to believe the mesh is harmful, even though the woman may not have complications from the implant. These firms provide upfront cash to cover travel to an “expert surgeon” who removes the mesh. The women are lead to believe that they will receive large legal settlements from companies making the mesh implant. What they end up with is a loan with a high-interest rate and in many cases, new or worsening complications following mesh removal. This appears to be a highly profitable business with financial backing from banks, private equity firms, and hedge funds.   I happen to be a provider who sees women who are seeking help for post-mesh-implant complications, such as urinary incontinence and pelvic pain. So I can relate to the women profiled in the article, who are now dealing with these same complications. For patients beware and see your trusted clinician.

Written by: Diane Newman, DNP, CRNP, FAAN, BCB-PMD, Nurse Practitioner (NP), Co-Director, Penn Center for Continence and Pelvic Health Director, Clinical Trials, Division of Urology, Adjunct Professor of Urology in Surgery, Penn Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

Published Date: August 14th, 2018

Further Related Content: 

How Profiteers Coax Women Into Surgery, in the New York Times
This was a quote from a patient who was treated for bothersome nocturia with a new formulation of desmopressin acetate (Noctiva).  Nocturia - awakening to urinate - is an all too common symptom reported by both men and women.  This is a commonly reported symptom in patients who report other lower urinary tract symptoms, such as incontinence, urgency and daytime frequency, but I also hear it from male patients who have benign prostatic hyperplasia (BPH).  It can be part of the overactive bladder (OAB) syndrome but unlike other symptoms, I have not been very successful in my behavioral or drug treatments.  Daytime symptoms seem to respond to these interventions but nighttime voiding- nocturia - is an outlier.  
I want to share with you the story of my approach to two of my patients being seen for overactive bladder symptoms of urgency and frequency during the day and night. I thought you might be interested in their stories as what I found to be successful treatments were not an approach often recommended. Their symptoms had defied most treatments.

The first patient was James, a 74-year-old man who was referred for Percutaneous tibial nerve stimulation (PTNS) treatments, having failed 2 injections of Botox and multiple overactive bladder (OAB) medications. He had refused an Interstim implant. James was tolerating his
Nocturia is a symptom reported by patients way too often.  As an expert in urology, I see the impact that nocturia has on both men and women, many of whom have been seeking help for a long time. I am leading this Center of Excellence to broaden awareness of nocturia and bring new treatments to patients. My practice is a tertiary, specialized practice and most of my patients have seen multiple providers prior to being referred. In the case of nocturia, roughly 40% do not see an improvement in symptoms with current treatments, although these treatments improve other bladder-related symptoms. People arrive in my office, desperately seeking relief from getting up in the middle of the night – twice or more – to urinate.

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