Urinary incontinence and voiding

• First-line: Lifestyle/behavioral changes; Kegel exercises
• Second-line: Medications
• Anticholinergics (dry mouth, blurred vision, AMS in older)
• Oxybutynin (Ditropan; cheap, non-selective) - start 5 mg TID
• More M3/bladder selective and 'fewer side effects': solifenacin (Vesicare)/tolteridine (Detrol)may reduce dry mouth; darifenacin
• Trospium does not accumulate in CNS = less cognitive impairment, better for older patients
• B3 agonist (HTN) - Myrbetriq/mirabegron, if cannot tolerate anticholinergics
• Risk of worsened hypertension with mirabegron
• Vibegron is newer, without risk of HTN
• Third-line: neuromodulatory stuff
• Botox (5% chance urinary retention)
• Inhibits release of acetylcholine at pre-synaptic junction
• Typically ~ 100 U for Botox naive, 200 U for SCI patients, up to 300 U per session. Divided into '3, 3, 3, 1' pattern of 10 injections
• Repeat ~ every 6 months
• Interstim sacral nerve (S3 foramen) stimulation.
• Stage 1 - test 1 side with temporary stim device; if 50% improvement in symptoms over 2 weeks, then return for permanent implantation
• S2: anal contraction, external rotation of leg
• *S3*: bellows, great toe plantarflexion
• S4: bellows, no toe (below S3 = bellows only)
• Ideal placement
• Mark 9, 11, 13 cm superior from tip of coccyx, and 2 cm lateral to find the sacral foramina (S2, S3, S4)
• Finder needle is slightly medial to lateral, inserted at the S3 foramen at a ~45-60 degree angle
• Lead is positioned with the distal leads (2 and 3) straddling the anterior border of the sacrum. Leads are numbered 0, 1, 2, 3.
• Stage 2 - permanent implantation (connect lead to an implantable generator placed in the buttock subcutaneous tissue
• Elliott - 3d Keflex post-op, f/u in 1 month
• Enemchukwu - 3d Keflex (500 mg BID) post-op
• Comiter - 3d Keflex, f/u in 2 months
• PTNS - clinic treatment 1x/week x 12 weeks
• All third-line treatments about equivocal in terms of # of leaks/day improvement. But Botox reported to have better 'completely dry' drates compared to SNS (20% vs 5%). SNS becomes cost effective at around year 4 compared to Botox (Also Botox is q6 mo forever while SNS can last for 15 years)