GLOBAL CONNECTIONS A PUBLICATION OF THE AMERICAN UROLOGICAL ASSOCIATION
VOLUME 10
ABOUT HIFU
E V SA
! E T DA
2017
boston
MAY 12–16
THE
www.AUA2017.org
CONTENTS 4
U P C LO S E & P E R S O N A L
Brian McNeil, MD
8
FE AT U R E
About HIFU
12
CO L L A B O R AT I O N S
AUA and SocietĂ Italiana di Urologia Partnership Global Connections is published twice-yearly by the American Urological Association Education and Research, Inc. (AUA). The AUA believes that the information in this newsletter is as authoritative and accurate as is reasonably possible and that sources of information used in preparation are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any kind are disclaimed. This newsletter is not intended as legal advice, nor is the AUA engaged in rendering legal or other professional services. For comments or questions email us at communications@AUAnet.org.
15
AUAUniversity
16
FE AT U R E
Overactive Bladder (OAB) Affects Millions Around the World
U P C LO S E & P E R S O N A L
DR. BRIAN MCNEIL
AN AUA JOURNEY The AUA Visiting Scholar and Exchange Programs allow young academic urologists to benefit from the sharing of knowledge and experiences with colleagues around the world. Medical advances are often the result of fruitful collaboration, and these programs are designed to facilitate such opportunities. The programs not only allow the exchange of information and experiences, but are designed to foster a closer alliance between the AUA and Sociedade Brasileira de Urologia (SBU), and assist in identifying future leaders within urological societies globally. Brian K. McNeil, MD traveled to Brazil as a 2014 AUA scholar and since then has remained involved in AUA’s International Education Programs and has just recently been selected for the 2016-2017 AUA Leadership Program. We reached out to him to find out more about his exchange program experience and his subsequent professional experiences over the past several years leading to his current selection as an AUA Leadership Program participant.
Q A
Why did you decide to apply for the AUA Academic Exchange Program?
A former mentor once shared a story about how one of his greatest discoveries resulted from a chance meeting with a scientist from another nation at an international meeting. Since then, I have pursued opportunities to learn from colleagues abroad about the way that they practice urology and what they consider to be the next steps that we must take to move our field forward, especially regarding the elimination of health care disparities among
VO L U M E 10 • G LO B A L CO N N EC T I O N S
Name: Brian Keith McNeil Year of Academic Exchange: 2014 Country and Institution(s) Visited: Brazil. Instituto Mario Penna and Universidade Federal de Minas Gerais, Belo Horizonte Current Hospital and Professional Position: SUNY Downstate Medical Center, Brooklyn, New York. Vice-Chair and Associate Residency Program Director, Department of Urology
varying patient populations. My yearning to learn from urologists abroad that treat a patient population that mirrors the diversity that I encounter in Brooklyn, New York is what led me to apply to the AUA/Sociedade Brasileira de Urologia (SBU) Academic Exchange Program. Being raised in, what some would consider, an economically underserved area in Philadelphia, I have thus far committed my career to addressing health care disparities amongst different populations. I hope to align myself with practitioners around the world with similar interests.
Q A
What were your expectations of the program? Was leadership in the AUA a goal of yours at the time?
Brazil is a nation that has changed a great deal over the last 50 years. Having recently hosted the World Cup and now with the Olympics approaching, Brazil’s economy and quality of life disparities have been highlighted. I thought that our nations had some things in common regarding health care and how to deliver it to both privileged and underserved populations. I hoped that the AUA/SBU program would help expand my network and provide a platform to collaborate with practitioners in Brazil well
U P C LO S E & P E R S O N A L
Dr. Andre L. Salazar and resident physicians at Instituto Mario Penna.
Belo Horizonte viewed from Praca Israel Pinheiro - Praca do Papa.
versed in caring for an extremely diverse population with regards to socioeconomic status and ethnicity. Leadership within the AUA was not a goal of mine at the time.
Q A
What moment or experience did you find to be the most impactful during your exchange?
There were several moments that altered my viewpoint of health care and what role in the community I could play as an urologist. I can recall spending a day in clinic with Drs. Andre L. Salazar and Wadson Miconi. I was impressed with the patience they had in the face of a growing crowd of patients waiting to be seen at Instituto Mario Penna Hospital Luxemburgo. There were families that traveled to Belo Horizonte from hundreds of miles away to seek care. Everyone was seen and several patients were scheduled for surgery soon after. I witnessed several operations performed by urologists who treat those from privileged and underserved populations at multiple hospitals. The quality of care was outstanding and when anecdotally comparing stage for stage outcomes, they seemed to be similar among different socioeconomic groups. Some assume that privilege guarantees better treatment. However, our colleagues in Brazil have revealed the importance of practitioners giving their all and what impact this has. Hospital Luxemburgo is located in one of Belo Horizonte’s favelas. For those who are unaware, favelas are settlements of jerry-built shacks often lying on the outskirts of Brazilian cities and are associated with crime and less than optimal living conditions. What I found in the favela surrounding Hospital Luxemburgo was a welcoming community that embraced the hospital and providers who practiced there. There were several people employed by the hospital that lived in the favela, leading to a greater level of community engagement. This stood out as a model that could be used in underserved communities here and abroad.
Q
Have you been asked to present to a group about your exchange experience? If so, where and to whom did you present your experience?
A
I have been asked to present to multiple groups about my exchange experience. Two in particular stand out. I was asked to speak at Paul Laurence Dunbar High School in Baltimore, Maryland about urology and my road to become a physician. I spoke to several groups of students interested in the sciences about the field of urology. I told them how the Brazil experience changed my life and reinforced a desire within me to give back to a community similar to the one in which I was raised. We discussed Belo Horizonte and how pursuing your dreams can lead one to places he or she never imagined going. I also gave a grand rounds presentation to the New York Presbyterian Hospital/Weill Cornell Medical College James Buchanan Brady Foundation Department of Urology about the delivery of urologic care to disadvantaged populations. I spoke about my exchange experience as an example of how disadvantaged populations are managed abroad.
Q A
Are you currently in contact with colleagues that you met during your exchange experience?
I remain in contact with several colleagues that I met during my exchange experience. I consider some of them dear friends. We communicate via email, text messaging and do our best to see each other during meetings. There are too many people to name who had an impact on me, but I will always be grateful for what I learned from Drs. André Salazar, Paulo Martins, Wadson Miconi, Walter Cabral and Carlos Corradi. I have grown as a surgeon, teacher, and leader because of them.
CO N T I N U E D O N P G 6 ▼
G LO B A L CO N N EC T I O N S • VO L U M E 10
U P C LO S E & P E R S O N A L
▼ CO N T I N U E D F R O M P G 5
Q
How has your communication and relationship with the AUA, staff and/or its leadership increased since your exchange experience?
A
My communication with the AUA has increased since my exchange experience. I am grateful for all that our home office in Linthicum does for the membership. I have also built relationships with various staff members that will only grow with time as we work together to further the mission of our organization.
Q
Do you currently hold any committee or leadership positions within the AUA or other sub-specialty associations?
A
I have been selected as a member of the incoming AUA Leadership Program class and am very excited to learn more and grow.
institution. It has also provided a morally satisfying focus for my practice.
Q
What are your career development goals in the next 5 – 10 years? Do you see the AUA being involved in this development?
A
Over the next 5-10 years, I hope to grow as a leader and make a greater impact in my community. Someone once told me that all boats rise with a rising tide. I hope to contribute to that rising tide and do what I can to help students, resident trainees, and fellows that I encounter realize their goals. I also hope to assist my local, national and international colleagues advance our field in any way that I can. I feel that this is possible through continued involvement with the AUA.
Q A
How has participating in this program influenced your participation in other international activities?
Participation in the program has increased my interest in other international activities. We must think globally and act locally to advance our field. Practitioners worldwide face similar challenges and we can accomplish more through increased collaboration. I have not hosted an international scholar, but hope to someday. Prior to being selected as an exchange scholar, I served as faculty at the AUA/Sociedad Argentina de Urología (SAU) Lessons in Urology Course. I hope to do more in the future.
Q A
How has the exchange program experience enhanced your professional development?
The exchange program experience has enhanced my professional development in several ways. I have grown as a leader because of it and have been able to manage increasing levels of responsibility within my home
VO L U M E 10 • G LO B A L CO N N EC T I O N S
Drs. William Patrick Springhart (AUA Scholar), Carlos E. Corradi and I at a welcome dinner at the SBU São Paulo meeting.
KEEP AUA GUIDELINES IN YOUR POCKET! 2016
New in 2016:
- Non-Muscle Invasive Bladder Cancer - Surgical Management of Stones - Urethral Stricture Disease
Download the FREE AUA Guidelines Mobile App! Available in the iTunes App Store and Google Play Store.
www.AUA2016.org
G LO B A L CO N N EC T I O N S • VO L U M E 10
F E AT U R E
ABOUT HIFU Authors: Inderbir S. Gill, MD, Professor, Catherine and Joseph Aresty Department of Urology, Keck School of Medicine of USC, Global Initiatives Chair, AUA and Taylor Titus, Social Media Specialist, AUA
High-intensity focused ultrasound (HIFU)
is a technology that uses ultrasound energy-generated heat to non-invasively destroy cancer cells in the prostate by means of a probe put into the rectum. Thus, precisely controlled treatment can be delivered to destroy the targeted prostate tissue. At its focal point, HIFU energy generates temperatures of 80-90 degrees centigrade, thus rapidly destroying the targeted tissue, while preserving the surrounding tissues intact. HIFU is typically an option for selected patients with organ-confined disease, without using any radiation or surgical incisions.
VO L U M E 10 • G LO B A L CO N N EC T I O N S
F E AT U R E
The
United
States
Fo o d a n d D r u g Administration (FDA) approved two types of HIFU for treating
prostate cancer in October 2015 after more than 10 years of clinical trials. These types include both the Sonablate and Ablatherm devices and the approved indication is for prostate tissue ablation. HIFU is suitable for men with localized prostate cancer. There are two types of HIFU treatment. Whole-prostate HIFU treats the whole prostate, with the treatment taking about 2-3 hours. This option is for men who have cancer in more than one area of their prostate. The other option is focal HIFU, which treats a smaller area of the prostate; this option can be considered for men who have unifocal disease, or disease confined to one lobe of the prostate. Only the targeted cancer lesion plus a small zone around it is treated, sparing the rest of the prostate and adjacent healthy tissues. Salvage HIFU can be used to treat cancer that has come back after radiotherapy, or recurrent prostate cancer. It promises to be an outpatient, non-invasive procedure with much reduced side effects that preserves quality of life. Potential side effects of HIFU include: proteinuria, pain in the treatment area, inability or difficulty to urinate, urinary tract infection, epididymitis, erectile dysfunction or impotence, rectal or urinary incontinence, hematospermia, prostatitis, retrograde ejaculation and more.
“HIFU treatment offers an alternative approach to treating localized prostate cancer,” said AUA member Dr. Stephen Scionti, who is medical director of Vituro Health and founder of the Scionti Prostate Center in Sarasota, FL. “Tissue ablation with HIFU is an option to traditional treatments such as surgery or radiation. The technology allows for focal targeted therapy and allows MRI images to be fused to ultrasound images to allow for targeted ablation in the prostate. The best candidates are men who have localized prostate cancer, a normal sized prostate, and a desire to preserve sexual and urinary function.”
PROS AND CONS There are advantages and disadvantages to HIFU, just like any other prostate cancer treatment option. The advantages of HIFU are it is minimally invasive with a short hospital stay and recovery time. The side effects are minimal. Also, HIFU treatments can occur a second time or other treatment options are possible if the cancer comes back. A main advantage of HIFU for prostate cancer is within a week most of the patients won’t even notice they had a procedure done. The main disadvantage of HIFU is its limited availability worldwide. Doctors also don’t know as much about the risk of side effects or how well it works in the longer term, after 10 years. It can also be very costly. “The goal of focal HIFU is to target and destroy only the significant cancer lesion, thereby preserving the delicate nerves around the prostate, thus protecting both continence and potency,” said AUA Global Initiatives Chair, Dr. Inderbir Gill, founding executive director of the USC Institute of Urology, and professor in the Catherine and Joseph Aresty Department of Urology at the Keck CO N T I N U E D O N P G 10 ▼
G LO B A L CO N N EC T I O N S • VO L U M E 10
F E AT U R E
▼ CO N T I N U E D F R O M P G 9
Photos credit: Ablatherm® HIFU
School of Medicine of USC. “This is a noninvasive, nonsurgical, outpatient procedure that does not involve any radiation. There is no blood loss, the recovery is quick and typically the patient is back on his feet and discharged the same day.”
HIFU ON A GLOBAL SCALE HIFU has been used to treat prostate cancer in Europe, Asia and other parts of the world for more than 15 years. In 1996 other HIFU options were approved throughout Mexico, South America and the Caribbean. The first HIFU facility in North America was established in 2000 by Dr. George Suarez at the Universidad Madre y Maestra in Santiago, Dominican Republic. “Well-selected prostate cancer patients can benefit by maintaining their quality of life and still treating their prostate
VO L U M E 10 • G LO B A L CO N N EC T I O N S
cancer,” said Dr. Scionti. “However, due to training requirements, I believe that the technology should roll out slowly over 12 to 24 months. Patients should be cautioned that excellent outcomes are only consistently obtained by highly trained users of the technology.” European surgeons have the option of using Sonablate, Ablatherm or Focal One, which has not been approved by the FDA. Ablatherm HIFU received European approval in 2000. More than 40,000 patients worldwide have had HIFU treatments since the procedure was approved in Europe. EDAP TMS, a developer and manufacturer of medical devices for urology, reported a growing momentum in Europe for HIFU treatment of prostate cancer. Health Canada approved Ablatherm HIFU in 2003. HIFU with
G LO B A L CO N N EC T I O N S • VO L U M E 9
F E AT U R E S
“... HIFU HAS ALL OF THE MAKINGS OF PRECISION MEDICINE AND IT PROMISES TO REVOLUTIONIZE THE WAY PROSTATE CANCER IS TREATED.” - Inderbir S. Gill
the Sonablate was approved in June 2005 and has been chosen by more than 11,000 patients. In 2015, Focal One became an approved HIFU method by Health Canada.
that can maintain their quality of life. HIFU has all of the makings of precision medicine and it promises to revolutionize the way prostate cancer is treated.”
Ablatherm HIFU has been used in over 30,000 prostate cancer treatments throughout the world including England, Belgium, France, Italy, Germany, Spain, Australia, South Korea and more, according to Maple Life HIFU. It is approved in the European Union, Canada, South Korea and Australia. Sonablate HIFU is commercially available in more than 30 countries, including Mexico, Bermuda, the Bahamas, and Canada. “I am looking forward to performing novel molecular and imaging research on HIFU-treated prostate and renal cancers to further advance this emerging field, said Dr. Gill. “In addition to offering prostate cancer patients personalized, targeted care
G LO B A L CO N N EC T I O N S • VO L U M E 10
CO L L A B O R AT I O N S
CONNECTING THE WORLD OF UROLOGY: AUA AND SOCIETÀ ITALIANA DI UROLOGIA PARTNERSHIP BY LORI AGBONKHESE
As a globally-engaged organization with more than 21,000 members, one-quarter of whom practice in nearly 120 countries, the American Urological Association (AUA) represents the world’s largest collection of expertise and insight into the treatment of urologic disease. The AUA has always recognized the value of collaboration and interchange of urological skills, experience, and knowledge and since its inception in 1902, AUA has worked to advance urologic education and the highest standards of urologic care through exceptional educational offerings, publications, research, policy, and philanthropy. The AUA values opportunities to collaborate with the global urologic community and believes that this type of exchange is critical to the continued success of urology worldwide. As AUA’s collaborations continue to increase around the world, we would like to thank all of our international colleagues and partners for their friendship and collaboration. Drs. Giuseppe Carrieri (SIU) and Gopal Badlani (AUA) execute a Memorandum of Understanding for educational collaborations. Drs. Maurizio Brausi (SIU President), Inderbir Gill (AUA Global Chair), and Giuseppe Carrieri (SIU-AUA Liaison) met during AUA2015 in New Orleans.
VO L U M E 10 • G LO B A L CO N N EC T I O N S
CO L L A B O R AT I O N S
Dr. Gopal Badlani plays the Chef in a murder mystery dinner with attendees of the SIU-AUA Summer School program.
Attendees and faculty at the inaugural SIU-AUA Summer School program in Montegridolfo, Italy.
The AUA has recently expanded its activities in Italy due in large part to the close bond of friendship and partnership that has developed between the AUA and Società Italiana di Urologia (SIU). Abraham Lincoln said, “The better part of one’s life consists of his friendships” and having the SIU as a friend and key partner has meant increased cooperation and educational collaboration in both the United States and Italy. The SIU and AUA collaborations have created not only numerous opportunities for educational exchange and networking amongst urologists and residents in Italy and North America, but have also established a solid foundation of friendship. Dr. Giuseppe Carreri has served as a liaison between the SIU and AUA for many years and also represents Italy on AUA’s International Member Committee. Dr. Carrieri said “the collaborative partnership between the SIU and AUA means a lot for the Italian urologists, since AUA has been a landmark over the years for many of us in terms of urological education. Our partnership is devoted to improve even more educational opportunities for young trainee urologists.” One such collaboration is the SIU/AUA Research Fellowship program whereby each year two Italian research fellows are selected by the SIU to participate in a one-year research fellowship at top academic institutions in the United States. The inaugural program included Dr. Francesca Carobbio completing her fellowship at University of Alabama under Dr. Dean Assimos and Dr. Nicola Pavan participating in his fellowship at the University of Miami under Dr. Dipen Parekh. This competitive program has received much positive feedback from all involved and is now entering its second year. This summer, Dr. Giovanni Cacciamani of Verona will begin a one-year fellowship at the University of Southern California in Los Angeles under the leadership of Dr. Inderbir Gill and Dr. Vito Cucchiara of Milan will conduct research at University of California-Davis under the aegis of
Dr. Gopal Badlani thanks Drs. Vincenzo Mirone, Maurizio Brausi, and Giuseppe Carrieri for their friendship and partnership.
Dr. Christopher Evans. These efforts with young urologists and residents not only promote the exchange of information between our countries, but also helps to identify the future leaders of both organizations to ensure the SIU-AUA relationship continues long into the future.
“I LOOK FORWARD TO SEEING THE SIU-AUA PARTNERSHIP CONTINUE LONG INTO THE FUTURE.” – GOPAL BADL ANI, MD Another significant educational collaboration is the SIU-AUA Summer School program. The inaugural course was held on October 8-10, 2015 in Montegridolfo, Italy. This intensive 3-day program covered a wide-array of urologic topics with Drs. Gopal Badlani, Dean Assimos, Kevin McVary, Sam Chang, and Drogo Montague serving as AUA faculty. The program not only provided opportunities for scientific exchange via lectures and case discussions, but also provided essential interaction and networking opportunities between the AUA and SIU faculty with the Italian residents – much of which continued long into the night at planned social functions. The AUA faculty and SIU leaders Drs. Maurizio Brausi, Vincenzo Mirone, and Giuseppe Carrieri are to be commended for making this wonderful and unique program possible. The AUA is already working with the SIU to plan the 2nd program to be held in Venice later this year. CO N T I N U E D O N P G 14 ▼
G LO B A L CO N N EC T I O N S • VO L U M E 10
CO L L A B O R AT I O N S
▼ CO N T I N U E D F R O M P G 13
Faculty celebrate the successful completion of the SIU-AUA Summer School program.
Dr. Francesca Carobbio, 2015 SIU-AUA Research Fellow, presents during the AUA Corner in Riccione.
Dr. Gopal Badlani commented, “This program was one of the highlights of my term as AUA Secretary and I would like to thank Drs. Brausi, Mirone, and Carrieri for their friendship and also the AUA faculty for taking time from their schedules to participate. I look forward to seeing the SIU-AUA partnership continue long into the future.” Last year, immediately following the SIU-AUA Summer School program, Drs. Badlani, Assimos, Chang, McVary, and Montague traveled to Riccione, Italy to attend the SIU’s Annual Meeting which also featured a program called the AUA Corner. The interactive program included both AUA and SIU faculty and covered case discussions and debates on the topics of Urolithiasis, Incontinence, Bladder Cancer, BPH, and Andrology/Impotence. Dr. Carreri stated, “The AUA Corner is held on day one of the SIU meeting and is one of the most attractive sessions with a very motivated audience.” AUA faculty are also utilized as speakers and moderators of other sessions during the SIU Annual Meeting as well. The next AUA Corner will be held during the SIU Annual Meeting in Venice on October 15-18, 2016. SIU has been hard at work planning for its upcoming meeting and Dr. Carrieri reported that attendees can expect to see a focus on the prevention of genitourinary cancer. “The SIU Scientific Board has created a very intensive live surgery program mainly focused on robotic surgery and other new technological procedures,” said Dr. Carrieri.
VO L U M E 10 • G LO B A L CO N N EC T I O N S
AUA faculty and SIU leaders celebrate the successful completion of the 2015 AUA Corner in Riccione, Italy.
AUA’s membership from Italy continues to increase which has also resulted in an expanded presence at the AUA Annual meeting. For the past several years, the SIU/AUA Joint Program has been held at the AUA Annual Meeting featuring expert faculty from both Italy and the United States. An exciting program has been developed for San Diego which will be held on Monday, May 9 from 2:30 pm – 5:30 pm. AUA’s Global Chair, Dr. Inderbir Gill, said “the SIU-AUA session will focus on prostate cancer and I am excited to participate alongside many of my Italian friends and colleagues and I encourage all to attend.” The SIU and AUA will continue to explore additional opportunities to further enhance and expand collaborations between our organizations.
For more information on AUA’s International Programs or to find a program near you, please email us at international@AUAnet.org or visit at www.AUAnet.org/Academy.
F E AT U R E
AUAUniversity
PROVIDES FREE EDUCATIONAL ACCESS ANYTIME The American Urological Association (AUA) is committed to providing urologic education to enhance patient care around the world. Each year, the AUA holds nearly 50 courses in different locations throughout the world, with opportunities to share urological skills, expertise and knowledge for urologists globally. In addition to live courses and the Annual Meeting, AUAUniversity (AUAU) was created to provide an opportunity for AUA members to access a unique, comprehensive collection of educational resources online, anytime—day or night. Using a tablet, smartphone or computer, AUA members have instant access to an unprecedented amount of information wherever they are in the world. The portfolio of offerings in the AUAUniversity alone includes: • More than 12,000 educational activities, sorted by 21 therapeutic areas • More than 11,500 abstracts • 2,300 posters • 1,000 videos • Webcasts, online modules and more!
One of the newest features of AUAU is the Clinical Problem Solving (CPS) online modules, which are based on the AUA Guidelines and located in AUAUniversity, consist of a pre-test, guideline review, a clinical case scenario and a post-test. There are currently 12 CPS modules. After completion of each online activity, participants should be able to interpret and explain the appropriate diagnosis, prevention and treatment of the related guideline, perform appropriate methods of evaluation and management according to the guideline, analyze the risks and benefits of treatment according to the guideline and integrate the clinical guidelines into practice. Moreover, AUA members can also access the updated Urology Core Curriculum, which has more than 80 topic areas that provide the foundation of knowledge for any practicing urologist or urology resident. This curriculum can be used in a variety of ways to include providing urologists with resources necessary for a case, patient care or preparing for a presentation. The Urology Core Curriculum is continuously updated as new information becomes available to ensure relevancy and usability. AUAUniversity’s flexible learning management tool also allows members to track and manage their educational activities, and view and print transcripts for documentation. Since its inception, the AUA has been dedicated to providing high quality education. AUAUniversity allows the AUA to provide quality educational content in a personalized delivery format and provides another valuable benefit for members that they can use at any point in their career. AUA members can take advantage of enhanced access and resources by visiting AUAnet.org/University. If you are interested in becoming a member of the AUA, visit AUAnet.org/Join. There is value in belonging to the AUA!
G LO B A L CO N N EC T I O N S • VO L U M E 10
F E AT U R E
OVERACTIVE BLADDER (OAB) AFFECTS MILLIONS AROUND THE WORLD
VO L U M E 9 • G LO B A L CO N N EC T I O N S
F E AT U R E
Authors: Lisa N. Hawes, MD, Urologist and OAB Specialist at Chesapeake Urology and Casey Callanan, Outreach Specialist, AUA.
Overactive bladder (OAB)
is the name given to a group of troubling urinary symptoms. It occurs in both men and women—and although it can occur at any age, risk increases as people grow older. The International Continence Society (ICS) defines OAB as the presence of “urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection (UTI) or other obvious pathology.” Prior estimates have reported that between 50 and 100 million people suffer from OAB worldwide (Urology 1999). The hallmark symptom of OAB is a sudden, uncontrollable urge to urinate that makes patients fear they’ll leak urine if they don’t get to a bathroom immediately. In some patients, the feeling of urgency is followed by urine leakage (urge incontinence). People with OAB may also experience other symptoms, including frequent urination (characterized as eight or more times a day) and nocturia (waking at night to urinate). Risk factors for OAB include: • Age • Neurological diseases such as stroke and multiple sclerosis (MS) • Menopause (in women) • History of prostate problems (in men) “OAB happens when the bladder muscle squeezes and passes urine even when the bladder isn’t full,” according to Kathleen Kobashi, MD, FACS, Head of the Section of Urology and Renal Transplantation at Virginia Mason Medical Center, Director of the Pelvic Floor Center and urology residency at Virginia Mason, and Clinical Professor at the University of Washington in Seattle.
WHO HAS OAB AROUND THE WORLD? In the United States, about 33 million Americans have OAB with as many as 30% of men and 40% of women living with symptoms. These numbers are likely a lot higher because many people living with OAB don’t ask for help. According to the Indian Journal of Urology, many OAB studies don’t account for those living in lower socioeconomic strata. Within these populations, symptoms may not be reported due to a lack of education or accessibility to medical care. The social stigma of having OAB may also play a role in these unreported cases.
CO N T I N U E D O N P G 18 ▼
G LO B A L CO N N EC T I O N S • VO L U M E 10
F E AT U R E
OAB AFFECTS ABOUT
17% OF MEN AND WOMEN
WHO WERE SURVEYED IN EUROPE
▼ CO N T I N U E D F R O M P G 17
Dr. Archimedes Nardozza, President of the Sociedade Brasileira de Urologia (SBU), mentioned that OAB is a major public health problem in South America. SBU has developed continuing medical education programs to increase awareness about latest advances in treatment of refractory OAB. According to Dr. Nardozza, botulinum toxin and sacral neuromodulation have recently been included in the health insurance coverage list in Brazil. “As of April 2016, mirabegron will be also available in the Brazilian market. These new treatment options will make life easier for OAB patients,” Dr. Nardozza said.
“Asian data on the prevalence and impact of OAB is very limited. A survey in 2001 suggested this could be as high as 53% among Asian women. More concerning were the findings that the majority of these women would not seek medical help,” said Dr. Rajeev Kumar, Editor of the Indian Journal of Urology. Lack of facilities and the expenses involved in treatment surely contribute to the under-reported numbers.”
DIET MAY INFLUENCE OAB SYMPTOMS
BJU International has reported that OAB affects about 17% of men and women who were surveyed in Europe. This number grows to 30-40% for people over 75 years old. The study also found that 65% of men and 67% of women with OAB said their symptoms affected their daily lives. “Besides the general nuisance of having to visit the bathroom so often, OAB can lead to other serious health issues that affect a patient’s lifestyle,” Dr. Kobashi said. “An increased risk of falls and fractures, urinary tract infections, skin breakdown, depression and lack of sleep are additional problems.”
“Diet likely plays a role in the symptoms of OAB and patients often find their own ‘trigger’ foods and traditional remedies that relieve symptoms,” said Dr. Kumar.
OAB has impacted the lives of those in Brazil, according to European Urology. Brazilians with OAB (who were surveyed) reported impairment on their abilities to carry out physical activities related to their household chores, sleep, work, social and sex life. People living with OAB in Brazil also report higher rates of depression, anxiety, shame and general tiredness as compared to those living without it.
VO L U M E 10 • G LO B A L CO N N EC T I O N S
People’s diets are different all around the world, but when it comes to controlling OAB symptoms patients should avoid caffeine, artificial sweeteners, alcohol and very spicy foods. Soda, citrus fruits, chocolate (not white chocolate) and food made with tomatoes may also make symptoms worse.
“Identifying if any foods and drinks may be contributing to a patient’s symptoms is important,” Dr. Kobashi said. “Once the patient figures out which foods and drinks make their symptoms worse, they can avoid them.” Patients should keep a daily “bladder diary” by writing down what they eat/drink and when they go to the bathroom for a few days to understand their symptoms better. A diary may help show what foods and drinks are making their symptoms worse. For example, symptoms may be worse after eating or drinking a certain kind of food. The bladder diary will help document any trends or triggers.
F E AT U R E
OAB IS A
MA JOR
PUBLIC HEALTH
PROBLEM
IN SOUTH AMERICA. TREATING OAB Thankfully, there are several good treatment options for patients suffering with OAB. However, no single OAB treatment is right for everyone. One treatment alone may work best, or several treatments at the same time could be the best approach. It all depends on the patient. “Setting expectations is important for the patient. Healthcare providers should work with their patients to achieve their treatment goals, ”Dr. Kobashi said. Limiting food and drinks that irritate the bladder and keeping a bladder diary are examples of lifestyle changes or “behavioral therapy” to treat OAB. Other examples include: • Emptying the bladder twice. This is helpful for people who have trouble emptying their bladders completely. After they urinate, they should wait a few seconds and then try to urinate again. • Following a set, daily bathroom schedule during the day, usually every two to four hours. • Doing exercises to relax the bladder muscle such as quickly squeezing and releasing the muscles in the pelvis a number of times when feeling the urge to go. When lifestyle changes aren’t enough, the next step may be to take medicine. There are several types that can relax the bladder muscle. These drugs (for example: Anti-muscarinics and Beta-3 agonists) can help stop the bladder from squeezing when it’s not full. Injections are another treatment option. This includes bladder injections (shots) of Botox® (botulinum toxin). Small amounts of Botox® can stop the bladder muscles from squeezing too much. Many tiny injections are used to gently paralyze the muscles. Additional treatments are given when this treatment wears off, anywhere from six to twelve months later. If urine is not draining well, the patient may need to catheterize temporarily.
Another treatment for people who need extra help is nerve stimulation, also called neuromodulation therapy. This type of treatment sends electrical pulses to nerves in the bladder. The two types of nerve stimulation therapy are Sacral Neuromodulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS).
THE FUTURE OF OAB Many patients are hesitant to discuss their symptoms because they may be too embarrassed. Research has shown that on average women wait 6.5 years between having symptoms and receiving a diagnosis. Starting the conversation by asking patients about OAB symptoms is important. According to the Korean Journal of Urology, the future of OAB treatments will coincide with improved understanding of the genome and biomarkers. Currently there are no established biomarkers of OAB. Future studies of OAB biomarkers could create a better understanding of OAB and allow patients to receive more personalized treatments. Review Overactive Bladder and Its Treatments Consensus Conference. London, United Kingdom, July 4, 1999.Urology. 2000 May; 55(5A Suppl):1-84.
G LO B A L CO N N EC T I O N S • VO L U M E 10
A SINCERE
Thank You
TO OUR INTERNATIONAL PRESIDENT’S CIRCLE PATRON
AND TO OUR CONTRIBUTORS
MEDICAL