\>\> GOOD MORNING.

I WOULD LIKE TO WELCOME YOU TO THE SECOND DAY OF THE CONFERENCE FOR
URINARY AND FECAL INCONTINENCE.

WE WILL CONTINUE THIS MORNING WITH PRESENTATIONS RELATED TO THE THIRD
QUESTION, WHAT ARE THE RISK FACTORS FOR FECAL AND URINARY INCONTINENCE
FUL WE\'LL BEGIN WITH A PRESENTATION BY DR. PATRICIA GOODE WHO IS THE
MEDICAL DIRECTOR OF THE UNIVERSITY OF ALABAMA AT BIRMINGHAM INCONTINENCE
CLINIC WHERE SHE\'S THE DIRECTOR OF THE INCONTINENCE CLINIC.

SHE WILL DISCUSS SURGICAL COMPLICATIONS INCLUDES PROSTATECTOMY AND OTHER
URLOGICAL PROCEDURES.

\>\> GOOD MORNING.

I\'M GOING TO TALK TO YOU TODAY ABOUT URINARY AND FECAL INCONTINENCE
AFTER PROSTATECTOMY I\'VE ALWAYS ADDED RADIATION TO MY TALK BECAUSE
I\'VE SEEN A LOT OF PATIENTS WHO HAVE HAD RADIATION THERAPY AFTER THEIR
SURGERY AND THEY\'RE HAVING INCONTINENCE.

I WILL START WITH PROSTATECTOMY INCONTINENCE AND IT WAS A GOOD STUDY,
VERY WELL CONDUCTED AND PROSTATE OUTCOME STUDY OF A MALE SURVEY OF
RADICAL PROSTATECTOMY PATIENTS 1288 OF THEM, 12% AFRICAN AMERICAN, 12%
HISPANIC AND WHITE.

AT SIX MONTHS AFTER THE SURGERY, 77% WERE INCONTINENCE AND OTHERS WERE
USING PADS AND THEN 31% IN PADS AND THAT WAS STABLE AFTER THAT WHICH WAS
SUPPORTED BY THE LITERATURE AT FIVE YEARS 65% INCONTINENT AND 26% USING
PADS AND THERE\'S A LOT OF EVIDENCE THAT RADICAL PROSTATECTOMY IS A RISK
FACTOR FOR URINARY INCONTINENCE.

THERE HAS BEEN SEVERAL GOOD STUDIES LOOKING AT RISK FACTORS FOR POST
PROCKECTOMY URINARY INCONTINENCE.

THE DEMOGRAPHIC FOUND THE MOST OFTEN AND OLDER AGE, OLDER MEN ARE LIKELY
TO HAVE INCONTINENCE THAN YOUNGER MEN.

LIFTERICAL FACTORS ARE HAVING PREOPERATIVE URINARY INCONTINENCE WHICH
MAKES A LOT OF SENSE IF YOU HAD IT PREOPERATIVELY THEN YOU WILL HAVE IT
POST OPERATIVELY.

AND THEN BENIGN PROSTATE FOR BENIGN PROSTATE DISEASE.

LACK OF PRESERVATION OF BOTH NEUROVASCULAR BUNDLE WHICH IS IS DUE TO THE
CANCER HAVING SPREAD AND BUNDLELES BEING RESECTED OR BOTH.

AND THEN THE TOTAL LENGTH OF THE POSTERIOR URETHRA AND THE LENGTH.

MY SURGICAL COLLEAGUES TELL ME IT TAKES LODGER IN THE SURGERY TO DO THE
DISSECTION AND PRESERVE AS MUCH AS POSSIBLE.

PATIENTS WHO DEVELOP STRICTURES ON MRI ARE SEEN TO HAVE PERIUREIGHTERAL
FIBROSIS AND LIKELY TO HAVE PROBLEMS AFTER SURGERY.

THERE\'S BEEN A GOOD BIT OF WORK ON SURGICAL TECHNIQUES TO IMPROVE THE
INCONTINENCE RATE AFTER PROSTATECTOMY.

THE FIRST WAS WALSH THE ANATOMICAL DISSECTION AND ONE OF THE BETTER
STUDIESS DEMONSTRATING THE UTILITY OF THIS PROCEDURE, SHOWED A DECREASE
MEDIAN TIME TO INCONTINENCE FROM 5.6 MONTHS TO 1.5 MONTHS WHICH IS A
VERY PRACTICAL IMPROVEMENT AND A INCREASED RATE OF INCONTINENCE FROM 82%
OF PATIENTS TO 95% OF PATIENTS.

YOU CAN SEE THAT THESE PERCENTAGES ARE HIGHER THAN THE PERCENTAGES YOU
SAW IN THE FIRST SLIDE THAT MORE OF THESE PEOPLE ARE DRY, AND FEWER OF
THE PATIENTS THAT FILLED OUT A SURVEY WERE DRY AND THAT\'S BEEN
DISCUSSED IN DETAIL, DIFFERENT TECHNIQUE OF ASCERTAINING WHO\'S
CONTINENT, MAY BE MORE FRANK TH THAN IN THE LAST TIME AND THEY\'RE
TRYING TO PLEASE AND THEIR PROSTATE IS UNDER GOOD CONTROL.

SURGICAL PROCEDURE.

AND VALUABLE RESULT, SINCE THEN.

ONE, WAS NAST MOTTIC SUTURES PLACED WITH INCREASE THE LEAK POINT
PRESSURE AND INCREASED POST INCONTINENCE RATE AND THEN PELVIC URETHRAL
STITCH WHICH SHORTENED TIME TO INCONTINENCE.

THE ROBOTIC ASSISTED PROSTATECTOMY HAS TAKEN OVER IN THIS COUNTRY AND IS
A LOT OF PROSTATECTOMYS ARE BEING DONE THIS WAY.

THE EVIDENCE IS A BIT LACKING FOR EXACTLY WHAT THAT\'S GOING TO
ACCOMPLISH IN TERMS OF INCONTINENCE AND WE\'LL LOOK FORWARD TO THOSE
STUDIESES.

THINKING ABOUT REHABILITATION THERE HAVE BEEN THREE RANDOMIZED CONTROL
TRIALS OF PELVIC FLOOR MUSCLE TRAINING PROGRAMS, THE FIRST STUDY BY VAN
CAMPEN WAS THE MOST INTENSIVE AND WEEKLY THERAPY, AND PELVIC FLOOR
MUSCLES WITH BIOFEEDBACK, IF THEY HAD WEAK PELVIC FLOOR MUSCLES THEY GOT
ELECTRICAL STIMULATION AND THEY WERE TREATED UNTIL THEY WERE DRY.

YOU CAN THE INCONTINENCE RATE AS AT THREE MONTHS WERE 88% VERSES
PATIENTS IN USUAL CARE AND THAT WAS HIGHLY SIGNIFICANT AND THE SECOND
STUDY, THESE ARE NOT IN CHRONOLOGICAL ORDER, THEY\'RE REVERSE
CHRONOLOGICAL ORDER, THE MIDDLE ONE IS THE MOST RECENT, THE MONA SERRA
STUDY WAS LOOKING AT SUCH AS BLADDER CONTROL TECHNIQUES DONE WITH THE
USUAL VISITS WITH THE UROLOGY, SO IT WAS FOUR OR FIVE VISIT AFTER THE
FIRST YEAR OF SURGERY AND CONTINENCE RATES WERE 83% VERSES 48 PATIENTS
WHO WERE IN THE CONTROL GROUP.

THE THIRD STUDY WAS OUR STUDY STUDY LOOKING AT THE TRAINING OF BIOFEED
BOOK, AND THEN WERE REMINDED AFTER SURGERY TO RESUME THESE AND THE
MEDIAN TIME TO INCONTINENCE ARE THREE AND HALF MONTHS VERSES MORE THAN
SIX MONTHSES IN OUR CONTROL GROUP IN THE USUAL CARE AND THE NUMBER
NEEDED TO TREAT ONE ADDITIONAL MAN OUT OF PADS BY SIX MONTHS WAS JUST
FIVE AT A COST OF \$150 PERMEN AND OUR COST DATA SHOWED UP TO \$180.

THIS IS STILL EXTREMELY COST EFFECTIVE IN TERMS OF HEALTHCARE.

NOW FECAL INCONTINENCE AFTER RADICAL PROSTATECTOMY IT APPEARS THAT THE
RATE OF FECAL INCONTINENCE DOES INCREASE JUST SLIGHTLY.

ONE STUDY IS A SERIES OF 127 MEN SHOWS NEW AWARDS IN FECAL INCONTINENCE
IN TWO% AND ANOTHER STUDY IN 655 SERIES OF 655 PATIENTS, AND SIX YEARS
AFTER RADICAL PROSTATECTOMY SHOWED FECAL URIGENCEY AND FECAL
INCONTINENCE IN TWO% VERSES 0 PERCENT OF CONTROLS.

SO IT\'S A SMALL PREVALENCE BUT IT SEEMS TO BE THERE.

I COULD FIND NO STUDIESS LOOKING AT POST PROCKECTOMY FECAL INCONTINENCE
PREVENTION TO HELP FREE VENT THAT.

URINARY AND FECAL INCONTINENCE WOULD BE ONE AND THIS HAS BEEN
RECOMMENDED ALREADY TO USE STANDARDIZED MEASURES IN PLAY THE RESULTS CAN
BE COMPARED ACROSS TRIALS EVEN IN THOSE THREE BEHAVIORIAL STUDIES I
SHOWED YOU, THE OUTCOME OF THE FIRST TWO WAS DIFFERENT.

ONE WAS AT THREE MONTHS, ONE WAS AT SIX, 12 MONTHS AND THEN OUR STUDY
WAS TIMED INCONTINENCE, SO IT WOULD BE DIFFICULT TO COMPARE THOSE TRIALS
BECAUSE OUR OUTCOMES WERE ALL DIFFERENT.

SO IT WOULD BE VERY HELPFUL TO HAVE STANDARDIZED MEASURES AND TIME
POINTS FOR SOMETHING THAT\'S POST OPERATIVE.

ALSO CONTINUE NOTHING INNOVATIONS AND TECHNIQUES WHICH ARE ONGOING, TO
DETERMINE THE OPT OPTIMAL TIMING AND INTENSITY FOR PELVIC FLOOR MUSCLE,
AND ALSO TO ADD FECAL INCONTINENCE OUTCOMES TO ANY PROST PROSTATECTOMY
URINARY INCONTINENCE INTERVENTION TRIAL TO HAVE DAT DATA ON BOTH THAT
WILL BE HELPFUL AND THEN LASTLY, THE FOUR MECHANISMS THAT LEAD TO IT,
THE STRICTURE FORMATION AND SCARRING IN SOME PATIENTS MAY BE A CLUE TO
WHAT HAPPENS IN SOME PATIENTS, SOME OF THE WORST PATIENTS I SEE THE MOST
SEVERE IS THE PATIENTS THAT HAVE SCARRING AND HAVE TO HAVE DILATATION,
THEY SEEM TO BE THE HARDEST TO FIX AND THE MOST RESISTANT TO TREATMENT.

D.

NOW WE\'RE GOING TO SWITCH OVER TO RADIATION THERAPY FOR PROSTATE
CANCER.

WHEN MEN ARE DIAGNOSED WITH PROSTATE CANCER IF IT\'S LOCALIZED AND THEY
HAVE AT LEAST A 10 YEAR LIFE EXPECTANCY, THEY HAVE THREE CHOICES OF
THERAPY, THEY CAN HAVE RADIATION THERAPY AND THE RADIATION CAN BE
EXTERNAL BEAM OR IT CAN BE IMPLANTED SEEDS WHICH IS CALLED BRACHYTHERAPY
OR THEY CAN HAVE WATCHFUL WAITING WHERE ARE THEY DO NOTHING AND WAIT AND
SEE HOW IT PROGRESSING.

THERE ARE STUDIES COMPARING THOSE AGAINST EACH OTHER BUT NOT WEAN STUDY
TO RANDOMIZE ALL THREE TO HELP ADVISE THE PATIENT.

BUT GIVEN THAT IF A MAN ELECTS EXTERNAL BEAM RADIATION, WHAT ARE THE
ACUTE SYMPTOMS, WHAT\'S HE GOING TO GO THROUGH THEN IN TERMS OF
INCONTINENCE AND THERE\'S A LOT OF STUDIES WITH THE CONSENSUS CONFERENCE
BUT A STATE OF THE SCIENCE CONFERENCE IN RADIATION THERAPY HELD BY MARKS
IN 1995 SO THERE ARE NEWER DATA BUT I COULDN\'T FIND ANY BETTER DATA THE
INCONTINENCE AND URINARY RATES WERE 10﷓ZERO%, LOOKING AT IT BACK WORDS
AND IT DEPENDED ON THE DEFINITIONS AND THE STUDIESS HAD DIFFERENT
DEFINITIONS, THE MOVE IMPACT WERE THE OVERACTIVE BLADDER SYMPTOMS OF
URIGENCEY FREQUENCY AND NOCCURIA AND THESE CAN BE BOTHERSOME OF PATIENTS
IF YOU\'RE URINATING SEVERAL TIMES A NIGHT YOU CAN BE BOTHERED.

EVEN IF YOU\'RE NOT INCONTINENT AND YOU MAKE IT TO THE BATHROOM.

THE INCIDENCE OF THOSE WAS 23 TO 80%.

THE GOOD NEWS WAS THESE ACUTE SYMPTOMS SUBSIDED FOR OVER SEVERAL WEEKS
FOLLOWING RADIATION THERAPY.

HOWEVER, THE RELATED SYMPTOMS THAT DEVELOP AFTER RADIATION, WHEN THE
PATIENTS COMPLETELY FINISHED HIS COURSE OF THERAPY AND THE PSA\'S ARE
DIDDING WELL, HE CAN CONTINUE TO DEVELOP SYMPTOMS OF INCONTINENCE FECAL
AND URINARY AND THE MEDIAN TIMED ONSET OF THESE CLINICAL SYMPTOMS AND 28
TO 30 MONTHS SO ABOUT A YEAR TO TWO YEARS.

IN A SERIES OF 301 PATIENTS TWO YEARS AFTER RADIATION, 35% REPORTED
URINARY INCONTINENCE, SIX% SEVERE ENOUGH TO REQUIRE PADS OR PROTECTIVE
DEVICES BUT THERE IS A LOT MORE THAN ACUTELY SO THERE\'S SOMETHING THAT
HAPPENSES IN THAT POST RADIATION HEALING IN THE REACTION TO THE
RADIATION THAT CAUSES THEM TO DEVELOP MORE INCONTINENCE.

THIS IS A SERIES AFTER BRACHYTHERAPY, LOOKING AT ACUTE SYMPTOMS AFTER
THE SEEDS ARE IMPLANTED AT TWO MONTHS LATER, 64% OF PATIENTS HAD URINARY
URIGENCEY AND ABOUT THE SAME NUMBER HAD BOTH DI URAN AND NOCURNAL
FREQUENCY, 66 AND 63% RESPECTIVELY AND 13% HAD NEW OR WORSE INCONTINENCE
AND AFTER THE EXTERNAL BEAM LOOKING 24 MONTHS AFTER SEED AND PLANTATION,
EASY FOR ME TO SAY, THE OVERACTIVE BLADDER SYMPTOMS CALMED DOWN, 38% HAD
URINARY URIGENCEY AND 37 AND 31% DI URNAL AND NOCURNAL FREE CONVINCEY
AND 20% NOW HAD NEWER WORSE THAN URINARY INCONTINENCE AND NINE%
DEVELOPED FECAL INCONTINENCE.

THIS IS A STUDY THAT LOOKED AT BOTH EXTERNAL BEAM AND BRACHYTHERAPY IN
THE SAME STUDY AND ALSO HAD CONTROL PATIENTS THAT WERE MATCHED FOR AGE
AND LOOKING AT FECAL URIGENCEY, 14% HAD FECAL URIGENCEY, THREE YEARS
AFTER EXTERNAL BEAM RADIATION, 19% WAS BRACHYTHERAPY, NOW THIS IS
PROBABLY ARTIFICIALLY HIGH BECAUSE HALF OF THESE BRACHYTHERAPY PATIENTS
ALSO HAD EXTERNAL BEAM RADIATION HAS PART OF THEIR TREATMENT PLAN, SO
THEY HAD BOTH TYPES OF RADIATION AND THIS MAY WELL BE A RISK FACTOR FOR
MORE SEVERE SYMPTOMS, THERE\'S A BIT OF EARLY RESEARCH ON THIS AND I\'LL
PRESENT WUANOTHER STUDY THAT SHOWS SOMETHING SIMILAR AND THEN FOUR%
FECAL URIGENCEY FOR CONTROL PATIENTS FOR FECAL INCONTINENCE, FOUR% IN
THE EXTERNAL BEAM GROUP, EIGHT% IN THE BREAKY THERAPY AND HALF OF THOSE
COMBINED WITH EXTERNAL BEAMS AND ZERO% FOR CONTROLS.

SERIES OF MORE THAN A THOUSAND PATIENTS TREATED WITH EXTURNOVERRAL BEAM
RADIATION, THIS IS LOOKING AT RISK FACTORS, HISTORICAL RISK FACTORS
HAVING HAD A TRANSURETHRAL SECTION OF THE PROSTATE, BEFORE RADIATION,
RISK RATE OF 10% VERSES SIX% FOR DEVELOPING PERSISTENT URINARY
INCONTINENCE.

THEY ALSO EXAMINED AGE AND DIABETES AND THEY WERE NOT RISK FACTORS.

UNFORTUNATELY THEY DIDN\'T LOOK AT PRIOR URINARY INCONTINENCE WHICH
WOULD HAVE BEEN NICE.

IF PATIENT HAD MORE ACUTE SYMPTOMSES TO RENDER RADIATION THERAPY, THEY
WERE LIKE TOW TO HAVE SYMPTOMS AFTERWARD, 11% VERSES FIVE PERCENT AND
AFTER THERAPY IF THEY GEEPED A STRICTURE AND HAD TO HAVE A TURP OR A
DILATION PROCEDURE, IT WAS 8 PERCENT THAT PERSISTED IN INCONTINENCE
VERSES ONE AND HALF PERCENT WHO DID NOT HAVE TO UNDERGO THESE
PROCEDURES.

LOOKING AT RISK FACTORS FOR FECAL INCONTINENCE AND FECAL URIGENCEY AFTER
EXTERNAL BEAM RADIATION, IF THEY HAD BOWEL SYMPTOMS PRIOR TO RAYIATION,
THE ODDS RATIO WAS SEVEN .4 TO DEVELOP FECAL INCONTINENCE OR FECAL
URIGENCEY AFTERWARD AND THAT MAKES SENSE.

AGE WAS NOT A FACTOR PRIOR TO TERM WAS NOT A FACTOR FOR FECAL
INCONTINENCE AND HORMONE THOAR APEY WAS NOT A FACTOR AND DIABETES,
CARDIO VASCULAR DISEASE, WHOO, I\'M HAVING TROUBLE WITH THESE LONG
WORDS, CARDIO VASCULAR DISEASE AND SMOKING EMPLOYING

I COULDN\'T FIBBED ANY﷓﷓FIND ANY AFTER BRACHYTHERAPY SO THAT\'S AN AREA
THAT COULD USE WORK.

RESEARCH PRI OARITIES AFTER RADIATION THERAPY INCLUDE DETERMINING RISK
FACTORS FOR URINARY AND FECAL INCONTINENCE.

AS WELL AS OVERACTIVE BLADDER SYMPTOMS, I THINK THESE ARE IMPORTANT TO
LOOK AT AS WELL AS INCONTINENCE.

BOTH ACUTELY AND TWO OR MORE YEARS FOLLOWING RADIATION SO WE CAN DETECT
THE LATENT SYMPTOMS THAT DEVELOP LATER AND PERSIST.

DETERMINE THE RISK FACTORS FOR URINARY AND FECAL INCONTINENCE DIFFER FOR
EXTERNAL BEAM VERSES BRACHYTHERAPY, IT MAY BE THAT PEOPLE SHOULD BE SORT
OF TARGETED TOWARD ONE OR THE OTHER DEPENDING ON PREEXISTING PROFILES.

AND ALSO DETERMINE OPTIMAL RADIATION PROTOCOLS TO ACHIEVE CANCER CONTROL
BUT ALSO TO PREVENT OVERACTIVE BLADDER AND BOWEL SYMPTOMS AS WELL
INCONTINENCE.

SO WHEN YOU\'RE RADIATING THE PROSTATE GLAPD WITH SEEDS OR EXTERNAL
BEAM, THE RECTUM\'S JUST THERE AND THAT\'S PART OF THE REASON OR ALL OF
THE REASON FOR THE PROBLEMSES WITH FECAL INCONTINENCE AND URIGENCEY.

ALSO, THINKING ABOUT THE BEHAVIORIAL THERAPY TO DETERMINE PELVIC FLOOR
MUSCLE PROGRAMS CAN DECREASE THE INCIDENCE OF RADIATION ASSOCIATED
BLADDER, WE HAD THE THREE GOOD STUDIESES TO POST PROST PROSTATECTOMY AND
NOTHING AFTER RADIATION, IF IT IS EFFECTIVE AFTER DECREASES
INCONTINENCE, OPTIMIZE THE PROTOCOLS TO THE COST EFFECTIVE AND EFFECTIVE
PROGRAM. AND LASTLY TO TEST PHARMACOLOGIC AND DIETARY PROTOCOLS THAT
DECREASE URINARY AND FECAL INCONTINENCE, PERHAPS, AND MAYBE FIBER FOR
DIET.

BOTH ALONE AND IN COMBINATION WITH PELVIC FLOOR MUSCLE TRAINING WHICH
MIGHT MAKE BOTH MORE EFFECTIVE.

NOW WITCHING SO ANOTHER PROCEDURE, WE\'RE LEAVING PROSTATE CANCER NOW
AND WE\'RE GOING INTO TRANSURETHRAL RESECTION OF THE PROSTATE FOR BENIGN
DISEASE.

THEORY IN FREQUENTLY DO HAVE YOU NEW URINARY INCONTINENCE AND MORE
FREQUENTLY YOU REDUCE OR RESOLVE THE INCONTINENCE NOW WE\'VE SEEN
PATIENTS AFTERWARD THAT HAVE NEW INCONTINENCE, THEY DO EXIST AND IT\'S
MORE COMMON THE WAY THE PROCEDURE ACTUALLY HELPS, THE ONE STUDY OF 151
PATIENTS, 12% HAD PREOPERATIVE INCONTINENCE AND 2.8% OF THESE SAME MEN
HAD POST OPERATIVE﷓﷓DEMONSTRATING FECAL INCONTINENCE EFFECTIVE MY
TERPAND I BEDN\'T FIND ANY THAT LOOKED EITHER BUT THERE\'S NO EVIDENCE
OF THAT.

LOOKING AT RISK FACTOR IT ISS FUR URINARY INCONTINENCE AFTER
TRANSURETHRAL RESECTION, THE MOST COMMONLY SIGHTED STUDY THAT\'S DONE IS
THE ONE BY AMEDA.

SHOWING THAT OLDER AGE PREOPERATIVE INCONTINENCE, PREOPERATIVE EURO
DYNAMICS SHOWS VOLUMES IN THE AMOUNT LEFT IN YOUR BLADDER AFTER YOU
VOID, LESS COMPLIANT BLADDER AS YOU GO UP FOR YOU FILL OR THE TRUTH OR
OVERACTIVITY PREDICT INCONTINENCE BUT WHEN YOU LOOK CLOSELY AT THE
ARTICLE, IT PREDICTS DELAYED RECOVERY OF INCONTINENCE, OR DELAYED
RECOVER OF THEIR CONTINENCE, ONLY FOUR% OF THEIR PATIENTS AND THEY HAD
OVER 400 PATIENTS, ONLY FOUR% OF THEM WERE INKONT CONTINENT AT SIX
MONTHS.

THREE OTHER STUDIESS HAD GOOD EVIDENCE FOR RISK FACTORS FOR URINARY
INCOLONELINENCE AFTER TERP, ONE SHOWING PRIOR RADIATION THERAPY, EITHER
EXTERNAL BEAM, BRACHYTHERAPY OR A HIGHER PREVALENCE IF THEY HAD BOTH
BREAKY THERAPY AND EXTERNAL BEAM RADIATION AND THEN ADVANCED LOCAL
PROSTATE CANCER WAS A RISK FACTOR SO IF THEY OBSTRUCT DUE TO CANCER AND
HAVE A TERPTO RELIEVE THE OBSTRUCTION THEY\'RE MORE LIKELY TO LEAK AFTER
THAT AND PATIENTS WITH NEUROLOGIC DISEASES AT PARKINSONS ARE AT HIGH
RISK FOR POST INCONTINENCE.

I ONLY FOUND ONE STUDY FOR PREVENTION OF INCONTINENCE FOLLOWING TURP,
THEY LOOKED AT A POFFLIC FLOOR MUSCLE EXERCISE AND IT\'S WAS DONE
PREOPERATIVELY AND SHOWED INCREASE STRENGTH IN THE MUSCLES BUT THERE
WERE NO CLINICALLY RELEVANT CHANGES IN STORAGE OR VOIDING SYMPTOMS.

THE RESEARCH PRIORITIESS AFTER TEMPERATURE WOULD BE TO ESTABLISH THE
PREDICTIVE VALUE OF FOR POST TURP, IN THOSE WITH OLD PATIENTS WITH
NEUROLOGIC DISEASE BECAUSE FACED WITH THE OBSTRUCTIVE SYMPTOMS HAVE YOU,
IF YOU\'RE NOT GOING TO HAVE PROLONGED INCONTINENCE, YOU\'RE GOING TO
PROLONG YOUR RECOVER, YOU MIGHT WANT TO HAVE IT BECAUSE IT WILL DECREASE
FREQUENCY AND INCONTINENCE AND PATIENTS IT\'S HARD FOR THEM TO FIND
TREATMENT BECAUSE THE SURGEONS ARE AFRAID THEY\'LL MAKE THEM WORSE.

TO FURTHER IDENTIFY POST TURP INCONTINENCE OTHER THAN THE RISK FACTORS
SHOWED YOU THAT HAVE BEEN PUT FORTH AND TO DEVELOP MODIFICATIONS OF THE
SURGICAL PROCEDURES OR PATIENT WHO IS DEVELOP OBSTRUCTIVE OVOIDS
SYMPTOMSS AND URINARY RETENTION AFTER THEY HAD PRIOR RADIATION OR IF
THEY HAVE ADVANCED CANCER AND HASTILY I\'M GOING TO TALK ABOUT BLADDER
CANCER TREATMENT, WHICH DOES CREATE INCONTINENCE.

I WILL SAY THAT BLADDER CANCER IS NOT VERY COMMON, NOT ANYTHING LIKE
PROSTATE CANCER WHICH IS THE MOST COMMON CANCER IN MEN, BUT IT IS CANCER
THAT DOES OCCUR IT PEOPLE AND IT\'S FOUND EARLY WHEN THEY DON\'T HAVE TO
HAVE SURGERY, BUT IF THE CANCER HAS SPREAD THROUGH AND IT\'S STILL
LOCALIZED THERE\'S THREE SURGICAL TREATMENTS THARS BASICALLY DONE, AND
ONE IS AN ILIEL CONDDUEIT AND THEY HAVE A STOMA ON THEIR ABDOMEN SO YOU
CAN SAY THEY\'RE INCONTINENCE ALL THE TIME BUT IF THEY HAVE A GOOD WOCN
NURSE TO MARK THEIR STOMA AHEAD OF SURGERY AND THEN FIT THEM WITH A GOOD
APPLIANCE THEY CAN BE VERY CONTINENT.

THERE\'S ALSO A VARIATION OF THAT, CONTINENT DI VERSION WHERE THEY
DON\'T WEAR AN EXTERNAL POUCH BUT THAT HAVE TO EMPTY THE NEOBLADDER AND
THEN THERE\'S BLADDER RECONSTRUCTION WHICH IS THE MOST RECENT ADVANCE
AND PATIENTS VOID IN THE NORMAL MANNER, THEIR RECONSTRUCTIVE BLADDER AND
HOOKED TO THE BLADDER IN THE URETHRA AND VOID THE USUAL MANNER AND THE
BEST DATA ON CONTINENCE FOLLOW THANKSGIVING LAST PROCEDURE, I COULD NOT
FIND GOOD DATA FOR INCONTINENCE, OR CONTINENT URINARY DI VERSION, AFTER
BLADDER RECONSTRUCTION, TOTAL OR GOOD DAY TIME INCONTINENCE AND THIS IS
BY HOP MAN AND HE DID A NICE REVIEW OF THE LITERATURE AND PRESENTED HIS
OWN SERIES OF OVER A THOUSAND PATIENTS AT TWO DIFFERENT INSTITUTIONS AND
THEY HAD TOTAL OR GOOD TIME INCONTINENCE AT 88 TO 95% OF PATIENTS AND
PATIENTS THOUGHT IT WAS SATISFACTORY IN 66﷓93%.

HIS OWN SERIES WAS ABOUT 72%.

THE ONLY RISK FACTOR I COULD COME ACROSS ARE PEOPLE WHO SMOKE CIGARETTES
ARE MUCH MORE LIKELY TO GET BLADDER CANCER AND LESS INCONTINENCE.

THE RESEARCH PRIORITIES FOR INCONTINENCE AFTER BLADDER CANCER SURGERY
ARE TO CONTINUE DEVELOP INNOVATIONS SURGICAL MEDICAL AND RADIATION THERE
APE TOW OPTIMALLY CONTROL BLADDER CANCER AND PRESERVE CONTINENCE.

AND I THANK YOU VERY MUCH.

(APPLAUSE).

\>\> THANK YOU DR. GOODE.

OUR SECOND SPEAKER THIS MORNING IS DR. ANN LOWRY WHO IS THE DIVISION OF
COLON RECTAL SURGERY AND DEPARTMENT OF SURGERY AT THE UNIVERSITY OF
MINNESOTA, SHE\'S SPEAKING ON RISK FACTORS FOR THE DEVELOPMENT OF FECAL
AND URINARY INCONTINENCE FOLLOWINGANO RECTAL SURGERY, COLO RECTAL
SURGERY AND RADIATION THERAPY FOR COLO RECTAL CANCER.

\>\> GOOD MORNING.

AS HE SAID I\'M GOING TO TALK ABOUT THE RISK FACTORS FOR FECAL
INCONTINENCE AFTERANO RECTAL SURGERY AND TREATMENT FOR RECTAL CANCER.

IT\'S SORT OF A MIXED BAG OF TOPICS AND WE\'LL GO THROUGH IT FAIRLY
QUICKLY.

I DO WANT TO START WITH A COMMENT ABOUT THE LEVEL OF EVIDENCE AS OPPOSE
TO DR. GOODE\'S TALK, THERE\'S LIMITED LEVEL ONE EVIDENT ABOUT THESE
CONDITIONS.

THERE ARE A FEW PROSPECTIVE STUDIES AND MOSTLY RETROSPECTIVE SERIES.

AS I SAID WE\'RE GOING TO TALK ABOUT THEANO RECTAL CONDIGS AND FOCUS ON
THE TREATMENT OF RECTAL CANCER, SURGERY AND RADIATION THERAPY AS THE
TREATMENT OF AB DOM NOEL COLON CANCER HAS MUCH LESS IMPLICATION FOR
FECAL INCONTINENCE.

THE THREE MOST COMMON CONDITIONS ARE THE TOP THREE HEMORRHOID FISHER AND
FISTULA WHICH ARE TYPICALLY NOT ASSOCIATED THEMSELVES WITH INCONTINENCE
WITH THIS ONE ACCEPTION OF HEMORRHOIDS WHICH I\'LL MENTION MORE
SPECIFICALLY.

I\'M NOT GOING TO COVER THE CONDITIONS THAT ARE﷓﷓IN WHICH THE
INCONTINENCE IS PART OF THE CONDITION, RECTAL PROLAPSE, RECTAL AND
SPHINCTER INJURY, DR. WHITE HEAD MENTIONED THOSE BRIEFLY YESTERDAY.

AS HE ALSO MENTIONED THE PREVALENCE OF HEMORRHOIDS IS ABOUT FOUR% IF YOU
GO BY PHYSICIAN REPORT, IT\'S UP TO 20% BY PATIENT SELF REPORT, WE HAVE
TO TAKE THAT WITH A GRAIN OF SALT BECAUSE MOST PATIENTS THINK ANYANO
RECTAL COMPLAINT IS HEMORRHOIDS.

PROBABLY BASED ON PREPARATION H ADVERTISING.

IT DOES AFFECT A SIGNIFICANT NUMBER OF PEOPLE IN THIS COUNTRY AND THE
ESTIMATES ARE THAT APPROXIMATELY 10 TO 20% OF THOSE PATIENTS WITH
SYMPTOMATIC HEMORRHOIDS REQUIRE SURGERY.

AS DR. WHITE HEAD MENTIONED, WHAT THESE ARE GREAT, THREE, BUT THE
HIGHWAY PATROL ROADWAYS THAT ARE PROLAPSING IN WHICH THE INTERNAL
PORTION, THEREFORE, MUCOSA IS PROLAPSING OUTSIDE, MAY CAUSE LEAKAGE OF
MUCUS AND SOILING.

AND THE THEORY BEHIND THAT IS THAT THIS MUCOSA KEEPS THE ANNAL CANAL
OPEN AND SO, SEEPAGE CAN OCCUR.

BUT OTHER THAN THAT HEMORRHOIDS ARE NOTE ASSOCIATED WITH INCONTINENCE
THEMSELVES AND SOME PEOPLE ACTUALLY ARGUE THAT THEY ARE A COMPONENT OF
CONTINENCE AND THAT THIS ANNAL CUSHION HELPS WITH CONTROL.

THOSE PATIENTS WHO NEED SURGERY, THERE ARE THREE SURGICAL OPTIONS
REALLY, TWO IN THIS COUNTRY.

A LARGE DILATATION IS A STRETCHING OF THE ANNAL SPHINCTER IT\'S A FOUR
FINGER STRETCH CONVENTIONAL HEMORRHOIDECTOMY IS THE REMOVE WILL AVE THE
SYMPTOMATIC HEMORRHOID TISSUE, BECAUSE THERE\'S SIGNIFICANT PAIN AND
PROLONGED RECOVER, WITH IT, THERE\'S A NEW TECHNIQUE THAT\'S DEVELOPED
CALLED THE STAPPLED HEMORRHOID PEEKSY AND YOU SEE A DEPICTION OF THAT IN
THE RIGHT LOWER QUADRANT.

WHEN WE LOOK AT THE LITERATURE OVER ALL, THE DILATATION HAS A
SIGNIFICANT LONG﷓TERM INCONTINENCE RATE AND FOR THAT REASON, AND
PROBABLY THE BARBARIC NATURE OF IT HAS NEVER BECOME POPULAR IN THE
UNITED STATES.

OVERALL REPORTS OF CONVENTIONAL HEMORRHOIDECTOMY SHOW RATES OF SOMEWHERE
BETWEEN HALF A PERCENT TO 20% OF INCONTINENCE LONG﷓TERM AND IT APPEARS
AT LEAST IN THE SERIES, CASE SERIES THAT STAPPLED PROCEDURES HAVE A
LOWER INCIDENCE OF INCONTINENCE POST OPERATIVELY.

HOWEVER, A RECENT INTERVIEW WHICH COMPARED THE RESULTS OF CONVENTIONAL
STAPPLED PROCEDURES FOUND NO DIFFERENT STATISTICALLY, BUT A TREPD TOWARD
WORSE SOILING IN AND INCONTINENCE WHO UNDERWENT A STAPPLED PROCEDURE, SO
IT\'S NOT CLEAR THAT THAT\'S THE ANSWER.

FOR ANNAL FISSURES THERE\'S LIMITED DATA.

THERE ARE SERIES THAT LOOK AT THE NUMBER OF PATIENTS WHO HAVE FISSURES
OUT OF THE NUMBER OF PATIENTS WHO RESENT TO COLO RECTAL SURGERY AND THAT
SEEMS TO BE CONSISTENTLY ABOUT 10%, BUT THAT\'S CLEARLY AN UNDERESTIMATE
AS MOST PATIENTS ARE CARED FOR IN THEIR PRIMARY CARE OFFICE BECAUSE WE
DON\'T KNOW THE DENOMINATOR, WE REALLY DON\'T KNOW WHAT PERCENTAGE
REQUIRES SURGERY AND THERE\'S ALSO CONFUSION ABOUT THE TERMINOLOGY
BETWEEN ACUTE AND CHRONIC FISSURES.

FISSURES ARE THOUGHT TO BE CAUSED AT LEAST TO INITIATE WITH CONSIPATION
OR DIARRHEA AND TO PERSIST BECAUSE OF AN INCREASE TONE IN THEA ANNAL
CANAL, THOUGHT TO BE SECONDARY TO SPASM IN THE INTERNAL SFIRCHGHTER AND
THAT SOME ARE FEELING THAT THERE MAY BE SOME EVIDENCE OF HIPOXIA IN THE
USUAL LOCATION OF FISSURES.

SO TREATMENT IS AIMED AT CORRECTING THOSE PREDISPOSING FACTORSS AND
REDUCING ANNAL CANAL PRESSURES.

THE FIRST FOUR UNDER THAT ARE CHEMICAL WAYS OF TRYING TO REDUCE THE
PRESSURES WITH THE GOLD STANDARD BEING LATERAL INTERNAL SPINKTEROT ME IN
WHICH A PORTION OF THE INTERNAL SPHINCTER IS DIVIDED TO REDUCE THE
PRESSURES.

FOR THE CHEMICAL SPHINCT ROT ME THERE IS A FAIRLY LOW INCONTINENCE RATE
AND ALMOST ALL OF THAT IS TEMPORARY.

HOWEVER, THE HEALING RATE IS ALSO LOWER AND THE RECURRENCE RATE HIGHER.

IN COMPLETE CONTRADICTION, THERE IS THE INCONTINENCE RATE IS HIGHER WITH
THE LATERAL INTERNAL SPHINCT ROT ME BUT THERE IS A CONSISTENT GOOD
HEALING RATE.

THERE ARE RANDOMIZED TRIALS OF VARYING DEPICTIONS COMPARING CHEMICAL AND
SPHINCTEROT ME AND THE RESULTS ARE CONSISTENT THAT FOR LATERAL, THERE
ARE BETTER HEALING RATES, LOW ARE RECURRENCE RATES, BUT MORE
INCONTINENCE EMPLOY.

FISTULAS ARE THE LAST CATEGORY OF THEANO RECTAL PROCEDURES THIS IS A
PATIENT WITH COMPLEX 50 RULA, THERE\'S LITTLE INCIDENCE DATA, ONE
POPULATION BASE STUDY DONE IN EUROPE THAT SHOWED THAT ONE TO TWO OUT OF
10 THOUSAND PEOPLE HAD TROUBLE WITH ANNAL FISTULAS, WE KNOW IN KRONE\'S
DISEASE IT\'S SIGNIFICANTLY HIGHER, MAYBE UP TO 25% OF PATIENTS.

50 LOT ME WHICH IS UNROOFING OF THE TRACT IS CURIAATIVE BUT THERE\'S A
VERY HIGH RATE OF INCONTINENCE WHICH DOES DEPENDOT EXTENT OF THE
SPHINCTER MUSCLE ON THE FISTULA.

SO AGAIN THE NUMBER OF ALTERNATIVES HAVE BEEN DEVELOPED TO TRY TO REDUCE
THAT RATE OF INCONTINENCE AND STILL HEAL THE FISTULAS, AND THESE TWO
WHICH ARE BASICALLY INVERSION OF SOMETHING IN THE TRACT TO CLOSE THE
TRACT HAVE VERY LOW INCONTINENCE RATES BUT IN MOST STUDIESS SHOW THAT
HEALING RATES ARE ALSO QUITE LOW, ADVANCEMENT FLAPS HAVE BETTER HEALING
RATES, BUT MORE SIGNIFICANT INCONTINENCE RATES, AND 50 LOT MES YOU CAN
SEE ARE VERY CURIAATIVE BUT CARRY SIGNIFICANT MORBIDITY WITH THEM.

WE DON\'T KNOW TOO MUCH ABOUT THE EDIOLOGY AND THE DATA IS NOT VERY
GOOD.

I\'M GOING TO SHOW YOU JUST ONE STUDY THAT LOOKED AT 93 PATIENTS WHO
PRESENTED FOR TREATMENT BECAUSE OF INCONTINENCE AFTER ANNAL SPHINCTER
SURGERY, IT\'S A MIXTURE OF MEN AND WOMEN, YOU CAN SEE THAT THE
INCONTINENCE WAS FAIRLY SIGNIFICANT.

62% WERE INCONTINENCE OF SOLID STOOL BUT THIS IS A SELECTION BIAS, THESE
ARE PATIENTS WHO REPRENTED FOR TREATMENT.

IT DIDN\'T SEEM TO MATTER WHICH PROCEDURE THEY HAD.

MAYBE IT\'S WORSE AFTER EMROADWAYECTOMY BUT ALL THE TREATMENTS FOR HIM
ROADWAY FISSURES AND FISTULAS CARRIED WITH THEM A SIGNIFICANT RATE OR
THE PATIENTS HAD SIGNIFICANT INCONTINENCE WHEN THEY PRESENTED FOR
TREATMENT.

WHEN ULTRASOUNDS WERE DONE, ESSENTIALLY ALL OF THEM HAD INTERNAL
SPHINCTER DEFECTS, THE 25% OF THOSE PATIENTS THAT WAS PART OF THE
PROCEDURE SO IF THEY UNDERWEPT A LAT RAT INTERNAL SPHINCTEROT ME, YOU
WOULD EXPECT THEM TO HAVE AN INTERN AT SPHINCTER DEFECT BUT 75% OF THEM
HAD AN INTERN AT SPHINCTER DEFECT THAT WAS NOT PART OF THE SURGICAL
PROCEDURE OR THE INTENDED SURGICAL PROCEDURE.

ANOTHER THIRD HAD EXTERNAL SURGICAL SPHINCTER DEFECT.

ABOUT 40% OF THOSE WAS EXPECT AS PART OF SURGERY WHICH WOULD BE FISTULA
SURGERY BUT TWO 2/3RDS OF THEM IT WAS UNINTENTIONAL CONQUENCE OF THE
SURGERY.

TAKING ANOTHER LOOK, AS ALMOST 3﷓QUARTERS OF THE WOMEN HAD A OCCULT
ANTERIOR SPHINCTER DEFECTS TRAUM AND NOT RELATED TO THE PROCEDURE
ITSELF.

SO, FROM THAT STUDY, AND OTHERS, WE KNOW THAT THE RISK FACTORS FOR
INCONTINENCE AFTER ANAL﷓RECTAL SURGERY WOULD BE OCCULT SPHINCTER DEFECTS
AND WITH THAT WOULD GO PREOPERATIVE KONT METROPOLITAN STATUS BUT SOME
RETRACTORS INCREASES THE RISK, AGE, GENDER, FISTULA TYPE BECAUSE OF THE
AMOUNT OF MUSCLE INVOLVED AND POOR SURGICAL TECHNIQUE IN WHICH
UNINTENTIONAL INJURY TO THE SPHINCTER OCCURS.

I\'M GOING TO CHANGE NOW TO RECTAL CANCER.

WE DO KNOW MUCH MORE ABOUT THE INCIDENCE OF THIS.

AND THE ESTIMATED NUMBER OF CASES, NEW CASES THIS YEAR IS ABOUT 41,000.

THE LOCATION OF THE TUMOR IS WHAT THE ISSUE IS.

YOU CAN SEE THAT IT\'S QUITE CLOSE TO ALL THE MECHANISMS THAT PROVIDE
CONTINENCE.

THE TREATMENT IS BASICALLY SURGERY WITH RADIATION, THERE ARE ISSUES WITH
THE DATA QUALITY IN TERMS OF FUNCTIONAL RESULTS AFTER TREATMENT FOR
RECTAL CANCER.

THE TERMINOLOGY AS WE\'VE HEARD MANY TIMES ABOUT FECAL INKONT﷓﷓RELATIVE
TO FECAL INCONTINENCE IS UNCLEAR BECAUSE THERE\'S ALSO ISSUES WITH THE
TERMINOLOGY ABOUT THE SURGICAL PROCEDURES THAT LIMIT COMPARISON BETWEEN
SURGICAL TRIAL.

VERY RARELY WAS A PRETREATMENT ASSESSMENT DONE THAT\'S CONTINENCE.

MOST STUDIESS ARE UNDERPOWERED FOR THIS OUTCOME AND VERY RARELY WAS
INDEPENDENT ASSESSMENT DONE.

THERE IS ONE BRIGHT LIGHT IN ALL THAT IN THAT THERE ARE VALIDATED
INSTRUMENTS FOR THIS CONDITION.

THE FIQL WE\'VE HEARD ABOUT, THERE\'S A EUROPEAN RESEARCH AND TREATMENT
OF CANCER CALLED QUALITY OF LIFE INSTRUMENT THAT INCLUDES MANY OF THE
ITEMS RELEVANT TO THIS CONDITION.

AND THERE IS A PERSON AT KETTERRING HAS DEVELOPED A SPECIFIC ONE FOR
SURGERY RECTAL CANCER AND THIS IS A VERY WELL STUDIED AND VALIDATED
INSTRUMENT BUT IT HAS NOT BEEN USED VERY MUCH IN PROSPECTIVE TRIALS YET
AS IT WAS JUST RECENTLY DEVELOPED.

TO US US ALLOT SAME PAGE THIS, IS JUST A REVIEW OF THE STAGING OF RECTAL
CANCER, AND THIS IS A VERY SIMPLIFIED TREATMENT ALEGORITHMS IF WE WERE
DISCUSSING THE ONCOLOGICAL RESULTS OF THIS TREATMENT, THIS WOULD BE VERY
CONTROVERSIAL.

BUT IT ALLOWS ME TO INTRODUCE THE DIFFERENT PROCEDURES AND THEIR IMPACT
ON INCONTINENCE.

SO FOR EARLY TREATMENT, LOCAL EXCISION MAY BE APPROPRIATE, IT CAN BE
DONE IN EITHER OF THESE WAYS.

THE LEFT HAND IS A TYPICAL CLASSIC TRANSANNAL EXCISION IN WHICH THE
TUMOR REMOVEDUTESSING STANDARD EQUIPMENT, AND THIS IS A PROCEDURE USING
WHICH BASICALLY LAPROSCOPY THROUGH THE RECTUM.

THE ADVANTAGE TO LOCAL EXCISION IS THAT IT AVOIDS THE PERMANENCE IT DOES
COME WITH A COST AND THAT IS INCONTINENCE.

THERE IS A FAIRLY SIGNIFICANT RATE OF INCONTINENCE REPORTED FROM DATA WE
HAVE AVAILABLE THAT APPEARS TO BE RELATEDDED TO INTERNAL SPHINCTER
INJURY AT THE TIME OF THE PROCEDURE, AS LOW RISKING TONES ARE VERY
CONSISTENT REPORTS IN THIS DATA.

MORE COMMON TREATMENT IS HURJICAL RESECTION, THAT INVOLVES PERO NEAL
RESECTION, PARTICULARLY FOR THE MIDDLE AND LOWER THIRD OF THE RECTUM.

AND AS DR. GEEDE﷓﷓DR. GOODE SAID THERE A ARE ALL INCONTINENCE, BUT IN
CIRCULAR END TO END STAPPLE WE\'RE ABLE TO DO A MUCH LOWER IN THE PELVIS
AND AFTER THE INTRODUCTION OF STAPPLES﷓﷓STAPPLES A MUCH LOTTER OF
PATIENTS HAVE APE DOMINAL PERO NEAL RESECTIONS WITH PERMANENT STOMA AND
MOST OF THOSE ARE CONFINED TO THE PATIENTS IN THE LOWER THIRD OF THE
RECTUM.

HOWEVER, THE PRICE TO PAY FOR THAT IS WHAT\'S KNOWN AS THE ANTER YORE
RESECTION SYNDROME AND THAT INCLUDES FREQUENT STOOLS, FRAGMENTATION
WHICH INVOLVES MULTIPLE TRIPS TO THE BATHROOM TO COMPLETELY EMPTY THE
RECTUM AND INCONTINENCE.

THIS SITE IS DIFFICULT TO READ BUT TO GIVE YOU A SENSE, THESE ARE THE
SYMPTOMS THAT ARE PART OF THE ANTERIOR RESECTION SYNDROME, THIS CROSS
HATCH IS SOMETIMES A RARELY, THIS IS ALWAYS FREQUENTLY, ALMOST ALL OF
THOSE SYMPTOMS ARE IN THE 80 TO FIND% OF PATIENTS.

SO IT\'S A VERY COMMON PROBLEM.

WHEN WE LOOK AT INCONTINENCE, IT\'S REPORTED IN A NUMBER OF SERIES IN 25
TO 50% OF PATIENTS.

THERE\'S BEEN SOME WORK LOOKING AT RISK FACTORS.

THE WHITE OR FACTORS THAT HAVE BEEN FOUND IN MOST OR ALL SERIES TO BE A
RISK FACTOR FOR INCONTINENCE, INTERESTINGLY ENOUGH, EXCESSIVE BLOOD LOSS
AT THE TIME OF SURGERY SEEMS TO BE A RISK FACTOR, THAT\'S NOT WELL
UNDERSTOOD, AGE AND THE USE OF PERIOPERATIVE DI VERSION HAVE NOT BEEN
FOUND TO BE RISK FACTORS FOR INCONTINENCE.

THERE ARE A COUPLE GOOD STUDIESS USING VALIDATED INSTRUMENTS WHICH DO
DEMONSTRATE THAT IN PATIENTS WITH AT LEAST A MODERATE LEVEL OF VALVE
DYSFUNCTION THAT IT DOES SIGNIFICANTLY DECREASE THEIR QUALITY OF LIFE
AND IN ONE OF THESE STUDIESS, THAT QUALITY OF LIFE IN THOSE PATIENTS WAS
EQUIVALENT TO THE QUALITY OF LIFE IN PATIENTS WHO HAD PERMANENT
COLOSTOMYS.

THE MECHANISMS ARE THOUGHT TO BE THE THOUGHT OF RECTAL RESERVOIR,
SENSORY DYSFUNCTION FROM THE DISRUPTION OF THE SENSORY MECHANISMS AT THE
LE VADER LEVEL, SYMPATHETIC DENERVATION AND IN ADVERTENT SPHINCTER
INJURY.

AND IN AN ATTEMPT TO CORRECT THE ISSUE HAS BEEN MADE WITH RECTAL
RECONSTRUCTION, IT CAN BE DONE IN ONE OF THESE TWO WAYS TO ENLARGE AND
REGAIN A RESERVOIR FUNCTION AT THE END OF THE RECTUM.

THE RESULTS ARE SOMEWHAT CONTROVERSIAL.

A METAANALYSIS PUBLISHED IN 2006 SAYS THAT POUCHS LED TO BETTER RECTAL
VALVE FUNCTION, SYSTEMIC REVIEW DONE BASICALLY THE SAME STUDIESES, CAME
TO AN OPPOSITE CONCLUSION, THIS IS PROBABLY REFLECTION MORE OF A POOR
QUALITY OF THE DATA THAN IT IS OF A TRUE UNDERSTANDING OF WHETHER THOSE
RECONSTRUCTIONS IMPROVE THE FUNCTIONAL RESULTS.

FOR MORE EXTENSIVE TUMORS LOCALLY OR ONES THAT INVOLVE LYMPHNODES,
ADJUVANT THERAPY IS NOW USED.

THERE ARE A NUMBER OF RANDOMIZED TRIALS COMPARING SURGERY TO PREOP
RADIATION WITH SURGERY.

PRIMARY OUTCOMES OF THOSE TRIALS VS BEEN LOCAL RECURRENCE IN SURVIVAL,
THEY\'VE CONSISTENTLY SHOWN LOWER RECURRENCE RATES AND THE SURVIVAL DATA
A LITTLE MIXED.

TWO OF THOSE LARGE TRIALS, BOTH FROM EUROPE HAVE HAD SECONDARY ANALYSIS
DONE LOOKING AT THE FUNCTIONAL RESULT AND THE TME DESCRIBES THE SURGERY
UP HERE AND SO THIS COLUMN IS THE PATIENTS WHO HAD SURGERY WITH
RADIATION, THIS COLUMN IS THE PATIENT WHO IS HAD SURGERY ALONE AND YOU
CAN SEE THAT ALTHOUGH THERE\'S A SIGNIFICANT RATE OF INCONTINENCE, IT
AND NEED FOR PADS, EVEN WITH JUST THE SURGERY THAT INCREASES IN ALMOST
TABLES WITH THE ADDITION OF RADIATION THAT WAS THE DUTCH RECTAL CANCER
TRIAL, SIMILAR RESULTS IN AN ANALYSIS OF THE SWEDISH RECTAL CANCER TRIAL
HAVE BEEN FOUND SO AGAIN, ALMOST DOUBLING OF THE RATE OF INCONTINENCE OR
SOILING WITH THE ADDITION OF RADIATION.

THE ANALYSIS OF THE SWEDISH TRIAL ALSO INCLUDED SOME NANO METRIC AND
ULTRASOUND TESTING, THE RESTING MEASURE PRESSURES AND SQUEEZE PRESSURES
WERE LOWER WITH THE PATIENTS WITH RADIATION AND THERE WAS ULTRASOUND
EVIDENT OF SCARRING AND THIS OF THOUGHT TO BE THE CONSEQUENCE OF
RADIATION THERAPYOT SPHINCTER MECHANISM.

AND THERE ARE ISSUES WITH HOW GENERALIZABLE THIS DATA IS TO THE UNITED
STATES BECAUSE IN EUROPE, THEY USE A SHORT COURSE OF RADIATION
PREOPERATIVELY, WHERE AS LONG COURSE RADIATION IS STANDARD IN IN
COUNTRY.

AND THERE HAVE NOT BEEN GOOD RANDOMIZED TRIALS WITH THE ANALYSIS OF
FUNCTIONAL RESULTS IN THIS COUNTRY AND ALL OF THIS DATA IS PREIMRT WHICH
ALLOWS THE RADIATION THERAPIST TO FOCUS THEIR RADIATION BEAM MORE ON THE
TUMOR AND PROTECT THE SPHINCTER MECHANISM.

SO, MY REAKED MINDATIONS AND SUMMARY WOULD BE FOR THESE CONDIGS I
DISCUSSED INCONTINENCE IS RELATED TO TREATMENT SO IF WE COULD PREVENT
THE UNDERLYING CONDITION, THERE WOULD BE NO ISSUE.

FOR RECTAL CANCER, SCREENING MIGHT RESULT IN THAT.

FORANO RECTAL CONDITIONS IT\'S REALLY UNCLEAR, AND IT\'S WHAT MIGHT
PREVENT THE CONDITION COMPLETELY.

SO FOR THE CURRENT STATE, I THINK WE NEED BETTER AND MORE EPIDEMIOLOGY
DATA ABOUT THEANO RECTAL CONDIGS, BETTER UNDERSTANDING OF THE TRUE
ETIOLOGY AND RISK FACTORS FOR CURRENT UNDERSTANDING AS IT\'S RELATED TO
DIET AND LIFESTYLE HOWEVER THAT UNDERSTAND SUGGEST NOT BASED ON MUCH
DATA BUT BASED ON THAT UNDERSTANDING, BETTER DIETARY AND LIFESTYLE
EDUCATION, PROVIDER EDUCATION IS NECESSARY SO THAT THE PRIMARY CARE
PHYSICIANS ARE BETTER ABLE TO SEPARATE OUT THESE DIFFERENTANO RECTAL
CONDITIONS AND SURGEONS NEED EDUCATION ABOUT THE APPROPRIATE SURGICAL
TECHNIQUES AND WE NEED ALTERNATIVE TREATMENTS FOR RECTAL CANCER AND
EVERYONE\'S BEEN SAYING USING VALIDATED INSTRUMENTS WORK TO IDENTIFY THE
RISK VACCORS,﷓﷓FACTORS BETTER UNDERSTANDING OF THE PHYSIOLOGY POST
OPERATIVELY AND TO DO THAT WE NEED INCLUDE FUNCTIONAL RESULTSES IN THE
STUDIESS OF THERAPY.

FUNCTIONAL RESULTS WILL ALWAYS BE SECONDARY OUTCOMES IN THE TREATMENT OF
CANCER, BUT IT IS IMPORTANT TO THE QUALITY OF LIFE FOR THOSE PATIENTS.

THANK YOU.

(APPLAUSE).

\>\> THANK YOU DR. LOWRY.

NEXT WE\'LL HEAR FROM DR. WEIN FROM THE CHIEF OF HOSPITAL OF UNIVERSITY
OF PENNSYLVANIA, HE\'S SPEAKING ON IATROGENIC DISORDERS AND DRUG SIDE
EFFECTS AND DEVELOPMENT OF URINARY AND FECAL INCONTINENCE AND THESE ARE
THE SLIDES FROM YESTERDAY\'S TALK.

\>\> WE NEED THE SLIDES FROM TODAY\'S TALK.

\>\> GIVE US JUST A MINUTE SINCE THIS IS THE LAST TALK BEFORE THE
DISCUSSION.

WE\'LL JUST GO AHEAD WITH THAT ONE.

\>\> THANK AND YOU GOOD MORNING, AGAIN.

MY TASK THIS MORN SUGGEST TO TALK ABOUT DRUG AFFECT AND THE DEVELOPMENT
AND IT\'S NOT JUST THE DEVELOPMENT ACTUALLY, IT\'S THE WORSENING IN
DEVELOPMENT OF URINARY AND FECAL INCONTINENCE.

THERE\'S A MISTAKE IN TABLE ONE, MY MISTAKE IN THE OUTLINE AND ACTUALLY,
UNDER AGENTS TO TREAT CONSIPATION, JUST CROSS OUT UUI.

PUT THAT IN ORIGINALLY, I LOOKED FOR ORIGINAL SOURCE REFERENCE AND
COULDN\'T FIND IT SO EVERYTHING ELSE IN THE TABLE IS CORRECT BUT THAT
ONE.

SO LET\'S START.

WELL INTENSIONED PHARMACOTHERAPY CAN CONTRIBUTE TO THE DEVELOPMENT OR AG
GRAVATION OR WORSENING AND IT\'S IMPORTANT TO REMEMBER THAT BECAUSE
OFTEN TIMES IT\'S NOT THE DEVELOPMENT, IT\'S THE AG GRAVATION OF AN
ALREADY EXIST EPT PROBLEM OF BOTH URINARY AND FECAL INCONTINENCE AND
FURTHER ESPECIALLY IN THE ELDERLY THE PHARMACOLOGIC EFFECTS OF A DRUG IS
THE AUGMENTED BY PHARMACOKINETIC CONSIDERATIONS AND ALSO BY DRUG/DRUG
INTERACTIONS.

NOW, LET ME JUST MAKE IT CLEAR THAT WHAT I\'M GOING TO DESCRIBE
PRIMARILY ARE EITHER THEORETICAL CONSIDERATIONS, CASE REPORTS OR
ANECDOTAL ASSOCIATIONS.

I SAW THIS ONCE AND I THINK I\'LL WRITE A PAPER ABOUT IT.

THERE\'S ESSENTIALLY NO LEVEL ONE EVIDENCE, THERE\'S ESSENTIALLY MOSTLY
LEVEL TWO EVIDENCE, USE THE OXFORD GUIDELINES, THE STATEMENTS I\'M GOING
TO MAKE ARE BASED PRIMARILY MOSTLY ON LEVEL FOUR EVIDENCE AND SOMETIMES
LEVEL THREE EVIDENCE.

SO THE CATEGORIES OF INCONTINENCE THAT WE MENTIONED YESTERDAY, HOW COULD
DRUGS WORSEN OR CAUSE URINARY INCONTINENCE IN EACH ONE OF THOSE
CATEGORIESS?

WE\'LL DO URINARY FIRST, FECAL SECOND EMPLOYING.

WELL, DRUGS CAN WORSEN OR CAUSE FUNCTIONAL URINARY INCONTINENCE BY
DEPRESSING COGNITIVE FUNCTION, PROVIDE DEPRESSING SENSATION.

DRUGS CAN WORSEN OR CAUSE OVERFLOW URINARY INCONTINENCE BY CONTRIBUTING
TO URINARY RETENTION.

SO ANY DRUG THAT DECREASES BLATTER CONTRACTTILITY OR ANY DRUG THAT
INCREASES OUTWARD RESISTANCE CAN DO THAT.

DRUGS CAN WORSEN OR CAUSE URIGENCEY, URINARY INCONTINENCE BY EITHER
DECREASING THE VOLUME THRESH HOLD FOR OVERACTIVITY, THAT WOULD BE BY
INCREASING BLADDER TONE OR CONTRACT ILITY WITH A PATHOMI METIC AGENT BY
REDUCING FUNKAL BLADDER CAPACITY AND CAUSING OVERACTIVITY TO OCCUR AT A
LOWER FUNCTIONAL BLADDER VOLUME THAN IT DID BEFORE, THAT IS BY
INCREASING RESIDUAL URINE VOLUME OR BY INCREASING THE FREQUENCY OR
INTENSITY OF AFFERENT STIMULATION AND YOU CAN DO THAT EITHER BY
INCREASING THE RATE OF BLADDER FILLING, AS WITH THE DIURETIC OR NIGHT IF
SOMEONE HAS EDEMA AND THAT FLUID SLIPS BACK IN THE VASCULAR SYSTEM AND
CAUSES AN INCREASED URINE OUTPUT OR ADDING A SUBSTANCE THAT ARE AN
IRRITANT TO SOMEONE BUT NOT ALL, BUT SAY LIKE CAFFEINE.

DRUGS CAN WORSEN OR CAUSE STRESS URINARY INCONTINENCE BY DECREASING
OUTLET RESISTANCE, MOSTLY IN FEMALE BUT SOMETIMESES IN THE MALE.

BUT LET\'S LOOK AT CATEGORIESS.

WHAT DRUGS THEN CAN CONTRIBUTE TO STRESS, URINARY INCONTINENCE.

ALPHA AMERGIC ANTAGONIST BY DECREASING OUTLET RESISTANCE AND THERE ARE
CASE REPORTS AND ONE SERIES IN THE LITERATURE TO DOCUMENT THAT.

SKELETAL MUSCLE RELAX ANTS BY DECREASING OUTLEGALITY RESISTANCE, MOSTLY
THEORETICAL, BECAUSE THERE REALLY ISN\'T AN ORALLY ADMINISTERED SKELETAL
RELUXURY ANT THAT DOES MUCH TO STRIDE THE SPHINCTER.

CAUSING SIDE EFFECT OF COULD YOU HAVE, AND ANTIPSYCHOTIC AGENTS, THE
ONES THAT DO HAVE AN ALPHA ANTA MERGIC BLOCKING CHARACTERISTIC
ASSOCIATED WITH IT.

AS YOU KNOW THERE\'S A GREAT CONTROVERSY ABOUT ORAL ESTROGEN, DOES IT
HELP?

DOES IT HURT?

MY FEEL SUGGEST THAT THE EVIDENCE IS THAT IT ACTUALLY HURTS, THAT IT
CONTRIBUTES TO STRESS URINARY INCONTINENCE.

DRUGS WHICH CAN CONTRIBUTE TO OVERFLOW INCONTINENCE BY DECREASING
BLADDER CONTRACT ILITY OR DECREASING OUTWARD RESISTANCE, COLD
MEDICATIONS AND PATHOMY O METIC INCREASING OUTLET RESISTANCE, THE COLO
MERGIC ANTAGONIST BY DECREASING BLADDER CONTRACTTILITY, SOME CALCIUM
CHANNELLAN TAGANIST BY DECREASING BLADDER CONTRACTTILITY.

OPIOID, EITHER BY DECREASING BLADDER CONTRACT ILITY OR BY DECREASING
SENSORY INPUT.

AND SOME PSYCHOTROPICS BY DECREASING AAFRIB INPUT AND A FEW PERHAPS BY
DECREASING BLADDER CONTRACTTILITY.

DRUGS WHICH CAN CONTRIBUTE TO OVERFLOW INCONTINENCE, ALCOHOL BY
DECREASING AFFERENT INPUT, ANTIDEPRESSANTS BY DECREASING BLADDER
CONTRACT ILITY AND BY DECREASING AFFERENT INPUT, SOME ANTIPARKSONIAN BY
DECREASING BLADDER CONTRACTTILITY AND DECREASING INPUT AND AGENTS
CAUSING CONSIPATION OR FECAL IMPACTION.

DRUGS WHICH CONTRIBUTE TO FECAL INCONTINENCE, THE ANTIPSYCHOTICS,
ALCOHOL, TRICYC LICK ANTIDEPRESSANTS, SOME ANT PARKSONIANS, OPIOID
ANALGESICS AND SOME PSYCHOTROPICS.

WHAT ABOUT FECAL INCONTINENCE, DRUGS CAN WORSEN OR CAUSE FECAL
INCONTINENCE BY EITHER CONTRIBUTING TO CONSIPATION OR IMPACTION OR BY
CONTRIBUTING TO DIARRHEA.

AND HOW DOES CONSIPATION OR IMPACTION CONTRIBUTE TO FECAL INCONTINENCE.

THE THOUGHT IS THAT A HARD STOOL MASS DECREASES THE ABILITY TO PURCEIVE
THE MOVEMENT OF NEW STOOL AND TO THE SIGMOID AND RECTUM AND REFLEXLY
DILATES THE INTERNAL ANNAL SPHINCTER ALLOWING LIQUID TO ESCAPE, SO
CALLED OVERFLOW FECAL INCONTINENCE AND THE POTENTIAL AGENTS WHICH CAN DO
THAT ARE THOSE THAT DECREASE BOWEL MOTILITY OR INCREASE STOOL
CONSISTENCY.

DIARRHEA CAN CONTRIBUTE TO TO FECAL INCONTINENCE BY OVERWHELMING A
ALREADY COMP ROMMIZED SPHINCTER MECHANISM AND AGAIN ESPECIALLY IN THE
ELDERLY.

SO DRUGS WHICH CAN CONTRIBUTE TO CONSIPATION OR FECAL IMPACT, ANTICOLON
URGICKICS, THE NARCOTIC ANALGESICS, IRON SUPPLEMENTS, CALCIUM CHANNEL
BLOCKERS.

DRUGS OR DIETARY INGREDIENTS OR SUPPLEMENTS, WHICH CAN CONTRIBUTE TO
DIARRHEA, ANTIBIOTICS, SERRA TON IN REUPTAKE INHIBITORS, FIVE H GFOUR
AGONIST, PROTEIN PUMP INHIBITORS, MAGNESIUM CONTAINING ANT ACIDS, DIGOX
IN, LAXATIVES ALSO EXCESS FIBER AND LACTOSE IN INDIVIDUALSES THAT HAVE
LACTOSE INTOLE CANC.

THIS IS A LIST OF THE REFERENCES, I WOULD ENCOURAGE YOU TO LOOK AT THE
VOLUME INCONTINENCE DONE BY THE INTERNATIONAL CONSULTATION ON
INCONTINENCE WHICH NOW INCLUDES FECAL INCONTINENCE AS WELL.

AND THANK YOU.

(APPLAUSE).

\>\> I\'D LIKE TO INVIDE THIS MORNING PEEKERS BACK UP TO FORM A PANEL
HERE AND WE\'LL NOW OPEN THIS SESSION TO QUESTIONS AND DISCUSSIONS
INITIALLY FROM THE PANEL AND THEN FROM THE AUDIENCE.

\>\> MC DEWINGAL BOSTON, MY QUESTION IS FOR DR. GOODE.

ARE YOU AWARE OF ANY﷓﷓THIS HAS TO DID WITH RADICAL PROSTATECTOMY.

ARE YOU AWARE OF ANY PROSPECTIVE STUDIES WHICH ARE SUFFICIENTLY POWERED
TO LOOK AT THE VARIOUS RISK FACTORS IN A MULTIVARIANT WAY?

I COME BACK TO SOME OF THE RISK FACTORS YOU MENTION FOR EXAMPLE,
ANTERIOR URETHRAL SUSPENSION WHICH TO MY UNDERSTAND SUGGEST ANEC DOTA
AND RETROSPECTIVE NUMBER OF BUNDLES PRESERVED AGAIN IS SUBJECTIVE
RETROSPECTIVE AND SO MY QUESTION IS: IS THERE ANY DATA OUT THERE IN A
PROSPECTIVE WAY SUFFICIENTLY POWERED, MULTIVARIANT CAPABILITY OF
MULTIVARIANT ANALYSIS AND THE FACTORS YOU WOULD WANT TO LOOK AT WOULD BE
AGE, CO﷓MORBIDITY, VOLUME OF DISEASE, RESECTED AND SO FORTH.

\>\> THE SLIDE THAT I SHOWED OW RISK FACTORS THOSE WERE FROM
MULTIVARIABLE ANALYSIS THAT WERE CONTROLLING THE SLIDES THAT I SHOWED
YOU ON PREVENTION STRATEGIESS LIKE THE SURGICAL TECHNIQUES THOSE ARE NOT
IN THE SAME STUDIESSS AND THEY\'RE NOT CONTROLLED FOR IN THE SAME WAY.

YOU\'RE RIGHT THEY\'RE ALL SURGICAL SERIES IN PREAND POST AND HISTORICAL
CONTROL TO NEW SURGERIES SO THERE\'S NOT BEEN RANDOMIZED CONTROLS IN AND
THE RISK FACTOR ANALYSIS IN ONE STUDY LARGE ENOUGH TO LOOK AT AGE AND
THE OTHER RISK FACTORS ALONG WITH SURGICAL TECHNIQUE AND TRY TO SEPARATE
THAT OUT.

THAT DATA DOESN\'T EXIST.

\>\> ANY PROSPECTIVE STUDY?

\>\> I\'D HAVE TO LOOK CLOSELY AT THAT AGAIN TO SEE IF THEY WERE PROPECK
SPECTIVE OR RETROSPECTIVE, THE ONES THAT WERE MULTIVARIABLE.

MOST LIKELY THEY WERE RETROSPECTIVE.

\>\> I\'M NOT AWARE OF ANY PROSPECTIVE STUDY.

\>\> ANOTHER NEED FOR MORE RESEARCH.

\>\> JUST ON A LOGICAL BASES YOU WOULD EXPECT ANY DISEASE OR CONDITION
THAT ADVERSELY EFFECTS THE AUTONOMIC NERVOUS SYSTEM TO INCREASE THE
INCIDENCE OF SINK TERRIC INCONTINENCE AFTER PROSTATECTOMY.

SO IF YOU LOOK AT SOMETHING, I WILL SUGGEST THAT SOMETHING LIKE
DIABETES, LET\'S SAY WOULD BE LOOKED AT BECAUSE YOU WOULD CERTAINLY
EXPECT THAT TO HAPPEN.

I MEAN IT\'S SORT OF A MYSTERIOUS THING IF YOU ASK ANYONE HERE THAT DOES
RADICAL PROSTATECTOMY, SCOTT, OR BILL STEERS, YOU KNOW THEY WOULD TELL
YOU THAT WHAT THEY TELL THEIR PATIENTS IS PROBABLY AN INCIDENCE OF
SOMEWHERE BETWEEN SIX AND EIGHT% ON A PERMANENT BASIS, NOT THAT\'S AFTER
LET\'S SAY, ONIER OR SO, AND YET IF YOU LOOK IN THE LITERATURE, YOU FIND
AN EXTRAORDINARILY HIGHER INCIDENCE OF THAT AND ALSO A PREVALENCE OF
THAT IN THE POPULATION THAT\'S HEAD RADICAL PROSTATECTOMY EVEN FIVE
YEARS AGO.

BUT I WOULD AGREE WITH DR. MC DUGALL THAT A LET OF THE REPORTS ABOUT I
DO THIS AND I DO THAT IN MY INCIDENCE IS TERRIFIC, I THINK THOSE ARE
ANECDOTAL AND THE PEOPLE WHO HAVE TRIED THOSE VARIOUS MODISKS HAVE COME
TO THE CONCLUSIONS THAT THEY MAY BE HELPFUL TO THAT INDIVIDUAL WHO
REPORTS THEM, BUT OVERALL, IN THE COLLECTION OF A HUNDRED SURGEONS WHO
DO A LOT OF PROSTATECTOMY, THAT THEY\'RE PROBABLY ISN\'T ONE MAGICAL
STEP THAT ONE PERSON DOES AND EVERYONE ELSE LEAVES OUT THAT IS GOING TO
RESULT IN A SIGNIFICANT INCREASE IN THE POST PROSTATECTOMY YOU KNOW
CONTINENCE.

\>\> A FOLLOW UP TO THAT QUESTION, WHICH YOU MAY HAVE ANSWERED TO DR.
GOODE.

FOR MANY CARDIO VASCULAR PROCEDURES THERE\'S A LOT OF DATA ON VARIATION
BETWEEN CENTERS AND SURGEONSES IN OUTCOME RATES, FOR RADICAL
PROSTATECTOMY, IS THERE DATA ON ANY SYSTEMATIC DATA ON VARIATION BETWEEN
CENTERS OR OPERATORS ON CONTINENCE RATES AFTERWARDS, JUST NOT﷓﷓

\>\> NO THERE\'S MORE INDIVIDUAL REPORTS, THIS CASE SERIES AND THAT CASE
SERIES BUT NOT WHAT YOU\'RE TALKING ABOUT WHICH WOULD BE VERY HELPFUL.

\>\> AND QUESTION FOR DR. WEIN.

MOST DRUGS OVER THE LAST THURT OR 40 YEARS AFTER A RANDOMIZED TRIAL AND
AN EFFICACY END POINT IS ANYBODY LOOKED TO SEE WHETHER INCONTINENCE IS
REPORTED AS ONE OF THE SIDE EFFECTS IN THOSE SYSTEM﷓﷓I\'M WONDERING IF
BURIED IN THOSE REPORTS WHETHER THEY WOULD﷓﷓THERE WOULD BE INCONTINENCE
RATES.

\>\> THE OHM ONE I\'M AWARE OF AND I WOULD SAY THE STUDIES ARE
SATISFACTORY, PERHAP NOT THE KIND OF STUDY YOU WOULD HAVE TO DO AT THE
ANT MERGIC ANTAGONIST AND INCONTINENCE IN WOMEN, I THINK IN SOME WOMEN
THAT\'S REAL.

I THINK THE REST ARE, I SAW THIS AND I THINK I\'LL WRITE A PAPER ABOUT
IT.

\>\> THANK YOU VERY MUCH.

GREAT PRESENTATIONS, TWO QUESTIONS, HILLRY STEPHENS, NEAR DR. GOODE, I
APPRECIATE THE WAY YOU SHOW THE INCONTINENCE INCIDENCE IN THE EELER
STUDIES AND THEN YOU MENTION YOUR STUDY, IS THERE ANYWAY YOU CAN GIVE US
THE PERCENTAGE OF INCONTINENCE IN YOUR STUDY?

AND IF NOT NOW, MAYBE, YOU KNOW LOOK AT YOUR DATA AGAIN JUST SO WE CAN
COMPARE A LITTLE BIT IN THE APPROACH THAT YOU USED HOW IT COMPARES TO
THOSE INCONTINENCE RATES IN THE BASELINE, SIX MONTHS, 12 MONTHS, FIVE
YEARS?

\>\> YES, IT WOULD TAKE A RECALCULATION OF THE DATA BECAUSE I HONED THAT
ARTICLE AND ALL THE DRAFTS AND LOOKED AT EVERYTHING TO SEE IF WE HAD
THAT DATA AND WE HAVE IT BUT WE DON\'T HAVE IT WHERE I COULD ACCESS IT.

I HAVE TO GET THE STATISTICIAN TO RUN IT BUT I COULD GET RATES.

NOT AT ONE YEAR BECAUSE WE ONLY FOLLOW THE PATIENTS TO SIX MONTHS SO WE
WOULD ONLY HAVE SIX MONTHS DATA BUT WE COULD GET THE PERCENTAGES.

\>\> I WOULD LOVE TO SEE THOSE DATA.

I THINK THAT WOULD BE CRITICAL BECAUSE IT LOOKS LIKE YOU\'RE DOING VERY
GOOD WORK AND IT\'S APPLES AND ORANGES AND IF REALLY DOES MAKE A
DIFFERENCE THAT MIGHT SHOW IT VERY NICELY.

AND ONCE I DID A RANDOMIZED CONTROL TRIAL ON EXERCISE IN THE ELDERLY WE
SHOWED NO EFFECT AND SOMEONE SAID WAIT, WAIT, YOU HAVE TO DO THE
ANALYSIS DIFFERENTLY AND IT BECAME A POSITIVE OUTCOME STUDY, IT WAS
REAL, IT WASN\'T JUST DATA SO THAT MAY BE A GOOD THING TO DO FOR YOUR
STUDY.

DR. WEIN, YOU MENTIONED THE GOOD LITERATURE ON THIS.

COULD YOU COMMENT THAT NIA HAS FUNDED GERIATRIC INCONTINENCE RESEARCH A
LOT THROUGH THE WONDERFUL NAMES, DR. RES NICK, OS LANDER, MARK BEERS DID
A LOT OF WORK ON DRUGS ON THE ELDERLY, DR. DUBEAUX HAS DONE A LOT OF
WORK ON THE ELDERLY AND I DON\'T THAN LITERATURE WELL AT THIS POINT.

DID HAVE YOU AN OPPORTUNITY TO LOOK AT THAT LIT THURE BECAUSE THERE\'S
BEEN SO MUCH WORK ABOUT THE ANGIO GENESIS OF DRUGSES IN THELEDDERLY BUT
IT SEEMSES THAT NONE OF IT WOULD MEET CRITERIA TO﷓﷓IN YOUR LITERATURE
REVIEW, SO I WAS A BIT VIS SURPRISED BY THAT.

COULD YOU PLEASE COMMENT?

\>\> YEAH, I THINK YOUR SURPRISE IS PRETTY COMMON.

YOU KNOW I REVIEW THE LITERATURE AND I REVIEWED, THE REVIEWS, IT\'S
PRETTY OBVIOUS THAT WHAT HAPPENS IS WHAT YOU GETTER TABLES.

YOU GET TABLESES THAT SAY, WELL, THIS COULD BE CAUSED BY THIS, AND
TABLES CATEGORIZED THE INCONTINENCE EITHER ACCORDING TO THE TYPE OF
INCONTINENCE AND THE DRUGS THAT MIGHT CAUSE THAT OR THEY CATEGORIZE IT
ACCORDING TO THE DRUGS AND THE TYPE OF INCONTINENCE THAT THEY MIGHT
CAUSE, BUT AS FAR AS I\'M AWARE, THERE ARE NO SYSTEMATIC STUDIESES THAT
HAVE BEEN DONE LOOKING AT SPECIFICALLY EITHER THE INCIDENCE OF NEW
URINARY INCONTINENCE OR THE INCIDENCE OF WORSENING URINARY INCONTINENCE
IN A GROUP OF PATIENTS EXCEPT ACTUALLY FOR THE ONE LARGE ESTROGEN STUDY.

I MEAN THAT\'S REALLY THE OHM ONE I\'M AWARE OF EXCEPT FOR THERE\'S ONE
SERIES THAT LOOKS AT AN ALPHA ANTA MERGIC ANTAGONIST IN WOMEN, BUT
THAT\'S REALLY ALL.

SO IT\'S MOSTLY, WELL YOU KNOW I DON\'T KNOW WHAT ABOUT TO SAY ABOUT
THIS IN MY CHAPTER SO I THINK I\'LL JUST MAKE A TABLE.

I MEAN KATHRYN\'S WAITING TO MAKE A COMMENT.

MAYBE HE CAN COMMENT ABOUT THAT BECAUSE I\'M HONESTLY NOT AWARE OF
SYSTEMIC STUDIESES THAT HAVE LOOKED PROSPECTIVELY AT THAT ISSUE.

\>\> THANK YOU.

AND THEN MY LAST﷓﷓

\>\> ALAN\'S ABSOLUTELY RIGHT.

WHEN WE\'VE DONE THE REVIEW FOR THE INTERNATIONAL CONSULTATION THIS IS
ALL﷓﷓

\>\> I LOOK FORWARD TO YOUR REVIEW.

\>\> THIS IS ALL ANECDOTAL EXPERT OPINION BEST GUESSS.

I DON\'T KNOW IF TED LOOKED AT THIS IN NOCCURIA OR ANYONE DONE THAT
SYSTEMATICALLY FOR NOCTURIA, HE SAYS IT\'S THE SAME SITUATION.

\>\> THANK YOU.

AND THEN, ON THE SURGICAL MANAGEMENT, MY BACKGROUND IS IN REHABILITATION
MEDICINE AND IT\'S TERRIFIC TO SEE THE DAA ABOUT PELVIC, GOOD OUTCOMES,
PREVENTING INCONTINENCE JUST WITH PELVIC MUSCLE EXERCISE, DO YOU THINK
THERE\'S PROMISE IN THIS WHOLE AREA, IN DOING MORE PREOPERATIVELY IN
GENERAL AND DOING AN INTERVENTION AT MULTIPLE LEVELS BECAUSE HERE WE\'RE
DEALING WITH WHOLE PEOPLE AND THERE\'S PROBABLY NOT GOING TO BE A SILVER
BULLET AND WE HAVE DATA OH, EXERCISE, THAT EMPOWERS THE PATIENT, THEY
FEEL BETTER PLUS WE HAVE LESS INCONTINENCE.

THE PSCHYCOLOGIAL BURDEN ISSUES FOR PATIENTS FOR THEIR CARE GIVERS IS
JUST HUGE.

SO I\'M WONDERING IF YOU COULD ENVISION FROM THE RESULTS YOU\'RE SEEING
THAT PREOP THERE\'S MORE TRAINING, THERE\'S PREPARATION, THERE\'S
EDUCATION AND WE MIGHT GET SOME REALLY GOOD BENEFIT, EVEN IF THERE IS
SOME INCONTINENCE AFTER THE FACT BY JUST EMPOWERING PEOPLE, LETTING THEM
KNOW WHAT\'S COMING DOWN THE PIKE AND THE SURGEON CAN\'T JUST TAKE CARE
OF ALL OF THAT, IT\'S A TEAM APPROACH AND THERE ARE LOW COST WAYS OF
EDUCATING AND CAN YOU COMMENT ON THAT WHOLISTIC PREOP INTERVENTION.

\>\> YEAH, I WOULD BE HAPPY TO.

I CAN CERTAINLY COMMENT, I CAN TELL YOU THERE ISN\'T VERY MUCH DATA
ABOUT THIS.

THERE IS SOME DATA ABOUT DOING PREOPERATIVE EDUCATION AND SPHINCTER
TRAINING PRIOR TO ANNAL SPHINCTER SURGERY WHICH I DIDN\'T TALK ABOUT
ANNAL SPHINCTER RECONSTRUCTION, BUT THERE ISN\'T SPECIFIC INFORMATION
THAT I CAN SHARE WITH YOU, AT LEAST THAT I\'M AWARE OF, BUT ON THE OTHER
HAND I THINK THAT THERE\'S A LOT OF DATA FROM A LOT OF DIFFERENT
CONDITIONS THAT PREOPERATIVE EDUCATION AND AT LEAST THEORETICALLY BETTER
KNOWING OF THE PHYSIOLOGY THERE OF BIOMECHANISMS AND PHYSIOLOGY OF THEIR
SPHINCTER MECHANISMS WOULD HELP SO THAT I﷓﷓YOU KNOW I THINK IT\'S A VERY
REASONABLE THING TO LOOK AT.

IT\'S A VERY﷓﷓ALL OF THE CONDIGS I TALKED ABOUT, ARE UNDERSTANDING OF
WHY THEIR INCONTINENCE IS SO LIMITED BECAUSE WE KNOW FROM THE
OBSTETRICAL LITERATURE THAT THERE\'S A SIGNIFICANT INCIDENCE OF OCCULT
SPHINCTER INJURY, BUT WE KNOW THAT ONLY SOME OF THOSE WOMEN ARE
INCONTINENT AND I SEE PATIENTS WITH A FULL CLOUGHACCA THEY HAVE NO
SPHINCTER AND THEY CLAIM THEY\'VE NEVER BEEN INCONTINENT.

AND THERE\'S A LOT WE DON\'T UNDERSTAND AND HEMORRHOID THAT WOULD BE
TRUE, FISSURE SURGERY WOULD BE TRUE FISTULA SURGERY WILL BE TRUE AND
THEN RECONSTRUCTION SURGERY AND IMPACT OF RADIATION.

SO THERE\'S A LOT WE DON\'T UNDERSTAND SO WE WOULDN\'T HAVE SPECIFIC
EDUCATION, BUT GENERAL EDUCATION I THINK WHICH IS GOOD FOR PEOPLE AND I
AGREE WITH YOU ABOUT THEIR, WHAT IT DOES FOR THEM PSCHYCOLOGILY.

AND I JUST WONDER ABOUT THE HIDDEN DECONDIGGING THAT\'S GOING ON IN ALL
OF THESE PATIENTS.

THE PREOP, I THINK THE DATA ARE GOOD FOR SOME OF THE ELECTED ORTHOPEDIC
SURGERY PREOP, GET THEM BACK CONDITIONED BECAUSE DECONDITION SUGGEST
PERVASIVE AND THAT\'S ONE TREATABLE COMPONENT.

THANK YOU.

\>\> JOSEPH KING YALE UNIVERSITY MVA CONNECTICUT, MY QUESTION IS FOR DR.
LOWRY.

I WAS STRUCK BY YOUR SLIDES IN THE CURE OR THE SUCCESS OF THE RATE OF
INCONTINENCE AND PROCEDURES AND CONDITIONS WE\'RE MAKING TRADE OFFS
BETWEEN DIFFERENT OUTCOMES AND I\'M WONDERING WHAT TYPE OF EVIDENCE
THERE IS HOW THESE DECISIONS AND PATIENTS ABOUT SHARED DECISION MAKING
AND ABOUT PATIENT EDUCATION AND TRADE OFFS THAT THEY\'RE MAKING, LIVED
WITH THE CONSEQUENCES OF THE SURGERY AND THE POSSIBILITY COMPLICATIONS
AND LONG﷓TERM?

\>\> THERE IS SOME INFORMATION ABOUT DECISION AND LOW MOST TO A
COLOSTOMY, AND THERE IS SOME﷓﷓I CAN\'T QUOTE IT SPECIFICALLY BUT THERE
IS SOME LITERATURE SHARE DECISION MAKING RELATIVE TO THE FUNCTIONAL
CONSEQUENCES OFLET OPERATIVE CHOICE.

I\'M NOT AWARE OF ANY SHARED DECISION MAKING LITERATURE WITH ANAL﷓RECTAL
CONDITIONS AND I THINK THAT\'S CORRECT, I MEAN THAT\'S CERTAINLY WHEN
YOU REVIEW THE LITERATURE THAT THE﷓﷓WHAT\'S REALLY HAPPENED IS THAT
HONEST INVESTIGATORS STARTED TO LOOK AT WHAT THE FUNCTIONAL RESULTS WERE
OF WHAT THEY WERE DOING.

FINDING THOSE RESULTS HIS FUNCTIONAL CONSEQUENCES PEOPLE STARTED LOOKING
FOR TREATMENTS.

WHEN WE LOOK AT TREATMENTS THEY DON\'T HAVE THE SAME CONSEQUENCE BUT
THEY ALSO DON\'T HAVE THE SAME SUCCESS.

\>\> I I\'M SURE THEY IMAGINE THERE ARE SIMILAR ISSUES WITH REGARD TO
PROSTATE INTERVENTIONS, AND SIMILAR BODY RESEARCH, I KNOW THE PROSTATE
INTERVENTION VS BEEN STUDIED MORE THAN COLO RECTAL AND ANAL﷓RECTAL
ISSUES CAN YOU COMMEND COMMENTA PATIENT REFERENCES.

\>\> WE HAVE MAY HAVE SOMETHING TO ADD TO THIS TOO, BUT THERE ARE TRADE
OFFS AND IF YOU LOOK AT THE LITERATURE, WE TALKED ABOUT RADIATION AND I
HAVE NOT SEEN THE LITERATURE COMPARING CUREERATES FOR BRACHYTHERAPY
ALONE AND BRACHYTHERAPY BLUES EXTERNAL BEAM RADIATION, I SEE MORE
COMPLICATIONS AFTER THE COMBINATION, BUT THE CURE RATE MAY BE DIFFERENT
AND ALSO IN CHOOSING BETWEEN A RADICAL PROSTATECTOMY AND RADIATION
THERAPY FOR A YOUNGER MAN, WITH PROSTATE CANCER FYOU\'RE LOOKING AT A
LONG﷓TERM CURE, HE PROBABLY HAS A BETTER CHANCE WITH RADICAL
PROSTATECTOMY, BUT WE DON\'T REALLY HAVE A GOOD DATA COMPARING THE
PROLONGED COMPLICATIONS WITH INCONTINENCE COMPLICATIONS SUCH AS FECAL
URIGENCE SCHEURINARY URIGENCEY SO WE BEING USE STUDIES LIKE THAT.

IT WOULD BE NICE TO HAVE A BIG REGISTRY WHERE WE PUT A LOT OF PEOPLE
INTO IT AND COULD DO A POWERFUL MULTIVARIABLE ANALYSIS.

\>\> IN REGARDSES TO SURGERY WHEN YOU\'RE DOING A RADICAL PROSTATECTOMY
AND I SPEAK FROM EXPERIENCE, I DO 150 TO 250 A YEAR, REMEMBER THE SLIDE
I SHOWED YESTERDAY, IT WAS THE MALE ANATOMY BEFORE AND THE MALE CORONAL
ANATOMY AFTER, WELL AFTERWARDSS YOU HAVE THE DISTAL SPHINCTER AREA, IF
THE ABEAKS IS CONTINUOUS DOWN IN THAT AREA AND SOMETIMES YOU CAN\'T
ALWAYS TELL, MAKE A CONSCIOUS DECISION ABOUT WHETHER YOU\'RE GOING TO
TAKE MORE DISTAL SPHINCTER AREA TO EXCISE THE APEEKS OF THE PROSTATE OR
LESS BECAUSE YOU KNOW YOUR RATE OF CONTINENCE IS GOING TO BE HIGHER AND
IF DO YOU A FROZEN SECTION ON THE URETHRAL MARGIN, AND IT COMES BACK
PROSTATE TISSUE, NO TUMOR SEEN, THEN YOU HAVE TO MAKE A EFFORT TO
SEE﷓﷓BILL\'S SMILING AND SCOTT KNOWS AS WELL, YOU HAVE TO MAKE A
CONSCIOUS DECISION ABOUT WHETHER YOU\'RE GOING TO TAKE DISTAL URETHRA
AND YOU KNOW YOU\'RE TAKING A CHANCE OF A HIGHER CONTINENCE OR
INCONTINENCE INCIDENCE OR LESS AND YOU KNOW YOU\'RE GOING TO HAVE A
HIGHER CHANCE OF HAVING A MEASURABLE PSA AFTERWARDS, SO WITH URINARY
INCONTINENCE, THERE\'S DEFINITELY A CONSCIOUS DECISION MAKING PROCESS,
THAT GOES ON.

YOU KNOW THAT\'S ACTUALLY INTRA OPERATIVELY.

\>\> WHAT DO WE KNOW ABOUT WHAT GOES INTO THOSE DECISIONS THOUGH?

SURGEONS WOULD HOPE EMPLOYLY TAKE INTO ACCOUNT PATIENT PREVENSES AND
PREOPERATIVE DISCUSSIONS ABOUT THESE TRADE OFS BUT DID WE HAVE RESEARCH
IN THAT AREA THAT SHOWS HOW THE DECISIONS ARE MADE AND HOW WELL THEY\'RE
TAKEN INTO ACCOUNT PATIENT PREVENS FERENCES WHEN THEY\'RE MAKING THESE
OPERATIVE DECISIONS.

\>\> I CAN SPEAK ONLY FROM MY EXPERIENCE.

I THINK WHEN SOMEONE CHOOSES SURGERY, THERE\'S CERTAINLY A PRIZE TO THE
RISK AND THERE\'S CERTAINLY A FACT THAT URINARY INCONTINENCE IS
DEFINITELY HIGHER AFTER SURGERY FOR PROSTATE CANCER, THEN IT IS FOR
RADIATION, I\'M QUITE HONEST WITH PEOPLE ABOUT THAT, AND I EVEN SEND ALL
OUR PATIENTS TO SEE THE RADIATION ONCOLOGIST SO THEY CAN HAVE A FULL
DISCONGRATULATION EVER THE ISSUES BIORADIATION ONCOLOGIST BEFORE AND
THEN THEY CAN MAKE THEIR OWN DECISION.

NOW AS TO WHETHER PEOPLE GO INTO WELL, THIS MIGHT OCCUR AND THAT IF THE
INCONTINENCE ISSUE IS ONE THAT\'S SUFFICIENTLY BOTHERSOME TO THEM, THAT
THEY THINK THE RISK BENEFIT RATIO IS IN FAVOR OF SOMETHING THAT CAUSES
LESS INCONTINENCE, THEY\'LL CHOOSE RADIATION WHETHER IT\'S IMRT, OR
BRACHYTHERAPY, OR IN THE FUTURE PROTON THERAPY ET CETERA.

SO I THINK THAT\'S THE DECISION THAT I THINK THE PATIENT MAKES UP FRONT
BETWEEN THE TWO MODALITIESS.

\>\> THANK YOU.

\>\> NOW OPEN TO QUESTIONS FROM THE AUDIENCE.

FILL WHITE HEAD UNIVERSITY OF NORTH CAROLINA.

DR. LOWRY IT WAS AN EXCELLENT OVERVIEW OF SURGICAL COMPLICATIONS WHAT I
WOULD LIKE TO ASK YOU ABOUT IS THE BASE RATE OF SOILING IN PATIENTS WITH
HEMORRHOIDS PRIOR TO SURGERY BECAUSE I THINK THIS HAS SOME SIGNIFICANT
IMPLICATIONS AS A TARGET FOR PREVENTION.

IN LOOKING OVER THE CASE SERIES, I FOUND A COUPLE THAT HAD ASKED
SPECIFICALLY ABOUT SOILING THAT WERE 80 TO 100 CASES MOR SCHEJO
HANSON\'S WORK AND THEY REPORTED QUITE HIGH RATES OF SOILING, BUT I
THINK YOU SUGGESTED THAT THE RATES ARE MUCH LOWER, COULD YOU COMMENT ON
THAT?

\>\> THERE ARE FEW STUDY STUDIESS THAT LOOK AT BEFORE SURGERY BUT THE
BUT IT\'S SO COMPLICATED BY THE FACT THAT WHETHER THEY HAVE﷓﷓WHAT
YOUR﷓﷓YOU DON\'T KNOW WHAT YOUR IDENTIFYING EXACTLY.

ARE YOU IDENTIFYING THAT THEY HAVE PROLAPSE IN MUCOSA THATTED WELLS TO
SOILING THAT THEORETICALLY SHOULD BE CORRECTED IF WE CORRECT THAT
PROLAPSE OR ARE YOU IDENTIFYING SOME UNDERLYING DYSFUNCTION THAT IS
SEPARATE FROM THE PROLAPSE MUCOSA THAT WOULD BE A RISK FACTOR FOR
PERSISTENT INCONTINENCE AFTER SURGERY?

AND TO MY KNOWLEDGE NO ONE HAS DONE THIS STUDY IN WHICH THEY\'VE TRIED
TO TEASE OUT THOSE TWO ASPECTS OF PREOPERATIVE SOILING.

\>\> THANK YOU.

\>\> DIANNA HANKY UNIVERSITY OF BUFFALO.

WONDERFUL PRESENTATION.

I HAVE A COUPLE OF QUESTIONS THAT ARE TRULY QUESTIONS BUT HOPEFULLY
THOUGHT.

BUT THE OBGYN LITERATURE HAS THINGS OS ELECTRICAL STEM THAT INDICATE
THAT ANNAL ANNAL STIMULATION CAN INCREASE RECTAL COMPLIANCE.

I DON\'T KNOW THE QUALITY OF THOSE STUDIESS AS WELL AS YOU DO OBVIOUSLY,
BUT IT OCCURS TO ME THAT WHEN WE HAVE MEN WHO\'VE HAD RADIATION AND HAVE
THE RADIATION PROCTITIS THAT ONE OF THE PROBLEMS WITH THAT IS OFTEN
THERE\'S A LOSS OF COMPLIANCE AND THEN WONDERING IF IT\'S POSSIBLE, IF
IT\'S SAFE, IF IT COULD BE RESEARCHED WHETHER ANNAL STIMULATION COULD
IMPROVE THEIR CONDITION?

THAT\'S MY FIRST QUESTION.

\>\> WE WOULD HAVE TO LOOKA AT THE PROSTATE OR THE RECTUM TO IMPROVE THE
SITUATION AND WE NEED PELVIC FLOOR MUSCLE EXERCISES AND TRAINING
TECHNIQUES, I THINK WE NEED STUDIES OF AND BIOFEEDBACK WHICH IS SO GOOD
AND FECAL INCONTINENCE AND PATIENTS WITHOUT RADIATION AND WE NEED
STUDIESS OF THAT IN MEN AND WOMEN AFTER RADIATION THERAPY FOR BOTH THESE
CONDITIONS, SO I THINK THE FIELD FOR THAT IS WIDE OPEN AND WE REALLY
NEED RESEARCH.

\>\> OKAY, THEN ANOTHER QUESTION IS, I BELIEVE IN EUROPE, IN SOME PLACES
THEY ACTUALLY PUT SOMETHING INTO THE BOWEL BEFORE THEY DO RADIATION TO
TRY TO GIVE IT SOME PROTECTION AND ALSO I KNOW IN THE LAY LITERATURE
THERE\'S SOME TALK OF PUTTING ALOE VERA INTO THE RECTUM DURING THE FIRST
WEEKS AFTER RADIATION TO PROMOTE HEALING SO THAT A YEAR AND HALF LATER
THAT THERE ISN\'T RECTAL INCONTINENCE, ARE YOU FAMILIAR WITH ANY OF
THAT?

DOES THAT SEEM LIKE A RESEARCHABLE SUBJECT OR JUST WAY OFF THE WALL?

\>\> I\'M NOT FEBRUARY WITH THAT WHATEVER THEY\'RE PUT NOTHING THE
RECTUM TO PROTECT IT AT LEAST IN TERMS OF USING RADIATION FOR RECTAL
CANCER SINCE THAT\'S WHAT RADIATED BUT THERE IS SOME﷓﷓I AM AWARE OF SOME
STUDIESS THAT LOOKED AT THE USE OF ORAL VITAMIN E SUPPLEMENTATION AND
THAT THEY\'RE NOT﷓﷓

\>\> IT SEEMS LIKE A REALLY GOOD PLACE FOR US TO GO WITH RESEARCH TO
LOOK AT NUTRITION AND IN THESE PATIENTS BECAUSE ESPECIALLY IN
THELEDDERLY IF THEY CAN\'T REPLICATE THEIR CELLS AS QUICKLY AND WE HAVE
ALL THAT SHEDDING IN THE DIGESTIVE TRACT THAT YOU\'RE GOING TO GET
NUTRITIONAL DEFICIENCY AND MAYBE PAROF THE REASON IT GETS WORSE OVER
TIME IS THAT THE NUTRITION NEEDS TO BE SUPPLEMENTED AND SOMETHING LEAK A
ENSURE OR A VITAMIN THAT THEY MAY BE LACKING IN WOULD BE VERY FRUITFUL
SO I\'M SUGGESTING TO THIS BODY THAT I\'D LOVE TO SEE RESEARCH IN THAT
AREA IF THAT SEEMS APPROPRIATE.

THANK YOU.

\>\> WE HAVE ABOUT FIVE MINUTES MORE FOR QUESTIONS.

I\'D LIKE TO ASK EACH OF THE QUESTIONERS IF YOU CAN DO JUST ONE QUESTION
SO WE CAN TRY AND AT LEAST GIVE EVERYBODY A CHANCE TO HAVE ONE QUESTION
AND IF THERE\'S MORE TIME CAN YOU COME BACK FOR MORE IF YOU HAVE MORE.

\>\> A A REAL QUICK QUESTION, DIANE SMITH FOR PHILADELPHIA FROM DR.
WEIN, I NOTICED ON YOUR SLIDE YOU WERE VERY CAREFUL TO TALK ABOUT ORAL
ESTROGEN, AND I AGREE WITH YOU WHOLE HEARTEDLY IN THE SPEAKER YESTERDAY
ABOUT THE ORAL ESTRO ESTROGEN STUDIESS BUT VAGINAL ESTROGEN IS USED BY
GERIATRIC WOMEN WHO ARE COMPLAINING OF FREQUENCY AND NOCCURIA, EVEN
THOUGH THE STUDIES ARE NOT AT THE LEVEL YOU ARE PRESENTING WOULD WILL
YOU MAKE A COMMENT ABOUT THE USE OF VAGINAL ESTROGEN OF WOMEN THAT ARE
COMPLAINING OF THOSE SYMPTOMS?

\>\> NOW IT SEEMED TO ME THAT WHETHER THE RESULTS OF ORAL ESTROGEN WOULD
DEPEND ON SERUM LEVELS AFTER VAGINAL ADMINISTRATION, SO I THINK THAT\'S
ONE AREA I\'VE BEEN TRYING TO CONVINCE PEOPLE TO DO AN ADEQUATE STUDY ON
FOR YEARS AND YEARS AND YEARS AND YEARS AND SNOWION SEEMS TO WANT TO OR
TO BE ABLE TO DO IT BUT THAT\'S ONE RECOMMENDATION THAT CERTAINLY WOULD
BE VERY NICE TO COME OUT OF THIS SESSION.

\>\> I\'M JEANETTE FROM THE UNIVERSITY OF CHICAGO AND ALSO AT MILWAUKEE
I WORK AT AURORA WOMEN\'S PAVE ILION WORKING IN COLO RECTAL SURGERY AND
NEUROGYNECOLOGY AND THIS QUESTION COMES FROM SOMEONE WHO\'S BEEN DOING
BIOFEEDBACK AND BEHAVIORIAL THERAPY FOR ABOUT 20 YEARSES IN THIS FIELD
AND ALSO FROM SOMEONE WHO TEACHES THE PROCEDURES TO OTHER THERE APISTS
TRYING TO LEARN PROCEDURESS AND I\'M AMAZED YET, SOMEONE YESTERDAY ASKED
WHY WE DON\'T HAVE BASIC SCIENCE AS TO MECHANISMS AND I HAVE THIS
QUESTION AND COMMENT AS DIRECTED TO DR. GUDEY BECAUSE IN ONE OF HER
RECOMMENDATIONS SHE DID RECOMMEND THAT WE BEGIN TO LOOK AT UNDERSTANDING
POSSIBLY THE BEST PROT COLS FOR BIOFEEDBACK AND BEHAVIORIAL THERE APE
NEE TERMS OF INTENSITY AND DURATION AND HOME PROGRAM AND I WOULD JUST
LIKE TO ASK HER WHERE SHE﷓﷓YOU KNOW FROM THE LITERATURE WHERE THAT
RECOMMENDATION COMES FROM.

FROM HER EXPERIENCE BECAUSE I TOO HAVE ABSOLUTELY NO DATA FROM WHICH I
CAN TELL MY STUDENTS HOW TO BEST TRAIN PELVIC FLOOR MUSCLE EXERCISES IF
THE GOAL OF OUR TREATMENT IS TO INCREASE THE RELATIVE PRESSURES AND THE
ANNAL CANAL OR THE URETHRA SPHINCTER WE DO NOT KNOW WHAT PROTOCOL
PROVIDES THAT OUTCOME AND SO I WOULD JUST LIKE THE COMMENT OF BOTH DR.
GOODE BUT THE OTHER PANEL MEMBERS AS WELL?

\>\> I THINK YOU SAID IT VERY ELEGANTLY.

WE NEED MORE RESEARCH AND WHAT KIND OF PROT COLS PRODUCE THE BEST
RESULTS BOTH PHYSIOLOGICALLY MEASURING SPHINCTERS AND THE OUTCOMES
RESEARCH AND WE DON\'T KNOW IF SOMEBODY SHOULD DO 20 OR 50 A DAY, WE
DON\'T KNOW WHETHER IT\'S BETTER TO TELL THEM TO SUSTAIN CONTRACTIONS OR
DO BRIEF FLICKS OR DO A COMBINATION OF BOTH.

WE VICTORY COMPARED ALL THE PROTOCOLS AND FOR CENTERS OUT THERE TRYING
TO LEARN BIOFEEDBACK, IF YOU READ ANY PARTICULAR STUDY, YOU WOULDN\'T
KNOW ENOUGH TO KNOW HOW TO DO WHAT THEY DID AND THE DIRECTIONS ARE NOT
SPECIFIC ENOUGH IN THE METHODOLOGY SO I THINK WE NEED RESEARCH IN ALL
THOSE AREAS.

I THINK IT\'S VERY, VERY, IMPORTANT BECAUSE IT\'S A VERY PROMISING
THERAPY THAT THE RESULTS SHOWN SO FAR ARE VERY GOOD AND WE JUST NEED
MORE WORK IN THE AREA.

\>\> THIS IS THE QUESTION FOR DR. GOODE.

WONDERFUL TALK, ADDITION TO PROSTATE AND CANCER TREATMENT IS WIDE SPREAD
USE OF ANTIANT GENS WHETHERRENER O ADJUVANT ORED ADJUVANT OR SUBSEQUENT
TREATMENT FOR RISING PSA AND I DON\'T KNOW THE OTHERS DOCTORS WOULD
AGREE BUT THE USE OF THIS IS EXPANDED OUTSIDE THE RECOMMENDATION IS
THERE ANY DATA IN OW THIS AFFECTS OUTCOMES OF INCONTINENCE OR URINARY OR
FECAL INCONTINENCE.

\>\> I HAVE TO SAY I DON\'T KNOW.

\>\> I AGREE I HAVE NOT SEEN DATA ON THAT AND SOMEONE DISCUSSED MAIL
MENOPAUSE THAT\'S INDICED BY THESE AGENTS YESTERDAY ANDS ASCERTAIN THE
EFFECT ON CONINENT WOULD BE VERY IMPORTANT BECAUSE IT IS WIDELY USED.

\>\> TED JOHNSON FROM EMERY UNIVERSITY IN THE BIRMINGHAM VA,
BIRMINGHAM﷓ATLANTA VA.

AND MY QUESTION IS TO DR. WEI# AND GOODEXAND THE TOPIC IS FECAL
INCONTINENCE AND URINARY INCONINENCE AND WE\'RE MENTIONING
NONINCONTINENCE LOWER URINARY TRACT SYMPTOMS IS IT IMPORTANT CLINICALLY
OR SCIENTIFICALLY TO BE MORE BROAD AND ENCOMPASS OTHERS OR IS IT MORE
IMPORTANT TO REMAINING ON FOCUSED ON JUST LEAKAGE?

\>\> THAT\'S A GREAT QUESTION.

I THINK IF YOU LOOK AT﷓﷓I\'LL JUST TAKE ONE SEGMENT OF LOWER URINARY
TRACT SYMPTOMS.

IF YOU LOOK AT THE OVERACTIVE BLADDER POPULATION AND YOU DIVIDE THEM
INTO OVERACTIVE BLADDER WET, THE ONES WHO IS LEAK BECAUSE OF URIGENCEY
OR INCONTINENCE AND THE ONE WHO IS DON\'T, THE ONES WHO IS HAVE URIGENCE
SCHEFREQUENCE BUT URINARY INCONTINENCE, YOU FIND QUALITY OF LIFE IS
GREATLY DECREASED IN BOTH SEGMENTS.

SO THEY THINK IT IS USEFUL IN TALKING ABOUT LOWER URINARY TRACT SYMPTOMS
URIGENCEY AND FREQUENCY TO LOOK AT THOSE AS WELL.

NOT EVERYONE WITH URIGENCEY HAS URIGENCEY, URINARY INCONTINENCE.

EVERYBODY WITH URENER INCONTINENCE DOES HAVE URIGENCEY.

\>\> JOHN DEULANCY UNIVERSITY OF MICHIGAN, VERY INTERESTING DISCUSSION,
I WONDERED FOR DR. LOWRY AND DR. WEIN IN TALKING ABOUT﷓﷓OR DR. GOODE,
WHEN WE TALK ABOUT POST OPERATIVE INCONTINENCE, THERE MAY BE
PREOPERATIVE FACTORS THAT INCREASE OR DECREASE IN INDIVIDUALS RISK THAT
DOESN\'T HAVE TO DO SPECIFICALLY WITH WHAT\'S DONE IN THE OPERATING ROOM
AND I\'M THINKING ABOUT THE HUGE VARIATION AMONG INDIVIDUALS IN
SPHINCTERIC FUNCTION FOR EXAMPLE THAT THERE ARE SOME INDIVIDUALS BORN
WITH OR WHO DEVELOP POOR SPHINCTERIC FUNCTION WHILE OTHERS HAVE GOOD
FUNCTION AND WONDER WHETHER YOU CAME ACROSS INFORMATION THAT WOULD ALLOW
US TO KNOW WHICH INDIVIDUALS ARE AT GREATEST RISK AFTERWARDS OR WHETHER
THAT WOULD BE MEANINGFUL TO BE ABLE TO KNOW FOR EXAMPLE IS AT A HIGH
RISK AND WHO\'S AT A LOW RISK?

\>\> FROM MY PERSPECTIVE, I THINK THERE IS NOT GOOD DATA BUT I THINK
THAT THE DATA WE HAVE WOULD SUGGEST THAT IT WOULD BE VERY IMPORTANT TO
KNOW.

FOR ALMOST EVERYTHING DONE IN THE GI TRACT WHETHER IF YOU HAVE IRRITABLE
BOWEL SYNDROME, YOUR OUTCOMES ARE WORSE, SO KNOWING THAT PREAND POST
PREOPERATIVELY WOULD BE HELPFUL.

THERE IS SOME DATA THAT PEOPLE WITH CONGENATIVELY ANNAL SHORT AND ANNAL
CANALSS AND HIGH PRESSURE ZONES HAVE WORSE OUTCOMES IN TERMS OF
CONTINENCE.

AGAIN, IT\'S, YOU KNOW CASE SERIES, SO IT ISN\'T REALLY SOLID DATA BUT
THERE IS ENOUGH SUGGESTION, I THINK FROM THE LITERATURE, THERE\'S
CERTAINLY SUGGESTION THAT OCCULT SPHINCTER INJURY WHICH IF THEY\'VE HAD
AN OBSTETRICAL SURGERY OR HEMORRHOID SURGERY THAT THE OUTCOMES ARE GOING
TO BE WORSE, SO THEY HAVE ENOUGH SUGGESTIVE INFORMATION TO SAY THAT IT
WOULD BE HELPFUL RESEARCH TO HAVE.

\>\> I THINK THAT YOU\'RE RIGHT, WITH RESPECT TO URINARY INCONTINENCE,
ANYTHING THAT ADVERSELY AFFECTS SPHINCTER FUNCTION BEFORE, I WILL EXPECT
LOGICALLY TO CAUSE A HIGHER INCIDENCE OF POST PROSTATECTOMY INCONTINENCE
AND ONE OF THE THINGS I WANT TO MAKE THE PANEL AWARE OF WITH RESPECT TO
PACK IN SON\'S DISEASE, IT\'S NOT JUST THAT, IT\'S MULTIPLE SYSTEM
ATROPHY.

THOSE PATIENTSES IN THAT SERIES HAVE BEEN LOOKED AT AND DETERMINED TO
HAVE MULTISYSTEM ATROPHY, THAT DEPREDISPOSE TO INCONINENCE AFTER
TRANSURERETHRAL STATIC RESUCTION AND THE FACT OF PARKINSON\'S DISEASE
ITSELF DOES NOT.

IF YOU DIAGNOSE OUTLET OBSTRUCTION AND SOME OF IT WAS PARKINSONS THEY
MAY HAVE URIGENCEY INCONTINENCE BUT THEY DON\'T HAVE A HIGHER RATE OF
SIN TERRIC INCONTINENCE.

BUT FIRST YOU HAVE TO CATEGORIZE THE DEC AND THEN YOU HAVE TO LOOK AT
THE RESULTS AFTERWARDSS, THE ONE I LOVE PEOPLE TO LOOK AT WOULD BE
DIABETES, BECAUSE ON A LOGICAL BASIS I WOULD EXPECT THE INCIDENCE OF
INCONTINENCE TO BE GREATENER THAT POPULATION.

BUT THAT\'S CERTAINLY NOT PROVEN AND THAT\'S JUST A HYPOTHESIS.

\>\> WE HAVE TO MOVE ON.

LET\'S THANK THE SPEAKERS.

\>\> LET ME REMIND THE AUDIENCE THAT THERE ARE COMPUTERS AT BACK FOR
FURTHER QUESTIONS OR COMMENTS THAT YOU HAVE FROM THE PANEL AND WE WILL
REVIEW THEM.

BUT NEXT WE\'LL HEAR FROM DR. AN OLD WALED IN THE SECTION OF
GASTROENTEROLOGY AND HEPATOLOGY AT THE UNIVERSITY OF WISCONSIN.

HE WILL PEEK ON THE IMPACT OF NEURLEDGEICAL DISORDERS SUCH AS STROKE,
PINEAL CORD INJURIES AND OTHER NUR LOGICAL CONDITIONS ON THE DEVELOPMENT
OF FECAL AND URINARY INCONTINENCE.

\>\> LIED LIKE TO THANK THE ORGANIZERS TO SPEAK IN IN AREA, I MIGHT UB
TITLE THIS TALK REFLECKS OF A GASTROENTEROLOGIST BECAUSE WHILE I\'M
TALKING ABOUT URINARY INCONINENCE HERE, THE PRESENCE OF A NUMBER OF
DISTINGUISHED PEOPLE HERE MAKING THAT TASK SOMEWHAT DAUNTING.

\>\> I THINK THE MAJOR POINT WE SHOULD MAKE WHICH IS A RECURRENT THEME
IN THIS CONFERENCE IS THAT LOSS OF VOLUNTARY CONTROL OVER BOWEL AND
BLADDER FUNCTION CONSIDER OCCURS﷓﷓OCCURS FREQUENTLY IN CNS DISORDER, IN
ADDITION TO OTHER DISORDERS, THIS SITUATION LEADS TO WITHDRAWAL AND
ISOLATION AND THERE\'S A TREMENDOUS, AND ALSO THE FAMILY CARE GIVERSS
AND INDEED THE HEALTH SYSTEM IN GENERAL.

CNS DISORDERS AND WE HAVE A NUMBER THAT WE\'VE LISTED IN THE TITLE HERE,
OBVIOUSLY CAN AFFECT BOWEL AND BLADDER FUNCTION IN A VARIETY OF WAYS
DEPEND UPON WHERE THE LESION IS AND HOW SEVERE THAT IS, AND IN GENERAL
FROM A GI STANDPOINT THERE\'S A LOSS OF AFFERENT FUNCTION AND IMPAIRMENT
BUT THERE\'S ALSO A LOSS OF VOLUNTEER CONTROL AND OTHER ASPECTS OF GI
FUNCTION.

AND FOR EXAMPLE, IN THE GI SYSTEM WHILE THE ENTERIC NERVOUS SYSTEM IS
FULLY INTACT AND FUNCTIONING WELL, THE LOSS OF CNS MODULATION IN THE
BOWEL LEADS TO A NUMBER OF CONSEQUENCES THERE,\'S DISMOTILITY, PROBABLY
THE MOST CHARACTERISTIC ABNORMALITY WE SEE IS DELAYED COLONIC TRANSIT,
CONSCIONIPATION AND OF COURSE FECAL INCONTINENCE.

NOW THESE ARE SOME OF THE CNS DISORDERS WHICH ARE ASSOCIATED WITH AN
INCREASED RISK OF NEUROGENIC URINARY AND NG I FUNCTION AND THEY\'RE
DIVIDED ALONG SUPRA AND SUBPONE TEEN LEVELS AND SO YOU CAN SEE THIS IS A
DI DIVERSE GROUP AND THE ONES I\'M GOING TO FOCUS ON OUR STROKE, SPINAL
CORD INJURY AND MULTIPLE CLEAROSEIS AS THREE EXAMPLES OF THE
CONSEQUENCES OF THESE DISORDERS ON BOTH URINARY AND GI FUNCTION.

DID EMPLOY.

ONE POINT TO MAKE IS THAT UNLIKE ABLING DISORDERS, A PATIENT WHO SUFFERS
A STROKE OR HAS A SPINAL CORD INJURY, THE ISSUE IS SUDDEN AND LEAVES THE
INDIVIDUAL AND THE FAMILY ILL PREPARED TO DEAL DEAL, SO THAT IN THE
REHABILITATION PROCESS THAT\'S GOING ON, ONE HAS TO BEGIN TO THINK OF
ISSUES LIKE INCONTINENCE AT A VERY EARLY STAGE.

AND THIS\' AN INCREASE RISK OF BOWEL DYSFUNCTION AND STROKE AND FINAL
CORD INJURY IN MULTIPLE CLEAROSEIS, LOOKING AT A NUMBER OF ARTICLES
REVIEWSS AND SO FORTH, ONE SEES INCIDENCES OF LOWER BOWEL DYSFUNCTION
HERE DEFINED AS CONSIPATION AND INCONTINENCE IS UP TO 23% IN STROKE
PATIENTS AS HIGH AS 75% IN SPINAL CORD INJURY AND AS MANY AS 70% IN MS.

AND THE URINARY CONSEQUENCES IN THESE DISORDERS ARE PROBABLY EVEN
HIGHER.

IF WE START WITH STROKE WHICH IS A SERIOUS CONDITION, AFFECTING
OBVIOUSLY IN ELDERLY POPULATION, WE CAN SEE HERE THAT TAKEN FROM THREE
DIFFERENT SURVEYS, THE INCIDENCE OF FECAL INCONTINENCE IN STROKES UPON
ADMISSION TO THE HOSPITAL IS HIGH RANGING UP TO 40%.

BY THE TIME OF DISCHARGE, MANY OF THEM HAVE HAD RESTORED BOWEL CONTROL,
BUT EVEN SIX MONTHS ABOUT SEVEN TO 9 PERCENT OF THESE INDIVIDUALS, WILL
HAVE ONGOING FECAL INCONTINENCE, A MAJOR ISSUE.

IN IS A LARGE STUDY FROM THE UK THAT MAJOR INCONTINENCE WAS
SIGNIFICANTLY HIGHER THAN THE NONSTROKE POPULATION, WHICH WAS MATCHED TO
THESE SURVIVORS BY BOTH AGE AND GENDER.

OF THESE MAJOR INCONTINENCE PROBABLY 80% HAD DUAL INCONTINENCE.

THAT IS THEY HAD BOTH URINARY AND FECAL INCONTINENCE.

IT WAS A CLEAR ASSOCIATION OF INCONTINENCE AND FUNCTIONAL LIMITATIONS
AND GENERALLY POOR HEALTH, A PROBLEM WITH THIS STUDY FOR EXAMPLE DOES
NOT SAY, WHAT CONSEQUENCES INCONTINENCE MAY HAVE HAD ON THIS, WE DON\'T
KNOW WHAT THESE WERE BEFORE.

THIS IS JUST ONE POINT IN TIME, BUT CLEARLY THE ASSOCIATION HERE,
BETWEEN INCONTINENCE, FECAL INCONTINENCE AND GENERAL HEALTH AND
FUNCTIONAL LIMITATIONS IS SIGNIFICANT.

URINARY INCONTINENCE AND STROKE SURVIVOR SYSTEM SOMEWHAT HIGHER.

AGAIN, ON ADMISSION IT RANGES AS HIGH AS 80% BY DISCHARGE AGAIN, MANY
HAVE DEPPED URINARY CONTROL, BUT EVEN SIX MONTHS LATER AS MANY AS 12 TO
19% WILL CONTINUE TO HAVE URINARY INCONTINENCE IN ONE FORM OR ANOTHER
AND IN SOME CASES, DOUBLE INCONTINENCE.

THIS IS A STUDY THAT LOOKED AT URINARY INCONTINENCE AFTER STROKE AND IN
A FAIRLY LARGE POPULATION RECENTLY PUBLISHED, AND ONE THING THAT CAME
ACROSS AGAIN AND AGAIN IS THAT URINARY INCONTINENCE AFTER STROKE IS A
VERY GOOD INDICATOR OF SEVERITY OF THAT STROKE.

IT\'S ALSO ASSOCIATED WITH POOR PHYSICAL HEALTH AND POOR QUALITY OF
LIFE, NOT DISSIMILAR FROM THE FECAL INCONTINENCE DATA THAT WE SAW IN THE
PREVIOUS STUDY.

THIS IS THE FIRST TIME IN NOT BEING A UROLOGIST I\'LL ALLOW OTHERS TO
COMMENT ON THIS, THAT WHEN PETTER SON IN A LONGITUDINAL STUDY NOW
LASTING OVER 12 MONTHS THIS IS THE THIRD ARTICLE IN A SERIES THAT
THEY\'VE PUBLISHED, LOOKING AT STROKE SURVIVORS AND URINARY
INCONTINENCE, THEY PHON IT THAT THEIR INCONTINENCE PATIENTS REALLY FELL
INTO TWO CATEGORIESS.

THERE WAS THE URGE INCONTINENCE THAT WE\'VE ALL HEARD ABOUT BEFORE IN
CONTRA DISTINCTION TO STRESS BUT THERE WAS ALSO A SUBGROUP THAT HAVE
INCONTINENCE WITH IMPAIRED AWARENESS WITH A NEED TO VOID WHETHER THIS IS
COGNITIVE OR SENSORY IS NOT CLEAR, BUT IN BOTH INSTANCES, IT WAS A
ASSOCIATION OF DROP OFF SPEED OF MEMORY AND ATTENTION AND IMPAIRMENTS
HERE, MUCH GREATER IN THIS SUBGROUP HERE AND EVEN AT 12 MONTHS THE
PRESENCE OF INCONTINENCE WITH AN IMPAIRED AWARENESS OF NEED TO VOID IS
THE STRONGEST PREDICTOR OF MORTALITY AND THE NEED FOR INSTITUTIONAL CARE
IN STROKE SURVIVORS.

THESE OBVIOUSLY SUGGESTED IN THIS GROUP WITH URGENT INCONTINENCE WITH
AWARENESS OF THE NEED TO GO THAT STUDIES TO IMPROVE MEMORY OR SPEED OF
RESPONSIVENESS OR EVEN PHYSICAL THERAPY BY O FEEDBACK MIGHT BE MORE
APPROPRIATE IN THIS GROUP WE ARE DOING WITH A DIFFERENT SUBPOPULATION.

SIMILARLY IN SPINAL CORD INJURY, WE HAVE A DIFFERENT GROUP.

THERE ARE ABOUT 200,000 INDIVIDUALS IN THIS COUNTRY AND IN CONTRAST TO
STROKE, MANY OF THESE ARE YOUNG AND BECAUSE OF GRADE ADVANCES THAT HAVE
BEEN MADE, THEY\'RE OUTLOOK IN TERMS OF LONGEVITY AND DURATION OF LIFE
IS IMPROVED.

IF YOU TALK TO PATIENTS WITH SPINAL CORD INJURY, ABOUT A THIRD OR MORE
WILL TELL YOU THAT THE NAGGER IS﷓﷓NATIONAL IS PROBLEMS WITH BOWEL AND
BLADDER FUNCTION, ABOUT A THIRD OF THOSE INDIVIDUALS WILL TELL YOU THAT
THE PROBLEM WITH BOWEL CONTROL IS THE SINGLE MAJOR LIMITING FACTOR IN
TERMS OF THEIR QUALITY OF LIFE.

NOTE THAT IN BOTH LESIONS RECTAL SENSATION HAS BEEN ADOLLISHED, EXTERNAL
SPHINCTER AND PUKE O RECTALIS FUNCTION, STRIATED MUSCLES ARE GONE AND
INTERNAL SPHINCTER TONE REMAINING ONS AS AN AUTONOMIC MUSCLE.

THE DIFFERENCE BETWEEN THE TWO IS THAT REFLECTS OF DEFECATION PERSISTS
IN THE SOUP ROUGH SACKERAL INDIVIDUAL AND THERE\'S AWFB A WARNING OF
DEFECATION ALTHOUGH IT MAY BE AN ALTERED WARNING FROM WHAT IT WAS BEFORE
THE INJURY AND THESE LESIONS ARE GONE.

AN INTERESTING STUDY FROM BARCELONA WAS JUST PUBLISHED THAT LOOKED AT
THIS SUBGROUP AND EVEN MORE AND REALLY CAME UP WITH THREE SUBCATEGORIESS
HERE.

THEY DIVIDED THEIR PATIENTSES WITH SPINAL CORD INJURY, ALL OF THEM INTO
THOSE WHO HAD A T﷓SEVEN OR HIGHER LESION AND THOSE WHO WERE LESS THAN
T﷓SEVEN OR LOWER THAN T﷓SEVEN WITH AND WITHOUT PRESERVATION OF SPINAL
REFLEXES AND NOW ONE CAN SEE THE MAJOR ISSUES FOR THE SO CALLED SUPER
RAY SACKERAL OR T﷓GREATER THAN SEVEN, CONSIPATION IS A MAJOR PROBLEM AND
THE WAY PATIENTS DEAL WITH THAT IS MECHANICALLY OPPOSE TO
PHYSIOLOGICALLY.

A MAJOR PROBLEM HERE IN PART IS THE AB ABSENCE OF THE ABILITY TO GO, SO
SPHINCTER AND PUBIS RECTALIS PROBLEM IS NOT MUCH OF AN ISSUE, DEFECATION
ISSUE IS INTACT, FECAL INCONTINENCE TENDSES TO BE MILD AND NOT A MAJOR
PROBLEM.

UNDER T﷓SEVEN YOU HAVE TO SUBCATEGORIES, THOSE WHO HAVE SPINAL REFLEXESS
HAVE LESS CONSIPATION.

THEY USE MORE PHYSIOLOGICAL THAN MECHANICAL MEANS MAINLY BECAUSE THEY
CAN NOW VAL SAFULLA IN GENERAL AS PART OF THEIR DEFECATION PROBLEM BUT
HERE THE MANGER﷓﷓MAJOR ABNORMALITY IS DEAF CATERY, A PARADOXICAL
INCREASE OR DISENERGIC MECHANISM GOING ON THAT MIGHT IMPAIR DEFECATION
HERE AND IN GENERAL INCONTINENCE IS MILD USING THE WEEKSENER SCORE.

SO WHEN SPINAL REFLEXESS ARE GONE, THEY CAN BEAR DOWN, THEY NO LONGER
HAVE DEAF CATERY DIFFICULT, THERE\'S NOTHING THERE.

INCONTINENCE BECOMES A MAJOR PROBLEM.

SO BY STRATIFYING THESE, ONE CAN BEGIN TO COME UP WITH STRATEGIESSES TO
IDENTIFY AND WORK WITH TREATMENT.

﷓﷓APPROACHESS.

WITH URINARY DYSFUNCTION IN SPINAL CORD INJURY, THIS REMAINING ONS A
MAJOR PROBLEM, ALTHOUGH INCONTINENCE HAS BEEN REALLY LEFT AS MORE OF A
MINOR ISSUE, AND THE REASON FOR THAT IS THAT FROM A PHYSIOLOGIC
STANDPOINT, THERE ARE CONCERNS ABOUT UPPER TRACT URINARY DYSFUNCTION.

IN PART THIS IS BECAUSE OF ELEVATION OF THE TRUESET PRESSURES INCREASING
THE RISK OF UPPER URINARY TRACT COMPLICATIONS NEPHRITIS, DISEASE, RENNAL
FAILURE AND﷓﷓REMAINING ONS A MAJOR CAUSE OF MORTALITY IN SPINAL CORD
INJURIESS SO MUCH EFFORT IS DEVOTED TO HERE.

IN CONTRAST, URINARY INCONTINENCE IS NOT A LIFE THREATENING CONDITION
AND OFTEN RECEIVES SHORTER SHIFT BUT THIS IS SHORT SIDED BECAUSE OF
EFFECTS OF URINARY INCONTINENCE AS WE\'VE TALKED ABOUT REPEATEDLY IN IN
CONFERENCE, CONFIDENCE ON SELF ETEEM AND PARTICIPATION IN DAILY
ACTIVITIES IS VERY VERY IMPORTANT AND SO OUTSIDE OF UROLOGIST IT SEEMSES
THAT MANY INDIVIDUAL WHO IS DEAL WITH THESIS PATIENTS REALLY ARE
UNDEREQUIPED BY TRAINING AND INTEREST TO REALLY HELP THEM IN A MAXIMAL
FASHION.

\>\> THERE IS A NEW URINARY INCONTINENCE QUESTIONNAIRE THAT CAME OUT,
THIS IS A EUROPEAN BASED STUDY, RECENTLY PUBLISHED AND BECAUSE IT IS THE
SPECIFIC FOR FINAL CORD INJURY, IT WAS TESTED FOR RELIABILITY AND
VALIDITY, IT SHOWS AN INTERESTING THING, THERE ARE SIGNIFICANT
CORRELATIONS BETWEEN THE SCORES, QUALITY OF LIFE SCORESS AND FREQUENCY
OF URINARY INCONTINENCE.

AS EXPECTED AND SHOWN REPEATEDLY, THE CORRELATIONSES WITH URODYNAMICS
ARE WEAK.

TO SUGGEST THE IMPORTANCE IN THIS, THE AUTHOR O CONCLUSION OF OUTCOME
MEASURES AND INVESTIGATING INTERVENTIONS FOR NEUROGENIC BLADDER AND
OBVIOUSLY IF ONE HAS A SCORE OR A QUESTIONNAIRE THAT IS SPECIFIC FOR
SPINAL CORD INJURY IT SHOULD BE USED FOR FUTURE INTERVENTION TREATMENTS.

FINALLY WE MOVE TO MULTIPLE SCLEROSIS AND THERE ARE 250,000 INDIVIDUALS
WITH MS IN THE UNITED STATES A YEAR AND 79AL CORD INJURY, THE ONSET OF
AGE OF MS IS IN THEIR THIRD AND FOURTH DECADES, ABOUT 60% OF WHOM ARE
WOMEN.

STUDIES WE DID AT PITTSBURGH MANY YEARS AGO, THAT LOOKED AT A COHORT OF
MULTIPLE SCLEROSIS PATIENTS REALLY UNSELECTED TO FIND OUT AND WE FOCUSED
REALLY ON LOWER BOWEL DISTONKS CONSIPATION AND INCONTINENCE AND CAN YOU
SEE HERE WHETHER THEY HAD IT FROM ZERO TO 10, 11 TO 20 OR GREATER.

THE INCIDENCE OF EITHER CONSIPATION, INCONTINENCE OR BOTH WAS
SUBSTANTIALLY HIGH.

IT IS TRUE THAT THERE WERE PERHAPS FEWER OR THERE WAS LESS PREVALENT
PROBLEMS IN THE EARLY YEARS OF MS, BUT AFTER 10 YEARS OR SO, CAN YOU SEE
THAT A LARGE PROPORTION OF INDIVIDUALS HAD FECAL INCONTINENCE AND/OR
CONSIPATION.

WE THEN DID STUDYINGS TO DETERMINE WHY THAT MIGHT BE SO AND THIS IS
EXTRACTED FROM STUDIESES WE DID SUBSEQUENTLY LOOKING JUST AT THE
MSPOPPULATION COMPARING THOSE WHO WERE INCONTINENT AT THE TIME OF STUDY
AND THOSE WERE NOT.

THIS ARE THE CONTROLS.

AS SPECTED ONE OF THE MAJOR PROBLEMS WAS APRENTINPUT, THE SENSATION OF
RECTAL DISTENTION OR NEED TO DEFECATE WAS QUITE HIGH RELATIVE TO
CONTROLS, CONTINENT MS PATIENTS WERE SOMEWHERE IN BETWEEN BUT DISTIELY
ABNORMAL.

RESTING MEASURE PRESSURES WERE NORMAL AS WE BEING EXPECT THE INTERNAL
SPHINCTER TO BE NORMAL SUCH A DISEASE AND THE STRIATED ENVELOPE HERE BY
THE EXTERNAL SFIRCHGHTER SQUEEZE WAS WEAK COMPARED TO CONTROLSS AND ONCE
AGAIN THE CONTINENT PATIENTS WERE IN BETWEEN.

WHETHER THESE PATIENTS CAN BE MODIFIED THROUGH BIOFEEDBACK IS REALLY
UNKNOWN.

WE DID A FEW STUDIESS AND WE WERE NOT IMPRESSED BY THEIR ABILITY TO
MODULATE RECTAL SENSORY THRESH HOLD AS WE HAD BEEN WITH DIABETES BUT WE
WOULD ADMIT THAT WE DID NOT DO EXTENSE OF STUDIESS, IT IS IMPORTANT
THOUGH TO RECOGNIZE THAT IN MS, THERE IS A SUBCLINICAL GROUP OF
INDIVIDUALS WHO ARE CONS PATED BUT DO NOT HAVE INCONTINENCE, BUT THE
OVERAGGRESSIVE TREATMENT OF THIS GROUP PROBABLY WOULD LEAD TO
INCONTINENCE BECAUSE OF THE URPD LYING ABNORMALITIES THAT ARE SEEN HERE.

IN MS WE HAVE A CONDITION IN WHICH WE HAVE PROBLEMS WITH BOTH BLADDER
RETENTION AND ALSO OVERACTIVITY.

BUT URINARY INCONTINENCE IS A MAJOR PROBLEM IN THE MS POPULATION, THIS
IS A RECENT CANADIAN STUDY, SHOWING THAT URINARY INCONTINENCE WAS 18, 19
TIMES MORE LIKELY TO BE REPORTED THAN A COMPARABLE MS POPULATION AS
SHOWN OVER HERE.

THIS IS NOT A LIFE THREATENING ISSUE, AGAIN, BUT IT GETS TO THE POINT OF
SOCIAL WITHDRAWAL AND ISOLATION.

THE GROUP OF STUDIESS HAVE SHOWN THAT URGENT INCONTINENCE WHICH IS THE
MAJOR ISSUE IN MS IS ONE OF THE MAIN REASONS FOR GIVING UP WORK, THIS
STUDY HERE, BEING INSTITUTIONALIZED, THIS STUDY HERE, DEVELOPMENT OF
PRESSURE SORES, AND INCREASED RISKS OF FALLS AS INDIVIDUALS TRY TO HUR
TOW GET TO THE BATHROOM AND THEN FALL AND HAVE FRACTURES AND THE LIKE.

SO URINARY INCONTINENCE IN MS IS ANOTHER REASON TO BE OF CONCERN HERE
AND IT WOULD REQUIRE SOME IRPT VENTION ALTHOUGH IT IS NOT A LIFE
THREATENING DISEASE.

SO I THINK THIS IS THE COMMON PATTERN WE HAVE IN CENTRAL NERVOUS SYSTEM
DISORDERS AND BOTH URINARY AND FECAL INCONTINENCE.

THANK YOU.

(APPLAUSE).

\>\> THANK YOU DR. WALD.

NEXT WE\'LL HEAR FROM DR. WILLIAM STEERS THE DEPARTMENT AND CHAIR OF
UROLOGY AT THE UNIVERSITY OF VIRGINIA.

DR. STEERS WILL SPEAK ON IMPACT OF DEPRESSION AND OTHER PSYCHIATRIC
CONDIGS ON THE DEVELOPMENT OF FECAL AND URINARY INCONTINENCE.

\>\> THANK YOU.

WELL IT WOULD SEEM INTUITIVELY OBVIOUS THAT PATIENTS WHO SUFFER FROM THE
EMBARRASSING DISORDERS OF FECAL AND URINARY INCONINENCE WOULD LEAD TO
TREMENDOUS EMOTIONAL DISSTRESS AND POSSIBLILY OVERT ANXIETY, ANXIETY
DISORDERS OR DEPRESSION.

IT IS NOT SO OBVIOUS, THAT IN FACT, A BI﷓DIRECTIONAL RELATIONSHIP MAY
EXIST SUCH THAT PATIENTS WITH URINARY OR FECAL INCONTINENCE ACTUALLY MAY
BE PREDISPOSED TO ANXIETY OR DEPRESSIVE DISORDERS AND I THINK ONE NEEDS
TO EXPLORE THIS HYPOTHESIS IF ONE NEEDS TO LOOK AT PREVENTION BECAUSE I
THINK IT PREVENTS VERY UNIQUE INVITES INTO WHY WE NEED TO THINK
DIFFERENTLY ABOUT THESE DISORDERS, SUBCATEGORIZE PATIENTS AND LEARN FROM
ADVANCES BEING MADE IN NUR O MOLECULAR PHARMACOLOGY BECAUSE IN THAT WAY
WE WILL HAVE TRUE ADVANCES.

SOME CAVEATS, MOST OF THEM DIRECTED AT OVERACTIVE BLADDER URGENT
CONINENT, IRRITABLE BOWEL, LITERATURE NOT KNOWN ON FECAL INCONTINENCE
WILL START WITH ASSOCIATIONS, STRENGTH OF THE ASSOCIATIONS WHETHER DOZE
RESPONSE EXISTS AND WE WILL GO AGAIN TO A MAJOR PART THAT HAS NOT BEEN
TALKED ABOUT MUCH IN THIS MEETING AND PLAUSIBILITY AND BASIC SCIENCE
THROUGH FURTHER KNOWING WHEN WE MAKE THESE ADVANCESS AND THEN LASTLY THE
CONCEPT OF REVERSIBILITY WHETHER ONE CAN TREAT DISORDERSS AND MAKE AN
IMPACT.

AGAIN THE DATA IS EXTREMELY LIMITED AND AGAIN LOOKING AT THIS MODEL.

FIRST THE LITERATURE IS REPLETE WITH OVER 40 STUDIES SHOWING A VERY
STRONG ODDS RATIO OF DEPRESSION WITH URINARY INCONTINENCE.

MOST OF THESE STUDIES ACROSS SECTIONAL OR CASE STUDIESS MOST OF THESE
STUDIESS FAILED TO CATEGORIZE STRESS AND URGE INCONTINENCE WHICH YOU
WILL SEE IS EXTREMELY IMPORTANT BECAUSE I THINK WE\'RE TALKING ABOUT
APPLESS AND ORANGES AND EVEN WITHIN THE CATEGORY I WILL SHOW YOU DATA
WITH INCONTINENCE THAT IT\'S DIFFERENT.

IT VARIES DEPENDING OBVIOUSLY ON THE METRICS USED TO DEFINE AND THE
FORMS ET CETERA AS WELL AS A NUMBER OF PATIENTED IN THE AGE OF THE
PATIENTS WHILE CASE STUDIESS IN NURSING HOMES ONLY A FEW OF THESE
STUDIESS, ACTUALLY THREES THREE LOOK AT THE ELDERLY POPULATION.

I\'VE CHOSEN A CROSS SECTION RATHER THAN PLOTS, GIVE YOU MORE
INFORMATION BECAUSE THIS HAS THE END AND A PORT THAT SHOWS THE VARIOUS
DEPRESSIVE INCIDENCES.

IN ONE OF THE LARGE OF THE ONGOING COMMUNITY BASEDDED STUDIESS OF
OVERACTIVE BLADDER WHICH INCLUDES TO OVERACTIVE WET AND INCONTINENCE IS
THE BOSTON HEALTH STUDY AND DID THEA GENERATED FROM THIS FELT IMPORTANT
BECAUSE FOR THE TEMPORAL RELATIONSHIP WHICH ONE IS REALLY LACKING MANY
OF THESE STUDIESS, ONE NEEDS TO LOOK AT LONG STEWED TAHLEQUAH STUDY AND
THE BASELINE DATA PRESENTED HERE THAT ONE OF THESE STRONGEST RISK
FACTORS FOR DEVELOPING URIGENCEY AND FREQUENCY AND URGING INCONTINENCE
WITH A HISTORY OF DEPRESSION.

EXTREMELY STRONG RISK FACTOR IN A MULTIVARIANT ANALYSIS.

ISN\'T THAT OBSERVATION INTERESTING?

ANOTHER FACT IS THE SEVERITY OF DEPRESSION THAT WAS SCORED INCREASE, AND
PREVALENCE OF URINARY INCONTINENCE INCREASEDDED.

ANOTHER INTERESTING OBSERVATION THAT NEEDS FOLLOW UP AGAIN USING ASSESS
D AND IN OUR CLINIC WE DONE DISPRESSIVE SCORING AND SOME PATIENTS ARE
SUICIDAL AND OUT OF PROPORTION YOU WOULD EXPECT FROM URINARY
INCONTINENCE.

THE STUDY THAT WAS ONE OF THE FIRST WHEN WE LOOKED AT TO AGAIN SHOW YOU
THAT NOT ALL IS CREATED EQUAL AND WE HAVE TO LOOK DIFFERENTLY IS A
UROLOGY BASED STUDY OF SEVERAL HUNDRED PATIENTS, WE SUBCATEGORIZED PURE
STRESS INCONTINENCE FOR MIXED URGE STRESS FROM IDIO PATHIC URGE, TO
URGENT CONINENT DUE TO OBSTRUCTION AND FOUND AN INTERESTING
RELATIONSHIP.

IF ONE USED THE DEPRESSIVE INDEX TO DIAGNOSE DEPRESSION VERSES A HISTORY
OF WITH THE INDEX OR ANTISEEDENT TREATMENT FOR DEPRESSION PRIOR TO
URINARY INDON\'TINENCE,﷓﷓INCONTINENCE ONE FOUND THAT UP TO 70% OF IDIO
PATHIC INCONTINENCE HAD MORE LIKELY HISTORY OF HAVING DEPRESSION PRIOR
TO INCONINENCE OR DURING INCONTINENCE HAD HIGH DEPRESSION, THREE OF
WHICH WERE SENT TO PSYCHIATRISTRY FOR SUICIDAL SCORING.

THE PREVALENCE OF DEPRESSIONOT VEX INDEX WAS THE SAME AS A COHORT
PATIENT GROUP HAVING KIDNEY STONES COMING INTO THE UROLOGY CLINIC, OKAY,
ROUGHLY, ABOUT 18%.

IF ONE HAD URGENT CONTINENCE DUE TO NEUROPATHIC CAUSES IT WAS DIFFERENT,
IT WAS A LOWER INDEX OF PREVIOUS HISTORY AND AGAINB STRUKZ WAS SOMEWHERE
BETWEEN MIXED URGE SUGGEST FIGURE ONE LOOKS AT THE IDIO PATHIC GROUP
THERE MAY BE SOMETHING VERY DIFFERENT ABOUT THIS GROUP.

NEUROPSYCHIATRISTS TELL US THAT CENTRAL VENTS FOR DEVELOPMENT OF BIPOLAR
DEPRESSION OR EPISODESS IN THE LIFE OF A WOMEN IS POSTPARTUM DEPRESSION,
THIS IS ALSO POTENTIALLY A BEO LOGIC MARKER FOR ALTERED SEROTONIN
FUNCTION WHICH IS HEIGHTENED BY HORMONAL CHANGES IMMEDIATELY FOLLOWING
DELIVERY AND THUS ONE LOOKING AT AND STUDIED WITH THE UNIVERSITY OF
MICHIGAN AND CATH AND DEHOLE FISH IS INVOLVED IN THE STUDY, WE LOOKED AT
PATIENTS WITH THE POSTPARTUM DEPRESSION AND URENER INCONTINENCE FINING A
HIGH ASSOCIATION WITH URGE INCONTINENCE OVERACTIVE BLADDENER THOSE WOMEN
WHO DEVELOPED POSTPARTUM DEPRESSION AND VERY SMALL POWERED STUDY ONLY
SEVERAL HUNDRED WOMEN, BUT IN FACT, SUGGESTING THERE WOULD BE SOMETHING
VERY DIFFERENT ABOUT THIS POPULATION TO DEVELOP URGENT INCONTINENCE AND
OVERACTIVE BLADDER.

NOW FOR FECAL INCONTINENCE WHEN I TRIED TO SEARCH THE LITERATURE, AGAIN
IT\'S NOT AN AREA OF SPECIALLY OF MINE AS UROLOGIST IN LOOKING AT
COHORTS OF FECAL AND DEPREEGZ, I WAS ONLY ABLE TO FIND TWOD IS ITS,
SPECIFICALLY LOOKING AT THIS ALTHOUGH DATA WAS PRESENTED YESTERDAY WITH
DEPRESSION SCORING, I SAW WITH FECAL INCONTINENCE, SHOWING SIMILAR TO
URINARY INCONTINENCE, THE ODDS RACIALLY ELEVATED FROM PEOPLE WHO SUFFER
FROM FECAL INCONTINENCE AND ANOTHER STUDY, ANXIETY AND DEPRESSION, A
THIRD OF PATIENTS COMPARED TO A REFERENCE POPULATION OF FECAL
INCONTINENCE.

THIS MAY BE DIFFERENT, BUT FECAL INCONTINENCE IS NOT SEGREGATED INTO A
LIQUID VERSES SOLID, BUT AGAIN DEPRESSION WAS MORE COMMON AND IT WOULD
BE EXPECT AS I TOLD ABOUT IN AUNE DIRECTIONAL RELATIONSHIP FROM
EMBARRASSING DISORDER CAUSING THIS.

SINCE THE EIGHTH CENTURY, IN CHINNAL, IT WAS FIRST REPORTED THAT IN
FACT, ANXIETY PANIC, AND EMOTIONAL HIST ARIA WERE DISASSOCIATED WITH
BLADDER DISORDERS AND AT LEAST SIX WELL PERFORMED STUDIESS OF ANXIETY
SCORING SHOWING THAT ANXIETY LEVELS ARE HEIGHTENED IN PATIENTS WITH
INCONTINENCE AND WHEN THEY SEGREGATE OUT STRESS VERSES INCONTINENCE, IT
WAS PREDOMINANTLY THE URGE URINARY INCOPINENCE OF THE PATHIC TYPE.

IN A STUDY AGAIN LOOKING FOR GENOMICSS AND POLYMORPHISMS IN GENES, OR
PANIC ATTACKS, DONE AT COLUMBIA UNIVERSITY, THEY FOUND BY HISTORY THAT
MANY OF THESE INDIVIDUALS HAD BLADDER PROBLEMS DIAGNOSED BY UROLOGISTS
AND STUDIESS HEIGHTENED HERE, IF ONE LOOKS AT INCONTINENCE IT FOUND THAT
IT WASN\'T STRESS INCONTINENCE ASSOCIATED WITH PANIC ATTACKS AND ANXIETY
DISORDERS IT WAS PREURGE ENS INCONTINENCE AND 27% OF MIXED SO IT WASN\'T
INCONTINENCE PER SE JUST LIKE DEPRESSION THAT LED TO THE HIGH ODDS RATIO
BUT SOMETHING DIFFERENT NOT JUST THE EMBARRASSMENT OF URINE LOSS, ONE MY
ARGUEUE THE UNPREDICTIVE NATURE OF URGENT INCONTINENCE MAY CONTRIBUTE TO
THIS.

WE KNOW THAT QUALITY OF LIFE SCORESSER MORE ADVERSELY DISTRESSED THAT
WAS TRUE THEN STUDIES NEUROPATHIC OR OTHER THINGS YOU MIGHT SHOW WHY IS
THIS DISPARITY IN THESE DISORDERS.

AGAIN FINDING THIS IN THE LITERATURE IN PANIC ATTACKS IS AGAIN IS
EXTREMELY RARE ALTHOUGH I DID COME ACROSS ONE STUDY QUITE INTRIGUING
THIS IS A MOTILITY STUDY DONE IN PATIENTS WITH ANXIETY DISORDERSS AND
PANIC ATTACKS AND THIS IS ONE TRACE HOG HAD A PANIC ATACT DURING THE
STUDY.

NORMALLY HIGH AMPLITUDE CONTRACTIONS OCCUR ONCE DAILY SO DEAF KEYING,
THIS IS I TRACING FOR AN INDIVIDUAL DURING A PANIC ATTACK, SHOWING
TREMENDOUS INCREASE IN BOWEL MOTILITY DURING THIS ANXIOUS MOMENT.

EVEN MORE INTERESTING IF ONE TALKSES TO A PEDIATRIC UROLOGY COLLEAGUES
MANY VOIDING PROBLEMS START IN CHILDHOOD.

AGAIN I\'M LOOPING UP WITH SEVERAL ISSUES BROUGHT UP YESTERDAY WITH ONE
QUESTION WITH A HISTORY OF ABUSE BUT THIS IS EXTREMELY IMPORTANT WHEN
ONE STARTS LOOKING AT PATHOPHYSIOLOGY.

THE DATA IS NOW BECOMING QUITE ROBUST THAT A HISTORY OF OVERACTIVE
BLADDER, WET OR DRY IS HIGHLY ASSOCIATED AS WELL AS PAIN DISORDERS WITH
A HISTORY OF SEXUAL PHYSICAL ABUSE IN CHILDHOOD.

THE ABUSE PERSISTS, STRESS AND PEER MANIFESTED AS RANGE OF SYMPTOMS
INCLUDES BLADDER SYMPTOMS, DEPRESSION AND ANXIETY.

OBVIOUSLY SEVERE STRESS CAN CAUSE ANXIETY CAN CAUSE DEPRESSION AS WELL.

FEW PATIENTS WILL REPORT THIS IS THE PROBLEM, THEY DON\'T VOLUNTEER THIS
INFORMATION.

SO YOU WON\'T KNOW THIS BUT WHEN YOU START NOW LOOKING AT BIOLOGIC
PLAUSIBILITY, THE NEUROCHEMICAL BASIS OF WHAT HAPPENS WITH NEONATAL
EARLY LIFE STRESS ALTERING CIRCUITRY THAT CAUSE EMOTIONAL DISORDERS
AGAIN IS VERY SIMILAR TO CANCER HYPOTHESIS AND IT\'S MULTIPLE HITS MAY
BE SOMETHING WE\'RE SEE FIGURE WE WANT TO PREVENT BLADDER AND BOWEL
DISORDERS.

AGAIN, GOING BACK TO THE BOSTON AREA COMMUNITY HEALTH STUDY WHICH I\'VE
BEEN PART OF, NEW ENGLAND RESEARCH INSTITUTE, 7000 MEN, WOMEN, OF
AFRICAN AMERICAN HISPANIC CAUCASIANS, THE HIGHEST PREDICTOR, BARRING
NONE WITH THE ODDS RATIO OF URGENT INCONTINENCE AND OVERACTIVE BLADDER
WAS A HISTORY OF SEXUAL OR PHYSICAL ABUSE.

INTERESTING.

IN FACT, THIS SLIDE SHOWS A DOSE RESPONSE RELATIONSHIP WHICH IS AGAIN
VERY INTRIGUING.

IT WAS GOING FROM NEVER TO SELDOM TO OCCASIONALLY OFTEN.

IT ONE LOOKS AT THE SYMPTOMS, THIS IS AGAIN YEARS AGO, ONE FINDS AN
INTERESTINGLY DOSE RESPONSE IN A MULTIVARIANT ANALYSIS WITH THESE
SYMPTOMS.

HOW DO THIS HAPPEN.

WHY DOES IT HAPPEN?

WHY ARE BEE NOT AWARE OF THESE SORTS OF ASSOCIATIONS BECAUSE ONE WOULD
ARGUE IF ONE WANTS TO TREAT PATIENTS WITH THESE DISORDERS, WE USE
BEHAVIORIAL THERAPIES, THIS SORT OF BACKGROUND MAY BE EXTREMELY
IMPORTANT IN DETERMINING SUCCESS RATES OF ALL OF OUR THERAPIESS.

NOW LET\'S MOVE FROM THESE ASSOCIATIONS TO BIOLOGIC PLAUSIBILITY AND GO
TO NEUROSCIENCE AND NEUROCHEMICAL BASES FOR HOW BLADDER AND BOWEL,
AGAIN, DISORDERS DEVELOP.

IT IS OBVIOUS AGAIN, THAT EMOTIONAL STATES DIRECT NERVOUS SYSTEMS,
BLADDER, BOWEL, HEART, COMMON MECHANISMS GIVE US FOR STRESS AND ANXIETY,
SO THAT WHILE WE NORMALLY THINK OF AND IT IS INDEED TRUE, THAT FECAL AND
URINARY INCONTINENCE BECAUSE OF SEVERE SYSTEMS CAN LEAD TO ANXIETY AND
DEPRESSION AND I\'LL TALK ABOUT REVERSIBILITY, ALTHOUGH THERE\'S VERY
LITTLE DATA.

MORE INTERESTINGLY TO BI﷓DIRECTIONAL RELATIONSHIP, NOT THAT ANXIETY AND
DEPRESSION CAUSE THESE DISORDERS, BUT THAT POSSIBLY SHARED BIOLOGIC
ENVIRONMENTAL FACTORS EXIST SUCH THAT THE SYMPTOMS MAY BE HEIGHTENED IN
THESE INDIVIDUALS.

AND YOU\'LL START SEEING THESE ASSOCIATIONS WE\'RE NOW SEEING BECAUSE
AGAIN A SHARING OF AUTONOMIC MECHANISMS.

LET\'S FIRST LOOK AT MODEL MEANS.

IF ONE STUDIESS CENTRAL CONTROL OF AUTONOMIC FUNCTION ONE FINDSES THAT
SERRA TON IN AND EPINEF RIN ARE STRONGLY ASSOCIATED LEADING TO PANIC
ATTACKS AS WELL AS DEPRESSION.

ISN\'T IT INTERESTING THAT CENTRAL MERGIC SURGE AND PATHWAYS ALSO
INFLUENCE BLADDER AND BOWEL FUNCTION?

MOST OF US AS CLINICIANS USED TO USING PERIPHERALLY SER TERNERGIC AGENTS
FOR BOWEL PROBLEMS AND ALPHA BLOCKERSS AND AGAIN, BUT WE FAIL TO
RECOGNIZE HOW IMPORTANT THESE CENTRAL PATHWAYS ARE TO CONTROLLING
MATURATION AND FECAL MOTILITY.

LET\'S FIRST TALK ABOUT SEROTONIN AND BLADDER.

FOR THE PAST 30 YEARS IT\'S BEEN GROWING EXPERIMENTAL EVIDENCE,
SEROTONIN PATHWAYS INFLUENCE BLADDER FUNCTION.

FOR EXAMPLE, SEROTONIN RECEPTORS K\'S INHIBIT MATURATION OF THE
BRAIN/SPINAL CORD.

OT OTHER HAND, DEPRESSION, ESPECIALLY BIPOLAR DEPRESSION HAS BEEN LINKED
TO ALTERATIONSES IN A PROMOTER AND POLYMORPHISMS IN THE GENE FOR THE
CORIA TONE IN PROMOTER, ONE MIGHT ASK WHY YOUNGER PEP ARE MORE DISPOSED
TO OVERACTIVE BLADDER AND URGE AND URGE INCONTINENCE THANE MEN?

WHY DEPRESSION, AND MORE PREVALENT IN WOMEN THAN MEN?

INTERESTING PET SCAN STUDIESES HAVE SHOWN THAT SEROTONIN FUNCTION IS
ABOUT 50% LOWER IN WOMEN THAN MEN WHICH ALSO HAS BEEN USED TO EXPLAIN
LOWER VIOLENT BEHAVIOR, LOW﷓﷓YOU KNOW HEIGHTENED FEEDING DISORDERS EATS
IT IS CONTROLLING A CREATOR VARIETY OF FUNCTIONS.

DURING REAM SLEEP IT\'S THE LOSTEST, CHAI IS WHEN FECAL INCONTINENCE CAN
OCCUR, IF CAN OCCURS DURING SLEEP BUT IT WOULD BE INTERESTING IF THEY
DID MOTILITY STUDIESS DURING THAT.

TWO PAPERS I THINK WILL BE FUNDAMENTAL TO OUR CHANGE IN THINKING ABOUT
HOW WE LOOK AT THIS.

AGAIN I USE THE ANALOGY OF MULTIPLE HITS TELEVISION CANCER AND THIS
PAPER APPEARED IN JOURNAL OF SCIENCE AND THIS PAPER IN SCIENCE.

THAT IN FACT SHOWED IF YOU TAKE NEONATAL STRESS, SEPARATING NEOINATES IN
MOTHERS, THINK OF PHYSICAL, SEXUAL ABUSE, VERY SEVERE STRESS EARLY, YOU
ACTUALLY CHANGE WILL POLYMORPHISM GENES OF THAT SERRA TON KNOW RECEPTOR
AND LOWER SEROTONIN RECEPTOR FUNCTION LEADING TO AGAIN WHEN THEY DO
PERFORMANCE STUDIESS FOR SWIM TESTS AND ET CETERA FOR DEPRESSION.

SIMILAR EFFECTS WERE SHOWN ON THE NEUROTROPIC GENE AND DEPRESSION THAT
THEY CAN SHOW MORPH LOGIC CHANGES WITH SEVERE STRESS IN NEONATAL ANIMALS
LEADING TO NOT ONLY MEMORY CHANGES BUT ALSO DEPRESSIVE TYPE BEHAVIORS IN
THESE ANIMALS SO THEREFORE ONE NEEDS TO PREVENT OVER ACTIVE BLADDER, ONE
MIGHT NEED TO GO BACK VERY EARLY INTO SOME OF THESE CHILDHOOD STRESSORS.

AILS, BASED ON IRRITABLE BOWEL STUDIESS AND STUDIESES IN DEPRESSION, WE
KNOW THE AREAS OF BRAIN THAT ARE ALTERED AND LOWER FUNCTION DURING
EPISODES INTERESTINGLY LIKE THE AREAS AND WHEN ONE DOES PET SCANNING
DURING THE DURATION AND TRYING TO HOLD URINE THESE SAME AREAS LIGHT UP
SUGGESTING AN OVERLAP OF BRAIN AREAS THAT ARE ALTERED WITH SERRA TON IN
FUNCTION WITH AGE RELATED DECLANS AND AGE RELATED DEPRESSION, SIMILAR
STUDIESES NEED TO BE DONE LOOKING MORE CLOSELY.

IN A STUDY WE DID SEVERAL YEARS AGO, WE HAD A HYPOTHESIS THAT IF ONE
LOWERS SEROTONIN IN NEOINATES WHAT HAPPENS TO BLADDER FUNCTION THIS, IS
DONE USING TRY CYCLICS THAT ARE GIVEN IN ANIMALS, BRADDER PRESSURE
STUDIESS SHOWING THEY\'RE ESSENTIALLY NORMAL UNTIL THEY HIT ADOLESCENCE
OR LATE LIFE AND THEN COMPARED THE SALINE CONTROL ANIMALS INCREASED
BLADDER ACTIVITY AND PURE SALINE CONTROL, INCREASE URINARY FREQUENCY
AFTER THE ACCIDENT SPECIALLY IN FEMALE ROUGH DEPTS TREATED.

ISN\'T IT INTERESTING THAT TRY CYCLICS WERE GIVEN TO BREAST FEEDING
WOMEN, VERY HIGH LEVELS OF IN BREAST MILK ALSO THAT PROBABLY YOU CAN
ACTUALLY MODEL CENTRAL FUNCTION AND THIS WILL BE IMPORTANT WHEN I TALK
ABOUT REVERSIBILITY THAT IF ONE GIVES LOKES TIN TO THESE ANIMALS, NORMAL
ANIMALS HAVE NO CHANGE WITH, SSRI\'S.

AND SIMILAR PATIENTS YOU GIVE IT THEY DIDN\'T DO ANYTHING, BUT IF THEY
HAVE A BACKGROUNDED LOWERED SERRA TON IN FUNCTION, NOT MALES BUT FEMALES
WILL LOWER MATURATION FREQUENCY AND THEN WHEN YOU GIVE STOCK INFLUKES
TIN IT GOES BACK TO ELEVATED LEVELS.

SUGGESTING THAT BEGAN WHEN ONE GIVES ANTIDEPRESSANTS OR AGENTS IT\'S NOT
ONE EVERYBODY MIGHT EXPECT TO RESPOND, ONLY A CERTAIN POPULATION.

IN A KNOCK OUT MOUSE WITH THE TRANSPORTER GENE, REMEMBER THAT PEOPLE
POSTULATE THAT NORMAL ONCE THESE URINARY FREQUENCY AND CONTRACTIONS BUT
EVEN MORE INTERESTING PROBABLY BESIDES MODEL AMINE SYSTEM CHLORRA TROPE
IN RELEASING FACTOR.

THERE\'S A LARGE BODY OF INFORMATION THAT CSF LEVELS THAT CHILDREN OF
PHYSICAL AND SEXUAL ABUSE ARE EXTREMELY HIGH CRF LEVELS AND ALTER
RESPONSIVENESS TO ACTH CRF.

ISN\'T IT INTERESTING THAT CRF IS CONTAINS IN THE PATHWAYS IN THE
NERVOUS SYSTEM, THE CENTRAL CONTROL CENTER FOR THE CENTRAL STRESS
RESPONSE FOR THE CENTRAL NEE CLEUS, THAT SENSE PROJECTION CONTAINS CRF
TO THE EFFECTS WHICH IS IN THE CORD AND BLADDER AREAS.

HUMAN BRAIN, STUDIESES HAVE SHOWN THAT THE PONDS OF HUMAN BRAIN LIGHTS
UP FOR CRF, THAT\'S THE COMMAND AND CONTROL CENTER FOR MATURATION.

EMLE RISK MACK IN OUR UNIVERSITY, HAS SHOWN THAT THESE NEURONS ALSO CO
LOCALIZE WITH THE ESTROGEN BETA RECEPTOR SUGGESTING HOW ESTROGENS MAY
MODULATE NEURONS DESCENDING TO BLADDER AND BOWEL COMMAND AND CONTROL
CENTERS SO IF THAT IF ONE LOOKINGS @ CORD AROUND IT, LOTS OF FIBERS THAT
COMFROM THE PONE TEEN CENTER, WE\'VE DONE STAINING FOR CRF ONE AND TWO
RECEPTOR.

CRFONE TO CRF ITSELF IN THESE SAME AREAS, THE DORSAL GANG LIE AN CELL
WHICH WOULD RESPOND AFTERKS AFRIB INPUT AFTER BLADDER AS WELL AS COLON
AND THESE ARE LABELED FOR BLADDER, SAME STUDIESS IN COLON SHOWING THEY
LIGHT UP FOR CRF ONE AND TWO RECEPTORS AND WHEN WE STAIN BLADDER SIMILAR
TO COLON STUDIESS THIS IS CRF ONE RECEPTOR STAIN NOTHING THE BLADDER.

MULTIPLE PLACES WHERE CRF COULD INFLUENCE MATURATION IN THE SAME
STUDIESES IN PARALLEL FORMED IN THE GUT.

IF ONE GIVES HYPER RESPONSIVE ANIMALS THAT ARE ANXIOUS HYPER TENSIVE
RAT, IS ANXIOUS, JUMPY, OKAY, HYPER TENSIVE.

CRF THEY HAVE INCREASED MATURATION FREQUENCY, YOU GIVE THE ANTAGONIST,
REDUCE TAND ACCOMPANY SUCH AS PFIZER ARE LOOKING AT THE DEVELOPMENT FOR
THE TREATMENT OF DEPRESSION AND IRRITABLE BOWEL AND ONE MIGHT ARGUE
POSSIBLY OVERACTIVE BLADDER.

AGAIN I WON\'T GO INTO THE CRF﷓ONE RECEPTOR FREES EXPRESSED MORE HIGHLY
IN THE RAT MODEL.

THIS IS THE COLONIC MODEL WITH CRF, FROM THERE IT\'S INCREASEDDED
BLADDER ACTIVITY.

ANIMALS WHO HAVE OVEREXPRESSED CRHAVE MORE FECAL PELLETS AND INCREASED
FREQUENCY BUT IT\'S KNOWN WITH EXTREME STRESS, ABUSE INCREASE BOWEL AND
BLADDER ACTIVITY.

BUT WHAT ABOUT REVERSIBILITY?

THERE\'S ONLY BEEN THREE REPORTED PAPERS I BELIEVED FIND, TWO WITH
STRESS SURGERY AND ONE ANTIMUSCULARURGICS THAT HAVE SHOWN IN THEUNE
DIRECTIONAL THING CAN YOU REDUCE DEPRESSION IF YOU TREAT THE
INCONTINENCE.

TREATMENT OF DEPRESSION HOWEVER, DOES NOT UNIFORMLY INFLUENCE
INCONINENCE, WHICH ONE WOULD EXPECT BECAUSE YOUR LIFE IS OLDSMOBILE A
CERTAIN SUBPOPULATION WILL ALTER SEROTONIN AND SSRI\'S ARE ASSOCIATE
WIDE RISK OF URINARY INCONINENCE, THEERB SPECIALLY INLED LEAR AND ONE MY
EXPLAIN THIS BY SAYING NOT ONLY YOU WANT TO EXPECT ALL PATIENTS RESPOND
TO THESE OF SEROTONIN AS A LOW BASELINE LEVEL ON THE SUBGROUP BUT
INTERESTINGLY SEROTONIN INHIBITS GABBA NEURONS AND MATURATION SO TWO
NEGFIVES CANCEL OUT THAT YOU MIGHT NOT SEE THESE.

SO AGAIN, WITHOUT GOING OVER TIME, ONE LOOKING AT DRUGS THAT AFFECT
DEPRESSION, AND BLADDER, AGAIN, DUKES PIN OR THESE SHOW INCREASE BLADDER
CAPACITY.

A NEWER DRUG DEVELOPED WITH THE TREATMENT OF DEPRESSION, DID YOU LOKES
TINE LOWER LEVELS AFFECTS THE SPINAL CORD INCREASE NERVE ACTIVITY AND
USE FOR POSSIBLE STRESS INCONTINENCE AT VERY HIGH LEVELS ACTUALLY WILL
ALSO REDUCE URGENT INCONTINENCE AND TREAT DEPRESSION.

SO IN SUMMARY, DEPRESSION AND ANXIETY ARE COMMON IN PATIENTS WITH
URINARY INCOPINENCE AND LESS DATA IS AVAILABLE ON FECAL INCONTINENCE.

A BI DRECKAL RELATIONSHIP MAY EXIST.

SHARED NEURO, CHEMICAL AND ENVIRONMENTAL CAUSES MAY ALSO EXIST.

THE POTENTIAL MAY IN THE FUTURE EXIST FOR BIOMARKERS FOR THESE
NEUROPSYCHIATRIC SYNDROMES SO WE MAY BE USING SUBCATEGORIES OF PATIENTS
WITH URINARY AND FECAL INCONTINENCE TO TARGET THERAPY AND CLINE IGS
SHOULD RECOGNIZE THE COMMONNALLITY AND NATURE OF THESE ASSOCIATIONS
BECAUSE IT MAY INFLUENCE OUR TREATMENT AND UNTREATED PSYCHIATRIC CONDIGS
ACTUALLY NEGFIVELY IMPACT THERAPY OR URINARY AND FECAL INCONTINENCE.

THANK YOU.

(APPLAUSE).

\>\> LET ME ASK DR. WALD TO JOIN US AND WE\'RE NOW OPEN FOR QUESTIONS
FROM THE PANEL AND THEN FROM THE AUDIENCE.

\>\> QUESTION FOR DR. STEERS, AS A PSYCHIATRISTOT PANEL I\'VE BEEN
WONDERING WHAT MY PURPOSE HAS BEEN AND I THINK YOU\'VE HELPED ME KNOW
THE PURPOSE, THAT WAS A REALLY TERRIFIC TALK THAT GIVES US SOME SENSE OF
WHAT SOME IDEAS FOR BASIC PHYSIOLOGY MIGHT BE IN THE FUTURE.

I WAS WONDERING ABOUT IF ANYONE\'S TRIED ANY TRIP TO FAN DEPLETION TESTS
WITH PATIENTS THAT HAVE URGENT CONSINENT SOEE IF THAT MIGHT IMPROVE THE
UNDERWENT CONTINENCE WITH THE RAISED LEVELS OF SEROTONIN BRIEFLY BUT
THROUGH DIET RETRICKS OF TRIP TO FAN AND I JUST WONDERING IF THAT MODEL
HAD BEEN USED?

\>\> I TALKED TO OUR PSYCHIATRIC COLLEAGUES AT UVA ABOUT IS ANYTHING
BEEN DONE IN THE LITERATURE AND ONE OF OUR PROBLEMSS AND I DON\'T THINK
THERE\'S AN AGREEMENT IN YOUR SPECIALTY IF WHAT BIOMARKERS THERE ARE FOR
THESE DISORDERS NOR WHAT EXACTLY THE DEFECT IS.

AND PART OF IT MAY BE THIS ENVIRONMENTAL ALTERATIONS COMBINED WITH
GENETIC BACKGROUND YOU, BUT THERE IS NO DATA.

I MEAN THERE\'S DATA THAT DIET CAN INPLU ENS URGENT CONTINENCE, MOST OF
THAT COMES OUT IN THE URINE AND IT IRRITATES THE BLADDER OR MAYBE
THERE\'S CHANGES IN THE GI TRACT.

WE KNOW IRATIONITATION OF THE COLON WILL INFLUENCE BLADDER FUNCTION
POTENTIALLY BUT THAT\'S A VERY GOOD POINT AND TRYING TO GET A PLATELET
LEVEL AND CSF, WE\'VE BEEN LOOKING BECAUSE THE BOX STUDY, I MEAN THAT\'S
ONE OF THE THINGS WE WOULD LIKE TO COMPLAIN WITH THE HEALTH GROUP AND
GIVE THESE PATIENTS A BIOMARKER FOR SENNA TONE IN FUNCTION, LET\'S SAY
AND SEE WHAT TELEVISION TELEVISION THERE\'S SOMETHING DIFFERENT IN THESE
PATIENTS BUT THERE\'S NO DATA I\'M AWARE OF.

\>\> AND IN THE TREATMENT OF DEPRESSION, COGNITIVE THERAPY HAS BEEN
USEFUL AND HAVE SOME NUR O BIOLOGICAL EFFECTS AND ONE COULD THINK ABOUT
COGNITIVE DISTORTIONS THAT INDIVIDUALS MIGHT HAVE IN TERMS OF BOTH
URINARY AND FECAL INCONTINENCE AND WELL, I THINK THE BIOLOGICAL
PATHOPHYSIOLOGY HERE IS VERY INTERESTING.

THE POTENTIAL FOR SOME SORT OF PSYCHOTHERAPEUTIC INTERVENTION, I THINK
ALSO EXISTS IN KNEES DISORDERS.

\>\> WELL CERTAINLY WE CAN DO A BETTER JOB THAT WE\'RE DOING TODAY WITH
LOTS OF SIDE EFFECTSS AND POOR OUTCOMES, ANYTHING WE CAN DEVELOP WOULD
BE INTERESTING SOUTH AMERICA THANKS AGAIN FOR A TERRIFIC PRESENTATION.

\>\> JOSEPH KING WITH THE VA UNIVERSITY AND AS A NEUROSURGEON ON THE
PANEL, DR. WALD I HAVE A QUESTION AND COMMENT, I REALLY YOU WERE FACED
WITH THE DAUNTING TASK OF LOOKING AT THE IMPACT OF A VARIETY OF
NEUROLOGIC CONDITIONS ON FECAL AND URINARY INCOPINENCE AND I COMPLEMENT
YOU ON THE THOROUGHNESS OF DISEASES YOU FOCUSED ON.

I WOULD LIKE TO BRING A COUPLE OTHER DISEASE PROCESSESSES THAT THINGS I
SEE IN MY PRACTICE INTO THE DISCUSSION HERE A LITTLE BIT.

WHEN YOU SPOKE ABOUT SPINAL CORD INJURY, AND YOU SPOKE ABOUT IT BEING AN
ACUTE EVENT, I THINK THERE\'S A ANOTHER COMPONENT OF CHRONIC
DEGENERATIVE CONDIGS SIDELINE DEGENERATIVE SPINE DISEASE, CERVICAL AND
THORACIC SPINEOSEIS CAN PUT DAMAGE ON THE SPINAL CORD AND LUMBAR
STENOSEIS CAN PUT IT ON THE NERVE ROOT 62 CAN PRODUCE A SYNDROME THAT
CAN RESULT IN RATHER SLOW AND DEVELOPMENT OF FECAL INCONTINENCE AS WELL
AS A CHRONIC DEGENERATIVE CONDITION AND SOME OF THESE DO HAVE SURGICAL
AND NONSURGICAL TREATMENT MODALITIES AND I WOULD LIKE TO CONSIDER NORMAL
PRESSURE HYDROCEPHALOUS, AN INCREASE IN THE SIZE OF THE VENTRICLES IN
THE BRAIN WITHIN ACCOMPANYING TRYAD OF SYMPTOMS, GAIT, DISTURBANCES,
URINARY AND FECAL INCONTINENCE, ALTHOUGH PRIMARY URINARY, AND DEMENTIA
AS A NEUROLODGE LOGIC CAUSE OF FECAL AND URINARY INCONTINENCE AND HAVE
VIABLE TREATMENT AND ALTERNATIVES.

DO HAVE YOU A COMMENT ON THAT.

\>\> WELL, I THINK YOU\'VE EXPOSED MY RATHER NAIVE APPROACH TO
NEUROSURGICAL DISORDERS.

AND AS YOU POINTED OUT I WAS TRYING TO FOCUS ON WHAT I CALL
REPRESENTATIVE DISORDERS, PARTICULARLY WITH THEIR CONSEQUENCES.

SO I THINK THAT YOUR POINTS ARE WELL TAKEN, NOT ALL SPINAL CORD
INJURIESS ARE ACUTE.

THEY CAN COME ON CHRONICALLY, THE POPULATION WILL DIFFER.

I THINK HOWEVER THE CONS FENCES ARE THE SAME AND I THINK WE HAVE TO LOOK
AT BOTH THE ISSUES OF INCONTINENCE, WHY THEY OCCUR AND TO DEAL WITH THEM
APPROPRIATELY.

I SUSPECT THAT DEMENTIA IS A SOMEWHAT DIFFERENT THING, MAYBE MORE AKIN
TO STROKE IN TERMS OF COGNITIVE IMPAIRMENT ISSUE.

WHEREAS THE OTHERS SEEM TO BE MORE SPRUNG FROM NEUROLOGICAL DAMAGE TO
VARIOUS NERVE ENDINGS AND SO FORTH.

BUT I WOULD THINK IN GENERAL, THE GENERAL PRINCIPLES THAT I ARTICULATED
WOULD BE APPLICABLE TO MOST OF THE NEUROSURGICAL DISEASES THAT YOU
MENTIONED.

\>\> IF I CAN MAKE A COMMENT.

I HAD A SLIDE IN PREVIOUS TALKING TALKING ABOUT THE SIMPLE FACT THAT
IT\'S ASSOCIATED WITH DEPRESSION AND URGENT INCONTINENCE AND WITH RELIEF
BOTH SCORES IMPROVE.

IT\'S INTERESTING THE ONLY DATA I KNOW TO DATE IS THERE\'S BEEN AN AWARD
BY THE AGING INSTITUTE OR GERIATRICS TO ONE OF MY FORMAL FELLOWS LOOKING
AT POPULAR SURGERY CANDIDATES WHERE THEY\'RE SCORING THIS TO LOOK
AT﷓﷓THEY\'RE NOT DOING FECAL INCONTINENCE BUT URINARY INCONTINENCE WITH
NORMAL HYDROCEPHALOUS AND RATES REVERSIBILITY AND PROGNOSTIC INDICATORS
BECAUSE IT\'S AN INTERESTING DISORDER BECAUSE, IT REVERSES.

\>\> BEFORE THE NEXT QUESTION, WE WILL HAVE DR. MINER ON THE PHONE WITH
US.

HE WAS THE PERSON WHO WAS PREPARED THE SLIDES I PRESENTED YESTERDAYOT
ECONOMIC AND PERSONAL BURDENS.

SO IF FOLKS K\'S THINK OF QUESTIONS THEY HAVE, FOR HIM AND WE DO HAVE
HIM ON THE PHONE.

\>\> BRUCE TRUCE, JOHNS HOPKINS, QUESTION FOR DR. WALED.

MOST OF THE STUDIES YOU SHOWED RELATING TO FECAL INCONTINENCE IN
MULTIPLE SCLEROSIS PATIENTS, REFERRED TO PATIENT POPULATIONS PRIOR TO
THE ADVENT OF THE NEWER THERAPY LIKE THE BETA INTERFERONSS AND I WONDER
IF THERE ARE ANY DATA ON WHETHER THESE THERAPIES HAVE HAD ANY IMPACT ON
EITHER FECAL OR URINARY INCONTINENCE?

\>\> I DON\'T KNOW OF ANY DATA.

I WOULDN\'T HAVE THAT INFORMATION.

\>\> THANK YOU.

\>\> WONDERFUL TALKS, GREAT TO HEAR COMMENTS FROM BOTH OF YOU.

DR. WALD YOU\'RE SHOWING FECAL INCONTINENCE IN STROKE PATIENTS, AGAIN MY
BACKGROUND IN PHYSICAL MS. AND REHAB AND STROKE REHABILITATION OF
INTEREST AND EXPERTISE, USUALLY THAT\'S SHOWING UP IN VERY ADVANCED
DEVASTATING STROKE.

IT\'S A COMMENT BUT ALSO HUGH WE DO OUR RESEARCHING﷓﷓HOW WE DO OUR
RESEARCHING IN FECAL INCONINENCE AND NEUROLOGIC DISORDERS, IT\'S
IMPERATIVE TO LOOK AT THE WHOLE CONSTELLATION BECAUSE BY THE TIME YOU
GET IT IT IN A STROKE SURVIVOR GENERALLY, THERE\'S A LOT OF DEPENDENY IN
AND THE APPROACH MAY BE MORE OF A PALLIAATIVE APPROACH THAN TRYING TO
DEAL WITH IT.

IT\'S A COMMENT YOU\'VE DONE A WONDERFUL REVIEW BUT I THINK IT\'S
IMPORTANT FOR EVERYONE HERE TO UNDERSTAND THE DIFFERENT CONTEXTS OF
FECAL INCONTINENCE.

\>\> I THINK THAT\'S A POINT WELL TAKEN AND I SUSPECT THAT INCONTINENCE
IN THAT POPULATION IS A MARKER FOR SEVERITY.

\>\> OKAY.

THEN I WOULD CORCURNOW AND A SECOND QUESTION, BOWEL PROGRAMSS AND TRYING
TO PREVENT FECAL INCOPINENCE AND SPINAL CORD INJURY, 15 YEARS AGO, A
SPINAL CORD PATIENT WOULD BE AN IN﷓PATIENT REHABILITATION PROGRAM FOR
WEEKS AND WE WOULD DEAL WITH THE BOWEL INCONTINENCE BY PUTTING TOGETHER
A BOWEL PROGRAM AND WHEN IT\'S A LOWER MOTOR NEURON PROBLEM AND NO MOTOR
CONTROL OF ANNAL OR URINARY SPHINCTERS, YOU PUT TOGETHER A BOWEL
PROGRAM, MADE SURE THERE\'S SOME LEVEL OF CONSIPATION AND TRY DIGITAL
STEM OR WHATEVER, TO GET THEM CONTINENT.

BUT WE ALWAYS KNEW, THAT\'S GOING TO TAKE A WHILE.

IT\'S NOT SOMETHING YOU DO IN A DAY OR TWO.

WITH THE WAY HEALTHCARE IS GOING RIGHT NOW, THESE EXTENDED IN﷓PATIENT IS
NO LONGER EXISTS.

PEOPLE ARE IN AND OUT, STROKE PATIENT ARE IN AND OUT IN TWO WEEKS FOR
REHAB.

SO I\'M VERY CONCERNED ABOUT THIS.

THEIR THRUST INTO THE COMMUNITY, THERE\'S NO TIME TO SUPER VISE THIS
\"DEVELOPING OF A VALVE PROGRAM.\"

CAN YOU COMMENT ON THIS NEED TO EMOTE TRAIN THE GUT, HOW IT TAKES A
WHILE TO GET A BOWEL HABIT?

I DON\'T KNOW THE DATA IN REHAB BUT THE IMPERRIC THING WAS JUST START A
PROGRAM, A TOILETING PROGRAM, AND YOU KNOW IN TWO WEEKS OR SO YOU MIGHT
COME UP WITH A GOOD PROGRAM.

SO THERE IS NOT FECAL INCONTINENCE.

\>\> WELL I THINK YOU\'RE TRYING TO TRUNCATE THE EXPOSE NUR PATIENT OR
YOU\'RE LOOKING TO EXTEND THE IN﷓PATIENT EXPERIENCE TO MORE OF AN
OUTPATIENT SETTING WHICH HAS BEEN DONE SUCCESSFULLY IN A NUMBER OF
DIFFERENT DISORDERS AND THAT OF COURSE REQUIRES A VERY DIFFERENT GROUP
AND A DIFFERENT APPROACH WITH PEOPLE VISITING EITHER THE REHABILITATION
AT HOME AND PROVIDING CARE TO THAT.

THE REAL ISSUE HOWEVER, IS THAT THE SCIENCE OF BOWEL CONTROL AND
TRAINING THE BOWELLE IS NOT VERY WELL DEVELOPED.

DESPITE WHAT WE SEE HERE AND DESPITE THE STRONG OPINIONS OF MANY OF US,
THERE\'S VERY LITTLE SCIENCE THAT UNDERLINES THE MANAGEMENT OF
INCONTINENCE CERTAINLY FECAL INCOPINENCE.

I SUSPECT THERE SEEMS TO BE MORE OF A SCIENCE FOR URINARY AND THERE\'S
BEEN MORE WORK DONE.

I DON\'T WANT TO USE THE WORD SIMPLER ORGAN BUT EYE MORE DIRECT ORGAN.

WHEREAS THE BOWEL IS﷓﷓IT MOVES INTERMITTENTLY.

THERE ARE A LOT OF DIFFERENT THINGS THAT DOES THE CONSISTENCY ALTERS
WHICH IS NOT TRUE OF URINE AND SO FORTH, SO, I DO THINK THAT THERE\'S
ROOM FOR A LOT OF RESEARCH INTO WHAT IS THE BEST WAY TO SO CALLED TRAIN
THE BOWEL, TAKING INTO CONSIDERATION THE INDIVIDUAL AND HIS OR HER
NEEDS, BUT ALSO THE SITE OF THE LESION AND WHAT\'S POSSIBLE.

THE PRESENCE OF THE ABILITY TO VAL SAFULLA MAKES FOR A VAIR DIFFERENT
SCENARIO THAN ONE THAT DOESN\'T.

THE ABILITY TO HAVE AN INTACT DEFECATION REFLEX IS VERY IMPORTANT AS
OPPOSE TO SOMEONE WHO HAS A SACKERAL CORD LESION.

AND SO, VERY MUCH RESEARCH IS NEEDED INTO THE BEST WAY TO DO THIS AND IN
THE MOST EXPEDEIENT WAY.

I DON\'T THINK THE SCIENCE IS THERE TO BE HONEST WITH YOU.

\>\> YEAH, OKAY, THANK YOU.

\>\> AND THEN FOR DR. STEERS, IT\'S BEEN EYE OPENING, YOU\'RE SHOWING
THIS DEPRESSION AND URINARY INCONTINENCE.

IS IT POSSIBLE WE\'VE HEARD SO MUCH THAT PEOPLE DON\'T GO TO THE DOCTOR
WITH THE SYMPTOM OF URINARY INCOPINENCE, IS IT POSSIBLE IT\'S BEEN THERE
ALL LONG AND WHAT WE\'RE STANDARDLY TAUGHT ABOUT DEPRESSION AND THE
VEGETATIVE SIGNS SIGNING O MOTOR RETARDATION, ALTERED BOWEL HABIT,
ALTERED INTAKE SO WEIGHT GAIN OR WEIGHT LOSS BUT I NEVER WAS TAUGHT AND
I\'VE BEEN PRACTICING A LONG TIME OH, THINK ABOUT INCONTINENCE?

IS IT POSSIBLE THAT JUST WE DIDN\'T PAY ATTENTION TO IT AND THAT THAT
FITS INTO THIS WHOLE CATEGORY OF VEGETATIVE SIGNS OF DEPRESSION THE WAY
THESE OTHER ONESES THAT CLINICALLY WERE ALWAYS TAUGHT TO LOOK FOR.

\>\> WELL ONE WAY I TRY AND MAKE THE BLAST SO IT\'S NOT THE RODNEY
DANGER FIELD OF THE BODY OF THE MEDICAL STUDENTS WHEN I LECTURE, IS THAT
THE BLADDER IS A WIND O TO THE NERVOUS SYSTEM.

IT\'S SO SENSITIVE TO CHANGESES IN NUREE FUNCTION THAT YOU SOMETIMES
MANIFEST SYMPTOMS IF YOU QUERY ABOUT IT.

ONE OF THE THINGS THOUGH, GETTING CHARGENTIAL TO YOUR POINT IS WHEN YOU
LOOK AT PREVALENT STUDIESS FOR EXAMPLE, OVERACTIVE BLADDER, OF 17% OF
THE POPULATION AND DRUG COMPANIES ARE REALLY INTO, WELL, YOU KNOW WE\'RE
ONLY CAPTURING FOUR% FOR OUR DRUGSS AND SEEING DOCTORS, WELL ONE
ALTERNATIVE HYPOTHESIS IS THOSE WHO ARE BOTHERED MOST WITH ANXIETY OR
DEPRESSIVE DISORDS MAY SEEK MEDICAL ATTENTION AND THAT\'S WHO COMES IN
AND YESTERDAY\'S COMMENTS WERE WHY ARE THE CERTAINTY SEVERITYS ONE PAD A
DAY IS MUCH MORE BOTHERED THAN SOMEBODY THREE OR FOUR.

THERE MAY BE SOMETHING INNATELY DIFFERENT ABOUT INDIVIDUALS BOTHER AND
QUALITY OF LIFE THAT\'S RELATED TO THE BACKGROUND PSYCHE﷓﷓IS THE WRONG
TERM, I\'M NOT A PSYCHIATRIST BUT THAT MAY MAKE THEM MORE BOTHERED OR
HYPER ACTIVE AND WE SEE THIS WITH A LOT OF COMPLAINTS IN UROLOGY IN MEN
AS L. SO I THINK THAT OF OF OF﷓﷓SO I THINK THAT IF YOU DO QUESTIONNAIRES
YOU WANT TO DO THE ENTIRE POPULATION OF BLADDER PROBLEMS IT WOULD BE
SUBSETS AND THAT\'S WHY YOU WOULDN\'T PICK IT UP IF YOU\'RE A
PSYCHIATRIST, IT\'S NOT ALL WITH URGENT INCONTINENCE, IT MAKES THE
STUDIESS VERY HARD, PLUS TO TARGET THERAPY IF YOU WANT TO APPROACH
PREVENTION, MY BIAS IS NOT ALL OF THEM ARE EQUAL, YOU MUST TARGET
PATHOLOGY, YOU MUST TARGET PATHOGENESIS AND THIS PATH MAY OFFER A
GLIMPSE INTO PATHEE GENESIS.

\>\> VERY GOOD.

MY ONE ANOTHER COMMENT THIS ASSOCIATION OF CHILDHOOD ABUSE, MAYBE 10
YEARS AGO, STARTED COMING OUT WITH US IN REHAB THAT CHRONIC PAIN STARTED
COMING OUT THAT CHRONIC PAIN PATIENTS, VERY HIGH ASSOCIATION WITH ABUSE
IN CHILDHOOD.

AND THEN, A WHILE BACK, I TALKEDDED TO A PSYCHOLOGIST DOING RESEARCH ON
OBESITY.

OBESITY, THERE, I DON\'T KNOW THE DATA HERE BUT I THINK THERE\'S
STARTING TO BE DATA ABOUT CHILDHOOD ABUSE, POSSIBLY ASSOCIATED WITH
OBESITY AND I HAD TO DO A REVIEW OF MUSK LO SKELETAL PROBLEMS AS
CO﷓MORBIDITYS AND LOOKING AT THE LITTLE BIT OF LITERATURE ON YOUNGER
ADOLESCENTS, THERE WAS A MUCH HIGHER CORRELATION OF PSYCHIATRIC ISSUES
CONCOMIT ANT WITH YOUNGER PEOPLE THAT HAD MUSK LO SKELETAL PROBLEMS AND
NOW WE\'RE HEARING A POO TECTIAL ASSOCIATION WITH PLAIDER PROBLEMS.

I\'M WONDERING IF BIT BY BIT WE\'RE SEEING THE MAJOR CONSEQUENCES OF
CHILDHOOD ABUSE.

IT\'S MORE A COMMENT BUT WERE YOU AWARE THESE OTHER ASSOCIATIONS WITH
THESE OTHER CONDITIONS?

\>\> WELL, IF UROLOGY WITH MALE PELVIC PAIN AND INSITTIAL CYSTITEIS,
AGAIN WE QUERY FOR IT IS PRES AND HE WANT THIS IS THAT UROLOGY ARE ILL
EQUIPPED AND CAREFUL WHAT YOU ASK ABOUT BECAUSE WHAT DO WE DO IF WE
DISCOVER IT BUT WE TAKE THAT ON OUR INSTRUMENTS IN OUR OFF OFFICE.

IT\'S TREMELY HIGH, I WOMEN IN THEIR 60S AND 50S WITH SEVERE RECTAL
BLADDER AND THEY GO INTO TEARSS AND THEY SAY MY GRANDFATHER ABUSED ME.

YOU KNOW, NOW WHAT?

DO I DO ABOUT THIS?

BUT WHAT\'S INTERESTING TO ME IS THE NEW DATA ON PATHOPHYSIOLOGY AND
THIS SORT OF ABUSE WILL ALTER NEUROCIRCUITRY AND UPREGULATE TRANSMITTER
SYSTEMS.

THAT\'S POTENTIAL FOR THERAPEUTIC INTERVENTION AND THAT\'S WHAT
INTERESTING BECAUSE THESE DISORDERS, THEY HAVE A COMMON TARGET SO YOU
ALMOST, PLUS I THINK THERAPY WHETHER IT\'S BEHAVIORIAL THERAPY, YOU NEED
TO BRING IT OUT BECAUSE I THINK IT\'S GOING TO INFLUENCE WHY THESE
PATIENTS, LIKE A RESIDENTS SAY I DO NEUROPSYCHIATRY THAT\'S WHAT I AM,
BUT WHY ARE THEY SO DIFFICULT.

WELL YOU FELL TOO MONTH ARE ARE﷓﷓ARE YOU HAPPY, NO?

WELL IT\'S HARD TO DEAL WITH EASE PATIENTS A MUSK LO SKELETAL IS ORDER,
FEEDING DISORDER, THE BACKGROUND IS USEFUL BECAUSE YOU HAVE TO APPROACH
THEM DIFFERENT.

NOW I\'M A SURGEON BY TRAINING THAT\'S WHAT I REALLY LIKE BUT THIS IS
TOUGH, THIS IS TOUGH STUFF.

BUT I THINK WHEN YOU START LOOKING, IT\'S INTRIGUING.

\>\> THANK YOU SO MUCH D.

\>\> DR. WALD, I THOUGHT THE DIFFERENTIATION OF THE URINARY INCONTINENCE
REALLY DEMENTIA WAS INTERESTING IN COGNITIVE IMPAIRMENT AND WHEN I WAS
LISTENING TO IT, I THOUGHT GHEE, IT MUST BE DEMENTIA BUT I WAS WONDER
FIGURE THAT POPULATION HAD BEEN CHARACTERIZED FURTHER BECAUSE CERTAINLY
PEOPLE THAT AREN\'T INTERESTED IN VOIDING MIGHT BE DEPRESSED, HAVE
PSYCHOMOTORRIC RETARDATION, LESS INTEREST IN ACTIVITIES AND I WAS
WONDERING WHETHER THERE WERE ANY DEALS THAT WERE USED TO BETTER DEFINE
THAT POPULATION WHETHER IT\'S COGNITIVE IMPAIRMENT OR MOOD DISORDER?

\>\> WELL I THINK THE IMPLICATION IN THE ARTICLE AS I RECALL WAS THAT IT
WAS MORE COG 95ATIVE THAN IMPAIRMENT, THEY WERE SICKER, THEIR MORTALITY
WAS HIGHER, INSTITUTIONALIZATION.

I DON\'T REMEMBER THAT THEY LOOKED AT ISSUES SUCH AS DEPRESSION OR OTHER
THINGS LIKE THAT MY IMPRESSION AS I READ IT WAS THAT IT WAS COGNITIVE.

\>\> THAT WAS MY IMPRESSION TOO AS YOU WERE TALKING.

\>\> I COULD REVIEW THAT BUT THAT\'S MY IMPRESSION.

\>\> THANK YOU.

\>\> I WISH WE HAD MORE TIME.

WE HAVE﷓﷓WE\'LL HAVE DR. MINER ON THE PHONE WHICH WILL PUT US BEHIND A
FEW MINUTES AND THEN WE\'LL HAVE TO MOVE ON TO THE NEXT SET OF SPEAKERS.

SO AGAIN, I WILL REMIND FOLKSES THAT WE DO HAVE COMPUTERS AT BACK FOR
FURTHER COMMENTS AND THERE MAY BE TIME, WE HAVE A HALF HOUR FOR
QUESTIONS AT END OF OUR NEXT SEGTHAT WE MAY BE ABLE TO ENTERTAIN FURTHER
QUESTIONS.

WE\'RE READY FOR DR. MINER.

\>\> DR. MINER?

(PHONE RINGING ).

\>\> THANK YOU AGAIN.

\>\> RECORDING: WE\'RE SORRY YOU MUST FIRST DIAL A ONE WHEN CALL
THANKSGIVING NUMBER WOULD YOU PLEASE HANG UP﷓﷓

(LAUGHTER.

\>\> HELLO?

\>\> DR. MINER?

\>\> YES.

\>\> HI, THIS IS SETH LANDEFELD.

\>\> RECORDING: WILL YOU PLEASE HANG UP AND TRIAL YOUR CALL AGAIN.

\>\> ARE YOU STILL WITH US?

\>\> YEAH.

\>\> CAN YOU RECEIVE ME OKAY?

\>\> YES.

\>\> I THINK YOU NEED TO CALL AGAIN I\'M GETTING IRPT FER ENS FROM THE
OPERATOR.

\>\> WELL, HOPEFULLY THEY CALL BACK?

\>\> HANG UP AND CALL BACK.

(LAUGHTER).

(BEEPING ).

CAREER CLEAR.

\>\> ARE THERE FOLKS WHO HAVE QUESTIONS FOR DR. MINER?

OKAY.

\>\> I\'M WONDERING IF WE MIGHT JUST START BOB, YEAH, AND THEN IF WE﷓﷓

IF HE SHOWS UP, WE CAN FEC TO HIM.

GREAT.

SO, AT THIS POINT WE\'LL TURN TO THE LAST TWO QUESTIONS WHEN ARE WHAT
CAN BE DONE TO PREVENT FECAL AND URINARY INCONTINENCE?

AND WHAT ARE THE STRATEGIES TO IMPROVE THE IDENTIFICATION OF PERSONS AT
RISK AND PATIENTS WHO HAVE FECAL AND URINARY INCOPINENCE?

THE FIRST SPEAKER AND DR. ROBERT CAIN﷓﷓

\>\> HELLO.

\>\> DR. MINER.

\>\> YES.

\>\> HI, I\'VE GOT﷓﷓I\'M HAVING ALL KINDS OF THE PROBLEMS WITH THE PHONE
HERE.

\>\> DON\'T HANG UP.

\>\> OKAY.

YOU CAN HEAR US OKAY.

THIS IS SETH LANDEFELD, THE CHAIR OF THE PANEL AND I HAD THE OPPORTUNITY
YESTERDAY TO TRY AND CHANNEL YOU IN PRESENTING YOUR SLIDES, AND WE ALL
APPRECIATED THEM AND I ESPECIALLY SINCE THEY WERE SO CLEAR AND EASY TO
PRESENT.

WE APPRECIATE YOUR JOINING US AND WOULD LIKE TO TAKE THIS OPPORTUNITY TO
HAVE MEMBERS OF THE PANEL AND THE AUDIENCE ASK YOU SOME QUESTIONS AT
LEAST BASEDDED ON THE SLIDE AND THE GENTLEMEN TOPIC OF ECONOM AND I CAN
PERSONAL IMPACT THAT YOU WOULD ADDRESS, WOULD THAT BE OKAY?

NTHAT WOULD BE GREAT, DO YOU MIND IF A MAKE A SUMMARY OF WHAT I THOUGHT
THE TALK WAS GOING TO BE EVEN THOUGH I SHOULD PROBABLY HIGH YOU IF YOU
THOUGHT IT WAS CLEAR, TO PRESENT MOST OF MY TALKS UH﷓HUH?

WE LOVED IT.

\>\> WELL, YEAH, THAT WAS JUST THE﷓﷓YOU JUST HAVE THE SLIDE VERSION FOR
PUBLICATION BECAUSE THE ONE FOR PRESENTATION HAD HER PICTURE ON IT.

SO.

BUT IF I COULD JUST MAKE A FEW COMMENTS.

FIRST OF ALL.

I I\'M VERY SORRY I CAN\'T BE THERE, THIS HAS TO BE A WONDERFUL
CONFERENCE FOR ALL OF YOU THAT ARE THERE AND I\'M VERY, VERY ISSUES
IMPORTANT TO IN ORD TORE TRY TO HAPPENED THIS AREA.

\>\> I\'M IMP PRISESSED BY THE VOID OF DATA ON FECAL AND URINARY
INCOPINENCE MAKING THIS A SEAT OF THE PANTS PRESENTATION.

THE﷓﷓IT\'S FAIRLY CLEAR THAT THE MEDICAL AND ECONOMIC COSTS OF THE
COMORBID CONDIGS EMBAY THE ECONOMIC COSTS MOVE OF THE TIME AND THIS WAS
ONE OF IMPORTANT POINTS THAT AN ABSTRACT THAT BILL WHAT I\'D HEAD
DISCUSSED WITH ME RECEIPTLY AND I\'M SURE HE DISCUSSED THAT YESTERDAY
MAKING IT DIFFICULT TO UNDERSTAND THESE ISSUES BUT GIVING US GOOD
OPPORTUNITIESS DOWN THE ROAD FOR LOOKING AT INCONTINENCE.

IT\'S ALSO CLEAR THAT THE COSTS ARE ENORMOUS BUT ALMOST ALL THE DAA IS
ACQUIRED BY INFERENCE AND THAT INCLUDES LOSS PRODUCTIVITY AND WAGESS AND
SOILED CLOTHE TAG NEEDS TO BE CLEANED OR DISCARD TED AND PLACEMENT IN
NURSING HOMES PRINCIPALLY FOR THE PROBLEM OF INCONINENCE AND I THEN IS
REALLY IS A BIG﷓﷓MAJOR ECONOMIC BURDEN THAT WE COULD PROBABLY CHANNEL
OUR RESOURCES IN TO IMPROVE.

AND I THINK THE PERSONAL IMPACT REALLY NEEDS OHM COMPASSIONATE
REFLECTION.

SCHOLARLY EFFORT IS LACKING AND NEEDS TO BE FOCUSED ON QUALITY OF LIFE
INSTRUMENTS THAT ARE SYMPTOM SPECIFIC WITH PERSPECTIVE AND PSCHYCOLOGY
STUDIES, IMPROVED MEDICAL ASSESSMENT AND CARE OF THE PHYSICAL
CONSEQUENCES OF INCONTINENCE AND SOCIALIO LOGIC AND ECONOMIC STUDIES OF
WORK, RECREATION AND SOCIAL INTERACTION NEED TO BE DONE TO UNDERSTAND
THIS AND MANY CHRONIC DISEASES I THINK THESE ARE﷓﷓WE HAVE DONE A FAIRLY
INADEQUATE JOB OF ADDRESSING SOME OF THESE ISSUES PARTICULARLY WHEN THE
AREA OF INTEREST FOR US, IS PART OF, SMALL PART OF A MEDICAL PROBLEMS,
SO MANY OF THESE PATIENTS HAVE.

AND JUST, IN TERMS OF LOOKING AT RESEARCH NEEDS THEY THINK ARE IMPORTANT
AND PROBABLY THE DIRECTION THAT THE NIH CONFERENCES REALLY LOOKING AT
ANYWAY, I THINK THERE NEEDS TO BE EXTENDED FUNDING FOR THE
NONPHARMACEUTICAL SOLUTIONS FOR THESE PROBLEMSS AND THAT WOULD BE
MEDICAL PROBLEMSS AND SOLUTIONS, BIOFEEDBACK FOR EXAMPLE, SURGICAL
SOLUTIONS AND THIS SHOULD ALSO INCLUDE COMPLIMENTARY AND ALTERNATIVE
MEDICINE AS ANY ISSUES THERE MAY BE HELPFUL.

I WOULD LIKE TO SUGGEST THAT IN﷓﷓AND IT THERE BE AN ECONOMIC ASSESSMENT
BY COMPUTER SUBRETUNESES THAT ISOLATE INCOPINENCE FROM OTHER RESEARCH
ISSUES SO BASICALLY PIGGY BACKING ON DISEASE STATE MEDICINE WHICH IS HOW
MOST OF THE RESEARCH IS BEING DONE FOR EXAMPLE, IN DIABETES, AND
NEUROLOGIC DISEASES.

AND I THINK THIS WOULD BE AN EFFECTIVE WAY OF TRYING TO TAKE SOME OF THE
THINGS THAT WE LOOK AT AS SUBXECIALISTS AND BECAUSE OF A COMPLICATIONS
THEY HAVE AND SPECIFIC DISEASES THAT ALLOW US TO GET THE INFORMATION
THAT WE NEED IN A PROSPECTIVE FASHION RATHER THAN TRYING TO RECONSTRUCT
IT WITH POST HOC DATA.

I THINK ISSUES IN LONG﷓TERM CARE FACILITYS AND RENEWING EFFORTS TO KEEP
ELDERLY IN THEIR HOMES IS HIGHLIGHT ON THIS TOPIC AND I THINK THE
PSCHYCOLOGIAL AREAS OF THIS AREA, IT\'S A RICH AREA FOR RESEARCH AND I
THINK ISSUES OF PROTECTIVELY ADDRESSING DEPRESSION AND COPING STRATEGIES
MAY BE PRIMARY STUDY AIMS AND WHEN IT AM CANS TO COPING STRATEGIES BASES
I THINK﷓﷓BECAUSE I THINK OUR STUDY OF NEARLY 20 YEARS AGO NOW
DEMONSTRATE THAD COPING SKILLS AND COPING STRATEGIESS ARE EXTREMELY
IMPORTANT IN THIS GROUP OF PATIENTS.

SO, THOSE WERE REALLY THE POINTS I WANTED TO MAKE.

I\'D BE HAPPY TO TRY TO ADDRESS ANY QUESTIONS THAT YOU MIGHT HAVE.

\>\> THANK YOU SO MUCH FOR THAT SUMMARY.

WE\'RE NOW OPEN FOR QUESTIONS AND COMMENTS, IN LIABLELY WE\'LL HEAR FROM
MEMBERS OF THE PANEL AND THEN WE\'LL OPEN THIS UP TO MEMBERS OF THE
AUDIENCE.

\>\> DR. MINER I\'M DRAY HOF MAN I\'M A WOMEN\'S HEALTH SPECIALIST FROM
NEW YORK UNIVERSITY AND WE\'RE TOLD THAT THE POPULATION OF WOMEN OVER
THE AGE OF 65 IS ABOUT TO DOUBLE WHICH MEANS THAT PREVALENCE WHICH IS
THE MOST SENSITIVE FACTOR THAT IMPACTS ON DIRECT COSTS IS ABOUT TO SKY
ROCKET SO WE\'RE LEFT WITH A SORT OF PAN DOR\'S BOX HERE IN TERMS OF
INCREASING AWARENESS AMONG PATIENTS AND AMONG CLINICIANS AND I WOBD
WONDERED WHETHER OR NOT THERE WERE ANY OCNOMIC MODELS AVAILABLE THAT
WOULD HELP FORMAT A COST BENEFIT RATIO TO DEAL WITH THIS.

\>\> YOU\'RE REALLY ADDRESSING THE WRONG PERSON, MY AREA IS NOT IN
MEDICAL ECONOMIC STUDIESS, SO THE ECONOMIC MODELS, I REALLY CAN\'T DEAL
WITH.

I\'M A RESEARCH GASTROENTEROLOGIST, SO I CAN\'T REALLY ADDRESS THAT
ISSUE.

I THINK THE MODELS IS VERY IMPORTANT.

OBVIOUSLY, IF YOU\'RE A GYNECOLOGIST, YOU\'RE A LOT OF YOUR EFFORTS IN
URINARY INCOPINENCE AND I THINK THAT MUCH OF WHAT THE DATA THAT IS EVEN
USEFUL IS IN THE URINARY INCONTINENCE AREA AND IN THE GASTROENTEROLOGY
AREA BUT I CAN\'T ADDRESS THAT BUT OBVIOUSLY YOU BROUGHT UP AN
EXTRAORDINARY NARRLY IMPORTANT BINE.

MY TWO OTHER QUESTIONS HAVE TO DO WITH ECONOMIC MODELS.

\>\> WELL I\'M SORRY.

EYE CAN\'T﷓﷓

\>\> LET ME REPHRASE IT THEN IS THERE ANY DATA TO SHOW THAT AN
INTERVENTION IN INCONTINENCE AT THE LOW END OF THE SPECTRUM WHERE
SOMEONE IS INDEPENDENT LIVING AND HAS INCONTINENCE AND THE DIRECT CAUSE
MOSTLY RETAIL COSTS OF PADS AND PRODUCTS AND AS THAT STREAM BEGINSES TO
CHANGE TO THE DEPENDENT PERSON, WITH AND WITHOUT NORMAL OR INFORMAL CARE
GIVERS, THEN TO THE NURSING HOME AND THEN TO THE LONG﷓TERM CARE
FACILITY, IS THERE ANY DATA TO SHOW THAT AN IRPT VENTION AT AN EARLIER
STAGE DECREASES COSTS, DOWN STREAM?

\>\> I\'M NOT AWARE OF ANY INTERVENTION THAT CAN DO THAT BUT OCI HAVE
USELY, PEOPLE JUST LOOK AT THE INFORMATION ABOUT WHY ( INAUDIBLE ).

WHY THEY YOU KNOW CARE AND USE AND THE TIMES ACQUIRES AND INCONTINENCE
ISSUES, I THINK IT\'S INTUITIVELY OBVIOUS THAT IF YOU\'RE ABLE TO (
INAUDIBLE ).

YOU SHOULD BE ABLE TO MANAGE THEM WELL.

AND MY EXPERIENCE WITH FECAL INCONTINENCE IS EXTREMELY IMPORTANT BECAUSE
CAN YOU OFTEN LEAVE THAT ( INAUDIBLE ).

AND PATIENTS WHO DO NOT HAVE NEUROLODGE LOGIC INJURY﷓﷓NEUROLOGIC INJURY
( INAUDIBLE ).

TO WELL OVER 88% OF THESE PATIENTS, VERY, VERY, SIMPLY AND VERY, VERY,
LOW COST.

NOW, THAT DOESN\'T MATTER WHAT AGE THEY ARE, I THINK THAT THE ONLY ISSUE
OTHER THAN THAT IS TO HAVE NEUROLOGIC ( INAUDIBLE ).

SO I THINK THAT WE\'RE MAKING A LOT OF PROGRESS WITH NEUROLOGIC IN TERMS
OF MANAGEMENT, AND I THINK THE PERSPECTIVE STUDY WILL BE EXACTLY WHAT
CAN HAPPEN, ARE PROBABLY NOT POSSIBLE BECAUSE YOUR CONTROL GROUP WOULD
BE DIFFICULT ( INAUDIBLE ).

AND MOSTLY THE ISSUES WE HAVE ARE SCIENCE APPLICATION IN INCONTINENCE
AND BIOFEEDBACK WHICH REALLY IS A SUSTAINABLE OVER A LONG PERIOD OF TIME
WITH REGARD TO ( INAUDIBLE ).

SO THE ANSWER I THINK IS OBVIOUS THAT THE DATA IS LACKING AND
UNFORTUNATELY, OR THE DATA IS LACKING FOR ALMOST EVERY﷓﷓THE DATA
REGARDING THE IMPORTANT QUESTION AND THEN ( INAUDIBLE ).

THAT I SPEAK ON IS INADEQUATE.

I THINK WE\'RE JUST BEGINNING TO DIRECT ATTENTION TO SOME OF THESE
IMPORTANT THINGS.

\>\> ONE MORE QUESTION AND THAT IS ABOUT THE, THE POINT THAT YOU BROUGHT
UP THAT THE COSTS OF INCONTINENCE ARE OFTEN SUBSOUPED UNDER THE COSTS OF
OTHER MEDICAL CONDITIONS LIKE CARDIO VASCULAR DISEASE OR STROKE OR
WHATEVER, BUT IS THERE ANY DATA TO SHOW FOR INSTANCE THE COST OF
INCONTINENCE AND THE RELATIONSHIP TO FALLS AND FRACTURESS WITH THAT HIGH
MORBIDITY AND MORTALITY WITH COST.

\>\> WELL CALL COSTS ARE ( INAUDIBLE ).

AND IT\'S HARD FOR URINARY INCONINENCE EACH THOUGH I\'M NOT FAMILIAR
WITH ALL THAT DAT AND ( INAUDIBLE ).

IT GIVES YOU AN EXAMPLE OF THE TOTAL COST IN THE SITUATION OR IN PATIENT
WITH THE MEDICAL COSTS OR A PATIENT WITH FECAL INCONTINENCE, ( INAUDIBLE
).

ONE WAS \$7000 THE ( INAUDIBLE ).

FOR THAT SAME PATIENT ARE ABOUT 390 EMPLOY SO WHEN YOU LOOK AROUND AT
COST, OF WHERE THE COMORBID CONDITIONS ARE, ( INAUDIBLE ).

VERY HIGH, MEDICAL COSTS FOR INCONTINENCE, THAT ( INAUDIBLE ).

HEALTHCARE RELATED COSTS, DOESN\'T INCLUDE THE OTHER ISSUES YOU BALL
PARK UP IN YOUR INTRODUCTION TO YOUR FIRST QUESTION.

AND SO I THINK THE LOOKING AT THAT, HOW, WE\'RE﷓﷓( INAUDIBLE ).

IN TERMS OF MANAGEMENT ISSUES AND RESEARCH, IT REALLY FOCUS OUR
ATTENTION ON IDENTIFYING ( INAUDIBLE ).

IN THESE POPULATIONS YOU\'RE TALKING ABOUT.

SO WE HAVE THE ABILITY TO CAPTURE THEM IN A PERCENTAGE FASHION (
INAUDIBLE ).

\>\> RIGHT.

\>\> AND ( INAUDIBLE ).

THAT BOTH THOSE YOU MENINGED EARLIER THAT WOULD INCLUDE A HOSPITALIZED
SITUATIONS WITH BROKEN LIMB FOR EXAMPLE, AND IT\'S VERY POOR HIGENE AND
THESE COSTS CAN BE DONE ( INAUDIBLE ).

IT\'S VERY ( INAUDIBLE ).

BUT IT DOES GET LOST IN THE BIG COST AND TANKLY IF YOU LOOK AT THE (
INAUDIBLE ).

AND FECAL INCONTINENCE, YOU LOOK AT URINARY INCOPINENCE IN NEUROLOGIC
PATIENTS ( INAUDIBLE ).

BUT ONLY IN RECENT YEARS THAT ANY ( INAUDIBLE ).

OF FECAL INCONTINENCE IN KNEES PATIENTS THAT THE GAP OF YOU KNOW SEVEN
YEARS SINCE WE TRIEDED TO DO THAT SO WHEN YOU\'RE ASKING QUESTIONS THAT
ARE LOOKING AT OPERATIONAL COSTS OR IN TERMS OF TIME IT\'S VERY, VERY,
DIFFICULT TO ( INAUDIBLE ).

COMPLICATED ILLNESSES, BUT NOT ( INAUDIBLE ).

HOW COMPLICATED THESE SITUATIONS ARE.

I THINK HAD IS YOUR QUESTION IS VERY GOOD AND EXACTLY WHAT THE PURPOSE
OF THIS TALK WAS FOCUSED TO ATTENTION ON ACQUIRING SPECIFIC INFORMATION
( INAUDIBLE ).

\>\> THANK YOU.

\>\> AT THE RISK OF GETTING THE SAME ANSWER THAT MORE RESEARCH IS
NEEDED, I\'D LIKE TO ASK A COUPLE OF OTHER QUESTIONS.

ONE OF WHICH I THINK WE CAN ANSWER.

THE DOLLARS YOU SITE IN YOUR PRESENTATION OF MAINLY THE COST OF PADS AND
DIAPERS AB CORPENCIES IS THAT COMING FROM INDUSTRY SOURCES AS OPPOSE TO
SPENDING.

\>\> YES IT IS AND THIS IS ALMOST﷓﷓THIS ALSO VERY FRUSTRATING BECAUSE I
CONTACTED KIMBERLY CLARK AND PROCTOR AND GAMLE ABOUT TO TRY TO GET THEM
TO ( INAUDIBLE ).

SIMILAR CONFERENCE SEVERAL YEARS AGO, AND AT THAT TIME I HAD THE
RESPONSIBILITY OF ( INAUDIBLE ).

THEY GAVE ME THEIR WHOLE BOOK THAT IS THEY GAVE ME A HARD COPY OF THEIR
INTERNAL BONG THAT LOOKED AT ALL THE ECONOMIC ISSUES THAT WERE INVOLVED
AND IT WAS VERY GOOD DATA, SO MOST OF THESE ARE VERY OLD DATA OR VERY (
INAUDIBLE ).

THAT REALLY ADDRESSED DIFFERENT PRODUCTS SO WE HAD THE ANSWER, MY POINT
( INAUDIBLE ).

ALL THE DATA IS VERY OLD AND VERY HARD TO OBTAIN BUT AGAIN, THE COSTS
ARE WHAT I\'VE GAINED FROM THE INDUSTRIESS.

\>\> OKAY, I GUESS﷓﷓

\>\> ( INAUDIBLE ).

FIVE YEARS OLD, THAT\'S WHAT THEY﷓﷓ALL OF THE MARKETING ISSUES (
INAUDIBLE ).

ALL OF THAT, THOSE KINDS OF THINGS WHEN WHICH HAVE YOU NO ACCESS TO AT
ALL.

\>\> I GUESS WE HAVE TO TO FEATURE MORE OF THEIR PRODUCTS AT OUR
MEETINGS AND EXPOSE THEM MORE AND THEN WE\'LL HAVE MORE COOPERATION.

\>\> I THINK THAT\'S A VERY GOOD, PROBABLY PUBLIC RELATIONS ISSUE WITH
THEM COULD MAKE A MAJOR RESEARCH PROJECT LOOKING AT HOW THEY DO THIS
BECAUSE THEIR MARKETING RESEARCH PEOPLE ARE VERY, VERY, SMART, THEY KNOW
A LOT MORE THAN THE NATIONAL LITERATURE SUGGESTS REGARDING THE WHOLE
MARKET OF WHERE IT DONATES AND ANSWER A LOT OF QUESTIONS THAT WE WOULD
WILL HAVE.

I THINK THIS IS SOMETHING ( INAUDIBLE ).

THAT THE PEOPLE IN MARKET WILL ALLOW US ACCESS TO THE DATA WITHOUT
TRYING TO MAKE IT ( INAUDIBLE ).

\>\> (LAUGHTER).

WELL RELATEDDED TO THE ECONOMICS AGAIN, I WAS WONDERING ISSUE YOU
DIDN\'T SITE ANY OF THE REAL ECONOMIC STYLE STUDIES SUCH AS BI DR. WHO
THAT HAVE BUILT UP FROM SOME ORIGINAL WORK ON USAGE OF ACTUAL PADS BY
PEOPLE AND KEEPING DIARIES AND COSTING THINGS OUT.

WAS THERE SOME REASON THOSE WERE LEFT OUT?

HAVE YOU READ THEM?

\>\> NO.

I WAS ( INAUDIBLE ).

I WAS FOCUSING ON THE FECAL INCONTINENCE PART OF THIS BECAUSE THAT\'S
SORT OF ( INAUDIBLE ).

I RECOGNIZE THERE\'S A LOT OF INFORMATION ABOUT THAT.

I DID PULL THE ARTICLES AND LOOK AT THEM BUT I DID THINK THAT THE
MESSAGE HERE IN TERMS OF THE SOME OF THE THINGS THAT ARE KEY, ARE WHERE
WE REALLY HAVE SOME DIFFICULT WITH INFORMATION AND I APOLOGIZE FOR NOT
PUTTING HIS WORK IN THERE.

( INAUDIBLE ).

\>\> I WAS WONDERING PARTICULARLY IF YOU HAD DISCOVERIED ANY UNTURNED
STONES ABOUT FECAL INCONTINENCE COSTS THAT ARE APPARENTLY MUCH POORLY
KNOWN THAN THE URINARY.

\>\> FECAL INCONTINENCE IS VERY, VERY, DIFFICULT BECAUSE IT\'S VERY
EPISODIC AND NOT RERIABLE, IT\'S DOM FAINTED BY THE OTHER ( INAUDIBLE ).

EARLY 1980S AND WE ARE﷓﷓THERE\'S﷓﷓THE INFORMATION, A LOT OF THE
INFORMATION FOR FECAL INCONTINENCE IS WITHIN THE POPULATION, PEOPLE WHO
ARE STRESSED, ( INAUDIBLE ).

﷓﷓THEY HAVE A LOT OF ANXIETY RIGHT BEFORE﷓﷓( INAUDIBLE ).

AND ECONOMIC COSTS ARE DIFFICULT TO CAPTURE IN THE POPULATION.

WHEN YOU LOOK AT THE DATA, ALL THE DATA IT DOESN\'T MATTER WHETHER IT\'S
PHYSIOLOGIC DATA OR ( INAUDIBLE ).

OR ECONOMIC DATA INVOLVED WITH THIS, IT\'S ALL IN THE COLLECTED OF THE
PATIENTS WHO HAVE WIDELY DIFFERENT PATTERNS OF INCONTINENCE.

SO IT\'S VERY DIFFICULT AND I THINK THAT\'S WHY I\'M SUGGESTING (
INAUDIBLE ).

TO GET SOME OF THIS INFORMATION BY LOOKING AT SOME ROUTINES FOR
INCONTINENCE INTO SOME OF THE OTHER STUDIES WE HAVE ( INAUDIBLE ).

I THINK THAT WOULD BE MOST HELPFUL IN THE LONG TERM IN UNDERSTANDING
THESE ISSUES.

( INAUDIBLE ).

\>\> SHUCKS.

ON THE NURSING HOME SIDE OF THINGS, ARE YOU AWARE OF ANY IS ITS THAT
MIGHT HAVE LOOKED﷓﷓STUDIESES THAT MIGHT HAVE LOOKED AT THE MARGINAL
EFFECT ON TIPPING PEOPLE INTO INSTITUTIONALIZE EGG.

WE KNOW IT\'S A FACTOR BUT I WAS WONDERING IF YOU﷓﷓

\>\> NO, I DIDN\'T FIND ANYTHING THAT WAS HELPFUL IN GETTING ( INAUDIBLE
).

ALL THE COMMENTS ARE IN THE LITERATURE OF THIS IS A MAJOR REASON FOR
NURSING HOME PLACEMENT BECAUSE OF THE BURDENS ON FAMILIESS AND PATIENTS
AND THE REQUIREMENT OF THE NEEDS THAT THEY NEED ( INAUDIBLE ).

PERSONAL TIME INVOLVED IN ( INAUDIBLE ).

FROM THESE ISSUES.

AND I THINK THAT THE﷓﷓ONCE AGAIN THERE\'S﷓﷓I EXCLUDED A SLIDE FROM THE
STUDY THAT WE DID EARLIER AND WE TRIED TO﷓﷓IT WAS IN A BIOFEEDBACK STUDY
WE DID, AND THERE WERE SO MANY ISSUES THAT WERE INVOLVED IN QUALITY OF
LIFE DECISION MAKING WITH REGARD TO WHAT THE CONTEXT WAS AND THEY
INCLUDED WHAT I CALL THE ( INAUDIBLE ).

FOR INCONTINENCE AND HOW INCONTINENCE WOULD BE TOLERATED BY THAT PERSON
SO IF THEY COULD HAVE YOU KNOW ( INAUDIBLE ).

WHICH IS A VERY, VERY, IMPORTANT THING FOR THEIR QUALITY OF LIFE, (
INAUDIBLE ).

AS YOU WERE POINTING OUT, ALTHOUGH THAT COMFORT LEVEL AND NOT BE ABLE TO
DO THOSE KINDS OF THINGS, SO MANY ISSUES WERE VERY DIFFICULT BECAUSE
THEY\'RE VERY THEIR ATTENTION WAS ON UNDERLYING ( INAUDIBLE ).

AND THEN COPING SKILLS THAT ARE ( INAUDIBLE ).

AND DEAL WITH ISSUES OF FECAL INCONTINENCE ( INAUDIBLE ).

SO HOW ALL THAT WORKS FOR A NURSING HOME IT DEPENDED ON THE FAMILY
ISSUES AS WELLS AS THE PATIENT ISSUES.

SO THAT, I DON\'T SEE, HOW YOU CAN REALLY IDENTIFY THAT SIMPLE, IN TERMS
OFICISM EM ANSWER TO THAT QUESTION.

\>\> SPEAKING OF QUALITY OF LIFE, IT SOUNDS LIKE YOU WOULD RECOMMEND
QUALITY OF LIFE MEASURES FOR CARE GIVERS AS WELL AS PATIENTS?

\>\> I THINK ( INAUDIBLE ).

CAN\'T BE IGNORED.

IT DRIVES MANY OF THESE ECONOMIC DECISIONS AND ( INAUDIBLE ).

SO AGAIN, I THINK THAT QUALITY OF LIFE IS VERY IMPORTANT IN TERMS OF THE
( INAUDIBLE ).

SO MANY OF US IN THE QUALITY OF LIFE ISSUES ARE VERY GENERIC AND
DIFFICULT TO ASSESS.

SOME OF THEM ARE ( INAUDIBLE ).

BECAUSE OF THE WAY THE QUESTIONS ARE ASKED OF THE PATIENT POPULATION,
YOU\'RE ALWAYS GOING TO HAVE CHANGE IN QUALITY OF LIFE AND THE QUALITY
OF LIFE INSTRUMENT ( INAUDIBLE ).

WITH THE COPING SKILLS.

SO I THINK MY PERSONAL OPINION ABOUT THE QUALITY OF LIFE HISTORY AT THE
PRESENT TIME IS THAT ALTHOUGH THEY\'VE BEEN THROUGH ( INAUDIBLE ).

THEIR DEVELOPMENT IN TERMS OF HOW WE CAN LOOK AT ISSUES THAT ARE
IMPORTANT, THEY NEED TO MOVE ON TO THE MORE ACCURATE REPRESENTING REALLY
WHAT HAPPENED TO PEOPLE WHO INCORPORATE BOTH SKILLSES TO SEE WHAT IS
NECESSARY TO MAINTAIN THE QUALITY OF LIFE AND HOW IT\'S IMPORTANT AND
THEN ( INAUDIBLE ).

DISEASES WOULD MANY PROBLEMS AND THE HEALTHY ( INAUDIBLE ).

THAT ALLOW US TO USE THEIR QUALITY OF LIFE.

AND YES, THEY ARE SAG SERIES COPING﷓﷓SKILLS AND QUALITY OF LIFE BECAUSE
THAT IS REALLY PHASEICAL, SO I THINK WE\'RE ( INAUDIBLE ).

AND I\'M NOT VERY ( INAUDIBLE ).

PARTICULARLY IN THE AREA OF URINARY INCONTINENCE, I DON\'T THINK ANYONE
OF THEM ( INAUDIBLE ).

EPISODES AND HOW THAT\'S﷓﷓THAT\'S REALLY NOT JUST AN INADEQUATE
ASSESSMENT AS ANYONE WOULD HAVE IN INCONTINENCE OF A MUCH DEEPER AND
MUCH MORE PROFOUND PROBLEM THAN THE QUESTIONNAIRES THAT REALLY PEOPLE
UNDERSTAND.

\>\> FOR THOSE WHO HAVE TO DO COST ANALYSIS AND COST BENEFIT ANALYSIS,
IT\'S EASY SOMETIMES TO FIGURE OUT THE DOLLARS IT COSTS TO DID A
PARTICULAR SURGERY AND WHAT PADS COST, ALL RELATIVE TO OTHER THINGS BUT
IF YOU\'RE LOOKING FOR AN OFFSET IN TERMS OF DOLLARS OF QUALITY, IF YOU
HAD TO QUANTIFY THAT PIECE OF IT SO YOU COULD ADD MAYBE MORE DOLLARS
COSTS BUT AS A INCREASED QUALITY OF LIFE THAT HAD TO BE COPYRIGHTIFIED,
I GATHER YOU DON\'T SEE THAT ANYTHING OUT THERE WOULD ALLOW THAT SORT OF
MEASUREMENT YET?

\>\> WELL, THAT\'S EXACTLY WHEYED, BUT I THINK THAT WHEN YOU\'RE LOOKING
AT﷓﷓WHEN I EXPLAIN ABOUT QUALITY OF LIFE, ( INAUDIBLE ).

AND IT DOES OPEN THE DOOR TO ( INAUDIBLE ).

AND HOW THEY SHOULD BE DEALT WITH AND THEY SHOULD BE DEALT WITH IN
IMPORTANT WAYS TO HAVE VERY USEFUL AND BENEFICIAL.

BUT WHEN WE START TALKING ABOUT IS IN MY OPINION THE EXTENT OVER MOST
QUALITY OF LIFE INSTRUMENTS THAT ARE OUT THERE.

WE CAN HAVE A FUNCTIONAL DISEASE AND QUALITY OF LIFE AS ( INAUDIBLE ).

AND SOME OF THESE THINGS ARE IN TERMS JUST QUALITY OF LIFE, WE REALLY
HAVE TO BE MORE SPECIFIC AND MORE UNDERSTANDING AND PARTICULARLY FOR
PEOPLE ( INAUDIBLE ).

I THINK YOU REALLY HAVE TO GET A LOT OF BENEFIT IN ( INAUDIBLE ).

NOT IN THE MEDICAL MARKET, BUT IN THE GENERAL MARKETPLACE AND THAT WILL
BE LOGICAL FOR LOTS OF WEIGHS AND LOTS OF PRODUCTIVITY AND THE (
INAUDIBLE ).

PERSONAL COSTS.

MANY TIMES THESE THINGS REALLY DON\'T MATTER WHEN IT COMES TO DRUG
DEVELOPMENT BECAUSE IT\'S ALL MEDICAL ECONOMIC COSTS THAT ARE IMPORTANT
AND I DON\'T THINK YOU\'RE GOING TO GET THAT KIND OF MEDICAL BENEFIT OFF
IT.

BUT THE ECONOMIC AND OTHER WAYS AND.

, SO YOU DON\'T THINK QUANTIFY NOTHING DOCTORS THE QUALITY OF LIFE IS AS
IMPORTANT AS THE STRAIGHT ECONOMIC BENEFIT?

\>\> I THINK I WOULD﷓﷓I\'M A VERY STRONG ADON VOCATE OF QUALITY OF
LIFE﷓﷓ADVOCATE OF QUALITY OF ARE LIFE.

THE TRIEWMENT OF MEASUREMENT AND WHAT THE ASSESSMENT TELLS YOU ABOUT THE
QUALITY OF LIFE, IS NOT A CONCEPT.

THE CONCEPT IS THERE AND I AM IN A POSITION ON CARE OF PATIENTS AND MAKE
THEIR LIFE BETTENER ANYWAY I CAN, WHETHER IT\'S ( INAUDIBLE ).

OR THEY HAVE SOMETHING THAT\'S REVERSIBLE, SO MY GOAL IN LIFE IS TO
MANAGE IT THAT WAY AND NOT DEAL WITH THE ECONOMIC COST AND ECONOM IG
MODELS THAT THEY\'RE TALKING ABOUT IS THE INTRODUCTION OF THE QUESTION
FOCUSES ON JUSTIFYING THE EXPENSE OF OTHER PEOPLE\'S DOLLARS FOR THE
BENEFIT OF ( INAUDIBLE ).

AND THIS IS VERY, VERY DIFFICULT IN THIS AREA AND COULD BE FOCUSED ON
QUALITY OF LIFE INSTRUMENTS THAT I THINK ARE A LITTLE BIT MORE
SOPHISTICATED THAN THE VALUE AND ANSWER ( INAUDIBLE ).

BUT WHEN WE LOOK AT THE DOMAIN NOW, AND EXACTLY WHAT HAPPENS IN TERMS OF
THE STUDIESS THAT I PRESENTED HERE IN TERMS OF DEPRESSION AND ANXIETY
AND THESE ISSUES ACCIDENT IT MAKE ITS DIFFICULT FOR ANY ONE TO
UNDERSTAND WHY ( INAUDIBLE ).

SO, IT\'S GOING TO HAVE PROBLEMS WITH ANXIETY AND OTHER KINDS OF ISSUES,
SO THEY ARE ALL A GENERIC ISSUE.

ONE DEC OR ANOTHER, ONE DISEASE QUALITY OF LIFE, ( INAUDIBLE ).

SO IT\'S TOO DIFFICULT, BUT VERY QUALITY OF LIFE ISSUES I GO NOT (
INAUDIBLE ).

THE INSTRUMENTS THAT I HAD TO LEARN ABOUT.

\>\> THANK YOU.

\>\> I WISH WE HAD MORE TIME, WE\'RE ABOUT﷓﷓WE APPRECIATE YOUR INPUT DR.
MINER.

AND I THINK WE SHOULD TURN TO THE NEXT SET OF SPEAKERS.

THANK YOU AGAIN FOR JOINING US AND SARRY FOR YOUR TRAVEL DIFFICULTIESS
YESTERDAY.

\>\> WELL, THANK YOU AND I AM SORRY THEY COULDN\'T BE THERE TO ENJOY THE
REST OF THE CONFERENCE.

\>\> SO WE\'LL NOW TURN TO THE LAST TWO QUESTIONS, WHAT CAN WE BE BE
DONE TO PRESENT FECAL AND URINARY INCONINENCE AND WHAT ARE THE STRAIT
EDGES TO IMPROVE IDENTIFICATION OF PERSONS AT RISK AND PATIENTS WHO HAVE
FECAL AND URINARY INCONINENCE AND DR. KING WILL PRESENT THESE.

\>\> IS THIS WORK?

I LIKE THAT BETTER.

\>\> WELL, THANK YOU.

I FIND MYSELF AT A VERY INTERESTING SITUATION NOW, WE\'VE HEARD A NUMBER
OF PRESENTATIONS BY PEOPLE WHO ARE EXPERT IN THE FIELD OF INCONTINENCE
BE IT FECAL OR URINARY, MY CREDENTIALS ARE REALLY THOSE OF A CAUSE I
EPIDEMIOLOGIST WHO DOES SISATTIC REVIEWS OF A VARIETY OF TOPICS SO I
THOUGHT IT MIGHT BE HELPFUL TO START BY GIVING YOU MY SENSE OF WHERE WE
ARE.

THIS IS A STATE OF THE SCIENCE CONFERENCE AND IT SEEMS TO ME THAT ONE OF
THE MAJOR OUTCOMES OF THIS MEETING COULD BE A CLEARER STATEMENT ABOUT
WHAT WE KNOW AND WHAT WE NEED TO KNOW.

AND I WOULD SUGGEST TO YOU THAT WE ARE DOING OURSELVES A GREAT INJUSTICE
BY CONTINUING TO DISCUSS THIS TOPIC OF INCONTINENCE EVEN IF WE ARE SO
BOLD AS TO SEPARATE IT INTO FECAL AND URINARY AS THOUGH IT WAS SOME KIND
OF A CONSTRUCT.

RATHER, I WOULD SUGGEST THAT INCONTINENCE IS REALLY A SYNDROME.

AND THAT OUR SCIENCE WILL BE BETTER AS WE BEGIN TO LOOK AT IT IN ITS
DISASSEMBLED FORMAT ANYMORE THAN I COULD CONSIDER US COMING TOGETHER TO
HAVE A STATE OF THE SCIENCE CONFERENCE ON COUGH.

AND I THINK WE﷓﷓YOU KNOW MANY OF THE THINGS I THOUGHT FOR EXAMPLE,
YESTERDAY\'S PRECEPTATION BY SNELLING WHEN HE SAID YOU COULD IDENTIFY
HALF THE PEOPLE IN NURSING HOMES WHO HAVE WHAT SEEM TO BE SITUATIONALLY
DETERMINED INCONTINENCE THAT IS READILY CORRECTED BY CHANGING THE
SITUATION AND ANOTHER HALF WHO DON\'T RESPOND TO THAT.

LIKELY SUPPOSE PEOPLE ARE RESPONDING TO A VERY DIFFERENT KIND OF A
PROBLEM, WITH A VERY DIFFERENT SET OF CAUSAL PATHWAYS THAN THE PEOPLE
WHO RESPOND TO THE SITUATIONAL TREATMENT.

I THINK WE NEED TO APPLY THAT SAME LOGIC ALL THE WAY DOWN HERE AS WE
BEGIN TO DO THIS AND SOME OF THE LACK OF INFORMATION THAT I\'M GOING TO
SHOW YOU IS PROBABLY DUE TO THE FACT THAT WE KEEP USING THIS COMMON END
POINT CALLED INCONTINENCE.

WE\'VE TALKED AT GREAT LENGTH ABOUT THE DIFFICULTS OF MEASURING IT JUST
IN TERMS OF SEVERITY IN TERMS OF FREE QUEEN SCHESORT OF THE MORE
TRADITIONAL DESCRIPTORS BUT WE HAVE TO GO FURTHER.

IN FACT I WOULD SUGGEST THAT INCOPINENCE IS MUCH LIKE THE WAY WINSTON
CHURCHILL DESCRIBED THE SOVIET UNION SOME YEARS AGO, IT A RIDDLE WRAPPED
IN ANIMISTRY INSIDE AN INEG NAY AND UNTIL WE BEGIN TO UNWRAP IT AND LOOK
AT IT MORE CAREFULLY WE\'RE NOT GOING TO MAKE THE PROGRESS THAT ALL OF
US ARE HOPEFUL WILL HAPPEN.

SO I\'M GOING TO TALK A LITTLE BIT ABOUT PREVENTION AND BY WAY OF
DEFINITION ONE CAN THINK ABOUT PRIMARY AND SECONDARY PREVENTION, PRIMARY
PREVENTION OR ACTIONS THAT ARE TAKEN IN THE ABSENCE OF A DISEASE IN
ORDER TO AVOID OR DELAY ITS ONSET WHERE SECONDARYACS ARE TAKEN BY PEOPLE
WITH DISEASE IN ORDER TO DELAY PROGRESSION.

NOW, ONE OF THE THINGS THAT WE TALK ABOUT IN THIS AREA IS SCREENING.

BUT AGAIN, I\'M NOT SURE THAT WE REALLY NEED SCREENING, BASICALLY
SCREENING IS USUALLY USED TO DETECT A DISEASE AND IT\'S IN ASYMPTOMATIC
STATE WHERE IT\'S BELIEVED THAT AN EARLY INTERVENTION WOULD CHANGE IT\'S
CLINICAL COURSE, URINARY AND FECAL INCONTINENCE ARE SYNDROMES NOT
DISEASES AND THEREFORE THERE\'S NO REASON TO EXEXPECT THAT JUMPING IN
EARLY IS NECESSARILY A VERY GOOD THING AND THERE\'S NO EVIDENCE TO
SUGGEST THAT IN FACT IT CHANGES THE COURSE OF THAT DISEASE.

WHAT WE\'RE REALLY TALKING ABOUT THEN, IS SOMETHING DIFFERENT WHICH IS
REALLY COMPARING SCREENING AS A RESPONSE TO A QUESTIONNAIRE TO RESPONSES
TO OTHER WAYS OF DETECTING THE DISEASE AND AGAIN ONE HAS TO BE CAREFUL
THERE\'S AN UNDERLYING TOATOLOGY HERE THERE\'S A DISCREPANCY BETWEEN
WHAT PEOPLE REPORT AND WHAT WE CAN MEASURE BY VARIOUS MANUMETROPOLITAN
RICK TYPES OF TESTS.

WE HAVE TENDERED, YOU KNOW THE CASE OF A TIE, THE CALL GOES TO THE
PATIENT AND NOT TO THE TESTER.

AND SO, TO SUGGEST AS YOU CAN VALIDATE A QUESTION AIR, BY BASICALLY
GOING BACK TO SOME PHYSIOLOGICAL MEASURE SEEMS TO BE ILLOGICAL ON ITS
FACE.

AND CERTAINLY, YOU KNOW THERE HAVE BEEN RELATIVELY FEW STUDIES THAT HAVE
TURNED TO GENERAL POPULATION GROUPS TO LOOK AT THE DEGREE TO WHICH A
QUESTIONNAIRE IS RELATED TO A SUBSEQUENT DIAGNOSTIC EVALUATION, THERE
WERE A COUPLE AND I\'LL SHOW YOU THOSE, BUT NOT VERY MANY.

SO WHEN WE TALK ABOUT SCREENING, WE NEED TO TALK ABOUT WHAT IS IT\'S
PURPOSE IN THE COMMUNITY WE WOULD DO IT FOR TWO PURPOSES, ONE IS TO
ESTIMATE THE PREVALENCE AND EPIDEMIOLOGICAL STUDIES AND THE THE OTHER
AND DETECT THE DISEASE EARLY WITH THE IDEA OF GOING OUT AND FINDING
CASES WE CAN THEN BRING UNDER TREATMENT.

IN THE CLINIC WE\'RE TALKING ABOUT SOMETHING DIFFERENT I THINK.

WE\'RE TALKING ABOUT A ESSENTIALLY RAISING THE SENSITIVITY OF CLINICIANS
TO THE FACT THAT THE DISEASE IS THERE.

AND THEN, GETTING THE PATIENT ENGAGED IN A SERIES OF PROCEDURES OR STEPS
THAT MIGHT THEN BRING THAT DISEASE MORE CLOSELY UNDER TREATMENT AND
THOSE TWO APPROACHESES, THE COMMUNITY PREVALENT DETREKZ APPROACH VERSES
THE CLINEICTION APPROACH HAS DIFFERENT IMPLICATIONS IN TERMS OF WHAT WE
WOULD DEMAND FROM INSTRUMENTS IN ORD TORE DO THOSE KINDS OF THINGS.

NOW THERE HAVE BEEN ABOUT 15 STUDIESES THAT LOOK AT SCREENING FOR
URINARY INCONTINENCE IN WOMEN, UNFORTUNATELY 13 OF THESE BASICALLY
INVOLVE CLINIC SAMPLES.

PEOPLE WHO SCREEN FOR THE PREVALENCE OF DISEASE IN CLINICS ARE NOT
OBVIOUSLY GETTING A PREVALENCE.

IT\'S INCREDIBLY SELECTIVE SAMPLE TO START WITH.

BUT IN TERMS OF RAISING THE ABILITY TO DETECT THE PROBLEM, ONE CAN USE A
STATISTICAL TEST, EYE PSYCHOMETRIC TEST CALLED THE POSITIVE REDICKIVE
LIKELIHOOD RATIO WHICH SHOWS HOW MUCH YOU IMPROVE THE PROBABILITY OF
IDENTIFYING THE DISEASE IF THE TEST IS POSITIVE AND IN THIS CASE, A GOOD
RATIO WOULD BE ABOUT 10 OF WHICH FOUR OUT OF THE 15 STUDIESS QUALIFIED,
AND ONE GOT BETTER RATIOS FOR OLDER WOMEN THAN FOR YOUNGER WOMEN.

WE CAN ALSO LOOK AT HOW WELL WE CAN SCREEN USING CLINICAL HISTORIES,
THERE WERE AGAIN 19 STUDIESS OF WHICH 16 WERE DONE IN THE CLINIC WHICH
VAST MAJORITY OF WHICH WERE FOCUSED ON WOMEN AND AGAIN WHAT CAN YOU SEE
HERE IS THAT THE POSITIVE PREDICTIVE LIKELIHOOD RATIOS FOR THESE
STUDIESS BOTH FOR THE YOUNGER AND THE OLDER WOMEN WERE QUITE POOR.

THERE HAVE BEEN A COUPLE STUDIES OF FECAL INCONTINENCE DETECTION USING
STABD ARDIZEED VALUE AND AGAIN THEY HAVE NOT SHOWN TO BE VERY EFFECTIVE.

THE VARIOUS PSYCHOMETRIC TESTS THAT WERE APPLIEDED HERE ARE NOT TERRIBLY
PROMISING.

SO LET\'S TALK ABOUT URINARY INCONTINENCE A BIT.

I SHOULD SAY THERE ARE TWO SETS OF INTERVENTIONS THAT ONE THINK ABOUT
FOR TRYING TO CHANGE THE COURSE OF THESE DISEASES, THEY OVERLAP A LITTLE
BIT BETWEEN URINARY AND FECAL INCOPINENCE AND WE\'LL DISCUSS SOME OF
THOSE FOR BOTH OF THESE GROUPS.

WHEN WE DID OUR SEARCH, YOU\'VE HEARD SOMETHING ABOUT HOW WE DID IT FOR
THE EPIDEMIOLOGICAL DATA HERE AND WE WERE LOOKING AT RANDOMIZED CONTROL
TRIALS AND SO OUR DATA WILL BE SMALLER THAN SOME OF THE VERY GOOD
PRESENTATIONS YOU HEARD EARLIER, WE APPLIED A VARIETY OF QUALITY
CRITERIA TO TRY AND FIND STUDIES THAT SEEM TO MEASURE UP TO THE
STANDARDS THAT WE HAD.

IN TERMS OF WHAT WE MIGHT THINK ABOUT AS PRIMARY PREVENTION, THAT IS
TREATING WOMEN BEFORE THEY PRESUMABLY HAVE DEVELOPED INCONTINENCE AND
THIS WOULD FOCUS ON WOMEN AROUND CHILD BEARING.

THERE HAVE BEEN STUDIESS DONE USING PELVIC FLOOR MUSCLE TRAINING AND
OTHER BEHAVIORIAL INTERVENTIONS AND THE CONTINENCE RATES AFTER THIS YOU
KNOW BASICALLY LOOKED PROMISING.

THERE WAS A STUDY DONE WITH PMFT WITH BIOFEEDBACK AND ELECT ELECTRICAL
STIMULATION THAT STARTED NINE WEEKS AFTER VAGINAL THEREFOREY AND WAS
ABLE TO SHOW A MARKED INCREASE IN INCONTINENCE 10 FOLD INCREASE COMPARED
TO USUAL CARE AT 10 MONTHS AFTER FOLLOW UP.

WHEN WE LOOK AT PRIMARY PREVENTION WITH SIMILAR KINDS OF TECHNIQUES WITH
MEN, THEY DON\'T SHOW NEARLY AS MUCH PROMISE.

YOU CAN SEE THE SPOT HERE, THE VAST MAJORITY OF THOSE LINES CROSS ONE
AND HENS ARE NOT VERY EFFECTIVE.

WHEN WE LOOK AT OTHER, SORT OF SECONDARY APPROACHES THINGS LIKE
ELECTRICAL STIMULATION IN MALES AND FEMALES, NEUROMODDULATION AND THE
USE OF BULKY AGENTS AGAIN THERE IS ISN\'T A GREAT DEAL OF POSITIVE
EVIDENCE HERE TO SHOW THAT THESE THINGS SEEM TO WORK.

THERE ARE SOME STUDIESS THAT HAVE TESTED THE USE OF MEDICAL DEVICES SUCH
AS VAGINAL CONES OR SUPER TAMPONS OR CONTINENCE GUARDSS AND CONTINENCE
TAMPONS AND NONE OF THOSE WERE SHOWN TO WORK.

WE\'VE TALKED A LOT ABOUT THE QUESTION ABOUT HORMONE THERAPY WHICH IS
INDEED A VERY FASCINATING QUESTION AND OUR REVIEW SHOWSES THAT THERE
WERE THREE RANDOMIZED TRIALS FOR LOCAL HORMONE THERAPY, WHICH SHOWED
SIGNIFICANT BENEFIT, BUT THAT SYSTEMIC HORMONE THERAPY AND THREE
RANDOMIZED TRIALS BASICALLY HAD THE OPPOSITE EFFECT, THAT IS IT MADE THE
CONTINENCE WORSE INSTEAD OF BETTER.

AND I THINK WE\'VE HEARD SOME THEORIESS ABOUT WHY THAT IS.

WE\'VE LOOKED AT A VARIETY OF SURGERIES FOR PROLAPSE IN WOMEN AND
THERE\'S A CONSISTENT BENEFIT EVEN DEPENDING ON THE DIFFERENCES IN THE
PARTICULAR NATURE OF THE APPROACH THAT\'S TAKEN, YOU CAN SEE THAT ALL OF
THE SUMMED SCORES ARE GREATER THAN ONE.

SO THERE\'S A GENTLEMEN CONSISTENCY OF BENEFIT THERE.

WHEN WE LOOK AT THE RATE OF CONTINENCE AFTER SURGERY FOR URINARY
INCONTINENCE, AGAIN, YOU CAN SEE THAT WE GENERALLY GET A POOLED
PREVALENCE OF KOPTINENCE, THIS IS THE POSITIVE SIDE OF THIS THAT
RAIRCHLGS SOMEWHERE BETWEEN 55 AND 75%.

WHICH IS QUITE ENCOURAGING AND ALL OF THOSE RELATIONSHIPS IN POOLED
STUDIESES ARE POSITIVE AND SIGNIFICANT.

WHEN WE LOOK AT THE RATES OF CONTINENCE AFTER THE BIRCH PROCEDURE AFTER
A SPECIFIC KIND OF APPROACH IF WE\'RE DOING THIS AGAIN, WE SEE
GENERALLIES POSITIVE RESULTS ALL OF WHICH ARE SIGNIFICANT AND IT IS
FAIRLY CONSISTENT ACROSS THE DIFFERENT KINDS OF TESTSS WITH THE
EXCEPTION WHEN YOU COMBINE SELF REPORT, MORE STRINGENT TEST OF SELF
REPORT, NEGATIVE STRESS TEST AND NEGATIVE TEST THAN THE RATE OF
CONTINENCE DROPS OFF.

WHEN YOU LOOK AT BEHAVIORIAL TRAINING, WHICH CAN BE EITHER DIRECTLY
BEHAVIORIAL TRAINING PROBABLY FOR MUSCLE TRAINING OR PELVIC FLOOR MUSCLE
TRAINING WITH BEHAVIORIAL TRAINING OR PELVIC FLOOR MUSCLE TRAINING WITH
EMG BIOFEEDBACK, WHAT YOU CAN SEE IS THAT IN GENERAL ALL OF THOSE
PRODUCE POSITIVE RESULTS AND THE POOLED RELATIVE RISK FOR THAT IS ALMOST
TWO WHICH IS QUITE ENCOURAGING AND AGAIN CONSISTENT WITH WHAT YOU\'VE
HEARD BEFORE SO THIS AS WELL A POTENTIAL HERE FOR A WAY OF INTERVENING
TO CHANGE THE COURSE OF THIS.

SIMILARLY IF YOU LOOK AT PELVIC FLOOR MUSCLE TRAINING TO IMPROVE URINARY
INCONTINENCE, YOU SEE AGAIN THAT THE DIAMONDS THERE WHICH ARE THE POOLED
ANALYSIS ARE GENERALLY GREATER THAN ONE AND THAT USUALLY IN THE RANGE OF
TWO AND IN THE CASE OF THE SAMPLE OF PELVIC FLOOR MUSCLE EXERCISES ARE
ACTUALLY IN THE RANGE OF FIVE WHICH IS QUITE ENCOURAGING.

WE HEARD SOME DISCUSSIONS ABOUT LIFESTYLE EFFECTS ON URINARY
INCONTINENCE.

THERE WAS ONE STUDY THAT CAME OUT OF THE DIABETES STUDIESES THAT LOOKED
AT THIS PARTICULARLY WELL AND SUGGESTED THAT LOSING OR MAINTAINING AT
11% OF YOUR INITIAL BODY WEIGHT AND ENGAGING IN MODERATE EXERCISE WAS
ACTUALLY ABLE TO REDUCE STRESS INCONTINENCE BY 15% AFTER ALMOST THREE
YEARS OF FOLLOW UP.

THERE WAS SOME DISCUSSION EARLIER AS TO WHETHER PEOPLE FELT THAT WOMEN
WOULD RALLY TO THE IDEA OF AVOIDING URINARY INCONTINENCE TO THE POINT
THEY WOULD CHANGE THEIR BEHAVIOR IN THESE DIRECTIONS.

WE HAVE NO EVIDENCE THAT THAT\'S INDEED THE CASE.

CERTAINLY THE FEAR OF DEATH SEEMS NOT TO BE A GREAT INSPIRATION FOR THEM
BUT HER HAPPENS DRIP SUGGEST WORSE THAN DYING.

﷓﷓DRIPPING IS WORSE THAN DYING.

I DON\'T KNOW.

IF WE LOOK AT FECAL INCONTINENCE, WHAT WE CAN SEE HERE IS THAT THERE\'S
A RATHER DIFFERENT RESULT FROM WHAT I SHOWED YOU EARLIER WITH REGARD TO
URINARY INCONTINENCE WITH REGARD TO FECAL INCONTINENCE, IF YOU LOOK AT
THE OUTCOME IN TERMS OF ACTUALLY ACHIEVING CONTINENCE, THEY\'RE
BASICALLY IS NO EFFECT, THE FIRST SET OF SPOTS THERE, AND IF YOU LOOK AT
IT IN TERMS OF IMPROVING FECAL INCONTINENCE, YOU DON\'T SEE AN EFFECT
EITHER.

SO, IN CONTRAST TO URINARY INCONTINENCE WHERE THERE SEEMSES TO BE VERY
GOOD EVIDENT THAT PELVIC FLOOR MUSCLE EXERCISES AS SOMEBODY POINTED OUT
YET TO BE WELL DEFINED IN TERMS OF EXACTLY WHAT THEY CONSIST OF, BUT
NONETHELESS ACROSS ALL THESE STUDIES SEEM TO SHOW A CONSISTENT EFFECT.

YOU DON\'T SEE THE SAME EFFECT FOR FECAL INCONTINENCE.

THERE HAVE BEEN EFFORTS TO LOOK AT PREVENTION IN FECAL INCONTINENCE WITH
REGARD TO PREGINANCE SCHEBIRTH.

AGAIN, NONE OF THESE﷓﷓PREGNANCY AND BIRTH.

NONE OF THESE SHOWED SIGNIFICANT EFFECTS PELVIC FLOOR MUSCLE EXERCISES
WITH BIOFEEDBACK, A SYSTEM OF SELF ADMINISTERED PERO NEAL MASSAGES OR A
PROGRAM WITH ASSESSMENT OF NURSES AT THE TIME OF DELIVERY AND THEN
ENCOURAGEMENT ON DOING PELVIC FLOOR MUSCLE KNERR CISE WHICH SHOWED A
SHORT﷓TERM EFFECT BUT NOT A LONG﷓TERM EFFECT.

THERE HAVE BEEN A NUMBER OF MEDICATIONS THAT HAVE BEEN SUGGESTED FOR
PREVENTING FECAL INCONTINENCE BUT AGAIN, NONE OF THESE SHOWED ANY
SIGNIFICANT RESULTS.

THIS IS JUST A SPOT TO SHOW YOU SOME OF THE THINGS THAT HAVE BEEN TRIED,
GELSS AND TOXINS AND YOU CAN SEE THEY ALL OVERLAP ONE.

ELECTRICAL STIMULATION OR NEUROMODDULATION HAS BEEN TRIED AND AGAIN WITH
THE ONE EXCEPTION OF THE SACKERAL NERVE CONTINUOUS STIMULATION STUDY
THEY HAVE NOT SHOWN ANY BENEFIT.

THERE\'S BEEN A LOT OF WORK ON SURGERY FOR FECAL INCONTINENCE, THIS HAS
BEEN WELL REVIEWED BY DR. LOWERY OUR TAKE ON THIS, I THINK IS A LITTLE
BIT DIFFERENT THAN WHAT I RECALL HER REPORTING.

BUT BASICALLY, IF YOU CAN DIAGNOSE A SPHINCTER TEAR EARLY RIGHT AFTER
VAGINAL DELIVERY AND REPAIR IT, YOU REDUCE THE RATE OF FECAL
INCONTINENCE RATHER DRAMATICALLY.

IF YOU USE AN ARTIFICIAL BIOSPHINCTER, YOU CAN REDUCE THE RATE OF
INCONTINENCE, BUT THERE ARE OTHER COMPLICATIONS THAT COME IN THAT ARE
ASSOCIATED WITH THAT PROCEDURE.

WHEN WE LOOKED AT REDUCTION FROM BASELINE AFTER PUTTING IN AN ARTIFICIAL
BOWEL, YOU CAN SEE THE RATES WERE ALL QUITE POSITIVE, THAT IS THEY
SHIFTED TO THE LEFT HERE WHICH REPRESENTS A HIGHER EFFECT AND THEY ARE
CONSISTENT FOR DIFFERENT KINDS OF MEASURES OF OUTCOMES.

WE LOOKED AT NINE RANDOMIZED TRIALS THAT LOOKED AT DIFFERENCES IN
SURGICAL TECHNIQUES FOR HEMORRHOIDECTOMY AND A ACROSS A A WIDE VARIETY
OF THINGS THAT WERE MUCH BETTER EXPLAINED BY DR. LOWERY AND IN OUR
REVIEW, NONE OF THOSE SHOWED ANY SIGNIFICANT BENEFITS WITH REGARD TO
FECAL INCONTINENCE.

WE LOOKED AT FIVE RANDOMIZED TRIALS THAT COMPARED SPHINCTEROT ME WITH
PHARMACOLOGICAL AGENTS AND AGAIN COULD NOT SEE ANY DIRECT BENEFITS FROM
DOING THOSE.

THIS IS A GRAPH THAT SHOWS THE COMPARISONS END TO END VERSES OVERLAPPING
SPHINCTER REPAIRS AFTER A DELIVERIESS AND YOU CAN SEE IN ONE CASE THERE
IS A BENEFIT WHEN YOU DO A POOLED SAMPLE BUT IN THE OTHER TWO CASES THE
DIAMONDS OVERLAP.

SO IF YOU\'RE LOOKING AT ACHIEVING CONTINENCE IN A FEW STUDIESS THAT
MEASURED THAT, WE SAW A BENEFIT, BUT THE SAME STUDIES AS YOU\'LL SEE
SORT OF REKER THROUGH EACH OF THOSE DIFFERENT EPD POINTS SO IT\'S NOT
LARGE NUMBERS OF STUDY, IT\'S THE SAME STUDIES LOOKING AT DIFFERENT END
POINTSS AND DEPENDING ON THE DIFFERENT END POINTS, YOU GET DIFFERENT
RESULTS.

SO WE LOOKED AT ANNAL SPHINCTER SURGERY FOR HIGH TRANSTINCTER FISTULAS,
ABSCESSES AND NEUROGENIC FECAL INCONTINENCE AND AGAIN DID NOT SEE ANY
BENEFITS FROM THOSE RANDOMIZED TRIALS.

WHEN YOU COMPARE DIFFERENT KINDS OF APPROACHES.

HERE WE\'RE LOOKING AT EFFECTS OF DIFFERENT PROCEDURES ON FOR RECTAL
PROLAPSE AND AGAIN, THERE\'S NO EVIDENCE OF BENEFIT COMPARING ONE TYPE
OF APPROACH TO ANOTHER.

NOW, I WOULD HASTE KNOW TO POINT OUT THAT IN﷓﷓HASTEN TO POINT OUT THAT
IN MANY OF THESE STUDIES WHERE WE\'RE LOOKING AT ACHIEVING INCONTINENCE,
THERE IS AN ASSUMPTION THAT HAS BEEN ALLUDED TO EARLIER BY OTHERS THAT
THE PEOPLE WERE CONTINENT, OR WERE INCONTINENT IN THE CASE OF CONTINENCE
THAT THEY KNEW WHAT THEIR BASELINE CONTINENCE STATUS WAS, BUT IN FACT A
LOT OF THESE STUDIESS WERE NOT NECESSARILY TARGETED AT THIS SPECIFIC
CONDITION AND DID NOT ALWAYS CAREFULLY MEASURE THIS AND SO A NUMBER OF
THESE﷓﷓A NUMBER OF THESE CASES, THE BASELINE CONTINENCE STATUS IS
ASSUMED OR AT LEAST IS NOT MADE OVERT IN THE PAPERS THAT WERE WRITTEN
ABOUT IT.

MORE IMPORTANT, THERE\'S A HUGE DIVERSITY IN TERMS OF THE NATURE OF THE
INTERVENTIONS USED.

WE\'VE TRIED TO FOR SIMPLICITY SAKE TO COLLAPSE THESE IN A NUMBER OF
CASES BUT THEY VAIR NEE TERMS OF THE INTERVENTIONS USE, POP EULOGYS
STUDIES, WHICH MAY VARY BY THEY THINK THINGS LIKE﷓﷓THINGS LIKE AGE AND
CO﷓MORBIDITYS, SOME OF THE SAMPLING STRATEGIES WITH REGARD TO COMING UP
WITH EFFECTIVENESS ABOUT EARLY INTERVENTION CERTAINLY VARY ENORMOUS
LALY.

SOME OF THEM COME OUT OF CLINIC POMMULATION, SOME OF THEM COME OUT OF
THE GENERAL POPULATION AND AS WE SAID OVER AND OVER AGAIN, DEFINITIONS
PLAGUE ALL OF THESE ANALYSIS BECAUSE WE DON\'T ALWAYS KNOW WHAT SOMEBODY
MEANS WHEN IS THEY SAY THEY WERE INKONT CONTINENT OR KOBT NEBT BECAUSE
OF COURSE THERE ARE SO MANY VARIATIONS TO THIS.

THE SURGICAL STUDIESES AS IS TRUE FOR SURGERY IN GENERAL ARE MORALLY TO
COMPARE ONE APPROACH FOR A TECHNIQUE TO ANOTHER APPROACH THAN SURGERY TO
NO SURGERY OR SURGERY TO MEDICAL CARE.

NOW THERE WERE A COUPLE OF EXCEPTIONSES TO THAT WHERE THEY WERE
COMPARING SURGERY TO SOME LOCAL PHARMACOLOGICAL PREPARATIONS BUT IN
GENERAL, I THINK YOU KNOW THERE\'S AN IMPLICIT ASSUMPTION THAT SURGERY
IS BENEFICIAL AND THE QUESTION IS NOT IF BUT WHAT KIND AT LEAST IN THE
MINDS OF SOME OF THE SURGEONS WHO IS ARE DOING THAT.

SO, WE WOULD CONCLUDE THE FOLLOWING: NUMBER ONE, PELVIC FLOOR MUSCLE
TRAINING AND SURGERY SEEM TO HAVE GREAT BENEFITS WITH REGARD TO URINARY
INCONTINENCE BUT THE EFFECTS FOR FECAL INCONTINENCE ARE LESS CLEAR.

THAT BEHAVIORIAL CHANGES IN WAYS OF PHYSICAL ACTIVITY﷓﷓WEIGHT AND
PHYSICAL ACTIVITY HAVE GREAT PROMISE IN TERMS OF DELAYING THE ONSET OF
URINARY INCONTINENCE BUT IT\'S NOT CLEAR THAT WE HAVE ENOUGH DATA YET TO
ARGUEUE THAT THESE REALLY ARE REALISTIC DIRECTIONS TO GO IN AND THAT
PEOPLE WILL REALLY ADHERE TO THESE REGIMENS VERY STRONGLY.

THEY CERTAINLY DO NOT IN MOST OTHER STUDIESS OF BEHAVIOR CHANGE FOR
OTHER CAUSES.

THE OUTCOME MEASURES THAT HAVE BEEN STUDIED VERY WIDELY, THEY RANGE FROM
SELF REPORTED SYMPTOMS TO SIGNS, THEY SOMETIMES ARE DEFINED IN TERMS OF
ACHIEVING INCONTINENCE AND IN TIMES OF ACHIEVING IMPROVEDDED LEVELS OF
CONTINENCE THAT THE SEVERITY IS ADDRESSED BY A VARIETY OF DIFFERENT
KINDS OF THINGS THAT INCLUDE VOIDING, PAD TEST WEIGHTS AND SOMETIMES
CONDIGS, QUALITY OF LIFE MEASURES, THAT THE CRITERIA FOR TREATMENT OF
SUCCESS ARE STILL NOT WELL ESTABLISHED AND THAT THE CHOICE OF OUTCOME
SOME VIE PLECTTHE PATIENT\'S PERCEPTION OF CURE AND QUALITY OF LIFE
RATHER THAN PROVIDER EVALUATION AND INSTRUMENTAL TESTING.

THERE WAS SOME PASSING REFERENCE YESTERDAY TO SOME OF THE MEASURES OF
QUALITY OF LIFE WHICH SHOWED DIFFERENT WEIGHTS PLACED ON THOSE OUTCOMES
BY PATIENTS AND SURGEONS IN TERMS OF FECAL INKONT CONTINENCE AND I THINK
WE NEED TO BE CAREFUL ABOUT YOU KNOW WHAT﷓﷓HOW WE DETERMINE A SUCCESS
WHEN WE\'RE TALKING ABOUT MEASURING THESE INTERVENTIONS.

WE CERTAINLY NEED TO STUDY SOME GROUPS MORE IN TERMS OF RACE,
CO﷓MORBIDITY AND CONCOMIT ANT TREATMENTS AND UNDERSTAND BETTER THE
UNDERLYING BASELINE PELVIC FLOOR DYSFUNCTION IN ORD TORE BEGIN TO LOOK
AT THIS AND I THINK ALL OF THIS IS REALLY ARGUING FOR SEPARATING OUT
SOME OF THESE DIFFERENT SUBSETS OF THINGS THAT ARE STILL LUMPED UNDER
INCONTINENCE AND BEGINNING TO UNDERSTAND THEM BETTER.

SO WE WOULD EPD WITH A GENERAL OBSERVATION THAT I THINK INCONTINENCE
SHOULD BE ADDRESSED AS A DIN CHROME THAT﷓﷓SYNDROME THAT HAS POLT PEL
POTENTIAL CAUSAL PATHWAYSS AND MULTIPLE POTENTIAL AREAS FOR INTERVENTION
AND THAT IN THIS CASE, THE SPLITTERS MAY HAVE IT OVERTHE LUMPERS.

IN TERMS OF BEGINNING TO THINK ABOUT THE DIRECTION IN WHICH THE SCIENCE
OUGHT TO GO.

THE EFFECTS AND RISKS THEN LEAD TO ADDRESS SPECIFIC ELEMENTS AND THAT WE
NEED TO THINK ABOUT THE POTENTIAL FOR USING COMP BINNATIONS OF
INTERVENTIONS RATHER THAN SINGLE MODALITIES, THAT THE LACK OF COMMON
DEFINITIONS OF BOTH INCONTINENCE AND THE OUTCOMES OF SUCH TREATMENT ARE
GOING TO COMPLICATE OUR UNDERSTANDING OF HOW TO INTERPRET THE STUDIES
AND THE RESULTS THAT WE FIND IN THE LITERATURE.

THANK YOU VERY MUCH.

(APPLAUSE).

\>\> THANK YOU DR. CAIN.

WE WILL HAVE DR. BURGIO PROFESSOR OF MEDICINE AT UAB AND UAB CONTINENCE
PROGRAM AND ASSOCIATE DRECKOR FOR RESEARCH AT THE BIRMINGHAM ATLANTA,
SPEAK ON EXERCISE, DIET, LIFESTYLE AND SMOKING NOTHING THE SETTING OF
CONTINENCE.

\>\> GOOD MORNING.

IT SEEMS LIKE IT SHOULD BE AFTERNOON BY NOW.

WE\'RE GETTING TOWARDS THE END OF OUR PROGRAM AND WE HAVE BEEN HEARING
AN AWFUL LOT ABOUT RISK FACTORS, AM I BETTER NOW?

OKAY.

WE\'RE GETTING TOWARDS THE END OF OUR PROGRAM NOW AND I SAY THAT MANY OF
THE PEOPLE ARE STILL HERE, WE\'RE ALMOST DONE.

WE\'VE BEEN HEARING A LOT ABOUT RISK FACTORSS AND CORIAALATES OF URINARY
AND FECAL INCONTINENCE BUT WHAT WE\'RE LEARNING IS THAT RELATIVELY
LITTLE RESEARCH HAS BEEN DONE IN THE REALM OF PREVENGE IN GENERAL SO
I\'LL BE SPENDING THE NEXT 15 MINUTES TRYING TO REVIEW WHAT HAS BEEN
DONE AND WHAT MIGHT BE DONE IN THE AREAS OF PELVIC FLOOR MUSCLE
EXERCISE, DIETARY FACTORSS AND WEIGHT LOSS, BOWEL AND BLADDER HABITS AND
SMOKING.

SO STARTING WITH PELVIC FLOOR MUSCLE EXERCISE AS DR. CAIN MENTIONED WE
HAVE A VERY GOOD LITERATURE ESTABLISHING THAT PELVIC FLOOR MUSCLE,
TRAINING AND EXERCISE IS A HIGHLY EFFECTIVE INTERVENTION FOR REDUCING
BOTH URINARY AND FECAL INCONTINENCE.

SO WE KNOW LESS ABOUT IT\'S VALUE OF THE PREVENTION STRATEGY.

PELVIC FLOOR MUSCLE EXERCISE PROGRAMS HAVE BEEN USED FOR PRIMARY
PREVENTION IN THREEAT RISK POPULATIONS THAT I COULD FIND: OLDER WOMEN,
CHILD BEARING WOMEN, AND MEN UNDERGOING RADICAL PROSTATECTOMY.

STARTING WITH OLDER WOMEN, I COULD ONLY FIND ONE STUDY.

THIS IS A STUDY THAT MANY OF YOU PROBABLY KNOW ABOUT, DONE BY A DOCTOR
AND HIS COLLEAGUESS AND THEY DEVELOPED A BEHAVIORIAL INTERVENTION FOR
CONTINENT OLDER WOMEN.

THEY DELIVERED THIS INTERVENTION IN A GROUP SETTING THEY DID TWO HOUR
TRAINING SESSIONS TO EDUCATE WOMEN ABOUT BLADDER FUNCTION THIS, TRAINING
INCLUDED INFORMATION ABOUT PELVIC FLOOR MUSCLE EXERCISES, AND THEN THEY
FOLLOWED UP WITH THEM AT A LATER TIME POINT AND DID INDIVIDUAL SESSIONS
TO EVALUATE THE PELVIC FLOOR MUSCLESS AND TO INSURE THEY WERE USING THE
PROPER EXERCISE TECHNIQUE TO MAKE SURE THEY WERE USING THE RIGHT MUSCLES
AND USING THEM IN THE PROPER WAY.

AND THEN THEY DID A RAN OMIZED CONTROL TRIAL TO TEST THIS INTERVENTION
IN WOMEN WHO WERE CONTINENT OR JUST HAD A LITTLE BIT OF INCONTINENCE, I
BELIEVE THAT THEY BEING HAVE HAD A LITTLE BIT OF INCONTINENCE AND MAYBE
ONE TO FIVE EPISODESES IN THE PREVIOUS YEAR.

AT ONE YEAR, MORE OF THE WOMEN WHO HAD RECEIVED THE INTERVENTION WERE
EITHER ABSOLUTELY CONTINENT OR IF THEY HAD HAD A LITTLE BIT OF
INCONTINENCE BEFORE OR AT LEAST THE SAME OR THEY WERE BETTER.

NOW FOR ABSOLUTE INCONTINENCE THEY DIDN\'T REACH THE STATISTICAL
SIGNIFICANCE BUT FOR SAME OR BETTER IT WAS A PVALUE OF .01.

SO THIS ESTABLISHS THE POTENTIAL OF USING THIS KIND OF GROUP TRAINING,
EDUCATION AND PELVIC FLOOR MUSCLE EXERCISE AS A STRATEGY TO REDUCE THE
INCIDENCE OF URINARY INCONTINENCE AND AT LEAST OLDER WOMEN.

I DIDN\'T FIND ANYTHING ON MEN.

THERE\'S MUCH MORE RESEARCH ON WOMEN, ON CHILD BEARING WOMEN, BUT I WILL
SAY THAT RIGHT UP FRONT THAT THIS IS A MIXED LITERATURE AND I THINK SOME
OF MY COLLEAGUES WOULD DISAGREE ABOUT THE INTERPRETATION WHEN YOU LOOK
AT THE WHOLE PICTURE BUT I\'M SORT OF A GLASS IS HALF FULL KIND OF
PERSON SO I FOCUS ON THE POO 55 TRIALS MORE THAN THE NEGATIVE TRIALS.

BUT I FEEL LIKE THERE\'S SIGH SIGNIFICANT LITERATURE DEMON TRAIT TAG
PELVIC FLOOR TRAINING AND MUSCLE EXERCISE HELPS TO ATTEND URINARY
INCOPINENCE LIKE AT 35 AND 36 WEEKS OF GUESTATION AS WELL AS IN
POSTPARTUM PERIOD AND UP TO SIX WEEKS AND EVEN A YEAR AFTER DELIVERY.

THE DATA ARE SQUARE AND WE FIND﷓﷓SCARCE AND WE FIND THESE IN THE
POSTPARTUM PERIOD.

THESE ARE THE RESULTS OF SOME TRIALS THAT USE ANTIPART UM OR ANTINATAL
PELVIC FLOOR MUSCLE TRAINING.

START NOTHING REG NANCY AND I HAVE TO TELL YOU THAT I TOOK OUT THE
MIDDLE STUDY BECAUSE I DISCOVERED THAT IT DIDN\'T ACTUALLY START UNTIL
POSTPARTUM BUT THE RILEY STUDY AND THE MORPHIS STUDY SAID THAT EXERCISES
DURING PREGNANCY AND FOUND THAT THE POINT THAT THE WOMEN WHO DURING
THREE MONTHS POSTPARTUM AND INITIATING THE PELVIC FLOOR MUSCLE EXERCISES
AFTER THE DELIVERY AND REDUCES URINARY INCONTINENCE AT SIX WEEKS THREE
MONTHSS AND AT 12 MONTHS.

NOW THERE IS A STUDY THAT SHOWS THE EFFECT IS DISSIPATES AT 12 MONTHS
AND THERE\'S A LONGER TERM STUDY THAT HAD SIGNIFICANT EFFECTS EARLIER ON
BUT BY SIX YEARS LATER, THERE WERE NO DINNERS BETWEEN THE GROUP BUT I
THINK THIS SHOWS POTENTIAL FOR REDUCING INCONTINENCE IN THE POSTPARTUM
PERIOD.

NOW SOME PEOPLE WILL AIRINGUE THAT WE SHOULD RECOMMEND PELVIC FLOOR
MUSCLE EXERCISES FOR ALL CHILD BEARING WOMEN, SOME PEOPLE WE SHOULD RECK
MEPD EXERCISES FOR ALL WOMEN OF CHILD BEARING POTENTIAL.

SOME PEEL LIKE WE SHOULD JUST TARGET THOSE WHO HAVE RISK FACTORS AND WE
DO HAVE A GOOD DATA INDICATE TAG WOMEN WHO HAVE URINARY INCONTINENCE
BEFORE PREGNANCY OR DURING PREGNANCY ARE AT PARTICULAR RISK OF HAVING
URINARY INCONTINENCE IN THE POSTPARTUM PERIOD AND VICTOR AND HIS
COLLEAGUES HAVE SHOWN THIS IS A RISK FACTOR FOR URINARY INCONINENCE UP
TO FIVE YEARS AFTER THAT DELIVERY.

SO I THINK WE HAVE HERE IN AN OPPORTUNITY TO BETTER IDENTIFY WOMEN WHO
ARE EXPERIENCED, ALREADY EXPERIENCED EVEN IF IT\'S A MINOR DEGREE OF
URINARY INCONTINENCE BEFORE OR DURING MEG PREGNANCY, MOST LIKELY TO HAVE
IT AFTER DELIVERY AND MERELY WAITING FOR THE PREGNANCY TO END, WE COULD
COUNSEL THESE WOMEN ABOUT THEIR INCREASED RISK AND SISMATICLY OFFER
CONSERVATIVE IRPT VENTIONS TO HELP WITH IT IN THE FUTURE.

NOW I DID FIND ONE TRIAL THAT ATTEMPTED TO DO THIS, THEY ADENTIFIED
WOMEN WHO HAD URINARY INCONINENCE AND THEY DIDN\'T FIND A SIGNIFICANCE
DIFFERENCE IN THE POSTPARTUM PERIOD BUT I FOUND THAT DISCOURAGING BUT
UPON CLOSER INSPECTION, I DISCOVERED THAT 2/3RDS OF THE WOMEN HAD
INSTRUCTION IN PELVIC FLOOR MUSCLE EXERCISES SO I THINK THIS IS ONE OF
THE CHALLENGES IN INTERPRETING SOME OF THESE STUDIESES IS THAT YOU MIGHT
HAVE INTERVENTIONS LIKE PHYSICAL THERAPISTS OR NURSES DOING THE RESEARCH
INTERVENTION BUT A LOT OF THESE WOMEN ARE RECEIVING INSTRUCTIONSES FROM
OTHER PEOPLE DOING THEIR ANTINATAL EDUCATION MIDWIFE ANDS THAT SORT OF
THING SO WOO HAVE TO LOOK AIRFULLY AT THE CONTROL GROUPS WHILE WE\'RE
INTERPRETING THE DATA IN THIS CARE.

﷓﷓AREA.

SO THE NEXTAT RISK GROUP WE WOULD LIKE TO DISCUSS IS MEN WHO ARE
UNDERGOING RADICAL PROSTATECTOMY AND DR. GOODE GAVE YOU A NICE VIEW OF
THIS EARLIER IN THE MORNING FELT JUST TO REITERATE WE HAVE A LARGE
NUMBER OF MEN WHO UPON SURVEY WILL TELL US THAT SAY AURINARY
INCOPINENCE, AT LEAST A YEAR AFTER THE PROSTATE SURGERY AND AS MANY AS
40% OF THEM ARE STILL USING PADS SO THIS IS A SIGNIFICANT GROUP OF
PEOPLE WHO ARE STILL SUFFERING FROM URINARY INCONTINENCE WAY AFTER THEIR
SURGERY.

THE VERY SMALL BODY OF LITERATURE DEMONSTRATE TAG PREOPERATIVE
BEHAVIORIAL TRAINING WITH PELVIC MUSCLE TRAININGER EXERCISES CAN REDUCE
DURATION OF POST OPERATIVE UI AS WELL AS SEVERITY OF INCONTINENCE AFTER
PROSTATECTOMY.

IN THIS ONE TRIAL THAT THE DOCTOR TOLD YOU ABOUT WE TESTED A
PREOPERATIVE SECTION OF BIOFEEDBACK TO TEACH THEM PELVIC FLOOR MUSCLE
CONTROL AND THEN AFTER THE CATHETER CAME OUT WE DID A REMINDER SESSION
AND WE FOUND REDUCTION BOTH IN THE DURATION ASK IN THE SEVERITY OF THEIR
POST PROSTATECTOMY INCONTINENT.

IF YOU LOOK AT THESE CURVES YOU SEE THAT THE PREVENTION GROUP, THE GROUP
WITH THE LOWER CURVE HAD A FASTER RECOVER OF THEIR CONTINENCE AFTER THE
SURGERY.

THEY ALSO HAD THE INTERVENTION GROUP HAD A SMALLER NUMBER OF PEOPLE WHO
HAD SEVERE OR CONTINUAL LEAKAGE AT SIX MONTHS POST PROSTATECTOMY.

THERE\'S OTHER STUDIESES THAT INITIATED FLOOR TRAINING EARLY IN THE POST
OPERATIVE EARLY PERIOD AND THREE TRIALS DID NOT SHOW BENEFIT, THESE WERE
INITIATE AS THE THREE WEEKS AND EIGHT WEEKS AFTER SURGERY SO I TO SAY
THESE ARE FAIRLY SMALL STUDIESS AND IT LOOKS TO ME LIKE THEY WERE
UNDERPOWERED.

WE DO NOW HAVE THREE VERY GOOD RAPED OMIZED CONTROL TRIALSES THAT SHOW
REDUCED DURATION AND SEVERITY OF INCONTINENCE UP TO 12 MONTHS POST
SURGERY.

\>\> THIS COMESES FROM ITALY AND WHEN YOU LOOK AT THE GROUP THAT WAS
TRAINED, YOU SEE FASTER RECOVER OF CONTINENCE IN THE TREATED GROUP.

THIS IS ANOTHER EXAMPLE OF THE KIND, THE NATURAL COURSE OF CONTINENCE
FOLLOWING PROSTATECTOMY.

SO PELVIC FLOOR MUSCLE TRAINING HERE ARE SOME OF THE QUESTIONS THAT I
HAVE AND WILL LIKE TO PURSUE.

WE HAVE THIS QUESTION OF WHO SHOULD BE TARGETED FOR PELVIC FLOOR MUSCLE
TRAINING, SHOULD IT BE EVERYBODY, SHOULD WE EDUCATE THE PUBLIC, SHOULD
WE ONLY EDUCATE THE PEOPLE WHO WE THINK ARE AT RISK OF DEVELOPING
INCONTINENCE.

WE\'VE BEEN ASKED BY REVIEWERS WHEN WE SEND IN OUR ARTICLES WHAT\'S THE
OPTIMAL TIME FRAME TO BEGIN PELVIC FLOOR MUSCLE TRAINING PROGRAM
PARTICULARLY AROUND PROSTATECTOMY, DOES IT NEED TO BE BEFORE THE SURGERY
WHEN THE MEN ARE NOT HAVING ANY PAIN AND EVERYTHING SEEMS NORMAL, OR
SHOULD WE WAIT UNTIL AFTER TO TAKE THIS WAIT A SEE APPROACH.

WE\'VE HAD PEOPLE SAY DON\'T FIX WHAT ISN\'T BROKEN OR JUST WAIT AND
SEE.

O MAYBE IT\'S EARLY RIGHT AFTER SURGERY SO THERE\'S A GREAT DEAL OF
DEBATE AND I THINK THE SAME ISSUE HOLDS TRUE FOR PREGNANT WOMEN AND THE
EARLY POSTPARTUM PERIOD.

A BURNING QUESTION FOR ANY KIND OF BI BEHAVIORIAL INNERVENTION IS IS HOW
CAN WE SUSTAIN IT OVER TIME.

THIS IS A CHALLENGE IN PREVENTION STUDY, NO HEART TAY PREVENTION YOU\'RE
TRYING TO DO, IF PEOPLE DON\'T EXPERIENCE THE PROBLEMS LIKE WITH PRIMARY
PREVENTION, IT\'S HARD FOR THEM TO IMAGINE THAT THEY WOULD EVER HAVE
THAT PROBLEM.

SO PREVENTING PEOPLE FROM EVENT INITIATING SMOKING SINCE THEY DON\'T
COME IN CONTRACT WITH CONNINGENCYS IT\'S DIFFICULT TO GET THEM TO START
BUT ALSO TO SUSTAIN THEIR EFFORTS OVER TIME.

WE DON\'T KNOW WHAT THE LONG﷓TERM EFFECTS ARE IN THE CONTEXT OF
PREVENTION.

AND WE DON\'T KNOW HOW TO BEST INTEGRATE PELVIC FLOOR MUSCLE TRAINING
INTO THE HEALTHCARE SYSTEM, LET ALONE HOW IT COULD BE PAID FOR.

SO TURNING NOW TO DIET AND WAIT LOSS, WE HEARD A﷓﷓WEIGHT LOSS, WE HEARD
A LOVELY PRESENTATION YESTERDAY, TELLS US WHAT A RISK FACTOR OBESITY FOR
URINARY INCOPINENCE, WE HAVE A NUMBER OF EPIDEMIOLOGICAL STUDIESS BUT
CLINICAL STUDIES TO SHOW THE ASSOCIATION BETWEEN OBESITY AND URINARY
INCONTINENCE AND WE ALSO HAVE EVIDENCE THAT OBESITY PLACES PATIENTS AT
INCREASED RISK OF FECAL INCONTINENCE AS L. THE INTERESTING THING ABOUT
THIS IS THAT OBESITY IS A MODIFIABLE RISK FACTOR OR AT LEAST A
POTENTIALLY MODIFIABLE RISK FACTOR AND NOT EVERYBODY WOULD AGREE THAT
IT\'S ALL THAT EASY TO CHANGE.

WE HAVE DATA FROM THE NURSES HEALTH STUDY, SHOWING THE WEIGHT GAIN WAS A
RISK FACTOR FOR INCIDENT URINARY INCOPINENCE AND WE HAVE DATA FROM
SEVERAL CLINICAL STUDIESS SHOWING IMPROVEMENT, REDUCTIONS IN URINARY
INCONTINENCE WITH WEIGHT LOSS AND THIS INVOLVES DECREASESES IN
PREVALENCE OF URINARY INCONTINENCE, HAVING FEWER INCONTINENT EPISODESS,
HAVING LESS NEED FOR AB CORPENT PADS AND ONE STUDY THAT SHOWED CHANGES
IN URODYNAMIC PARAMETERS.

THESE ARE DATA FROM A STUDY WE DID AT THE UNIVERSITY OF ALABAMA,
BIRMINGHAM, THIS WAS A WEIGHT LOSS STUDY USING BARIATRIC WEIGHT LOSS
SURGERY AND AS CAN YOU SEE THE PREVALENCE OF URINARY INCONTINENCE
DECREASED FROM ABOUT 66% BEFORE THE BARIATRIC WEIGHT LOSS SURGERY TO
ABOUT 37% 12 MONTHS AFTER THEY HAD THE SURGERY AND INCIDENTALLY THIS IS
ASSOCIATE WIDE AN 18﷓POINT﷓﷓18 BMI POINT WEIGHT LOSS.

IN THIS STUDY, THE MAGNITUDE OF CHANGE IN BMI WAS STRONGLY CORRELATED IN
THE CHANGE IN INCONTINENCE STATUS, SO THE MORE WEIGHT YOU LOSS, THE MORE
LIKELY YOU WERE TO REGAIN YOUR CONTINENCE STATUS IF YOU WERE
INCONTINENCE GOING INTO THIS STUDY.

IN ADDITION TO URINARY INCONTINENCE WE SAW CHANGES WITH FECAL
INCONTINENCE.

FROM 19.4% BEFORE THE SURGERY, TO 8.612 MONTHS FOLLOWING THE﷓﷓A .6 12
MONTHS FOLLOWING THE SURGERY.

SO WE CONCLUDE THAT IT COULD BE EXPECTED TO PREVENT POSSIBLY FECAL
INCONTINENCE, I THINK DR. CAIN BROUGHT UP THE POINT POINT THAT NOT
EVERYONE MIGHT CONSIDER WEIGHT LOSS AS A PRIMARY APPROACH TO THE
TREATMENT OF URINARY INCONTINENCE OR PRIMARY APPROACH TO PREVENTION, BUT
WE ALSO HAVE THE OPGZ OF TO THINK OF THIS IN TERMS OF THIS BEING ANAD
RISK POPULATION AND INSTEAD OF THINKING THEY HAVE TO LOSE WEIGHT, MAYBE
THIS A GROUP THEY WANT TO TARGET FOR PELVIC MUSCLE FLOOR TRAINING OR
COMP PENSATORY INTERVENTION.

ASIDE FROM DIET FOR WEIGHT LOSS, THERE ARE MANY DIETARY FACTORSES THAT
HAVE BEEN IMPLICATED AS RISK FACTORS FOR URINARY AND FECAL INCONTINENCE.

IT\'S WIDELY BELIEVED THAT THESE SUBSTANCES ARE BLADDER IRRITANTS,
CAFFEINE, SPICY FOODS CARBONATED BEVERAGESS AND SUBSIDIARY CONSTITUTES
AND THERE ARE PEOPLE IN THE AUDENS WHO WOULD LOVE TO COME UP HERE AND
TOOL ME ABOUT OTHER THINGSES THAT SHOULD HAVE BEEN ON THIS LIST BUT
PATIENTS AND CLINE IGS REPORT THAT SOME OF THESE SUBSTANCES INCREASE THE
OCCURRENCE OR SEVERITY OF URIGENCEY IN URINARY INCONTINENCE.

THE BEST EVIDENCE EXISTS FOR THE ROLE OF CAFFEINE.

THERE ARE STUDIESES THAT SHOW THAT CAFFEINE INCREASES THE TERMS OF
PRESSURE AND IT STIMULATES BOWEL MOTILITY AND SHOWS THAT THE ELIMINATION
OF CAFFEINE FROM THE DITET IMPROVED BOTH STRESSED AND URGENT
INCONTINENCE.

WHAT ABOUT FACTORSES THAT DIETARY FACTORS FOR FECAL INCONTINENCE?

WELL WE\'VE HEARD EARLIER IN IN MEETING THAT FECAL IMPACTION AND
CONSIPATION ARE RECK RECOGNIZED WITH FACTORS CUBING TO FECAL AND URINARY
INCONTINENCE PARTICULARLY IN NURSING HOME POPULATIONS.

SO IT MAKES SENSE THAT RECOMMENDATIONS FOR NORMAL FLUID INTAKE OR
DIETARY FIBER OR WHATEVER WOULD HELP TO MAINTAIN NORMAL STOOL CONS
CYSTENCY MAY HELP TO AVOID FECAL INCONTINENCE AS WELL AS URINARY
INCONTINENCE.

WE KNOW VERY LITTLE ABOUT WHAT ARE THE MOST HEALTHY BLADDER HABITS BUT
IT IS THOUGHT BY MANY PEOPLE THAT HABITUAL FEE PRENTURINATION CAN
CONTRIBUTE TO REDUCE BLADDER CAPACITY, URIGENCE SCHEURGENT CONTINENCE.

WE DO HAVE A VERY EFFECTIVE INTERVENTION CALLED BLADDER TRAIN TAG BREAKS
THE CYCLE OF URIGENCEY USING VOIDING SCHEDULES AND THIS HAS BEEN SHOWN
TO BE EFFECTIVE AS A TREATMENT FOR URGENT INCONTINENCE BUT WE DON\'T
KNOW IF ALTERING VOIDING AB HABITS WILL BE EFFECTIVE AS A PREVENTION.

WE HAVE STUDIED﷓﷓WE HAVE STUDIES LACKING ON THE NATURAL HISTORY OF
URINARY INCONTINENCE, IN PEOPLE WHO ARE VARIOUS BLADDER HABITS, FOR
EXAMPLE PEOPLE WHO VOID FREQUENTLY, WHAT WHAPS TO BLADDER CONTROL,
LONG﷓TERM OR PEOPLE WHO VOID VERY INFREQUENTLY.

BUT GIVEN THE EFFICACY OF VOIDING SCHEDULES WE USE WITH BLADDER TRAINING
IT\'S CONCEIVABLE THAT WE COULD IDENTIFY PATIENTSES WITH FREQUENT
URINATION OR INFREQUENT IRINATION AND WE COULD TEACH THEM ABOUT NORMAL
BLADDER HABITS AND INCLUDES INARMAL FREQUENCY OF URINATION AND THIS
MIGHT HELP PREVENT BLADDER CONTROL PROSPECTS PROBLEMS.

THERE ARE CERTAIN BOWEL HABITS THAT ARE THOUGHT TO CONTRIBUTE TO FECAL
INCONTINENCE, FOR EXAMPLE POSTPONING BOWEL MOVEMENTS FOR LONG
TOWARDS﷓﷓PERIODS OF TIME AND CAN AGGRAVATE FECAL INCONTINENCE SO IT\'S
REASONABLE TO THINK ABOUT THE POSSIBILITY FOR TEACHING NORMAL BOWEL
HABITS TO PEOPLE THAT THESE MIGHT HAVE PREVEPTIVE VALUE AND
SPECIFICALLY, INTERVENTIONS THAT INVOLVE JUST ESTABLISHING A NORMAL
ROUTINE FOR HAVING BOWEL MOVEMENTS AND TEACHING PEOPLE THAT IT\'S BEST
TO RESPOND TO THE URGE TO DEFECATE RATHER THAN TO IGNORE IT FOR LONG
TOWARDS PERIODS OF TIME AND FINALLY SMOKING, THERE ARE SEVERAL STUDIESS
NOW THAT PROVIDE EVERYDAY FOR A LINK BETWEEN SMOKING NOT ONLY URINARY
INCONTINENCE BUT FECAL INCOPINENCE AS WELL.

I DIDN\'T FIND ANY STUDIES THAT TESTED THE EFFECTS OF SMOKING CESSATION
ON URINARY OR FECAL INCONTINENCE.

AND IT PROBABLY WILL NEVER BE A PRIMARY APPROACH, BUT THE RELATIONSHIP
BETWEEN SMOKING AND INCONTINENCE MIGHT BE ANOTHER REASON TO DISCOWER AN
THE INITIATION OF SMOKING OR TO MOTIVATE PEOPLE TO STOP SMOKING.

SO IN CONCLUSION, SOME OF THE RECOMMENDATIONS FOR RESEARCH, I THINK ARE
CLEAR, WE NEED MORE RESEARCH IN ALL AREAS RELATED TO PREVENTION OF
URINARY INCONTINENCE AND FECAL INCOPINENCE.

FECAL INCONTINENCE IS PARTICULARLY UNDERSTUDIED WHEN IT COMES TO
PREVENTION AND MEN ARE PARTICULARLY UNDERSTUDIED WHEN IT COMES TO
PREVENTION.

WE NEED MORE MODELS FOR FECAL INCONTINENCE IN OLDER MEN AND WOMEN.

IF ANYTHING IS PREDICTABLE IS THAT WE\'RE ALL GOING TO GET OLDER AND ALL
THE STUDIES SHOW THAT INCONTINENCE INCREASESES WITH AGE SO WE KNOW IT\'S
COMING, IT SEEMS LIKE WE COULD BE THINKING ABOUT MODELS FOR SOMETHING
THIS PREDICT ANNUAL.

WE DO NEED MORE WORK ON MODELS FOR TO HELP SYSTEMS FOR WOMEN,
PARTICULARLY CHILD BEARING WOMEN AND MORE MUSCLE FLOOR TRAINING FOR MEN
WHO ARE PLANNING PROSTATECTOMY AT THE VERY LEAST AND RESEARCH IS NEEDED
ON GENERAL PUBLIC EDUCATION REGARDING LIFESTYLE DECISION, WHAT WE EAT,
HOW MUCH WE\'RE GOING TO WEIGH, PELVIC FLOOR MUSCLE EXERCISES BLADDER
AND BOWEL HABITS AND I THINK YOU\'RE GOING TO HEAR MORE ABOUT SOME OF
THESE ISSUES FROM OUR NEXT SPEAKER.

(APPLAUSE).

\>\> THANK YOU.

\>\> AND OUR NEXT SPEAK SER DISCI AN NEWMAN THE CO DIRECTOR OF CENTER
FOR CONTINENCE AND PELVIC HEALTH AT THE DIVISION OF UROLOGY AND
UNIVERSITY OF PENS PEN.

\>\> A LOT OF MY TALK HAS BEEN HEARD SO I\'M GOING TO GO THROUGH THIS
WICKLY.

TRIED TO DIVIDE IT UP INTO FECAL INCONTINENCE AND IDENTISKS OF PERSONS
AT RISK AND SO WE TALK ABOUT PREVENTION.

I THINK WE NEED TO REALLY THINK ABOUT THESE THREE AREAS.

PRIMARY, SECONDARY AND TERBIARY AND I THINK IT\'S IMPORTANT WHEN WE MOVE
FORWARD FOR THE RESEARCH THAT WE REALLY DEFINE THESE THREE TYPES OF
PREVENTION.

BECAUSE I THINK THAT JUST CONTINUING TO LOOK AT INDIVIDUALS WHO HAVE
INCONTINENCE ARE AT RISK, YOU KNOW WE MAY WANT TO GO LOOK AT PRIMARY
PREVENTION AND I THINK IN WOMEN.

WE HAVE TO LOOK AT POPULATIONS AT RISK AND IDENTIFY FACTORS ASSOCIATED
AND STRATEGIESS THAT OF COURSE ULTIMA MODIFIABLE RISK FACTORS AND AGAIN
I WANT TO EMPHASIZE EARLY TREATMENT.

WE KNOW﷓﷓OH, THIS IS NOT MY SLIDE SET FROM TODAY.

WHAT I WANT TO TALK ABOUT IS THAT\'S WE NEED TO GO TO PRIMARY AND
SECONDARY SCHOOL AGE CHILDREN.

CATHY JUST TALKED A LITTLE BIT ABOUT THE FACT THAT SHE WAS TALKING ABOUT
VOIDING HABITS AND HEALTHY BLADDER HABITS.

AS INCONTINENCE, WHETHER IT\'S FECAL OR URINARY ARE REALLY HIGENIC
PROBLEMS, THEY\'RE SOCIAL TABUS WE NEED TO THINK ABOUT PERHAPS
DISCUSSING IT IN SECONDARY GRADE SCHOOL EDUCATION AT THOSE PROGRAMS WE
HAVE PROGRESSESS ON SMOKING CESSATION, WE HAVE PROGRAMS ON UNPROTECTED
SEC, AND WE NEED TO TALK ABOUT THIS TOO.

WE HAVE﷓﷓WE HAVE PRIMARY PREVENTION THERE\'S NO RESEARCH ON THIS COUNTRY
ON THAT.

YOU DO SEE SOME APPROACH IN OTHER COUNTRIESSA FAR AS DISCUSSING PELVIC
FLOOR MUSCLES TO HIGH SCHOOL CHILDREN AND ESPECIALLY IN EUROPE BUT NOT
IN THE UNITED STATES I\'M GOING TO BE OFF KILTER BECAUSE THIS IS NOT THE
SLIDE SET.

OKAY.

WE KNOW ENOUGH ABOUT PREGGANCY AND CHILD BIRTH IN FACT THAT PREVENTION
STRATEGIES SHOULD BE INVESTIGATORRED AS FAR AS OBSTETRICAL INJURY AND
C﷓SECTION IS AN ISSUE.

I THINK THE C﷓SECTION RATE IS INCREASING SIGH THINK IT\'S A CONCERN.

AND DO WE HAVE OP STETRICAL INJURY AND SHOULD WE OFFER WOMEN PRIOR TO
CHILD BIRTH, THE TRAINING, THE ONLY THING I WANT TO TREES TO YOU AS A
CLINE CISION THAT IF YOU GO BACK TO PELVIC FLOOR MUSCLE EXERCISES THEY
ARE KEGLE EXERCISES AT LEAST 98% OF MY POPULATION OF WOMEN WHO SEE 92 IN
EYE TERBIARY CENTER, I DON\'T SEVEN SEE THEM, THEY TELL ME THEY HAVE
DONE THEM AND THEY\'RE NOT SUCCESS EMPLOY WHEN YOU LOOK AT THIS
RESEARCH, THIS A VERY STRUCTURED TRAINING PROGRAM.

SO WE\'VE BEEN DOING KEGEL EXERCISES SINCE THE 1940 WHEN IS IT WAS FIRST
DESCRIBE.

I DIDN\'T IT HASN\'T BEEN STRESSED ENOUGH, THIS IS A VERY INTENSIVE
TRAINING PROGRAM AND MOST OF THIS RESEARCH.

AND YOU HAVE TO GET OVER THE BARRIER OF WOMEN TO SAY, WELL, NO WE\'RE
NOT TALKING ABOUT KEGEL EXERCISES ALTHOUGH I\'M TALKING ABOUT A NEW
PHYSICAL MEDICINE PROGRAM THAT I\'M GOING TO TEACH YOU.

AND I THINK MIGHT HAVE TO BE CAREFUL OF THAT, OKAY?

AND I WANT TO REALLY STRESS THAT TO YOU IS WE NEED TO THINK OF THAT
BECAUSE THESE HAVE BEEN AROUND A LONG PERIOD OF TIME AND WE\'VE ADDED
TRAINING WHICH IS A SKELETAL MUSCLE PROGRAM.

AS FAR AS LIFETIME CHANGES AS CATHY SAID WE ALL DO IT IN CLINICAL
PRACTICE BUT WE DON\'T HAVE ANY TYPE OF LONGITUDINAL STUDIES OS THESE,
WITH THE FACT THAT IF YOU LOOK AT THE FDA LABELS AND OVERTHE COUNTER
PRODUCTS OVER A THOUSAND HAVE CAFFEINE IN THEM, WE NOW HAVE CAFFEINE IN
MINTS, PATIENT ARE NOT AWARE OF THE A LOT OF PRODUCTS THAT HAVE IT AND
WE DO THAT CORRELATION.

IT\'S ASTOUNDING TO ME WHEN I SIT WITH PATIENT AND SAY CAFFEINE MAY BE
IMPACTING YOUR URGENT CONTINENCE BUT IN THE SOUTH THEY DRINK SWEET TEA
EVERY HOUR, THEY DO CHOCOLATE IS AND WHEN YOU GIVE THEM A LIST THEY COME
BACK AND SAY, WELL YOU WERE RIGHT, I DO SEE THAT THIS CAUSES IT.

AND AGAIN I ALL WE HAD TO THINK ABOUT LIFESTYLE IRPT VENTIONS ON
BEHAVIORIAL MODISKS BUT WE NEED TO THINK IT OF IT LONG﷓TERM.

MEN OVER AGAIN, PROSTATECTOMY, I THINK THE ELEPHANT IN THE ROOM THAT NO
HAS BERATE UP AND HOW DO YOU PAY FOR TEACHING THESE MEN HOW TO DO PELVIC
FLOOR MUSCLE TRAINING PRE﷓OP.

YOU HEARD THEM SAY THEY DO A LOT OF RADICALS AT UNIVERSITY OF PENS
EXPENSE AND I\'VE BEEN ASKED BY HIM AND MY SURGEON WHO\'S ROBOTIC WHO BY
THE WAY TOLD ME NONE OF HIS PATIENTS HAVE INCONTINENCE BUT TWO YEARS
LATER I HAPPENED TO SEE SOME, WE HAVE PATIENTS HAVE EVEN WRITTEN TO US
SAYING WE WANT TO LEARN THESE PRE﷓OP.

WE DON\'T KNOW HOW TO DO THAT WITHIN A CERTAIN STRUCTURE OF HEALTHCARE.

AND I THINK THAT\'SAN ELEPHANT IN THE ROOM THAT NO ONE\'S BRINGING UP,
WE NEED WERE ON HOW DO THAT AND THAT WILL AFFECT HOW WE\'VE INN
REIMBURSED BUT THE OTHER THING IS AGAIN MEN WITH POST MATURATION
DRIBBLE, GIVE THEM STRATEGIES TO EMPTY OUT THAT URETHRA HAVE BEEN
EFFECTIVE AND I CONSIDER THAT IN MEN IN BPh AND UNDER POST HERSS AND
OLDER ADULTS AS FAR AS PRIMARY I\'LL SHOW YOU,﷓﷓MODIFICATION PROGRAM,
WHEN YOU LOOK AT THIS PROGRAM THEY HAD TEACHERS THAT WERE UROLOGIST,
UNDERSTOOD THE PELVIC FLOOR, THEY WERE TAUGHT, THEY TESTED PELVIC FLOOR
STRAINTS AND DIGITAL EXAM AND PELVIC TROLL C THE CONTROL WAS NO
TREATMENT, THEY SAW MEASURABLE EFFECT AT ONE YEAR.

THEY TALK ABOUT THIS IS THE SUSTAINABLE, THIS PROGRAM HAS﷓﷓WAS A TACHLE
AT ONE YEAR AND THIS HAS HUGE APE PRIICATION IN THE COMMUNITY AS FAR AS
THE STRATEGY AND I THINKCATHY SHOWED THIS BUT BASICALLY WHAT YOU SEE IS
THAT BOTH GROPE GROUPS WHETHER PARTICULAR THE CONTROL OF TREATMENT HAD
39% CONTINENCE, THEY WERE TREATMENT AT BASELINE AND THEY WERE LIKELY TO
REMAINING ON OR BECOME KONT NEBS SO AGAIN THIS CAN BE REPLICATED.

CAN THIS BE DONE ACROSS SENIOR CENTERS ACROSS ASSISTIVE LIVING.

WE TALK ABOUT INCONINENCE IS A PROGRESSION WHETHER IT\'S URINARY OR
FECAL TO LONG﷓TERM CARE, WHERE DON\'T WE REPLICATE THIS PROGRAM THIS, IS
A PRIMARY PREVENTION PROGRAM, SO WHAT YOU SEE AGAIN IS THAT YOU SAW
DECREASED FREQUENCY DURING NOCCURIAN RATS I THINK HAD THIS IS A NICE
AGAIN PREHAIAL MODIFICATION, WHEN YOU SAY THAT WE ARE COMBINING TIME
TOILETING, WE\'RE COMBINING MUSCLE TRAINING, LIFESTYLE SUCH AS CAFFEINE
REDUCTION, WE\'RE ASKING ABOUT THE BOWELS SO WE\'RE COMBINING MANY
INTERVENTIONS YOU HEARD OVER THE LAST TWO DAYS INTO ONE TYPE OF PROGRAM.

SO BASICALLY PRIMARY PREVENTION STUDY SHOULD BE LIMITED TO INTERVENTIONS
BUT THAT\'S DIFFICULT TO DO BUT WE HAVE TO LOOK AT POPULATION BASIC
HEALTH STAT EDGY TO IDENTIFY POPULATIONS AT RISKS RISK FACTORSS AND
DEVELOPMENT OF AWARENESS STRATEGIES TO HELP INDIVIDUALS AND AGAIN WE
SHOULD FOCUS ON EARLY TREATMENT.

ROBBER

FECAL INCONTINENCE IS NOT REALLY A LOT OF DATA AND ONE OF THE SLIDES I
HAD IN HERE, WAS THE ICI BOOKS OF WHICH I HAD GIVEN NIH AND YOU, I HEAR
THEY BURN THE CD FOR YOU, SO CAN YOU GO TO THAT BOOK AND LOOK AT THIS
STUFF IN PREVENTION, THERE ARE FOUR CHAPTERS THAT ADDRESS PREVENTION IN
THAT TEXT AND IT WAS PUBLISHED IN 2005, SO SOME OF THE SPEAKER VS GIVEN
YOU MORE RECENT INFORMATION, BUT IT\'S IN THE SECTION UNDER EDUCATION,
CONTINENCE PROMOTION, IT\'S UNDER IN WOMEN, IT\'S UNDER IN MEN AND WE
HAVE TWO CHAPTERS IN FECAL INCONTINENCE AND THE CHAPTER DOES TALK ABOUT
PRIMARY AND SECONDARY PREVENTION.

AND I THINK THAT YOU KNOW AGAIN IT\'S AROUND THE SAME THINGS THE
SPEAKERS ARE TALKING ABOUT AS FAR AS DELIVERY OF WOMEN, DOESN\'T IT LEAD
TO PEOPLE AND OBSTETRICAL INJURY AND THEN THE ISSUES AS FAR AS PERSON
WITH FREQUENT AND LOOSE STOOLS, LACTOSE INTOLERANTS AND OTHER FOOTS THAT
CAUSE DIARRHE A. WE NEED LONGITUDINAL STUDIES OF FECAL INCONTINENCE AND
GI DISORDERSS AND THEN AGAIN PREVENT ANATOMICAL GEE TECT SUCH AS
STRAINING, HOW MANY WOMEN STRAIN BECAUSE OF CONSIPATION AND IS IT
RELATED TO BIODYSFUNCTION BECAUSE OF AGE.

AND SO REALLY THAT WE HAD TO LOOK OBSTETRICAL AND AGAIN IN THE AREA OF
DELIVER SCHEPELVIC FLOOR MUSCLE EXERCISE PRIOR TO DELIVERY.

BUT I WANT TO SPEND TIME ON IN A SCREENING, YOU KNOW WE\'VE GOT TO
FIGURE OUT HOW TO IDENTIFY THESE PERSONS AND I\'VE BEEN IN IN FIELD FOR
20 YEARSS AND I GO BACK AND FORTH ON HOW TO DO IT BECAUSE I HAVEN\'T
SEEN REALLY MUCH IMPROVEMENT AND THIS IS REALLY WHAT IS A SUMMARY OF
BOTH OF THESE CONDITIONS, THAT BASICALLY NEARLY 2/3RDS WAIT TWO YEARS SO
WOMEN WAY A LONG PERIOD OF TIME BEFORE SEEKING TREATMENT.

HITOLE YOU THAT BEING IN UROLOGY AND SEEING A LOT OF POST RADICAL MEN,
MEN DO NOT WAIT.

MEN DO NOT PUT UP WITH THIS.

MEN WILL HAVE THAT CATHETER OUT AFTER SURGERY AND BE CALLING IN TWO DAYS
TO HAVE AN POINTMENT WITH ME BECAUSE THEY CANNOT HANDLE THE WETNESS.

WOMEN DO WAIT FOR A LONG TIME WHEN YOU SEE THESE PATIENTS EVEN AT THE
TERBIARY LEVEL THEY\'VE WAITED 10 YEARS 15 YEARS WAIT A BIT OF TIME
BEFORE THEY COME FORWARD.

THEY SELF MANAGE, WE NEED TO INVESTIGATE THIS MORE, THEY THINK IF THEY
DON\'T DRINK, THEY WON\'T WET, THEY VOID MORE FREQUENTLY WHICH IS CALLED
TOILET MAPPING AND THEY GO TO AB CORPENT PRODUCTS.

IN THE UNITED STATES WE ARE A COUNTRY THAT HAVE INCONTINENCE PRODUCTS IN
RETAIL, IN OTHER COUNTRIES IT\'S PART OF THE HEALTH SYSTEM WHERE ARE YOU
SUPPLIESS THOSE AS PART OF YOUR INSURANCE.

OKAY?

I DON\'T SEE THAT EVER CHANGING.

SO THE POINT IS THAT IF YOU GO TO ANY CVS ECKERED OR WAL﷓MART OVER
WHATEVER, HAVE YOU A WHOLE AISLE OF PRODUCTS.

WHEN I STARTED MEN STRAIGHTING THAT WAS NOT THE CASE, YOU WOULD FINE THE
PAD UNDERNEATH THE BOTTOM LEVELS AND I\'M NOT THAT OLD YET, SO THE THING
IS NOW YOU SEE A WHOLE LOT OF INCONTINENCE PRODUCTS DIFFERENT FROM THE
MEN TRAIL PRODUCTS.

PERCEIVED A LOW PRIMARY HEALTH PROVIDERS LESS THAN 50% QUESTION ABOUT
INCONTINENCE AND WHEN THEY DO QUESTION, ONLY 40% OF PATIENTS GIVEN
SUGGESTON SO AGAIN IT\'S ON A REPORT UNDERTREATED WHEN YOU LOOK AT FECAL
CONINENCE, THIS IS TABU SUBJECT.

IF ANY OF YOU MOTHERS OF CHILDREN, I HAVE THREE DAUGHTERS AND WHEN MY
GIRLS WERE LITTLE AND I WAS TOLD, COME CAREER DAY AT SCHOOL, I MEAN I
NEVER DID IT.

AND MY DAUGHTERS WOULD SAY I\'M GOING TO COME AND TALK ABOUT THE BOWEL
AND DAUGHTER AND ALL DAUGHTERS THREATEN TO LEAVE HOME AND RUN AWAY SO
NEVER DID IT HOWEVER I SANE OFF AS A MOTHER, WHAT?

PROTECTED SEX FORMS THEY\'RE GOING TO TALK ABOUT SEX IN CLASS, HOWEVER
WE DON\'T WANT TO TALK ABOUT, YOU KNOW, WHETHER THEY HAD A BOWEL
MOVEMENT THAT DAY, WE WOULDN\'T WANT TO TALK ABOUT THAT, BUT THE POINT
IS THAT THESE ARE VERY TAB OO SUBJECTS, LESS THAN PATIENTS REPORTED IT
THE PROVIDERS, SO FECAL OR ANNAL INCONTINENCE IS UNDERREPORTED AND UNDER
TREATED. THIS WHAT YOU HEAR THE DOCTOR WON\'T KNOW HOW TO HELP, THERE\'S
NO SOLUTION ANYWAY, I\'M ENBAR ASSED TO TALK ABOUT, I CAN COPE, THAT\'S
WHAT YOU HEAR.

I COPED WITH THIS FOR YEARS NOW IT\'S OUT OF HIGH CONTROL.

IT\'S NOT SERIOUS ENOUGH TO NEED A MEDICAL SOLUTION.

OKAY?

IT\'S NOT REALLY SERIOUS ENOUGH, I HAVE OTHER PROBLEMS, MY FRIENDS HAVE
OTHER PROBLEMS, THIS IS MINOR.

PHYSICIANS AND PATIENTS PERCEPTIONS DIFFER, AGAIN WHEN THEY TALK ABOUT
IT IN THIS CARTOON IT\'S TIMICAL DON\'T WASTE THE DOCTORS TIME WITH
QUESTIONS, WE ARE BEING SQUEEZED TO TURN THESE OFFICES AROUND IN OUR
OFFICE FOR FINANCIAL REASONS SO THAT INCONTINENCE MAY WESTBOUND YOUR
HAND\'SOT DOOR KNOB AND THEN THEY HAVE A QUESTION ABOUT SO AGAIN YOU DO
NOT SEE IT BEING BROAD UP.

﷓﷓BROUGHT UP.

WHEN YOU LOOK AT TERMINOLOGY AROBED THE WORLD IT\'S NOT REALLY
UNDERSTAND, PATIENTS WITH THINGS IN BLADDER HEALTH, BLADDER 50NESS AFTER
50 THAT, GOES OVER REAL WELL, INCONTINENCE NOBODY COMES, BLADDER
CONTROL, I DON\'T HAVE BLADDER CONTROL, I LEAK, I WET, I HAVE A LEAKY
BLADDER.

POOR BLADDER BOWEL CONTROL, OVERACTIVE BLADDER IS I S A TERM, THEY
UNDERSTANDND STABILITY, THEY DON\'T UNDERSTAND ANNAL INCOPINENCE, FECAL
INCOPINENCE, IS THIS A DIN CHROME A SYMPTOM A DIGITEXTIS, NO ONE SEEMSES
TO BE CLEAR ON WHAT IS THIS.

IT\'S A DEC WELL WE HAVE SO MANY THINGS WE CALL IT WELL THEN WHY I
PATIENTS CONFUSED.

THE TERMINOLOGY IS NOT CLEAR, WHEN YOU LOOK AT RESEARCH IN IN AREA, WHY
HOLD OLDER ADULTS DON\'T ASK ABOUT IT THIS, IS ONE STUDY WHERE THEY
RATED IT, NOT A BIG PROBLEM, PART OF AGING I\'M GETTING OLD, OKAY MY
BLADDER\'S WEAK, EMBARRASSED AFRAID THEY\'RE GOING TO GET AN OPERATION,
OR UROLOGY OR GYNECOLOGY, OR UNDERWARE TREATMENT OPINGS, CONSEQUENCES OF
CHILD BIRTH, IT HAPPENED WHEN I HAD THE BABE, SO WHAT THIS WAS MINOR.

DOCTOR BROUGHT UP THE TOPIC, NORMAL PART OF BEING A WOMAN.

THERE\'S A LOT OF MISCONCEPTIONS, THE BARRIERS TO SEEKING TREATMENT FOR
THESE CONDITION SYSTEM LACK OF KNOWLEDGE, AAVAILABLE TREATMENTS,
SYMPTOMS THOUGHT TO BE NORMAL.

OR CHILD BIRTH IN APPROPRIATE MEDICAL ISHT VENTION, OLDER PEOPLE MORE
LIKE TO ACCEPT SYMPTOMS AND THEY DON\'T WANT TO BOTHER THEIR DR. AGAIN,
THEY HAVE CHRONIC PROBLEMS, EMBARRASS, MISCONCEPTION, IT\'S NOT A
MEDICAL PROBLEM.

THIS IS TIED IN THE USE OF WOMEN, I\'M WORN A PATTED FOR MENSTRUATION I
WEAR ONE FOR INCOPINENCE AND THIS IS GYNECOLOGICAL CLINIC IN UK WHEN
THEY LOOKED AT WHICH﷓﷓THEY ACTUALLY LOOKED AT URINARY INCOPINENCE AND
ANNAL INCONTINENCE, URINARY ONLY YOU SEE THE NUMBER OF THE PATIENTS THAT
ACTUALLY SPECIFICALLY ASK ABOUT URINARY AND THESE STATISTICS I\'M VERY
SAD TO SAY ARE OVER 20 YEARS HAVEN\'T CHANGED WE\'RE NOT INCREASING THE
NUMBER OF PEOPLE THAT REPORT THIS IN PRACTICE NO MATTER WHERE YOU SEE
THIS TYPE OF DATA.

AGAIN YOU SEE AROUND ANNAL AND MIXED IT\'S LOW AND THEY HAD ONLY ANNAL
AND THIS IS AGAIN THAT ONE﷓THIRD STATISTIC WE YOU SEE IN ALL THESE
STUDIES.

WHEN YOU LOOK AT THIS WAS PUBLISHED RECENT LEAP AND KYESENER SAN DIEGO
WHEN YOU LOOK AT CARE SEEKING BEHAVIOR AND INCONTINENCE AGAIN, THEY
BROKE IT DOWN IF URINARY ANAL AND THIS IS LARGE GROUPS PAST OR PRESENT
CONDITION, URINARY, 61%, NONSEEK BEING 39%.

ANNAL THESE NUMBERS GO DOWN, NONSEEKING 72, AND 59%.

SO AGAIN, PATIENTS ARE NOT REALLY SEEKING TREATMENT AND THIS IS WITHIN A
KISER SYSTEM, SO MANAGED CARE.

SO AGAIN, WHEN YOU LOOK AT THIS ONE FASCINATING WITH PROLAPSE, WOMEN ARE
LIKELY SPECIALLY AS A AGE, THE YELLOW AND PELVIC ORGAN PROLAPSE,
THEY\'LL COME IN AND REPORT THAT AS OPPOSE TO URINARY AND AND AGAIN, IT
SEEMS THAT THIS IS THE PERCENTAGE OF INDIVIDUALS WITH THESE DISORDERS.

NOW WHENEVER THEY DO, YOU KNOW SAY THEY DO COME TO A PROVIDER AND THEN
THEY BRING IT UP, THIS IS WHAT HAPPENS AS FAR AS DOWN THE ROAD AND AGAIN
THIS IS FAIRLY RECENT DATA.

ANY QUESTIONS, ANSWER QUESTIONS UNCARE﷓﷓SEEKING 80%, DID NOT DISCUSS,
BUT IF AGAIN THEY DISCUSSED IT, 40% SURGERY, CABLES ONLY, AND GENE WE
GOT THE KEGEL IN THERE.

THEY WEREN\'T GETTING ANY INTERVENTION.

THEY DID NOT DISCUSS, NINE% WERE PERFORMING KEGELS.

WHEN YOU LOOK AT SEVERE AND I THINK IT WAS THOSE﷓﷓IT DOES SEEM TO BE
THAT THE SEVERITY DOES PUSH THESE INDIVIDUALSES TO SEEK TREATMENT, AND
AGAIN WITH SEVERE INCONTINENCE 88% ANSWERED THAT THEY HAD IT, DISCUSSED
63% SURGERY, CABLELES ONLY NO TREATMENT SO LOOK AT THESE NUMBERS FOR NO
TREATMENT.

PHOTONS NO TREATMENT, DISCUSS AGAIN SMALL NUMBERS OF KEGELS AND SO YOU
KNOW AND THIS STATUS IS FAIRLY RECENT AND I THEN IS AGAIN IN AN HMO IN
WASHINGTON STATE.

SO THERE\'S A LOT OF FACTORS INFLUENCING ACCESS TO THE SERVICES, WE HAVE
BEAR YEARS AND OPPORTUNITIESS THOSE SEEKS HEALTH AND MANAGING THROUGH
BEHAVIORIAL LIFETIME CHANGES, REACTIONSES TO INCONTINENCE, BELIEFS ABOUT
CAUSES, I\'M GETTING OLD, ATTITUDES OF AGING AND HEALTH, MEDIAN
INFLUENCE AND ADVERTISING AND THEN THEIR CONTACT WITH PRIMARY CARE SO WE
HAVE TO LOOK AT ALL THESE WHEN WE THINK ABOUT SCREENING AND ACCESS TO
THESE SERVICES.

AND THERE\'S A LOT OF HURDLE,S WE HAVE TO OVERCOME AND THERE ARE
HURDLE,S ON THE SIDE OF PATIENTS BUT THERE ARE ALSO HURDLE,S ON THE SIDE
OF EMBARRASSMENT.

I FEEL A LOT OF PROVIDERS EMBUYER ASSED TO BRING IT UP WITH PATIENTS
WHETHER IT\'S A GENDER ISSUE, WHETHER THEY DON\'T FEEL THEY\'RE COMTENT
TO DEAL WITH IT, WHETHER THEY DON\'T HAVE TIME THIS, IS REALLY A PROBLEM
AND I THINK THAT YOU KNOW WE NEED TO ADDRESS THESE TO MOVE FORWARD.

IT IS WONDERFUL TODAY THESE LAST TWO DAYSES TO HEAR FROM ALL THESE
RESEARCHERS BUT LET ME TELL YOU WE HAVE TO TRANSLATE THAT INTO CLINICAL
PRACTICE AND THE REALITY OF CLINICAL PRACTICE FOR A CONDITION THAT IS
LARGE NUMBERS OF PATIENTS.

SO WHAT DO THEY WANT?

WELL THEY WANT TO BE DIAGNOSED, YOU KNOW THEY WANT TO BE EDUCATED BIDE
SOMEONE WHO\'S KNOWLEDGEABLE, CHOICES OF THERAPY REALIST EXPECTATIONS OF
TREATMENT OUTCOMESS AND THEY WANT TO HAVE CLINICAL EFFICACY AS FAR AS
COMPLICATIONS SIDE EFFECTS AND THEY WANT TO BE IMPROVED WHAT\'S ALSO
INTERESTING IN IN AREA OF MEDICINE IS IF YOU HAVE LOW BACK PAIN, YOU
WANT YOUR BACK PAIN GONE, IF YOU HAVE PAIN YOU WANT IT GONE.

THIS POPULATION WHEN YOU HAVE SOMEBODY WHO\'S VOIDING 43 TIMES A DAY
WHICH IS SOMETIMES WHEN YOU SEE, GOING DOWN TO 23, IS TO THEM CURED.

IS WHEN I TALK TO HEALTHCARE PROVIDERS THEY\'RE SHOCKED BY THAT.

YOU KNOW WE NORMALIZE THE BLOOD PRESSURE, THAT\'S NOT THE CASE WITH
THIS.

NOT ALL PATIENTS THOUGH, THAT TO THEM MAY BE WHAT THEIR EXPECTATIONS ARE
SO WE NEED TO LOOK AT WHAT A REALIST EXPECTATIONS DEPENDING ON
SYMPTOMMAATOLOGY, SO THESE ARE STRATEGIESS, AND I WANT TO GO THROUGH
THIS HE\'S SCREENING.

WE NEED TO EDUCATE REALLY AT NURSING AND PHYSICIAN LEVEL.

WHEN YOU LOOK AT NURSING EDUCATION, WE DO HAVE SOME EDUCATION AT
ADVANCED PRACTICE NURSES AT THE MPC NS LEVEL.

WE NEED TO PUSH FOR THIS.

WE\'RE NOT GOING TO CHANGE THE SCREENING CONDITION UNLESS IT GETS FIST
THE CURRICULUM OF NURSING AND MEDICAL EDUCATION.

THE OTHER THING THAT DIDN\'T GET IN IS I WANT TO GO THROUGH THIS, MAYBE
ONE MODEL, ONE OF YOU BROUGHT UP YESTERDAY HA OTHER MODELS AND OTHER
AREAS CAN WE APPLY.

I WANT TO SHOW YOU YOU MIGHT BE ABLE TO APPLY BUT THIS IS A NICE STUDY
AND ACTUALLY, THEY﷓﷓THIS STUDY WAS TAKING THE ACPR GUIDE LINES WHICH ARE
HRQ NEW FROM 1996 AND IN THERE WE TALKED ABOUT MOW TO ASSESS, HOW TO
SCREEN AND ALL THAT STUFF, AND WHAT THEY DID, IS THEY LOOKED AT﷓﷓THEY
TOOK THOSE GUIDELINES SO 41 PRIMARY CARE PRACTICES, THEY GOT THREE CMRE,
PATIENT EDUCATION MATERIALS TO GIVE OUT, ONSEAT PHYSICIAN OFFICE SUPPORT
AND THIS GROUP HAD USUAL CARE.

AND WHAT YOU SEE IS DISTURBING.

IT DIDN\'T MATTER WHICH GROUP, ONLY 20% WERE SCREENED.

SO IT DIDN\'T MATTER ALL THAT EICATION BUT WHAT WAS THE ISSUE AGAIN THIS
IS THE ELEPHANT IN THE ROOM, IF THEY SPENT MORE TIME WITH PATIENTS THEY
WERE MORE LIKELY TO SCREEN.

TIME TRANCEALATES INTO RBU\'S AND THAT TRANSLATES INTO DOLLARS.

SO THIS IS IMPORTANT.

ARE WE UNREALISTIC IN THE CURAIN MODEL OF THE DELIVERY OF HEALTHCARE TO
EXPECT PRIMARY CARE TO SCREEN, I SAY YES, I SAY WE GO TO THE DIABETIC
MODEL, WHAT DO WE HAVE IN DIABETES TO HELP WITH THIS.

THE DIABETIC NURSE EDUCATOR.

THAT IS ACTUALLY A MODEL THAT HAS BEEN PUT IN PLACE THAT\'S REIMBURSABLE
AND THAT DIABETIC NURSE EDUCATOR COMES MISS AND EDUCATES ABOUT DIABETES,
WHAT IS YOUR DIET, HOW ARE YOU CHECKING YOUR SUGARS, THAT MAY BE A
MODEL, THAT IS IN ENDOCRINOLOGY PRACTICE THIS THIS TYPE OF CHRONIC
ILLNESS.

AND THE OTHER THING TO LOOK AT IS CAN REGULATORY CHANGE THIS WHOLE AREA
AND I\'M GOING TO END WITH THESE FEW SLIDES.

WE DO HAVE REPORTING MECHANISMS, NOW THE CMS PHYSICIAN VOLUNTARY
REPORTING PROGRAM IS OUT THERE ON ACUTE CARE, WE ARE GOING TO ELECTRIC
AT THESE.

THESE ARE THE AREASES THAT\'S GOING TO HAPPEN.

AND AS CAN YOU SEE WOMEN OVER THE AGE OF 65, ARE WE ASSESSING, WHAT THE
CHARACTERISTICS AND PLAN OF CARE.

AND SO THAT MIGHT IMPROVE SCREENING, BECAUSE THAT IS GOING TO BE A
REGULATORY REQUIREMENT.

IN HOME CARE, YOU ACTUALLY HAVE THE OASIS ASSESSMENT SO WHENEVER
THEY\'RE AUDITING AND THEY\'RE LOOKED AT FOR REIMBURSEMENT AS FAR AS
COMPLIANCE THEY HAVE INKOPT INNOCENCE AS PART OF THE THE OASISAIN\'RE
ASSESS CEMETERY.

THEY\'RE USE INDEED LONG﷓TERM CARE CAN THAT BE APPLIED IN OTHER SETTINGS
AND INCONTINENCE WHETHER IT\'S FECAL OR URINARY PROBLEMS SYSTEM IN THERE
AND THEN OF COURSE THIS CMS SURVEYOR OR LONG﷓TERM CARE.

SO REGULATORY MAY BE A WAY TO REALLY IMPROVE SCREENING OF THESE
CONDITIONS.

SO TO END WITH THIS STRATEGIESS YOU KNOW WE HAVE TO LOOK AT EDUCATION
PROGRAMS, ESPECIALLY MINIMUM STANDARDS FOR CONTINENCE SPECIALISTS AND
GENERAL AND PUBLIC CONSUMER USE HAPPENING THE WEB BASED PROGRAM, DISTANT
LEARNING TECHNIQUES ALONG SIDE TRADITIONAL METHODS, I THINK WE REALLY
NEED TO STRESS THE FACT THAT WE HAVE TO HAVE COMPULSORY INCLUSION OF
CURRICULUM OF HEALTHCARE PROPRIDERS AND THIS SHOULD BE AN ADENTIFIED
PLAN AND PREFERABLY TAUGHT AS A SEPARATE TOPIC NOT AS PART OF MAYBE A
ANOTHER TYPE OF AREA, AND AGAIN, THIS SHOULD BE AT THE HIGHEST LEVELS
AND THEN WE NEED TO LOOK AT PUBLIC ELDICATION PROGRAMS AS WELL AS PUBLIC
HEALTH PROGRAMS.

AND I THINK THAT\'S IT.

ALL MY PREFERENCES I HAVE IN THERE.

THANK YOU.

(APPLAUSE).

\>\> THANK YOU VERY MUCH.

LET ME INVITE THE DOCTORS BACK UP FRONT HERE AND WE\'LL NOW BE OPEN FOR
QUESTIONS FROM THE PANEL.

\>\> DR. KRAMER IS OFFICIALLY POINTING OUT THAT WE\'RE AT THE END OF OUR
HOUR FOR THE PRESENTATIONS BUT SINCE WE HAD THE EXTRA TIME WITH DR.
MINER, WE\'LL GO FOR ANOTHER 20 MINUTES UNTIL 1:00.

\>\> I\'D LIKE TO JUST PICK UP ON SOMETHING THAT DIANE SAID ABOUT
TRAINING OF PHYSICIANS AND NURSING.

AND THE ARTICLE THAT THE STUDY THAT WAS SHOWN WAS REALLY VERY
DISCOURAGING AND IT SUPPORTS THE OLD ADAGE THAT DOCTORS DON\'T DO WHAT
THEY\'RE NOT TRAINED TO DO.

AND THE FOCUS THEN IS IF THE TRAINING CAME EARLIER ON IN MEDICAL SCHOOL
OR RESIDENCY TRAINING WOULD IT THEN BE A PART OF WHAT\'S NORMAL TO DO
AND THEREFORE GETS DONE AT HIGHER RATES ONCE PEOPLE ARE OUT IN PRACTICE?

AND I HAD THE PLEASURE OF BEING INVOLVED WITH APE GO IN THE DEVELOPMENT
OF COMPETENCES ARE MEDICAL EDUCATION IN TERMS OF WOMEN\'S HEALTH AND I
AS AN INTERNIST FOUND THAT BE TO WONDERFUL BECAUSE THERE WAS AN
INTERDISCIPLINARY EFFORT TO LOOK AT INFORMING ALL POTENTIAL DISCIPLINES
ABOUT THESE ISSUES.

BUT I HAVEN\'T SEEN THEM BEING USED IN REALTIME OR APPLIED AND I
WONDERED WHETHER OR NOT, YOU HAVE ANY DATA ON WHETHER OR NOT THOSE KINDS
OF COMPETENCIESS HAVE BEEN INTEGRATED BETTER IN NURSING EDUCATION.

\>\> THE ONLY PLACE YOU SEE NURSING EDUCATION IS ACTUALLY AT THE NURSE
PRACTITIONER LEVEL, THEY HAVE AS PART OF SAY DEMENTIA AND ALL THAT, YOU
DO NOT SEE IT AT THE BASIC NURSING LEVEL AND WHEN WE TALK ABOUT
INCONTINENCE WHETHER IT\'S FECAL OR URINARY IN NURSING IT\'S AT THE
BASIC LEVEL OF NURSING CARE.

I DON\'T SEE THAT IN THE﷓﷓

\>\> CAN I JUST MAKE A COMMENT HERE.

I THINK ONE OF THE REASONS YOU SEE PHYSICIANS UNWILLING TO TAKE THIS ON
IS BECAUSE OF THE PERACCEPTING THAT THERE\'S NOTHING THEY CO DO ABOUT
IT.

AND BEFORE WE START PUTTING COMPETENCIES INTO CURRICULUM, WE NEED TO PUT
INFORMATION IN.

WE NEED TO REALLY IDENTIFY AND I\'M NOT SURE WE ARE READY TO DO THAT
YET, WHAT IS THE IMPERICAL EVIDENCE THAT IRPT VENTIONS MAKE A
DIFFERENCE, WHAT PROPORTION AND AGAIN THIS COMES BACK TO THIS, YOU KNOW
OVERARCHING INCONTINENCE AS OPPOSE TO SUBSCAT GOREYS AND IF HAVE YOU
THESE CHARACTERISTICS HERE\'S A TREATMENT THAT WORKS, HERE\'S THE DAA
THAT SHOWS IT WORKS.

\>\> I HAVE TO CHALLENGE YOU SINCE WE DON\'T HAVE THAT SINCE WE SHOULD
JUST LEAVE IT ALONE.

\>\> THE ANSWER IS IF WE HAVE SOMETHING TO SAY IS WE SHOULD SHUT UP.

\>\> SO WE SHOULD IGNORE IT.

\>\> IT\'S VERY HARD TO COME INTO A GROUP OF PEOPLE WHO ARE ALL
ENNEWSIASTS ABOUT INCOPINENCE AND SAY THAT MAYBE, YOU KNOW STARTING
EARLY CHILDHOOD EDUCATION ON INCONTINENCE PROBABLY ISN\'T AS
IMPORTANTING AS LEARNING HOW TO READ, BUT IT MAY NOT BE.

IT MAY WELL BE THAT THIS IS A NEGLECTED SUBJECT AND THAT\'S TRAGIC, BUT
IN FACT WHAT WE﷓﷓THIS IS A STATE OF THE SCIENCE CONFERENCE, WE NEED NOR
SCIENCE.

﷓﷓MORE SCIENCE AND THAT EXHOOTERRING PEOPLE TO BE KIND AND CONSIDERATE
AND TO CARE, WON\'T YOU KNOW BE AS EFFECTIVE AS REALLY SHOWING PEOPLE
THAT THERE\'S SOMETHING﷓﷓WHEN WE HAVE IT THERE\'S SOMETHING CAN YOU DO,
THIS PART OF IT IS TREATABLE, FOCUS ON THE PART THAT\'S TREATABLE.

\>\> THERE\'S ALSO A FAILURE TO FOR SCIENCE, THE KNOWLEDGE ABOUT SCIENCE
TO DIFFUSE INTO MEDICAL AWARENESS AND MEDICAL EDUCATION AND TRAINING AND
POST GRADUATE TRAINING AND I GO BACK TO A COMMENT THAT WAS MADE BEFORE
ABOUT WHO KNOWS WHAT THE PELVIC FLOOR IS?

LET ALONE TO TALK ABOUT PELVIC FLOOR MUSCLE THERAPY, MOST DOCTORS
PRIMARY CARE DOCTORS NORTHE EVEN AWARE OF THAT AND WE\'VE BEEN SHOWN
THAT YOU KNOW ALTHOUGH IT MAY NOT BE STANDARDIZED IT DOES HAVE
BENEFICIAL RESULTS.

AND EVEN IF PHYSICIAN PHYSICIANS KNOW ABOUT﷓﷓PELVIC FLOOR MUSCLE THERAPY
BECAUSE THEY READ ABOUT IT OR HEARD ABOUT IT, THEY DON\'T KNOW WHO TO
REFER TO GET THOSE SERVICES, SO I DIFFER WITH YOU ABOUT THE NEED FOR
PROFESSIONAL EDUCATION.

WHAT WE CURRENTLY HAVE OUT THERE.

\>\> YEAH, AGAIN, LET ME JUST POINT OUT THAT IN THE STUDIESS WE\'VE BEEN
TALKING ABOUT FOR THE LAST TWO DAYS, THERE ARE VERY FEW STUDIES THAT
SHOW LONG﷓TERM EFFECTS.

EVEN SOMETHING AS PROMISING AS PELVIC FLOOR MUSCLE EXERCISES.

YOU KNOW YOU GET A YEAR, SOMETIMES TWO YEARS, BUT YOU KNOW IF YOU\'RE
GOING TO START AT AN EARLY AGE AND YOU\'RE GOING TO YOU KNOW WE TALKED
BODY DOING COST BENEFIT ANALYSIS, I MEAN THIS A PHENOMENAL UNDERTAKING
WITH SO LITTLE INFORMATION TO START JUMPING INTO TRYING TO CALCULATE THE
COST BENEFIT OF THESE KINDS OF INVESTMENTS, WE ARE DATA BEREST IN THIS
AREA﷓﷓BEREST AND THIS PANEL HAS A REAL OPPORTUNITY TO IDENTIFY WHAT ARE
THOSE AREAS WHERE WE NEED TO DEVELOP THIS INFORMATION AND YOU\'RE GOING
TO HAVE TO DECIDE WHETHER YOU WANT AND COMPASSIONED CARING, CERTAINLY
THE LADDER.

\>\> JUST TO BE SPECIFIC, I WAS GOING TO ASK YOU WHAT EVIDENCE IS THERE
FOR LONG﷓TERM DURABILITY SPECIFICALLY ABOUT SURGICAL PROCEDURES AND
PELVIC FLOOR EXERCISES AND BY LONG﷓TERM I MEAN GREATER THAN TWO TO THREE
YEARS.

\>\> THE ANSWER IS WE\'VE﷓﷓I DON\'T THINK WE HAVE IT.

\>\> ﷓﷓IT SEEMS TO ME THERE\'S﷓﷓IT\'S BECOME THE STANDARD OF ASSESSING
OUTCOMES OF SURGICAL PROCEDURES TO HAVE LONGER OUTCOMES AND IT SEEMS TO
ME THAT IT\'S BECOMING OR HAS ALREADY BECOME THE STANDARD OF TWO YEARS
BEFORE PEOPLE ARE REALLY INTERESTED IN WHAT THE OUTCOME IS AND
BEHAVIORIAL INTERVENTION PELVIC FLOOR MUSCLE TRAINING WE HAVE A
SMATTERING OF LONG﷓TERM FOLLOW UP THAT GENERALLY SHOWS SOME REGRESSION
BUT NOT A TOTAL REGRESSION AND NOW WE\'RE HAVING TO DEAL WITH ISSUES OF
LONG﷓TERM ADHERENCE TO SEE IF WE CAN SUSTAIN THESE EFFECTS OF DURABILITY
IS STILL AN ISSUE FOR RESEARCH.

BUT A LOT OF THE STUDIESS STILL REMAINING ON TO REMAINING ON HAVING UT
COMES AT SIX MONTHS, EIGHT WEEKS, SIX MONTHS, IN A YEAR ESTABLISHING
WHAT\'S THE MOST EFFECTIVE WAY TO DO IT AND THEN DURABILITY HAS ALWAYS
BEEN SORT OF AN AFTERTHOUGHT.

\>\> I WOULD PUSH BACK ON THAT, WE HAVE LONG﷓TERM OUTCOMES ON CANCER
FIVE AND 10 YEAR SURVIVALS AND I DON\'T KNOW YOU HAVE BETTER LET RATTURE
TAB I OF ANY I\'M TALKING FIVE OR 10 YEARS LATER THAT LOOKED
PROSPECTIVELY, AND THERE\'S TIME THERE\'S A FALL OUT BUT\'S ONLY OVER A
TWO OR THREE YEAR PERIOD, I WOULD LOVE TO KNOW ABOUT IT BUSINESS?

THINK YOU\'RE PUTTING YOUR HANDS OS A REAL ISSUE AND I WANT TO JUST MAKE
SURE WE SEPARATE TWO THINGS WHEY WE TALK ABOUT THINGS LIKE PELVIC FLOOR
EXERCISES THERE\'S SOME COMBINATION OF WHETHER SHORT TIME DYNAMIC
EFFECTS AND AND PRODUCE A SUSTAINED EFFECT OR WHETHER THEY HAVE TO BE
CONTINUED IN ORD TORE STAY WITH THE REGIMEN IN ORD TORE MAINTAIN
BENEFIT, AND I DON\'T THINK WE KNOW ENOUGH TO MAKE THAT DISTINCTION FOR
THE LATTER.

SO THE ANSWER WHY THEY\'RE NOT SUSTAINABLE IS THAT THAT PROCEDURE IS NO
LONGER DONE.

SO BE CAREFUL INFER﷓﷓

\>\> THAT\'S BECAUSE THEY DIDN\'T WORK.

\>\> WELL, NO, NO, BUT THAT\'S WHAT I\'M SAYING IT\'S DIFFICULT TO LOOK
DETERMINE TAY LOSS.

\>\> I\'M I\'M MIKE FROM THE UNIVERSITY OF NORTH CAROLINA MY AREA IS
EXPERTISE AND EVALUATION AND FIRST OF ABOUT SCREENING IN THE SECOND
ABOUT TREATMENT, WITH RESPECT TO SCREENING OR MAYBE YOU MIGHT WANT TO
CALL IT ORGANIZED DETECTION, I THINK THERE IS ANOTHER PARADIGM THAT
WE\'VE ALREADY USED IN MEDICINE AROUND THE ISSUE OF SCREENING FOR
ORGANIZED PROGRAMS TO DETECT DEPRESSION AND IN THAT SETTING AGAIN, IT\'S
SYMPTOMATIC CONDITION THAT\'S UNDERREPORTED OR SIGMAITIZED.

I WONDER IF YOU CAN TALK A LITTLE BIT ABOUT THE EVIDENCE THAT WE DO HAVE
ABOUT STRATEGIES FOR DETECTION.

YOU MENTION STUDIESS THAT WERE DONE IF CLINICAL STUDIES WERE THOSE
CONDUCTSES IN PRIMARY CARE SETTINGS, CAN YOU TALK A BIT ABOUT THE
TRIEWMENTS USEDDED, HOW SHORT THEY WERE BECAUSE AGAIN FOR PRIMARY CARE
INITIAL SCREENS WHERE 2/3RDS OF THE POPULATION DOES NOT HAVE HAVE THE
CONDITION THAT PECULIAR BECOMES IMPORTANT AND MAYBE DESCRIBE A LITTLE
BIT ABOUT ALSO THE NEGFIVE PREDICTIVE VALUE WHICH YOU DIDN\'T REPORT ON
IN THE QUESTIONNAIRES BECAUSE AGAIN LEVELED SCREENING IS IMPORTANT FOR
US TO BE SENSITIVE BUT WE WOULD FOLLOW IT MORE SPECIFIC TESTS.

\>\> YEAH, WE DID NOT LOOK AT THE FALSE/POSITIVE RATE.

I CAN\'T TELL YOU ABOUT THAT.

WITH REGARD TO THE SCREENING, IF YOU USE THE MODEL OF DEPRESSION, I MEAN
CAN YOU GET PROBABLY 90% IF YOUR PURPOSE IS CLINICAL DETECTION WITH ONE
QUESTION.

I MEAN, ARE YOU DEPRESSED.

I\'M NOT SURE FROM THE EXPERIENCE AND INCONTINENCE WHETHER THE SAME
HOLDS.

IT SEEMS TO ME THIS IS AN AREA THAT SEEMS TO BE﷓﷓YOU HAVE TO FROM THE AT
LEAST THE ANECDOTAL DATA YOU HAVE TO PROBE MORE DEEPLY.

THE MEASURES THAT WERE USED FOR THESE VARIED AND I WOULD HAVE TO SHOW
YOU THE LIST OF THEM, MOST OF THEM ARE YOU KNOW QUESTIONS THAT GO DOWN
THROUGH A HIGHER ARCHY OF YOU KNOW DO HAVE YOU ANY PROBLEMS, HOW OFTEN
DO YOU HAVE THEM, HOW SEVERE ARE THEY AND THEN USE DIFFERENT
DEFINITIONSES TO TRY TO ELUCIDATE THIS.

THE EMPHASIS IN THOSE STUDIESS WAS ON SENSITIVITY AND SPECIFICITY, THE
GOAL WAS TO TRY AND FIND CASES BECAUSE THERE WAS A PRESESMGZ THAT THEY
WEREN\'T BEING DETECTED.

\>\> I WONDER IF THE OTHER PANELISTS WANT TO COMMENT ON IF THEY HAVE
BRIEF INSTRUMENTS THEY BELIEVE PERFORM WELL WE\'RE EITHER URINARY OR
FECAL INCONINENCE, WHAT YOU PRACTICE MOST OF IS WE DON\'T USE, WE DON\'T
HAVE TIME AND BASICALLY YOU EITHER HAVE THE PATIENT DO YOU WET YOURSELF
OR YOU NOTICE ON PHYSICAL EXAM.

I HATE TO TELL YOU BUT THAT\'S WHEN WE DO.

THESE QUESTIONNAIRES ARE WONDERFUL, BUT WE CAN\'T APPLY THEM IN CLINICAL
PRACTICE.

I MEAN IT WOULD BE NICE YOU\'RE RIGHT IF WE HAD ONE QUESTION LIKE
DEPRESSION, SO TO SAY THAT AND I\'M TALKING EVEN TERBIARY LIKE YOU\'RE
SAYING YOU\'RE RIGHT, PRIMARY CARE, THAT\'S ANOTHER BIG CONCERN.

\>\> MY SECOND QUESTION OR COMEBT IS ABOUT TREATMENT AND I JUST WANT TO
ACKNOWLEDGE THAT ONE OF THE TOMMICS OF TREATMENT WE\'VE NOT DISCUSSED AT
ALL HERE IS NOT PART OF THIS FORUM IS TREATMENT WITH MEDICINES FOR URGE
INCONTINENCE, IT\'S IMPORTANT FOR US TO HAVE IN DECIDE BEING WHETHER OR
NOT TO SCREEN AN IDEA ABOUT WHETHER OR NOT THERE IS EFFECTIVE TREATMENT
FOR THE KIND OF URINARY OR FECAL INCONNEBS THAT WE WOULD DETECT AND I
HAVE YET TO HEAR CONSENSUS ABOUT IN GENERAL ONCE YOU APPLY THE VARIOUS
ADDITIONAL DIAGNOSTIC WORK UP YOU WOULD NEED TO BEND PEOPLE INTO THE
APPROPRIATE GROUP WHETHER WE THINK FROM THE PATIENT CENTER PERSPECTIVE
TO TREATMENT TO TREATMENTS AVAILABLE TO JUSTIFY LOOKING FOR IT AT THE
INITIAL LEVEL.

\>\> WELL WE\'VE HAD A VERY INTERESTING PUBLIC EFFECT ON URGING
CONTINENCE BECAUSE IT\'S BECOME DIRECTED CONSUMER ADVERTISED AND THAT
HAS CHANGED A GREAT DEAL SORT OF HOW THIS IS HANDLED AND I IT\'S
INTERESTING THAT THE DRUGS THAT ARE BEING ADVERTISED TO CONSUMERS ARE
THE SAME DRUGS WE HAVE BEEN DISMISSING FOR MANY YEARS AS HAVING
POTENTIAL SIDE EFFECTSS AND BEING RELATIVELY INEFFECTIVE SO, I DON\'T
KNOW HOW TO ANSWER YOUR QUESTION.

YOU KNOW YOU CAN SAY THAT DIRECT TO CONSUMER ADVERRIZING HAS BEEN
EXTREMELY BENEFICIAL, HOWEVER, CONFUSING THE TERMINOLOGY IN TERMS OF YOU
KNOW JUST AS DEPENDS MADE IT MORE POSSIBLE TO TALK ABOUT INCONTINENCE IN
PARTICULARLY OLDER PEOPLE, THESE DRUGS NOW MAKE IT MORE REASONABLE FOR
PEOPLE TO COME TO THE MEDICAL CARE SYSTEM AND IF ONCE FOUND WE COULD
APPROPRIATELY TRIAGE THEM TO GET THE RIGHT KINDS OF TREATMENTS I THINK
THAT MIGHT BE A USEFUL THING TO DO.

I WOULD COME BACK TO YOU.

YOU\'RE﷓﷓I THINK WE\'RE PUTTING THE CART BEFORE THE HORSE IN WORRYING
ABOUT COMING UP WITH THE IDEAL QUESTIONNAIRE WHEN IN FACT, THE BIG BANG
IS AS I THINK THE DATA THAT IS NEWMAN TALKED ABOUT SHOWS THERE\'S NO
RESPONSE.

PEOPLE JUST DON\'T EVEN ASK ABOUT THESE KINDS OF PROBLEMSES IN MANY
CASESS AND IT SEEMS TO ME IF WE GET OVER THAT HUMP THEN WE CAN WORRY
ABOUT POLISHING OFF THE MOST EFFECT, PSYCHO﷓﷓METRICICALLY APPROPRIATE
QUESTION.

\>\> WELL FROM SOMEONE WHO DOES IMPLEMENTATION RESEARCH WHEN I GO OUT TO
IMPLEMENT VARIOUS THINGS THAT ARE EFFECTIVE, PEOPLE WANT TO KNOW WHAT
THE WORK IS, AND SO, KNOWING WITH WHETHER IT\'S GOING TO BE A ONE
QUESTION SCREENER OR 20 QUESTION SCREENER EFFECTS ENTHUSIASM FOR
ADOPTING THIS AS OPPOSE TO THE LAST ADOPTABLE THING.

\>\> IF YOU\'RE ASKING IF MEDICATIONS FOR URGENT CONTINENCE SURE THEY
ARE THERE,\'S NO QUESTION THAT YES THEY ARE EFFECTIVE AND IT SHOULD BE
SCREENED AND THEY SHOULD BE OFFERED DO THEY MAKE IT SO YOU NEVER HAVE TO
GO TO THE BATHROOM NO BUT THEY DO IMPROVICISMAATOLOGY AND.

\>\> AND FOR CASE THERE\'S MORE THAN ONE WAY TO APPROACH TTHE LAST
QUESTION IS A FAIRLY SPECIFIC ONE, THE TRIAL YOU SHOWED OF PELVIC FLOOR
MUSCLE TRAINING IN OLDER WOMEN, HOW WAS THAT GROUP RECRUITED I KNOW IT
WAS FROM THE COMMUNITY BUT WHAT WERE THEY TOLD BECAUSE GETTING PEOPLE TO
PARTICIPATE IN A RELATIVE INTENSIVE PROGRAM BEFORE THEY HAVE SYMPTOMS
MAY BE DIFFICULT.

\>\> I DON\'T REMEMBER THE DETAILS.

\>\> THEY DO A LOT OF RECRUITMENT AND IT IS DESCRIBED IN THE REFOR
INSTANCE.

\>\> I HAVE THE ARTICLE WITH ME I COULD LOOK IT UP AFTER THE DISCUSSION.

\>\> THANK YOU.

\>\> BOB FROM YALE.

TODAY WE HEARD A LOT OF REALLY GOOD IDEAS ABOUT PREVENTION STRATEGIES
WITH THE OUTCOME MEASURE BEING RECREASING THE PROGRESS OF THE
INCONTINENCE, I E I\'M WONDERING ABOUT OTHER PROGRESSION STAT EDGIES
THAT MIGHT HAVE DIFFERENT OUTCOMES AND THE ONE I\'M PARTICULARLY
INTERESTED IN IS DECREASING THE PROGRESSION OF QUALITY OF LIFE FOR
WORSENING WITH INCONTINENCE SO OTHER HIGHLY SIGMAITIZED DISORDER AND
SUCH AS HIV AND CANCER AND COME UP WITH EVIDENCE BASED STRATEGIES THAT
REALLY TARGET THE QUALITY OF LIFE ISSUES, SO, IF IT\'S SOMETHING LIKE
YES, HAVE YOU THIS DISORDER AND WE MAY OR MAY NOT BE ABLE ON DO
SOMETHING ABOUT IT BUT WE\'RE REALLY GOING TO WORK WITH YOU TO MAKE SURE
THAT YOU\'RE LIFE, THAT YOU CONTINUE TO LIVE YOUR LIFE.

SO WORK FUNCTION AND FAMILY FUNCTION AND SEXUAL FUNCTION.

ALL THOSE ARE INDEPENDENT AREAS WHERE WE LOOK FOR DECREASING IN QUALITY
OF FOR IMPROVING QUALITY OF LIFE AND I WAS WONDERING IF YOU COULD
COMMENT ON THAT WITH REGARD TO INCONTINENCE.

\>\> I\'VE NEVER REALLY THOUGHT OF THAT AS PREVENTION.

BUT THERE\'S CERTAINLY ARE A NUMBER OF INTERVENTIONS AND THERE ARE
INVESTIGATES WHO HAVE CERTAINLY LOOKED AT WAYSES TO COPE WITH
INCONTINENCE AND MANAGING INCONTINENT AND COMPENSATE FOR INCONTINENCE
AND DIANE YOU\'RE FAMILIAR WITH THOSE.

\>\> YEAH AND ALSO IN THE THIS LITERATURE WE PRESENT THERE, IS STUFF
ABOUT WERE THEY ABLE TO GO OUT MORE, THEY WERE ABLE TO DO MORE ACTIVITY
SO YOU SEE THAT TYPE OF THING AS FAR AS IMPROVING QUALITY OF LIFE.

THAT\'S WHY I SAID YOU MAY NOT GET TRINESS BUT NOW I\'M ABLE TO BE MORE
ACTIVE, KITRAVEL AND WE ASK THAT SO YOU DO SEE THAT EMBEDDED IN THIS
RESEARCH, SURE.

WE SEND TO NOT﷓﷓TEND TO NOT PUSH﷓﷓I\'M SAYING THAT BECAUSE WE WANT
TANGIBLICISMAATOLOGY IMPROVE BUT SUCH AS QUALITY OF LIFE BUT YOU DO SEE
IT IN PATIENTS I MAY THINK, I WANT TO MAKE THAT INDIVIDUAL DRY OR I
DON\'T WANT THEM GETTING UP AT NIGHT BUT THE PATIENT\'S FINE WITH ONCE
AT NIGHT BECAUSE NOW, YOU KNOW THEY FEEL BETTER DURING THE DAY WHICH IS
IMPROVES THEIR QUALITY OF LIFE AND HOW THEY CAN FUNCTION.

SO YOU\'RE RIGHT, THAT IS EMBEDDED IN THIS.

\>\> AND MAKE THAT DISTINCTION BETWEEN TREATMENT C MANAGEMENT.

\>\> YEAH.

\>\> MANAGEMENT GENERALLY REFERS TO ALL THOSE OTHER STRATEGIES THAT
IMPROVE QUALITY OF LIFE.

\>\> BUT THESE ARE EVIDENCE BASEDDED TREATMENTS SO THE THINK THE IDEA IS
THAT THERE\'S SORT OF A DISCRIMINATION AGAINST MANAGEMENT AS BEING AS
ACTIVE OR INVOLVED.

\>\> WELL WE DON\'T DISCUSS AT THAT AT THIS MEETING AT ALL THERE. \'S A
WHOLE THING AS FAR AS THEY MANAGE, I MEAN, YOU MAY SAY WE DON\'T HAVE
THE RESEARCH FOR THESE INTERVENTIONS BUT INDIVIDUALS ARE MANAGING THEIR
URINE AND FECAL LEAKAGE AND THAT\'S GOING TO GO ON WITH THE NUMBERS WE
SEE AND THE INCREASING AGING POPULATION.

\>\> SIMILARLY THERE MIGHT BE EVIDENCE BASED TREATMENTS THAT MIGHT HELP
THEM MANAGE OR IMPROVE THEIR WALT OF LIFE.

\>\> RIGHT, IT WASN\'T ON OUR AGENDA FOR THIS MEETING.

\>\> THANK YOU.

DID EMPLOY.

\>\> CATHY HART MAN, VANDERBILT UNIVERSITY, EYE WOULD LIKE TO TALK ABOUT
THE COMMENTS.

WE ARE AS A GROUP DESPITE THIS NECESSARY DIVERSE BETWEEN TREATMENT AND
DATA AND THE TOPICS THAT WE\'RE ABLE TO HAVE, ON THE SYMPOSIUM, CHARGED
WITH TALKING ABOUT SCREENING AND AS MIKE ALLUDED TO ONE OF THE
NECESSITIESS OF DETECTION OR SCREENING DEPENDING ON WHICH PARADIGM YOU
LIKE, BETTER AS A SIM APTIC CHOICE, HIRCHLGS ON THE AVAILABILITY OF
TREATMENT, SO WE WOULD ALLOW, I BELIEVE THOSE WHO DO WORK IN IN
BEHAVIORIAL AND MEDICAL AND SURGICAL THERAPEUTIC INTERVENTIONS AVAILABLE
THAT MAKE DETECTION A WORTH WHILE GOAL.

BUT WE GONE THE WHOLE CONFERENCE WITHOUT MEN OF US IN THE ROOM SAYING
WHICH TWO QUESTIONS WOULD WE ASK?

SO I\'M DIEING TO ASK YOU.

\>\> I\'VE BEEN TRYING FOR YEARS AT THE END OF EVERY TALK TO JUST MAKE A
PLEA FOR ALL HEALTHCARE PROVIDERSES TO JUST ASK YOUR PATIENT ASS PART OF
THE REGULAR REVIEW OF SYSTEMS ASK THEM IF THEY HAVE PROBLEMS WITH
BLADDER OR BOWEL.

\>\> AND ANY QUESTION RAISES THE ISSUE.

\>\> THEN YOU\'RE NEXT QUESTION IS, SAY, OH, YOU DON\'T﷓﷓DO YOU EVER
WEAR ANY PRODUCTS TO COLLECT BECAUSE THEY VIEW THE PRODUCT AS SOLVING
THEIR PROBLEM.

SO I DON\'T HAVE A PROBLEM ANYMORE, BUT SURE I WORK HARD﷓﷓I\'M WEARING A
DIAPER THREE TIMES A DAY.

SO THOSE ARE THE TWO QUESTIONSES ARE IS THAT YOU ALWAYS ASK THAT SECOND
ONE I BELIEVE AND SHE\'S RIGHT.

PEOPLE UNDERSTAND BLADDER AND BOWELS.

THEY DON\'T UNDERSTAND GASTROENTEROLOGY BUT THEN THE ANSWER IS NO I
DON\'T, WELL ARE YOU WEARING ANYTHING FOR PROTECTION?

I MEAN FEMME GET HA AND THAT WHERE I THINK WOULD BE HELPFUL.

\>\> I THINK THERE\'S BEEN SOME CROSS CUT NOTHING THE LITERATURE ABOUT
THE SENSITIVITY OF DO HAVE YOU PROBLEMS WITH BLADDER OR BOWEL AND SOME
DESIRE TO SEE US AND AGAIN I UNDERSTAND COMPLETELY WE ARE WORKING IN THE
DARK IN THE ABSENCE OF EVIDENCE BUT DO﷓﷓WHAT IS THE OPINION IN THE ROOM
ABOUT THE NEED TO INCLUDE ACCIDENTAL LOSS OF URINE OR STOOL VERSES
FUNCTIONAL MEASURES LIKE PROTECTION IN THAT FIRST﷓﷓IN THOSE FIRST COUPLE
QUESTIONS.

DO YOU NEED TO FURTHER PA RAMITIZE IT IN YOUR EXPERT OPINION.

I THINK THE GOAL IS TO OPEN UP THE TOPIC.

IN THE MOST GENERAL WAY IN THE LEAST THREATENING WAY SO THAT THE PERSON
CAN ACKNOWLEDGE THAT THERE\'S SOMETHING GOING ON AND THEN CAN YOU PURSUE
WHAT IT USING CLINICAL JUDGMENT.

WHAT IS GOING ON?

LEAKAGE O RUNNING TO THE BATHROOM ALL THE TIME IT CAN GO FROM THERE BUT
YOU CAN OPEN UP IN THE MOST NONTHREATENING AND GOODBYE WAY THAT\'S WHAT
I WOULD RECOMMEND.

\>\> YEAH, ACCIDENTS TO PATES ARE LIKE, OH, YOU KNOW, SOMETHING BAD AND
CONTROL AND WE KIND OF LEARN FROM CHILDHOOD, WE CONTROL OUR BOWELS AND
BLADDER WE\'RE TAUGHT THAT THAT\'S IMPORTANT TO US AS CHILDREN.

SO THE LACK OF CONTROL PROBLEMS MAKES THEM UNDERSTAND.

I KNOW YOU SEE ACCIDENT, BUT I NEVER USE THAT TERM IN PRACTICE,
ACCIDENTS.

BUT THAT\'S YOU KNOW?

\>\> DOES THAT ANSWER THE QUESTION?

\>\> YEAH, DOES THAT?

DOES THAT HELP?

NO?

SORRY.

\>\> I THINK OUR PANEL WILL STRUGGLING WITH THIS ISSUE OF INCONTINENCE
AND WHICH OUTCOME DO YOU USE AND ESPECIALLY WITH THE REHAB MODEL WE\'RE
DEALING WITH PATIENTS AND THIS ALL CAME OUT OF TRYING TO ELIMINATE
SUFFERING OUT THERE AND I THINK WE NEED EVERYTHING FROM THE
PATHOPHYSIOLOGY TO THE DIAGNOSIS AND THESE OTHER OUTCOMES THAT ARE
CRITICAL AND VALUABLE AND I JUST LAST IN METHOD METHODOLOGY AND SCIENCE,
ARE YOU FAMILIAR WITH DR. VUVAN\'S HORN\'S WORK WHERE WE VERY
SCIENTIFICALLY GOES IN AND THIS IS FOR SPECIFICALLY LET\'S TALK ABOUT
INCONTINENCE PREVENTION IN THE NURSING HOME, YOU MEASURE PATIENT IN
DETAILED RATIO THE WHOLE COMPUTER PROGRAM FOR THAT, YOU MEASURE
PROCESSESS AND YOU MEASURE OUT COME THEN YOU LOOK AT WHAT PROCESSES ARE
ASSOCIATED WITH THAT ARE OUTCOME, YOU GIVE THAT DATA BACK TO THE
CERTIFIED NURSING ASSISTANTS, SHE\'S SHOWING INCREDIBLE RECUTSES WITH
DECREASING PRESSURE ULCER AND COST, IT DOES NOT INCREASE COST.

BETTER DOCUMENTATION BY THE CNA\'S AND IT\'S REDUCING COST AND SHE SAYS
WE\'RE SHOWING WE REDUCE PRESSURE UTTERS AND BEHAVIORS ARE IMPROVED AND
WEIGHT LOSS IS IMPROVED SO THIS IS USING SCIENCE BUT MANAGEMENT SCIENCE
AND GOING WAY BEYOND THE MORE NARROW PATHOPHYSIOLOGIC TRAY DIGGAL
APPROACHES, I FIND IT VERY PROMISING REAL WORLD APPROACH.

CAN YOU COMMENT?

HAVE YOU HEARD ABOUT THIS?

WHAT ARE YOUR THOUGHTS?

\>\> I\'M VERY FAMILIAR WITH SUZANNE\'S WORK, I THINK YOU\'RE MORE
ENNEWSIASTIC THANE PEOPLE﷓﷓ENTHUSIASTIC THAN PEOPLE WHO REVIEWED IT.

IT\'S A PROMISING EFFORT, THE PERSON WHO HAS DONE THE MOST IN THIS AREA
IS JACK SNELLY, THERE\'S A NUMBER OF STUDIES HE\'S DONE TRYING TO
IDENTIFY SPECIFIC BEHAVIORS THAT CAN BE DONE, THE PROBLEM THAT HE HAS
FOUND AND PEOPLE WHO HAVE WORKED WITH HIM AND IN PARALLEL SIMILAR
PROJECTS IS YOU CAN COMMIN AND MAKE AN INTERVENTION BUT YOU CAN\'T DO IS
SUSTAIN IT.

\>\> DR. HORN\'S WORK IS SUSTAINABLE TAY DATA AND DATA FEEDBACK.

\>\> I﷓﷓I MEAN, THESE PROJECTS ARE NOT GOING TO GET SUSTAINED UNTIL YOU
CAN DEVELOP AN ENVIRONMENT THAT WILL IN FACT REENFORCE THE ORGANIZATIONS
PURSUE TAG GOAL.

\>\> AND SHE HAS DATABASES, THE DATA GOES IN THE THAT\'S RUE SEEN O
IT\'S A BROADER MANAGEMENT.

\>\> I UNDERSTAND THAT BUT IF YOU LISTEN TO DR. SNELLY YESTERDAY, I MEAN
WHAT HE WAS SAYING WHAT WAS THAT THERE NEED TO BE SOCIAL REENFORCERS.

TO MAKE THIS A VIABLE BUSINESS CASE IN ORD TORE DO THESE KINDS OF
THINGS.

THE ISSUE ISN\'T KNOWING WHAT TO DO IN MANY CASES, IT\'S DECIDING THAT
YOU\'RE GOING TO DIVIDE YOUR RESOURCES TO DOING THAT AND THEN LOOKING
OVER THE WHOLE OF THE NURSING HOME TO DECIDE WHAT AREN\'T YOU DOING AS
RAY VIE ULT OF PUTTING YOUR EFFORTS INTO THAT AREA.

AND THESE ARE VERY, VERY, DIFFICULT﷓﷓I MEAN THE DIFFERENCE BETWEEN
CHOOSING A TOPIC AND TRYING TO IMPROVE THE OVERALL QUALITY OF NURSING
HOME CARE REQUIRED TWO VERY DIFFERENT STRATEGIESS.

\>\> AGREED AND THIS DOESN\'T INCREASE COSTS IT\'S A SUSTAINABLE
APPROACH.

\>\> THIS CERTAINLY AN AREA THAT HAS A LOT OF POTENTIAL IS DOESN\'T HAVE
A LOT OF WORK ON IT AND I THAN JACK AND OTHERS HAVE LOOKED AT SORT OF
THE QUALITY INDICATOR WITH FOOD BACK PLANS BUT I JUST﷓HIHAVEN\'T HEARD
ABOUT THEM IN SEVERAL YEARS BUT I KNOW THEY WERE LOOKING INTO IT AND IT
HAS THE SAME POTENTIAL AS LOTS OF OTHER INTERVENTIONS AND IT\'S A
GENERAL RECOGNITION THAT INTERVENTIONS IN THE NURSING HOME HAVE TO DO
WITH IRPT VENTIONS WITH THE STAFF.

\>\> AND IT\'S BANG TO WHAT I SAID ABOUT BEAR YEARSS AND HURDLE,S,
EVERYONE IN THIS ROOM WANTS TO KNOW, EVERYBODY, WHETHER NURSING OR NOT
ARKS PRESSURE ULCER IS BAD, RIGHT?

EVERYBODY AGREES, INCONTINENCE MAY NOT BE VIEW AS THAT BY NURSING STAFF.

REMEMBER, WE SAID A THIRD OF WOMEN POST CHILD BIRTH HAVE INCONINENCE SO
I THIRD OF THAT FEMALE STAFF OF CNA\'S HAVE INCONTINENCE IS THEN TO
TOILET MRS. SO AND SO AT NIEPT TOO GET HER TO THE BATHROOM THERE ARE
ATTITUDES AS ROUND THE WHOLE CONDITION AND WE HAVE HAVEN\'T ADDRESSED
THAT.

\>\> THIS ISN\'T EVEN ATTITUDE THIS IS ECONOMICS IF YOU LOOK AT ECNOMIC
OF TREATS INCONTINENCE AS JACK AS HONE AND OTHERS HAVE SHOWN, IT IS
CHEEPER.

﷓﷓CHEAPER TO CHANGE THEIR DIAPERS THAN IT IS DO GIVE THEM THE ADDING
NURSING TIME TO DO THAT.

THE DOWN SIDE COSTS OF INCREASED HOSPITALIZATION ARE NOT BORNE BY THE
NURSING HOME AND AREN\'T ACTUALLY THAT LARGE, SO THE DIFFERENCE IN THE
ECONOMIC BUSINESS CASE MODEL FOR PRESSURE SORE AND FOR INCONTINENCE ARE
QUITE DIFFERENT.

\>\> YEAHI I JUST WANT TO SAY THAT THERE HAS BEEN RESEARCH IN CULTURE
CHANGE INITIATIVES AND THERE HAVE BEEN SOME KDS STUDIESS THAT SHOWED AN
IMPACT ON INCONTINENCE AND OTHER THINGS THAT HAVE BEEN SUSTAINED OVER
TIME AND THOSE ARE ABOUT ORGANIZE EGGAL MODELS AND MODELS OF ADVANCED
PRACTICE NURSING NOT JUST STAFFING MODELS AND LEVELS.

UNFORTUNATELY MOST OF THE RESEARCH LOOKING AT OUTCOMESES IN AND STAFFING
IS ABOUT NUMBER OF STAFF DOESN\'T LOOK AT WHO THE STAFF ARE HOW THEY\'RE
DEPLOYED EDUCATIONAL LEVELSS AND CONTINUING EDUCATION LEVEL IN THE
FACILITY.

SO, THERE IS SUM RESEARCH THAT SHOWS THAT THOSE THINGS DO MAKE A
DIFFERENCE AND ARE SUSTAINED OVER TIME.

\>\> AND MORE RESEARCH IS NEEDED BECAUSE THERE\'S MODEL WHAT\'S HAVEN\'T
LEGALLY THOUGHT ABOUT.

\>\> WE\'RE ACTUALLY OVER THE AUDIENCE HAS BEEN EXTRAORDINARY AIR ILEY
PATIENT AND WE\'LL TAKE FOUR MORE MINUTES AND WRAP UP AT 10 AFTER THE
HOUR.

SO IF WE COULD HAVE BOTH BRIEF QUESTIONS AND BRIEF RESPONSES.

\>\> HI, I\'M AN OBESE TRICIAN AND I WORK IN A MULTIDISCIPLINARY GROUP
AT UCSD AND WE HAVE A GASTROENTEROLOGIST AND UROLOGIST WORKING TOGETHER
AND AND WE WORK VERY HARD TO COME UP WITH YOU KNOW, DO RESEARCH ON
PATHOPHYSIOLOGY OF SI AND﷓﷓FI AND UI AND WHAT IS INTERESTING ME DURING
THIS CONFERENCE IS THE INFORMATION BEING GIVEN AND THERE\'S A LOT OF
VARIABILITY AND AT THE END OF DISCUSSION, IT\'S THE SAME EXCUSE OR SAME
REASONING WE DON\'T HAVE A DEFINITION, WE DON\'T HAVE, YOU KNOW COMMON
QUALITY OF LIFE SCALES, AND I HEARD DR. CAIN MENTION THAT MANY TIMES YOU
KNOW ELEVATE OURSELVES FROM THAT AND TALK ABOUT AS ISSUE MORE OF A
SYNDROME HOE WE CAN GO TO TO DOING MORE MEANINGFUL RESEARCH ABOUT
PATHOPHYSIOLOGY AND AND TREATMENT BECAUSE THAT WILL EVENTUALLY LEAD TO
PREVENTION.

SO MY QUESTION TO DR. KEEN IS WHAT ARE SOME OF THE EXACT STEPS THAT AS
RESEARCHERS WE NEED TO TAKE OR HAVE TAKEN TO PUT AN END TO THIS CONFLICT
OF YOU KNOW, WHAT\'S DONE BECAUSE ALL THIS IS CORRUPTING DELAYING AND
DISTRACTING MEANINGFUL INFORMATION OR RESEARCH THAT NEEDSES TO BE
PUMPEDDED OUT FROM YOU KNOW GROUPS LIKE OURS?

\>\> WELL THE QUESTION HOW TO CREATE A NEW TAXONOMY FOR INCONTINENCE A
CHALLENGING ONE AND NOT ONE THAT LENS ITSELF TO A QUICK ANSWER BUT LET
ME SUGGEST THERE ARE TWO PARADIPS CAN YOU PURSUE.

ONE IS TO TRY AND DO IT BY WHAT YOU THINK ARE THE URPD LYING MECHANISMS
IF YOU CAN TAKE SOME OF THE BIG TICKET HINGES LIKE FOR EXAMPLE, THE
PEOPLE WHO YOU THINK ARE ENVIRONMENTALLY BEHAVIORIALLY CHALLENGED OPPOSE
TO THE ONES WHO ARE PHYSIOLOGICALLY CHALLENGEDDED WOULD BE ONE CUT AT
THAT.

THE OTHER IS TO THINK ABOUT YOU KNOW SORT OF STARTING IT, THE BACKWARDS
WAY THAT MAKES ME NERVOUS BAY MACK A START WHICH IS RESPONDING TO
TREATMENTS.

YOU KNOW, DIFFERENT KINDS OF INCONTINENCE RESPOND TO DIFFERENT KINDS OF
TREATMENTS.

NOW THERE\'S A DANGER OF BEFINING PNEUMONIA AS THE ABSENCE OF PEN SILLEN
AND I DON\'T WANT TO GO DOWN THAT ROAD TOO QUICKLY BUT EVEN IN WHAT
WE\'VE HEARD OVER THE LAST TWO YEARS, THERE ARE PRETTY CLEAR STARTING
POINTS AT LEAST FOR SAYING WE CAN SUBDIVIDE THESE INCONTINENCE CASES
INTO AT LEAST SOME BIGGER OR SMALLER BLOCKS.

THEY MAY NOT BE THE ULTIMATE BLOCKS AND THAT\'S CLEARLY A RECOMMENDATION
THAT NEEDS TO BE PURSUED MORE SISATICALLY BUT WE AUGHT TO BE ABLE TO
RECOGNIZE THERE ARE TWO DIFFERENT KINDS OF INCONTINENCE AMONG NURSING
HOME PATIENTS RELATED TO AGING AND MAY HAVE SEVERAL DIFFERENT COMPONENTS
TO IT THAT NEED TO BE TEASED OUT AND INCONTINENCE ASSOCIATE WIDE
NEGNANCY MAY NOT BE THE SAME AS AND JUST BEGIN TO LOOK AT SOME OF THOSE
AND THOSE MAY THEN GIVE US THE THIS BETTER OPPORTUNITY TO GET TREATMENTS
THAT WORK AND SORT OF HELP CLINICIANS DECIDE WHICH THINGS OUGHT TO GO
WHERE AND THEN MAYBE MAKE THIS A MORE APPROVABLE SITUATION SO IT\'S NOT
JUST AN AFFECTIVE DISORDER IT\'S A COGNITIVE SCIENCE.

\>\> I WOULD LOOIC TO POINT OUT THAT WE\'RE NOT FINISHED EVEN THOUGH
WE\'RE ABOUT READY TO GO OHM, THIS WHOLE PROCESS OF HAVING A STATE OF
SCIENCE CONFERENCE IS ONLY PART WAY THROUGH AND I KNOW MYSELF I\'M
LOOKING FORWARD TO THE STATEMENT FROM THE PANEL OF EXPERTS BECAUSE I
THINK ONE OF THE TASKS THEY HAVE OVER THE NEXT DAY AND MAYBE EVEN ALL
NIGHT IS HOW TO POOL THIS ALL TOGETHER AND SO, I KNOW THAT THEY\'RE
THINKING DEEPLY AND THEY\'RE ASKING THESE DIFFICULT QUESTIONS BUT EVEN
THOSE OF US WHO HAVE PRESENTED ARE LOOKING FORWARD TO A SYNTH SIS AND
CONSENSUS BECAUSE THAT\'S THE PURPOSE OF HAVING THIS KIND OF A PROCESS
AND THIS KIND OFAVE MEETING.

DID.

\>\> THANK YOU WANDA JONES HHS OFFICE ON WOMEN\'S HEALTH.

YOU RIGHTLY POINTED OUT THE DIFFICULTS OF KEGELS TEACHING THEM EVEN WITH
DIGITAL LURE, SINCE THE ELECTRONIC SENSOR FEEDBACK MECHIMISMSANISMS ARE
THERE OTHER﷓﷓MECHANISMS ARE THERE SIMPLER PLEA A PELVIC FLOOR TYPE
EXERCISESES THAT COULD BE CONSIDERED AND NEED TO BE LOOKED AT IN
ADDITION TO AND COMPARISON TO WHATEVER THE KEGEL BECAUSE WOMEN CAN\'T
DIFFERENTIATE THEIR BUTTOCKS FROM THE MUSCLES NECESSARY TO CONTRACT IN
THE KEGEL.

MAKING IT DIFFICULT F IT WOULD BE NICE TO SEE THAT BECAUSE YOU SEE
PATIENTS TELL THAT YOU YOGA BY SYMPTOMS IMPROVED WHEN I WENT INTO YOGA
AND THERE\'S NO RESEARCH ON THAT BUT I THINK YOU\'RE RIGHT.

I THINK THERE MAY BE OTHER WAYS OUT THERE THAT WE CAN TEACH WOMEN HOW TO
DO THEM BUT AGAIN YOU DON\'T﷓﷓YOU DON\'T SEE ANY RESEARCH, PI LAT EASE,
I HEAR THAT ALSO.

AND SO, YOU KNOW, I DON\'T KNOW.

THE OTHER THING TOO TO REMEMBER AND ONCE THEY START BACK EXERCISES AND
EXERCISE PROGRAM, THEIR SYMPTOMS IMPROVE SO IS IT BECAUSE THEY\'RE
EXERCISES AND MUSCLE STRENGTH AND IMPROVING BUT THERE\'S NO RESEARCH IN
ANY OF THAT BUT IT IS TRUE WHAT YOU SAID, WOMEN AND MEN DO NOT
UNDERSTAND HOW TO DO THESE UNLESS YOU REALLY DO MORE INTENSIVE
INSTRUCTION AND A LOT OFLEDDERLY WOMEN DON\'T HAVE PELVIC EXAMS AND
THAT\'S A PRIME TIME WHEN WE CAN TEACH IS WHEN WOMEN HAVE YEARLILY
PELVICS BECAUSE YOU CAN ASSESS AND SEE WHAT\'S GOING ON WITH THAT AND
THAT\'S NOT DONE.

\>\> KATHRYN FROM THE UNIVERSITY OF CHICAGO, MY COMMENTS ARE FOR DR.
CAIN, I APPRECIATE YOU SHOWING US OUR DIRTY LAUNDRY IN THE FIELD AS TO
DO OF THE PROBLEMS IN OUR LITERATURE AND HOW WE THINK ABOUT IT, BUT I
THINK WE ALSO HAVE TO PUT IT IN THE PERSPECTIVE OF OTHER FIELDS AND
WOULD ASK TO YOU SHOW ME THE DATA THAT 10 YEAR TREATMENTS AND STATINS
AND DIABETICS PROVES QUALITY OF LIFE IN A GIVEN IN OUR CARE AND MY
MOTHER COMMENT HAS TO DO WITH THE STATEMENT ABOUT THE POOR STATE OF THE
SCIENCE IN OUTCOMES, YOU SIGHT THE INTERNATIONAL CONTINENCE SOCIETY
STANDARDIZATION DOCUMENT BUT THAT\'S ONLY I BELIEVE THE ONE THAT YOU
SITED WAS STANDARDIZATION OF TERMINOLOGY.

THERE ARE SEPARATE ONES, THERE ARE TWO ON STANDARDIZATION OF OUTCOMES
ONE IN GENERAL AND ONE IN THE ELDERLY.

THERE IS ALSO EXTENSIVE INFORMATION ON CODIFICATION AND EVIDENCE
BASEDDED ASSESSMENT OF OUTCOMES MEASURES IN THE LATEST INTERNATIONAL
CONSULTATION ON INCONTINENCE WHICH SOUNDS LIKE THE PANEL HAS A COPY OF
AND I WOULD ENCOURAGE PEOPLE TO LOOK AT IT.

ARE WE DONE WITH OUTCOMES AND DETERMINING THE BEST?

I DON\'T THINK SO.

THERE ARE ALSO IS EVIDENCE THAT SCREENING USING THE STICK REGULATORY
APPROACH DOES IMPROVE OUTCOMESS AND THAT\'S FROM THE AKOF PROJECT ACUTE
CARE OF THE VOLLENERRABLE﷓﷓NOT ACUTE CARE, CARE OF THE VULNERABLE
ELDERLY WHERE THE INCONTINENCE MEASURES DID INCREASE THE NUMBER OF
PATIENTS DETECTED.

\>\> I JUST POINT OUT THIS IS A STATE OF THE SCIENCE CONFERENCE ON
PREVENTION OF INCONTINENCE AND THE FACT THAT OTHER AREAS ARE DEFICIENT
SHOULD NOT BE WHAT WE FOCUS ON THE GOAL IS TO IDENTIFY FOR THE PANEL
WHAT ARE THE ACTIONABLE STEPS THAT WE WOULD LIKE TO SEE HAPPEN IN ORD
TORE MOVE THIS FIELD FORWARD AND I﷓﷓IF WE CAN SORT OF NOT BECOME ATTACK
OR DEFENDER BUT RATHER BEGIN TO THINK MORE PRECISELY ABOUT HOW DO WE
FOCUS IN ON THOSE THINGS THAT WOULD MAKE THIS A FIELD IN THE SCIENCE IN
IN FIELD STRONGER I THINK WE ALL BENEFIT FROM THAT.

\>\> PATRICIA, BRIEF QUESTION OR MORE OF A COMMENT ABOUT RANDOMIZED
CONTROLLED TRIALS UNDER POWERED, AWFUL LOT OF CLINICAL TRIALS OUT THERE
THAT DON\'T HAVE ENOUGH SUBJECTS TO DIFFERENTIATE AND THEY REACH A
CONCLUSION THAT THERE\'S NO DIFFERENCE BETWEEN TWO TREATMENTS OR
PREVENGES OR TWO ANYTHING\'S AND TO GIVE THOSE THE SAME WEIGHT ANN
ADEQUATEEE TRIALED POWER, AND THE WE I THINK WE NEED TO DEAF
REPRESENTIATE NAY THAT IN OUR LITERATURE REVIEW.

\>\> IN METAANIGHS WE WEIGHT TRIALS DIFFERENTLY ON THEIR AMPLE SIZE SO
THERE\'S EFFORT TO LOOK AT THAT.

\>\> UNIVERSITY OF NORTH CAROLINA, WE HAD A SLIDE SHOWING 84 RANDOMIZED
CONTROL TRIALS FOR PELVIC FLOOR MUSCLE EXERCISES AND URINARY
INCONTINENCE AND THREE FOR TREATMENT OF URINARY INCONTINENCE WITH
BIOFEEDBACK AND THE THOSE DEFENDANT\'S EXHIBIT MATCH WELL WITH THE
UNCONTROLLED TRIALSES IN THE LITERATURE SO I WOULD HOPE THAT ONE OF THE
GOALS OR RECK MEPDATIONS OF THE PANEL IS TO CALL FOR MORE RANDOMIZED
CONTROL TRIAL FOR BIOFEEDBACK FOR FECAL INCONTINENCE AND ONE OTHER
COMMENT.

WE PRESENTED DAT AVE A STUDY WE DID COMPARING TO BIOFEEDBACK TO PELVIC
FLOOR MUSCLE EXERCISE AND SHOWING OUR BIOFEEDBACK TO BE SUPERIOR IN AN
ADEQUATELY PERFORMED TRIAL AND THAT MANUSCRIPT IS BEING REVIEWED.

\>\> UNIVERSITY OF MICHIGAN.

I YESTERDAY, I WAS DISAPPOINTED, TODAY I\'M A BIT FRUSTRATED, I SEE THAT
THE STATE OF THE SCIENCE IS TOTALLY IG NOD, THE SCIENCE OF MUSCLE AND
THE SCIENCE OF SPHINCTERS, AND WHETHER MUSCLE SMOOTH OR SKELETAL, AND
I﷓﷓I DON\'T KNOW WHAT TO SAY, I MEAN WHY CAN\'T ANYBODY MENTION ABOUT
THE PROMISING THINGS LIKE THE WORK THAT WAS PUBLISHED IN 2007 USING
AUTOLOGOUS INJECTIONS STEM CELLS WHY DO WE WANT TO GO, WE DON\'T WANT TO
TALK ABOUT LONGITUDINAL STUDIESES AND THIS IS THAT.

UNLESS WE FINDIE A NEW WAY OF DEALING WITH THINGSS AND THINK OUTSIDE THE
BOX, WE\'RE NOT GOING TO GO ANYWHERE.

IT\'S LIKE SAYING, HOUSTON WE HAVE A PROBLEM.

YES WE KNOW WE HAVE PROBLEM, NOW HOW DO WE GET TOGETHER AND FIND OUT A
BASIC SCIENCE SOLUTION TO SOLVE THE PROBLEM, BECAUSE WE KNOW THE PROBLEM
IS THERE.

WE DON\'T NEED TO CONVINCE YOURSELF IN IN ROOM THAT THERE IS A PROBLEM.

WE NEED TO THINK OUTSIDE THE BOX TO JUST FIND DIFFERENT WAYS OF DEALING
WITH THE PROBLEM.

WE CANNOT KEEP DOING THE SAME THING.

THANK YOU.

\>\> MATT BARBER CLEVELAND CLINIC THIS A FOLLOW UP ABOUT SCREENING, I
WOULD THINK ONE OF THE QUESTIONS ABOUT THE ALONG THE LINE OF SCREENING
HAS TO BE TO THE PATIENT WHETHER OR NOT IT\'S A BOTHERSOME PROBLEM TO
THEM OR NOT BECAUSE IF IT\'S NOT﷓﷓WE DON\'T GENERALLY NEED NONBOTHERSOME
DISEASE OR PREVENT NONBOTHERSOME DISEASE AND WE SCREEN EVERY FOR
INCONTINENCE AND WOMEN IN WOMEN WE ARE GOING TO HAVE A HUGE BURRED EXTEN
PEOPLE DON\'T KNOW WHY THEY\'RE THERE AND DON\'T WANT TREATMENT.

THAT\'S MY FIRST COMMENT.

THE SECOND COMMENT WE HAVE TO FOLLOW UP ON THAT IS, AS WAS MENINGED MANY
TIMES THE DEGREE OF BROTHER AND DEGREE OF IMPAIRED QUALITY OF LIFE AND
BEST WITH SEVERITY OF DISEASE, OTHER FACTORS DISEASE SPECT THAT GO INTO
THAT AND IDENTIFYING THOSE THINGS PROBABLY ARE OTHER IMPORTANT TARGETS
THAT WE SHOULD BE LOOKING AT OUTSIDE OF DISEASE PROCESS ITSELF IN
LOOKING AT PREVENTION OF BOTHER AM DISEASE AND DECREASES BURDEN OF
ILLNESS ON SOCIETY BECAUSE SOME OF OTHERS THINGS ISN\'T A BURDEN.

\>\> BUT AGAIN WHEN YOU LOOK AT THIS INFORMATION AS FAR AS SCREENING
WE\'RE ONLY﷓﷓WE\'RE NOT KEEN FIGURE IT SO WE\'RE NOT KEENING PATIENTS SO
IT\'S TIME TO GET TO BOTHER UNLESS YOU AT LEAST ASK ABOUT IT.

FIRST YOU SHOULD ASK ABOUT IT AND THEN YOU SHOULD BOTHER.

I HOPE HAVE TO CHALLENGE YOU IN WHAT DISEASE DO WE SAY I BOTHER YOU,
WELL HIGH BLOOD PRESSURE, I DON\'T WANT TO ARGUE BUT MY THING IS ABOUT
BOTHER, I FIND PATES WHO WEAR PADS SO THEY\'RE NOT BOTHERS BUT DO WE
KNOW LONGITUDINALLY WHAT HAPPENS TO THEM DOWN THE ROAD BUT NO IT
DOESN\'T BROTHER AND YOU XYAND C SO I UNDERSTAND THE BOTHER THING BUT
I\'M TIRED OF THE BOTHERED, I\'M BOTHERED BY THE BOTHER, I WANT YOU TON
BEING IN IN FIELD SO LONG BAUDS I DON\'T KNOW APPROXIMATE ANYTHING IN
MEDICINE WHERE ARE YOU BOTHERED BUT YOU\'RE RIGHT WE DON\'T HAVE THE
DATA TO THEM LONG﷓TERM WHY THEY SHOULD BE BOTHERED, OKAY IN BUT YOU\'RE
RIGHT.

FIRST IF WE GET SCREENING THEN WE\'LL GET DOWN THAT BOTHER, BUT I DON\'T
USE THAT AS A SCREENING QUESTION.

I\'M SEERRY, I DON\'T.

\>\> I\'M GOING GOING HAVE TO DRAW THINGS TO A CLOSE IT\'S ABOUT 1:20.

YOU GUYS GET TO GO DO SOMETHING FUN TONIGHT, WE DON\'T.

THE WE WILL I WILL LIKE TO THANK ALL THE SPEAKERS AGAIN AND THIS
EXTRAORDINARY AUDIENCE.

WE WILL CONVENE AGAIN TOMORROW AT 9:00 FOR THE PRESENTATION OF THE DRAFT
STATE OF THE SCIENCE STATEMENT AND WE\'LL HAVE AN HOUR AND HALF AFTER
THAT FOR PUBLIC DISCUSSION WITH THE AUDIENCE AND WE LOOK FORWARD TO THAT
VERY MUCH.

THANK YOU.

(APPLAUSE).