Interview with The 2017 Continence Care Champion Award Winner

Interview with Dr. Timothy Boone

2017 Recipient of the Rodney Appell Continence Care Champion Award

1.)   What lead you to focus on neuroscience and spinal cord injury with veterans specifically?

 I got my Ph.D. in neuroscience and my father was a urologist, so I grew up around urology. Initially, I was interested in becoming an ENT, but my father and colleagues talked to me about how much we still don’t know about in the field of neurourology.  Most of the work I did in neuroscience had to do with speech and the brain and changing to the field [of urology] allowed me to use what I knew in neuroscience and bring that in.  Bill Steers and Rodney Appell were big influences in my career.  Bill introduced me to the power of networking and “who you know,” and he connected me to academic neurourology, the brain and the connection to the bladder.  I met Rodney through SUFU while he was at the Cleveland Clinic and recruited him to come to Houston. 

2.)   What do you believe are the biggest challenges for in caring for patients with neurological conditions and spinal cord injury? 

Neurological conditions include those with MS, Parkinson’s, stroke survivors, brain tumor patients, brain injuries and dementia.  Once of the biggest challenges working with the VA is trying to get patients to the spinal cord center where their care would improve and you are not taking on the whole VA system. Working with vets can be challenging given all they have been through and their issues beyond urology including anxiety, depression and PTSD. Often, the biggest challenge is to get them to do self-catheterization.  They need physical rehab, many have ulcers and malnutrition and are non compliant with catheterization.  They may have survived Vietnam, but they could succumb to renal failure and malignant stone disease if not managed well. Intermittent catheterization and draining the bladder is critical to saving many vets.

3.)   So many patients with incontinence issues believe that it is product of getting older or that it’s just the nature of their condition, and they are resigned to dealing with incontinence on their own. What do you believe could be improved to get treatment for the millions who remain undiagnosed, untreated or unsuccessful in their treatment?

With any patient, regardless of the kind of neurological condition, education is critical. These patients need to know why their condition occurs and why it is important to take control and seek treatment.   Without proper education, it is really hard to get patients to do something like self-catheterization or physical therapy. Buy-in comes with education and with better education comes better compliance.

4.)   Since you have been in practice, what changes have you observed in patient expectations of clinical outcomes?

The biggest change I have observed is the proliferation of advertising and news stories in prime time.  News and advertising about drugs for the bladder, diapers and ED commercials.  This kind of money could have a big impact on research, but the advertising has elevated the awareness for a condition that most patients rarely understood.

5.)   What do you believe are the critical success factors in treating your patients?

I believe in data collection and the use of physical therapy. I have incorporated physical therapy much more into my practice. It is amazing how much more can be done with PT as a part of the treatment plan. PT can do a lot of good for patients in pain and with incontinence and intimacy. I am more educated now on physical therapy and more of a believer in the importance of it and having trained professionals do that.

 It should be a bigger part of the treatment plan for men and women. Physical therapy is something that can empower them, like being healthy and exercising.

There is a lot to be said for the power of this practice. It is important to outcomes.

8.)  What accomplishments in your career are you most proud of?

I am most proud of my trainees and residents.  I enjoy helping them succeed and fostering education with them. It is gratification that is similar to having kids.  Rodney felt the same way. He was big on education and he was close to the fellows he trained.  Your greatest pride is seeing the the success of the ones you participated in training and educating.

9.)  What kind of advances or changes in the field of urology and urology care would you like to see over the next 10 years?

Technology has evolved so much, with wireless and bluetooth technology changing the way our equipment operates. This has advanced the field in many ways and I embrace that change. I think now with phones present everywhere and always in peoples’ hands that apps for urologic conditions should become more successful.  Apps could provide reminders for timed voiding and voiding diaries. Even help with self- diagnosis for conditions like nocturia with simple metrics to encourage finding the proper diagnosis and treatment will be possible. These kinds of new apps would be a tremendous application for everyone in reach of a phone regardless of age. There will be new discoveries in pharma, new classes of drugs that are more targeted and work a lot better. I am hopeful we will see that, too.

10.) You were just selected as the 2017 SUFU Rodney Appell Continence Care Champion. Can you tell us how it feels to be named a Continence Care Champion after your fellow friend and colleague?

My connection with Rod is the highest honor.  Rodney was a good and trusted faculty member.  Rodney was always the one to volunteer to do anything including the thankless jobs. He always raised a hand or offered to take calls at a public hospital. He was glad to do it and was selfless in that regard. He was not a wallflower. We learned that you better not ask him a question if you were not prepared for his answer. He always had an opinion.  He always had a great story to tell and was hilarious to be around.  

 

 

 

 

Botox for Overactive Bladder and Incontinence

Eric S. Rovner, MD

Professor of Urology, Medical University of South Carolina

Overactive bladder (OAB) is a condition characterized by urinary urgency, frequency with or without incontinence, is often treated with a combination of behavioral therapy, pelvic floor exercises and/or pharmacotherapy. A variety of oral pharmacological drugs and the ability to increase the dose of these drugs(titrate) provide considerable options and flexibility. However, many patients will ultimately fail such therapy. Few options exist for these refractory patients with a condition that can greatly affect quality of life. Sacral neuromodulation (SNM) and posterior tibial nerve stimulation (PTNS) have been utilized with some success. PTNS requires patients to come to the office at least of 12 times over the course of therapy to optimize effects. SNM requires surgery.

OnobotulinumtoxinA is another option. Better known as Botox.  (Allergan, Irvine, CA) OnobotulinumtoxinA is the only botulinum toxin currently available and approved for use in the urinary tract in the US. It is administered using a telescope (cystoscopically) through the urethra, as an intravesical injection using a needle placed through either a flexible or rigid cystoscope. This is most often done as an office based procedure without general or regional anesthesia. After being administered, the therapy takes about three to ten days to take effect, and may last up to six to nine months, after which time a repeat injection is needed to maintain the effect. The exact mechanism by which onobotulinumtoxinA exerts its favorable effects is unclear but it is likely related to relaxation of the bladder muscle (detrusor) as well as perhaps some effects on sensation relating to a decreased sense of urgency to urinate. At least in part, its effects are mediated via blockade of a neurotransmitter called acetylcholine and perhaps other peptides as well. [1]. Several publications have demonstrated the utility of onobotulinumtoxinA in many thousands of patients. (2-6). Success rates in reducing urinary incontinence, urinary urgency and frequency vary from 60-80%. The major side effects of Botox include urinary tract infection and difficulty urinating after injection.

Overall, Botox is an exciting advance in the treatment of OAB and urinary incontinence. There continues to be active research on this medication including improved dosing, and alternative methods of delivering the medication without requiring injection needles.

 

 

ERIC S. ROVNER, MD

(NAFC BOARD MEMBER TREASURER)

Eric S. Rovner, M.D. is a Professor in the Department of Urology at the Medical University of South Carolina (MUSC) in Charleston, South Carolina.  He is the director of the Section of Voiding Dysfunction, Female Urology and Urodynamics in the Department of Urology at MUSC.    

He is Board Certified in Urology as well as Female Pelvic Medicine and Reconstructive Surgery.   He is a member of the American Urological Association, International Continence Society, Fellow of the American College of Surgeons, Society of Pelvic Surgeons, and the American Association of GU Surgeons.  Dr. Rovner has served on several committees for the International Consultation on Incontinence.    He served as a member of the AUA/ABU Examination Committee, the AUA Urodynamics Guidelines Committee, and the AUA SUI Guidelines Committee, and is Past President of SUFU.

Dr. Rovner’s research interests include the study of voiding dysfunction, overactive bladder, interstitial cystitis, neurourology and urodynamics.  He has a highly specialized clinical practice within Urology and sees mostly patients with complex voiding problems including urinary incontinence, vaginal prolapse, urinary fistulae and neurogenic bladder dysfunction. He has held several visiting professorships and is the author or coauthor of over 100 peer-reviewed scientific articles, over 25 book chapters, dozens of monographs as well as books on urinary incontinence and urodynamics.  He has been an invited speaker on numerous occasions throughout the United States and the world, and has been the Principal or co-investigator on multiple grants.     

  SOURCES:

1. Kalsi V, Apostolidis A; Gonzales G; Elneil, S; Dasgupta P; Fowler, CJ: Early effect on the overactive bladder symptoms following botulinum neurotoxin type A injections for detrusor overactivity. European urology 2008, 54(1):181-187.

2. Cruz F, Herschorn S, Aliotta P, Brin M, Thompson C, Lam W, Daniell G, Heesakkers J, Haag-Molkenteller C: Efficacy and safety of onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity: a randomised, double-blind, placebo-controlled trial. European urology 2011, 60(4):742-750.

3. Herschorn S, Gajewski J, Ethans K, Corcos J, Carlson K, Bailly G, Bard R, Valiquette L, Baverstock R, Carr L et al: Efficacy of botulinum toxin A injection for neurogenic detrusor overactivity and urinary incontinence: a randomized, double-blind trial. The Journal of urology 2011, 185(6):2229-2235.

4. Rovner E, Kennelly M, Schulte-Baukloh H, Zhou J, Haag-Molkenteller C, Dasgupta P: Urodynamic results and clinical outcomes with intradetrusor injections of onabotulinumtoxinA in a randomized, placebo-controlled dose-finding study in idiopathic overactive bladder. Neurourology and urodynamics 2011, 30(4):556-562.

5. Denys P, Le Normand L, Ghout I, Costa P, Chartier-Kastler E, Grise P, Hermieu JF, Amarenco G, Karsenty G, Saussine C et al: Efficacy and safety of low doses of onabotulinumtoxinA for the treatment of refractory idiopathic overactive bladder: a multicentre, double-blind, randomised, placebo-controlled dose-ranging study. European urology 2012, 61(3):520-529.

6. Dmochowski R, Chapple C, Nitti VW, Chancellor M, Everaert K, Thompson C, Daniell G, Zhou J, Haag-Molkenteller C: Efficacy and safety of onabotulinumtoxinA for idiopathic overactive bladder: a double-blind, placebo controlled, randomized, dose ranging trial. The Journal of urology 2010,184(6):2416-2422.

7. Grosse J, Kramer G, Stohrer M: Success of repeat detrusor injections of botulinum a toxin in patients with severe neurogenic detrusor overactivity and incontinence. European urology 2005, 47(5):653-659.

 

 

NAFC Names Dr. Cindy L. Amundsen Continence Care Champion

Dr. Cindy L. Amundsen recognized for lifetime of medical contributions

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Charleston, SC (December 6, 2017) - The National Association for Continence is proud to announce that the 2017 AUGS recipient of the Rodney Appell Continence Care Champion is Dr. Cindy L. Amundsen.  Dr. Amundsen was presented the award during the 2017 AUGS annual meeting in Providence RI on Oct 6th, 2017.  Dr. Amundsen was recognized for her outstanding work with patients, research and support of patient education.

The award is the among the most prestigious recognitions in the field of continence care, conferred upon those whose distinguished careers and outstanding contributions in research, clinical practice and patient education have made them role models for others in the discipline.

“It is a great pleasure and honor to present Dr. Amundsen this award,” said Steven G. Gregg, Ph.D., Executive Director for the National Association for Continence. “We were inspired by the more than 20 years of work he has done in Uro-gynecology care as well as clinical research and support for greater patient education.  She is particularly successful treating those that often do not respond to the first or second line therapies”.

Currently, Dr. Cindy Amundsen is a Urogynecologist at Duke University Medical Center, Durham, NC. She received her medical degree from University of Tennessee College of Medicine and has been in practice for more than 20 years. She specializes in treated those women with pelvic floor disorders, urinary incontinence and voiding dysfunction.  Her commitment to giving it her all to patient care makes her well deserving of this award.

Dr. Amundsen is an active researcher and has published was the first multicenter clinical trial comparing Botox Therapy with InterStim in those women with refactory urgent urinary incontinence.  She is an active member of American Urogynocology Society.

CLICK HERE FOR AN INTERVIEW WITH DR. AMUNDSEN

ABOUT NAFC

National Association for Continence is a national, private, non-profit 501(c)(3) organization dedicated to improving the quality of life of people with incontinence, voiding dysfunction and related pelvic floor disorders. NAFC's purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments and management alternatives for incontinence. More information is available online at www.NAFC.org.