Urogynae Flashcards
Incidence of prolapse
Difficult to estimate prevalence and incidence accurately
1 in 10 (9%) women affected
Lifetime risk of requiring an operation for prolapse or incontinence is 11-19%
7% for POP (RANZCOG)
29% reoperation rate
2/3 in same compartment
Risk factors for POP
Age - (double risk for every decade)
Parity and vaginal delivery - 50% incidence in parous c.f. 2% in nulliparous. Vaginal tears (including episiotomy) are associated with increased risk.
Obesity
Chronic increased intra-abdominal pressure (cough, weight lifting, constipation, occupation)
FHx and genetic risk
Genetic connective tissue disorders
Previous gynae surgery
- Hysterectomy - Recent review suggests that hysterectomy for benign conditions other than prolapse does not seem to be a risk factor for POP
- Sacrospinous fixation and sacrocolpopexy - increased risk of anterior vaginal wall prolapse
- Colposuspension - increased risk of enterocele
What levels of anatomical support of the vagina
Level 1 = Suspension
Uterosacral and cardinal ligaments
Apex or upper third of the vagina
Level 2 = Attachment
Lateral attachment of the vagina in its middle third. Connective tissue which is part of the endopelvic fascia
Level 3 = Fusion
The lower third of the vagina is supported by the fusion of the vaginal endopelvic fascia to the urogenital diaphragm and the perineal body
What use a system like POP-Q?
Used to quantify, describe and stage pelvic support
A standardised means of documenting, comparing and communicating clinical findings with proven inter-observer and intra-observer reliability
For research and audit
To compare post-op
Describe the POP-Q
Aa = anterior vaginal wall 3cm proximal to the external urethral meatus (-3cm to +3cm) Ba = most distal position of the remaining upper anterior vaginal wall (-3cm to + tvl) C = Most distal edge of cervix or vaginal cuff scar (-10cm to +10cm) D = Posterior fornix (n/a if post-hysterectomy) Ap = Posterior vaginal wall 3cm proximal to the hymen (-3cm to +3cm) Bp = Most distal position of the remaining upper posterior vaginal wall (-3cm to + tvl)
gh = Genital hiatus - measured from middle of external urethral meatus to posterior hymen ph = Perineal body - measured from posterior margin to gh to middle of anal opening tvl = Total vaginal length - depth of vagina when point D or C is reduced to normal position
POP-Q staging system
Stage 0 = no prolapse
Aa, Ba, Ap, Bp = -3cm, and C (if post hysterectomy) or D (pre-hysterectomy) equals or nearly equals TVL (- TVL to - (TVL - 2) cm)
Stage I = stage 0 criteria not met and leading edge < -1cm
Stage II = Leading edge > -1cm but < +1cm
Stage III = Leading edge > +1cm but < +(TVL - 2) cm
Stage IV = Leading edge > + (TVL - 2) cm
Eversion of the total length of the vagina
Prevention of POP
Avoidance of increased intra-abdominal pressure may help (no studies to demonstrate a protective effect)
Avoid constipation
Effectively manage chronic chest pathology
Smoking cessation
Antenatal perineal massage, hot packs during second stage - reduce tears, no evidence that reduce POP incidence
No evidence that PFMT presents the development or worsening of POP
McCall’s culdoplasty - done during vaginal hysterectomy
Prophylactic sacrospinous fixation is unnecessary, unless there is marked uterovaginal prolapse making the uterosacral ligaments too weak to provide any support
What is McCall’s culdoplasty
Done during vaginal hysterectomy to prevent subsequent vault prolapse
Obliteration of the posterior cul de sac by a series of sutures from the uterosacral ligament on one side the uterosacral ligament on the other side
Need to reach the highest point of the sac so ensure complete obliteration
Uterosacral ligaments approximated in the midline and fixed to the vault
Also helps maintain vaginal length
Management of POP
Do nothing
Lifestyle advice (wt loss if BMI >30, minimise heavy lifting, preventing or treating constipation)
Topical oestrogen (if atrophy or using pessary)
PT
Pessary
Physiotherapy for POP
Consider supervised PFMT for >16 weeks as a first option for women with symptomatic POP-Q stage 1 or 2 POP
PFMT vs. no active treatment
- Reduces pelvic floor symptoms and specific prolapse symptoms, e.g. bulge
- Does not reduce prolapse severity based on POP-Q
Cochrane
- benefit to 6/12 of supervised exercised, no long term data
- no enough evidence for PFMT as an adjunct to surgery
PT associated with significant improvement in prolapse symptoms
Pessaries
Stretch the vagina wider than the genital hiatus through the pelvic floor –> stay above the level of the pelvic floor
Limited evidence to recommend one type over another
Work best for apical and anterior prolapse
Studies found at 6y only 14% continuing to use
Widened genital hiatus >6cm then likely pessary will fall out
Problems with pessary use
Discuss limitations of sex life and complications
Difficult removal and insertion Neglected pessary - Can erode into the vagina is left too long - Urinary or bowel fistulae - Can become impacted and therefore difficult to remove Vaginal ulceration Urinary retention Infection Bleeding Vaginal discharge Pain and constipation Change of size and/or type of pessary Resort to surgery
Counselling around POP surgery
Goals
- Restore anatomy and relieve symptoms
- Maintain or restore bowel and/or bladder function
- Maintain vaginal length and capacity for sexual function
Discuss above
Do not offer surgery to prevent incontinence in women having surgery for prolapse who do not have incontinence
Risk of post-op urinary incontinence in those having anterior or middle compartment prolapse repair
Up to 29% of women will require an additional operation following primary prolapse surgery
Post-op advice
Avoid heavy lifting, strenuous exercises, prolonged straining etc. for 3 months
Sex can be resumed at 6 weeks
Surgery for recurrent prolapse
Recurrence can be contributed to by:
- Poor surgical technique
- Genetic predisposition to POP
- Continued unhealthy lifestyle - straining, obesity
Direct recurrence = at site of previous surgery
Indirect recurrence = no previous surgery was carried out there
Management
- Pessary
- Surgery - Risk of failure increases with repeat surgery, can be more challenging because of distorted planes, mesh has been suggested but awaits more robust evidence
Complications of anterior repair
Bleeding - Infiltration with LA + vasoconstrictive agent to limit Bladder or urethral injury - Can cause fistula if not detected at time Infection - Wound, UTI Initial voiding dysfunction Occult stress UI may be unmasked Failure and recurrence of prolapse
Steps of anterior repair
DVT prophylaxis, IV antibiotics, prep and drape
Submucosal infiltration of local anaesthetic
Midline incision in vaginal epithelium
Bladder is dissected off the overlying vaginal skin using sharp and blunt dissection - in avascular plane
Vesico-vaginal fascia is plicated in the midline using delayed absorable sutures - interrupted sutures or purse-string
Close the vagina with vicryl 2/0
Cystoscopy to ensure ureteric patency and no intravesical sutures
Insert:
- IDC
- Vaginal pack 12-24h
Success rates up to 100% reported
Recurrence rates up to 43% reported
Steps of posterior repair
DVT prophylaxis, IV antibiotics, prep and drape
Submucosal infiltration of local anaesthetic
Midline incision in vaginal epithelium
Rectum is dissected off the overlying vaginal skin using sharp and blunt dissection - in avascular plane
Rectovaginal fascia is plicated using 2/0 vicryl or PDS sutures
Close the vagina with vicryl 2/0
Commonly performed with a perineorrhaphy
- perineal muscles may need to be approximated from each side of rebuild the perineal body
- Perineum sutured with subcut 3/0 vicryl rapide
Do PR to check no sutures placed into the rectum
IDC +/- pack
Vaginal hysterectomy steps
Grasp cervix (with Vulsellum)
Infiltration with LA + vasoconstrictive agent
Circumferential incision made around the cervix
Continue reflection posterior, opening the Pouch of Douglas between the cut uterosacral ligaments
- Can use blunt dissection to reflect
Sims speculum inserted posteriorly though the peritoneum to guard rectum
Can use finger posteriorly and around uterus to identify anatomy and open vesico-uterine peritoneal reflection
Standard 3 pedicle hysterectomy
- Uterosacral and cardinal ligaments are clamped, divided and ligatured.
- Followed by the uterine vessels
- Finally the tubo-ovarian and round ligaments
Culdoplasty then performed
- Sutures tied in the midline and brought through the posterior part of the vault, to be tied after closing the vault
Peritoneum is closed keeping all pedicles extraperitoneal
If anterior repair required, carry out now
Close vault
Culdoplasty sutures then tied
If posterior repair required and planned, carry out at the end along with sacrospinous fixation if appropriate
SACROSPINOUS HYSTEROPEXY
Entails sacrospinous fixation of the back of the cervix and uterosacral ligaments using permanent sutures (usually ethibond)
2 permanent, or slowly absorbable, sutures are passed through the right sacrospinous ligament, 2cm medial to the ischial spine, using Miya hook or similar
PR needed to exclude rectal perforation
Approaches - vaginal, or abdominal
Bleeding
- Haematoma can develop in rectovaginal space or ischiorectal fossa
Occult SUI might be unmasked
Right buttock pain
- 1 in 20 patients
- Usually subsides within 3 months with the absorption of PDS
Comparison with vaginal hysterectomy
- No significant difference in outcome
- Significant reduction in blood loss and operating time
Need for repeat surgery for recurrent POP is low
MANCHESTER REPAIR
No longer used
Attempted to preserve fertility in patient’s with POP
Cervical amputation followed by approximating and shortening the cardinal ligaments anterior to the cervical stump and elevating the uterus
SACROHYSTEROPEXY
Attach the back of the cervix to the sacral promontory using a piece of prolene mesh
Peritoneum over sacral promontory is opened to reach the anterior longitudinal ligament
Prolene mesh is attached to the posterior aspect of the cervix with permanent sutures secured at the level of insertion of the uterosacral ligaments
Mesh then attached to the anterior aspect of the sacral promontory with permanent suture or screw tacks
Sacrocolpopexy - vaginal vault is attached to the sacral promontory using mesh
Abdominal or laparoscopic approach
Low recurrence rate
Use of mesh is associated with potential risk of mesh erosion and infection
Prevention of post-hysterectomy vault prolapse
12% of hysterectomies performed for POP will have vault prolapse (c.f. 2% for other indications)
McCall culdoplasty at the time of vaginal hysterectomy is effective in preventing subsequent PHVP
Suturing the cardinal and uterosacral ligaments to the vaginal cuff is effective in preventing PHVP following both abdominal and vaginal hysterectomies
SSF at the time of vaginal hysterectomy should be considered when the vault descends to the introitus during closure
ABOUT SACROSPINOUS FIXATION
Aims to fix the vaginal vault to the right sacrospinous ligament
- Maintains horizontal position of the upper vagina on standing
- Avoid rectosigmoid on the left
Long term success rates >90%
Recurrence rate of vault prolapse - 5-7% reported
Risk of anterior vaginal wall prolapse
- Because of exaggerated retroversion
Associated with dyspareunia
- Best avoided in women who are sexually active
Right buttock pain - 1 in 20 women, usually subsides within 3 months with absorption of PDS
Bleeding from pudendal vessels will require suturing and may require laparotomy to ligate the internal iliac artery
Surgical steps of sacrospinous fixation
If doing pelvic floor repair:
- Do before anterior repair
- Do after posterior repair
Submucosal infiltration
Vaginal incision with sharp dissection in the vascular plane between the rectum and vaginal mucosa
Adequate mobilisation of rectovaginal fascia from the vaginal epithelium with attention to haemostasis
Enter the rectovaginal space and pararectal fossa
Dissection taken up to the level of the ischial spine (uni or bilaterally)
Palpate right sacrospinous ligament
Sutures (PDS) passed through the ligament using appropriate technique and instrumentation, to prevent neurovascular injury - Suture should be passed 2cm medial to the ischial spine to avoid injury to the pudendal nerve and vessels as they curve around the ischial spine. Encircling the full thickness of the ligament is avoided
Haemostasis
Retrovaginal plication of fascia
Close vagina
PR exam to exclude rectal perforation
SACROCOLPOPEXY
Support vaginal vault by fixing it to the sacral promontory using a piece of mesh (or rectus sheath fascia)
Can perform abdominally or laparoscopically
Division of adhesions and handling of tissue as may be required
Traction and counter traction techniques by use of vaginal probes and forceps to facilitate dissection of peritoneum and bladder from vaginal vault with attention to tissue planes, integrity of bladder and haemostasis
Retroperitoneal dissection from the vaginal vault to sacral promontory between the large bowel and right ureter to allow clear exposure of sacral promontory and retroperitoneal space
Mesh is attached over the vagina and retroperitoneally to sacral promontory
- Tension free fashion
Closure of peritoneum from sacrum to vaginal vault
Cystoscopy to exclude bladder or ureteric injury
PR to exclude rectal injury
Haemostasis and closure
Outcomes of sacrocolpopexy
Bleeding
- Especially from the pre-sacral venous plexus and sacral artery
Injury to the right ureter and sigmoid colon
Infection
Mesh erosion and infection (rare, decreased erosion rates <3% compared to vaginal mesh surgery)
Gold standard for post-hysterectomy vaginal vault prolapse
Success rates from 93-100% reported
Backward displacement of the vagina exposes the anterior vaginal wall to increased intra-abdominal pressure
Sacrocolpopexy vs. SSF
Good long term results
Procedure of choice in younger, sexually active patients
Significantly lower rates of recurrent vault prolapse, dyspareunia and post-op SUI. This is not reflected in significantly lower reoperation rates or higher patient satisfaction.
SSF - Earlier recovery, cheaper, quicker. Increased dyspareunia
COLPOCLEISIS
Obliterate the vagina either partially or totally Precludes sexual activity Can perform under LA Usually reserved for frail Direct recurrence 3% Need endometrial sampling prior
Mesh erosion
- incidence
- symptoms
1-2% of midurethral slings
10-12% of operations where TVM is used for prolapse
In some cases, erosion is asymptomatic
May cause bleeding, discomfort, awareness by either or both partners during sex
Tender or exposed area may be treated with Ovestin, or require minor procedure to relieve symptoms
Evidence for mesh
Posterior and apical compartment - No evidence to support use of mesh
Anterior compartment - polypropylene mesh anterior vaginal wall repair associated with significantly improved subjective outcome without difference in dyspareunia. But higher operating time, blood loss, indirect recurrence and de novo SUI. Mesh exposure in 10%, with 6.8% requiring surgical intervention.
Can access mesh via national MDT by approved practitioners on case-by-case basis or under ethics-approved trial
RANZCOG guidelines for using mesh
Patient consent and written info
Explain type of mesh and use of mesh
Details of procedure
Short and long term outcomes on national registry
Assessing mesh complications
Take Hx of all past surgical procedures including types of mesh, site and dates
Using pelvic floor Sx and pain questionarie
Perform vaginal exam - Is mesh palpable, exposed or extruded?
- Localised pain and its anatomical relationship to mesh
PR - ? Perforation or fistula
Neurological exam
- Assess distribution of pain, sensory alteration, or muscle weakness
If mesh related complication confirmed, refer to specialist, report to clinical auditing systems
If exposure <1cm, and no other symptoms, start topical oestrogen and review after trial of this
Urethra anatomy
3-5cm in length
Three layers - each provides 1/3 of resting closure pressure of the urethra
Inner mucosal and submucosal layer - Cushion like effect which occludes the lumen
Smooth muscle layer - inner longitudinal and outer circular layer. Runs the length of the urethra. Suppliesd by sympathetic and parasympathetic nerves
Outer striated muscle layer - formed by circular muscle of the striated urogenital sphincter, spans 60% of the length of the urethra. Supplied by the pudendal nerve. Can be voluntarily contracted when increased closure pressure is required to avoid leakage
Nervous control of the micturition cycle
Bladder stretch receptors → feed back to Spinal cord micturition centre (S2, S3) →feedback to PMC → PMC activated once certain level of stretch → activation of parasympathetic neurons in spinal cord and inhibition of sympathetic neurons → contraction of detrusor muscle and relaxation of internal and external urethral sphincter → voiding
In later life, PMC receives information from higher brain centres and can be switched on or off through voluntary control
Parasympathetic nerves: S2-4 - Pelvic nerve (efferent) and pelvic plexus
Sympathetic nerves: T10-L2 - Hypogastric nerve (efferent) and pelvic plexus
Pudendal nerve (S2, 3, 4)
Reflexes
Guarding reflex - Abrupt increase in bladder stretch receptor activity, e.g. coughing –> activation of Onuf’s nucleus in spinal cord –> pudendal nerve –> contraction of the straited urethral sphincter
Urodynamics
- Uroflowmetry - assess flow rate, max flow rate, voided volume, voiding pattern.
- Cystometry - measure of pressure / volume relationship of bladder during bladder filling
- assess bladder sensation during filling, bladder capacity, detrusor pressure - Post-void residual (PVR)
- Pressure flow studies - relationship between pressure in bladder and urine flow during emptying, i.e. detrusor contractility
- Urethral pressure profilometry - the urethral ability to maintain a closed bladder outlet
Urethral closure pressure <25cm H2O suggests weak urethral sphincter. >25cm H2O suggests hypermobility due to loss of suburethral support - Leak pressure points - Abdominal LPP - intravesical pressure at which urine leakage occurs due to increase intra-abdominal pressure in absence of detrusor contraction
Uroflowmetry
Void into flowmeter / commode
- Records urine volume
- Reports urine flow rate
Maximum flow rate (Qmax) should be >15ml/s
Dependent on volume voided, should be >200ml for the test to be valid
Prolonged flow and decreased Qmax –> Obstruction or hypocontractile bladder
Cystometry
Evaluates filling and voiding phases of micturition
- Measurement of the pressure-volume relationship of the bladder during filling
Two catheters in bladder
- One for filling the bladder
- One for measuring bladder pressure = intravesical pressure (Pves)
One catheter in the rectum to measure intra-abdominal pressure (Pabd)
Detrusor pressure (Pdet) = Pves - Pabd
Used to diagnose:
- Detrusor overactivity
- Urodynamic SUI
- Records bladder sensations at different bladder volumes
OAB = if pressure change seen on Pves and Pdet but not on Pabd, then due to detrusor contraction
If changes seen in both Pves and Pabd but not Pdet, it is due to raised intra-abdominal pressure. If leakage occurs then SUI
Volume at which subjective sensations occur are recorded as the bladder is filled
- Increased bladder sensation occurs when sensations occur at reduced bladder volumes - Detrusor overactivity, interstitial cystitis (causing a small bladder). Hypocontractile bladder suggested if sensations occurs at higher bladder volumes
Pressure flow studies
Patient voids after cystometry
Flow rate correlated with detrusor pressure
Low pressure and low flow rate = hypocontractile bladder
High pressure and low flow rate = obstruction, e.g. cystocele
Urinary incontinence incidence
Prevalence ranges from 13-35%
- Increases with age, reaches an initial peak in the 50s, then proceeds to dip slightly
- Rises again in the 60s and continues to do so thereafter
SUI most common - 50%
- MUI - 36% - tends to be more severe / significant, women experience higher impact on QoL and more functional limitations
UUI - 11%
Implications of UI
33% of women in Australia avoid physical exercise because of incontinence Depression Hinders: - Healthy lifestyle - Travel - Self-esteem - Sex life Increased falls risk in elderly
Classification of UI
Stress incontinence
- Describes a symptoms, sign and a diagnosis
- Can only diagnosis urodynamic stress incontinence after urodynamic investigation
Overactive bladder / detrusor overactivity
- Detrusor overactivity = urodynamic observation
- OAB describes the symptom complex of urgency with or without UUI, in the absence of UTI or any other obvious pathology
- usually with frequency and nocturia
Overflow incontinence Fistulae Urethral diverticulum Congenital anomalies (ectopic ureter) Functional incontinence, e.g. immobility Temporary incontinence, e.g. constipation, UTI
Risk factors for UI
Age - other factors associated with aging can undermine continence (e.g. dementia)
Pregnancy and childbirth - if develop UI antenatally or sooner after delivery, the RF for developing UI in the longer term
Smoking >20/day ? Due to coughing or collagen changes
Obesity - weight loss reduces SUI from 61% to 12%
Hysterectomy ? Damage endopelvic fascia and nerves. Subtotal hysterectomy does not decrease the risk
Menopause - loss of oestrogen –> OAB Sx
Connective tissue abnormality
Stress UI causes
Poor suburethral support
- Urethral hypermobility
- Suburethral support is provided by the anterior vaginal wall - fused to proximal 2/3
A weak urethral sphincter (intrinsic sphincter deficiency)
- Causes: scarring, ischaemia, denervation from pelvic or vaginal surgery or radiotherapy
- Childbirth can cause denervation injury (pudendal nerve shows delayed nerve conduction)
Indications for pre-op urodynamics in SUI
Clinical suspicion of detrusor overactivity
Hx of previous surgery for stress UI or anterior compartment prolapse
Symptoms of voiding dysfunction
Management of SUI
Exclude pathology, infection
Bladder diary
Behavioural modification - diet, fluids, bowel
WEight loss
Duloxetine - not first line, SNRI, alternative to surgery
All women should be recommended to have PF PT and / or see a continence nurse for PFE, and bladder training as first line
If fail conservative treatments, can offer continence surgery
PFMT - Cure rates for SUI between 21-84% have been reported
Greater effect if SUI alone, supervised PFMT programme for >3/12
=/>8 contractions performed 3 times/day
Surgical options for SUI
90% cure rate if appropriate, properly performed primary procedure
Aim: elevate bladder neck and proximal urethra into an intra-abdominal position
Vaginal:
- Urethral bulking agents
- Retropubic tape procedures
- Transobturator tape procedures
Abdominal (open or laparoscopic):
- Burch colposuspension
Combined:
- Fascial sling / endoscopic bladder neck suspension
Urethral bulking agents
Injection of pliable bulking agent into the submucosal tissues of the urethra, or bladder neck
May increase the resistance to flow within the urethra
Transurethral via cystoscope or blind approach
Success rates tend to be lower than with midurethral tape procedures
Can be done under LA or GA Minimally invasive Repeat injections may be needed Effectiveness decreases over time Uncertainty over long term safety
Burch colposuspension outcomes
Corrects both SUI and cystocele
- At the expense of increasing tendency for posterior wall prolapse
Simultaneous hysterectomy does not improve results- only do if uterine pathology
Cochrane 2016
- Overall continence rate 85-90% at 1y, 70% at 5y
- Superior to anterior repair
- Compared to MUS - no significant differences in continence rates
COMPLICATIONS
Voiding difficulties
- Usually resolve. If persist, then made need self-catheterisation
Urgency or UUI may arise de novo
Exacerbation of rectoenterocele due to repositioning of the vagina
Complications are more common compared to MUS
Burch colposuspension technqiue
Low transverse suprapubic incision, just above the symphysis pubis (lower than a pfannenstiel)
Bladder, bladder neck and proximal urethra are dissected medially off the underlying paravaginal fascia
2-4 pairs of PDS sutures are inserted between the paravaginal fascia and the ipsilateral iliopectineal ligament. Tied to elevate bladder neck.
Leave suction (redivac) drain in retropubic space
IDC on free drainage for at least 2/7, then clamp regimen initiated
Use perioperative Abs
Midurethral sling summary
Gold standard for SUI
Complete cure or significant improvement 80-90%
Retropubic (RP) MUS - TVT = tensionfree vaginal tape
Transobturator (TO) MUS
Single incision (SIS) MUS - third generation, only under trial conditions in Au/NZ
Exit site is what varies
Vaginal incision usually 1cm proximal to external urethral meatus
Complications of MUS
Sling too loose - persisting incontinence
Sling too tight - retention
Sling may erode into the urethra or vagina
Pain
Mesh exposure rate 2%
Early pain - cystoscopy, ? Remove sling (not too difficult to remove sling within 7 days)
Retropubic slings - TVT procedure
Drain bladder
Abdominal incisions: mark the two planned abdominal exit points for the tap at the superior margin of the pubic bone, 2cm lateral to the midline
Appropriate sub urethral infiltration and incision. Lateral dissection to the urogenital diaphragm bilaterally.
Insert the tape needles through the vaginal incision negotiating up through the retropubic space on each side, ensuring safe passage to minimise risk of bladder and vascular injur.
Appropriate tape placement and tensioning dependent upon make of sling and manufacturers guidelines and instructions for use
Repeat the same process on the contralateral side
Appropriate tape tensioning technique ensuring a tension-free placement
Exclude bladder / urethral injury by cystoscopy
Exclude vaginal sulcal mucosal tears at completion
Close vaginal incision
Post-op: voiding trial prior to discharge
Transobturator MUS
Bladder injuries and haematomas less common than with TVT
Risk of thigh pain
Compared to retropubic
- Higher failure rate
- Lower visceral injury, shorter length of hospital stay, and post-op voiding dysfunction
- Higher rates of post-op pain and reoperation
- Also removal is harder
TO approach may be preferred in:
- Women with extensive previous abdo surgery
- Unable to cease anti-coagulation
PUBOVAGINAL SLING = FASCIAL (AUTOLOGOUS) SLING
Median subjective cure rate 70%
Longer operation and post-op stay
Recovery is slower
Success rates similar to MUS
RANZCOG mesh use for MUS
MUS surgery should only be undertaken by those regularly carrying out MUS surgery
Cystoscopy recommended for insertion of all types of MUS
Chronic pain in MUS - up to 5%
- Variable severity
Removal for severe pain occurs in 1 in 150
Resolution of pain in 81% with removal of mesh. Difficult to remove in 1 in 5
RANZCOG strongly emphasise that the US FDA publications clearly state that traditional MUS were not the subject of their safety communication
Overactive bladder
Prevalence ranges from 13-16%
Symptom-based diagnosis
Defined as urgency, with or without urge incontinence (wet or dry OAB), usually with frequency and nocturia, in the absence of UTI or other underlying bladder pathology
~1/3 also have urge leakage
Types of detrusor overactivity
Neurogenic detrusor overactivity
- Lesions above the pons –> loss of voluntary inhibition of micturition, e.g. cerebrovascular disease, Parkinson’s, dementia, tumours
- Spinal cord lesions initially cause retention, then get detrusor overactivity from reorganisation of spinal reflexes
Detrusor overactivity due to obstruction
- Can occur after continence surgery
Idiopathic detrusor overactivity
- Muscle denervation found in detrusor biopsies
Treatment of detrusor overactivity / OAB
Conservative
If mixed UI, treat the OAB symptoms prior to resorting to surgery Lifestyle changes and behavioural intervention - Optimise underlying conditions - Reduce fluid intake to 1-1.5L/day - Avoid tea, caffeine, alcohol - Reduce fluids in the evening - Weight loss may improve Sx of UUI - Review medications
Bladder training / re-education - min of 6/52, void every 1.5h
- 90% continent after 6/12
- 40% relapse within 3y
Acupuncture - RCT compared with placebo - reduction in incontinence episode frequency and improvement in QoL
Treatment of detrusor overactivity / OAB
Medication
Antimuscarinic medication
- Oxybutynin
- Vesicare = solifenacin (better, less side effects)
Reduce OAB symptoms by up to 75%
ADR: Dry mouth, Constipation , Blurred vision
Associated with low compliance and persistence rates
- Poor efficacy and troublesome side effects
<20% of women continue to take them at 6/12
Symptomatic improvement greater than with bladder retraining alone
Caution in the elderly
- Anticholinergic drugs may be associated with significant decline in cognitive ability (dementia, Alzheimer’s)
Mirabegron (Betmiga)
β3 adrenoreceptor agonist
Selective agonist –> detrusor relaxation and increased stability during bladder storage
Mirabegron not inferior to solifenacin
Lower rates of dry mouth
Improved symptoms with combination mirabegron + solifenacin, compared to either alone
- No difference in ADR
Botox for OAB
Indication: refractory OAB
Interfere with neural transmission by blocking calcium-dependent release of neurotransmitter, acetylcholine –> affected muscle becoming weak and atrophic
New development of nerve terminals and synaptic contacts allows recovery of function
Success rates over 60%
Duration of clinical response: 9-12 months
Complications - dose dependent:
- Urinary retention approx 5%
- Catheterisation up to 16%
Peripheral neuromodulation for OAB
PTNS = posterior tibial nerve stimulation
Tibial nerve is a mixed nerve containing L4-S3 fibres
- Originates from the same spinal cord segments as the innervation to the bladder and pelvic floor
60% success rate
PTNS vs. antimuscarinic meds -no significant different in the change in bladder diary parameters, less side effects for PTNS
Sacral neuromodulation for OAB
Stimulation of the dorsal sacral nerve root using a permanent implantable device in the S3 sacral foramen
Somatic fibres are larger in diameter and therefore have a lower threshold of activation, therefore can selectively stimulate pelvic floor without causing bladder activity
50% improvement
Reconstructive surgery
Clam cystoplasty
- Bladder bisected almost completely and patch of gut (ileum) equal in length to the circumference of the bisected bladder (~25cm) is sewn in place
- Converts high pressure system to low
- Need to strain to PU
- Side effects: Chronic exposure of ileal mucosa to urine may –> malignant change (5% adenocarcinoma risk)
Detrusor myectomy
- Excise whole thickness of detrusor from the bladder dome to create bladder diverticulum with no intrinsic contractility
Urinary diversion
- Ileal conduit to create an incontinence abdominal stoma
Causes of urinary retention
Neurological Inflammatory - Urethritis - e.g. honeymoon cystitis - Vulvitis - e.g. herpes - Vaginitis - e.g. severe candidiasis Drugs - TCA - Antimuscarinic agents - Ganglion blockers - Epidural anaesthesia Obstruction - Urethral stenosis or stricture - Oedema following surgery or parturition - Fibrosis due to repeated dilation or irradiation - Pelvic mass Myogenic - Atonic detrusor secondary to overdistension
Fistula
Post-surgical fistula
- Direct injury during dissection
- Process takes from days up to a month
- Transvaginal mesh for prolapse
After Childbirth / obstetric fistula
- Operative delivery, MROP
- After CS, uterine rupture
Pelvic pathology- Advanced malignancy
Inflammation - PID, diverticulitis, IBD
After radiation therapy
Trauma - Pessaries not removed
Diagnosis of fistula
Dye test
- Methylene blue into bladder
- Tampon or large cotton swabs placed in the vagina and checked for dye
- Blue staining - suggests vesicovaginal fistula
- No staining - may indicate ureterovaginal fistula
Cystoscopy
- Can assess the bladder for residual injury, surgical materials
Intravenous urography
- Might miss leak of ureter near bladder (would obscure small leak)
CT urogram
MRI
Treatment of fistula
Surgical
- Fistula must be fully mobilised and the edges debrided
- Repair performed with absorbable sutures in one or two layers
Uretero-vaginal fistula - repair ASAP to prevent upper urinary tract damage
Vesicovaginal fistula are usually treated conservatively initially
- Bladder drainage and antibiotics - works in 10%
- If spontaneous closure does not occur, then surgical
Post-op care
- IDC for 3/52 with antibiotics until removed
- Cystogram to check integrity prior to TROC
- Avoid sex for 3/12
Urethral diverticulum presentation
Pouch or pocket that forms along the urethra
Becoming more common, due to increased incidence of STIs
Clinical presentation:
- Pain, particularly after micturition
- Postmicturition dribble
- Recurrent UTI
- Dyspareunia
Urethral diverticulum presentation
Radiologically
- Micturating cystogram
- Video cystourethrogram
- Urethroscopy
- MRI - Can help identify the anatomy and location of the ostia draining into the urethra
MANAGEMENT:
Conservative initially
- Intermittent antibiotics if necessary
If severe symptoms –> surgical excision of diverticulum . Do subtotal diverticulectomy to avoid urethral stricture formation
Physiology of defecation
IAS responsible for 80% of resting pressure
Distended rectum –> cerebral cortex –> IAS relaxation
If appropriate to BO, impulses sent for contraction of rectal muscles and relaxation of EAS, pelvic floor, puborectalis sling
Investigations of faecal incontinence
Anorectal manometry - Assessment of anorectal physiology (pressure, muscle tone, coordination of anal sphincters and rectum)
Endoanal USS -Assess anatomy of anal sphincter complex
Defecating proctogram - Assessment of dynamic defecation
Painful bladder syndrome
Previously referred to an interstitial cystitis
Chronic pain syndrome
Pelvic pain, pressure or discomfort perceived to be related to the bladder lasting >6/12 and accompanied by >1 other urinary symptoms (e.g. urgency, frequency in the absence of other identifiable causes
Associated medical problems:
- IBS - Vulvodynia - Endometriosis - Chronic fatigue syndrome - Autoimmune diseases
Typical cystoscopic appearance:
- Glomerulations and bleeding during draining the bladder
- Hunner’s ulcer
Management of painful bladder syndrome
Conservative
- Education
- Avoid caffeine, alcohol, acidic foods and drinks
- Stress management
- Regular exercise
- Analgesia
Pharmacological: Amitriptyline
Intravesical treatments
Last resort: Total cystectomy and urinary diversion
Haematuria
Rule out and treat UTI
Renal USS
Cystoscopy
Refer urology
When should caution should be exercised in using transvaginal mesh implants in which patients?
Primary prolapse cases
Patients younger than 50y of age
Lesser grades of prolapse (POP-Q original grade 2 or less)
Posterior compartment prolapse without significant apical descent
Patients with chronic pelvic pain
Post-menopausal patients who are unable to use vaginal oestrogen therapy (first line therapy in the event of erosion)
