Urogynaecology An Introduction Ismaiel Abu Mahfouz MSc MRCOG

Urogynaecology; An Introduction Ismaiel Abu Mahfouz MSc, MRCOG, CCT

Richard Turner-Warwick

Urogynaecology “Neither the general urologist nor the general obstetrician and gynaecologist, but someone who has special training and expertise in genitourinary problems in women” “We should expand this definition to include urogynaecology and reconstructive pelvic surgery. Such a description implies a surgeon with specialized training in the conservative and surgical management of women with urinary or faecal incontinence, persistent genitourinary complaints, and disorders of pelvic floor supports” Turner-Warwick 1986

A 1000 years of missed literature!

Al-Zahrawi (Albucasis) (936– 1013 AD)

• • Cystolithotomy in women Instruments to visualise the interior of the urethra

Introduction • Terminology • Patients’ Assessment • Urinary Incontinence (UI) • Pelvic Organ Prolapse (POP)

Terminology

LUTS Terminology • • • Urinary incontinence The complaint of any involuntary leakage of urine Urgency Sudden compelling desire to pass urine, which is difficult to defer Increased daytime frequency The complaint by the patient that he/she voids too often by day Nocturia The complaint that the patient has to wake up at night one or more times to void Nocturnal enuresis The complaint of loss of urine occurring during sleep

LUTS Terminology • Urge urinary incontinence (UUI) Involuntary leakage accompanied by or immediately preceded by urgency • Mixed urinary incontinence (MUI) Involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing

Overactive Bladder Syndrome (OAB) Detrusor Overactivity (DO) • Overactive bladder (OAB) Urgency, with or without urge incontinence, usually with frequency and nocturia Also known as o The overactive bladder syndrome o o • Urge syndrome Urgency-frequency syndrome Detrusor overactivity (DO) A urodynamic observation characterised by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked

Stress urinary Incontinence (SUI) Urodynamic Stress incontinence (USI) • Stress urinary incontinence (SUI) Observation of involuntary leakage from the urethra, synchronous with exertion / effort, sneezing or coughing • Urodynamic stress incontinence (USI) Involuntary leakage of urine during increased abdominal pressure, in the absence of a detrusor contraction

POP: Definition and Prevalence Loss of support of uterus, bladder, colon or rectum leading to prolapse of one or more of these organs into the vagina Common condition Site: Most frequent: anterior > posterior > apical Race • Compared to white women odds ratios Black 0. 6 Hispanic 1. 2

POP-Q Ordinal stages Stage Description 0 No descend of pelvic structures during straining The leading surface of the prolapse does not descend bellow 1 I cm above the hymenal ring II The leading edge of the prolapse extends from 1 cm above the hymen to 1 cm through the hymenal ring The prolapse extends more than 1 cm beyond hymenal ring, but III not complete vaginal eversion IV Complete eversion of the vagina

Assessment

Clinical evaluation

Abdominal and Pelvic examination

Imaging

Investigations Basic Advanced • Urine test • Conventional subtracted cystometry • Bladder diary • Videocystourethrography • Pad test • Ambulatory Urodynamics Monitoring • Urethral pressure profilometry • Imaging studies • Cystourethroscopy

Basic investigations Urine test Bladder diary Pad Test

The Bladder Diary “Voiding diary, Frequency–Volume chart” • Objective information on the number of voids and their distribution between day and night • Records fluid intake, voided volumes, incontinence episodes • Used to measure changes in response to Rx

Advanced investigations • Conventional cystometry (UDS) • Videocystourethrography (VCU) • Ambulatory urodynamics (AUM) • Urethral pressure profilometry (UPP) • Imaging studies • Cystourethroscopy

Urodynamics Studies (UDS) Definition Studies of lower urinary tract function and dysfunction Why urodynamics? The UDS • Free flow study • Filling Cystometry • Voiding cystometry

Uroflowmetry • • • Simple Non-invasive Voided volume and flow rate Normal study o Peak flow rate >15 ml/sec o Voided volume >150 ml o PVRV <100 mls

Normal Urodynamics

Complex investigations • Videocystourethrography (VCU) • Ambulatory Urodynamic Monitoring (AUM) • Urethral Pressure Profilometry (UPP) • Imaging studies Bladder Wall Thickness (BWT) Magnetic Resonance Imaging Voiding Cystourethrography • Cystourethroscopy

Urinary Incontinence

UI: Potential risk factors 4 th ICI 2009 • • • Age Pregnancy Obesity Menopause Diabetes Hysterectomy Urinary tract infections Cognitive impairment Depression Physical activity Smoking, cough and chronic lung disease

Types of urinary Incontinence • Urodynamic Stress Incontinence (USI) • Detrusor Overactivity Incontinence (DOI) • Overflow incontinence • Fistulae • Congenital (e. g. ectopic ureter) • Urethral diverticulum • Other (e. g. UTI, faecal impaction, medications) • Functional (e. g. immobility)

Rx: All about balance

Treatment of UI General Consideration for all types • Lifestyle modification Fluid intake Caffeine, tea, Coke Wt reduction Smoking • Pelvic Floor Muscle Training (PFMT)

SUI: Conservative Management • Effective. Few complications • Does not compromise further surgery • Useful in women who are • Unfit for surgery • Have not completed their family • Breast feeding • Less than six months post-partum Conservative measures include • Pelvic Floor Muscle Training (PFMT) • • Biofeedback Electrical stimulation Vaginal cones Urethral devices

Devices A: Ring B: Schatz C, D, F: Gellhorn E: Ring with support G: Risser H: Smith I: Tandem cube J: Cube K: Hodge with knob L: Hodge M: Gehrung N: Incontinence dish with support O: Donut P: Incontinence ring Q: Incontinence dish R: Hodge with support S: Inflatoball

USI: Pharmacological management Duloxetine • Potent serotonin-noradrenaline reuptake inhibitor • Enhances urethral striated sphincter activity via a centrally mediated pathway Efficacy and safety • • Significant decrease in incontinence episodes Optimal effect: after 4 weeks of therapy • Nausea: 25 % • Useful in women awaiting surgery • Synergistic effect with PFMT

USI: Surgical management • • • Colposuspension Sub-urethral tapes (TVT/TOT) Urethral bulking agents

SUI: Surgical management Colposuspension Outcome • • Cure rates: 80– 94 % Long-term follow up to 20 years Post-operative complications • • • Voiding difficulties: 5% Detrusor overactivity: 12 -18% Development of enterocele / rectocele: 7 - 17%

Mid-urethral tapes ‘Mid-urethral theory’ / ‘Integral theory’ The concept • Maximal urethral closure pressure is at mid-urethra • Damage to pubourethral ligaments impairs mid-urethral support

Mid-urethral tape procedures Retropubic mid-urethral tapes (TVT) Cure rates • At one year : 90% • At five years: 85% • At seven years : 81% • At 11 years: 90% Post-operative complications • Short-term voiding difficulties: 2. 5– 19% • Bladder perforation : • de novo urgency : • Bleeding : 2. 7– 5. 8% 0. 2– 15% 0. 9– 2. 3%

Urethral Bulking agents

Overactive Bladder (OAB) Detrusor overactivity (DO)

OAB/DO: Conservative management • Advice regarding fluid intake (1 -1. 5 L / day) • Reduce caffeine and alcohol intake • Bladder retraining (BT): Cure rate: 44 - 90 % • Pelvic Floor Muscle Training (PFMT)

OAB/DO: Pharmacological Rx No specific drugs that act on the bladder and urethra which do not have systemic effects • Oxybutynin • Tolterodine • Solifenacin • Darifenacin • Trospium • Fesoterodine Side effects • Dry mouth • Constipation • Blurred vision • Insomnia

OAB/DO: Intravesical Therapy Botulinum toxin • Botulinum. Toxins serotypes: A–G • A and B used for intravesical therapy • Blocks acetylcholine release, causing reversible muscle weakness , reduced contractility • Axons regenerate in 3 to 6 months • Temporary effect Efficacy • Dryness rate: 86% • Urgency resolved: 82% • Duration of improvement: 6 +/- 2 months • Voiding difficulties

OAB/DO: Neuromodulation Sacral neuromodulation • Stimulation of the dorsal sacral nerve root in the S 3 sacral foramen • Invasive and expensive • Significant benefits 65% Peripheral neuromodulation (PTNS) • Posterior Tibial Nerve (PTN) originates from the same spinal cord segments as the innervation to the bladder and pelvic floor • Improvement > 50 %

$OAB/DO: Surgical management 10 % remain refractory to medical and behavioural therapy Different surgical$

OAB/DO: Surgical management 10 % remain refractory to medical and behavioural therapy Different surgical techniques Augmentation • Clam cystoplasty • Auto-augmentation (Detrusor Myomectomy) Urinary Diversion

Pelvic Organ Prolapse (POP)

Treatment of POP

Prevention of POP • Avoid chronic increases in intra-abdominal pressure o Constipation o Chronic pulmonary diseases • ? HRT: may decrease incidence to date (no studies) • Smaller family size • Improvements in antenatal and intrapartum care • Role of C / section: studies showed mixed results • Antenatal and postnatal PFMT : ? may be protective

POP: Conservative management Physiotherapy • May have a role in mild cases • Young women who find intra-vaginal device unacceptable • May use • PFMT • Biofeedback • Electrical stimulation • Vaginal cones Intra-vagina devices (vaginal pessaries) • Younger women who have not completed their families • During pregnancy and postpartum • Unfit for surgery • While waiting for surgery

POP: Surgical management Anterior compartment • Anterior colporrhaphy • Paravaginal repair Posterior compartment • Posterior colporrhaphy • Enterocele repair Central Compartment • Vaginal hysterectomy • Uterine preserving repair • Vaginal vault prolapse

Uterine preserving POP surgery Suspend the uterus The evidence for such procedures is limited Rationale to preserve the uterus • Preservation of fertility • Role of uterus in orgasm and female sexuality • Influence on female sexual identity • Lack of uterine pathology Routes • Abdominal: Sacrospinous hysteropexy • Vaginal: Manchester repair, sacrospinous hysteropexy and uterosacral ligament plication • Laparoscopic: Round ligament plication, sacrohysteropexy, uterosacral plication

Recurrent POP • 30% of operations for POP are for recurrence • Vaginal epithelium may be scarred, making surgical correction more difficult and increasing risk of damage to bladder and rectum • Increased risk of dyspareunia secondary to vaginal shortening and stenosis

Mesh repair The use of synthetic mesh is becoming increasingly common May offer further support compared to traditional repair ? ? The ideal mesh • Strong, flexible allowing ease of use • Adequate pore size to allow the ingrowth of fibroblasts Vaginal mesh kits • High objective cure rates: 87 - 95 % • High risk of mesh erosion: 4. 6– 11% • Re-operation rates: 6% • Dyspareunia: a common complication

Mesh

Overactive bladder: summary • BT should be considered as first-line therapy • Placebo effect associated with all drug interventions • Oxybutynin is effective, but significant side effects • More specific agents have similar efficacy but with fewer side effects • Oestrogens: little evidence to support their use • Botulinum toxin: useful option in intractable DO • Neuromodulation: alternative to reconstructive surgery • Surgical interventions: reserved for cases for which no other treatment has succeeded and quality of life is poor

Stress urinary incontinence: summary • PFMT of at least three months should be offered as firstline treatment to all women with SUI or MUI • Retropubic tapes: recommended where conservative management failed • Colposuspension: recommended alternatives • Bulking agents: considered for the management of SUI if conservative management has failed • Anterior repair, needle suspension procedures, paravaginal defect repair and the MMK procedure are not recommended

Pelvic organ prolapse: summary • Common and associated with a high degree of morbidity • Incidence increases with age and parity • Lifetime risk of surgery is 11 % • May be associated with urinary and faecal incontinence • Conservative management : may be effective? • Surgery: tailored to the needs of the individual patients • Use of synthetic mesh for repeat procedures only • High risk of recurrence, 30% require further surgery

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