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    Ürojinekoloji - www.jinekolojivegebelik.com Ürojinekoloji - www.jinekolojivegebelik.com Presentation Transcript

    • UPDATE IN UROGYNAECOLOGY
      • Bern ar d T. Haylen
      • St. Vincent’s Clinic , Mater & Randwick Urodynamic Centres, Sydney
      • www.bladder.com.au
    • UROGYNAECOLOGY
      • AREA OF GYNAECOLOGY AND FEMALE
      • UROLOGY INVOLVING THE ASSESSMENT
      • AND TREATMENT OF LOWER URINARY
      • TRACT AND PELVIC FLOOR DYSFUNCTION
      • INCLUDING UTERINE AND VAGINAL
      • PROLAPSE
    • INCIDENCE OF UROGYNAECOLOGICAL PROBLEMS
      • OVERALL:
      • High
      • INCONTINENCE:
      • 34% Australian women (11% severe)
      • PROLAPSE:
      • 50% of postmenopausal women at routine gynaecological examination will have some degree of prolapse
    • UROGYNAECOLOGY
      • DIAGNOSES
    • UROGYNAECOLOGY - COMMON DIAGNOSES
      • URODYNAMIC STRESS INCONTINENCE
      • (USI) - 70%
      • DETRUSOR OVERACTIVITY (DO) – 15%-40%
      • VOIDING DIFFICULTIES – 14%-39%
      • (Definition dependent)
      • UTERINE/VAGINAL PROLAPSE - 65%
    • UROGYNAECOLOGY - URODYNAMIC STRESS INCONTINENCE (USI)
      • The diagnosis of USI is urinary incontinence due to weakness or incompetence of the bladder neck and/or urethral sphincter closure mechanisms that normally maintain continence
      • The symptom of stress incontinence is the involuntary loss of urine with coughing, sneezing, running, jumping etc. This is the most likely associated symptom of USI.
    • UROGYNAECOLOGY - DETRUSOR OVERACTIVITY (DO)
      • Abnormal contractions of the intrinsic bladder (detrusor) musculature
      • Irritable bladder symptoms such as frequency, urgency, urge incontinence and nocturnal enuresis are more likely to be present with this condition
    • UROGYNAECOLOGY – VOIDING DIFFICULTY
      • Abnormally slow or incomplete micturition
      • Abnormally slow urine flow rate or high postvoid residual urine volume
      • If high residual (over 30mls) – recurrent urinary tract infections can ensue
      • May be due to hypotonic or atonic bladder or bladder outflow obstruction
    • UROGYNAECOLOGY - UTERINE/VAGINAL PROLAPSE
      • Abnormal descent into the vagina of the uterus, bladder (cystocoele) vaginal vault (enterocoele) or rectum (rectocoele)
      • 560 Consecutive urogynaecology patients with incidence of:
      • . Uterine prolapse (15% overall)
      • . Cystocoele (57% overall)
      • . Rectocoele (41% overall)
      • . Enterocoele ( 8% overall)
    • UROGYNAECOLOGY - OTHER DIAGNOSES
      • MIXED DIAGNOSES:
      • It’s very common for women to have more than one of the most common diagnoses e.g USI/DO, USI/prolapse
      • Women with prolapse often have USI and may also have DO and voiding difficulties
      • INTERCURRENT DIAGNOSES:
      • 8% of urogynaecology patients will have other pelvic pathology (e.g. fibroids, ovarian pathology) whilst many more will have other gynaecological symptomatology.
      • OTHER DIAGNOSES:
      • . Inflammation, Fistula, Urethral Diverticulum
    • UROGYNAECOLOGY – RECURRENT URINARY TRACT INFECTIONS
      • One of the most common bacterial infections in General Practice.
      • 40% women affected sometime in their life
      • 27% have a recurrence within 6 to 12 months
      • Definition: uncertain to date
      • “ 2 or more symptomatic and medically documented UTI in the last 12 months”
    • UROGYNAECOLOGY – RECURRENT URINARY TRACT INFECTIONS
      • 1140 consecutive first visit referrals for urogynaecological assessment
      • Full history, examination, urodynamics
      • Prevalence: 18.6%
      • Main Risk factors:
      • Nulliparity: 3.7x (18-50yrs); 1.8x (over 50)
      • Postvoid Residual (PVR): over 30mls
    • UROGYNAECOLOGY
      • AETIOLOGY
      • (for background reading)
    • UROGYNAECOLOGY – AETIOLOGY OF URODYNAMIC STRESS INCONTINENCE
      • 1: CHILDBIRTH : Number 1 cause by far
      • Risk Factors: Vaginal delivery; heavy baby (>4kg); prolonged 2 nd stage labour (>1hr pushing). Caesarean section protective in short term.
      • 2: MENOPAUSE: Mean age for presentation of women with urinary tract and pelvic floor dysfunction is 55 years.
      • 3: HYSTERECTOMY: Much incontinence present but not discussed at time of hysterectomy. Some new dysfunction post-hysterectomy with voiding difficulties not uncommon.
    • UROGYNAECOLOGY – AETIOLOGY OF DETRUSOR OVERACTIVITY
      • MANY THEORIES:
      • 1: IDIOPATHIC: Absence of inhibitory neuro-transmitters or increased spontaneous detrusor contractions
      • 2: NEUROGENIC: Lesions to frontal lobe, pontine lesions or lesions above S2-4 give detrusor overactivity
      • 3: OBSTRUCTIVE: Postsurgical or with prolapse
      • 4: INFECTIVE:
    • UROGYNAECOLOGY – AETIOLOGY OF PROLAPSE
      • 1: CHILDBIRTH
      • 2: HYSTERECTOMY
      • 3: MENOPAUSE
      • 4: PREVIOUS PROLAPSE / INCONTINENCE SURGERY
    • UROGYNAECOLOGY – AETIOLOGY OF VOIDING DIFFICULTY
      • 1: BLADDER OUTFLOW OBSTRUCTION
      • Idiopathic . Drugs (e.g tricyclics)
      • Postoperative . Obstructive effect of prolapse
      • Psychogenic . Distal urethral (ageing) changes
      • Infective . External pressure (retroversion)
      • 2: HYPOTONIC / ATONIC BLADDER
      • Postpartum retention
      • LMN Lesion (diabetes, peripheral neuropathy)
      • Overdistension
    • UROGYNAECOLOGY
      • ASSESSMENT
    • UROGYNAECOLOGY - INITIAL ASSESSMENT - (ALL PRACTITIONERS)
      • 1: HISTORY –
      • Full history with symptoms of incontinence, bladder irritability, prolapse and voiding difficulty sought
      • 2: EXAMINATION –
      • General, Clinical Stress Leakage, Sims Speculum (prolapse), Bimanual
      • 3: MSU
      • 4: BLADDER CHART
      • 5: POSTVOID RESIDUAL (U/S)/ RENAL TRACT U/S: if recurrent UTI
    • UROGYNAECOLOGY - COMMON SYMPTOMS
      • 1: INCONTINENCE:
      • Stress, Urge, Coital, Nocturnal
      • 2: IRRITATIVE:
      • Urgency, Frequency (> 7), Nocturia (>1)
      • 3: VOIDING:
      • Hesitancy, Poor stream, Sense of incomplete emptying, Need to immediately revoid, Strain to void
      • 4: PROLAPSE:
      • Pelvic pressure, Vaginal lump, Sacral backache,
      • Dyspareunia.
      • 5 : OTHER:
      • Gynaecological (pelvic pain, menstrual dysfunction), Neurological, Diabetes
    • UROGYNAECOLOGY - ROLE OF SYMPTOMS
      • MOST WOMEN WITH PELVIC FLOOR
      • DYSFUNCTION WILL PRESENT WITH
      • MULTIPLE SYMPTOMS SUGGESTIVE OF
      • MORE THAN ONE UROGYNAECOLOGICAL
      • DIAGNOSIS.
    • UROGYNAECOLOGY – COMMON SIGNS
      • A: CLINICAL STRESS LEAKAGE:
      • . Bladder FULL , Standing or left lateral position
      • . Occult stress – prolapse reduced to see leakage
      • B : PROLAPSE (UTERINE/VAGINAL)
      • . Bladder EMPTY , Left lateral (Sims) position
      • C: INTERCURRENT GYNAE/UROLOGY PATHOLOGY:
      • . Bimanual pelvic examination
      • . Speculum examination
      • . Vulval examination
      • . Vaginal ultrasound examination ( generally
      • specialist assessment)
    • FEMALE URINARY INCONTINENCE: CLINICAL EXAMINATION
      • GRADING OF PELVIC ORGAN PROLAPSE (POP) - ICS
      • For each of uterine prolapse, cystocoele, rectocoele, enterocoele
      • GRADE 0: No prolapse
      • GRADE 1: Descent towards vaginal introitus (>1cm above hymen)
      • GRADE 2: Descent to vaginal introitus (hymen +/- 1cm from hymen)
      • GRADE 3: Descent through introitus (> 1cm below hymen)
      • GRADE 4: Prolapse totally outside introitus
      • (uterine grade 4 = “procidentia”)
    • Figure 1: Prolapse staging – 0,1,2,3,4 (uterine – by the position of the leading edge of the cervix) N.B. vaginal eversion in stages 3 & 4 Symphysis Position: Section 2D (ii/iii) BH / JL 2007 0 1cm 1cm Hymen Bladder (Empty) Rectum 4 3 2 1
    • Figure 11: Pelvic Organ Prolapse Stage 2 Anterior Vaginal Wall Prolapse Position: Section 2D (v) OR Section 4E (i) Stage 4 Enterocele / Vaginal Vault Prolapse Position: Section 2D (iv) OR Section 4E (i) Stage 3 Uterine Prolapse Position: Section 2D (iii) OR Section 4E (i)
      • 33% of women with symptoms of pelvic floor dysfunction will have frequency and/or dysuria - ? UTI
      • UTI might cause or exacerbate symptoms of pelvic floor dysfunction
      •   Recurrent UTI’s might be a reflection of a chronic abnormally high postvoid residual (above 30mls can lead to recurrent UTI’s)
      UROGYNAECOLOGY – ROLE OF MID STREAM URINE
    • UROGYNAECOLOGY – ROLE OF BLADDER DIARY
      • 3 DAYS CHARTING TIME AND AMOUNT OF EACH VOID, FLUID INTAKE AND EPISODES OF INCONTINENCE
      • Indicator of urinary frequency or nocturia ( this can be altered by bladder training)
      • Indicator of average voided volume (should be 200-300mls)
      • Indicator of severity of incontinence (number of leaks)
      • Indicator of above average (>2 litres) or below average (under 1 litre) fluid intake
    • Figure 2: Bladder Diary This simple chart allows you to record the fluid you drink and the urine you pass over 3 days (not necessarily consecutive) in the week prior to your clinic appointment. This can provide valuable information. • Please fill in approximately when and how much fluid you drink, and the type of liquid. • Please fill in the time and the amount (in mls, or ounces) of urine passed, and mark with a star if you have leaked or mark with a “P” if you have needed to change your pad. (Please find below an example of how to complete this form.) Summary Frequency = 9 Nocturia = 1 Urine pr oduction / 24 hour = 1250 ml Maximum voided volume = 300 ml Average void = 125 ml Position: Section 2F (i/ii) DATE/TIME DD.MM.YY LIQUID INTAKE (mls) VOLUME OF URINE (mls. or ounces) LEAKS PAD CHANGE 21.02.06 0215 150 0715 250 0800 Mug coffee 250ml 0820 60 P 0930 Cup Orange juice 1000 100 1200 2 mugs coffee 1400 300 1430 20 1530 Cup of Tea 200ml P 1600 100 1800 Cup of Tea 200ml 1900 100 2000 Glass Beer 200ml 20 2030 Glass wine 50ml 2200 P 2300 150
    • UROGYNAECOLOGY – INITIAL GENERAL MEASURES
      • WEIGHT LOSS : often reduces symptom of stress incontinence
      • REDUCED CAFFEINE : reduced frequency, bladder irritability
      • IMPROVE CHEST CONDITIONS: or other exacerbating factors for stress incontinence
      • VAGINAL OESTROGENS: May improve frequency, nocturia, urgency and condition of the vaginal mucosa. Little proven benefit for incontinence over placebo
      • MEDICATIONS: Adverse effect of diuretics, Minipress
      • PHYSIOTHERAPY: Best if incontinence is mild to moderate and stress incontinence is the main symptom
    • UROGYNAECOLOGY
      • ? REFERRAL /
      • URODYNAMIC TESTING
    • UROGYNAECOLOGY – REFERRAL FOR URODYNAMICS
      • MIXED SYMPTOMS - Diagnosis uncertain
      • SEVERE SYMPTOMS
      • FAILURE OF INITIAL MEASURES
      • DEFINITIVE TREATMENT ANTICIPATED : - Surgery for Urodynamic Stress Incontinence
      • - Anticholinergics for Detrusor Overactivity
    • UROGYNAECOLOGY – AIMS OF URODYNAMICS (a)
      • 1: IDENTIFY/ ELIMINATE DETRUSOR OVERACTIVITY
      • TEST: Cystometry
      •  
      • 2 : IDENTIFY/ ELIMINATE VOIDING DIFFICULTIES
      • TESTS : Urine flow rate, Residual urine, Voiding cystometry
      •  
    • UROGYNAECOLOGY – AIMS OF URODYNAMICS (b)
      • 3: CONFIRM PRESENCE OF URODYNAMIC STRESS INCONTINENCE
      • TESTS: Stress urine leakage, ultrasound
      • imaging
      •  
      • 4: IDENTIFY PRESENCE OF PROLAPSE AND INTERACTION WITH OTHER BLADDER DYSFUNCTION
      •  
      • 5: ASSESS SEVERITY OF ALL DIAGNOSES PRESENT
    • UROGYNAECOLOGY – URODYNAMICS – WHAT’S INVOLVED?
      • 1 hour assessment – Including initial and final discussion
      • History and Examination
      • Vaginal Ultrasound (Bladder neck, postvoid residual and pelvic, uterine assessment)
      • Uroflowmetry
      • Filling and voiding cystometry
    • UROGYNAECOLOGY
      • URODYNAMIC TESTING
      • - CRITERIA FOR DIAGNOSES
      • ( Further Reading)
    • UROGYNAECOLOGY – Dx OF GENUINE STRESS INCONTINENCE
      • CLINICAL STRESS LEAKAGE (Examination, Pad Test)
      • BLADDER STABLE
      • (or stable when leakage occurs)
      • IMAGING EVIDENCE –
      • Bladder neck incompetent
    • Figure 5: Schematic diagram of filling cystometry Flow rate mls/sec P abd cmH 2 O P det cmH 2 O P ves cmH 2 O Fill volume mls 30 40 20 10 20 40 60 80 20 40 60 80 20 40 60 80 100 200 300 400 FD ND SD U filling cystometry voiding cystometry CC 48 year old female with urinary frequency. No phasic activity during filling. Voided with normal flowrate at normal detrusor pressure. Normal study. FD = First Desire to Void, ND = Normal desire to void, SD = Strong desire to void, U = Urgency, CC = Cystometric Capacity (permission to void given). Position: Section 3C (v – vii), Section 3D (iii/iv) BH / JL 2007
    • UROGYNAECOLOGY – Dx OF DETRUSOR OVERACTIVITY
      • CYSTOMETRY –
      • PRESENCE OF UNSTABLE BLADDER CONTRACTIONS ON FILLING OR PROVOCATION ASSOCIATED WITH SYMPTOM OF URGENCY
      • Bladder Capacity normally 500mls with < 10cm H20 pressure rise
      • Pressure increases over 15cm H20 abnormal
      • Under 400mls capacity is low
    • Figure 9: Schematic diagram of detrusor overactivity Flow rate mls/sec P abd cmH 2 O P det cmH 2 O P ves cmH 2 O Fill volume ml 30 40 20 10 20 40 60 80 20 40 60 80 20 40 60 80 100 200 300 400 FD ND SD U filling cystometry voiding cystometry L L 52 year old female with urgency and frequency. Phasic activity during filling. Leakage associated urgency and detrusor contractions. L = leakage, MCC = Maximum Cystometric Capacity. U MCC Position: Section 3D (v:b) & Section 4B (i) BH / JL 2007
    • UROGYNAECOLOGY – Dx OF VOIDING DIFFICULTIES
      • SLOW URINE FLOW –
      • (Under 10 th Centile of Liverpool Nomogram)
      • HIGH RESIDUAL URINE –
      • Over 30mls is abnormal. 85% of women have no residual
      • VOIDING CYSTOMETRY -
      • . No Contraction, poor or no flow - Hypotonic or atonic
      • . Strong Contraction, slow flow - Bladder outflow obstruction
    • Figure 4: Liverpool Nomogram for maximum urine flow rate in women Reference: 20 Position: Section 3A (ix) Equation: Ln (Maximum flow rate) = 0.511 + 0.505 x Ln (voided volume) Root mean square error = 0.340
    • Reference: 23 Figure 10: Voiding difficulty Vaginal Probe (Ultrasound) Pubis Example of voiding difficulty Voided volume = 250ml Qmax = 15mls/sec < 10 th centile on Liverpool Nomogram and / or Post void residual (TV USS) = 78ml PVR = (H x D) x 5.9 – 15 = X ml PVR = (4.5 x 3.5) x 5.9 – 15 = 78ml Reference: 20 Position: Section 4D (i) Height (H=4.5) Depth (D=3.5) X
    • UROGYNAECOLOGY
      • URODYNAMIC STRESS
      • INCONTINENCE
      • - MANAGEMENT
    • UROGYNAECOLOGY – CONSERVATIVE TREATMENT OF USI
      • PHYSIOTHERAPY:
      • 50-65% improvement, 20-40% cure if properly supervised. 40 Contractions per day for maximal compliance.
      • AIDS TO PHYSIO:
      • . Perineometer
      • . Vaginal Cones
      • . Electrical Stimulation
      • MECHANICAL DEVICES:
      • . Tampons
      • . Pessaries
      • SURGERY FOR USI
      • Minimally Invasive :
      • . Tension-free Vaginal
      • Tape – J & J
      • . “Advantage” - Boston
      • Traditional
      • Colposuspension
      UROGYNAECOLOGY – SURGICAL TREATMENT OF USI
    • UROGYNAECOLOGY – TENSION-FREE VAGINAL TAPE (TVT)
      • Minimally invasive, day-only or overnight surgery
      • Inert prolene mesh – no rejection or infection
      • Most scientifically proven continence surgery in the history of Urogynaecology
      • Around 800,000 TVT’s performed worldwide (20,000 in Australasia)
      • Excellent combination with prolapse surgery
      • 90% success rate (Primary USI)
    • UROGYNAECOLOGY
      • DETRUSOR OVERACTIVITY
      • - MANAGEMENT
    • UROGYNAECOLOGY – TREATMENT OF DETRUSOR OVERACTIVITY
      • CAN BE DIFFICULT –
      • 50% response from most treatments versus 30% for placebo
      • MILD/MODERATE: Behavioural
      • . Bladder Training
      • . Maximal electrical stimulation
      • . ? Acupuncture/ Hypnosis
      • MODERATE/SEVERE: Medication
      • . Anticholinergics
      • . Antidepressant
      • . Antidiuretics
    • UROGYNAECOLOGY – BLADDER TRAINING FOR DETRUSOR OVERACTIVITY
      • SUPPRESS URGENCY
      • INCREASE VOIDED VOLUMES
      • DECREASED FREQUENCY
      • DECREASED URGENCY
    • UROGYNAECOLOGY – DRUG TREATMENT OF DETRUSOR OVERACTIVITY - DAYTIME
      • PROPANTHELINE ( Probanthine )
      • - (15 - 30mg tds) - anticholinergic
      • OXYBUTYNIN (Ditropan) ( 2.5 - 5mg tds) – musculotrophic, antispasmodic, anticholinergic
      • . Patch form available ( Oxytrol)
      • TOLTERODINE (Detrusitol) (1 - 2mg BD)
      • antispasmodic, antimuscarinic - reduced S/E
      • SOLIFENACIN ( Vesicare ) – 5 -10mg daily
      • - antimuscarinic - probably least S/E
    • UROGYNAECOLOGY – DRUG TREATMENT OF DETRUSOR OVERACTIVITY – NIGHT TIME
      • IMIPRAMNE (Tofranil) (25-75mg)
      • AMITRYPTALINE (Endep) (10-25mg)
      • DESMOPRESSIN ACETATE (Minirin) (200mcg ½ - 1 nocte) - Antidiuretic for enuresis
    • UROGYNAECOLOGY
      • UTEROVAGINAL PROLAPSE
      • - MANAGEMENT
    • UROGYNAECOLOGY – TREATMENT OF UTEROVAGINAL PROLAPSE
      • A: CONSERVATIVE: Future child bearing desired; younger (under 34) Medically compromised
      • physiotherapy
      • ring pessary
    • UROGYNAECOLOGY – TREATMENT OF UTEROVAGINAL PROLAPSE
      • B : Future childbearing
      • unlikely : under 40 years
      • conservative measures
      • unsuitable
      • Manchester repair & sacrospinous hitch (St. Vincent’s Repair )
    • UROGYNAECOLOGY – TREATMENT OF UTEROVAGINAL PROLAPSE
      • C : No future childbearing:
      • over 40 years
      • vaginal hysterectomy + repairs +/- sacrospinous hitch (easiest effective vaginal vault support)
    • UROGYNAECOLOGY – SURGICAL TREATMENT OF PROLAPSE
      • 1 : UTERINE:
      • . Family Complete - Vaginal Hysterectomy
      • . Family Incomplete - Manchester
      • 2: CYSTOCOELE:
      • . Primary - Anterior Repair
      • . Recurrent - Anterior or Paravaginal Repair
      • 3: RECTOCOELE: Posterior Vaginal Repair
      • 4: ENTEROCOELE:
      • . Small: Posterior Vaginal Repair
      • . Medium/Large: Sacrospinous Hitch (90% Success )
    • UROGYNAECOLOGY
      • RECURRENT UTI /
      • VOIDING DIFFICULTY
      • - MANAGEMENT
    • UROGYNAECOLOGY – RECURRENT UTI
      • MEDICAL THERAPY:
      • Milder: 1 – 2 Courses antibiotics then
      • Hiprex 1Gm / Vit C 500mg each BD for
      • 3 – 5 months according to no. of UTI
      • Stronger: Rotating low dose antibiotics
      • e.g Keflex 500mg, ½ Triprim, or Macrodantin 100mg each nocte 2/12 with cranberry tablet mane
      • Strongest: Long term Noroxin
    • UROGYNAECOLOGY – RECURRENT UTI
      • SURGICAL THERAPY:
      • . If many UTIs: Cystoscopy
      • . Poor flow, High PVR, No prolapse
      • Cystoscopy & urethral dilatation
      • . Poor flow, High PVR, Prolapse
      • ? Cystoscopy & prolapse repair.
    • UROGYNAECOLOGY – TREATMENT OF VOIDING DIFFICULTIES
      • CAUSE TREATMENT
      • . Uterine/Vaginal Prolapse . Repair Prolapse
      • . Idiopathic High Residual . Longterm UTI Prophylaxis
      • (Recurrent UTI’s) (Hiprex/ Macrodantin)
      • . Postoperative, Postpartum . Catheterisation
      • (Suprapubic/ Self-cath)
      • . Distal Urethral Stenosis . Urethral dilatation
      • Vaginal oestrogens
    • UPDATE IN UROGYNAECOLOGY
      • Bern ar d T. Haylen
      • St. Vincent’s Clinic , Mater & Randwick Urodynamic Centres, Sydney
      • www.bladder.com.au