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Stress Urinary Incontinence & Cytoceles


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Dr. Wagener explains what stress urinary incontinence and cytoceles are.

He also looks at causes and treatment options.

Published in: Health & Medicine
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Stress Urinary Incontinence & Cytoceles

  1. 1. Christopher W. Wagener MD<br />Affinity Medical Group <br />Obstetrics and Gynecology<br />Stress Urinary Incontinence & Cytoceles<br />
  2. 2. Overview<br />Stress Incontinence<br />What is it?<br />What causes it?<br />How is it treated?<br />Cystocele<br />What is it?<br />What causes it?<br />How is it treated?<br />What’s new and what should you be aware of?<br />
  3. 3. Incontinence<br />International Continence Society (ICS)<br />(2002) The complaint of any involuntary leakage of urine.<br />It increases with age, but is not normal and treatment is available.<br />
  4. 4. Incontinence<br />Stress incontinence 50%<br />Overactive bladder syndrome 25%<br />Mixed incontinence 25%<br />Overflow incontinence<br />Fistulae<br />Urethral diverticulum<br />Functional<br />Reversible causes<br />
  5. 5. How the Urinary System Works<br />Kidney<br />Ureter<br />Bladder<br />Bladderneck<br />Urinarysphincter<br />Urethra<br />
  6. 6. Stress Incontinence<br />Involuntary leakage of urine on effort or exertion, or on sneezing or coughing<br />Usually small amounts<br />Pressure in the bladder exceeds the urethral pressure<br />No bladder contraction<br />
  7. 7. Stress Incontinence<br />Causes<br />Pregnancy/Childbirth<br />Age<br />Obesity<br />BMI 25-30, 2x increase<br />BMI >40, 66%<br />Chronic cough<br />ACE inhibitors<br />Smoking<br />Genetics<br />Evaluation<br />History<br />Physical exam<br />Cough stress test<br />Urethral mobility<br />Assess for prolapse<br />Urine test<br />Possibly urodynamic testing<br />
  8. 8. Stress IncontinenceTreatment<br />Weight loss, treatment of chronic cough<br />Physiotherapy<br />Pelvic floor muscle training<br />Vaginal cones<br />Biofeedback<br />Pessary with incontinence knob<br />Midurethral sling<br />Periurethral bulking agents<br />
  9. 9. Tension-Free Vaginal Tape Sling<br />Indicated when conservative treatment fails<br />Child bearing is complete<br />Restores the urethral support<br />85 to 90 % success rate<br />Minimally invasive<br />6 weeks of restrictions, recommend 2 weeks off work<br />Risks<br />Bleeding, infection, bladder or other organ injury<br />Mesh erosion, urinary retention, overactive bladder symptoms<br />
  10. 10. TVT Sling<br />
  11. 11. Bulking Agents<br />Minimally invasive<br />Consider for patients with non-mobile urethra, prior unsuccessful incontinence procedures, significant health problems<br />40- 60 % success rate<br />No restrictions after surgery<br />May take more than one procedure<br />No long term studies to show it is long lasting<br />Risks: Urinary tract infection, retention, discomfort<br />
  12. 12. Bulking Agents<br />
  13. 13. Cystocele<br />Protrusion of the bladder into the vagina (hernia)<br />Also called a dropped bladder/prolapsed bladder<br />May be associated with uterine prolapse, rectocele, or enterocele<br />May notice a vaginal bulge or pressure<br />Urinary symptoms including incomplete bladder emptying<br />
  14. 14. Cystocele<br />
  15. 15. Cystocele<br />Causes<br />Childbirth<br />Age<br />Genetics<br />Occupation<br />Medical conditions<br />COPD, cough<br />Obesity<br />Constipation<br />Evaluation<br />History<br />Symptoms<br />Incontinence<br />Pelvic exam<br />Stage prolapse<br />Strain or bear down<br />Check uterus and ovaries<br />+/- Cough stress test<br />+/- Urine test<br />
  16. 16. Natural History<br />Prospective observational study<br />259 postmenopausal women, with a uterus<br />Over 3 years<br />Maximal descent increased by >2 cm in 11.0%<br />Maximal descent decreased by >2 cm in 2.7%<br />Obesity and grandmultiparity were risk factors for worsening prolapse<br /> Bradley, Obstet. and Gyn. 2007; 109:848<br />
  17. 17. Cystocele Treatment: Pessary<br />Appointment to fit <br />Trial <br />May not work for certain patients<br />Side effects<br />Discharge<br />Pressure sores<br />UTI<br />
  18. 18. Surgery<br />Cystocele repair<br />Anterior repair<br />Anterior colporrhaphy<br />Without grafts<br />Suture repair<br />With grafts<br />Biological grafts<br />Synthetic grafts<br />
  19. 19. Cystocele Treatment<br />Symptom likely to resolve<br />Questionable if symptom will resolve<br />Bulge <br />Pressure<br />Urinary <br />Gastrointestinal<br />Sexual function<br />Pelvic and back pain<br />Consider pessary trial<br />
  20. 20. Grafts<br />Lower rate of failure<br />Fewer hysterectomies with graft use<br />Patient acceptance<br />Possible risk factor for incontinence<br />Minimize risks of intra-abdominal complications<br />Complications<br />
  21. 21. Graft supporting bladder and uterus<br />21<br />
  22. 22. Risks of Synthetic Grafts<br />Erosion 3-8 %<br />Infection<br />Rejection of mesh<br />Dyspareunia (pain with sex) 10%<br />Injury to adjacent structures<br />
  23. 23. FDA Public Health Notification<br />October 2008<br />Over 1000 reports of complications in a <br /> 3-year period<br />Specific characteristics of the patients at risk have not been determined<br />Complications of erosion through the vaginal epithelium, infection, pain and urinary problems<br />
  24. 24. Recommendations for Physicians<br />Obtain specialized training for each mesh placement technique, and be aware of its risks. <br />Be vigilant for potential adverse events from the mesh, especially erosion and infection. <br />Watch for complications associated with the tools used in transvaginal placement, especially bowel, bladder and blood vessel perforations. <br />Inform patients that implantation of surgical mesh is permanent, and that some complications associated with the implanted mesh may require additional surgery that may or may not correct the complication. <br />Inform patients about the potential for serious complications and their effect on quality of life, including pain during sexual intercourse, scarring, and narrowing of the vaginal wall (in POP repair). <br />Provide patients with a written copy of the patient labeling from the surgical mesh manufacturer, if available. <br />
  25. 25. Grafts<br />Consider for patients with recurrences<br />Paravaginal defects<br />Severe prolapse or poor native tissue<br />Weigh risks and benefits<br />
  26. 26. The Future<br />Robotically assisted prolapse surgery<br />Minimally invasive<br />Vaginal apex prolapse<br />