IRCCS Ospedale San Raffaele Milano        Università Vita-Salute San RaffaelePROLASSO ED INCONTINENZA ASSOCIATI:        CO...
SUI E POP          1-   40% of women with POP report SUI symptoms                                                  Grody...
SUI E POP   2-             CONCOMITANT SUI GENITALPROLAPSE     OCCULT SUI
Latent (Occult) urinary stress incontinence             What is it?    How and when to diagnose?     If, when and how to t...
OCCULT SUI -DEFINITION-
External   OUrethral                C             urethral       Ekinking            compressi   C   T               on   ...
OCCULT SUI -HOW TO DIAGNOSE?-
 In women presenting with POP w/o SUI the rate of urodynamic  stress incontinence detection is lower with pessary than wi...
OCCULT SUI -HOW TO                 DIAGNOSE?-Pessary test procedure: Pessary placed at maximum cystometric capacity or at...
OCCULT SUI -HOW TO                DIAGNOSE?-   VAGINAL     PACK  Pessaries have a tendency to fall out in theabsence of th...
OCCULT SUI                -DIAGNOSIS-   Filling cystometry at 400-500 ml CC   Cough test at CC in sitting position repea...
OCCULT SUI               -DIAGNOSIS-   Prolapse reduced by pessary   In case of pessary loss -> use of vaginal    pack
VAGINAL VAULT PROLAPSE ANDOCCULT SUI    Patients with vault prolapse have high incidence of     uccult SUI    The change...
POSTERIOR VAGINAL DEFECTS ANDOCCULT SUI  Pessary test procedure:   A posterior blade of a Pederson speculum was used   B...
OCCULT SUI -HOW TO TREAT-
322 women randomized   157 underwent abdominal sacrocolpopexy with Burch    colposuspension (Burch group)   165 underwen...
OCCULT SUI -HOW TO TREAT-                        Abdominal POP                                             POP repair     ...
OCCULT SUI -HOW TO TREAT- Anterior plication of                         Objective rate   Subjective rate endopelvic fascia...
OCCULT SUI -HOW TO TREAT-                                 UROLOGY 76: 1358–1363, 2010   117 women with POP and occult SUI ...
UROLOGY 76: 1358–1363, 2010Comparison of subjective cure rate between anti-incontinence  procedures               TVT-O  ...
OCCULT SUI -POSSIBLE                    SOLUTIONS-   Perform anti-incontinence surgery in ALL patients    undergoing POP ...
MORE STUDIES ARE NEEDED…
PATIENT INFORMATION   Risk of develop postoperative SUI   Need of preoperative urodynamic evaluation to    reveal occult...
CONCLUSIONS  Standardized defintion by ICS/IUGA since 2010  No standardized method for prolapse reduction and evaluation...
GRAZIE!
Upcoming SlideShare
Loading in …5
×

Il prolasso ed incontinenza associati_Salvatore

481 views

Published on

Dr. Salvatore Corso GLUP TV - 22-23 marzo 2013

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
481
On SlideShare
0
From Embeds
0
Number of Embeds
41
Actions
Shares
0
Downloads
0
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Il prolasso ed incontinenza associati_Salvatore

  1. 1. IRCCS Ospedale San Raffaele Milano Università Vita-Salute San RaffaelePROLASSO ED INCONTINENZA ASSOCIATI: COSA E COME FARE STEFANO SALVATORE
  2. 2. SUI E POP 1- 40% of women with POP report SUI symptoms Grody Occult SUI ranges from 36% to 80% Bergman/Richardson 11-22% preoperatively continent women developed SUI after POP repair Stanton/ Borstad and Rud
  3. 3. SUI E POP 2- CONCOMITANT SUI GENITALPROLAPSE OCCULT SUI
  4. 4. Latent (Occult) urinary stress incontinence What is it? How and when to diagnose? If, when and how to treat?
  5. 5. OCCULT SUI -DEFINITION-
  6. 6. External OUrethral C urethral Ekinking compressi C T on U I Increased L O intra-urethral T L pressure O S G U Y I Occult SUI
  7. 7. OCCULT SUI -HOW TO DIAGNOSE?-
  8. 8.  In women presenting with POP w/o SUI the rate of urodynamic stress incontinence detection is lower with pessary than with speculum prolapse reduction (LE1) The pessary test has also been suggested to predict the result of POP surgery on urinary symptoms. In this indication the predictive value of the pessary test remains unclear (LE3), and it is not recommended to use it routinely (Grade C) Different methods for POP reduction:  Large swab placed at the apex  Posterior blade of a bivalve speculum  Sims speculum  Vaginal pessary
  9. 9. OCCULT SUI -HOW TO DIAGNOSE?-Pessary test procedure: Pessary placed at maximum cystometric capacity or at 400mls (whatever reached first) Patients were asked to cough repeatedly for 5-6 times
  10. 10. OCCULT SUI -HOW TO DIAGNOSE?- VAGINAL PACK Pessaries have a tendency to fall out in theabsence of the uterus and it is difficult to knowwhether the prolapse is adequately reduced andwhether urethral obstruction has occured -> useof vaginal pack Gallentine
  11. 11. OCCULT SUI -DIAGNOSIS- Filling cystometry at 400-500 ml CC Cough test at CC in sitting position repeated 3 times before flowmetry Loss of urine after 1 cough -> severe IUS Loss of urine after 3 cough -> moderate IUS Loss of urine after 5 cough -> mild IUS
  12. 12. OCCULT SUI -DIAGNOSIS- Prolapse reduced by pessary In case of pessary loss -> use of vaginal pack
  13. 13. VAGINAL VAULT PROLAPSE ANDOCCULT SUI  Patients with vault prolapse have high incidence of uccult SUI  The change in ALPP is much higher than in patients with vault prolapse than in patients with moderate grade cystoceles and rectoceles
  14. 14. POSTERIOR VAGINAL DEFECTS ANDOCCULT SUI Pessary test procedure:  A posterior blade of a Pederson speculum was used  Bladder filled up to 300 mls  Patients performed three separate sets of Valsalva maneuvers, and urine leakage was noted Results:  12 (54%) of 22 women revealed occult SUI
  15. 15. OCCULT SUI -HOW TO TREAT-
  16. 16. 322 women randomized 157 underwent abdominal sacrocolpopexy with Burch colposuspension (Burch group) 165 underwent only abdominal sacrocolopexy (controls)RESULTS:23.8% Burch group vs 44.1% controls had stress incontinence after surgeryCONCLUSIONS:Burch colposuspension singnificantly reduced post-operative symptoms ofstress incontinence
  17. 17. OCCULT SUI -HOW TO TREAT- Abdominal POP POP repair repair + Burch alone colposuspension Incontinence rate 54.2% 39.1% after surgeryCONCLUSIONS: Burch colposuspension does not provide anybenefity in POP repair in patients with urinary incontinence
  18. 18. OCCULT SUI -HOW TO TREAT- Anterior plication of Objective rate Subjective rate endopelvic fascia + TVT 92% 96% - TVT 56% 64%
  19. 19. OCCULT SUI -HOW TO TREAT- UROLOGY 76: 1358–1363, 2010 117 women with POP and occult SUI who had concomitant prolapse repair and TVT-O RESULTS: Subjective cure rate: 97.8% Objective cure rate: 86%
  20. 20. UROLOGY 76: 1358–1363, 2010Comparison of subjective cure rate between anti-incontinence procedures  TVT-O 97.8%  TVT 98%  Burch 96%  Pubovaginal sling 95%
  21. 21. OCCULT SUI -POSSIBLE SOLUTIONS- Perform anti-incontinence surgery in ALL patients undergoing POP surgery Perform anti-incontinence surgery in NO patients undergoing POP surgery Perform anti-incontinence surgery in SOME patients undergoing POP surgery based on some set of clinical predictors (i.e. presence of symptons of SUI, clinical observation of SUI on stress testing or occult SUI on stress testing with prolapse reduction)
  22. 22. MORE STUDIES ARE NEEDED…
  23. 23. PATIENT INFORMATION Risk of develop postoperative SUI Need of preoperative urodynamic evaluation to reveal occult SUI Decide for prophylactic anti-incontinence precedure in case of occult SUI Decide the more effective and safer anti- incontinence procedure
  24. 24. CONCLUSIONS  Standardized defintion by ICS/IUGA since 2010  No standardized method for prolapse reduction and evaluation of occult SUI  Treatment choice include postponed or concomitant anti- incontinence procedure with prolapse repair  Overall success rate on a short, medium and long term basis should be part of preoperative counseling as well as LUT functional effectsLatent (Occult) urinary stress incontinence. What is it? How andwhen to diagnose? If, when and how to treat?
  25. 25. GRAZIE!

×