Editors:Stephen Jeffery Peter de Jong
Editors:Stephen Jeffery Peter de Jong
Developed by theDepartment of Obstetrics and GynaecologyUniversity of Cape TownEdited by Stephen Jeffery and Peter de Jong...
ContentsList of contributors                                       1Foreword                                              ...
Use of Mesh, Grafts and Kits in POP surgery       154Management of Third and Fourth degree tears       181Management of Ur...
ContributorsCorina Avni                      Suren RamphalWomen’s Health Physiotherapist   Department of Obstetrics andLav...
ForewordFirst Edition of Textbook of UrogynaecologyUrogynaecology is an exciting and dynamic subspecialty. The last decade...
Chapter 1The Urogynaecological HistoryStephen JefferyPelvic floor dysfunction is           the doctor have been shown to be...
Nocturia                                comfortably deferred by theThis is the number of times a           woman.woman has...
These symptoms are not ascommon in women as in men             Prolapse symptomsbut if present, should prompt         Wome...
which is often underreported and       be recorded.seldom elicited by the clinician.      Medications                     ...
Causes of Incontinence I.    Stress Incontinence         Sphincter Dysfunction         Abnormal Bladder neck support 2.   ...
Chapter 2Lower urinary tract symptomsand urinary incontinence: anoverviewPeter de JongDefinitions of Symptoms              ...
individual has to wake at night                     Stress urinary incontinence is theone or more times to void.          ...
Nocturnal enuresis is the complaint   or in comparison to others.of loss of urine occurring duringsleep.                  ...
used when an individual describes    incontinence episodes.the involuntary loss of urineimmediately after passing urine,  ...
Table 2 Comorbid conditions             and nitrites, although infectioncausing LUTS                            may exist ...
basis for treatment’.                  Videocystourethrography is used                                       in advanced c...
also a necessary aid to diagnosis.     of these conditions may mimicThe latter has been shown to           the symptoms as...
Clinical Diagnosis versus               History, clinical examinationurodynamic diagnosis                    and basic tes...
up clinical diagnosis with specialinvestigations.In the larger centres in SAthere are facilities available forperforming u...
Chapter 3Physical Examination and thePOP-QPeter de Jong, Stephen JefferyAll women presenting with           lower limbs. T...
also adequately assessed for any      Grade I: Descent halfway to theuterine or vaginal vault descent.     introitisThis c...
the system appears complicated                      the following table.and difficult to master butonce it is understood, i...
TABLE 2: The POPQ Grid – Used                        Both the patient’s position duringto Record Examination Results.     ...
Point Aa                                 Point BpIf an imaginary small man walked         Again, this point describes more...
anus in the midline.22
Chapter 4Essential UrodynamicsStephen JefferyUrodynamics                           bladder is has a double lumen, one     ...
1. Free flow phase                       are measuring appropriately,The woman is asked to arrive            when the women...
cystometric capacity.                  During voiding Cystometery                                       Pressures are meas...
Chapter 5The Medical Managementof the Overactive BladderSyndromePeter de JongIntroduction                         17.5 mil...
any medication that may have            prescribed for OAB have anan impact on lower urinary tract        antimuscarinic c...
comprises the symptoms of                is in line with current opinionfrequency (>8 micturitions /             regarding...
medical advice for OAB symptoms;     18 years and representative ofand current previous therapy         the US population ...
their condition (e.g voiding           incontinence and noctuira havefrequently in an effort to avoid       been shown to ...
accurate and sensitive method           and healthcare professionals infor evaluating changes in urgency       community b...
Maintain healthy bowel           worldwide. It has antimuscarinic      actions. Eat high fibre foods     activity acting pr...
compared with the IR preparations       oxybutynin metabolites areand, hence, a much more stable          the principal ca...
Different anticholinergics available in RSA Drug Name                      Brand Name                 Licensed dose Tolter...
The ER formulation was released        voiding diary parametersas a once – daily preparation          (frequency, urgency ...
derivative and is the most selective   to cardiac effects and M3 andM3 receptor antagonist. It has         M5 to visual ef...
system and were given grade            of symptoms caused by significantA recommendations by the               genital atro...
is available in 10mg and 25mg           overall benefits of OAB treatment,tablets, and the usual starting         it is cri...
medical therapy for OAB, therehave been no new importantsurgical innovations. These lasttwo options have supercededbladder...
Chapter 6Intractable Overactive Bladder:Advanced ManagementStrategiesStephen JefferyIntroduction                         f...
bacteria which is commonly found       using either a flexible or rigidin the soil and 1g of the toxin can    cystoscope us...
Botox 300u. Up to six months          self catheterization or have afollow-up, they reported a 50 %       suprapubic cathe...
than 35000 devices having been         reduction in leakage episodes.implanted worldwide to date. In        A further syst...
Textbook of Urogynaecology - 2010
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The field of Urogynaecology has expanded dramatically over the past decade with the advent of a number of new medical and surgical treatment modalities. The evidence base on pelvic floor dysfunction has also grown extensively. This multi-contributor textbook will prove invaluable to gynaecology, urology and surgery registrars and specialists. Physiotherapists and nurses working in the field of Urogynaecology will also find it extremely useful.

Editors: Stephen Jeffery, Peter De Jong

Institution: University of Cape Town

This resource is part of the African Health Open Educational Resources Network: http://www.oerafrica.org/healthoer. The original resource is also available from the authoring institution at http://opencontent.uct.ac.za/.

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Textbook of Urogynaecology - 2010

  1. 1. Editors:Stephen Jeffery Peter de Jong
  2. 2. Editors:Stephen Jeffery Peter de Jong
  3. 3. Developed by theDepartment of Obstetrics and GynaecologyUniversity of Cape TownEdited by Stephen Jeffery and Peter de JongCreative Commons Attributive Licence 2010 This publication is part of the CREATIVE COMMONSYou are free:to Share – to copy, distribute and transmit the workto Remix – to adapt the workUnder the following conditions: Attribution. You must attribute the work in the manner specified by the author or licensor (but not in any way that suggests that they endorse you or your use of the work) Non-commercial. You may not use this work for commercial purposes. Share Alike. If you alter, transform, or build upon this work, you may distribute the resulting work but only under the same or similar license to this one. For any reuse or distribution, you must make clear to others the license terms of this work. One way to do this is with a link to the license web page: http://creativecommons.org/licenses/by-nc-sa/2.5/za/ Any of the above conditions can be waived if you get permission from the copyright holder. Nothing in this license impairs or restricts the authors’ moral rights. Nothing in this license impairs or restricts the rights of authors whose work is referenced in this document Cited works used in this document must be cited following usual academic conventions Citation of this work must follow normal academic conventionshttp://za.creativecommons.org
  4. 4. ContentsList of contributors 1Foreword 2The Urogynaecological History 3Lower Urinary Tract Symptoms and Urinary incontinence:Definitions and overview. 8Examination and the POP-Q 17Essential Urodynamics 23Medical Management of the Overactive Bladder 26Intractable OAB: Advanced Management Strategies 40The Treatment of Stress Incontinence 45Management of Voiding Disorders 55Sexual Function in women with Incontinence 64Urinary Tract Infections (UTIs) in Women 71Neurogenic Bladder 76Interstitial Cystitis 95Introduction to Pelvic Organ Prolapse 97Pathoaetiolgy of Prolapse 108Conservative Management of Pelvic Organ Prolapse 119Surgical Management of Urogenital Prolapse 126Sacrocolpopexy 133Pelvic Floor Muscle Rehabilitaion 137Management of Faecal Incontinence 149
  5. 5. Use of Mesh, Grafts and Kits in POP surgery 154Management of Third and Fourth degree tears 181Management of Urogenital Fistulae 186Role of the laparoscope in Urogynaecology 198Suture Options in Pelvic Surgery 201Thromboprophylaxis in Urogynaecological Surgery 213
  6. 6. ContributorsCorina Avni Suren RamphalWomen’s Health Physiotherapist Department of Obstetrics andLavender House GynaecologyKingsbury Hospital University of NatalClaremontCape Town Peter Roos Department of UrogynaecologyDick Barnes University of Cape TownDepartment of UrologyUniversity of Cape Town Trudie Smith Department of Obstetrics andHennie Cronje GynaecologyDepartment of Obstetrics and University of the WitwatersrandGynaecologyUniversity of the Free State Douglas Stupart Department of Colorectal SurgeryPeter de Jong University of Cape TownDepartment of UrogynaecologyUniversity of Cape Town Paul Swart Department of Obstetrics andEtienne Henn GynaecologyDepartment of Obstetrics and University of PretoriaGynaecologyUniversity of the Free State Kobus van Rensburg Department of Obstetrics andBarry Jacobson GynaecologyDepartment of Haematology University of StellenboschUniversity of Witwatersrand Frans van WijkStephen Jeffery Pretoria Urology HospitalDepartment of Urogynaecology PretoriaUniversity of Cape Town 1
  7. 7. ForewordFirst Edition of Textbook of UrogynaecologyUrogynaecology is an exciting and dynamic subspecialty. The last decadehas seen a rapid advance in the management options available to thegynaecologist in treating women with pelvic floor dysfunction. Stressincontinence surgery was revolutionised by the development of the TVTand exciting long term data has confirmed this device as a gold standardin the management of SUI. Overactive bladder has seen the launch ofa number of new anticholinergic drugs with better side-effect profilesand dosing schedules. We also now have some alternatives to the drugsincluding Botulinum Toxin A and neuromodulation. We are developinga greater understanding of the role of childbirth and pregnancy in pelvicfloor dysfunction. The last three years has seen the launch of intriguingpelvic floor replacement systems and although we are some way off fromachieving long term data on these devices, this is no doubt an importantstep in the evolution of pelvic floor surgery.This book has been written by a number of authors from different partsof South Africa. The field of urogynaecology is still in its infancy and wetherefore have many unanswered questions. In this volume, the readerwill therefore encounter varying opinions. There is a significant amountof overlap and difference of opinion and we hope this will stimulate thereader to read widely and formulate his or her own opinion.The electronic format of this text has made it possible to offer it to thereader at an affordable price. We trust that this book will contribute toa better understanding and management of South African women withpelvic floor dysfunction. We dedicate it to the women of South Africa.A special thanks to Robertha and Anthea Abrahams for secretarial work,and Dr Julie van den Berg for assistance with proof reading.The Editors2
  8. 8. Chapter 1The Urogynaecological HistoryStephen JefferyPelvic floor dysfunction is the doctor have been shown to beassociated with multiple fraught with subjective influences.symptoms including bladder, A number of questionnaires arebowel and sexual complaints. In now available which are able toaddition, women may present elicit symptoms in a standardisedwith neurological symptoms, form and quantify them. This ispsychological issues and particularly useful in a researchrelationship dysfunction. It is setting but these instrumentstherefore imperative that the are now increasingly beinghistory and examination are used in day-to-day practice.performed in a comprehensive Similarly, the examination of thefashion. urogynaeological patient has become more scientific with theUrogynaecological symptoms advent of more detailed andare never life-threatening but scientific prolapse scoring systems.they can have a profound impacton the women’s quality of life.Clinical assessment thereforeaims to determine the extent of Historythe impairment on quality of life Urinary Symptomsand thereby institute the mostappropriate route of investigation Frequencyand management. This is defined as the number of voids during waking hours. NormalClinicians use the traditional frequency is considered to beapproach of history and between four and seven voids aexamination. Symptoms as elicited day.by the traditional interview by 3
  9. 9. Nocturia comfortably deferred by theThis is the number of times a woman.woman has to awake from sleep topass urine. This varies with the age Urgency Incontinenceof the woman, with an increase Here, the women describes thereported in woman above the age symptoms of urgency and she isof 70 years where normal would unable to get to the toilet in timebe considered to be twice at night, and develops incontinence as athree times for women over 80 result.and four times for women over 90years of age. Determining the severity of IncontinenceIncontinence It is important to make a clinicalSymptoms of Urinary Incontinence attempt to determine the severityare notoriously difficult to of the incontinence symptoms. Theevaluate. The International woman could be asked to quantifyContinence Society defines the symptoms on a scale of 0 tothis as the “involuntary loss I0. When this is done using a chartof urine which is a social or it is called a visual analogue scalehygienic problem and objectively (VAS). Many women present withdemonstrable”. mixed symptoms of both stress and urge incontinence and by askingStress Incontinence them to quantify each symptomThis is the involuntary loss of urine using the visual analogue score,with a rise in intra-abdominal we are able to determine which ispressure. Factors that commonly more severe.elicit stress incontinence includerunning, laughing, coughing, The patient should also be askedsneezing and standing up from a about the use of continence aidsseated position. such as pads and how often she changes her underwear. TheUrinary urgency number of incontinence episodesThis is the compelling desire to per day can also be indicative ofvoid which is difficult to defer. the severity of the condition.It must be differentiated fromurinary urge which is a normal Symptoms of voidingdesire to void which can be dysfunction4
  10. 10. These symptoms are not ascommon in women as in men Prolapse symptomsbut if present, should prompt Women with prolapse have athe appropriate investigation of broad range of symptoms. Studiesurinary residual and flow rate. have shown that the symptomsThese symptoms include: increase significantly with stage 2 Hesitancy prolapse or greater. Most women Straining to void will complain of a bulge or a lump, Incomplete Emptying whilst others will describe either Post- Micturition dribbling discomfort or a burning sensation. Poor Stream Still others will describe associated Double Voiding voiding or defaecatory difficulty, needing to reduce the prolapse toBladder pain void or completely evacuate theirWomen with bladder pain should bowels.be questioned in detail regardingthe nature and occurrence Bowel symptomsof the symptoms. Pain that is Evaluation and questioningrelieved with passing urine may regarding bowel symptoms is anbe associated with Interstitial essential part of the evaluation ofCystitis/ Painful Bladder Syndrome. the pelvic floor.Women with pain as a significantsymptom should be evaluated Anal Incontinencewith cystoscopy and biopsy since This is the involuntary passage ofpain may also be associated with flatus.tumours and stones. Faecal IncontinenceUrethral Pain This is defined as the involuntaryThis may be associated with passage of liquid or solid stool.infections or urethritis. This should be quantified by asking the women about the frequency,Haematuria severity, use of continence aidsWomen with urinary symptoms and impact on quality of life.should always be questionedregarding the presence or Faecal urgency and urgeabsence of blood in the urine and incontinenceinvestigated appropriately. This is an important symptom 5
  11. 11. which is often underreported and be recorded.seldom elicited by the clinician. Medications A note should be made ofDefaecatory dysfunction medications that may beWomen should be asked about worsening the symptoms, includingany difficulty in completing diuretics and alpha –blockers.defaecation including digitation,splinting or manual evacuation. Medical History Diabetes Mellitis and Insipidus areConstipation usually associated with polyuria.A record should be made of Cardiac failure can presentfrequency of stools and any with nocturia as a result of thesymptom of constipation. redistribution of fluid when the patient is lying down.Sexual HistoryA detailed history of sexual Fluid Intakefunction is vital to a thorough The amount and type of fluidassessment of pelvic floor consumed on a daily basis shoulddisorders. Women should be be recorded. Caffeine and alcoholasked if they are sexually active. can exacerbate symptoms ofAny problems should be noted overactive bladder significantlyincluding dyspareunia, vaginal and these products in particularslackness, vaginal tightness, should be enquired about.anorgasmia, coital faecal or urinaryincontinence during intercourse. Obstetric History The number and type of deliveries are important as well as any historyOther relevant parts of perineal or anal sphincter injury.of the history Surgical History Previous pelvic surgery, includingNeurological history prolapse and incontinence surgery,Women should be questioned should be noted.regarding symptoms of limbweakness and sensory fallout.Any history of multiple sclerosis,parkinsonism, spinal cord injury,stroke or spina bifida should also6
  12. 12. Causes of Incontinence I. Stress Incontinence Sphincter Dysfunction Abnormal Bladder neck support 2. Detrusor Overactivity Idiopathic Neurogenic 3. Mixed incontinence 4. Overflow Incontinence 5. Functional Incontinence Confusion Dementia 6. Pharmacologic 7. True incontinence Fistulae 8. Transient Incontinence UTI Restricted Mobility Constipation Atrophic Urethritis 9. Congenital Abnormalities I0. Excessive urine production Diabetes Mellitis and Insipidus Diuretics Cardiac failureAdapted from Textbook of FemaleUrology and Urogynaecology EdsCardozo and Staskin. 7
  13. 13. Chapter 2Lower urinary tract symptomsand urinary incontinence: anoverviewPeter de JongDefinitions of Symptoms symptoms cannot be used to makeLower urinary tract symptoms, a definitive diagnosis. However(LUTS) are equally bothersome LUTS can also indicate pathologiesto men and women, and greatly other than lower urinary tractaffect the quality of life (QOL). dysfunction, such as urinary infection. The clinician will makeThe term “Lower urinary tract his/her best efforts to excludesymptoms” is used to describe other causes of LUTS.a patient’s urinary complaintswithout implying a cause. Lower Lower urinary tract symptoms areurinary tract symptoms were categorized as storage, voidingdefined by the standardization sub and post micturition symptoms.– committee of the International (Table 1)Continence Society. Storage Symptoms are experiencedLUTS are the subjective indicators during the storage phase of theof a disease or change in bladder, and include daytimeconditions as perceived by the frequency and nocturia.patients, carer or partners and maylead her to seek help from health Increased daytime frequency iscare professionals. Symptoms may the complaint by the patient whoeither be volunteered or described considers that he/she voids tooduring the patient interview. They often by day. The average personare usually qualitative. voids 6 times a day.In general, lower urinary tract Nocturia is the complaint that the8
  14. 14. individual has to wake at night Stress urinary incontinence is theone or more times to void. complaint of involuntary leakage on effort or exertion, or onUrgency is the complaint of a sneezing or coughing.sudden compelling desire to passurine, which is difficult to defer. Urgency urinary incontinence is the complaint of involuntary leakageUrinary incontinence is the accompanied by or immediatelycomplaint of any involuntary preceded by urgency.leakage of urine.In each specific circumstance, Mixed urinary incontinence is theTable 1 LUTS FILLING / STORAGE EMPTYING / VOIDING POST VOIDING SYMPTOMS Frequency Hesitancy Post – micturition dribbling Urgency Straining to void Feeling of incomplete emptying Nocturia Poor stream Urgency Incontinence Intermittency Stress Incontinence Dysuria Nocturnal Incontinence Terminal dribbling Bladder / Urethral Pain Absent or Impaired Sensationurinary incontinence should be complaint of involuntary leakagefurther described by specifying associated with urgency and alsorelevant factors such as type, with exertion, effort, sneezing orfrequency, severity, precipitating coughing.factors, social impact, effecton hygiene and quality of life, Enuresis means any involuntarymeasures used to contain the loss of urine. If it is used to denoteleakage, and whether or not the incontinence during sleep, itindividual seeks or desires help should always be qualified withbecause of urinary incontinence. the adjective “nocturnal”. 9
  15. 15. Nocturnal enuresis is the complaint or in comparison to others.of loss of urine occurring duringsleep. Intermittent stream or Double voiding (Intermittency) is the termContinuous urinary incontinence used when the individual describesis the complaint of continuous urine flow which stops and starts,leakage and may denote urinary on one or more occasions, duringfistula. micturition.Bladder sensation can be defined, Hesitancy is the term used whenduring history taking, into four an individual describes difficultycategories. in initiating micturition resulting in delay in the onset of voidingNormal: the individual is aware after the individual is ready to passof bladder filling and increasing urine.sensation up to a strong desire tovoid. Straining to void describes the muscular effort used to initiate,Increased: the individual feels an maintain or improve the urinaryearly first sensation of filling and stream.then a persistent desire to void. Terminal dribble is the term usedReduced: the individual is aware when an individual describes aof bladder filling but does not feel prolonged final part of micturition,a definite desire to void. when flow has slowed to a trickle or dribble.Absent: the individual reportsno sensation of bladder filling or Post micturition symptoms aredesire to void. experienced immediately after micturition.Voiding symptoms are experiencedduring the voiding phase. Feeling of incomplete emptying is a self – explanatory term forSlow stream is reported by the a feeling experienced by theindividual as the perception individual after passing urine.of reduced urine flow, usuallycompared to previous performance Post micturition dribble is the term10
  16. 16. used when an individual describes incontinence episodes.the involuntary loss of urineimmediately after passing urine, FVC’s have been shown to beusually after leaving the toilet. reproducible and more accurate when compared with the patient’sFrequency – Volume Chart recall. The optimal length of(Bladder Diary) a diary varies according to theFrequency – volume charts (FVC) parameter assessed and precisionhave become an important and sensitivity required. Inpart of the evaluation of LUTS. addition, if one is trying to assessMost experts would agree that change, the baseline parameterthese charts provide invaluable (e.g number of voids, incontinenceinformation about a number episodes) will affect the lengthof symptoms including urinary of the diary needed to detectfrequency, urgency, incontinence a certain change. A 7 day diaryepisodes, and voided volume. In is a reasonable option for mostfact some symptoms, like nocturia, patients with incontinence. Ifcannot be properly evaluated record keeping for 7 days increaseswithout a chart. Frequency – a patient’s burden the number ofvolume charts are critical for the days required to evaluate voidingdistinction between nocturnal symptoms should be reduced.overactive bladder and nocturnalpolyuria, two common causes The majority of informationof nocturia. Despite this the collected on FVC’s or bladderstructure, content and duration diaries has been used to establishof chart keeping for evaluation baselines or to study patients withhas not been standardised. There OAB or incontinence.are a number of parametersthat can be assessed by the FVC, Physical examinationincluding: total number of voids A general physical examinationper 24 hours, total number of of the patient is mandatory, sincedaytime (awake) voids, total many co–morbid conditions arenumber of night time voids, likely to impact on the symptomstotal fluid intake, total voided of LUTS (Table 2)volume, maximum, minimum andmean voided volume, number ofurgency episodes, and number of 11
  17. 17. Table 2 Comorbid conditions and nitrites, although infectioncausing LUTS may exist in the absence of pyuria and, in the elderly population, Medical disorders pyuria may develop in the absence ›! Hypertension / heart failure of UTI. Microscopic haematuria can ›! Mulitple sclerosis be easily identified by dipsticking ›! Diabetes Mellitus because of the presence of Reduced mobility haemoglobin. The detection of Alzheimers haematuria is important because Medical therapy, i.e diuretics the condition is associated with Neurological disorders a 4 – 5% risk of diagnosing a urological disorder or malignancyA detailed gynaecological within 3 years. Because of theassessment is important, with high prevalence of urinary tractparticular attention to pelvic infection (UTI) and the increasefloor disorders, and prolapse. A of LUTS in the presence of UTI, allfull neurological examination guidelines on the managementis also required. Digital rectal of patients with LUTS and urinaryexamination is useful to evaluate incontinence, endorse the usethe possibility of co – existent anal of urinalysis in primary care/ faecal incontinence. management.Special investigations Urodynamic InvestigationsUrinalysisUrinalysis is not a single test What is meant by the term- complete urinalysis includes Urodynamic investigations?physical, chemical, and microscopic In 1970 Bates coined the expressionexaminations. Dipstick urinalysis that ‘the bladder often proves tois certainly convenient but false be an unreliable witness’, meaningpositive and false negative results that the presenting symptomsmay occur. It is considered an of the patient and the eventualinexpensive diagnostic test able to diagnosis of the problem are oftenidentify patients with urinary tract at variance. In 1972 Moolgaokerinfection (UTI) as indicated by the stated that ‘urinary symptoms inpresence of leucocyte esterases the female do not form a scientific12
  18. 18. basis for treatment’. Videocystourethrography is used in advanced centres and is theUrodynamic tests have been gold standard of the investigationdeveloped to confirm the of female urinary incontinence.underlying diagnosis in a patient It involves contrast media andcomplaining of symptoms of screening radiology superimposedurinary incontinence. These upon conventional cystometry totests identify the etiology of provide an accurate diagnosis. Thisthe problem and elucidate its modality is not widely available.pathophysiological mechanism.Their use is sometimes debatable, Increasingly, ultrasound imaging issince grade A evidence supporting also being used to measure boththe general use of urodynamics in bladder neck descent and bladderthe investigation of incontinence, wall thickness. Electromyographyis not available. and cystoscopy are adjuncts toThe most basic form of urodynamic urodynamics in complex patientstesting which is used in present with atypical pathology.day practice consists of: The measurement of urethral 1. Uroflowmetry (otherwise resistance pressure has recently known as a ‘free flow been pioneered. This does have measurement’ potential as a diagnostic tool of 2. Multichannel urodynamics the future. However, at present which involve filling and its widespread use as a routine voiding cystometry (the latter urodynamic tool is questionable being a so – called ‘pressure – and it should only be used in flow’ study). research studies aimed at clarifying its value.Depending on the sophistication ofthe apparatus used, either a leak Basic tests which should be– point pressure measurement, or performed on patients prior tourethral pressure profilometry may urodynamic testing include abe performed additionally as a test urine microscopy and culture,of urethral function. Urodynamic and a measurement of residualtesting can either be static or urine volume, either by catheterambulatory. or ultrasound. A bladder diary (frequency / volume chart) is 13
  19. 19. also a necessary aid to diagnosis. of these conditions may mimicThe latter has been shown to the symptoms associated withprovide valuable information on stress incontinence and destrusorthe patient’s voiding pattern and overactivity.functional bladder capacity, as wellas giving an indication of leakage A cough – induced bladderepisodes. contraction causing leakage may be confused with stressIt can be said that most incontinence (so called ‘stress –urodynamic tests are expensive, induced instability’).time consuming and invasive(involving catheterization of There may be serious sequelae ifthe patient). They also require a patient suffering from urinaryconsiderable expertise and access incontinence is not adequatelyto sophisticated equipment. evaluated and an incorrectThere should therefore be sound diagnosis is made. The most seriousmotivation for their use as a of these is inappropriate surgery.diagnostic tool. Failure to recognize concomitant detrusor overactivity and / orClinical Indications for voiding dysfunction may alsoUrodynamics Investigations affect the outcome of appropriateThere are many etiological factors surgery.leading to urinary incontinencein women. Certainly the most Table 1 lists the most importantcommon problems are urodynamic indications for urodynamic studies.stress incontinence due tourethral sphincter weakness or Table 1: Indications forbladder neck hypermobility, and urodynamic studiesdetrusor overactivity leading toincontinence (in most cases ‘urge 1. Prior to surgeryincontinence’). Other causes of 2. Failed medical or surgical treatmentincontinence include fistulae, 3. Complex symptomatologyurethral diverticulae, urethralinstability, the urethral syndrome 4. Neurological dysfunctionand also the contributory effect 5. Voiding dysfunstionof urinary tract infection. It 6. Medico – legal casesmust be emphasized that many14
  20. 20. Clinical Diagnosis versus History, clinical examinationurodynamic diagnosis and basic testsOver the past 35 years there have In the ongoing search for anbeen ongoing discussions in the uncomplicated and cost – effectiveliterature on how best to evaluate approach to the pre – operativepatients with incontinence. The evaluation of a patient foraccurate identification of patients stress incontinence surgery,with SUI has received considerable several authors looked at otherattention parameters which could prove useful.The accuracy of history aloneMost of the early papers looked In summary the addition of otherat the discriminatory value of clinical parameters and simplea pure history of either stress office tests do enhance theincontinence or detrusor instability. sensitivity of a history. However,Symptoms alone were used to the various authors still foundmake a diagnosis before patients the combination inadequate forwere subjected to confirmatory a reliable diagnosis and mostcystometry. Most of the earlier felt that additional research wasstudies had relatively low numbers warranted.of patients. In summary, it is clearfrom the majority of studies that In South Africa, Urogynaecology asa history of incontinence alone is a subspeciality is still in its infancy.not enough to enable a clinician Treatment decisions in femaleto make an accurate diagnosis urinary incontinence managementfor a decision on whether or not are mostly made on clinicalto embark on stress incontinence judgment. There are very fewsurgery. The symptom of stress management protocols in placeincontinence may be very sensitive, and this is an area which urgentlybut is so nonspecific as to render it requires development, particularlyof little diagnostic value. at specialist level.History is best used as a guide to Medical practice is increasinglythe subsequent evaluation process becoming dogged by litigation andand to serve as a measure of practitioners have to be able todisease severity. show that they have their patient’s best interest at heart by backing 15
  21. 21. up clinical diagnosis with specialinvestigations.In the larger centres in SAthere are facilities available forperforming urodynamic studiesbut these are mostly underutilised.They are often also run by staffwho are not properly trained toprovide good quality results andinterpretation.There is an increasing number ofpractitioners in SA who have aspecial interest in Urogynaecologyand who manage female patientswith urinary incontinence. It isthese practitioners who shouldbe at the forefront of attemptsto develop mechanisms which areaimed a providing the best possibleservice for their patients. “Bestpractice’ therefore also meansa move away from ‘preference– based’ to ‘evidence – based’medicine.16
  22. 22. Chapter 3Physical Examination and thePOP-QPeter de Jong, Stephen JefferyAll women presenting with lower limbs. The anal sphincterpelvic floor dysfunction should tone should be tested.be thoroughly examined inthe supine, left lateral andstanding positions. Where a Gynaecologicalsurgical intervention is planned,the responsible surgeon should Examinationdetermine exactly what may It is impossible to perform anbe required at operation – so adequate urogynaecologicalthat the appropriate consent examination without using acan be obtained and the correct Sims speculum and in someintervention planned. circumstances two Sim’s speculae are required. The examination begins with the woman in theGeneral dorsal position. The vulva and vagina are inspected for anyThe women’s mobility and general lesions, atrophy or excoriation.condition should be noted. The woman is then asked to cough or valsalva while the clinician observes for any stressNeurological incontinence. She is then askedexamination to turn onto her left side and the Sims speculum is used to inspectThe spinal segments S2,3.4 should the anterior and posterior vaginalbe assessed by testing the tone, walls for prolapse. It is imperativestrength and sensation in the that the middle compartment is 17
  23. 23. also adequately assessed for any Grade I: Descent halfway to theuterine or vaginal vault descent. introitisThis can be difficult, but if one Grade 2: Descent down to theuses two Sims speculae placed vaginal introitisanteriorly and posteriorly, while Grade 3: Descent beyond thethe women strains down, it introitis but not maximalis relatively easy to assess this Grade 4: Maximal descentcompartment. The prolapse shouldbe graded using either the Baden- This grading system is useful in dayWalker or POP-Q systems (see to day clinical practice but it has abelow). If the women’s symptoms number of shortcomings. It doesare not adequately explained by not give a quantitative impressionthe findings at examination, it may of the severity of the prolapse.be useful to perform an additional It does not address the vaginalassessment with her standing. This length, perineal body size or theis accomplished by asking her to length of the urogenital hiatus.stand with her legs apart while The POP-Q (Pelvic Organ Prolapsethe examiner bends in front of Quantification System) wasthe patient and gently palpates developed by the Internationalthe anterior, middle and posterior Continence Society to addresscompartments. She is then asked these issues and it supercedes theto cough again in the standing previous systems used to describeposition. POP. The new objective assessment allows a clear and unambiguous description of prolapse, facilitatingClassification and better objective assessment, management and surgicalgrading of prolapse comparison. Precise staging made gynaecological oncology anGrading and classification of pelvic objective progressive disciple, andorgan prolapse enables clinicians it is hoped that introduction ofto communicate with each other POP – Q will allow similar advancesand is also useful in a research in the management of prolapse.setting. The most commonly used Terms used in the past such as forgrading system is the Baden- example small, medium or large,Walker halfway system which cystocoele or rectcoele, are nogrades prolapse as follows: longer applicable. At first glance,18
  24. 24. the system appears complicated the following table.and difficult to master butonce it is understood, it can be All measurements are made to theperformed in less than 30 seconds nearest 0.5cmwhile performing a routinegynaecological examination. It Consensus and validation of theis based on measurements that new system has been extensive.are taken using the introitis as The clinical examination isreference. Any measurement performed and the measurementsabove this is negative and recorded on the “POPQ grid”.anything below this is positive. (Table 2)The measurements are taken usinga marked Pap smear spatula. Sixspecific vaginal sites (points Aa, Ba,C, D, Bp and Ap) and the vaginallength (tvl) are assessed usingcentimeters of measurement fromthe introitus. The length of thegenital hiatus (gh) and perinealbody (pb) are measured.The points are defined as follows,with the ranges as suggested inTABLE 1: POP - Q DEFINITION AND RANGES Point Measurement Range Aa Anterior vaginal wall 3cm proximal to the hymen -3 to +3 Ba Leading – most point of anterior vaginal wall prolapse -3 to +tvl C Most distal edge of cervix or vaginal cuff (if cervix is absent) -/+ tvl D Most distal portion of the posterior fornix -/+ tvl Ap Posterior vaginal wall 3cm proximal to the hymen -3 to +3 Bp Leading – most point of posterior vaginal wall prolapse -3 to +tvl gh Perpendicular distance from mid – urethral meatus to posterior hymen No limit pb Perpendicular distance from mid – anal opening to posterior hymen No limit tvl Posterior fornix or vaginal cuff (if cervix is absent) to the hymen No limit 19
  25. 25. TABLE 2: The POPQ Grid – Used Both the patient’s position duringto Record Examination Results. the examination (lithotomy, anterior anterior anterior birthing chair, or standing) and the wall wall wall state of her bladder and rectum Aa Ba C (full or empty) should be noted genital perineal total vaginal hiatus body length Staging of the grade of pelvic support is objectively done on a gh pb tvl five – stage system. (Table 4) posterior posterior posterior wall wall fornix Table 4: The five stages of Ap Bp D* Pelvic Organ Support Stage 0: No descent of any compartments*Measurement D is not taken in Stage 1: Descent of the most prolapsedthe absence of a cervix compartment between perfect support and – 1cm, or 1cm proximal to the hymenThe measurement of prolapse Stage 2: Descent of the most prolapsedis performed in accordance compartment between -1cm andwith certain measurement +1cm.fundamentals. (Table 3) Stage 3: Descent of the most prolapsed compartment between +1cm and (tvl -2cm)Table 3: POPQ MeasurementFundamentals Stage 4: Descent of the most prolapsed compartment from (tvl -2cm) to All measurements are made to the nearest complete prolapse 0.5cm All measurements are made relative to the hymen Points proximal to the hymen are negative Explanation of (inside the body) individual points Points distal to the hymen are positive (out- side the body) Points Aa, Ab, Pa and Pb are the The hymen is assigned a value zero most difficult to understand. They gh, pb, and tvl measurements will always represent the extent of prolapse, have a positive value be it above the introitis ( ie All measurements, except for tvl, are made negative) or below the introitis ( ie while patient is bearing down positive)20
  26. 26. Point Aa Point BpIf an imaginary small man walked Again, this point describes morefrom the introitis up the anterior extensive prolapse beyond thevaginal wall and made a mark once 3 cm mark of Ap similar to Ba.he had covered 3 cm this would be Again if there is no prolapse, bypoint Aa. The distance this point convention it is -3.descends on the vertical plane cantherefore be either -3, -2, -1 if it Point Cis above the introitis, 0 at the This describes the prolapse of theintroitis and +1,+ 2 or +3 below the cervix or vaginal vault. If the cervix,introitis. This point is therefore for example, is 7cm above thenever more than 3 and represents introitis, this point is then -7, if it isthe bottom 3cm of the vagina. 4 cm below C is +4.Point Ba Point DThis point describes additional This describes the descent of theprolapse of the anterior vaginal posterior fornix again similar towall that goes beyond the first the cervix.3 cm. It is the most distal part ofthe prolapse. It can therefore be Total vaginal Lengthgreater than the +3 described for This is the measurement ofpoint Aa. For the milder prolapse, the length of the vaginal tubeit often equates to that of Aa. from top to bottom. It is usuallyBecause it essentially defines more measured with the marked spatulaextensive prolapse, when there inserted to its maximum into theis no prolapse, by convention we vagina.make it the same as Aa. Urogenital hiatusPoint Ap The measuring spatula is placedAgain our imaginary man makes anteroposteriorly along thethe 3cm trip up the posterior wall introitis and measures from thewhere he marks off point Ap. The urethral meatus to the midline ofdistance this point descends can the posterior hymen.again be therefore either -3, -2, -1if it is above the introitis, 0 at the Perineal bodyintroitis and +1,+ 2 or +3 below the Again the perineum is measuredintroitis. from the posterior hymen to the 21
  27. 27. anus in the midline.22
  28. 28. Chapter 4Essential UrodynamicsStephen JefferyUrodynamics bladder is has a double lumen, one to measure the bladder pressureWhole books have been written (Pves) and the other lumen is usedon Urodynamic practice and to fill the bladder with water viatechnique. The diagnosis in women the pump system. Sometimes,with urinary incontinence based two separate catheters are usedon clinical findings is correct in for filling and pressure recording.only 65% of cases. There is a large The rectal probe measures theoverlap between symptoms and intra-abdominal pressure (Pabd)examination and urodynamic and this pressure could thereforefindings. 55% of women with also be obtained by inserting thestress incontinence will have a line into the vagina or even intomixed picture. The cystometrogram a colostomy. A Urodynamic reportbecomes essential, in a number usually gives 3 pressure tracings:of women, to enhance diagnostic Pves (bladder pressure), Pabdaccuracy and therefore enable us (abdominal) and Pdet (detrusorto institute treatment. pressure). The detrusor pressure is obtained by the following formula Pdet = Pves-Pabd. Urodynamics is therefore often called SubtractedThe equipment Cystometry.The Urodynamics system comprisestwo catheters, one placed in thebladder and another in the rectum, The Procedurea computer and the urodynamicssoftware and pressure transducers, The test comprises threea pump system, and a flowmeter. phases.The catheter that is placed in the 23
  29. 29. 1. Free flow phase are measuring appropriately,The woman is asked to arrive when the women coughs, thereat the investigation with a full should be no deviation of thebladder. She is then asked to Pdet – only on the vesical line andvoid on the flowmeter, which is the abdominal line since theseusually mounted on a commode, in are both under the influenceprivacy. It should be noted that this of abdominal pressure. In otherpart of the test differs from the words, when there is a rise invoiding cystometry, which is done abdominal pressure with coughing,after the filling phase once the the same pressure is transferredbladder is full and the lines are in to the bladder. The Pdet willsitu to measure the pressures. therefore be zero since Pves minus Pabd is zero and the detrusor lineFlow Meter Commode will be flat with deviations only in the Pabd and Pves. Bladder filling is commenced once the operator is satisfied that the tracing is technically correct. The patient is asked to report on her first desire as well as the moment she has a strong desire to void. Any urgency and associated incontinence is noted. Provocative measures through the filling phase2. Filling phase include asking the woman to heelThe bladder and rectal lines are bounce, wash hands and cough.inserted with the patient supine This will also hopefully elicit anyand any urinary residual is noted. stress incontinence which is usuallyThe lines are flushed and the also occasionally recorded on thesystem is zeroed. The women trace by a flowmeter but if thisis asked to cough to check that modality is not available on thethe Pdet measurement is correct. filling phase, is usually observedFor example, if the Pabd is not by visual inspection of the vulva.measuring correctly, the Pdet will When the patient is unable tonot be accurately calculated. If tolerate any more filling, the pumpboth the vesical and rectal lines is stopped, this is the maximum24
  30. 30. cystometric capacity. During voiding Cystometery Pressures are measured during3. Voiding Cystometry the voiding cystometry phaseThis is done by asking the patient and therefore parameters suchto void while the pressures are as PdetQmax, the detrusorrecorded. pressure during maximum flow, is measured. A pressure greater than 20cmH2O would suggest anPossible Diagnoses obstruction.During Free FlowFlow rate is abbreviated as Q. Anormal flow curve is bell-shaped.An obstructive pattern is flat orwith intermittent sections of flow.The maximum flow is denotedas Qmax. A normal flow rate isdefined as less than I5ml/s.During Filling phaseAny contractions of the detrusortracing suggest a diagnosisof detrusor overactivity (DO).One should always look at theabdominal tracing and thisshould be flat during a detrusorcontraction to diagnose DO. If theabdominal curve is also elevated,this would suggest possible poorsubtraction and a diagnosis ofDO should not be made. If theDetrusor pressure curve risesslowly during the filling phase, thiswould suggest poor compliance. Ifone notes both stress incontinenceand DO during filling, a diagnosisof mixed incontinence is made. 25
  31. 31. Chapter 5The Medical Managementof the Overactive BladderSyndromePeter de JongIntroduction 17.5 million women in the USA who suffer from the condition.The term “overactive bladder” The prevalence increases withwas proposed as a way of increasing age being 4 percent inapproaching the clinical problem women younger than 25 years andfrom a symptomatic rather than 30 percent in those older than 65a urodynamic perspective. The years. The overall prevalence ofoveractive bladder syndrome OAB in individuals aged 40 years(OAB) has been defined by the and older is 16%. Frequency, theInternational Continence Society most common symptom, occurs inas urinary urgency with or without 85% of respondents, while 54%urge incontinence usually with complain of urgency and 36% offrequency and nocturia. It is a urge incontinence.diagnosis based on lower urinarytract symptoms alone. While not Initial management of OAB shouldlife threatening, it can have a take into account the individual’sconsiderable adverse impact on lifestyle and any appropriatethe quality of lives of those who interventions that can besuffer from it, and it is highly employed to minimize symptoms.prevalent within society. Recent For example, reducing excessiveepidemiological studies have fluid intake (25ml / kg / day isreported the overall prevalence sufficient) and minimising caffeineof OAB in women to be 16%, and alcohol consumption maysuggesting that there could be be helpful, as well as reviewing26
  32. 32. any medication that may have prescribed for OAB have anan impact on lower urinary tract antimuscarinic component, andfunction, such as diuretics. this limits compliance with the treatment because of a lack ofBehavioral therapies and, acceptability to some people.particular, bladder retraining Recent advances have includedmay help a person regain central sustained release preparations ofcontrol of micturition and can be existing compounds, innovativehighly effective in well – motivated routes of administration andindividuals, although there is a newer antimuscarinic preparations.recognized high relapse rate. While many people will beDrug therapy is the mainstay of considerably improved and eventreatment for OAB, and from cured of their symptoms by drugthe number of preparations that therapy, there are always thosehave been studied, it is clear who do not respond and for them,that there is no ideal drug for all it is most important that furtherpeople. In the past, clinical results investigations are undertaken toof treatment have often been ensure that the correct problemdisappointing due to both to poor is being addressed. Urodynamicefficacy and unacceptable adverse studies will confirm (or otherwise)effects. Earlier preparations were a diagnosis of detrusor overactivitynot subjected to the current in which case, further trialsrigorous randomised controlled of different antimuscarinictrials and, therefore, lack evidence preparations would be desirable,– based data. Comparison of whereas in the absence ofdrug therapies for this condition proven detrusor overactivity,is difficult due to the placebo an alternative diagnosis shouldeffect of 30 – 40%, and since the be sought to avoid furtherresponse to any of the available ineffectual treatment and, hencedrugs is only in the region of 60%, disillusionment and a waste ofany differences that are detected resources.are likely to be small, and thusrequire large – scale studies to Definition of OABshow efficacy. syndromeThe drugs that are currently OAB is a clinical diagnosis and 27
  33. 33. comprises the symptoms of is in line with current opinionfrequency (>8 micturitions / regarding the importance of24 hours), urgency and urge urgency as the driving force behindincontinence, occurring either the other components, frequency,singly or in combination, which nocturia and incontinence,cannot be explained by metabolic which are also mentioned in the(e.g diabetes) or local pathological definition. Urgency is, however,factors (e.g urinary tract infections, difficult to measure and in manystones, interstitial cystitis). of the clinical trials assessing the pharmacological treatment of OABIn clinical practice, the empirical syndrome, micturition frequencydiagnosis is often used as the has often been used as the primarybasis for initial management endpoint as it is easier to quantify.after assessing the individual’slower urinary tract symptoms,physical findings and the The OAB – howresults of urinalysis, and otherindicated investigations. Thus, the common is it?International Continence Society in There are at present only a fewits Standardisation of Terminology population – based studies thatreport from 2002 defined the have assessed the prevalenceOAB syndrome as urgency with or of OAB. The prevalence of OABwithout urge incontinence, usually symptoms was estimated in a largewith frequency and noctuira. European study involving moreThese symptom combinations than 16 000 individuals. Data wereare suggestive of urodynamically collected using a population –demonstrable detrusor overactivity, based survey of men and womenbut can be due to other forms of aged 40 years, selected fromurethro – vesical dysfunction. The the general population in France,term “overactive bladder” can be Germany, Italy, Spain, Sweden andused if there is no proven infection the UK using a random, stratifiedor other obvious pathology. approach. The main outcome measures were prevalence ofIn the current International urinary frequency (>8 micturitionsContinence Society (ICS) definition /24 hours), urgency and urgeof the OAB syndrome, urgency incontinence; proportion ofis an obligatory component. This participants who had sought28
  34. 34. medical advice for OAB symptoms; 18 years and representative ofand current previous therapy the US population by sex, age,received for these symptoms. and geographical region wasThe overall prevalence of OAB assessed. The overall prevalencesymptoms in this population of of OAB was similar between menmen and women aged 40 years (16.0%) and women (16.9%) andwas 16%. About 79% of the was similar to the results reportedrespondents with OAB symptoms earlier from Europe. The impacthad experienced symptoms for of OAB symptoms on quality ofat least 1 year and 49% for 3 life was assessed in a subset of theyears. Sixty – seven percent of participants from the NOBLE study.the women and 65% of the men In individuals who reported OABwith OAB symptoms reported that symptoms, these symptoms had atheir symptoms had an impact clinically significant negative effecton daily living. The prevalence on quality of life, quality of sleep,of OAB symptoms increased with and mental health.age in both men and women.OAB symptoms were relativelymore common in younger women Impact of OABcompared with men, while theopposite was found for the older symptoms onage groups where symptoms were employment, socialmore common in men. However, interactions, andwhen comparing the total emotional wellbeingpopulation of men and women,there was little difference in the Symptoms suggestive of an OABoverall prevalence reported in often have a profound negativewomen and men. influence on quality of life. It is not only episodes of leakageThe prevalence of OAB symptoms that effect wellbeing but alsohas also been assessed in a urgency and frequency havelarge population based survey considerable detrimental effectsfrom the USA. The National on daily activities. Constant worryOveractive Bladder Evaluation about when urgency is going to(NOBLE) was designed to assess strike results in the developmentthe prevalence and burden of of elaborate coping mechanismsOAB. A sample of 5204 adults to enable people to manage 29
  35. 35. their condition (e.g voiding incontinence and noctuira havefrequently in an effort to avoid been shown to be associated withleakage episodes, mapping out an increased incidence of falls andthe location of toilets, drinking fractures among elderly.less, or the use of incontinencepads). It is not difficult to see how The intensity of urinary urgencythese troublesome symptoms may has a significant associationdisrupt people’s daily lives and with other symptoms of OAB.occupations. Despite the negative Urgency is the ‘driving’ symptomimpact of these symptoms on in OAB, those experiencing OABquality of life, many affected frequently experience urgency atindividuals fail to report this inconvenient and unpredictablecondition to their physicians of times and consequently, oftensymptoms for many years. This lose control before reaching themay be due to embarrassment or toilet. This adversely affects theirpossibly because of the mistaken physical and psychological state byopinion that effective treatment is limiting daily activities, intimacy,not available. compromising sexual function and worsening self – esteem. It is no surprise therefore thatThe management of improvements in urgency are often stated by people to be the mostoveractive bladder noticeable response to therapy.Incontinence occurs in Urgency is a sensory symptomapproximately a third of people and as such is difficult to define,presenting clinically with OAB, to communicate to both patientsand approximately a third of them and colleagues alike and thehave a mixed picture of combined measure and quantify. Despitesphincteric weakness and detrusor the difficulties, urgency and theoveractivity. The prevalence of other symptoms of OAB resultOAB is higher among the elderly in a significant deterioration inpopulation (age 64 and above); it HRQL. To date, patient diaries haveis estimated to be approximately been shown to be a reliable way30 – 40% among persons older to collect various OAB symptoms,that 75 years, and this may have including urgency episodes, andadditional ramifications as both diary entry remains the mosturinary urgency, associated30
  36. 36. accurate and sensitive method and healthcare professionals infor evaluating changes in urgency community based primary carewith pharmacotherapy. Data services play a pivotal role inobtained on the basis of 3 – or 4 the management of incontinent– day diaries suggest that short – patients.duration diaries are just as reliableas those recorded for 7 days, and Behavioural therapy andbecause they impart less patient pharmacotherapy are theburden, may be an acceptable mainstay of treatment, and theremethod of assessing the symptoms is continuing search for moreof OAB. Apart from increases effective and selective drugsin cystometric capacity, invasive with minimal adverse effectspressure flow studies have failed to (AEs). About 50% of peopleshow positive results with existing gain satisfactory benefit fromantimuscarinic therapy. pharmacotherapy. The role of physiotherapy in the treatment ofInitial assessment must include urge incontinence remains uncleara thorough history and physical as evidenced by systematic reviewexamination. A complete of clinical trials.pelvic and neurological examis mandatory, to exclude other Treatment of OAB is multifaceted.conditions that may mimic OAB Effective treatment modalitiessymptoms. Urine analysis, and include lifestyle modifications,microscopy and culture will exclude medications, bladder retraining,urinary infections. Further special and exercises to strengthen theinvestigations are not required. pelvic floor (Kegel Exercises)Treatment for all forms of 1. Lifestyle modificationsincontinence should commence The patient should limitwith conservative methods before intake of foods and drinksprogressing to more complex that may irritate the bladdersurgical procedures if these do not or stimulate the productionwork. A multidisciplinary approach of urine e.g alcohol, caffeine,is important in its management. coffee, tea and fizzy drinks,In addition to urologists and and aspartate sweeteners.gynaecologists, continence nurse Drink 25ml / kg / day ofspecialists, physiotherapists fluids 31
  37. 37. Maintain healthy bowel worldwide. It has antimuscarinic actions. Eat high fibre foods activity acting primarily on the such as wholewheat bread M1 and M3 receptor over the M2 and pastas. receptor. Two oral formulations Stop smoking of this drug are now available on Lose weight (if obese) our market and include immediate – release (IR) and extended –2. Bladder retaining release (ER) forms. More recently, a transdermal formulation has beenThe patient should - introduced. Several randomised Gradually increase the time placebo controlled trials have between voids shown oybutynin IR to be Increase the time intervals by effective in producing subjective 15 minutes until she reaches improvement in patients (at least an optimal time which is 50% improvement in incontinence comfortable for her. episodes) as well as objective parameters. Dose begins at 2.5mg3. Pelvic floor muscle exercises bd, going up to a maximum of (Kegel Exercises) (See 5mg tds. Adverse effects include elsewhere) dry mouth, blurred vision, constipation, urinary retention,Surgical options (some still gastro – oesophageal reflux,experimental) have been added dizziness and central nervousin recent years and these include, system (CNS) effects. The AEs,neuromodulation and botulinum particularly dry mouth, can lead totoxin injection therapy, but these a high (up to 80%) dropout rateinterventions are reserved for cases within 6 months of commencingwhere medical therapy fails. treatment. In an attempt to reduce theDrug therapy incidence of these AEs, a new formulation, allowing a moreThere are a number of controlled release of the drug overantimusarinic agents in a 24 – hour period (oxybutynincontemporary use. Oxybutynin ER) was introduced. The sustainedchloride is the most commonly release produces a more sustainedprescribed anticholinergic for OAB plasma concentration when32
  38. 38. compared with the IR preparations oxybutynin metabolites areand, hence, a much more stable the principal cause of AEs,steady – state concentration for 24 alternative delivery routes havehours. Tablet doses between 5 and been sought that would avoid10 mg are available, and several oral administration and firstrandomized controlled studies pass metabolism. Consequently,have shown that oxybutynin ER a transdermal preparation ofis as effective as IR preparations oxybutynin has been developed.with the additional benefit At the present time, this agent hasof a reduction in dry mouth. not yet been licensed for use inOther modes of oxybutynin SA. An initial short – term study ofdelivery include intravesical and transdermal verus oral oxybutynintransdermal administration. IR in adults with urinary urgeIntravesical therapy was developed incontinence reported that bothto increase the balance in treatment options had similarfavour of efficacy over AEs in efficacy, but the transdermalthose patients routinely using route produced significantly lessintermittent self – catheterisation. dry mouth. A double – blindedOxybutynin (typically 5mg) is randomised controlled trial (RCT)mixed with normal saline and of transdermal oxybutynin at 3.9administered twice a day via a mg administered twice weeklyurethral catheter. Several small versus placebo, reduced theopen – label studies have shown number of weekly incontinencethat intravesical administration of episodes, reduced average dailyoxybutynin can reduce subjective urinary frequency increasedand objective detrusor overactivity. average voided volume andClearly, the main limitation of this significantly improved quality ofroute of administration, associated life (QOL) compared with placebo.with the use of intermittent self The incidence of dry mouth– catheterisation, is the increased was similar in both the groups,risk of developing cystitis due to an and the main AEs associatedirritant effect of the solution, and with transdermal delivery werea higher risk of developing urinary erythema and pruritis at the site oftract infections with subsequent application.high dropout rates.Following the hypothesis that 33
  39. 39. Different anticholinergics available in RSA Drug Name Brand Name Licensed dose Tolterodine tartrate ER Detrusitol XL 4mg o.d Darifenacin hydrobromide Enablex 7.5 – 15mg tds Oxybutynin hydrochloride Ditropan 2.5mg b.i.d – 5mg tds Oxybutynin hydrochloride ER Lyrinel XL 5 – 20mg o.d Oxybutynin hydrochloride tds Kentera 1 patch twice weekly Trospium chloride Uricon 20mg b.i.d Solifenacin succinate Vesicare 5 – 10mg o.d Propiverine hydrochloride Detrunorm 15mg o.d. – tds Propiverine hydrochloride ER Dertrunorm XL 30mg o.d.Key:o.d. = once dailyb.d. = twice dailytds = three times dailyPropiverine hydrochloride is a with OAB, propiverine 15 mgtertiary amine with a half – life three times daily was comparedof approximately 20 hours, with oxybutynin 5 mg twiceshowing peak levels in serum daily and placebo. Both drugsafter approximately 2.3 hours produced objective and subjectiveafter ingestion. Like oxybutynin improvements compared withit exhibits a mixed action, placebo at 4 weeks comparedexhibiting both anticholinergic with baseline. Propiverine was asand musculotropic effects (calcium effective as oxybutynin in reducingchannel blocking activity). Doses urgency and urge incontinence,vary between 15 and 30 mg but was associated with a lowerdaily. The clinical trials and data incidence of dry mouth.with this agent are limited toa month’s duration or less. In a Tolterodine was launched indouble – blinded randomized 1998 and was the first modernplacebo – controlled trial of people anticholinergic on the market.34
  40. 40. The ER formulation was released voiding diary parametersas a once – daily preparation (frequency, urgency and urgeaimed at producing a stable serum incontinence) for up to 52 weeksconcentration over 24 hours. ER after trospium 20 mg twice – dailyhas peak serum concentration at treatment.2 – 6 hours post administration.Therapy with tolterodine ER 4mg Two new anticholinergic agentsappears to be efficacious in both have been released in recentolder and younger people with years, namely solifenacin andOAB; it is useful for at least up to darifenacin. Solifenacin has a12 months with improvement in mean time to maximum plasmavoiding diary parameters including concentration of 3 – 8 hours andurgency, and patient perception of long elimination half – life of >45their condition with a benefit of – 68 hours. Solifenacin producesHRQL based on the King’s health a significant reduction in voidingquestionnaire. The ER formulation frequency and a significantis more effective than placebo in increase in volume voided/void indifferent degrees of incontinence people with OAB and urodynamicseverity. It has been shown to be evidence of detrusor overactivity.effective in treating women with The recommendation is formixed urinary incontinence with a an initial 5 mg dose with thepredominance of urge symptoms possibility of dose flexibility byover stress. increasing the dose to 10 mg as required. The long term efficacyTrospium chloride, a quaternary of solifenacin has been reportedamine, is purported to lack in an open – label extension ofCNS effects as it does not cross randomised placebo – controlledthe blood – brain barrier. Its trials. The efficacy seen in thehalf – life is between 12 – 18 initial trials was maintained forhours and reached peak plasma up to 52 weeks. About 85% ofconcentrations between 4 and the study population was satisfied6 hours. The usual dose is 20mg after 24 weeks of flexible dosing,twice daily. Trospium 20 mg twice and with regard to efficacy, 74% ofdaily has shown similar results the population were satisfied afterwhen compared with oxybutynin 24 weeks of flexible dosing.5 mg twice daily, with significantreduction in urodynamic and Darifenacin is a tertiary amine 35
  41. 41. derivative and is the most selective to cardiac effects and M3 andM3 receptor antagonist. It has M5 to visual effects. Certainly, inbeen shown to have a higher this population, this would be ofdegree of selectivity for the M3 greater significance due to theover the M2 receptor compared existence of comorbidity and thewith other anticholinergics, with susceptibility to impaired cognitivemarginal selectivity for the M1 function and nervous systemreceptor. In healthy volunteers effects. Definitive comment onafter oral administration of this subject will inevitably awaitdarifenacin, peak plasma adequately powered head – to –concentrations are reached after head comparative studies. Doseapproximately 7 hours with flexibility has been explored withmultiple dosing, and steady – darifenacin and clearly showedstate plasma concentrations that some people who do notare achieved by the sixth day respond to a lower dose of drugof dosing. In a double – blind, (7.5mg) will do so at higherradomised, crossover study doses (15mg), but will developcomparing darifenacin with more pronounced AEs inevitably,oxybutynin in people with however, they may accept this asproven detrusor overactivity and part of the ‘trade – off’ for theassociated symptoms of OAB, greater efficacy experienceddarifenacin was as effectiveas oxybutynin in terms of the It is clear that among the manyambulatory urodynamic variables drugs tried for the treatmenttested but darifenacin 15 and of OAB, acceptable efficacy,30 mg controlled release was documented in RCT’s of goodsignificantly better in salivary flow quality, has only been showncompared with oxybutynin 5 mg for a limited number. Thethree times daily. anitmuscarinics tolterodine, trospium, solifenacin andThe introduction of darifenacin has darifenacin, the drugs mixedfuelled debate over the potential actions, oxybutynin andimportance of pharmacological propiverine, and the vasopressinselectivity as related to the AE analogue, demopressin, wereprofile. M1 and M3 receptor have found to fulfill the criteriabeen attributed to dry mouth, for level1 evidence accordingM1 to cognitive impairment, M2 to the Oxford assessment36
  42. 42. system and were given grade of symptoms caused by significantA recommendations by the genital atrophy. Oestrogen isInternational Consultation on not useful for treating urinaryIncontinence. All antimuscarinics incontinence, but may reduce theapart from oxybutynin IR were incidence of UTI’s.found to be well tolerated. Drymouth was the most commonlyreported adverse event and nodrug was associated with an MIXEDincrease in any serious adverse INCONTINENCEevent. EthipramineGenerally there is little or no goodevidence to choose between the Tricyclic anti – depressants haveanticholinergics been used widely for symptoms of frequency, urgency, urge incontinence and especiallyOestrogen nocturia for many years. Although grade 1 evidence justifying theirWhilst the use of oestrogen in the use is lacking, many patientstreatment of women with stress are satisfied with the results.incontinence is controversial, its Ethipramine is inexpensive anduse in women with the irritative widely available, with a multitudesymptoms of OAB is more of effects – and side effects.established. Postmenopausalwomen with genital atrophy or Its actions are anticholinergicOAB symptoms may receive oral in nature, with an adrenergicor topical therapy provided no effect on the bladder neck.contra – indications exist, but at Theoretically at least, this makespresent, oestrogen therapy for it ideal for mixed incontinence,stress incontinence is unwise. As but its side – effects are oftenwe wallow in post “Women’s troublesome. It causes cardiacHealth Initiative” hype, we must conduction defects and this hasremember the negative impact caused the WHO to warn againstof withholding the beneficial its use. Dry mouth and drowsinesseffects of oestrogen on the pelvic are the most bothersome sidefloor, and not precipitate a host effects, limiting its use. The drug 37
  43. 43. is available in 10mg and 25mg overall benefits of OAB treatment,tablets, and the usual starting it is critical that RCTs use validateddose is 10mg in the mornings, instruments to assess HRQL and towith 25mg or 50mg at night. The relate these changes to changes insoporific effect of ethipramine may OAB symptoms. The Internationalbe used to advantage, allowing Continence Society advocates theincreased evening dosage. Contra use of HRQL measures in clinical– indications are as for other anti – research has provided increasingcholinergics. If clinicians prescribe evidence for the HRQL benefitsethipramine, they must be aware conferred by effective OABof its cardiac effects especially in treatments.elderly women. The future emphasis of work in this field must also incorporateImipramine patient – perceived outcomes using existing tools to assess bother andThe use of imipramine is parallel QOL.to that of ethipramine – with theproviso that it remains untestedas a pure anticholinergic for use The futurein incontinence. Imipramine isprimarily, with amytriptyline, an There is an overall trend towardsantidepressant, and its useful development of once dailyanticholinergic effects are purely extended release preparations forfortuitous. Clinicians must be existing anticholinergics, such asaware that these agents are of extended release oxybutynin andlimited use as niche agents, and propiverine. Multiple strengthsthat ethipramine is perhaps more are now available in certain onceclinically useful. daily agents such as solifenacin, allowing more flexible therapeuticPharmcotherapy remains the options. Urinary urgency does notmainstay of therapy for the always arise within the bladder,treatment of OAB, and the and that when investigating OABcontemporary literature shows that we should consider a variety ofantimuscarinic agents are used pathological causes. With theas a first line therapy for OAB. To exception of botulinum toxingain a better understanding of the and neuromodulation for failed38
  44. 44. medical therapy for OAB, therehave been no new importantsurgical innovations. These lasttwo options have supercededbladder augmentation by bowelinterposition, since they are far lessinvasive, are reversible, and havefewer side effects. 39
  45. 45. Chapter 6Intractable Overactive Bladder:Advanced ManagementStrategiesStephen JefferyIntroduction from the incontinence clinic, only 7% of the cohort reported beingThe mainstay of treatment cured, with 65% still sufferingfor Overactive Bladder is fluid significant symptoms. Previously,management, bladder retraining the only therapeutic option forand anticholinergic drug therapy. these patients was surgery in theThere are, however, a subset of form of bladder augmentation.women who do not respond to These operations, however,these standard treatment regimens carry a high morbidity withand remain incontinent, their most having voiding dysfunctionsymptoms having a profound requiring clean intermittent selfimpact on their quality of life. catheterization, and troublesomeStudies have shown that only mucus production.18% of women stay on their A number of newer promisingdrug treatment for longer than treatment options have been6 months. This appears to be as developed, including Botulinuma result of inadequate efficacy Toxin and nerve stimulationand not side effects. Morris et al techniques.performed one of the only trialson long –term outcomes of women 1. Botulinum Toxintreated for OAB with a standard Botulinum Toxin, which iscare package of anticholnergics produced by the bacterium,and bladder retraining. Looking Clostridium Perfringens, is theat the same subjects a mean of most potent toxin known to man.eight years following discharge It is a Gram positive, anaerobic40
  46. 46. bacteria which is commonly found using either a flexible or rigidin the soil and 1g of the toxin can cystoscope using a flexible 26kill 1 million people. It blocks the gauge needle that is threadedrelease of acetylcholine at the through the working channel ofneuromuscular junction in the the scope. The toxin is diluteddetrusor muscle. Amongst those into 20 ml of normal saline andwho have contributed to the injected in 1ml aliquots underscience of Botulinum Toxin, credit local or general anaesthesia.must be given to Schantz who Most practitioners avoid injectingpurified the toxin and enabled its the bladder trigone because ofmass production. Its first clinical the theoretical risk of reflux.use was in 1980 when it was Recent work has, however, shownused to treat strabismus. There that trigonal injections are notare 7 subtypes, A, B, C, D, E, F , associated with reflux and haveG, however only Toxins A and B equivalent efficacy to the extra-are available commercially. The trigonal administration. When aBotulnum A Toxin preparation, flexible cystoscope is used, theBotox® (Allergan Inc.) is probably Botox can be given using localthe most well known, but there anaesthetic gel but sedation oris an alternative called Dysport® general anaesthesia is usually(Ipsen Pharma). Botulinum Toxin necessary when using a rigid scope.B is marketed by Solstice. Schurch et al were the first to useBotox® has been more extensively intradetrusor Botox injections forevaluated in the literature than the treatment of severe detrusorDysport®, but there are now overactivity in spinal cord injureda number of studies that now patients. Profound improvementsconfirm its efficacy. Botox® is were demonstrated, with 17 of 19three times more potent than patients achieving continence. ADysport and most reports use large amount of data has emerged300u for Neurogenic DO and 200u since then suggesting excellentfor Idiopathic DO. Exact dosages efficacy in Neurogenic DO. Schurchfor Dysport are less clear and et al reported again in 2005 onranges from 500u to 1000u are 59 NDO patients. This was doubleadministered. blind placebo controlled parallel group study. They gave patientsThe toxin is usually administered either placebo, Botox 200u or 41
  47. 47. Botox 300u. Up to six months self catheterization or have afollow-up, they reported a 50 % suprapubic catheter inserted.reduction in incontinence episodeswith 49% of the cohort reporting The Botulinum Toxin effect on thebeing dry. The urodynamic findings detrusor lasts for approximatelycompared to placebo were six to nine months and it usuallyremarkable with highly significant requires repeat administrationincreases in maximum cystometric following this. As the urgency andcapacity at two, six and 24 weeks urge incontinence return, normalcompared to placebo. voiding is also regained in those women who developed urinaryFollowing the success in NDO a retention.number of studies began lookingat the treatment of Idiopathic An important factor to take intoDO. The problem with IDO is the consideration is the cost of therisk of voiding dysfunction – since Botulinum Toxin product. Botox isunlike in NDO, most of these sold in vials of 100u and a singlepatients have normal voiding course of 300u would have a costfunction. Popat et al published in excess of R6000. Dysport hasthe first data on IDO using Botox, only recently been launched inachieving continence rates of South Africa and would have a57%. The incidence of de novo comparable price tag. One wouldvoiding dysfunction was 19%. In need to add to this the costs ofa further randomized controlled administration, including surgeonstrial, Sahai et al report profound fees, theatre time and disposables.improvements in multipleoutcomes following the injection 2. Sacral Nerve Stimulationof Botox when compared to (SNS)placebo. This device works by implanting a pacemaker-like neurostimulatorThe main adverse event following in the lower back that sends mildBotulinum injections is temporary electrical impulses to electrodesurinary retention, with a reported that are usually placed adjacentincidence of between 19% to to the third sacral nerve root.35%. Women who develop The device received Europeanthis complication are required Union approval in 1994 and USAto perform clean intermittent FDA approval in 1999 and more42
  48. 48. than 35000 devices having been reduction in leakage episodes.implanted worldwide to date. In A further systematic reviewpatients with OAB, SNS restores confirmed these findings withthe balance between inhibitory 67% of patients reporting beingand excitatory control systems dry or having a more than 50%at various sites in the peripheral improvement in symptoms.CNS. This involves stimulation of Another trial that followedsomatosensory ascending tracts patients up for a mean of moreprojecting from the bladder into than 5 years reported continuedthe pontine micturition centre success in 76% of the cohort.in the brain stem. The electricalimpulses also activate the pelvic Despite these success rates, thisefferent hypogastric sympathetic therapeutic option is not accessiblenerves, which promotes to the majority of women largelycontinence. due to the cost of the device and the expertise required to place andThe device is inserted in two maintain the neurostimulator. It isphases. The test phase includes the available in South Africa, suppliedtemporary insertion of a needle by Medtronic, but retails forinto the sacral foramen under approximately R55000.local anaesthetic and the electricalstimulation is derived from an There are also significant adverseexternally placed battery and events associated with thisgenerator. If the subject reports a equipment including pain andsatisfactory response after three to discomfort, seroma formation,four weeks, defined as more than disturbed bowel function and50% improvement in symptoms, wound dehiscence.a permanent device is sited.This involves the implantation 3. Posterior Tibial Nerveof a long-term battery and Stimulationneurostimulator in the buttock and Because of the technical andlower back. cost implications of SNS, indirect neuromodulation of S2,3 and 4A RCT reported continence via stimulation of the posterioroutcomes of 47% at six month tibial nerve, was developed. Thefollow up, with a further 29% technique is performed by passingreporting more than 50% an electric current between a 43

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