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Urogynaecology - Incontinence and Prolapse by 132Healthwise
- 1. Urogynaecology - Incontinence and Prolapse Ms C Domoney Mr M Stafford Chelsea and Westminster Hospital
- 2. Urinary continenceUrinary continence • Learnt phenomenon • Development inhibitory pathways • Intact nerve pathways • Intact lower urinary tract
- 4. Urinary Incontinence A condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrated. International Continence Society
- 5. Risk factors • Congenital abnormalities • Developmental or behavioural factors • Female • Childbirth • Aging and the menopause • Medical disorders • Surgery or other trauma • Drug therapy ∀ ↑ abdominal pressure or pelvic mass
- 7. Classification Urethral • Genuine stress incontinence • Detrusor overactivity • Mixed incontinence • Voiding dysfunction • Congenital • Functional Extra-urethral • Congenital • Fistula
- 8. Classification Urethral • Genuine stress incontinence • Detrusor overactivity • Mixed incontinence • Voiding dysfunction • Congenital • Functional Extra-urethral • Congenital • Fistula
- 9. History • Urinary frequency - day / night, volume. • Fluid intake - caffeine, alcohol • Urinary urgency - ability to defer, triggers • Incontinence - type, duration, severity • Enuresis - current or previous • Coital incontinence - penetration / orgasm • Voiding difficulties - ↓ stream, strains, incomplete emptying • Irritative, recurrent UTI symptoms, pain
- 10. History • Obstetric - Number, type delivery, fetal wt • Gynaecological - fibroids, prolapse • Medical - DM, DI, renal disease • Surgical - previous continence / prolapse ops • Psychiatric - Depression, schizophrenia • Neurological - MS, CVA, Parkinsons • Drugs - Diuretics, cold remedies, prazosin
- 11. Examination General • General mobility, BMI • Respiratory - Asthma, COAD • Abdominal - palpable kidneys, pelvic mass • Neurological - general / direct 2,3,4 roots
- 12. Examination Gynaecological • Genital urinary dermatoses / atrophy • Bladder neck mobility and incontinence on coughing • Bimanual examination • Prolapse grading, vaginal capacity • Vaginal scarring or pain • Anorectal tone
- 13. Investigations • Urinary frequency volume diary • MSU - microscopy, culture, cytology • Pad test • Cystometry • Diagnostic cystoscopy • Bladder neck or renal tract ultrasound
- 14. Bladder Diary
- 16. MSU
- 18. Urodynamics Indications • Failed conservative treatment • Complex symptoms • Surgery considered • Previous or failed continence surgery • Fistula suspected • Neurological signs or symptoms • Voiding dysfunction
- 19. Urodynamics Diagnosis • Normal • Urodynamic stress incontinence • Detrusor overactivity • Neurogenic detrusor overactivity • Voiding disorder
- 24. normal pressure flow study.gif
- 25. Cystoscopy Indications • Intractable sensory urgency • Recurrent UTI’s • Suspected fistula • Suspected interstitial cystitis • Haematuria • Neoplasm ?
- 31. Conservative therapy Stress urinary incontinence • Fluid restriction (1.5 - 2.0 litres daily) • Reduce exacerbating factors - eg. cough • Pelvic floor exercises • Tampons / foam pessaries • Vaginal cones • Electrical therapy • Biofeedback therapy • Drug therapy
- 33. SSurgical therapyurgical therapy • Burch colposuspensionBurch colposuspension • Mid urethral slingsMid urethral slings – retropubic tape Eg TVTretropubic tape Eg TVT – Tranobturator tape TOTTranobturator tape TOT • Pubovaginal slingsPubovaginal slings – Cadaveric fascia, harvested slings – rectus sheathCadaveric fascia, harvested slings – rectus sheath • Periurethral injectablesPeriurethral injectables • Artificial sphinctersArtificial sphincters •
- 34. Effective surgical therapyEffective surgical therapy • Minimally invasiveMinimally invasive • Minimal perMinimal perii-operative morbidity-operative morbidity • Short hospital stayShort hospital stay • High longHigh long term continence rate (>80% at 10 years)term continence rate (>80% at 10 years)
- 36. Colposuspension • Continence rate of 85 –90% at 1 year • Falls to 70% at 5 years • Cochrane review – most effective treatment for SI esp. in the long term • Data up to 12 years
- 37. Colposuspension • Voiding dysfunction 10.3% (2-27%) • De novo DO 17% (8-27%) • New prolapse 13.6% (2.5 – 26%)
- 38. Sling Procedures • Autologous or Synthetic materials • Erosion vs failure • Vaginal Erosion 0 - 16% • Urethral Erosion 5% • De novo DO 3.7 – 66% • Voiding Dysfunction 10% (2%)
- 40. Obturator Canal with Vessels Obturator Foramen Transobturator Midurethral Sling Urethra Delivery Needle Point of Entry Retropubic Midurethral Sling Inferior Pubic Ramus Property of Boston Scientific: do not copy or distribute
- 44. TVT • At 3 years – 86% cured – 11% improved • Approved by NICE “Similar subjective and objective continence rates to colposuspension with shorter hospital stay” • Need for long term data! • Bladder perforation 3.8 % • Voiding Dysfunction 2.3%
- 47. Transobturator Tape • NICE Guidelines January 2005 • Current evidence on safety and short term efficacy support the use of the TOT
- 48. Trans-urethral Bulking AgentsTrans-urethral Bulking Agents
- 49. Medical Therapy for SI • DULOXETINE ( Yentreve) • Blocks the reuptake of serotonin & noradrenaline in the sacral spinal cord • Believed to increase pudendal nerve activity increasing sphincter contraction & thus reducing stress urinary incontinence symptoms
- 50. Medical Therapy for SI • Mild to moderate primary stress incontinence in a primary care setting • Family not complete • On the waiting list for surgery • To facilitate pelvic floor retraining • Unfit for surgery • Declines surgery • Mixed incontinence
- 52. Urge Urinary Incontinence Detrsusor Instability (old term) = Detrusor Overactivity (new term)
- 53. Differential Diagnosis •Severe stress incontinence •Urethral diverticulum •Urinary tract fistula •Cystitis •Bladder foreign body •Bladder tumour •Urethritis
- 54. Management Conservative • Reduce fluid intake • Avoid caffeine and alcohol • Bladder retraining • Biofeedback • Electrical therapy • Drugs
- 55. Commonly used drugs • ANTICHOLINERGICS • Oxybutynin: 2.5 mg bd - 5 mg qds and ER/ Patch •NB NICE guidelines 1st line as cheap but Ses + • Tolterodine: 1 mg - 2 mg bd and ER • Fesoterodine: 4-8mg od • Propiverine: 15 mg bd-tds • Trospium chloride: 20 mg bd-tds • Solifenacin 5 –10mg od •May be used empirically with fluid restrictionMay be used empirically with fluid restriction aandnd bladder drill if fails refer for UDS. Success 60 - 70%bladder drill if fails refer for UDS. Success 60 - 70%
- 56. Commonly used drugs OTHERS • Imipramine - 25 - 50 mg nocte • Desmopressin - 100 - 200 mcg nocte
- 57. Surgical intervention for DO Indications • Significant symptoms • Failed conservative and drug therapy • NB Realistic expectations
- 58. Surgical intervention Procedures • Botox into detrusor muscle • Sacral Neuromodulation • Clam cystoplasty • Ileal conduit
- 61. Acute retention • > 6 hours • volume equal to or greater than capacity • usually painful Chronic retention • Insidious and painless • < 50% bladder capacity
- 62. Voiding dysfunction - treatment Catheterisation • Intermittent self catheterisation (ISC) • Urethral • Suprapubic Adjuvant • Double or triple voiding • Oestrogen therapy • Antibiotic prophylaxis • Urethrotomy
- 64. Prolapse Anterior compartment • Urethrocele • Cystocele Miccle compartment • Uterine • Vault Posterior compartment • Enterocele • Rectocele • Perineum [ Each site graded 1 - 4 ]
- 71. Prolapse Therapy Conservative • Reduce exacerbating factors • Pelvic floor exercises • Vaginal pessaries (eg. ring or shelf)
- 73. Aims of prolapse surgery • Alleviate symptoms • Restore normal anatomy • Restore normal visceral function • Avoid new bladder or bowel symptoms • Preserve sexual function • Avoid surgical complications
- 74. Primary genital tract prolapse Surgery Uterine - hysterectomy or hysteropexy with vault support Anterior or Posterior compartment - •Primary - vaginal repair •Recurrent prolapse - repair + mesh - repair + sacrospinous fixation
- 75. Classification of Surgery for Apical Prolapse Vaginal Abdominal Laparoscopic
- 76. Surgery for apical prolapse VAGINAL SUSPENSION PROCEDURES 1. Sacrospinous ligament suspension / fixation 2. Modified McCall culdoplasty 3. Iliococcygeus fascia suspension 4. High uterosacral ligament suspension 5. LeFort partial colpocleisis 6. Colpectomy and colpocleisis
- 77. Surgery for apical prolapse ABDOMINAL SUSPENSION PROCEDURES 1. Sacrocolpopexy 2. Sacrohysteropexy 3. High uterosacral ligament suspension LAPAROSCOPIC SUSPENSION PROCEDURES • All of the Abdominal Procedures +/- reinforcement