Textbook of Urogynaecology

Editors: Stephen Jeffery Peter de Jong Developed by the

Department of Obstetrics and Gynaecology

University of Cape Town

Edited by Stephen Jeffery and Peter de Jong

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Contents

List of contributors 1

Foreword 2

The Urogynaecological History 3

Lower Urinary Tract Symptoms and Urinary incontinence: Definitions and overview. 8

Examination and the POP-Q 17

Essential Urodynamics 23

Medical Management of the Overactive Bladder 26

Intractable OAB: Advanced Management Strategies 40

The Treatment of Stress Incontinence 45

Management of Voiding Disorders 55

Sexual Function in women with Incontinence 64

Urinary Tract Infections (UTIs) in Women 71

Neurogenic Bladder 76

Interstitial Cystitis 95

Introduction to Pelvic Organ Prolapse 97

Pathoaetiolgy of Prolapse 108

Conservative Management of Pelvic Organ Prolapse 119

Surgical Management of Urogenital Prolapse 126

Sacrocolpopexy 133

Pelvic Floor Muscle Rehabilitaion 137

Management of Faecal Incontinence 149 Use of Mesh, Grafts and Kits in POP surgery 154

Management of Third and Fourth degree tears 181

Management of Urogenital Fistulae 186

Role of the laparoscope in Urogynaecology 198

Suture Options in Pelvic Surgery 201

Thromboprophylaxis in Urogynaecological Surgery 213

Contributors

Corina Avni Suren Ramphal Women’s Health Physiotherapist Department of Obstetrics and Lavender House Gynaecology Kingsbury Hospital University of Natal Claremont Cape Town Peter Roos Department of Urogynaecology Dick Barnes University of Cape Town Department of Urology University of Cape Town Trudie Smith Department of Obstetrics and Hennie Cronje Gynaecology Department of Obstetrics and University of the Witwatersrand Gynaecology University of the Free State Douglas Stupart Department of Colorectal Surgery Peter de Jong University of Cape Town Department of Urogynaecology University of Cape Town Paul Swart Department of Obstetrics and Etienne Henn Gynaecology Department of Obstetrics and University of Pretoria Gynaecology University of the Free State Kobus van Rensburg Department of Obstetrics and Barry Jacobson Gynaecology Department of Haematology University of Stellenbosch University of Witwatersrand Frans van Wijk Stephen Jeffery Pretoria Urology Hospital Department of Urogynaecology Pretoria University of Cape Town

1 Foreword

First Edition of Textbook of Urogynaecology

Urogynaecology is an exciting and dynamic subspecialty. The last decade has seen a rapid advance in the management options available to the gynaecologist in treating women with pelvic floor dysfunction. Stress incontinence surgery was revolutionised by the development of the TVT and exciting long term data has confirmed this device as a gold standard in the management of SUI. Overactive bladder has seen the launch of a number of new anticholinergic drugs with better side-effect profiles and dosing schedules. We also now have some alternatives to the drugs including Botulinum Toxin A and neuromodulation. We are developing a greater understanding of the role of childbirth and pregnancy in pelvic floor dysfunction. The last three years has seen the launch of intriguing pelvic floor replacement systems and although we are some way off from achieving long term data on these devices, this is no doubt an important step in the evolution of pelvic floor surgery.

This book has been written by a number of authors from different parts of South Africa. The field of urogynaecology is still in its infancy and we therefore have many unanswered questions. In this volume, the reader will therefore encounter varying opinions. There is a significant amount of overlap and difference of opinion and we hope this will stimulate the reader to read widely and formulate his or her own opinion.

The electronic format of this text has made it possible to offer it to the reader at an affordable price. We trust that this book will contribute to a better understanding and management of South African women with pelvic 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 Editors

2 Chapter 1 The Urogynaecological History

Stephen Jeffery

Pelvic floor dysfunction is the doctor have been shown to be associated with multiple fraught with subjective influences. symptoms including bladder, A number of questionnaires are bowel and sexual complaints. In now available which are able to addition, women may present elicit symptoms in a standardised with neurological symptoms, form and quantify them. This is psychological issues and particularly useful in a research relationship dysfunction. It is setting but these instruments therefore imperative that the are now increasingly being history and examination are used in day-to-day practice. performed in a comprehensive Similarly, the examination of the fashion. urogynaeological patient has become more scientific with the Urogynaecological symptoms advent of more detailed and are never life-threatening but scientific prolapse scoring systems. they can have a profound impact on the women’s quality of life. Clinical assessment therefore aims to determine the extent of History the impairment on quality of life Urinary Symptoms and thereby institute the most appropriate route of investigation Frequency and management. This is defined as the number of voids during waking hours. Normal Clinicians use the traditional frequency is considered to be approach of history and between four and seven voids a examination. Symptoms as elicited day. by the traditional interview by

3 Nocturia comfortably deferred by the This is the number of times a woman. woman has to awake from sleep to pass urine. This varies with the age Urgency Incontinence of the woman, with an increase Here, the women describes the reported in woman above the age symptoms of urgency and she is of 70 years where normal would unable to get to the toilet in time be considered to be twice at night, and develops incontinence as a three times for women over 80 result. and four times for women over 90 years of age. Determining the severity of Incontinence Incontinence It is important to make a clinical Symptoms of Urinary Incontinence attempt to determine the severity are notoriously difficult to of the incontinence symptoms. The evaluate. The International woman could be asked to quantify Continence Society defines the symptoms on a scale of 0 to this as the “involuntary loss I0. When this is done using a chart of urine which is a social or it is called a visual analogue scale hygienic problem and objectively (VAS). Many women present with demonstrable”. mixed symptoms of both stress and urge incontinence and by asking Stress Incontinence them to quantify each symptom This is the involuntary loss of urine using the visual analogue score, with a rise in intra-abdominal we are able to determine which is pressure. Factors that commonly more severe. elicit stress incontinence include running, laughing, coughing, The patient should also be asked sneezing and standing up from a about the use of continence aids seated position. such as pads and how often she changes her underwear. The Urinary urgency number of incontinence episodes This is the compelling desire to per day can also be indicative of void which is difficult to defer. the severity of the condition. It must be differentiated from urinary urge which is a normal Symptoms of voiding desire to void which can be dysfunction

4 These symptoms are not as common in women as in men Prolapse symptoms but if present, should prompt Women with prolapse have a the appropriate investigation of broad range of symptoms. Studies urinary residual and flow rate. have shown that the symptoms These 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 to Bladder pain void or completely evacuate their Women with bladder pain should bowels. be questioned in detail regarding the nature and occurrence Bowel symptoms of the symptoms. Pain that is Evaluation and questioning relieved with passing urine may regarding bowel symptoms is an be associated with Interstitial essential part of the evaluation of Cystitis/ Painful Bladder Syndrome. the pelvic floor. Women with pain as a significant symptom should be evaluated Anal Incontinence with cystoscopy and biopsy since This is the involuntary passage of pain may also be associated with flatus. tumours and stones. Faecal Incontinence Urethral Pain This is defined as the involuntary This 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 aids Women with urinary symptoms and impact on quality of life. should always be questioned regarding the presence or Faecal urgency and urge absence of blood in the urine and incontinence investigated appropriately. This is an important symptom

5 which is often underreported and be recorded. seldom elicited by the clinician. Medications A note should be made of Defaecatory dysfunction medications that may be Women should be asked about worsening the symptoms, including any difficulty in completing diuretics and alpha –blockers. defaecation including digitation, splinting or manual evacuation. Medical History Diabetes Mellitis and Insipidus are Constipation usually associated with polyuria. A record should be made of Cardiac failure can present frequency of stools and any with nocturia as a result of the symptom of constipation. redistribution of fluid when the patient is lying down. Sexual History A detailed history of sexual Fluid Intake function is vital to a thorough The amount and type of fluid assessment of pelvic floor consumed on a daily basis should disorders. Women should be be recorded. Caffeine and alcohol asked if they are sexually active. can exacerbate symptoms of Any problems should be noted overactive bladder significantly including dyspareunia, vaginal and these products in particular slackness, vaginal tightness, should be enquired about. anorgasmia, coital faecal or urinary incontinence during intercourse. Obstetric History The number and type of deliveries are important as well as any history Other relevant parts of perineal or anal sphincter injury. of the history Surgical History Previous pelvic surgery, including Neurological history prolapse and incontinence surgery, Women should be questioned should be noted. regarding symptoms of limb weakness and sensory fallout. Any history of multiple sclerosis, parkinsonism, spinal cord injury, stroke or spina bifida should also

6

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 failure

Adapted from Textbook of Female Urology and Urogynaecology Eds Cardozo and Staskin.

7 Chapter 2 Lower urinary tract symptoms and urinary incontinence: an overview

Peter de Jong

Definitions of Symptoms symptoms cannot be used to make Lower urinary tract symptoms, a definitive diagnosis. However (LUTS) are equally bothersome LUTS can also indicate pathologies to men and women, and greatly other than lower urinary tract affect the quality of life (QOL). dysfunction, such as urinary infection. The clinician will make The term “Lower urinary tract his/her best efforts to exclude symptoms” is used to describe other causes of LUTS. a patient’s urinary complaints without implying a cause. Lower Lower urinary tract symptoms are urinary tract symptoms were categorized as storage, voiding defined by the standardization sub and post micturition symptoms. – committee of the International (Table 1) Continence Society. Storage Symptoms are experienced LUTS are the subjective indicators during the storage phase of the of a disease or change in bladder, and include daytime conditions as perceived by the frequency and nocturia. patients, carer or partners and may lead her to seek help from health Increased daytime frequency is care professionals. Symptoms may the complaint by the patient who either be volunteered or described considers that he/she voids too during the patient interview. They often by day. The average person are usually qualitative. voids 6 times a day.

In general, lower urinary tract Nocturia is the complaint that the

8 individual has to wake at night Stress urinary incontinence is the one or more times to void. complaint of involuntary leakage on effort or exertion, or on Urgency is the complaint of a sneezing or coughing. sudden compelling desire to pass urine, which is difficult to defer. Urgency urinary incontinence is the complaint of involuntary leakage Urinary incontinence is the accompanied by or immediately complaint of any involuntary preceded by urgency. leakage of urine. In each specific circumstance, Mixed urinary incontinence is the

Table 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 Sensation

urinary incontinence should be complaint of involuntary leakage further described by specifying associated with urgency and also relevant factors such as type, with exertion, effort, sneezing or frequency, severity, precipitating coughing. factors, social impact, effect on hygiene and quality of life, Enuresis means any involuntary measures used to contain the loss of urine. If it is used to denote leakage, and whether or not the incontinence during sleep, it individual seeks or desires help should always be qualified with because of urinary incontinence. the adjective “nocturnal”.

9 Nocturnal enuresis is the complaint or in comparison to others. of loss of urine occurring during sleep. Intermittent stream or Double voiding (Intermittency) is the term Continuous urinary incontinence used when the individual describes is the complaint of continuous urine flow which stops and starts, leakage and may denote urinary on one or more occasions, during fistula. micturition.

Bladder sensation can be defined, Hesitancy is the term used when during history taking, into four an individual describes difficulty categories. in initiating micturition resulting in delay in the onset of voiding Normal: the individual is aware after the individual is ready to pass of bladder filling and increasing urine. sensation up to a strong desire to void. Straining to void describes the muscular effort used to initiate, Increased: the individual feels an maintain or improve the urinary early first sensation of filling and stream. then a persistent desire to void. Terminal dribble is the term used Reduced: the individual is aware when an individual describes a of 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 reports no sensation of bladder filling or Post micturition symptoms are desire to void. experienced immediately after micturition. Voiding symptoms are experienced during the voiding phase. Feeling of incomplete emptying is a self – explanatory term for Slow stream is reported by the a feeling experienced by the individual as the perception individual after passing urine. of reduced urine flow, usually compared to previous performance Post micturition dribble is the term

10 used when an individual describes incontinence episodes. the involuntary loss of urine immediately after passing urine, FVC’s have been shown to be usually after leaving the toilet. reproducible and more accurate when compared with the patient’s Frequency – Volume Chart recall. The optimal length of (Bladder Diary) a diary varies according to the Frequency – volume charts (FVC) parameter assessed and precision have become an important and sensitivity required. In part of the evaluation of LUTS. addition, if one is trying to assess Most experts would agree that change, the baseline parameter these charts provide invaluable (e.g number of voids, incontinence information about a number episodes) will affect the length of symptoms including urinary of the diary needed to detect frequency, urgency, incontinence a certain change. A 7 day diary episodes, and voided volume. In is a reasonable option for most fact some symptoms, like nocturia, patients with incontinence. If cannot be properly evaluated record keeping for 7 days increases without a chart. Frequency – a patient’s burden the number of volume charts are critical for the days required to evaluate voiding distinction between nocturnal symptoms should be reduced. overactive bladder and nocturnal polyuria, two common causes The majority of information of nocturia. Despite this the collected on FVC’s or bladder structure, content and duration diaries has been used to establish of chart keeping for evaluation baselines or to study patients with has not been standardised. There OAB or incontinence. are a number of parameters that can be assessed by the FVC, Physical examination including: total number of voids A general physical examination per 24 hours, total number of of the patient is mandatory, since daytime (awake) voids, total many co–morbid conditions are number of night time voids, likely to impact on the symptoms total fluid intake, total voided of LUTS (Table 2) volume, maximum, minimum and mean voided volume, number of urgency episodes, and number of

11 Table 2 Comorbid conditions and nitrites, although infection causing LUTS may exist in the absence of pyuria and, in the elderly population, • Medical disorders pyuria may develop in the absence of UTI. Microscopic haematuria can ››Hypertension / heart failure be easily identified by dipsticking ››Mulitple sclerosis because of the presence of ››Diabetes Mellitus • 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 malignancy A detailed gynaecological within 3 years. Because of the assessment is important, with high prevalence of urinary tract particular attention to pelvic infection (UTI) and the increase floor disorders, and prolapse. A of LUTS in the presence of UTI, all full neurological examination guidelines on the management is also required. Digital rectal of patients with LUTS and urinary examination is useful to evaluate incontinence, endorse the use the possibility of co – existent anal of urinalysis in primary care / faecal incontinence. management.

Special investigations Urodynamic Investigations Urinalysis Urinalysis 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 expression examinations. Dipstick urinalysis that ‘the bladder often proves to is certainly convenient but false be an unreliable witness’, meaning positive and false negative results that the presenting symptoms may occur. It is considered an of the patient and the eventual inexpensive diagnostic test able to diagnosis of the problem are often identify patients with urinary tract at variance. In 1972 Moolgaoker infection (UTI) as indicated by the stated that ‘urinary symptoms in presence of leucocyte esterases the female do not form a scientific

12 basis for treatment’. Videocystourethrography is used in advanced centres and is the Urodynamic tests have been gold standard of the investigation developed to confirm the of female urinary incontinence. underlying diagnosis in a patient It involves contrast media and complaining of symptoms of screening radiology superimposed urinary incontinence. These upon conventional cystometry to tests identify the etiology of provide an accurate diagnosis. This the problem and elucidate its modality is not widely available. pathophysiological mechanism. Their use is sometimes debatable, Increasingly, ultrasound imaging is since grade A evidence supporting also being used to measure both the general use of urodynamics in bladder neck descent and bladder the investigation of incontinence, wall thickness. Electromyography is not available. and cystoscopy are adjuncts to The most basic form of urodynamic urodynamics in complex patients testing 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 of the apparatus used, either a leak Basic tests which should be – point pressure measurement, or performed on patients prior to urethral pressure profilometry may urodynamic testing include a be performed additionally as a test urine microscopy and culture, of urethral function. Urodynamic and a measurement of residual testing can either be static or urine volume, either by catheter ambulatory. or ultrasound. A bladder diary (frequency / volume chart) is

13 also a necessary aid to diagnosis. of these conditions may mimic The latter has been shown to the symptoms associated with provide valuable information on stress incontinence and destrusor the patient’s voiding pattern and overactivity. functional bladder capacity, as well as giving an indication of leakage A cough – induced bladder episodes. contraction causing leakage may be confused with stress It 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 if the patient). They also require a patient suffering from urinary considerable expertise and access incontinence is not adequately to sophisticated equipment. evaluated and an incorrect There should therefore be sound diagnosis is made. The most serious motivation for their use as a of these is inappropriate surgery. diagnostic tool. Failure to recognize concomitant detrusor overactivity and / or Clinical Indications for voiding dysfunction may also Urodynamics Investigations affect the outcome of appropriate There are many etiological factors surgery. leading to urinary incontinence in women. Certainly the most Table 1 lists the most important common problems are urodynamic indications for urodynamic studies. stress incontinence due to urethral sphincter weakness or Table 1: Indications for bladder neck hypermobility, and urodynamic studies detrusor overactivity leading to incontinence (in most cases ‘urge 1. Prior to surgery incontinence’). Other causes of 2. Failed medical or surgical treatment incontinence include fistulae, urethral diverticulae, urethral 3. Complex symptomatology instability, the urethral syndrome 4. Neurological dysfunction and also the contributory effect 5. Voiding dysfunstion of urinary tract infection. It 6. Medico – legal cases must be emphasized that many

14 Clinical Diagnosis versus History, clinical examination urodynamic diagnosis and basic tests Over the past 35 years there have In the ongoing search for an been ongoing discussions in the uncomplicated and cost – effective literature on how best to evaluate approach to the pre – operative patients with incontinence. The evaluation of a patient for accurate identification of patients stress incontinence surgery, with SUI has received considerable several authors looked at other attention parameters which could prove useful. The accuracy of history alone Most of the early papers looked In summary the addition of other at the discriminatory value of clinical parameters and simple a pure history of either stress office tests do enhance the incontinence or detrusor instability. sensitivity of a history. However, Symptoms alone were used to the various authors still found make a diagnosis before patients the combination inadequate for were subjected to confirmatory a reliable diagnosis and most cystometry. Most of the earlier felt that additional research was studies had relatively low numbers warranted. of patients. In summary, it is clear from the majority of studies that In South Africa, Urogynaecology as a history of incontinence alone is a subspeciality is still in its infancy. not enough to enable a clinician Treatment decisions in female to make an accurate diagnosis urinary incontinence management for a decision on whether or not are mostly made on clinical to embark on stress incontinence judgment. There are very few surgery. The symptom of stress management protocols in place incontinence may be very sensitive, and this is an area which urgently but is so nonspecific as to render it requires development, particularly of little diagnostic value. at specialist level.

History is best used as a guide to Medical practice is increasingly the subsequent evaluation process becoming dogged by litigation and and to serve as a measure of practitioners have to be able to disease severity. show that they have their patient’s best interest at heart by backing

15 up clinical diagnosis with special investigations.

In the larger centres in SA there are facilities available for performing urodynamic studies but these are mostly underutilised. They are often also run by staff who are not properly trained to provide good quality results and interpretation.

There is an increasing number of practitioners in SA who have a special interest in Urogynaecology and who manage female patients with urinary incontinence. It is these practitioners who should be at the forefront of attempts to develop mechanisms which are aimed a providing the best possible service for their patients. “Best practice’ therefore also means a move away from ‘preference – based’ to ‘evidence – based’ medicine.

16 Chapter 3 Physical Examination and the POP-Q

Peter de Jong, Stephen Jeffery

All women presenting with lower limbs. The anal sphincter pelvic floor dysfunction should tone should be tested. be thoroughly examined in the supine, left lateral and standing positions. Where a Gynaecological surgical intervention is planned, the responsible surgeon should Examination determine exactly what may It is impossible to perform an be required at operation – so adequate urogynaecological that the appropriate consent examination without using a can be obtained and the correct Sims speculum and in some intervention planned. circumstances two Sim’s speculae are required. The examination begins with the woman in the General dorsal position. The vulva and vagina are inspected for any The 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 stress Neurological incontinence. She is then asked examination to turn onto her left side and the Sims speculum is used to inspect The spinal segments S2,3.4 should the anterior and posterior vaginal be assessed by testing the tone, walls for prolapse. It is imperative strength and sensation in the that the middle compartment is

17 also adequately assessed for any Grade I: Descent halfway to the uterine or vaginal vault descent. introitis This can be difficult, but if one Grade 2: Descent down to the uses two Sims speculae placed vaginal introitis anteriorly and posteriorly, while Grade 3: Descent beyond the the women strains down, it introitis but not maximal is relatively easy to assess this Grade 4: Maximal descent compartment. The prolapse should be graded using either the Baden- This grading system is useful in day Walker or POP-Q systems (see to day clinical practice but it has a below). If the women’s symptoms number of shortcomings. It does are not adequately explained by not give a quantitative impression the findings at examination, it may of the severity of the prolapse. be useful to perform an additional It does not address the vaginal assessment with her standing. This length, perineal body size or the is accomplished by asking her to length of the urogenital hiatus. stand with her legs apart while The POP-Q (Pelvic Organ Prolapse the examiner bends in front of Quantification System) was the patient and gently palpates developed by the International the anterior, middle and posterior Continence Society to address compartments. She is then asked these issues and it supercedes the to cough again in the standing previous systems used to describe position. POP. The new objective assessment allows a clear and unambiguous description of prolapse, facilitating Classification and better objective assessment, grading of prolapse management and surgical comparison. Precise staging made gynaecological oncology an Grading and classification of pelvic objective progressive disciple, and organ prolapse enables clinicians it is hoped that introduction of to communicate with each other POP – Q will allow similar advances and is also useful in a research in the management of prolapse. setting. The most commonly used Terms used in the past such as for grading system is the Baden- example small, medium or large, Walker halfway system which cystocoele or rectcoele, are no grades prolapse as follows: longer applicable. At first glance,

18 the system appears complicated the following table. and difficult to master but once it is understood, it can be All measurements are made to the performed in less than 30 seconds nearest 0.5cm while performing a routine gynaecological examination. It Consensus and validation of the is based on measurements that new system has been extensive. are taken using the introitis as The clinical examination is reference. Any measurement performed and the measurements above this is negative and recorded on the “POPQ grid”. anything below this is positive. (Table 2) The measurements are taken using a marked Pap smear spatula. Six specific vaginal sites (points Aa, Ba, C, D, Bp and Ap) and the vaginal length (tvl) are assessed using centimeters of measurement from the introitus. The length of the genital hiatus (gh) and perineal body (pb) are measured.

The points are defined as follows, with the ranges as suggested in

TABLE 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 TABLE 2: The POPQ Grid – Used Both the patient’s position during to 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 prolapsed the absence of a cervix compartment between perfect support and – 1cm, or 1cm proximal to the hymen The measurement of prolapse is performed in accordance Stage 2: Descent of the most prolapsed compartment between -1cm and with certain measurement +1cm. fundamentals. (Table 3) Stage 3: Descent of the most prolapsed compartment between +1cm Table 3: POPQ Measurement and (tvl -2cm) Fundamentals 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 Point Aa Point Bp If an imaginary small man walked Again, this point describes more from the introitis up the anterior extensive prolapse beyond the vaginal 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, by point Aa. The distance this point convention it is -3. descends on the vertical plane can therefore be either -3, -2, -1 if it Point C is above the introitis, 0 at the This describes the prolapse of the introitis and +1,+ 2 or +3 below the cervix or vaginal vault. If the cervix, introitis. This point is therefore for example, is 7cm above the never more than 3 and represents introitis, this point is then -7, if it is the bottom 3cm of the vagina. 4 cm below C is +4.

Point Ba Point D This point describes additional This describes the descent of the prolapse of the anterior vaginal posterior fornix again similar to wall that goes beyond the first the cervix. 3 cm. It is the most distal part of the prolapse. It can therefore be Total vaginal Length greater than the +3 described for This is the measurement of point Aa. For the milder prolapse, the length of the vaginal tube it often equates to that of Aa. from top to bottom. It is usually Because it essentially defines more measured with the marked spatula extensive prolapse, when there inserted to its maximum into the is no prolapse, by convention we vagina. make it the same as Aa. Urogenital hiatus Point Ap The measuring spatula is placed Again our imaginary man makes anteroposteriorly along the the 3cm trip up the posterior wall introitis and measures from the where he marks off point Ap. The urethral meatus to the midline of distance this point descends can the posterior hymen. again be therefore either -3, -2, -1 if it is above the introitis, 0 at the Perineal body introitis and +1,+ 2 or +3 below the Again the perineum is measured introitis. from the posterior hymen to the

21 anus in the midline.

22 Chapter 4 Essential Urodynamics

Stephen Jeffery

Urodynamics bladder is has a double lumen, one to measure the bladder pressure Whole books have been written (Pves) and the other lumen is used on Urodynamic practice and to fill the bladder with water via technique. The diagnosis in women the pump system. Sometimes, with urinary incontinence based two separate catheters are used on clinical findings is correct in for filling and pressure recording. only 65% of cases. There is a large The rectal probe measures the overlap between symptoms and intra-abdominal pressure (Pabd) examination and urodynamic and this pressure could therefore findings. 55% of women with also be obtained by inserting the stress incontinence will have a line into the vagina or even into mixed picture. The cystometrogram a colostomy. A Urodynamic report becomes essential, in a number usually gives 3 pressure tracings: of women, to enhance diagnostic Pves (bladder pressure), Pabd accuracy and therefore enable us (abdominal) and Pdet (detrusor to institute treatment. pressure). The detrusor pressure is obtained by the following formula Pdet = Pves-Pabd. Urodynamics is therefore often called Subtracted The equipment Cystometry.

The Urodynamics system comprises two catheters, one placed in the bladder and another in the rectum, The Procedure a computer and the urodynamics software and pressure transducers, The test comprises three a pump system, and a flowmeter. phases. The catheter that is placed in the

23 1. Free flow phase are measuring appropriately, The woman is asked to arrive when the women coughs, there at the investigation with a full should be no deviation of the bladder. She is then asked to Pdet – only on the vesical line and void on the flowmeter, which is the abdominal line since these usually mounted on a commode, in are both under the influence privacy. It should be noted that this of abdominal pressure. In other part of the test differs from the words, when there is a rise in voiding cystometry, which is done abdominal pressure with coughing, after the filling phase once the the same pressure is transferred bladder is full and the lines are in to the bladder. The Pdet will situ to measure the pressures. therefore be zero since Pves minus Pabd is zero and the detrusor line Flow 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 phase 2. Filling phase include asking the woman to heel The bladder and rectal lines are bounce, wash hands and cough. inserted with the patient supine This will also hopefully elicit any and any urinary residual is noted. stress incontinence which is usually The lines are flushed and the also occasionally recorded on the system is zeroed. The women trace by a flowmeter but if this is asked to cough to check that modality is not available on the the Pdet measurement is correct. filling phase, is usually observed For example, if the Pabd is not by visual inspection of the vulva. measuring correctly, the Pdet will When the patient is unable to not be accurately calculated. If tolerate any more filling, the pump both the vesical and rectal lines is stopped, this is the maximum

24 cystometric capacity. During voiding Cystometery Pressures are measured during 3. Voiding Cystometry the voiding cystometry phase This is done by asking the patient and therefore parameters such to void while the pressures are as PdetQmax, the detrusor recorded. pressure during maximum flow, is measured. A pressure greater than 20cmH2O would suggest an Possible Diagnoses obstruction.

During Free Flow Flow rate is abbreviated as Q. A normal flow curve is bell-shaped. An obstructive pattern is flat or with intermittent sections of flow. The maximum flow is denoted as Qmax. A normal flow rate is defined as less than I5ml/s.

During Filling phase Any contractions of the detrusor tracing suggest a diagnosis of detrusor overactivity (DO). One should always look at the abdominal tracing and this should be flat during a detrusor contraction to diagnose DO. If the abdominal curve is also elevated, this would suggest possible poor subtraction and a diagnosis of DO should not be made. If the Detrusor pressure curve rises slowly during the filling phase, this would suggest poor compliance. If one notes both stress incontinence and DO during filling, a diagnosis of mixed incontinence is made.

25 Chapter 5

The Medical Management of the Overactive Bladder Syndrome

Peter de Jong

Introduction 17.5 million women in the USA who suffer from the condition. The term “overactive bladder” The prevalence increases with was proposed as a way of increasing age being 4 percent in approaching the clinical problem women younger than 25 years and from a symptomatic rather than 30 percent in those older than 65 a urodynamic perspective. The years. The overall prevalence of overactive bladder syndrome OAB in individuals aged 40 years (OAB) has been defined by the and older is 16%. Frequency, the International Continence Society most common symptom, occurs in as urinary urgency with or without 85% of respondents, while 54% urge incontinence usually with complain of urgency and 36% of frequency and nocturia. It is a urge incontinence. diagnosis based on lower urinary tract symptoms alone. While not Initial management of OAB should life threatening, it can have a take into account the individual’s considerable adverse impact on lifestyle and any appropriate the quality of lives of those who interventions that can be suffer from it, and it is highly employed to minimize symptoms. prevalent within society. Recent For example, reducing excessive epidemiological studies have fluid intake (25ml / kg / day is reported the overall prevalence sufficient) and minimising caffeine of OAB in women to be 16%, and alcohol consumption may suggesting that there could be be helpful, as well as reviewing

26 any medication that may have prescribed for OAB have an an impact on lower urinary tract antimuscarinic component, and function, such as diuretics. this limits compliance with the treatment because of a lack of Behavioral therapies and, acceptability to some people. particular, bladder retraining Recent advances have included may help a person regain central sustained release preparations of control of micturition and can be existing compounds, innovative highly effective in well – motivated routes of administration and individuals, although there is a newer antimuscarinic preparations. recognized high relapse rate. While many people will be Drug therapy is the mainstay of considerably improved and even treatment for OAB, and from cured of their symptoms by drug the number of preparations that therapy, there are always those have 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 further people. In the past, clinical results investigations are undertaken to of treatment have often been ensure that the correct problem disappointing due to both to poor is being addressed. Urodynamic efficacy and unacceptable adverse studies will confirm (or otherwise) effects. Earlier preparations were a diagnosis of detrusor overactivity not subjected to the current in which case, further trials rigorous randomised controlled of different antimuscarinic trials and, therefore, lack evidence preparations would be desirable, – based data. Comparison of whereas in the absence of drug therapies for this condition proven detrusor overactivity, is difficult due to the placebo an alternative diagnosis should effect of 30 – 40%, and since the be sought to avoid further response to any of the available ineffectual treatment and, hence drugs is only in the region of 60%, disillusionment and a waste of any differences that are detected resources. are likely to be small, and thus require large – scale studies to Definition of OAB show efficacy. syndrome The drugs that are currently OAB is a clinical diagnosis and

27 comprises the symptoms of is in line with current opinion frequency (>8 micturitions / regarding the importance of 24 hours), urgency and urge urgency as the driving force behind incontinence, 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 many stones, interstitial cystitis). of the clinical trials assessing the pharmacological treatment of OAB In clinical practice, the empirical syndrome, micturition frequency diagnosis is often used as the has often been used as the primary basis for initial management endpoint as it is easier to quantify. after assessing the individual’s lower urinary tract symptoms, physical findings and the The OAB – how results of urinalysis, and other indicated investigations. Thus, the common is it? International Continence Society in There are at present only a few its Standardisation of Terminology population – based studies that report from 2002 defined the have assessed the prevalence OAB syndrome as urgency with or of OAB. The prevalence of OAB without urge incontinence, usually symptoms was estimated in a large with frequency and noctuira. European study involving more These symptom combinations than 16 000 individuals. Data were are suggestive of urodynamically collected using a population – demonstrable detrusor overactivity, based survey of men and women but can be due to other forms of aged ≥ 40 years, selected from urethro – vesical dysfunction. The the general population in France, term “overactive bladder” can be Germany, Italy, Spain, Sweden and used if there is no proven infection the UK using a random, stratified or other obvious pathology. approach. The main outcome measures were prevalence of In the current International urinary frequency (>8 micturitions Continence Society (ICS) definition /24 hours), urgency and urge of the OAB syndrome, urgency incontinence; proportion of is an obligatory component. This participants who had sought

28 medical advice for OAB symptoms; 18 years and representative of and current previous therapy the US population by sex, age, received for these symptoms. and geographical region was The overall prevalence of OAB assessed. The overall prevalence symptoms in this population of of OAB was similar between men men and women aged ≥ 40 years (16.0%) and women (16.9%) and was 16%. About 79% of the was similar to the results reported respondents with OAB symptoms earlier from Europe. The impact had experienced symptoms for of OAB symptoms on quality of at least 1 year and 49% for 3 life was assessed in a subset of the years. Sixty – seven percent of participants from the NOBLE study. the women and 65% of the men In individuals who reported OAB with OAB symptoms reported that symptoms, these symptoms had a their symptoms had an impact clinically significant negative effect on 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 relatively more common in younger women Impact of OAB compared with men, while the opposite was found for the older symptoms on age groups where symptoms were employment, social more common in men. However, interactions, and when comparing the total emotional wellbeing population of men and women, there was little difference in the Symptoms suggestive of an OAB overall prevalence reported in often have a profound negative women and men. influence on quality of life. It is not only episodes of leakage The prevalence of OAB symptoms that effect wellbeing but also has also been assessed in a urgency and frequency have large population based survey considerable detrimental effects from the USA. The National on daily activities. Constant worry Overactive Bladder Evaluation about when urgency is going to (NOBLE) was designed to assess strike results in the development the prevalence and burden of of elaborate coping mechanisms OAB. A sample of 5204 adults ≥ to enable people to manage

29 their condition (e.g voiding incontinence and noctuira have frequently in an effort to avoid been shown to be associated with leakage episodes, mapping out an increased incidence of falls and the location of toilets, drinking fractures among elderly. less, or the use of incontinence pads). It is not difficult to see how The intensity of urinary urgency these troublesome symptoms may has a significant association disrupt people’s daily lives and with other symptoms of OAB. occupations. Despite the negative Urgency is the ‘driving’ symptom impact of these symptoms on in OAB, those experiencing OAB quality of life, many affected frequently experience urgency at individuals fail to report this inconvenient and unpredictable condition to their physicians of times and consequently, often symptoms for many years. This lose control before reaching the may be due to embarrassment or toilet. This adversely affects their possibly because of the mistaken physical and psychological state by opinion that effective treatment is limiting daily activities, intimacy, not available. compromising sexual function and worsening self – esteem. It is no surprise therefore that The management of improvements in urgency are often stated by people to be the most overactive bladder noticeable response to therapy.

Incontinence occurs in Urgency is a sensory symptom approximately a third of people and as such is difficult to define, presenting clinically with OAB, to communicate to both patients and approximately a third of them and colleagues alike and the have a mixed picture of combined measure and quantify. Despite sphincteric weakness and detrusor the difficulties, urgency and the overactivity. The prevalence of other symptoms of OAB result OAB is higher among the elderly in a significant deterioration in population (age 64 and above); it HRQL. To date, patient diaries have is estimated to be approximately been shown to be a reliable way 30 – 40% among persons older to collect various OAB symptoms, that 75 years, and this may have including urgency episodes, and additional ramifications as both diary entry remains the most urinary urgency, associated

30 accurate and sensitive method and healthcare professionals in for evaluating changes in urgency community based primary care with pharmacotherapy. Data services play a pivotal role in obtained on the basis of 3 – or 4 the management of incontinent – day diaries suggest that short – patients. duration diaries are just as reliable as those recorded for 7 days, and Behavioural therapy and because they impart less patient pharmacotherapy are the burden, may be an acceptable mainstay of treatment, and there method of assessing the symptoms is continuing search for more of OAB. Apart from increases effective and selective drugs in cystometric capacity, invasive with minimal adverse effects pressure flow studies have failed to (AEs). About 50% of people show positive results with existing gain satisfactory benefit from antimuscarinic therapy. pharmacotherapy. The role of physiotherapy in the treatment of Initial assessment must include urge incontinence remains unclear a thorough history and physical as evidenced by systematic review examination. A complete of clinical trials. pelvic and neurological exam is mandatory, to exclude other Treatment of OAB is multifaceted. conditions that may mimic OAB Effective treatment modalities symptoms. Urine analysis, and include lifestyle modifications, microscopy and culture will exclude medications, bladder retraining, urinary infections. Further special and exercises to strengthen the investigations are not required. pelvic floor (Kegel Exercises)

Treatment for all forms of 1. Lifestyle modifications incontinence should commence • The patient should limit with conservative methods before intake of foods and drinks progressing to more complex that may irritate the bladder surgical procedures if these do not or stimulate the production work. 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 of specialists, physiotherapists fluids

31 • 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 been The 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 2.5mg 3. 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 nervous in recent years and these include, system (CNS) effects. The AEs, neuromodulation and botulinum particularly dry mouth, can lead to toxin injection therapy, but these a high (up to 80%) dropout rate interventions are reserved for cases within 6 months of commencing where medical therapy fails. treatment.

In an attempt to reduce the Drug therapy incidence of these AEs, a new formulation, allowing a more There are a number of controlled release of the drug over antimusarinic agents in a 24 – hour period (oxybutynin contemporary use. Oxybutynin ER) was introduced. The sustained chloride is the most commonly release produces a more sustained prescribed anticholinergic for OAB plasma concentration when

32 compared with the IR preparations oxybutynin metabolites are and, hence, a much more stable the principal cause of AEs, steady – state concentration for 24 alternative delivery routes have hours. Tablet doses between 5 and been sought that would avoid 10 mg are available, and several oral administration and first randomized controlled studies pass metabolism. Consequently, have shown that oxybutynin ER a transdermal preparation of is as effective as IR preparations oxybutynin has been developed. with the additional benefit At the present time, this agent has of a reduction in dry mouth. not yet been licensed for use in Other modes of oxybutynin SA. An initial short – term study of delivery include intravesical and transdermal verus oral oxybutynin transdermal administration. IR in adults with urinary urge Intravesical therapy was developed incontinence reported that both to increase the balance in treatment options had similar favour of efficacy over AEs in efficacy, but the transdermal those patients routinely using route produced significantly less intermittent self – catheterisation. dry mouth. A double – blinded Oxybutynin (typically 5mg) is randomised controlled trial (RCT) mixed with normal saline and of transdermal oxybutynin at 3.9 administered twice a day via a mg administered twice weekly urethral catheter. Several small versus placebo, reduced the open – label studies have shown number of weekly incontinence that intravesical administration of episodes, reduced average daily oxybutynin can reduce subjective urinary frequency increased and objective detrusor overactivity. average voided volume and Clearly, the main limitation of this significantly improved quality of route 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 associated irritant effect of the solution, and with transdermal delivery were a higher risk of developing urinary erythema and pruritis at the site of tract infections with subsequent application. high dropout rates.

Following the hypothesis that

33 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 daily b.d. = twice daily tds = three times daily

Propiverine hydrochloride is a with OAB, propiverine 15 mg tertiary amine with a half – life three times daily was compared of approximately 20 hours, with oxybutynin 5 mg twice showing peak levels in serum daily and placebo. Both drugs after approximately 2.3 hours produced objective and subjective after ingestion. Like oxybutynin improvements compared with it exhibits a mixed action, placebo at 4 weeks compared exhibiting both anticholinergic with baseline. Propiverine was as and musculotropic effects (calcium effective as oxybutynin in reducing channel blocking activity). Doses urgency and urge incontinence, vary between 15 and 30 mg but was associated with a lower daily. The clinical trials and data incidence of dry mouth. with this agent are limited to a month’s duration or less. In a Tolterodine was launched in double – blinded randomized 1998 and was the first modern placebo – controlled trial of people anticholinergic on the market.

34 The ER formulation was released voiding diary parameters as a once – daily preparation (frequency, urgency and urge aimed at producing a stable serum incontinence) for up to 52 weeks concentration over 24 hours. ER after trospium 20 mg twice – daily has peak serum concentration at treatment. 2 – 6 hours post administration. Therapy with tolterodine ER 4mg Two new anticholinergic agents appears to be efficacious in both have been released in recent older and younger people with years, namely solifenacin and OAB; it is useful for at least up to darifenacin. Solifenacin has a 12 months with improvement in mean time to maximum plasma voiding diary parameters including concentration of 3 – 8 hours and urgency, and patient perception of long elimination half – life of >45 their condition with a benefit of – 68 hours. Solifenacin produces HRQL based on the King’s health a significant reduction in voiding questionnaire. The ER formulation frequency and a significant is more effective than placebo in increase in volume voided/void in different degrees of incontinence people with OAB and urodynamic severity. It has been shown to be evidence of detrusor overactivity. effective in treating women with The recommendation is for mixed urinary incontinence with a an initial 5 mg dose with the predominance of urge symptoms possibility of dose flexibility by over stress. increasing the dose to 10 mg as required. The long term efficacy Trospium chloride, a quaternary of solifenacin has been reported amine, is purported to lack in an open – label extension of CNS effects as it does not cross randomised placebo – controlled the blood – brain barrier. Its trials. The efficacy seen in the half – life is between 12 – 18 initial trials was maintained for hours and reached peak plasma up to 52 weeks. About 85% of concentrations between 4 and the study population was satisfied 6 hours. The usual dose is 20mg after 24 weeks of flexible dosing, twice daily. Trospium 20 mg twice and with regard to efficacy, 74% of daily has shown similar results the population were satisfied after when compared with oxybutynin 24 weeks of flexible dosing. 5 mg twice daily, with significant reduction in urodynamic and Darifenacin is a tertiary amine

35 derivative and is the most selective to cardiac effects and M3 and M3 receptor antagonist. It has M5 to visual effects. Certainly, in been shown to have a higher this population, this would be of degree of selectivity for the M3 greater significance due to the over the M2 receptor compared existence of comorbidity and the with other anticholinergics, with susceptibility to impaired cognitive marginal selectivity for the M1 function and nervous system receptor. In healthy volunteers effects. Definitive comment on after oral administration of this subject will inevitably await darifenacin, peak plasma adequately powered head – to – concentrations are reached after head comparative studies. Dose approximately 7 hours with flexibility has been explored with multiple dosing, and steady – darifenacin and clearly showed state plasma concentrations that some people who do not are achieved by the sixth day respond to a lower dose of drug of dosing. In a double – blind, (7.5mg) will do so at higher radomised, crossover study doses (15mg), but will develop comparing darifenacin with more pronounced AEs inevitably, oxybutynin in people with however, they may accept this as proven detrusor overactivity and part of the ‘trade – off’ for the associated symptoms of OAB, greater efficacy experienced darifenacin was as effective as oxybutynin in terms of the It is clear that among the many ambulatory urodynamic variables drugs tried for the treatment tested but darifenacin 15 and of OAB, acceptable efficacy, 30 mg controlled release was documented in RCT’s of good significantly better in salivary flow quality, has only been shown compared with oxybutynin 5 mg for a limited number. The three times daily. anitmuscarinics tolterodine, trospium, solifenacin and The introduction of darifenacin has darifenacin, the drugs mixed fuelled debate over the potential actions, oxybutynin and importance of pharmacological propiverine, and the vasopressin selectivity as related to the AE analogue, demopressin, were profile. M1 and M3 receptor have found to fulfill the criteria been attributed to dry mouth, for level1 evidence according M1 to cognitive impairment, M2 to the Oxford assessment

36 system and were given grade of symptoms caused by significant A recommendations by the genital atrophy. Oestrogen is International Consultation on not useful for treating urinary Incontinence. All antimuscarinics incontinence, but may reduce the apart from oxybutynin IR were incidence of UTI’s. found to be well tolerated. Dry mouth was the most commonly reported adverse event and no drug was associated with an MIXED increase in any serious adverse INCONTINENCE event. Ethipramine Generally there is little or no good evidence to choose between the Tricyclic anti – depressants have anticholinergics been used widely for symptoms of frequency, urgency, urge incontinence and especially Oestrogen nocturia for many years. Although grade 1 evidence justifying their Whilst the use of oestrogen in the use is lacking, many patients treatment of women with stress are satisfied with the results. incontinence is controversial, its Ethipramine is inexpensive and use in women with the irritative widely available, with a multitude symptoms of OAB is more of effects – and side effects. established. Postmenopausal women with genital atrophy or Its actions are anticholinergic OAB symptoms may receive oral in nature, with an adrenergic or topical therapy provided no effect on the bladder neck. contra – indications exist, but at Theoretically at least, this makes present, oestrogen therapy for it ideal for mixed incontinence, stress incontinence is unwise. As but its side – effects are often we wallow in post “Women’s troublesome. It causes cardiac Health Initiative” hype, we must conduction defects and this has remember the negative impact caused the WHO to warn against of withholding the beneficial its use. Dry mouth and drowsiness effects of oestrogen on the pelvic are the most bothersome side floor, and not precipitate a host effects, limiting its use. The drug

37 is available in 10mg and 25mg overall benefits of OAB treatment, tablets, and the usual starting it is critical that RCTs use validated dose is 10mg in the mornings, instruments to assess HRQL and to with 25mg or 50mg at night. The relate these changes to changes in soporific effect of ethipramine may OAB symptoms. The International be used to advantage, allowing Continence Society advocates the increased evening dosage. Contra use of HRQL measures in clinical – indications are as for other anti – research has provided increasing cholinergics. If clinicians prescribe evidence for the HRQL benefits ethipramine, they must be aware conferred by effective OAB of its cardiac effects especially in treatments. elderly women. The future emphasis of work in this field must also incorporate Imipramine patient – perceived outcomes using existing tools to assess bother and The use of imipramine is parallel QOL. to that of ethipramine – with the proviso that it remains untested as a pure anticholinergic for use The future in incontinence. Imipramine is primarily, with amytriptyline, an There is an overall trend towards antidepressant, and its useful development of once daily anticholinergic effects are purely extended release preparations for fortuitous. Clinicians must be existing anticholinergics, such as aware that these agents are of extended release oxybutynin and limited use as niche agents, and propiverine. Multiple strengths that ethipramine is perhaps more are now available in certain once clinically useful. daily agents such as solifenacin, allowing more flexible therapeutic Pharmcotherapy remains the options. Urinary urgency does not mainstay of therapy for the always arise within the bladder, treatment of OAB, and the and that when investigating OAB contemporary literature shows that we should consider a variety of antimuscarinic agents are used pathological causes. With the as a first line therapy for OAB. To exception of botulinum toxin gain a better understanding of the and neuromodulation for failed

38 medical therapy for OAB, there have been no new important surgical innovations. These last two options have superceded bladder augmentation by bowel interposition, since they are far less invasive, are reversible, and have fewer side effects.

39 Chapter 6 Intractable Overactive Bladder: Advanced Management Strategies

Stephen Jeffery

Introduction from the incontinence clinic, only 7% of the cohort reported being The mainstay of treatment cured, with 65% still suffering for Overactive Bladder is fluid significant symptoms. Previously, management, bladder retraining the only therapeutic option for and anticholinergic drug therapy. these patients was surgery in the There 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 with and remain incontinent, their most having voiding dysfunction symptoms having a profound requiring clean intermittent self impact on their quality of life. catheterization, and troublesome Studies have shown that only mucus production. 18% of women stay on their A number of newer promising drug treatment for longer than treatment options have been 6 months. This appears to be as developed, including Botulinum a result of inadequate efficacy Toxin and nerve stimulation and not side effects. Morris et al techniques. performed one of the only trials on long –term outcomes of women 1. Botulinum Toxin treated for OAB with a standard Botulinum Toxin, which is care package of anticholnergics produced by the bacterium, and bladder retraining. Looking Clostridium Perfringens, is the at the same subjects a mean of most potent toxin known to man. eight years following discharge It is a Gram positive, anaerobic

40 bacteria which is commonly found using either a flexible or rigid in the soil and 1g of the toxin can cystoscope using a flexible 26 kill 1 million people. It blocks the gauge needle that is threaded release of acetylcholine at the through the working channel of neuromuscular junction in the the scope. The toxin is diluted detrusor muscle. Amongst those into 20 ml of normal saline and who have contributed to the injected in 1ml aliquots under science of Botulinum Toxin, credit local or general anaesthesia. must be given to Schantz who Most practitioners avoid injecting purified the toxin and enabled its the bladder trigone because of mass production. Its first clinical the theoretical risk of reflux. use was in 1980 when it was Recent work has, however, shown used to treat strabismus. There that trigonal injections are not are 7 subtypes, A, B, C, D, E, F , associated with reflux and have G, however only Toxins A and B equivalent efficacy to the extra- are available commercially. The trigonal administration. When a Botulnum A Toxin preparation, flexible cystoscope is used, the Botox® (Allergan Inc.) is probably Botox can be given using local the most well known, but there anaesthetic gel but sedation or is 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 use Botox® has been more extensively intradetrusor Botox injections for evaluated in the literature than the treatment of severe detrusor Dysport®, but there are now overactivity in spinal cord injured a number of studies that now patients. Profound improvements confirm its efficacy. Botox® is were demonstrated, with 17 of 19 three times more potent than patients achieving continence. A Dysport and most reports use large amount of data has emerged 300u for Neurogenic DO and 200u since then suggesting excellent for Idiopathic DO. Exact dosages efficacy in Neurogenic DO. Schurch for Dysport are less clear and et al reported again in 2005 on ranges from 500u to 1000u are 59 NDO patients. This was double administered. blind placebo controlled parallel group study. They gave patients The toxin is usually administered either placebo, Botox 200u or

41 Botox 300u. Up to six months self catheterization or have a follow-up, they reported a 50 % suprapubic catheter inserted. reduction in incontinence episodes with 49% of the cohort reporting The Botulinum Toxin effect on the being dry. The urodynamic findings detrusor lasts for approximately compared to placebo were six to nine months and it usually remarkable with highly significant requires repeat administration increases in maximum cystometric following this. As the urgency and capacity at two, six and 24 weeks urge incontinence return, normal compared to placebo. voiding is also regained in those women who developed urinary Following the success in NDO a retention. number of studies began looking at the treatment of Idiopathic An important factor to take into DO. The problem with IDO is the consideration is the cost of the risk of voiding dysfunction – since Botulinum Toxin product. Botox is unlike in NDO, most of these sold in vials of 100u and a single patients have normal voiding course of 300u would have a cost function. Popat et al published in excess of R6000. Dysport has the first data on IDO using Botox, only recently been launched in achieving continence rates of South Africa and would have a 57%. The incidence of de novo comparable price tag. One would voiding dysfunction was 19%. In need to add to this the costs of a further randomized controlled administration, including surgeons trial, Sahai et al report profound fees, theatre time and disposables. improvements in multiple outcomes following the injection 2. Sacral Nerve Stimulation of Botox when compared to (SNS) placebo. This device works by implanting a pacemaker-like neurostimulator The main adverse event following in the lower back that sends mild Botulinum injections is temporary electrical impulses to electrodes urinary retention, with a reported that are usually placed adjacent incidence of between 19% to to the third sacral nerve root. 35%. Women who develop The device received European this complication are required Union approval in 1994 and USA to perform clean intermittent FDA approval in 1999 and more

42 than 35000 devices having been reduction in leakage episodes. implanted worldwide to date. In A further systematic review patients with OAB, SNS restores confirmed these findings with the balance between inhibitory 67% of patients reporting being and 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 followed somatosensory ascending tracts patients up for a mean of more projecting from the bladder into than 5 years reported continued the pontine micturition centre success in 76% of the cohort. in the brain stem. The electrical impulses also activate the pelvic Despite these success rates, this efferent hypogastric sympathetic therapeutic option is not accessible nerves, which promotes to the majority of women largely continence. due to the cost of the device and the expertise required to place and The device is inserted in two maintain the neurostimulator. It is phases. The test phase includes the available in South Africa, supplied temporary insertion of a needle by Medtronic, but retails for into the sacral foramen under approximately R55000. local anaesthetic and the electrical stimulation is derived from an There are also significant adverse externally placed battery and events associated with this generator. If the subject reports a equipment including pain and satisfactory response after three to discomfort, seroma formation, four weeks, defined as more than disturbed bowel function and 50% improvement in symptoms, wound dehiscence. a permanent device is sited. This involves the implantation 3. Posterior Tibial Nerve of a long-term battery and Stimulation neurostimulator in the buttock and Because of the technical and lower back. cost implications of SNS, indirect neuromodulation of S2,3 and 4 A RCT reported continence via stimulation of the posterior outcomes of 47% at six month tibial nerve, was developed. The follow up, with a further 29% technique is performed by passing reporting more than 50% an electric current between a

43 small acupuncture needle 4cm of neuromodulation and Botox above the medial malleoulus and has provided us with additional an electrode on the sole of the options prior to resorting to patient’s foot. The device has surgery. Augmentation procedures only recently become available also have a high incidence of and marketed by Manta Surgical urinary retention requiring under the name of “Urgent PC” in catheterization. South Africa. There is a significant disposable component to the 5. Alternative therapy equipment, including a single use A number of studies have shown electrode and needle and this acupuncture to be a useful unfortunately drives up the cost of adjunct to therapy. A study using this device. The treatment performed in the late 1980’s regime consists of up to 12 weekly reported a 77% reduction in sessions of 30 minutes although urgency and frequency in 77% of it may be efficacious after shorter their patients versus only 20% treatment periods, it does not last in placebo. These findings have indefinitely and it needs to be been confirmed by Bergstrom et repeated after a few months. al who also demonstrated reduced incontinence episodes. The most It has been shown to be efficacious interesting data have emerged in two trials with one reporting from a trial where women were more than 50% reduction in randomised to acupuncture in leakage episodes in 70% of bladder specific points versus their cohort, 46% of the subjects relaxation point acupuncture. reporting being dry. 71% of the They demonstrated significant cohort of 53 patients in another improvements in quality of life trial reported treatment success. and frequency episodes in the group receiving bladder specific 4. Surgical Therapy acupuncture. Acupuncture is Clam ileocystoplasty and readily available, is inexpensive augmentation procedures are and can be performed by many usually reserved for patients physiotherapists- and hence should with neurogenic detrusor be kept in mind for those women overactivity and high pressure who do not want medication. bladders with the potential of upper tract damage. The advent

44 Chapter 7 The Treatment of Stress Incontinence

Peter de Jong

Stress Urinary Incontinence is exercises extending over a number defined as the complaint of of weeks. involuntary leakage on effort or exertion, or on sneezing or Pelvic Muscle Exercises coughing. Do 45 pelvic muscle exercises every day, 15 at a time, 3 times a day: Stress incontinence occurs when 15 lying down in the morning one coughs, sneezes or jumps, 15 standing up in the afternoon resulting in a few drops or urine 15 sitting down in the evening leaking out. It is caused by vaginal childbirth, aging and genetic For each exercise: factors. Squeeze the pelvic muscles for 10 seconds (start at 1 second and build up) Where do we begin? Relax for 10 seconds

– Physiotherapy Remember to relax at the muscles in your abdomen when you do The first step in therapy is to have these exercises, and continue to the sufferer visit a physiotherapist breathe normally. with a special interest in pelvic floor rehabilitation. The physio will Test the power and effectiveness of assess the strength of the patient’s your exercises by placing 2 fingers pelvic floor, and suggest exercise in the vagina, and squeezing. The to enhance the muscle power of physio will assist in assessing pelvic the Levator muscles. She will need muscle tone. to have a programme of daily

45 The physiotherapist may recovery. also choose to employ the following: Physiotherapy is also useful in the Weighted vaginal cones, which management of the overactive are placed in the vagina while bladder, when exercises are known the patient actively squeezes the as the “urge strategy”, and help pelvic muscles to prevent the in the management of urge vaginal cones from falling out. The incontinence weights begin at 20g, and increase until the woman can manage to retain a cone of 100g, for 30min When Is Surgery twice daily. Indicated? Faradism, where tiny electric When the relief obtained by impulses are sent through an physiotherapy is unsatisfactory, electrode placed in the vagina. then other options may be The current stimulates the correct explored. muscles to contract, and so build Levator power. For women with significant symptoms (for example, they need Bio feedback, where the patient to wear a pad daily), some form of squeezes a balloon placed in the surgical option may be indicated. vagina, reflecting on an indicator the power of the pelvic muscle contractions. The Surgical If a woman persists in Management Of physiotherapy, there is no doubt Stress Incontinence that the technique will result in better muscle strength and control, Vaginal birth and aging are with a corresponding improvement important causes of urinary in bladder control. stress incontinence. Ingenious operations to cure this common Bear in mind that physiotherapy and distressing symptom in women is without side effects, may be have been devised. As a better done at home, and empowers understanding of the mechanisms the sufferer to take charge of her of continence have evolved,

46 operations to cure the condition long – term voiding complication have improved. following this procedure approaches zero. Over the years there have been many operations for the treatment One of the first effective of urinary incontinence, suggesting procedures to gain acceptance no single procedure is effective was the Burch colposuspension. in the management of this John Burch described his common and distressing condition. operation in the 1950’s and it Recently new procedures have became the accepted benchmark. become available, being safer, Several sutures plicate the and more effective, than previous peri – urethral fascia to elevate interventions. the anterior vaginal wall and bladder. Colposuspension is still applicable today, if the patient Historical Perspective requires a continence procedure and is fortuitously undergoing Traditionally the anterior repair laparotomy. of a cystocoele using Kelly plication sutures have been useful While the Burch procedure is as in the management of stress effective as modern sub – urethral incontinence. However the effect slings, a prospective randomized is transient, and while it cures trial showed higher morbidity anterior compartment prolapse, than the sling so it is nowadays the anterior repair is not an probably best reserved for women authentic continence operation. subject to serindipidous pelvic Meta analyses of heterogenous surgery. Several drawbacks attend studies suggest a continence rate the operation, chief of which is of 67% - 72%, but generally the subsequent enterocoele formation. success is around 66%. Long term Voiding dysfunction, detrusor results are poor, and at 5 years overactivity and uterovaginal success falls to 37%. The major prolapse are consistently reported indication for a bladder buttress sequelae to colposuspension. in contemporary practice is for the The widespread adoption of the woman who prefers to sacrifice modern TVT has been primarily continence for a reduced chance driven by the reduced surgical of complication – the incidence of morbidity of such procedures. In

47 a recent randomized controlled voiding dysfunction (refractory trial between the TVT and urge incontinence, the need for colposuspension, analysis after 2 clean intermittent catheterisation, years reported an objective success and sling revision) occur in 10% of rate for the Burch of 51% versus cases. Rectus fascia procedures are 63% for the TVT group. safe, with good longterm results and have became the benchmark In the 1960’s needle suspension for this form of sling surgery. procedures were popularized by Autologous slings can be used to Stamey, Pereyra, Raz and others, provide effective long term cure of but time has shown that while stress incontinence, but allograft short – term cure was reasonable, and xenograft slings should only they were insufficiently robust be used in the context of well to maintain continence. Needle constructed research trials. suspensions are now perhaps only indicated in the less – mobile In the 1980’s the laparoscopic elderly where a quick gentle Burch was introduced, riding the procedure will suffice. Efficacy in crest of the endoscopic revolution. the long term is poor, with only This sporting procedure was the 50% - 60% cure at 4 years. Needle province of the laparoscopic suspensions do not produce a affecionado, but showed no lower complication rate than advantage over the other the colposuspension, and there procedures of the time. There is a is little evidence to support their higher cure rate with the “open” continued use. Burch procedure, and the evidence on laparoscopic Burch is limited Having been described and used by short – term follow – up, small more than a century previously, the numbers, poor methodology and rectus sheath sling was all the rage its technical difficulty. in the 1970’s. While this effectively cures stress incontinence, the Peri - urethral injectable agents procedure suffers considerable have been used for the treatment morbidity, and comes with the of SI for the past century, but high price of voiding difficulty newer agents have caused a and irritative storage bladder re – focus on these methods. A symptoms. The mean cure rate variety of substances have been is a pleasing 86% but long term reported to be safe including GAX

48 collagen, Teflon, zirconium beads, 10mm sub – urethral sling placed hyaluronic acid, and autologous without tension mid – urethrally, fat and cartilage. But the ideal afforded remarkable results with agent remains elusive. Agents little morbidity. The original are applied without general or retropubic approach (TVT-R) has regional anaesthesia, but there now in the new millennium been is no agreed method, technique, superceded by the transobturator location, volume or equipment slings – safer, easier vaginal for the procedure. Although short procedures with the same tension term efficacy in some agents is – free sub – urethral principle, but satisfactory, evidence shows that avoiding the pelvic cavity and its long term durability of more than viscera completely. 4 years is poor, and no agent is superior to another in terms of Long term data suggested that (at efficacy, durability or safety. A least until recently) the retropubic recent report suggests that stem TVT-R had become the benchmark, cells may be injected adjacent with excellent cure rates in a to the urethral sphincter. No well described, standardized data is available suggesting how procedure, easily reproduced stem cells obtain innervation, or by most urogynaecologists with functional potential. This form predictable outcomes. The Burch of therapy is for now at least, colposuspension, conversely, still very experimental. Para – had many modifications and urethral injections can be offered variations of sutures, approaches to women with SI on the basis of and methods, yielding variable low operative morbidity – if they outcomes as a result. are prepared to accept a poor long term success rate. With progress in minimally invasive surgery, and the idea In the 1990’s the concept of urinary instead of using trochars attached continence being maintained by to synthetic slings instead of sub – urethral fascial support was open incision, the retropubic mooted by Petros and Ulmsten in midurethral sling (MUS) was their “Integral Theory” of female developed. continence. From this came the Tension- Free Revolution, with the For descriptive purposes, the term realization that an open – weave MUS will be used to describe

49 the group of synthetic slings evidence exists to support this placed under the midurehtra notion. Given that transobturator with a small incision using various approaches are probably safer and trochar devices. This is in contrast equally as effective as retropubic to the traditional slings which TVT, the thoughtful continence typically were placed under the practitioner must consider if the proximal urethral through larger “inside – out” route is safer, or incisions without trochars. The 2 otherwise, than the “outside – in” general categories of MUS are the transobturator approach. retropubic and transobturator Cede The New Transobturator The Retropubic TVT Approach (TVT-R) Transobturator “outside – in” The classic retropubic tension procedures – free vaginal tape (TVT-R) is This concept was first described a safe and well – tolerated in 2001, and represented a procedure with an 81% cure completely different approach at 7 years follow – up, and an for placement of the tension – improvement rate of 94%. Some free mid – urethral tape. Initially fatalities have occurred due to a welded semi – rigid tape of bowel damage and uncontrolled non – woven monofilament retropubic haemorrhage. A polypropylene was used, with few small, retrospective, non – 5% elasticity and 70% porosity randomized studies comparing (Obtape TOT device). This tape is retropubic to the newer now obsolete. Women are placed transobturator procedures show in the Lithotomy position, and the similar cure rates, but these 10mm tape passes sub – urethrally studies are too underpowered through the obturator fossa to exit to show meaningful differences the skin through a small incision in complications rates. Review on the medial aspect of the inner papers suggest the obvious, that thigh. The introducer passes from obturator approaches are safer the obturator fossa medially because of avoidance of pelvic inwards towards the vagina, hence cavity viscera – but no hard

50 the “outside – in” appellation. Another popular “outside – in” device is the MonarcR tape, and The manufacturers (Mentor – one – year data shows similar Porges) have since introduced the results. The objective cure rate is ArisR type 1 light weight superior 82%, with adverse events including mesh, being woven in such a mesh erosions, urinary retention manner as to have low elasticity. and urinary tract infections. Since 2002 more than 25, 000 TOT procedures have been performed, Data are very difficult to interpret giving a reported success rate and care must be taken when of 80% - 90%, improvement comparing studies. Since no “head in continence of 7% – 9%, to head” prospective randomized and a failure rate of up to 7%. comparative trials of methods have Complications include bladder been presented, it is impossible injuries in 0.7% of cases, and a at this point to claim superiority 3% – 5% incidence of voiding or safety of one product over dysfunction. another.

Post – operative retention occurs in Transobturator “inside – out” around 0.5% of cases, with other procedures complications including thigh pain, The Transobturator “inside – haematomas, vaginal and urethral out” approach was first mooted erosions. The overall Obtape by de Leval in 2003. The device complication rate is around 3.6%. is introduced through a 10mm These results have been carefully suburethral vaginal skin incision, collated by a French Multicenter and passed laterally through the Registry with ObtapeR surveillance, obturator fossa to the medial thigh comprising 9 centres and including area, and hence the “inside - out” data from some 730 women. moniker. This novel approach was developed after extensive In a recent study of 117 women, cadaveric dissection and one the ObtapeR afforded a 92% year data suggest a 91% cure cure (defined as complete or rate, with 5% of cases showing partial satisfaction), with a 5% improvement. Post operative complication rate. Tape erosions complications include voiding over the 22 month follow – up dysfunction in 5% of women, period, occurred in 3 cases. with a 12% incidence of transient

51 inner thigh pain and a few cases The original technique of Delorme of vaginal healing defects. In a is intuitive and uncomplicated, 2004 prospective series, Waltregny even in obese subjects. found a cure rate of 94% with no Theoretically the passage of the reported complications. Procedures vaginal finger may cause some typically take around 20 minutes tissue destruction because of to perform, and may be done as the more extensive dissection, day case procedures if the patient particularly in the atrophic prefers. Although general or vagina with thinner vaginal skin, regional anaesthesia is the norm, leading to infection, erosion they may be done under local or tape displacement. With anaesthetic. Intra – operative the introduction of the new cystoscopy is not generally improved type 1 mesh (ARISTM), required. a lower erosion rate is expected. Complications involving the It is difficult to draw conclusions urethra, bladder and vagina have from these data, and clinical trials been described. will show comparative success rates and the incidence of perioperative The “Inside out” approach of de complications. It has become Leval common to measure the “passing This dissection is less extensive distance” of the different devices without the need for digital to vital anatomical structures control, and the mesh used is in preserved or fresh cadaver extra - ordinarily well tolerated specimens, but once again this with long – term clinical data does not necessarily translate to available. Whilst the urethra and clinical safety or otherwise. bladder may be at less risk than in the original outside - in technique, clinical trials will need to confirm, Transobturator or refute the notion of increased “Outside In” Vs safety using the newer operation. “Inside Out” – Which Hysterectomy during a Is Best? continence procedure Hysterectomy is a commonly performed operation in The “Outside in” approach of gynaecology, and SI is a common Delorme

52 condition. Should hysterectomy points. The mini – sling type be combined with a prophylactic operations work on a different continence procedure? Is the principle to the conventional efficacy of either procedure obturator approach, and are affected by concomitant surgery? placed with the mesh adjacent to Assuming that SI is a symptomatic the urethra. At this stage no long and demonstrable problem, term comparative data regarding evidence suggests that abdominal efficacy are available. Stem cells hysterectomy performed at the injected para – urethrally remain time of a Burch colposuspension an interesting possibility, but are has no adverse effect on the still, at this stage, experimental. cure rate of stress incontinence, but complications are increased significantly. However vaginal Conclusion hysterectomy at the time of a TVT has no adverse effect on surgical The obturator approach to the outcome. Bear in mind that when treatment of stress incontinence performing an anterior repair offers many advantages over procedure, a significant percentage previous operations, especially of cases will develop de – novo ease of surgery, safety and good SI because urethral obstruction predictable cure rates. Apologists is relieved. It is very difficult to for each method have preferences predict which cases will develop de that should be respected – but at novo SI, and no predictive tests are the present time there is no sound currently available to determine clinical evidence comparing the which cases should be offered “outside – in” to the “inside – out” “prophylactic” incontinence transobturator approach, and procedures. this data is awaited with interest. Theory and opinion do not translate to clinical evidence. While The Future the retropubic approach is still popular, the obturator approach Recently the “mini – sling” has many probable advantages to products have become available, recommend this technique, and consisting of shorter lengths of make it the treatment of choice. mesh introduced vaginally below A multitude of sling products are the subpubic arch, with no exit now available on the South African

53 market, many being fake copy – cat counterfeits of the originators. While the ersatz knock – offs may be slightly cheaper (since no development costs were involved), the originators have the advantage of published clinical trials proving good outcomes. Fake products are seldom an improvement on the originals and must be used with caution.

References

Extensive use has been made of detailed reviews by Cardozo and Chapple published in the BJOG. The interested reader is urged to obtain the BJOG supplements, and obtain references from the reviews.

54 Chapter 8 The Management of Voiding Disorders

Peter Roos

Introduction Aetiology

Incomplete bladder emptying There are essentially only 3 reasons and urinary retention can lead that an individual will experience to severe urinary tract infection difficulty with voiding: and upper urinary tract disease • Inefficient or absent detrusor as a consequence of retrograde contractility. Impaired detrusor infection and hydronephrosis. contractility (IDC) and detrusor Obviously these problems all carry areflexia (DA). quite a significant morbidity and • Obstruction to urinary flow even mortality if unrecognised often called bladder outlet and untreated. Undiagnosed obstruction in males. (BOO) problems related to voiding will • Lack of co-ordination between often be diagnosed only when detrusor contraction and one encounters the troublesome relaxation of the urethral complication of urinary retention sphincter, known as detrusor- following pelvic floor surgery. It is sphincter dyssynergia (DSD). therefore essential that anybody practicing gynaecology, urology It would seem quite simple to now or uro-gynaecology should have present a trainee in gynaecology, an understanding of the causes, urology or uro-gynaecology with diagnosis and management of a set of tables giving the causes voiding disorders. of the three different types of dysfunction. The problem however is that neurological pathology can often be a cause

55 of these dysfunctions and various Most conditions of the central neurological conditions can cause nervous system can produce the overactive bladder symptoms, full range of bladder symptoms, impaired detrusor contractility varying sometimes from one stage and incontinence. A good starting of the disease to another. point therefore is to list the various neurological factors which can Sacral spinal injuries, lumbar-sacral affect the lower urinary tract nerve route compression and (Table I) peripheral nerve damage usually cause DA. Table I: Neurological Disorders Affecting Voiding Important causes of DSD are spinal • Cerebrovascular accidents cord injuries and multiple sclerosis. Brain tumours These conditions can cause high • Cerebral Palsy pressures within the bladder • Parkinsons disease of above 40cmH20 without the • Shy-Drager Syndrome urethral sphincter opening. This • Multiple sclerosis causes severe back pressure and • Spinal cord injuries – suprasacral upper urinary tract damage. and sacral Fortunately most neurological • Infectious conditions (tabes conditions causing bladder dorsalis, poliomyelitis, transverse pathology will be perfectly myelitis, herpes zoster) obvious. It is however important • Skeletal abnormalities of the in the patient with atypical or spine (disc problems, ankylosing mixed urinary symptoms to be spondylitis) on the lookout for more subtle • Peripheral nerve damage neurological changes before (radical surgery, diabetes instituting treatment, especially mellitus) surgical treatment.

Neurological disorders often Table 11: Other Causes Of overwhelm the average clinician, Voiding Dysfunction who probably slept through neurology lectures at university. Obstructive These are just a few important • Urethral stenosis things to remember. • Urethral sphincter hypertrophy • Pelvic masses

56 • Uterine prolapse Diagnosis • Anterior vaginal wall prolapse • Foreign bodies History • Post surgical, especially surgery A good history is usually the most for urinary stress incontinence important aspect of making a diagnosis for any condition. Until Inflammatory recently, however, the correlation • Severe vulvo vaginitis (genital between history, clinical findings herpes, severe vulvo-vaginal and special investigations has candidiasis) shown poor correlation in women • Urethritis and cystitis and been more extensively and better defined in men. Pharmacological • General anaesthesia The following urinary symptoms • Regional anaesthesia are however important in making • Analgesics (Morphine) the diagnosis of suspected voiding • Anti depressants abnormalities. Be aware however • Anti cholinergics that different studies have linked these symptoms differently to Detrusor Muscle Abnormalities confirmed voiding disorders • Detrusor myopathy • Over distention • Hesitancy • Straining to void Psychogenic • Feeling of incomplete emptying • Terminal dribble Post Partum Voiding Difficulty • Post micturition dribble • Splitting and spraying of urine Idiopathic • Changing position to void

Surgical The above urinary symptoms • Will be discussed later in this may also be associated with chapter overactive bladder symptoms and incontinence.

Further important questions in the history would be careful questioning about the usage

57 of medications, recent pelvic or for infection and haematuria abdominal surgery, neurological • Post micturition residual symptoms and symptoms of utero- volume. For a long time, a vaginal prolapse. residual volume of 100ml was considered to be cut off point for normality, however more Examination recently it has been suggested that any residual volume over A good general examination 30ml might be associated with looking for systemic causes of urinary tract infection. Residual urinary symptoms is vital. volumes can be measured either by catheterisation or ultrasound Abdominal and pelvic scanning. Ultrasound scanning examinations should concentrate is less invasive and causes on detecting local lesions and less discomfort than urinary anomalies, which might cause catheterisation. It is important urinary obstruction, such as pelvi- to remember however that the abdominal tumours, utero-vaginal accuracy of this measurement prolapse, vulvo-vaginitis, urethritis depends on the time since the and evidence of pelvic floor spasm last passage of urine until the or relaxation. time of the measurement of the residual volume. In difficult cases, with mixed • Uroflowmetry is an excellent urinary symptoms, or where non invasive screening test symptoms have had sudden onset, for voiding dysfunction. A careful neurological examination flow rate of less than 15ml per including inspecting the lumbar second would be considered spine, assessing sensory and to be abnormal. This flow motor function in the pelvic area rate however also needs to be and checking peripheral reflexes compared to the voided volume are all important features of the and the Liverpool Nomogram, examination. plotting flow rate against voided volume, is used for this purpose. • Uro-dynamic studies. If the Special Investigations diagnosis of voiding dysfunction has been made, uro-dynamic • Mid stream urine examination 58 studies are important for practitioners taking care of this confirmation of this diagnosis particular patient, changes in and to assess whether the medication, which might be voiding dysfunction is associated causing the problem should be with poor detrusor contractions considered as well as attention to or obstruction, associated with the psychological and psychiatric high bladder pressures of more health of the individual. than 20cm H2O with maximum If the condition is untreatable or flow of less than 15ml/sec. chronic, such as in neurological • Imaging of the bladder disorders, the following options and lower urinary tract by are recommended: means of ultrasound or • Timed voiding with assistance in videocystourethrography can increasing abdominal pressure, also be used. such as the Valsalva manoeuvre • Other simple non invasive or Crede’s manoeuvre, where investigations could include the patient or an assistant voiding diaries and frequency increases the abdominal and volume charts kept by the pressure by pushing supra- patient. pubically. • Intermittent clean catheterisation. This has Treatment Of Voiding proven to be a very useful and safe method of emptying the Disorders bladder without continuous (Excluding Voiding Difficulty catheterisation. This can be done After Incontinence Surgery) at 2-4 hourly intervals and can be performed by the patient The treatment of voiding themselves if they have the disorders obviously is dependant necessary motor co-ordination on the underlying cause. If the to do it. In spinal injuries underlying cause is obstructive, below C7, most patients can such as in pelvic swellings, utero- manage this themselves. Clean vaginal prolapse, constipation or catheterisation as opposed foreign bodies, these problems to sterile catheterisation is should obviously be attended to. quite acceptable in the home Treatment of vulvo-vaginitis and environment, however in urethritis goes without saying. hospital, it might be more In consultation with the medical

59 appropriate to use sterile complication for both patient and techniques to prevent cross surgeon. Having said that, the infection. incidence is probably becoming • Continuous catheterisation. less with the use of mid urethral This can either be done by tapes, this condition probably also trans-urethral catheter or remains under diagnosed and supra-pubic catheterisation. under reported. These patients need careful surveillance for urinary tract The two major issues concerning infection, stone formation and post operative urinary retention regular cystoscopy to exclude are: the development of bladder 1. Can it be predicted and carcinomas. therefore prevented • Medical therapy. Medical 2. What to do about the problem therapy should be aimed at once it arises. treating urinary tract infections and reducing the risks of high Causes Of Post Operative pressure bladders with a closed Voiding Dysfunctions urethra by using anti cholinergic • Undiagnosed pre-existing agents. Medical therapy to condition. increase detrusor contractions • Factors related to anaesthesia has been disappointing. e.g general anaesthesia, • Neuromodulation with regional anaesthesia, atropine, stimulators might be used in anaesthetic reversal agents and some of these conditions. analgesics • Post operative pain. • Oedema and swelling around Voiding Difficulty the urethra and bladder neck. • Constipation. After Incontinence • Operative technique e.g over- Surgery elevation of the bladder neck with colpo-suspension and Voiding difficulty and retention of urethral compression with mid- urine following surgery for urinary urethral tapes. stress incontinence is becoming • Other possible causes of post less common, but is nevertheless operative voiding dysfunction a stressful and uncomfortable are previous incontinence

60 surgery, age and post agreement, it is important to menopausal status pay attention to the symptoms of voiding dysfunctions listed Incidence above. The reported incidence of post • History of age, menopausal operative voiding difficulty and status and previous surgical retention of urine varies greatly history should be taken into in the literature and is frequently account. thought to be under reported. • The presence of a raised residual urine. Comparative studies between • Uroflowmetry of less than 15ml/ colpo-suspension and tension free second. vaginal tapes suggest that the • Abnormalities of uro- incidence is approximately 7% in dynamic studies, particularly both of these procedures. The those suggestive of outflow reported incidence of voiding obstruction and poor detrusor dysfunction following mid urethral activity for whatever cause. tapes, either by the retro-pubic • Inexperienced surgeon not or trans-obturator route seems to following recommended settle between 4 and 6 % but has techniques been reported as high as 10%. Reported incidence of voiding Management dysfunction in previously used • Prevention. Attention should be procedures such as Burch colpo- given to the above predisposing suspension, Marshall Marchetti factors. In the care of a trained Krantz procedures, slings and uro-gynaecologist after careful needle suspensions have varied assessment, these factors do not between 5 and 22%. necessarily preclude the use of surgery for the treatment of Voiding dysfunction following the urinary stress incontinence. injection of bulking agents, does • Counselling. Patients having not seem to have been a major surgery for urinary stress problem. incontinence should all be counselled that urinary Prediction Of Post Operative retention and voiding difficulty Urinary Retention might be a complication in up • Although there is no universal to 10% of cases. Furthermore,

61 in cases where voiding difficulty days before tissue ingrowth has might be anticipated, it might taken place. This can be done be worthwhile teaching clean, as a simple surgical procedure intermittent self catheterisation with local anaesthesia. The pre-operatively. vaginal epithelium over the tape • Temporary causes of voiding is opened and the tape itself is dysfunction and retention pulled down 1-2 cm. should be treated expectantly. • Later diagnosis of voiding Within a few days, swelling, difficulty in the presence of bruising and oedema should mid urethral tapes, when tissue disappear and various drugs ingrowth has already taken contributing to the problem place, needs to be done as a should be excreted. The more formal surgical procedure treatment of pain and either cutting or removing a constipation are important. portion of the tape underneath the urethra. Post operative voiding difficulty • Other forms of surgical release with high residual volumes include transvaginal and and urinary retention might retropubic urethrolysis. occur either in the immediate post operative period or much A very nice description of the later, even after years. The methods of releasing post surgical management of the problem obstruction can be found in the related to the surgical procedure Textbook of Female Urology itself, particularly with the use of and Uro-gynaecology, Volume mid urethral tape, is according 2 Chapter 68 by Huckabay and to whether the diagnosis is made Nitti, Editors Cardozo and Staskin, in the immediate post operative Publishers Informa Healthcare, period or much later 2006

• Early post operative voiding The early and late release of mid difficulty, particularly with the urethral tapes is very successful presence of a mid urethral tape, in the management of voiding which persists beyond the time difficulties and interestingly, up when the reversible causes to more than 60% of patients will have disappeared, is usually remain continent despite cutting treated early in the first 7-10 or removing the tape, however in

62 some of these patients, overactive Recommended bladder symptoms might persist. Reading There is some difference of opinion 1. Vasavada S, Appell R A, Sand P as to whether when removing a K, Raz R eds. Female Urology, tape for obstruction, one should Uro-Gynaecology and Voiding replace it immediately with a Dysfunction. London: Taylor and new tape. There are some who Francis 2005. recommend removing the tape 2. Abrams P. Urodynamics third and then doing a cough test to edition. Springer-Verlag London assess whether there is stress 2006. incontinence, before putting a new 3. Cardozo L, Staskin D Textbook tape in. It would seem however of Female Urology and Uro- appropriate to adopt a wait and Gynaecology Second Edition see policy in view of the fact that Informa Healthcare 2006. so many people, particularly with 4. Lansang R S. Bladder late release of tapes will remain Management March 2006. continent after the tape cutting or eMedicine Specialities, removal. Rehabilitation Protocols. Massagli T L, Talavera F, Salcido In the event of planning R, Allen K L, Lorenzo C T editors. conservative management for the 5. Both the International Uro- above problems, it is frequently Gynaecology Journal (including necessary to perform intermittent pelvic floor dysfunction) and BJU catheterisation and pay special International are journals worth attention to the treatment of consulting on a regular basis, overactive bladder symptoms with where you will find updates, anti cholinergics. With the easy reviews and original articles access to changing tension and on the topics discussed in this removing and cutting mid urethral chapter. tapes, conservative management with prolonged catheterisation and the use of anti cholinergics is becoming less popular.

63 Chapter 9 Sexual function in women with urinary incontinence

Kobus van Rensburg

Introduction Classification of Diseases-10 defined female sexual dysfunction Urinary incontinence and pelvic (FSD) as “the various ways in organ prolapse can adversely affect which an individual is unable to almost every aspect of a woman’s participate in a sexual relationship life, including her sexuality. as she would wish”. In1998, Basson Sexual function is complex and et al received consensus on the impacts the woman to affect the classification of sexual dysfunction perception of her own image and and divided it into four major the formation of relationships with categories including dysfunction others. of desire, arousal and orgasm with a fourth category for sexual Sexuality and urinary incontinence pain disorders. The final category are often considered to be included other sexual pain taboos in the minds of many disorders not associated with coitus people, but recently the fields (Table1). The American Foundation of urogynaecology and female for Urologic Diseases classification urology have focused attention system includes personal distress in on female sexual function to align each category and therefore the it with the extensive research general opinion is that in order to performed in male sexuality. make a diagnosis of FSD, it must be associated with personal distress. At present, there is no consensus regarding the definition of normal The focus of this chapter will be sexual function. In 1992 the World directed towards the impact of Health Organization International urinary incontinence on female sexuality.

64 Prevalence during orgasm (15.4%) compared to women with SUI (6.6%). This i) FSD confirms then the commonly According to the National Health held notion that SUI occurs more and Social Life Survey FSD is commonly during penetration and common, with a prevalence of UUI during orgasm. 43% in women between the ages of 18 and 54 years. Lack of desire Etiology of sexual is the most common category with dysfunction 32% of patients describing this as reason for their dysfunctional sex i) FSD lives. (Table 2) The etiology of FSD is multi dimensional including ii) FSD and urinary incontinence physiological and psychological Coital urinary incontinence (CUI) factors, and interpersonal and occurs in 24- 34% of women. sociocultural influences. (Table 3) Thirty-two percent of women reported urinary incontinence Physiological factors, such as at intercourse in a recent South medical condition involving the African study, with 31% avoiding urogenital tract, contribute to intercourse altogether due to their the complex etiology of FSD. urinary leakage. In the same study, Psychological factors such as mood stress urinary incontinence (SUI) disturbances, stress and substance was more commonly associated abuse are also etiological factors. with leakage during penetration Interpersonal relationship such as (32%) when compared to urge partner illness or lack of privacy urinary incontinence (UUI) (7.8%). might also contribute to FSD. However, women with urge urinary Finally, sociocultural influences, incontinence leaked more often such as cultural and religious

Table I. Categories of sexual dysfunction Low sexual desire Difficulty with Difficulty with Sexual pain Arousal orgasm disorder

Hypoactive sexual Female arousal Dyspareunia desire disorder disorder Vaginismus Sexual aversion Other non-sex causes

65 beliefs have an important impact • Societal taboos on sexual function. Table III: Etiology of female ii) FSD and urinary incontinence

Table II Prevalence of female sexual dysfunction

sexual dysfunction (FSD) Urinary incontinence can be (Bachman et al. In CD: Insights associated with FSD for a number in FSD (2004) of reasons, including physical and psychological factors, performance • Physiol anxiety, pain and an unsympathetic • Psycol reaction from the partner. Other • Urogenital issues contributing to a sense • Depression / Anxiety of reduced sexuality include a • Neural poor self-esteem, mood changes • Prior abuse associated with decreased libido, • CVS the use of protective underwear • Stress and reduced spontaneity. The fear • Medication of leaking urine and a concern • Alcohol / Substances about odour also induce a sense • Hormonal loss of anxiety. Women who leak and • FSD have developed a vulval dermatitis • Interpersonal Sociocultural as a result may occasionally present influences with Dyspareunia. • Inadequate education • Conflict family, religious Looking at the overall impact of

66 stress, urge and mixed urinary and mental wellbeing. incontinence, it would appear that a mixed picture has the Different methods of evaluating most significant impact on sexual of QOL are available. Validated function in women. questionnaires represent a more objective assessment and have Coital incontinence should always become an essential tool used be evaluated in the context of the to standardize and collect data. women’s age since this has also Two types of questionnaires are been identified as an independent available, including a general risk factor for a decline in questionnaire and a condition sexual activity. Specifically, the specific questionnaire. The general menopause is known to be questionnaire is insensitive significantly associated with a to a condition such as urinary decrease in libido, sexual activity incontinence, whereas a condition and responsiveness. Caution should specific questionnaire is more therefore always be exercised surgery sensitive to the effect of when evaluating a woman with lower urinary tract symptoms on FSD, where coital incontinence QOL, but in turn does not evaluate is occasionally blamed for sexual other health related issues. problems which pre-existed. Questionnaires are often intrusive and ask very intimate questions. Evaluation of FSD However, in a study that was used to develop and validate a Currently there are no completely questionnaire looking at urinary reliable instruments available incontinence and sexual function to measure or diagnose sexual (SF-IUIQ), 82.2% of the women did dysfunction. It is essential that a not report feeling too embarrassed women’s sexual function causes to complete the questionnaire. personal distress before the The short form of the pelvic organ clinician makes a diagnosis of FSD. prolapse/urinary incontinence Sexuality is only one aspect of sexual questionnaire (PISQ-12) quality of life (QOL). The World is a useful condition specific Health Organization defines QOL questionnaire. In the clinical as not only the absence of disease, setting this short form of the PISQ but also complete physical, social provides a template for clinicians

67 to discuss sexuality and helps to reduction of only 10% in the evaluate outcome before and placebo group. Admittedly, this after treatment intervention which was a small study but it certainly could be conservative or surgical. supports the role of PFMT as a first line in reducing coital incontinence. Treatment of Urinary For some patients, simple advice such as emptying the bladder incontinence and prior to intercourse or a change in Female sexual position are effective in reducing dysfunction coital urinary incontinence.

In most studies looking at the Women with overactive bladder outcomes of treatment for urinary find the symptoms particularly incontinence, objective measures more bothersome compared to of continence outcomes are usually those patients complaining of the primary aims and sexual stress urinary incontinence since function is usually assessed as a urinary leakage is not the only secondary outcome. symptom. Bladder training and anticholinergic drugs are the Conservative treatment treatments of choice, but the cure These measures usually reduce rates and the impact on sexuality urinary incontinence and remain unclear. improve QOL and sexuality. The International Continence Society Surgical treatment and sexual (ICS) includes pelvic floor muscle function training (PFMT) as first line therapy When surgery is planned the risk for stress urinary incontinence, of post-operative dyspareunia urge urinary incontinence and related to each type of operation, mixed urinary incontinence. A should always be considered. An number of small studies have been increasing number of papers have done to evaluate the impact of raised the issue of FSD in women PFMT on coital incontinence. In a who undergo urogynaecological RCT of 59 women with SUI , Bo surgery but conflicting data have et al reported a 50% decrease in been reported. coital incontinence in the group In the past the Burch receiving PFMT compared to a colposuspension was most

68 commonly performed operation studies have reported varying for the surgical treatment of stress results ranging from deterioration urinary incontinence. During to equivocal with some reporting the last decade, however, the improvement in outcomes. (Table mid-urethral tapes, employing IV) Mesh erosion is an important polypropylene monofilament cause of dyspareunia for both mesh, have become the gold sexual partners. In a prospective standard. Baessler et al were the study looking at urodynamic stress first to report, in a retrospective incontinence treated with either study on Burch colposuspension, retropubic TVT or transobturator on a 70% decrease in coital TVT, overall scores as measured incontinence following surgery. by the PISQ sexual questionnaire It decreases incontinence at improved significantly with specific penetration by 80% and during improvements in the physical and orgasm by 75%. partner related domains. The behavior/emotive domain showed A review of vaginal surgery for no significant improvement. SUI and female sexual function Other treatment reports that the retropubic TVT Estrogen treatment requires does not appear to adversely affect further research, but currently overall sexual function. Other it does not appear to be of retrospective and prospective value in the treatment of urinary

TableI V: Sexual function after tension-free vaginal tape procedure Sexual Study type Number Unchanged Improved Worsened function % of Reference: Patients

Maaita et al Retrospective 43 72 5 14 (2002)

Yeni et al (2003) Prospective 32 No pre- and postoperative difference

Elzevier et al Retrospective 65 72 26 1.6 (2004)

Glavind and Retrospective 48 60 25 6 Tetche (2004)

Mazouni et al Prospective 55 74 2 24 (2004)

Ghezzi et al Prospective 53 62 34 4 (2006)

69 incontinence.

Conclusions Sexuality is complex and the etiology of female sexual dysfunction is multidimensional. FSD is common and the taboo nature of sexuality and urinary incontinence is a challenge for the clinician. Coital incontinence and urinary incontinence can cause FSD. Validated questionnaires, evaluating sexuality will render more reliable and objective data in the future. These instruments also have a role in assessing FSD pre- and post treatment. The use of pelvic floor muscle training should be considered as the first line of treatment for coital incontinence. Simple advice to empty the bladder prior to intercourse should also be offered. Surgical treatment for stress urinary incontinence does not adversely affect female sexual function but further research, specific to mixed urinary incontinence, is required. Sexuality should be an essential outcome measure with intervention studies on the surgery for SUI.

70 Chapter 10 Urinary Tract Infections (UTIs) in Women

Dick Barnes

Incidence urethra is short and close to the faecal reservoir (source of most Urinary Tract Infections are organisms causing UTIs) hence extremely common in women the higher incidence of UTIs in of all ages. 25-30% of women females compared to males. The aged 20-40 years have had a UTI main defence mechanism against and 40% of patients with UTIs infection is the hydrokinetic will have a recurrence within one effect of regular effective voiding. year. The prevalence of UTIs in For a significant infection to young women is thirtyfold that develop, an organism needs to of young men but with increasing gain access to the urinary tract, age this ratio decreases due to adhere to the urothelium and high incidence of BPH in men. multiply in numbers. Virulent The elderly (20% of women) bacteria can overcome normal have a significant incidence of host defence mechanisms whereas bacteriuria (predisposing factor to less virulent bacteria result in development of UTI). significant infections in patients with abnormal urinary tracts or those with compromised immunity. During sexual intercourse the Pathogenesis faecal organisms causing UTIs colonise the vagina and thus sexual The urinary tract is normally sterile activity encourages ascending above the level of distal urethra. In infection. the majority of UTIs, the organism ascends to the urinary tract via the ascending route. The female

71 The microbiology of UTI is as autonomic neuropathy may follows: cause a lower motor neuron neuropathic bladder with poor • Escherichia coli (E coli) bladder emptying. responsible for: • Immunocompromised patients: ›› 85% of community acquired ›› malnutrition } UTIs ›› HIV/AIDS ›› 50% of hospital acquired } ›› cancer • other common Gram-negative ›› chemotherapy organisms: ›› immunosuppression ›› Klebsiella • Analgesic abuse ›› Proteus ›› can cause papillary necrosis ›› Pseudomonas • Gram-positive organisms can Local Factors also cause UTIs: Any condition that impairs the ›› Strep. faecalis normal flow of urine, or interferes ›› Staph. aureus with normal emptying can ›› Staph. epidermidis predispose to infection. ›› Staph. saprophyticus • Obstruction of upper tracts • In diabetics and (kidneys and ureters) immunocompromised patients ›› stones fungi (Candida) and viruses ›› PUJ obstruction (adenovirus, cytomegalovirus) ›› sloughed papillae (diabetics) cause a significant proportion of • Bladder outflow obstruction UTIs ›› urethral stricture ›› post mid-urethral tape surgery • Neuropathic bladder Predisposing Factors • Vesico-ureteric reflux • Foreign bodes in urinary tract General Factors ›› bladder catheter › double J ureteric stent • Females › Urological “procedures” • Elderly • › cystoscopy • Diabetes mellitus: The glucose › in urine is a good culture ›› urodynamics medium for organisms. Diabetes • Vesico colic fistula also impairs the function of • Pregnancy white blood cells and diabetic • Vaginal infections

72 Acute Pyelonephritis • Blood Culture ›› NO imaging (i.e. U/S) is Acute pyelonephritis is an acute needed in the acute phase bacterial infection of the renal UNLESS: parenchyma and is the commonest »» diabetic disease of kidney. »» immunocompromised »» history of stone disease Complications of Acute »» no response to antibiotics Pyelonephritis within 72 hours • Septicaemia and septic shock Treatment • Abscess General Measures ›› intra-renal • › admission to hospital if toxic, ›› perinephric › vomiting • Chronic pyelonephritis › intravenous fluids if ›› healing with scarring › inadequate hydration • Renal failure › blood culture if high ›› if bilateral chronic › pyelonephritis temperature • Antibiotics Clinical Presentation ›› Goals of treatment » eradicate infection • History » » prevent complications ›› fever and rigors » › Ideal antibiotic ›› loin or back pain › » bactericidal ›› nausea and vomiting in some » patients »» broad spectrum » high penetration and ›› LUT symptoms (frequency, » dysuria) often absent concentration in urine and renal tissue • Examination › Antibiotics most frequently ›› ill and pyrexial › used: ›› loin tenderness » Aminoglycosides • Urine » » Fluoroquinolones ›› Dipstick: WBCs ++ Nitrite test » positive »» Cephalosporins » Co-amoxiclav (Augmentin) ›› Microscopy: pus cells ++ » organism + »» Amoxycillin and Co- Trimoxazole are not useful ›› Culture: send specimen before starting antibiotics agents for empirical

73 therapy because of high Agents used: incidence of resistance to • Fluoroquinolones E coli • Co-amoxiclav »» antibiotics should be given • Cephalosporins for 7-14 days and whichever • Nitrofurantoin agent is used, cure rate = 90% Recurrent Cystitis • Urological Investigation (once • recurrent cystitis in females is acute infection has resolved) very common and is usually re- ›› All women with recurrent UTIs infection ›› Associated haematuria »» patients with recurrent General Measures acute pyelonephritis in • good fluid intake the absence of urinary • local hygiene tract abnormality should • sexual intercourse have long-term continuous • void before and after low dose antimicrobial intercourse prophylaxis (see below) • avoid spermicidal creams and diaphragm contraceptives ›› topical oestrogens for Cystitis atrophic vaginitis ›› treat constipation Clinical Presentation • frequency and urgency Specific Measures • suprapubic and back pain Three options: • dysuria 1. Continuous low dose • no pyrexia chemoprophylaxis • elderly patients may present Nitrofurantoin, Cephalosporin with sudden onset of nocte dose for 6-9 months incontinence and/or smelly urine 2. Post intercourse single dose therapy if UTIs related to Treatment intercourse. Antimicrobials as Three day course of treatment above is sufficient to eliminate 3. “Self-start” Therapy. Patient uncomplicated cystitis completely has supply of treatment (usually Single dose therapy only 70% Fluoroquinolone), when effective. symptoms of cystitis begin send

74 urine specimen for culture and initiate therapy, attend doctor few days later when culture result available

75 Chapter 11 Neurogenic Bladder

Frans van Wijk

Introduction It is also important to know of treatment modalities so that the In a normal urogynecology patient can have access to different practice, physicians might from options if necessary. time to time see patients with underlying neurologic diseases. NLUTD (neurogenic lower urinary These women may present to the tract dysfunction) is a condition clinic with symptoms of lower where diagnosis and treatment urinary tract dysfunction including needs to be tailored to the incontinence, incomplete bladder individual patient and underlying emptying or recurrent bladder disease. It is often the most infections. It is important to have challenging as well as the most a basic knowledge of possible gratifying condition to treat and underlying neurological conditions care for. that might cause these symptoms. It is not the aim of this chapter to include all neurologic conditions Physiology and give a complete overview of all the possible treatment Normal voiding is a complex modalities. It is, however, interaction of supraspinal and important to understand the basic spinal control. This will cause concepts and therefore a proper relaxation of the urethra and knowledge of the physiology and sustained contraction of the anatomy of bladder function is detrusor to facilitate complete essential. The physician will then empting of the bladder. be able to localize the site of the lesion and adjust the treatment. Neural control of normal

76 micturition is a complicated system. in the pre central gyrus, lateral A simplified summary is as follows: prefrontal cortex and anterior cingulate gyrus. These centers The supra-pontine control centres mainly inhibit the midbrain area, in the frontal cortex of the limbic the so-called pontine micturition area and the cerebellum have an center (PMC). CNS control of inhibitory effect on the function micturition centers around the of the bladder. The pons has middle pons. Barrington showed two regions, the M- region for in cats that the motor tone of the stimulation and the L- region bladder arises in this region. The for inhibition. The spinal cord Pontine Micturition Centre (PMC) will relay the sympathetic, is called the M-region and causes parasympathetic and somatic fibers stimulation of detrusor muscle to the lumbar and sacral areas and relaxation of the sphincter. and the parasympathetic system Stimulation of this center will will stimulate the detrusor muscle lower urethral pressure, inhibit whereas the sympathetic system pelvic floor contraction and will increase outflow resistance. stimulate detrusor contraction. The somatic system has control of the rhabdo muscle of the urethra Stimulation on the same level as as well as control of the pelvic the M-Region but more lateral, the floor muscles. All 3 systems must so called L-region, will stimulate work in balance to create normal Onuf’s nucleus to contract the storage and voluntary voiding of urethra. Thus the midbrain will the bladder. control either storage or emptying function of the bladder through A neurogenic bladder can the M and L pontine micturition be described as the effect of regions. neurological disease on lower urinary tract function. CNS control centers around the middle pons, where Barrington To understand the function better showed in cats that the motor tone the different systems will be of the bladder arises, is the most discussed separately. important.

Central nervous system (CNS) The midbrain gets inhibitory and The cortical pathways originate stimulatory control from many

77 different regions in the brain piriformis muscle overlying the namely frontal cortex, cerebellum, sacral foramina and form the and hypothalamus. pelvic plexus which in turn supplies the pelvic organs. The fibres The main neurotransmitters in the terminate in ganglia in the wall of CNS are glutamate for stimulation the bladder making it vulnerable and GABA and glycine for to injuries of the bladder e.g. over- inbibition. stretching, infection or fibrosis.

A central concept in the In the ganglia, the nerves development and organization of are stimulated by nicotinic the brain is plasticity. This means acetylcholine receptors. Other that the brain can adjust its hard- neurotransmitters are also active at wiring through conditioning or ganglia level but not as important. external stimuli. Postganglionic parasympathetic This is mainly achieved by fibres diverge and store the organization of the neurotransmitters in synaptic interconnections through the vesicles. On electrical impulse white matter. It is now understood the vesicle binds to the synaptic that the white matter is an membrane and deposits the extremely dynamic part of brain acetylcholine in the synapse to development. stimulate muscarinic receptors on the muscle fibres stimulating The changes of aging on the muscle contraction through brain have a variable effect and intracytoplasmic calcium release. may cause abnormal sensory perceptions or reduced inhibition Sympathetic system of bladder function. Sympathetic stimulation reaches the bladder through Parasympathetic System preganglionic fibres from Parasympathetic stimulation thoracolumbar spinal segments will start in the M-regions of the that synapse in paravertebral pontine micturition center to the and paravertebral sympathetic intermedial grey matter of the pathways. Postganglionic neurons spinal cord at level S2-4.These reach the upper vagina, bladder, fibres will then emerge from the proximal urethra and lower ureter

78 through the hypogastric and These increase the effect of the pelvic plexuses. The sympathetic excitatory neurotransmitter, preganglionic neurotransmitter glutamate, on pudendal motor is mainly acethylcholine, acting neurons. The effects on the on nicotinic receptors and post rhabdo sphincter are achieved ganglionic transmitters, primarily by acetylcholine stimulation of norepinephrine. Stimulation of nicotinic cholinergic receptors. B-adrenergic receptors in the bladder causes relaxation of the Sensory pathways smooth muscle and stimulation The two important sensory of alpha-one receptors in the feedbacks are transported to the bladder base and smooth muscle central nervous system through the of the urethra causing muscle parasympathetic and sympathetic contraction. system. They have a contra and ipsilateral supply. Norepinephrine also suppress secretion of the presynaptic Proprioceptive endings are present parasympathetic cholinergic in collagen bundles in the bladder neurotransmitter. Urine storage and these are responsible for is thus attained by detrusor stretch and contraction sensations. relaxation, urethral muscle contraction and inhibition of Free nerve endings (C fibres) are parasympathetic stimulation all in the mucosa and submucosa through sympathetic stimulation. and stimulated through pain and temperature. The sensory Somatic innervation endings contain acetylcholine and Skeletal muscle is present in the substance P. distal portion of the urethra Urethral sensation is transmitted and pelvic-floor muscles. The mainly through pudendal nerve. innervations come from Onuf’s somatic nucleus in the anterior Central areas that receive bladder horn of S2-4 segments. This and urethral sensation are the nucleus gives rise to the pudendal periaqueductal grey matter (PAG), nerve, which supplies the rhabdo insula and anterior cingulate gyrus. urethral sphincter. Important An area in the frontal cortex is neurotransmitters include also activated at times of filling. serotonin and norepinephrine. A study of both normal patients

79 and those with overactivity of the that neurological conditions bladder showed different areas are considered, especially if the of predominant activity. Using symptoms do not fit together. functional magnetic resonance imaging (fMRI)4), the insula is stimulated to a greater extent Classification anteriorly with unpleasant bladder sensations. These sensations are It is clear from the previous received by the PAG and mapped physiologic description that in the insula. It would therefore a simple classification is not seem that not only normal sensory possible. Therefore, the physician impulses but also abnormal should evaluate detrusor and impulses or abnormal mapping are sphincteric function as separate responsible for overactivity of the entities. Both of these can be bladder. It is easy to understand either normal, hyperactive or that diffuse neurologic disorders hypoactive in function. It is also might have an effect on the important to make sure that perception of sensory impulses of a there is co-ordination between normal LUT. the detrusor and sphincteric function. Sphincteric function has an autonomic (sympathetic) and Epidemiology a somatic control. Incoordination is described as detrusor-sphincter There are no exact figures on the dyssynergia. The diagnosis of prevalence of neurologic disease detrusor-sphincter-dyssynergia will of the lower urinary tract. It is not state which system causes the important, however, to recognize outflow obstruction (sympathetic that patients with neurological or somatic). These can, however, disease should be evaluated for be differentiated by proper lower urinary tract function. Any examination. A distinction should patient with unexplained lower be made between detrusor-smooth urinary tract symptoms should be muscle sphincter dyssynergia evaluated for possible neurologic or detrusor-striated muscle abnormality. It is even more dyssynergia. important that, before invasive The higher the lesions, the surgery, including prolapse more hyperactivity we find and and incontinence operations, the lower the lesion, the more

80

This classification will give a good description of the pathophysiology as well as guide further treatment hypofunction.

The evaluation of the patient Neurologic should include: Conditions • Detrusor function • Urethral function Supra-pontine lesions • Co-ordination between the two Supra pontine lesions e.g.

81 Alzheimer or stroke patients. catheterize. Treatment decisions These conditions will lead to less must take into account the inhibition of bladder control. It progression of the disease. is important to understand that aging will cause atrophy of the If lower urinary tract symptoms cortex and can therefore also develop early then Multiple System cause less control of the bladder Atrophy (MSA) must be considered. function. This might not directly be associated with pathology but Voiding dysfunction occurs in occur as part of the normal aging 35-75% of patients. It normally process. High lesions will mostly consists of frequency, urgency, cause over activity of the bladder nocturia and urge incontinence. but coordinated voiding with Urodynamically they normally have normal urethra. detrusor overactivity. Generally they have coordinated sphincters Diverse neurologic conditions: although sporadic involuntary activity of the striated muscle Parkinson’s disease might occur as shown by EMG Parkinson’s disease gives a diffuse measurements without any true dysfunction of the neurologic obstruction. system because of degeneration of primarily the dopaminergic Multiple Sclerosis (MS) neurons. Dopamine deficiency Multiple Sclerosis is a progressive in the substantia nigra accounts disease affecting young and for the classical motor features middle aged people with of the disease. This leads to twofold predilection for resting tremors and slow onset females. The primary lesion is of movements. This condition neural demyelination with axon will only cause lower urinary tract sparing and it is possibly immune dysfunction after many years and mediated. Demyelination often there is a slow progression in the affects the corticospinal and disease. Treatment must always reticulospinal columns of the take into consideration that spinal cords. Therefore voiding and the condition might deteriorate sphincteric dysfunction is common. and that the patient might lose Voiding symptoms will be present proper motor activity of the hands in 50-90% of patients. Detrusor and later not be able to self- overactivity with striated sphincter

82 dyssynergia is the most common sphincter control. finding. Detrusor areflexia might also be present. Up to 15% of These patients will normally end patients might present with the up having treatment in a center urinary symptoms before the for neurologic rehabilitation. It primary neurologic diagnosis of is important to have a high index Multiple Sclerosis is made. of suspicion for cauda equina lesions or spinal cord compression Multiple System Atrophy (MSA) in patients that develop new This is a progressive degenerative symptoms of lower urinary tract neurologic disease that is dysfunction, especially if it is characterized by combination of associated with fallout in the lower Parkinsonism, cerebellar ataxia extremities. It is normally caused and autonomic failure. In this by central disc compression at the condition the lower urinary level of L5 or S1 where the cauda tract function will be affected equina is central in the spinal fairly soon after the start of the space before it exits through the disease. Therefore, aggressive foramina. Cauda Equina syndrome rehabilitation for the urinary is characterized by perineal tract dysfunction is often not sensory loss, loss of both anal indicated and not very satisfactory. and bladder voluntary sphincters The cause of the disease is and sexual responsiveness. They unknown and it is a progressive have acontractile detrusor muscle neurodegenerative condition with and no bladder sensation. These a life expectancy of a mere 9 years. patients will have to be evaluated The so called Shy-Drager syndrome urgently to prevent permanent is possibly the end stage of the damage. Even with emergency disease. decompression, permanent detrusor areflexia is common. Spinal cord damage Complete spinal cord lesions below Spinal cord damage, as in spinal T6 will normally give detrusor over cord injuries, spina bifida patients activity with smooth sphincter and compression of the spinal cord synergia and striated sphincter due to disc compression, tumors dyssynergia. Sensory loss will also or cysts as well as cauda equina be present below the lesion. lesions can all lead to different types of fallout of the bladder and Lesions above T6 might have

83 smooth muscle sphincter and surgical trauma to pelvic dyssynergia as well, because of plexus during radical surgery to sympathetic damage. the pelvic organs. In obstructed labor, minor damage can happen Treatment of spinal cord injuries to the innervation of the lower should aim to create a low- urinary tract. This will normally pressure system and emptying with lead to atonic or hypoactive clean intermittent catheterization. function of the detrusor or sphincter muscle. Fortunately, A complication of the above T6 damage to the pelvic plexus is lesions is Autonomic Hyperreflexia. often transient and temporary This is characterized by an acute measures are strongly advised in autonomic response (primarily the initial period. The condition sympathetic) causing headache, will stabilize and function will hypertension and flushing of the return spontaneously to the pelvic body above the lesion. Avoidance plexus. Correction of the under of stimuli in susceptible patients lying neurologic damage is almost is important and sublingual never possible. nifedipine either as prophylactic or therapeutic treatment seems Diverse very effective. Dosage of 10- 20 mg might be used as it prevents HIV smooth muscle contraction The true incidence of lower urinary through calcium channel blockade. tract symptoms in the acquired immunodeficiency syndrome is Transverse myelitis is a rapidly not known. The whole spectrum developing condition affecting of dysfunctions can be present in motor, sensory and sphincter these patients but seems to be in function. It will mostly stabilize in the more advanced stages of the 2-4 weeks and recovery is usually disease. Treatment principles are complete. the same as other neurological conditions. Peripheral Nerve Damage Peripheral nerve damage is Fowler Syndrome normally associated with diseases This syndrome presenting in young like diabetes, herpes virus women below 30 presenting infection, Guillain-Barre Syndrome with acute retention and often

84 have polycystic ovarian disease. patient might have the normal A classical EMG finding of the anatomic abnormalities of the sphincter was described by urogynae patient and good pelvic Fowler characterized by the floor examination must be carried inability to relax the sphincter. It out. is in the absence of demonstrable neurologic disease and very Knowledge of the dermatomes susceptible to neuromodulation and reflexes will help to localize therapy. the lesion.

Special investigations Clinical Evaluation Ultrasound of the bladder, urine dipstick and serum creatinine is The evaluation of the neurologic indicated. If any abnormality is patient includes the normal picked up with these screening physical, biochemical and dynamic tests, the necessary workup must testing that is important in all be done. patients with lower urinary tract symptoms. The only difference Urodynamic evaluation is that special attention must be Standard Urodynamic testing taken to include the state of the gives information on bladder and upper tract and neuromuscular urethral function. To evaluate evaluation. EMG measurements co-ordination between bladder will give a better understanding of contraction and urethral relaxation the exact lesion. cystometogram and EMG or video urodynamics will give more History and physical information. examination Thorough history and physical In the neurogenic patients, examination is necessary with care urodynamic studies are very to evaluate perineal sensation, important to evaluate the precise sphincter tone and lower extremity function of the lower urinary reflexes and sensation. Abdominal tract. Urodynamic studies should examination will sometimes detect be performed in a specialized unit a full bladder. where good studies will be done as well as EMG measurements Remember that the neurogenic of the pelvic floor if needed.

85 Video urodynamics or ultrasound only as part of a full evaluation. visualization of the bladder and 3. EMG of the sphincter. It is the bladder outlet might enhance recommended that EMG of the the information available on urethral sphincter can be used normal urodynamic studies. In a in the diagnosis of neurologic high-pressure bladder system with bladder dysfunction. There is detrusor pressures reaching more not a good correlation between than 40 cm of water, especially in anal sphincter activity and the presence of detrusor sphincter urethral function. dyssynergia, it might lead to 4. The following tests are currently upper tract deterioration. The still experimental and there is physician must make sure that no clear clinical proof that it will proper knowledge of bladder add to the information on the function as well as urethral and specific patient. pelvic floor activity is known after a full urodynamic evaluation. EMG of the detrusor muscle Specific attention should be given Dynamic bulbocaverneus reflex to sensation of the bladder at the Nerve conduction studies time of urodynamic study to plan Somatosensory evoke potentials further treatment. Urodynamic Electro sensitivity of the low evaluation must always try to urinary tract mimic the real life symptoms Sympathetic skin response during the study. More research is necessary before Specialized tests these specific tests can prove to be 1. Ice water test might give useful as a clinical tool. information on the difference between reflex and areflexic Treatment neurologic bladders, but is controversial. AIMS: 2. Betanecol super sensitivity • Protect renal function, prevent test might also give more infection information on the difference • Restore continence between neurologic or miogenic • Restore emptying a contractile bladders. The • Controlled collection of urine current recommendation is that if restoration of function not it has to be used with care and possible

86 Planning of treatment is important Kidney Function as the underlying disease and It is very important for the the effect on the lower urinary treating physician to remember tract symptoms is almost never the effect of the lower urinary stable and neither is the physical tract symptoms on kidney function condition of the patient. These before decisions on treatment patients are therefore better are made. Unstable bladder with cared for in a team situation or detrusor sphincter dyssynergia with close interaction with the (DSD) will lead to impairment of neurologist. kidney function. If augmentation or diversion procedures are Underlying condition should be considered, kidney function and stable. upper tract anatomy should be E.g. - The spinal cord injury patient evaluated. Absorption of urea needs to be over the shock phase. and electrolytes by the intestinal The Parkinson patient, on effective interposition can cause metabolic treatment. changes. The stroke patient rehabilitated and stable, etc. Conservative treatment Conservative treatment entails Mobility of the patient triggered reflex voiding, bladder The next component of decision expression through crede or making is the mobility of the valsalva maneuver, timed voiding patient. Both in their ability to and fluid restriction. This get to the toilet as well as good treatment is normally given for hand function and mobility. supra-spinal lesions because of Treatment like timed voiding, self balanced bladder function. In the intermittent catheterization and spinal lesions, diffuse neurologic catheter care might be impossible conditions and lower lesions it for certain patients. In other cases must only be considered if the the patient might have access bladder is a low-pressure system. to support like nurses, family or The reason is that there may institutions that can help with be D-S-D with a risk to kidney care of basic body functions, the function. decision making might differ according to circumstances. Conservative treatment must always form part of the total

87 treatment of the patient, even in cases where more invasive Indwelling catheters are inserted treatment is indicated. It is either suprapubically or trans- difficult in the neurologic patient urethrally for patients where to completely restore normal there is either a high-pressure function, therefore measures like system or the possibility of self- timed voiding, fluid restriction and catheterization is not available, effort to empty completely need or in cases where patients lose to be emphasized constantly. Pelvic mobility or cognitive function. floor exercise are normally not There are significantly more indicated in neurologic conditions risks with indwelling catheters but might give some improvement compared to CISC and Silicone in patients with MS. Electric catheters should be used. stimulation or biofeedback have Catheters normally need changing the same limitations. every 3 months but there are some patients that might need more Catheters frequent changing. Crystallization Catheters are used to drain and blocking are the biggest the bladder in patients where problems retention or incomplete voiding is present. They can also be used in Recommendations On The Use incontinent patients, especially if Of Catheters cognitive function is impaired. Self clean intermittent Intermittent catheterization can catheterization is superior to any be used if the storage pressures of the other techniques as long as are low, the bladder has a good the bladder is not a high-pressure capacity and there is good hand system. control. Clean self-intermittent catheterization is still the best Indwelling catheters are safe way to empty the bladder. It is and sufficient for short-term important to motivate the patient management of urinary retention. to start doing it. Once they are The use of indwelling catheters used to it the result is usually good. routinely for the management The recommended frequency is of the neurologic bladder is not 4-6 times per day with a bladder recommended. capacity of not more than 400ml and a 12-14-size catheter is used. Complications of supra-pubic

88 catheters are similar to those of Detrusor muscle relaxing drugs: urethral indwelling catheters. • Oxybutynin Apart from insertion, that has a • Darifenacin higher risk, supra-pubic catheters • Solifenacin have the possibility of bowel • Tolterodine perforation and urethral catheters • Properverine cause urethral incompetence over • Trosium time. • Propantholene • Flavoxate Protective pads and diapers, • Tri-cyclic anti-depressants protective clothing or pads for the incontinent patient is sometimes Discussion the only way to protect the patient Drugs to reduce over activity of from skin reactions and a bad the bladder and increase the odour. storage function of the detrusor. The mainstay of treatment in this Pharmacotherapy group are the anticholinenrgic Pharmacotherapy is mainly used drugs. The newer anticholinergic for overactivity of the bladder. drugs as in Oxybytinin, Darifenacin, There are practical options for Tolterodene and Solifenacin are improving of bladder emptying. all available as a long acting Again, as with the previous preparations. This gives better treatments, the detrusor function, long-term effects and less side as well as the urethral function affects. The side effect profile of have to be seen as separate the different medications is well entities and a decision on which known as in central nervous system pharmacotherapeutic agent effects, cardio vascular effects, will work best in each specific dry mouth and constipation. instance is important. Only broad There are specific advantages guidelines will be given on which and disadvantages of each of treatment modalities will work the long acting anticholinergic better for a specific condition. medications. It is important to decide which ones will work Drugs Available For Treatment best in a specific case and it is Of Neurologic Lower Urinary important to make sure the Tract Overactivity: patient complies with the intake of the medication and that the long

89 term effect thereof is measured. Botulinum toxin A is the most With proper care and information potent biologic toxin known the side effect profile is limited. to man. It binds the snap 33 Oxybutynin is also available as docking protein in the nerve an intravesical installation as terminal. Inhibiting acetylcholine well as a transdermal absorption release from the nerve terminal application. There is no clear and thus preventing muscle recommendation that any of these contraction. This can give clinical drugs is superior in all cases of improvement for six to nine detrusor over activity. months in neurologic patients by lowering detrusor contraction and Drugs work on nerve function increasing bladder capacity. • Valinoïds eg. Capcacin and Numerous studies have been Resinoferatoxin blocks sensory done which shows efficacy of nerves for afferent sensation to the Botulinum toxin, starting the brain. within the first six days and • Botulinum toxin has an optimum effect after six weeks. The individual response is Vaniloids fairly specific for a patient. If the The study showed that effect lasts for six months the first Resinoferatoxin is a much more time, the follow up injection will potent sensory antagonist than normally also last about that long. Capcacin and is superior in terms The current use in neurologic of efficacy. In studies it has overactivity is 300 units as an intra- been shown that the maximum vesical injection. Two Botulinum cystometric capacity increased type A toxins are available. Botox significantly but it did not change is most widely used in current detrusor pressure significantly. It studies. Botox is normally given is currently recommended that as a 10 unit per m/L in 30 different further randomized trials must sites of the bladder. It can be be done to determine the exact given under general, regional place for this treatment modality. or local anaesthetic. No clear It has been studied in neurogenic randomized study has been done bladders and compared to Botox to evaluate the specific treatment but shown to be less effective. strengths. Botulinum toxin can also be used into the sphincter to Botulinum toxin A reduce the outflow resistance. The

90 dose used in the sphincter is 50 – • Alpha adrenergic blockers – 100 units. It was clearly shown to lowers urethral resistance e.g. reduce the post void residual. Tamsulosin, alfuzosin, The side effect profile is extremely • Cholinergic - increases detrusor low and systemic complications contraction almost unheard of. Other form of Botulinium A (Dysport) has been Discussion studied but not as widely and is 1. Alpha-Adrenergic blockers: also effective with other possible Alpha-adreno receptors side effects, and different dosage have been reported to be regimens. predominantly present in the bladder base and urethra. Drugs to enhance sphincter Alpha-blockers can therefore be function used to lower the resistance of • Alpha -adrenergic agonists the bladder neck and urethra. • Estrogens They have been proven to lower • Beta-adronergic agonists the detrusor leak point pressure • Tri-cyclic anti-depressants in children. 2. Cholinergic: In general Betanecol Several drugs including Alpha- chloride seems to be of limited Adronergic agonists, Estrogens, benefit of detrusor areflexia Beta-adrenergic agonists, as well and for elevated residual urine. as Tricyclic anti-depressants have These drugs should not be used been used to increase the bladder in the presence of detrusor outlet resistance. There is no sphincter dyssynergia. clear recommendation whether these can be used for long-term Invasive treatment treatment of sphincter deficiency. A noradrenaline serotonin re- Neuromodulation and electrical uptake inhibitor (duloxitene) has stimulation been well studied and will increase Sacral nerve neuro modulation urethral resistance. The side effect has been well proven to treat the of this is nausea and it is also used refractory overactive bladder as in the treatment of depression. well as the imbalance in pelvic floor stimulation. It is essential Drugs to facilitate bladder that there be normal neural emptying connections for this modality

91 to be effective. The efficacy of Detrusor Myectomy: (auto- the sacral neuromodulation also augmentation) includes afferent stimulation and This will produce a diverticulum in therefore intact neuropathways the dome of the bladder if ±20% are necessary. It does not work of detrussor muscle is removed. in the spinal cord injury or The urothelium is left intact. It is spina bifida patients. The sacral mostly done as an extraperitoneal neuromodulation is an electrode procedure. Laparoscopic placed usually at S3 foramina and techniques are also described. left in as a temporary stimulation for 2 to 3 weeks. If there is a more Enterocyctoplasty that 50% improvement in their It is the best reproducible symptoms, a permanent generator operation to enlarge bladder is implanted on the lateral aspect capacity and increase storage of the buttock. This can be set function of the bladder especially with an external programmer. The in the small fibrotic bladders. placement of the electrode can Complications include infection, be done in different positions, mucus production and incomplete periurethrally or next to the bladder emptying. Absorption pudendal nerve. Sacral root through bowel might lead to stimulation is currently the most metabolic acidosis. Kidney extensively documented. function evaluation is very important before the procedure is Electrical Stimulation considered. Ileum clam cystoplasty Sacral anterior root stimulation. is done most often. The This is not a technique that urotheluim can be left intact and will normally be done at the the bowel muscle used to cover urogynaecology clinic but is more it. This will decrease the mucus for specialized spinal units. It is production, and absorption. only performed on spinal patients where a posterior rhizotomy has Bladder replacement been done. This is an exciting New bladder can be preformed for development but not for discussion patients with severely contracted at this level. and damaged bladders. Small or large bowel can be used and Augmentation procedures a good storage pouch will be formed. The pouch is connected

92 to the sphincter. The majority of catheterization can also be used these patients will have to self- with the sphincter if she has catheterize. voiding dysfunction.

Procedures to enhance outflow Diversions resistance Continent urinary diversions: if Bulking agents can be used to the normal urinary tract cannot increase passive urethral closing be used for storage and emptying pressure. The result of bulking function, a continence pouch can agents is ± 60% in improving the be formed, through which the incontinence. patient will self-catheterize. The technique is fairly difficult and the Mid-urethral slings complication rate in the long term Mid- urethral slings are classically is relatively high. These include used for stress urinary incontinence infections, stone formation, (SUI). They are also very effective mucus production, strictures of in the neurologic patient with SUI. the stoma or ureter and metabolic disturbances. Small or large Mid urethral slings can also be intestine can be used for the pouch used to obstruct the urethra in and a number of valve mechanism patients with a hypotonic urethra. can be formed It is better to use retropubic mid- urethral slings for obstructive Conduit diversion: an incontinent procedures than trans-obturator diversion can be made with ileum routes or mini slings. The patient and anastomosis of the ureter to then has to self catheterized if a short piece of ileum. The classic the outflow is obstructed and the Bricker Ileostomy is still used for storage function of the bladder is patients where no restoration of normal. normal urinary tract can be done.

Artificial sphincter Bladder disconnection The artificial sphincter (AMS800) In cases where there is a damaged can be used to close the bladder bladder with a hypoactive or outlet. It is opened using a special dilated urethra and incontinence, valve system and the patient can a bladder disconnection should void spontaneously if she has be considered, especially if the normal detrusor function. Self- patient’s mobility or hand function

93 is not good. The urethra can be closed and a permanent supra pubic catheter placed. The urethral disconnection can be done as a vaginal procedure under local anaesthetic.

94 Chapter 12 Interstitial Cystitis (IC)

Dick Barnes

Incidence Clinical Features

This is a rare condition occurring Pain mainly in middle-aged women • very debilitating with a female to male ratio of • suprapubic pain 10:1. • worse with a full bladder • improved after voiding (doesn’t disappear) Etiology • may also have perineal pain and dysuria There are many theories regarding the etiology of interstitial Irritative Voiding Symptoms cystitis but a deficiency of • severe frequency (day and night) glycosaminoglycans (GAGS) in the • severe cases may void half- urothelium is best documented. hourly GAGs are the polysaccharide macromolecules which cover the Urine urothelium of bladder, preventing • may have a sterile pyuria noxious substances in urine (such as potassium) penetrating urothelium and the bladder wall. Diagnosis GAG deficiency leads to urine penetrating the bladder wall, Usually confirmed on cystoscopy release of neuropeptides resulting (under general or regional in pain. anaesthesia): Petechial bleeding is seen from the bladder wall (particularly after second filling of the bladder with

95 irrigation fluid). There is usually allergic response and hence a small bladder capacity and an antihistamine may prove rarely an area of ulceration of the beneficial. bladder wall (Hunner’s ulcer) It is recommended that above Differential Diagnosis three agents are used together to IC is a diagnosis of exclusion maximise effect.

1. Cystitis – urine dipstick and • Anticholinergics: Usually culture ineffective in this condition 2. TB – urine for AFBs and TB culture Intravesical Treatment 3. Bladder carcinoma (particularly • Dimethylsulphoxide (DMSO) CIS) – urine cytology • Heparin based solutions 4. Bladder stone – U/S and cystoscopy Surgery 5. Pelvic infection • Bladder hydrodistention: 6. Endometriosis Bladder distention under Intravesical Potassium Test anaesthesia often gives good If instillation of a solution with temporary symptomatic relief high potassium concentration and can be repeated. reproduces the patient’s pain this is • Surgery: Only in highly selected diagnositic of IC. cases and includes cystoplasty to increase bladder capacity and occasionally cystectomy and Treatment urinary diversion.

Medical Treatment • Sodium Pentosan Polysulphate (Tavan SP): This is a synthetic form of GAG that replenishes the deficient GAG layer • Amitryptiline: Useful for pain control • Hydroxyzine (Aterax): (Antihistamine) Some cases of IC are associated with an

96 Chapter 13 Introduction to Pelvic Organ Prolapse

Peter de Jong

Introduction aging population, reconstructive surgery for the management of Despite prolapse being a concept pelvic organ prolapse (POP) will readily grasped by generations command increasing resources. of medical students, a basic Surgery is required to correct understanding of the concept has symptoms of POP, restore the changed recently. This chapter anatomy, retain bowel, bladder will highlight some of the new and sexual competence, and be developments in pelvic organ durable. We intuitively perceive prolapse (POP), and examine that prolapse is the result of aging, modern surgical interventions with vaginal parity, chronic elevation evidence supporting their use. of intra – abdominal pressure and hysterectomy. Following novel anatomical insights occasioned by the cadaver dissections of Delancey How Common Is and Richardson before him, a Prolapse? new description of prolapse and classification of the staging has Pelvic organ prolapse (POP) is a emerged. distressingly common condition and 11% of women have a lifetime We have hitherto considered risk of surgery for this condition. pelvic organ prolapse as consisting Despite this, its aetiology is of a cystocoele (prolapse of the poorly understood, and the bladder), uterine or vault prolapse natural course of prolapse is (depending on whether or not the grasped more in the anecdotal uterus is present), or a rectocoele than scientific arena. With an (prolapse of the rectum). Whilst

97 we suppose that the cystocoele “rectocoele”) is any descent of contains the bladder, a vault the posterior vaginal wall so that prolapse consists of the apex of the a midline point on the posterior vagina and a rectocoele contains vaginal wall 3cm above the level of part of the rectum, this is not the hymen or any posterior point always the case. proximal to this is, less than 3cm above the plane of the hymen.

New Definitions Is Prolapse “Normal”? Pelvic Organ Prolapse(POP) is the descent of one or more of anterior Clearly some degree of prolapse vaginal wall, posterior vaginal is the norm, especially in a parous wall, and apex of the vagina population. Women with prolapse (cervix / uterus) or vault (cuff) after beyond the hymenal ring have a hysterectomy. significantly increased likelihood of having symptoms. In a general Anterior vaginal wall prolapse population of women between (previously termed a “cystocoele”) 20 – 59, the prevalence of prolapse is descent of the anterior vagina was 31%, whereas only 2% of all so the urethra – vesical junction (a women had prolapse that reached point 3cm proximal to the external the introitus. Some estimations urinary meatus) or any anterior suggest that a degree of prolapse point proximal to this, is less than is found in 50% of parous women, 3cm above the plane of the hymen. and up to 20% of these cases are symptomatic. An estimated 5% of Prolapse of the apical segment all hysterectomies result in vaginal of the vagina (previously termed prolapse. “vault prolapse”) is any descent of the vaginal cuff scar (after Apical prolapse is a delayed hysterectomy) or cervix, below a complication of hysterectomy, and point which is 2cm less than the follows vaginal and abdominal total vaginal length above the hysterectomy in equal numbers: plane of the hymen. it’s occurrence may be the result of damage to the upper vaginal Posterior vaginal wall prolapse supports occurring at the time of (previously known as a surgery.

98 Urinary Incontinence When To Operate? And Prolapse Prolapse is not always progressive, Urinary incontinence and POP and will not necessarily worsen are separate clinical entities with the time. Thus it may be an that may or may not coexist. over simplification to suggest Significant protrusion of the surgery to avoid an operation “at a vagina may obstruct voiding later stage”. and defecation. Surgical repair of one pelvic support defect POP symptoms are vague and without repair of concurrent correlate poorly with the site and asymptomatic pelvic support severity of prolapse. They include: defects appears to predispose to accentuation of unrepaired • Pelvic pressure defects and new symptoms. • Vaginal heaviness Women with POP may have to • Irritative bladder symptoms digitally reduce their prolapse • Voiding difficulty in order to void or defecate. • Urinary incontinence Although pelvic anatomy can now • Defecatory difficulty easily be measured accurately • Back – ache and reliably, the relationship of • Coital problems these anatomic findings with functional abnormalities is Back – ache and pelvic pain not well understood. Support may or may not be associated abnormalities of the anterior with POP. The level of evidence vaginal wall are common in to support the notion that vaginally parous women; but stress surgery consistently alleviates incontinence is not consistently these symptoms is poor. When associated with this finding. Distal physiotherapy fails to alleviate posterior vaginal wall support symptoms of POP, or vaginal abnormalities may exist with or pessaries are unsuccessful or without defecation abnormalities. complicated by ulceration, The relationship between anatomy then surgical POP repair may and function is one of the most be indicated in symptomatic pressing research priorities in the individuals. Up to 30% of domain of physical examination of operations for prolapse fail. women with POP. It is probably unrealistic to

99 use weakened native tissue to In general terms, there is restore fascial defects. Ligaments good level 1 evidence that the and tissues are attenuated by abdominal approach is more age and childbirth, and further robust, effective and durable traumatised by the dissection and for correcting the anatomy and de – vascularisation of prolapse preserving vaginal and lower repair. Healing by fibrosis is urinary tract function. The unpredictable, and the further vaginal route has fewer serious insults of age, obesity and estrogen perioperative complications. deprivation makes the temptation Maher demonstrated that vaginal to succumb to prosthetic repair sacrospinous colpopexy was seem attractive. faster and cheaper with quicker return to normal activities, but has a significantly higher risk Route Of Surgery of recurrent anterior or apical prolapse than abdominal surgery There are hundreds of operations using a mesh or sacral colpopexy described for the correction of technique. The vaginal approach POP, with either an abdominal or a is commonly preferred for the vaginal approach. Most textbooks obese, chronic strainer who smokes suggest that prolapse surgeons and suffers obstructive pulmonary be adept at both abdominal and disease. vaginal procedures, but in reality the majority of POP surgery is performed via the vaginal route. Prolapse And However there are no good data Concomitant on which to base the decision as to route of surgery. Reviewing Hysterectomy prolapse literature is difficult Although hysterectomy is because of the heterogeneous frequently a bedfellow of POP nature of the condition, variability repair, there is no evidence that in inclusion and exclusion criteria, it improves prolapse surgery the variety of procedures, non outcomes. In three studies it – standardized definitions of appeared that uterine preservation outcomes, lack of independent or removal did not affect the reviews and short term follow – risk of POP recurrence. Some up.

100 authorities feel that hysterectomy to conserve the uterus, options are is a major contributor to the restricted and evidence to support occurrence of POP, and is part specific procedures is very limited. of the problem rather than the solution. Theoretically at least, Recently a number of novel cervical conservation at abdominal techniques have been described hysterectomy should maintain involving Type 1 Prolene mesh apical support and prevent vault placement vaginally, with fixation prolapse. Randomized trials will be through the obturator foramen needed to asses whether cervical and sacrospinous ligament. conservation prevents vault (ProliftR: Johnson & Johnson prolapse in the long term. Womens Health Urology, PerigeeR, ApogeeR, American Medical Systems). There is no specific Procedures For need for vaginal hysterectomy when these mesh kits are used. Prolapse Lateral prolene straps pass through ligamentous structures to Apical (Vault) Prolapse provide support for central mesh Procedures hammocks placed without tension A well supported vaginal apex is vaginally. The mesh systems are the cornerstone of pelvic organ safe and minimally invasive but support, and recognition of apical at present long term data are not defects is critical prior to prolapse available. Efficacy in the short correction. term appears to be promising with few side – effects being Apical Support Procedures With encountered, but review of larger The Uterus Present studies is desirable. Although these Establishment of vaginal support at procedures using propriety kits the time of vaginal hysterectomy are easily mastered by proficient is recommended and may be prolapse surgeons, proper achieved by a “prophylactic” training and expert instruction is attachment of the vaginal cuff to mandatory. the uterosacral or sacrospinous ligaments (level 4 evidence). If the surgeon does not wish to use a propriety mesh kit, there are a When women with a uterus have few reports of uterine preservation apical vaginal prolapse and wish

101 with apical support procedures, is safe without any increase in being small retrospective case surgical risks. Mesh erosions series involving fewer than 50 range from 3% to 40%. There is cases with short follow – up and at present no data to clarify the poorly defined outcomes. (Level 3 use of routine culdoplasty with evidence) the procedure, and there are no standardized outcome measures to Vaginal obliterative procedures assess sacrocolpopexy success. (colpocleisis) have a role to play in stage III – IV POP in cases where Level 1 evidence suggests an apical women no longer wish to preserve prolapse cure in 85% - 90% of coital function, and surgery is cases, but quality of life data in balanced by a positive impact these cases is very limited. Surgery on daily activities. The vagina is may result in a dysfunctional obliterated, the enterocoele is not vagina with dyspareunia, and addressed and the uterus is left so anatomical support does not in – situ unless there is separate necessarily equate to patient pathology. The procedures are satisfaction. The risk of prolapse gentle with a speedy return to at other sites subsequently has not normal activity, with good success been sufficiently studied. rates described (level 3 evidence). The distal anterior vaginal wall Abdominal sacrocolpopexy may should be spared and not drawn also be approached by means into the operation, to reduce the of the laparoscopic route, but risk of stress urinary incontinence. vast experience and patience is required to achieve good results within reasonable time frames. Apical Support At present little published data evaluates laparoscopic vault Procedures Post support procedures. Hysterectomy In this country, Cronje Transabdominal procedures has performed perineo – Sacrocolpopexy is durable with colposacrosuspension (PCSS) in level 1 evidence supporting its use, many hundreds of cases, when and several workers have reported women have stage 3 or stage 4 that concomitant hysterectomy prolapse, or stage 2 symptomatic

102 prolapse - particularly with the level of the ischial spines, and obstructive defecation (sometimes maintains the vaginal apex in the combined with a STARR midline. However ureteric injury procedure). This comprehensive occurs in up to 11% of cases, with repair represents major surgery, post – op bowel dysfunction due and is beyond the scope of the to recto - sigmoid narrowing. But “generalist” gynaecologist. The it optimizes vaginal length and recurrent prolapse rate is 10%, provides good vaginal support. with a 5% occurrence of de – novo This procedure has the same dyspareunia. principle of action as the Mayo or McCall culdoplasty, although no comparative data exist. Vaginal Suspensory Procedures Anterior Prolapse The sacrospinous ligament Procedures suspension Sacrospinous ligament suspension The surgical management of (SSLS) or fixation is popular, anterior vaginal prolapse is allowing simultaneous repair of controversial with limited and anterior or posterior vaginal wall often conflicting data available. defects with less postoperative The traditional vaginal repair for bowel dysfunction. Infrequent cystocoeles was first described by complications include buttock pain Kelly in 1913, and in controlled or a sacral / pudendal nerve injury. trials has a 57% chance of curing The recurrence of a high cystocoele cystocoeles. An abdominal is around 22% and may be a approach is also feasible with the problem. Randomized trials favour abdominal paravaginal repair the robust abdominal approach having a success rate of up to 97%. of the sacrocolpopexy, with the But the abdominal approach may reservations mentioned previously. carry significant complications – including ureteric obstruction, High uterosacral ligament bleeding, haematomas and abscess suspension (HUSLS) was first formation. reported in 1997, and suspends the vaginal apex to the remnants No randomized control studies of the uterosacral ligaments at have evaluated and compared

103 the abdominal, laparoscopic have no long – term follow up or vaginal route of repair in data in the published literature at isolation. Goldberg and co – present, and the results of studies workers demonstrated in a case are awaited with interest. The control study in women with use of mesh would be particularly anterior prolapse and stress useful where conventional incontinence, that the addition techniques have already failed, in of a pubovaginal sling to the large defects or in individuals with anterior colporrhaphy significantly obstructive pulmonary disease reduced the recurrence of a or other predisposing causes of anterior prolapse from 42% in prolapse. the control group to 19% in the anterior repair and sling group. The surgeon should bear in Which begs the question – does mind that a certain percentage the addition of type 1 soft mesh of women develop stress to a vaginal repair make the incontinence following anterior procedure more robust, with an repair procedures. About 15% - acceptable complication rate? It 20% may need urinary continence has already been established that procedures, and all patients having the type 1 large pore prolene mesh anterior repairs must be councelled is extra – ordinarily well tolerated to this effect. in the vagina with very few long term complications. Workers have proposed that a tension – free Posterior Prolapse mesh buttress may serve as a scaffold for collagen ingrowth and Procedures so reduce the incidence of repair Nowdays several approaches are failure. feasible for the repair of posterior wall prolapse. The ProliftR and PerigeeR systems have been developed for this The Abdominal Route purpose and allow minimally The abdominal approach is well invasive vaginal techniques described, and involves placement anchoring a mesh hammock in of a mesh buttress anterior to situ by means of mesh extensions the rectum behind the posterior emerging through the obturator vaginal wall fascia, commonly foramen. These novel procedures as part of a sacrocolpopexy

104 procedure. However a significant vaginal wall has been alluded to, number of failures are still and these prolene mesh hammocks reported, with 10% of women with supporting straps which pass needing surgery for complications through the sacrospinous ligament specific to the surgery. The are being evaluated. laparoscopic approach to the posterior prolapse requires further The Transanal Route evaluation. A number of papers have appeared describing a novel The Vaginal Route procedure to deal with posterior Variations abound in transvaginal compartment prolapse and techniques. The traditional Jeffcoat obstructed defecation. The levator ani plication produced STARR procedure, or “stapled an acceptable anatomical result, transanal rectal resection for outlet but 50% of patients described obstruction”, employs a double – significant dyspareunia. stapled circumferential resection Continuous midline plication of the of the lower rectum together rectovaginal fascia recognized the with any associated rectocoele, problems of the levator plication intusseception or mucosal and was an advance on this prolapse. The procedure is popular earlier technique. More recently in continental Europe, and uses Richardson attributed rectocoeles two ProximateR PPH – 01 stapling to breaks in the rectovaginal guns (Ethicon Endosurgery, Ohio, fascia, and advocated the isolated USA). However evidence to support repair of the focal defects. its widespread implementation Discrete fascial repair offers is tenuous at this stage. On the good anatomical outcome with basis of two randomized trials,8 acceptable sexual function, but with 3 series of transanal stapled midline fascial plication is superior resections published to date, it in correcting obstructed defecation seems that this novel procedure in 80% of cases. Site - specific is of potential benefit but repair is less robust and durable needs careful evidence – based than midline fascial plication, evaluation. Level 1 evidence with less entrapment of faeces demonstrates that the vaginal on straining (grade A evidence). approach to rectocoele repair is The recent introduction of mesh superior to the transanal method. kits for prolapse of the posterior

105 Prosthetic Materials or not the use of these grafts confers advantage over standard And Surgery prolapse repair, and in which category of patient they should be There are insufficient data at employed. present to draw any evidence - based conclusions with regard to This will allow appropriate the role of prosthetic materials selection of both the type of in prolapse surgery. Part of the prosthesis and the optimal surgical problem arises from the paucity approach in women requiring of baseline data regarding the reconstructive pelvic floor surgery. efficacy of “traditional” anterior However, synthetic prostheses will and posterior vaginal repairs. As a not compensate for poor surgical result of this the efficacy of adding techniques or a poorly conceived prosthetic material for primary procedure. A host of “copy – cat” or recurrent prolapse affecting prostheses are available on the these compartments is difficult market, riding the wave of more to assess. While adding synthetic established mainstream product type 1 mesh grafts suggests a usage. A prudent surgeon will theoretical advantage, this must evaluate published data on specific be balanced against increased cost products before using “me – too” and potential morbidity. operations.

There is also a need for further long – term prospective studies, ideally in the form of randomized Conclusions controlled trials as well as from structured personal series audits, New insights classification systems in order to determine the long have modified previously held – term efficacy and potential beliefs in the field of pelvic morbidity associated with the use organ prolapse. POP is a vast of prosthetic materials in primary and amorphous field of surgery. or recurrent prolapse repair. Different causes of prolapse and Standardized criteria for staging a host of confounding variables POP, adequate follow – up and makes one approach and any one assessment of effects of surgery on standard procedure unscientific. bladder, bowel and sexual function The “one – operation fits all” are required to determine whether methods of the past must be

106 eschewed, and a more thoughtful and evidence – based approach cultivated. If necessary, specialist knowledge and expertise may need to be consulted in an approach to difficult cases of POP.

107 Chapter 14 Pathoaetiology of Prolapse and Incontinence

Paul Swart and Etienne Henn

Prolapse and Incontinence not caused by a single event or are the result of physiological deficiency, but is the culmination and anatomical failure. The of an interplay between complex mechanisms involved are complex multifactorial aetiologies which with multiple factors playing a vary between women. It would role. Because this is such a diverse not be wise to reduce the end field, these aspects are addressed result to a specific event and the by two authors in this chapter. best science can offer us, until we have greater understanding of these complex interactions, is to analyze different risk factors in - Paul Swart Part 1 a population and assign relative risks or odds ratios. It is difficult The Aetiology of Prolapse to counsel women regarding the The aetiology of pelvic organ ideal mode of delivery using the prolapse (POP) and stress urinary currently available evidence. incontinence (SUI) are inseparable. These two conditions are different Risk factors for POP can be sides of the same coin and share classified into predisposing, common aetiological variables. inciting, promoting or Detrusor overactivity and urinary decompensating. Predisposing urgency, dry or wet, may co-exist in factors include congenital women with SUI and POP, but is a anomalies, race, gender and separate condition with different hereditary defects such as Marfan’s aetiological factors beyond the syndrome. Inciting factors include scope of this discussion. pregnancy and vaginal delivery, Pelvic organ prolapse (POP) is surgical procedures and certain

108 myopathies and neuropathies. 40% of primigravid women had Factors outside the pelvis that some SUI before falling pregnant, could elicit POP, include obesity, which always worsened during smoking, pulmonary disease the pregnancy, improved after the that leads to chronic coughing pregnancy and recurred with later and lifestyle variables including pregnancies. This would eventually repetitive heavy lifting during become a problem even when they occupational duties or during were not pregnant. The hormonal recreational activities. These would changes associated with pregnancy be considered to be promoting have an effect on the elasticity and causes. Decompensatory distension of the pelvic contents mechanisms include aging, by their effect on the muscle menopause, neuropathy, and collagen content as well as myopathy, debilitating diseases the changes in circulation of the and medication such as cortisone. pelvic floor. In addition there A combination of factors each is the added stress of increased influence the development of intra-abdominal pressures and this disease to a greater or lesser distension by the fetal presenting degree. Overall, the risk factors part. most strongly associated with prolapse include advanced age, There are three mechanisms high gravidity and parity, number whereby labour influences the of vaginal deliveries and previous integrity of the pelvic floor and hysterectomy. the continence mechanisms. Firstly, mechanical distension and tearing Pregnancy of muscle and connective tissue Although increasing parity is a invariably occur. Secondly, vascular risk factor for prolapse, nulliparity compression with the potential does not provide absolute for hypoxic damage to the same protection. In the Women’s Health structures as well as the urinary Initiative (WHI) study nearly 20% tract, and subsequent replacement of nulliparous women had some of active tissue by scar formation, degree of POP. There is, however, has also been shown to occur. The no doubt that both pregnancy third mechanism is compression, and the delivery of a baby play stretching or hypoxic damage to a role in the aetiology of POP nerve structures including both and SUI. Francis et al found that motor and sensory. EMG studies

109 and pudendal nerve terminal times more likely to report urinary motor latency (PNTML) studies incontinence than her nulliparous have demonstrated defects twin sister. In the WHI study, after vaginal deliveries which it was concluded that a woman are not apparent following having a history of at least one elective caesarean section. Strong delivery had double the risk of POP associations are described for when compared to nulliparous long labours, macrosomic babies, controls. forceps deliveries, 3rd degree tears and multiparity. There are (i) Myogenic damage: numerous studies that confirm We have histological confirmation these findings. and radiological evidence, using ultrasound and MRI, Among premenopausal women, demonstrating that the mechanical those who have delivered at least trauma of delivery leads to rupture one baby, have a higher prevalence of the pelvic muscles. Imaging of both SUI and urgency than studies have also shown an inverse nulliparous women. In contrast, correlation between prolapse and among postmenopausal women, the total volume of levator muscle pregnancy and childbirth seem and muscle strength. to have a smaller impact on SUI. Older nulliparous females have (ii) Neuromuscular damage: been shown in some studies to The mechanism of neurological have the same prevalence of SUI damage during labour is unknown, as parous women. Co-morbidities, but pudendal nerve compression particularly aging, outweigh the certainly plays a significant role. effect of previous pregnancies Snooks et al have shown that after in these women. Goldberg and vaginal delivery there is prolonged Abramov report interesting PNTML and this correlates with findings after looking at pelvic greater perineal descent during floor dysfunction in a group of straining. Forceps deliveries identical twin sisters, with a mean appear to make the greatest age of 47 years (range 18 and impact on PNTML whereas subjects 85 years). The sibling who had having an elective caesarean at least two vaginal births was section were no different from three times more likely to report nulliparous controls. Most women faecal incontinence and four will recover as innervation is re-

110 established but in some women SUI. There was, however, the same it never returns to normal. trend with a larger RR for a parity Viktrup et al, in a study on the of two or more. risk of incontinence after delivery, report that most patients who (iii) Damage to the endopelvic are incontinent after the birth fascia: of their babies improve but are During labour, tears develop in at a greater risk of developing the connective tissue. This might incontinence a few years later. Of not be immediately apparent the women who had SUI three but with continuous trauma and months after the delivery, the aging it plays an important role majority of whom were dry 1 year in the development of prolapse. later, 92% became incontinent 5 It would appear that some years later. Sultan et al have also women have a more vulnerable shown that a caesarean section collagen. Studies have shown performed after the onset of that there is a decreased collagen labour is less protective than an content in nulliparous women elective section. In the Term Breech with SUI. There is also an increase trial, 4.5% of patients who had a in the concentration of weak caesarean section were incontinent cross-linked collagen in women after 3 months compared to 7.3% with prolapse compared to the of the women that delivered strong cross-linked collagen in vaginally with a relative risk (RR) of women without prolapse. These 0.62 and a confidence interval of differences are quantitative as well 0.41 to 0.93. as qualitative on histo-chemical level. Furthermore, there is an Data from the EPINCONT study, increase in the metalloprotease suggest that after one baby, the enzyme activity in patients with RR for SUI becomes 2.4 in women prolapse suggesting an increase aged 20-34 years but only 1.8 in the breakdown of collagen of when they are between 35 and 64 these patients. years of age. In both age groups, however, the associations are There is thus no question that statistically significant. Once the pregnancy and the mode of patients were over 65 years of age, delivery influences subsequent there was no significant association prolapse and SUI. However, most between delivery and the risk of women have pregnancies and

111 deliveries without residual long- and POP find a positive association. term POP or SUI. The scientific There is however controversy as to challenge is therefore to identify the role of the menopause. a subgroup of women who are vulnerable to the consequences Constipation of pregnancy and to offer There certainly appears to be appropriate counselling and an association between POP possible intervention. Currently and constipation. Posterior the only available intervention is compartment prolapse can lead caesarean section but the influence to difficult rectal emptying, due of this on subsequent pregnancies to herniation of the rectocele has to be accepted. into the vagina. It has been shown that chronic constipation Epidural analgesia is possibly with repetitive straining leads associated with subsequent POP or not only to pelvic floor muscular SUI. It may indeed increase the use damage, but also to neuropathy. of forceps in some institutions and Constipation appears to be this in turn might have deleterious significantly more common in effects on the pelvic floor but it women developing POP. seems unlikely that the epidural block per se has any deleterious Occupational Stresses role. There are studies from Italy and the USA reporting a correlation The use of episiotomy to prevent between a patient’s income pelvic floor damage has no and the prevalence of POP. The support in the literature. There lower the income, the higher the is no evidence that first or second prevalence of POP. The authors degree tears are associated with postulated that this was probably later POP. Third degree tears do due to harder manual labour. appear to be associated with Nursing has also been shown to subsequent POP and SUI. In some be a risk factor. A study looking studies, episiotomies contributed at 28,000 Danish nurses found an to third and fourth degree tears. odds ratio of 1.6 for developing POP or a herniated lumbar disc Aging compared to same-aged controls. Virtually all studies that address the relationship between aging

112 Obesity Collagen Synthesis Obesity increases the intra- Abnormalities abdominal pressure significantly As already stated above there and chronically. Most studies are qualitative and quantitative have found a positive correlation differences in the connective between obesity and POP as well tissue of women with and without as a greater risk for surgical failure POP. These would also include in the obese. differences in the muscle actin, myosin and extra-cellular matrix Hysterectomy proteins. According to the Oxford Family Planning Study, the incidence Variations In Skeletal Anatomy of POP is higher in women who Increases in thoracic kyphosis and undergo a hysterectomy for decreases in lumbar lordosis both reasons other than prolapse. If increase the risk for POP. The same a woman undergoes surgery for is true for a wider transverse pelvic POP the subsequent risk appears inlet. to be even higher. It is uncertain whether a sub-total hysterectomy Race carries the same risk. It would seem that POP is more common in women from European Previous Prolapse Surgery descent than African women but There is little doubt that certain older publications show bigger surgical procedures predispose differences than more recent patients to prolapse in other publications. Access to health compartments. Two examples care facilities might play a role include an increase in posterior but quantitative and qualitative compartment prolapse after a histochemical differences in Burch colposuspension and a collagen and muscle tissue are greater number of cystocoeles awaited. after sacrospinous ligament fixation. There are also reports of prolapse of the vaginal vault after transection of the uterosacral ligaments for chronic pelvic pain.

113 important to note that although Part 2 - Etienne Henn vaginal birth is the most important etiological factor in pelvic Pelvic floor damage due to floor dysfunction, other factors childbirth contribute including advancing Pelvic floor disorders (PFD) age, vascular disease, spinal cord include urinary incontinence injury, primary bowel disease, (UI), anal incontinence (AI), and molecular and genetic factors. pelvic organ prolapse (POP). It This chapter shall focus on the has been shown on numerous impact of childbirth and delivery occasions, that one of the main factors on the development of causes of female pelvic floor pelvic floor dysfunction. We shall dysfunction is vaginal childbirth. divide the available evidence into The consequences can be short different compartments to enable term or lifelong. The potential a thorough overview of this impact space in the female pelvis is limited on the pelvic floor. and has been shown, in relative terms, to have decreased over Trauma to the nervous system time. Human evolution theory, Neuromuscular function of the postulates that the fetal head pelvic floor is dependent on the has enlarged significantly over integrity of the nervous system. time, and thus a larger fetal head Pelvic floor peripheral nerves, has to pass through the female such as the nerves to the levator pelvis at childbirth. About 1.5 ani, and the pudendal nerves are million years ago, Homo erectus at greatest risk of injury during had a cranial capacity of 900 cm3 pregnancy and childbirth. The while Homo sapiens now has a pudendal nerve is particularly cranial capacity of approximately prone to damage where it curves 1800 cm3. It is therefore not around the ischial spine and surprising that the structures of enters the pudendal canal. Ample the pelvic floor are damaged due evidence links neurologic injury to pregnancy as well as childbirth. with PFD. Prolonged pudendal Some studies have shown that one nerve motor latency (PNML) has in two parous white women will been reported after delivery suffer pelvic floor dysfunction, to in 42% of women delivering varying degrees, due to vaginal vaginally, but not in those women childbirth. Of these women, up to delivered by planned caesarean 60% of will undergo surgery. It is

114 section. PNTML returned to normal and maternal expulsive efforts in 60% of these women at two during the second stage of labor. months postpartum. Another The most important muscles of the study found evidence of pudendal pelvic floor are the puborectalis, nerve denervation in 80% of pubococcygeus and anal sphincter women after vaginal delivery. The muscles. The genital hiatus in mechanism of injury is most likely nulliparous women measures 6-36 to be a combination of direct cm2 during valsalva while the trauma and traction injury during surface area of the fetal head is 70- delivery. Risk factors included a 100 cm2. This clearly demonstrates long second stage (> 56.7 minutes), the extent (± 300%) that the a large baby (> 3.41 kg), and a levator ani muscle is required to forceps delivery. Weakness was stretch during childbirth. Partial shown in both the levator ani levator avulsion has been shown muscle and the external anal to occur in 15% of women during sphincter after vaginal delivery. delivery (Figure 1). These women This is the result of a combination are at an increased risk for severe of loss of total motor units as well pelvic organ prolapse, urinary as asynchronous activity in those incontinence and even recurrent that remained. Sensory nerve prolapse after surgical treatment. function is also likely to become Studies on MRI of the pelvic floor impaired by nerve damage. This did not identify any levator ani will be clinically most evident defects in nulliparous women, in in the anal canal, with its many contrast to the findings in 20% afferent nerve endings, resulting of primiparous women, who had in anal incontinence or faecal a visible defect in the levator ani urgency. Caesarean section has muscle. These defects were usually been shown to be protective, but in the pubovisceral portion of the only in women who delivered levator ani muscle. Reported risk electively. factors include higher maternal age (>35 yrs), large babies, Trauma to the pelvic floor prolonged second stage, and muscles forceps delivery. Pelvic floor muscle Anatomical and functional changes strength has been also been shown to the pelvic floor can develop to decrease by 25-35% following secondary to pelvic floor distension vaginal delivery compared to during descent of the fetal head caesarean section. Interestingly,

115 6-10 weeks postpartum there is Figure 2: Two-dimensional however no significant difference endoanal ultrasound image of anal from antenatal values, excepting sphincter disruption secondary to for a lower intravaginal pressure in obstetric injury. multiparous women.

Injury to the anal sphincter during Connective tissue trauma childbirth occurs either as a result Pelvic organ support essentially of direct disruption of the muscles consists of or relies on the or due to injury to the pudendal endopelvic fascia and the nerves. The incidence of anal condensations of this fascia that sphincter damage varies between forms the ligaments (uterosacral, 0.5 – 2.5% where mediolateral transverse sacral). Increased pelvic episiotomies are used, and 7% organ mobility (POM), manifesting where midline episiotomies as pelvic organ prolapse (POP), are used. The use of endoanal occurs as a consequence of ultrasound has demonstrated a weakness of these supports. It is far much higher incidence of anal more common in parous women sphincter injuries (Figure 2) in (50%), compared to nulliparous asymptomatic women, the so- women (2%). During vaginal called occult injuries with as many delivery, the mechanism is most as 35% of primiparous and up to likely due to mechanical trauma of 44% of multiparous women having these supporting structures with evidence of sphincter disruption. subsequent degrees of disruption. Risk factors for both the overt and Spontaneous healing might also occult sphincter injuries include lead to weaker collagen and so forceps delivery, prolonged second predispose to incontinence and stage, large birth weight, midline prolapse. episiotomy, and occipitoposterior positions.

Figure 1: Levator avulsion injury on ultrasound, the vagina reaching the pelvic sidewall (arrow) with no intervening muscle, unlike the healthy contralateral side.

116 Effect of childbirth on It is important to remember that after adjusting for other potential specific pelvic floor causes of pelvic floor damage, disorders a woman’s risk for moderate to severe incontinence decreases Urinary incontinence from about 10% to 5% if all of her Urinary incontinence is a children are delivered by caesarean common symptom in pregnancy section. The protective effect of and has been reported in up caesarean delivery and nulliparity to 85% of women. Women dissipates around the sixth decade reporting antenatal stress urinary of life, such that the women incontinence (SUI) are at an have the same incidence of UI increased risk for future SUI. De regardless of their delivery status. novo SUI has been reported to develop in 7% of primigravid Anal incontinence women immediately following AI is a distressing social handicap vaginal delivery but this only and vaginal delivery is a major persisted in 3% at one year. etiological factor. AI occurs The most likely mechanism is a in as many as 29% of women combination of nerve and tissue nine months after delivery. The damage. At five-year follow reported incidence of AI following up, 19% of women without anal sphincter rupture is in the urinary symptoms after the first region of 16-47%. There is some delivery reported SUI. In contrast evidence to suggest that elective 92% of women reporting stress caesarean section is protective incontinence three months after against AI but the impact of delivery, had SUI five years later. delivery mode appears to decline Antepartum incontinence has also with age. The use of forceps is been reported to strongly predict the single independent risk factor postpartum incontinence. It is associated with anal sphincter remains unclear as to whether it damage and the development is the pregnancy or specifically of AI. The first vaginal delivery the vaginal delivery that is the has been suggested to be the risk factor for developing urinary most significant event leading incontinence. It would appear that to damage of the anal sphincter. vaginal delivery roughly doubles a Retrospective studies have woman’s chance of developing UI. reported that the prevalence of

117 AI 30 years after delivery was stage of labour, delivery of a large comparable, regardless of mode of baby, midline episiotomy, and the delivery. use of a forceps for delivery. Less pelvic floor damage may occur Pelvic organ prolapse after elective caesarean section, Pelvic support defects appear to but not necessarily with emergency occur before delivery. Pregnant caesarean section. The advantage women have been shown to be of caesarean section appears, more likely to have POP than however, to dissipate in the long their nulliparous counterparts. term in the majority of women and Parity increases the risk for POP it is therefore not recommended and is the variable most strongly in all women. It will not only be related to surgery for POP. We unnecessary in at least 50% of await prospective studies on the parturients, but many women impact of vaginal delivery and desire the experience of vaginal intrapartum management, on the delivery. Ideally, women should be development and prevention of offered strategies to reduce pelvic defects in the connective tissue floor injury such as pelvic floor and levator muscles that lead to exercises. Adequate management pelvic organ prolapse. of labour is essential and elective caesarean section should only be Conclusion offered to women at high risk for There appears to be a strong pelvic floor damage. association between the development of pelvic floor disorders including UI, AI and POP and pregnancy and childbirth. Mechanisms of injury include direct muscular trauma, disruption of connective tissues, and denervation injury. The first vaginal delivery is the most significant event impacting of the development on subsequent pelvic floor dysfunction. Other risk factors include advanced maternal age at first delivery, prolonged second

118 Chapter 15 Conservative management of pelvic organ prolapse

Trudie Smith

Pelvic organ prolapse is common be considered in conservative and is seen in 50% of parous management consist of the women .One recent community following: survey by Slieker-ten et al found that 40% of the general female • Lifestyle interventions population aged 45 to 85 years had • Physiotherapy evidence of pelvic organ prolapse • Pessaries of at least stage two.

Pelvic organ prolapse is rarely 1. Life Style life-threatening, but may have a significant impact on a woman’s Interventions quality of life. Choice of treatment Several studies have addressed for prolapse depends on the the association of heavy lifting severity of prolapse, its symptoms, and strenuous physical activity and the woman’s general health in the causation of pelvic organ and preference. Options available prolapse. Jorgensen and colleagues for treatment can be categorized compared the incidence of surgery as conservative, mechanical for prolapse in 28 619 Danish and surgical. Conservative or nursing assistance compared to mechanical treatment is generally a staggering 1652533 female considered for women with a mild population controls. The nursing degree of prolapse, those who assistants occupation constantly wish to have more children, the exposed them to repetitive heavy frail or those unwilling to undergo lifting. He found that these surgery. nursing assistants where 1.6 times The interventions which could

119 more likely to undergo surgery however, a cross-sectional study than their controls. This study and did not allow any inference did not however adjust for parity about causal relationships. and other contributing factors. In another study by Spernol et al There is no conclusive evidence they found that 68% of women that lifestyle changes are going to with prolapse reported heavy to improve the degree of prolapse or medium work compared to 0% the symptoms associated with the of controls. Again there was no prolapse. adjustment for parity, mode of delivery, or other contributing 2. Physiotherapy factors. Pelvic muscle training (Kegel Body weight was also considered exercises) is a simple, noninvasive a risk factor in the British Oxford intervention that may improve Family Planning Association Study. pelvic function. Whether Kegel All of these studies unfortunately exercises can resolve prolapse were cross -sectional studies and has not been adequately studied do not control for parity, degree in good randomized controlled of prolapse or other confounding trials since Kegel’s original articles. factors. While systematic reviews and randomized controlled trials (RCT) Constipation and a history of have shown a convincing effect irritable bowel syndrome were of pelvic floor muscle training strong and independent risk for stress and mixed urinary factors for symptomatic prolapse incontinence, there seems to in an epidemiological trial done by be a paucity of data for other Guri Rortveit et al. This association conditions associated with pelvic between constipation and floor dysfunction. It is commonly prolapse has not been observed recommended as adjunct therapy in other studies that included for women with prolapse, often the condition as a potential risk with symptom directed therapy. factor for prolapse. Straining with The POPPY Trial, a multi-centre chronic constipation may damage randomized controlled trial of a the pelvic floor; alternatively, pelvic floor muscle training for constipation may be a symptom women with pelvic organ prolapse, of posterior prolapse. This was which is currently being conducted

120 in Australia, may address this issue. group and in the pelvic floor muscle training group, respectively. Prevention Harvey et al in a systematic The two main hypotheses on the review on the role of pelvic floor mechanism of action of PFMT exercises in preventing pelvic floor include morphological changes prolapse, failed to validate its use occurring after strength training as a preventative measure. Piya- and the use of a conscious Anant et al performed a cross contraction during an increase sectional study in 682 women in abdominal pressure in daily and an intervention study of activities. There is an urgent need 654 of the same cohort . Seventy for good quality RCT’s, preferably percent of the subjects in the cross using the POP-Q system and using sectional study had POP. Thirty standardized exercise programmes. percent were classified as severe and 40% as mild prolapse. The women were randomly allocated 3. Vaginal Pessaries to an intervention or a control group. Women in the intervention Pessaries have been manufactured group were taught to contract from many materials including the pelvic floor muscles 30 times silicone, rubber, clear plastic, soft after a meal every day. Women plastic and latex. Most pessaries not able to contract were asked to today are made of silicone and return to the clinic once a month as a result are non allergic ,do until they could perform corrected not absorb odours or secrete contractions. They were also substances. Silicone is resistant advised to eat more vegetables to breakdown with repeated and fruit and to drink at least two cleansing and autoclaving. liters of water per day to prevent Pessaries are often used in constipation. They were followed- pregnant patients, the elderly and up every six months throughout in patients who do not want or the 2-year intervention period. are too frail to undergo surgery. The results indicated that the Pessaries may also be used to intervention was only effective in facilitate preoperative healing the group with severe prolapse. of vaginal and cervical ulcers The rate of worsening of POP was in patients who present with 72.2 and 27.8% in the control a procidentia. Another useful

121 advantage of these devices is that to ensure that the integrity of the they can be used to elicit occult silicone is intact .The vagina should stress incontinence before surgical also be examined for signs of repair of genital prolapse. A constant pressure. pessary can also predict whether surgery will correct problems such Patients should be advised that as pelvic and back pain. intercourse may be possible with a ring in situ. She should be aware While pessary manufacturers that it may cause some discomfort provide suggestions for different to both partners in the beginning pessary shapes to manage different but this often settles as the types of prolapse, experience patient and her partner become suggests that trial and error is comfortable with it. Women who really the only way to determine are able to remove and reinsert the best fit for each patient . This the pessary should be encouraged depends on factors such as the to do so prior to intercourse. site, severity and the symptoms associated with the prolapse. Other factors, such as the patient’s physical capacity and willingness to participate in the care of the pessary, together with the size of the introitus, the patient’s weight and her physical activity also play a role when choosing a pessary. Fritzinger et al stated that there is no scientific data outlining the A simulated picture depicting the standards of care for users of position and placement of the vaginal pessaries. However, most pessary authors agree that routine follow up of women using pessaries is necessary to minimize the risk of complications associated with Contraindications to Pessary their use. At each visit the pessary Insertion should be removed and cleaned • Severe untreated vaginal using mild antibacterial soap and atrophy warm water. It should be examined • Vaginal bleeding of unknown

122 origin remain in place • Pelvic inflammatory disease • Abnormal pap smear • Dementia without possibility of dependable follow-up care • Expected non-compliance with follow-up

Types of Pessaries Often referred to as the “incontinence ring” since it has been designed for use in women with stress incontinence. • Has a membrane to support White silicon cube prolapse. Indications: Third-degree prolapse, • Has holes for drainage. cystocele or rectocele, with or • Knob applies pressure to the without good vaginal tone. urethra against the pubic bone. • Often this is the only satisfactory support for women with a complete prolapse • Excellent for vaginal wall prolapse in that it keeps the vaginal walls from collapsing at the six pressure points. • May be used by an athlete and removed after exercise. • Mucosa molds to the concavities creating a negative pressure

Soft silicone, donut shaped. • Occludes upper vagina and supports a uterine prolapse • Useful for cystocele or rectocele • May be used for vault prolapse • Adequate tone of the introitus is necessary for the pessary to

123 Incontinence Dish while supporting the anterior • Dish-shaped pessary with holes wall to allow for drainage. • It is malleable and can be • The flexible membrane of the shaped to suit the shape of the dish supports and elevates a vagina mild cystocele. • Creates a “bladder bridge” • Used in patients with stress urinary incontinence with 1st or Ring - with and without 2nd degree prolapse, or a mild support cystocele. • Helps support the urethra and bladder neck. • Membrane provides additional support for a cystocele. • Useful for a first or mild second-degree uterine prolapse associated with a mild cystocele.

Complications of pessaries All authors listed vaginal discharge and odor as the most common complication. Other complications which may occur are pelvic pain, Arch Heel Gehrung bleeding and development of • U-shaped device that provides urinary incontinence. Failure to support to the anterior vaginal retain a pessary in the vagina, wall. The heel rests flat on the or failure of the pessary to vaginal floor hold the prolapse properly is • It avoids pressure on the rectum an obvious disadvantage. Flood and Hanson described erosions of the vaginal wall as being a common problem. They state that early intervention using an estrogen-based cream or vaginal lubricant are essential to proper pessary care. Severe complications such as vesico-vaginal fistulae, hydronephrosis, sepsis, and even

124 small bowel incarceration were cited in the literature as the result of inadequate follow-up. Poma, reports in a review of 2,341 vaginal cancers, that 10.1% were associated with a pessary .It is debatable if this is a risk factor for vaginal malignancy.

Conclusion There is paucity of good randomized controlled trails that evaluate the use of conservative methods for the management of pelvic organ prolapse. Perhaps with the POP Q scoring system for prolapse and renewed interest in non surgical management, this will change in the future.

125 Chapter 16 Surgical Management of Urogenital Prolapse

Stephen Jeffery

Introduction • Bothersomeness of symptoms and extent of prolapse Urogenital prolapse is a common • Desire for future pregnancy condition and though not life- • Sexual function threatening, it has a significant • Age impact on the quality of life of • Fitness for surgery and women. Its treatment is one of the anaesthesia most common surgical indications • Associated incontinence in gynaecology, accounting for symptoms 20% of elective major surgery with • Patient’s wishes this figure increasing to 59% in the elderly population. Despite Important point numerous modifications to the There is as yet no surgical traditional surgical techniques and technique that can guarantee the recent introduction of novel 100% success in treating prolapse procedures, the permanent cure of and some procedures such as urogenital prolapse remains one of anterior colporrhaphy carry failure the biggest challenges in modern rates of up to 30%. This important gynaecology. point needs to be emphasized whenever counselling patients regarding the management of Surgical Management prolapse. General principles The following factors need to All women should receive be taken into account when prophylactic antibiotics to considering surgical intervention cover gram-negative and gram for prolapse: positive organisms, as well as

126 thromboembolic prophylaxis in fascial plication. Many surgeons the form of low dose heparin and place an additional plication thromboembolic deterrent (TED) layer of support using a delayed stockings. absorbable suture such as PDS in the levator connective tissue Patients having pelvic surgery medial to the iscniopubic rami. are positioned in lithotomy Skin edges are trimmed and closed with their hips abducted and using polyglycolic sutures (Vicryl, flexed. To minimise blood loss, Ethicon). local infiltration of the vaginal epithelium is performed using Mid-urethral tapes such as the TVT 0.5% xylocaine and 1/200 000 or TOT should be placed through adrenaline although care should a separate incision to prevent the be taken in patients with co- tape from migrating up towards existent cardiac disease. the bladder neck.

Vaginal Paravaginal Repair 1. Surgical options Some surgeons perform an extensive dissection stretching for Anterior from the pubis anteriorly to the Compartment ischial spine posteriorly. Up to prolapse four sutures are placed along the white line. This is the vaginal 1.1. Vaginal Approach paravaginal repair.

Anterior Vaginal Repair 1.2 Abdominal Approach (Anterior Colporrhaphy) An incision is made in the vaginal Abdominal Paravaginal Repair epithelium below the urethral This is the abdominal approach to meatus to the cervix or vaginal anterior compartment prolapse. vault. A diamond-shaped incision It is employed when another is sometimes made. The cystocele intra-abdominal procedure eg. is dissected off the overlying sacrocolpopexy or hysterectomy is vaginal skin using scissors and being performed. blunt dissection. The underlying Through a Pfannenstiel incision, pubocervical fascia is then reduced the retropubic space is opened using vicryl 3/0 sutures, known as and the bladder swept medially,

127 exposing the pelvic sidewall, very at the level of the hymenal similar to a burch colposuspension remnants, allowing the calibre procedure. Two fingers are placed of the introitus to be estimated. in the vagina and it is elevated Following infiltration, the digitally. The pubocervical fascia perineal scarring is excised and is reattached to the pelvic sidewall the posterior vaginal wall opened using interrupted polydioxanone using a longitudinal or triangular (PDS, Ethicon) sutures from the incision. The rectocele is mobilized pubis to just anterior to the ischial from the vaginal skin by blunt and spine. sharp dissection. The rectovaginal fascia is then plicated using either an interrupted or continuous 2. Surgical Options absorbable suture (Vicryl 3/0), to repair the defect. This is often For Posterior called the site-specific repair. Care Compartment should be taken not to create a Prolapse constriction ring in the vagina which will result in dyspareunia. Traditionally this compartment The redundant skin edges are is approached vaginally when then trimmed taking care not to operated on by the gynaecologist. remove too much tissue and thus It is important to remember narrow the vagina. The posterior that the colo-rectal surgeons vaginal wall is closed with a also operate on the posterior continuous Vicryl 2/0 suture. Many compartment using a transanal surgeons, in addition to the site- approach. The patient should be specific plication, place a number referred to a colorectal surgeon of interrupted lateral sutures for assessment if the following are that incorporate the Levator Ani present: concurrent anal or rectal muscles. This Levator plication has pathology such as hemorrhoids, been shown to be associated with rectal wall prolapse or rectal significant dyspareunia and is no mucosal redundancy. longer recommended. Finally a perineorrhaphy is performed by placing deeper absorbable sutures Posterior Colpoperineorrhaphy into the perineal muscles and Procedure fascia thus building up the perineal Two allis or littlewood forceps body to provide additional support are placed on the perineum

128 to the posterior vaginal wall and uterosacral ligament sutures are lengthening the vagina. Injury to therefore tied in the midline and the rectum is unusual but should brought through the posterior be identified at the time of the part of the vault and tied after procedure so that the defect the vault has been closed. For can be closed in layers using an additional support, a high absorbable suture and the patient uterosacral ligament suspension managed with prophylactic can be performed by placing antibiotics, low residue diet and additional PDS sutures through faecal softening agents to avoid the lateral aspects of the vaginal constipation. vault on each side and securing these to the ipsilateral uterosacral ligament. This procedure places 3. Middle the ureters at risk and therefore ureteric patency should be Compartment confirmed post-operatively by cystoscopy. These sutures are also tied after the vault has been 3.1 Uterovaginal prolapse closed. An alternative to the high uterosacral ligament suspension 3.1.1 Vaginal hysterectomy is a McCall suture. This is a purse- string suture that goes through The cervix is circumscribed and the both corners of the vaginal vault, utero-vesical fold and pouch of through the uterosacral ligaments Douglas opened. The uterosacral and also through the posterior and cardinal ligaments are divided peritoneum to obliterate the and ligated first, followed by the pouch of Douglas to prevent uterine pedicles and finally the enterocele formation. tubo-ovarian and round ligament pedicles. In cases of procidentia, 3.1.2 Uterine preservation care should be taken to avoid procedures kinking of the ureters which are often dragged into a lower Sacrohysteropexy position than normal. The most (See a separate chapter on important part of the procedure Sacrocolpopexy) is support of the vault since these women are at high risk for post- This technique involves hysterectomy vault prolapse. The

129 attaching the uterus to the prolapse and enterocele formation. sacral promontory using a broad piece of prolene mesh. 3.2 Enterocele repair Through a Pfannenstiel incision An enterocele repair is normally the peritoneum over the sacral performed using a vaginal promontory is opened. The approach. The vaginal epithelium prolene mesh is attached to the is dissected off the enterocele sac posterior aspect of the uterus with which is then reduced using two or the sutures secured at the level more polyglycolic (Vicryl, Ethicon) of insertion of the uterosacral or polydioxanone (PDS, Ethicon) ligaments. The mesh is then purse string sutures. It is not attached to the anterior aspect essential to open the enterocele of the sacral promontory using sac although care should be taken either an Ethibond suture or screw not to damage any loops of small tacks. The perioneum is then bowel which it may contain. The partially closed over the mesh. This vaginal skin is then closed. operation can be combined with an abdominal paravaginal repair An abdominal approach may also in a women with a cystocele and a be used although this is much colposuspension in a patient with less common. The Moschowitz stress incontinence. procedure is performed by inserting concentric purse string Manchester repair (Fothergill sutures around the peritoneum repair) in the pouch of Douglas thus This procedure is only rarely preventing enterocele formation, performed nowadays. Cervical although care must be taken not amputation is followed by to ‘kink’ or occlude the ureters. approximating and shortening the cardinal ligaments anterior to 3.3 Vaginal vault procedures the cervical stump and elevating Risk of post-hysterectomy apical the uterus. This is combined prolapse is about 0.36% per year; with an anterior and posterior or 1% (at 3yrs) and 5% (at 17yrs). colporrhaphy. The operation The vaginal vault can be supported has fallen from favour as long vaginally or abdominally. term problems include infertility, miscarriage and dystocia in addition to recurrent uterovaginal

130 Vaginal procedures that suspend the the Capio® ligature carrier (see apex picture) has been launched

Sacrospinous ligament fixation (Sacrospinous which makes the procedure colpopexy) significantly easier. Both right and

Modified McCall cul-de-plasty (Endopelvic left Sacrospinous ligaments can fascia repair) be used to support the vagina. Iliococcygeus fascia fixation Some surgeons employ only one ligament but there is no evidence High uterosacral ligament suspension with fascial reconstruction to suggest that a uni-or bilateral is better. Vaginal obliterative procedures

Colpectomy & colpocleisis Care must be taken to avoid Abdominal procedures that suspend the the sacral plexus and sciatic apex nerve which are superior to the Sacralcolpopexy ligament, and the pudendal New techniques vessels and nerve which are

Transobturator- procedures including Prolift, lateral to the ischial spine. The Apogee and Avaulta sacrospinous sutures are then tied to support the vaginal vault 3.3.1 Vaginal Procedures from the sacrospinous ligament. Since the vaginal axis is changed Sacrospinous Ligament Fixation by the procedure there is a risk (SSF) of post-operative dyspareunia A longitudinal posterior or anterior and development of stress vaginal wall incision is performed incontinence. Success rates for this to expose the ischial spine using procedure are in the region of 80- sharp and blunt dissection. The 95%. sacrospinous ligament may then be palpated running from the Complications of SSF: ischial spine to the lower aspect of • Haemorrhage the sacrum. A delayed absorbable • Buttock pain suture (PDS) is passed through the • Nerve injury ligament. A number of techniques • Rectal injury are available to do this. A standard • Stress incontinence long needle holder or a specially • Vaginal stenosis designed Miya hook ligature • Anterior vaginal wall prolapse carrier can be used. Most recently,

131 3.3.2 Illiococcygeus Fixation anterior and posterior aspects of In this procedure, the vaginal vault the prolapse. These raw areas are is fixed to the illiococcygeus muscle then sutured together, thereby fascia on both sides, just anterior burying the cervix and obliterating to the ischial spines. The procedure the vagina. In total colpocleisis all can be performed through either the vaginal skin is removed and an anterior or posterior vaginal the anterior and posterior vaginal incision. A delayed absorbable walls approximated. In both suture is used and secured to the these procedures, an aggressive vaginal vault and is associated perineorrhaphy is performed. with a good anatomical result There is a high incidence of with an adequate vaginal stress incontinence (up to 42%) length with no deviation. A trial following these procedures and comparing illiococcygeus fixation therefore a concomitant mid- and sacrospinous fixation found urethral tape is mandatory. similar outcomes and comparable These procedures are performed complication rates. on an outpatient basis with an immediate return to normal 3.3.3 Abdominal Procedures activities, and success rates as high as 100% have been described. Abdominal Sacrocolpopexy See separate chapter

3.4 Obliterative Procedures

Colpocleisis Colpocleisis is an excellent option in patients who are certain that they will not want to be sexually active in the future. This is often a last resort in many women who have had recurrent procedures for vaginal prolapse. In partial colpocleisis (so-called Le Fort colpocleisis), the vagina is obliterated by excising rectangles of vaginal epithelium from the

132 Chapter 17 Sacrocolpopexy

Hennie Cronjé

Definition Vagina to Sacrum or Perineal body Sacrocolpopexy (SCP) is the or mid-vagina or Vault suspension of the vaginal vault to the sacrum. A synthetic mesh is The longer the mesh extends usually used which is fixed to the along the vagina, the lower the vaginal vault and to the anterior recurrence rate for prolapse. longitudinal ligament of the However, complications such as sacrum opposite S1 – S2. The mesh overactive bladder symptoms and is usually placed retroperitoneally mesh erosion increase with longer and the procedure is done mesh. abdominally by laparotomy or laparoscopy. 3. Material Type 1 macroporous monofilament Variations synthetic mesh is recommended. There are numerous variations: 4. Rectum 1. Tension Rectum mobilization with The tension of the mesh can vary elevation and fixation of it to the from tension-free to a moderate mesh (rectopexy) is recommended tension. Due to fibrosis the mesh but not proven to be beneficial. shrinks and therefore, excessive tension should be avoided. Indications Any type of prolapse, stage 3 2. Length or 4 (POPQ). It is particularly The length of mesh along the useful for vault prolapse and large vagina can vary: enterocoeles. It is also performed From: for anterior compartment Introïtus or mid-vagina or Vault prolapse, but the larger the cystocoele, the greater the extent 133 of bladder mobilisation. from above (between bladder and vagina). Contraindications Insert a strip of mesh (about 15 x 3 Patients too young (<40 yr) cm) into the abdomen. Patients too old (> 70 yr) Fix the bottom of the mesh to Marked obesity the arcuate ligament below the Medical problems that may create symphysis pubis and surrounding post-operative problems such as vaginal wall. deep vein thrombosis. Close the anterior vagina. Patients on anticoagulants, Open the posterior vaginal wall. including Disprin. Open the rectovaginal space and join it with the abdominal cavity. Age group Insert a second strip of mesh. The ideal age group is 45 – 65 If necessary, perform a perineal years. body repair. Fix the mesh to the perineal body Recommended technique and surrounding vaginal wall. The operation consists of a Close the vagina. laparotomy and can be divided in three parts: *Hydrodissection is recommended before incision. Use 200ml (i) Abdominally saline with 2 ampules Por-8 Separate the bladder from the (omnipressin). It is injected vagina to the level of the bladder between the vagina and bladder neck. or rectum. Open the peritoneum medially to the rectum from the sacral (iii) Abdominally promontory to the vagina. The two strips of mesh are fixed to Open the rectovaginal space for a the vaginal vault and then to the short distance. sacrum at level S1-2. Moderate Open the presacral space and tension should be applied. aggressively mobilize the rectum Thereafter the rectum is pulled down to the pelvic floor. upwards and along its medial side fixed to the mesh. Finally, (ii) Vaginally* the peritoneum is pulled over the Open the bladder neck area. mesh (it is often trimmed) and Open the space already made sutured to the rectum. A markedly

134 elevated pouch of Douglas is Overactive detrusor 40-60%, but characteristic of this operation. the incidence decreases over time. Stress urinary incontinence in A suprapubic catheter is usually about 10% of cases. Physiotherapy inserted for determining the or a mid-urethral tape should be residual volume on day 3-4 considered. postoperatively. It should be less than 70ml. A vaginal plug Abdominal pains during the first 6 is inserted after the operation months. and removed 36-48 hours postoperatively. The skin Vaginal bleeding during the first stitches are kept in for 2 weeks. month. Anticoagulant therapy is applied from the first day after the Dyspareunia 5 – 6% (the same operation. figure as preoperatively). Although the bowel action Bowel action is important improves markedly in most postoperatively and when she patients, a minority of women is discharged. Initially, laxatives have persistent constipation. should be given. Antibiotics are If obstructive defaecation also given for the first few days. persists after the operation, a defaecogram should be done (very Results: similar to a barium enema). If a The main results of SCP as rectocoele (particularly with rectal described above are the following: intussusception) is demonstrated, Recurrent prolapse about 10% a STARR procedure could be (depending on the surgeons’ considered (consult a colorectal experience and the type of surgeon). prolapse). Outcomes Mesh erosion about 10-15% of 1. Cronjé HS. Colposacrosuspension which 95 – 98% can be treated in for severe genital prolapse. Int J the consulting room by excision Gynecol Obstet 2004; 85: 30-35. of the exposed mesh followed by Recurrent prolapse: 8% vaginal estrogen cream 1 – 2x/ Repeat surgery: 4% week. TVT /Ob-tape postoperatively: 12%

135 2. Cronjé HS, De Beer JAA. 6. Cronjé HS, De Beer JAA, Nel Abdominal hysterectomy and M, Picton AJ. The length of Burch colposuspension for mesh used in sacrocolpopexy and uterovaginal prolapse. Int subsequent recurrence of prolapse. Urogynecol J 2004; 24: 408-413. (In press). Recurrent prolapse: 10% Mesh from vaginal vault to sacrum: Repeat surgery: 9% 24% recurrent prolapse. TVT/Ob-tape: 3% Mesh from mid-vagina to sacrum: 9% recurrent prolapse. 3. Cronjé HS, De Beer JAA. Mesh from vaginal introitus to Vault prolapse treated by sacrum: 8% recurrent prolapse. sacrocolpopexy. S Afr J Obstet Gynaecol 2007; 13: 80-83. Recurrent prolapse: 14% Repeat surgery: 8% TVT/Ob-tape: 8%

4. Cronjé HS, De Beer JAA. Combined abdominal sacrocolpopexy and Burch colposuspension for the treatment of stage 3 and 4 anterior compartment prolapse. S Afr J Obstet Gynaecol 2007; 13: 84-90. Recurrent prolapse: 16% Repeat surgery: 6% TVT/Ob-tape: 8%

5. Cronjé HS, De Beer JAA. Culdocele repair in female pelvic organ prolapse. Int J Gynecol Obstet 2008; 100: 262-266. Recurrent prolapse: 10 Repeat surgery: 5 TVT/Ob-tape: 13

136 Chapter 18 Pelvic floor muscle rehabilitation

Corina Avni

Introduction loading and the associations with movement and visceral function. Interest and expertise in pelvic floor function and rehabilitation Work on muscle rehabilitation was has expanded markedly over profoundly impacted by Andre recent years. While the field of Vleeming’s description of forces Women’s Health physiotherapy around the sacroiliac joint (SIJ). is not yet deemed mainstream, The concept of form closure and it is a growing specialty and is force closure as they apply to increasingly included as a first line the body (skeletal vs. muscular of investigation and management and fascial systems) resulted in in conditions ranging from non- a rethink of the transmission of resolving lower back pain (LBP) pressure between the central to urinary urgency/frequency. core of the lower spine and It is now accepted as standard the abdomen (intra-abdominal treatment for female urinary pressure (IAP)), the thorax incontinence and pelvic floor re- (breathing) and limbs (activity). education is included as routine Evidence based research describes care in many obstetric services. the types of muscle function under varying degrees of load, looking This popularization within at the different muscles that physiotherapy can be partially stabilize and mobilize the body. attributed to an improved Muscle function is further divided understanding of the pressures in into local and global systems, each the pelvis and lumbar spine, and having partner muscles working how these relate to pelvic floor within functional slings. Control and quality of movement are

137 now central treatment objectives, • Sexual dysfunction: whereas the older benchmarks • pain on penetration, of strength and range of motion • dyspareunia, (ROM) are simple progressions. • post-coital pain, • orgasmic disorder, This chapter aims to examine the • vaginismus diverse roles and functions of the pelvic floor. We will address the • Bowel dysfunction: need for specificity in assessment • faecal incontinence (FI), and rehab selection and outline • flatus, urgency, treatment options and techniques • incomplete evacuation, used to quantify and qualify PF • constipation, function. • disordered ano-rectal function, • anismus The scope of physiotherapy and • Pelvic organ prolapse (POP) aims of pelvic floor The scope of physiotherapeutic rehabilitation management extends from conservative measures, A broad range of complaints including behavioural and conditions occur as a result modification, pelvic floor of pelvic floor dysfunction muscle rehabilitation to and may therefore respond to electrotherapy. pelvic floor rehabilitation. Recent additions to the pelvic • Bladder dysfunction: floor rehab repertoire include • stress incontinence (SI), myofascial techniques, trigger • overactive bladder (OAB), points and low load vs. high load • frequency/urgency, nocturia, muscle activation. • post void residuals (PVR) and other voiding dysfunction, • hesitancy, interstitial cystitis, • leaking with intercourse, recurrent urinary tract infections (RUTIs)

138 Pelvic floor function and dysfunction Characteristic Function Dysfunction

Base element of core Control changes in IAP Poor generation of IAP with function e.g. weak cough

Lumbar and pelvic load Lumbopelvic stability Low back pain and chronic pelvic pain/pelvic girdle pain

Fast twitch muscle activity With activity and physical SI, POP High load stress

Slow twitch muscle activity For antigravity support, POP, OAB, FI Low load bladder inhibition, anorectal angle

Eccentric muscle activity Release pelvic sling whilst Obstructed defaecation, POP supporting ano-rectum during defaecation

Tone and elasticity Supportive sling POP

Sexual participation Sexual awareness/enjoyment Dysparuenia, decreased sexual enjoyment

The physiology of micturition muscles. (Storage phase - late) as it relates to the pelvic floor • The Urethrosphincteric • The pelvic floor co-ordinates guarding reflex stimulates a cortically stimulated activities powerful contraction of the (when and where to void). external striated urethral Other functions are mediated sphincter in response to urine at the spinal level. in the proximal urethra and/ • There are a number of reflexes or increasing tension in the acting between the pelvic floor trigone. (Storage phase - under and the bladder: stress) • The Perineodetrusor inhibitory reflex inhibits detrusor activity Abdominopelvic synergy in response to increasing tone in The pelvic floor has been shown the pelvic floor muscles. (Storage to have ‘partner muscles’ that co- phase - early) activate to form functional slings. • The Perineobulbar detrusor inhibitory reflex inhibits contraction of the detrusor in response to contraction of the perineal and pelvic floor

139 Some of the notable partners are: The pelvic floor as a Abdominal Muscle Pelvic Floor pressure mediator for Stress Incontinence Rehabilitation Transversus Abdomi- Pubococcygeus (PC) nis (TA) & anterior PF aims to enhance the mechanical

Obliques Levator ani functioning of the pelvic floor, particularly speed and strength. Rectus Abdominis Puborectalis (RA) The woman needs to learn to recruit the guarding reflex, which consists of a concomitant NB: Whilst the PF is defined along PF contraction with increasing anatomical lines, its function IAP, when coughing or any other should be considered as part of a similar events. This is a focal greater unit. Indeed, the associated contraction. abdominal co-contraction may be more important than contracting The pelvic floor as a pressure the PF in its entirety. mediator for OAB rehabilitation The pelvic floor as a pressure aims to normalize detrusor mediator activity via tonal changes in the PF (see reflexes above). The normal pelvic floor, with Functional use of the PF to intact fascia, needs little more mediate detrusor activity is than its inherent elasticity usually focal. Postmenopausal and reflex activity to function women invariably have decreased adequately. When the normal pelvic floor tone secondary to fascial attachments, however, atrophic changes, and therefore are compromised by pregnancy in this group particularly, and other factors increasing IAP, prophylactic PF focused advice and forces are exerted unequally education will be of benefit. If the through the pelvis, hence loading inhibitory reflexes are insufficient, different compartments selectively harnessing S2-4 dermatomes and and repeatedly. The pelvic myotomes may also improve the floor therefore usually requires PF contraction. It is important that selective rehabilitation to ensure these are not used in place of, but appropriate activation for either SI, in conjunction with an appropriate OAB or POP. PF contraction

140 Dermatomes for Myotomes for S2-4 Objective Assessment S2-4

Saddle area (sitting Gluteus Muscles An objective assessment with on e.g. arm of chair) (buttocks gripped) clearly defined parameters is Back of legs (rub- Adductors (knees essential, to formulate a patient bing back of legs) together) specific rehab programme. Clitoris (manual Plantar flexors (up perineal pressure) on toes) Posture changes over time. Intrinsic foot muscles Repeated incorrect posture (up on toes) over time becomes habitual III S2-4 Dermatomes and Myotomes progressing into a movement pattern. Poor spinal posture The pelvic floor as a pressure inhibits appropriate use of the mediator for frequency/ core. urgency Rehabilitation aims to differentiate urgency secondary Breathing habits as with to decreased detrusor posture, become habitual. The inhibition as opposed to normal muscle ratio of breathing urgency secondary to abnormal is mostly diaphragmatic with a pelvic floor firing (autonomic smaller lateral thoracic component up-regulation, disturbing and the least from the thoracic normal detrusor activity) as a apex. This becomes disordered and result of pelvic floor trigger the normal bellows-action of the points. lungs, filling from the oxygenated bases rather than the apices, is The pelvic floor as a pressure compromised. The decrease in mediator for hesitancy diaphragmatic work (often due to and incomplete emptying splinting) results in less efficient rehabilitation aims to normalize breathing. Furthermore, the core inappropriate PF activity is loaded from the top leading to with voiding (dyssynergia). greater dysfunction. Voluntary relaxation is essential and this usually co-exists with Abdominal wall a functional inability to de- The abdominal wall is assessed activate abdominal bracing. for skin changes, muscle tone and integrity, and myofascial trigger points (TPs). Many abdominal TPs

141 will refer to the abdominopelvic outcomes are recorded. area. Symptoms of pain and discomfort include vulvodynia, Palpation – anterior, lateral and coccydynia, levator ani syndrome, posterior walls are assessed vulvar vestibulitis, dyspareunia, for laxity and movement in vaginismus and pelvic floor tension response to changes in IAP. myalgia. Physiotherapists do not grade according to POPQ although Visceral effects include should be familiar with the frequency-urgency syndrome, scale. Any areas of focal interstitial cystitis and irritable tenderness are explored as bowel syndrome (IBS). TPs can trigger points. exacerbate, and in extreme cases, cause pudendal neuralgia/nerve Perfect Score entrapment. The subject performs a maximal contraction against the therapist’s Neurological testing of index finger. dermatomes is mandatory and P records power according to a if any abnormality is detected, Modified Oxford Scale warrants further testing of S2- With a brief consistent rest 4. between contractions, the following are assessed: External perineal examination E records endurance to a max of Observations of skin, mucosa and 10seconds at said power scarring are noted. The movement R records repetitions to a max of relationship between the perineal 10 repetitions at said power and body and PF is observed. endurance.

Internal digital examination After 1 minute rest: A digital vaginal exam is indicated F records fast contractions to a max in all patients except those who of 10 before fatigue cannot give consent, and those ECT reminds us that every who are not yet sexually active. contraction is timed to formulate a The international guidelines are patient specific formula continually being updated to Therefore: 4/8/4//7 records a good include qualitative measures. As contraction, held for 8 seconds, with all assessments, quantitative repeated 4 times before fatigue;

142 Score Response on fingers

0 = nil Muscle bulk present/absent

1 – flicker/very weak (min) Very weak/fluctuating

2 – weak (poor) Increase in tension

3 – moderate (reasonable) Lift

4 – some strength (good) Lift + resistance

5 – strong (max) Lift + strong resistance IV. Muscle Testing – the Modified Oxford Scale and after a minutes rest, 7 quick defaecation? contractions before fatigue. Technique Initiation and stability An overall assessment of the ease The speed and control of initiation of activation and appropriate co- and the stability of the contraction activation of the abdominopelvic are noted, along with any coupled unit is recorded. A strong PF movement and breathing patterns. contraction with breath-holding is non-functional and therefore Voluntary contraction – absent/ needs rehab. present Is the subject able to perform a QOL question satisfactory PFC? A quality of life questionnaire allows the subject to self-grade. Involuntary contraction - If you were to spend the rest of absent/present your life with your symptoms as Does the PF automatically kick-in they are now how would you feel? with increased IAP? If indicated – spine, hip/pelvic Voluntary relaxation - absent/ girdle, myotomes, reflexes, present sensation, biofeedback Is the subject able to relax Behaviour appropriately? Two consecutive days (48 hour) of behaviour are charted, be it Involuntary relaxation - absent/ fluid intaket/output or food diary. present Symptoms (notably leakage) are Does the PF relax with noted.

143 Treatment PF Muscle Rehab Physiotherapists specialise in Behavioural modifications muscle function and rehabilitation. 1. Fluid/diet management; diaries PF rehab follows very similar are of great use as behaviour guidelines to general muscle sensitisers. rehab, relying on the same 2. Education and counselling physiological responses of exercise are of particular importance and overload (without fatigue) in identifying triggers and to cause muscle hypertrophy. breaking psychological All aspects of muscle function sensitisers. need to addressed. Furthermore, 3. Bladder training using the the specific function of that PF as an inhibitor of detrusor particular component needs to be activity helps to decrease urge considered e.g. fast twitch work incontinence, control urgency, of the compressae urethrae. The delay voiding, increase bladder PF, working as it does as a low capacity and decrease nocturia. load support (bladder inhibition, Often, in that order! support of pelvic viscera, support 4. Defaecatory technique teaching of rectum during defaecation) correct positioning and pressure and a high load resistor (fast

QOL Delight- Pleased Satis- Fence Dissatis- Un- Terrible ed fied sitting fied happy

Score 0 1 2 3 4 5 6 V. QOL scale

transmission can alleviate the signs and symptoms of twitch activity with rapid changes obstructed defaecation. in pressure/speed), needs to be 5. Disability management; rehabilitated through a variety although the aim is a clean of diverse functions. A balance dry subject, there will be times needs to be found between when management of disability power and endurance training. is the best short-term solution; Pure technique needs to be offset this includes the use of pads against functional outcome and occlusive devices in sports and skill acquisition. The PF women. muscles, like the fascial muscles,

144 control a number of openings, that they can do before medication through a range of activites, for or surgery need to be explored. a variety of functional outcomes. A basic rehab program would The challenge with the PF lies progress as follows: in sensory motor integration. Virtually all other muscle rehab Rehab Outcome can be mediated by some form of Assessment Baseline feedback, usually visual. The PF and its actions cannot be seen or Active exercise Muscle conditioning mediated. Biofeedback remains an Skill training Functional invaluable tool for the PF specialist Recruitment of Patterning for auto- physio. muscle and reflexes matic function Sensory awareness Improved efficiency Re-ed breathing Biofeedback, prefer- All rehab should begin with basic ably EMG Enhanced awareness body awareness and breathing. Neuromuscular Enhanced awareness Some form of automatic speech stimulation and function e.g. counting is often beneficial Rehabilitation of Muscles as it mediates the breath whilst giving auditory feedback. Not all subjects will require the full scope of rehab. Re-ed PF In the 1940s Kegel described Re-ed abdopelvic synergy a basic contraction of the PF Research in the field of musculature. To date, aspects such orthopaedic manual therapy (OMT) as stablility and ease of activation is increasingly showing coupled are as important as strength and relationships between the PF and endurance. Despite enjoying a abdominal muscles. This research is certain popularity (notoriety?) in ongoing. At a glance: the media (women’s magazines), many medical staff remain dubious Abdominal Muscle Pelvic Floor about the benefits of specific Transversus Abdomi- Pubococcygeus (PC) rehab for the PF. Whilst there is nis (TA) & anterior PF increasing emphasis on ante and Obliques Levator ani post natal care and education, many women are not being Rectus Abdominis (RA) Puborectalis advised that there is something Abdominopelvic Partners

145 These muscle pairings allow for skill acquisition. A maintenance different types of spinal load (low programme is invaluable. Many load, rotation, high load) to be women choose to include PF work distributed evenly through the to improve their current sporting pelvis. function or to enhance another form of exercise Rehab any objective deficits Biofeedback, a useful tool in any Biofeedback rehab setting, is invaluable in In cases of poor sensation and rehabilitation of the PF due to proprioception, biofeedback serves the lack of other forms of sensory as an external mediator of internal feedback. function, allowing the subject to If the deficit includes a marked create ‘movement memories’. motor component (

146 guidelines difficult. Electrotherapy tonal abnormalities from the up- should not be considered as a scaling of a PF contraction to the single treatment option, but down-regulating of high resting the next level of conservative tone. management. Different settings on the equipment can select for Neuromuscular Stimulation slow or fast twitch neuromuscular Where the PF has a strength of activation. EMG in combination less than Grade 3, or has very with NMS allows accurate feedback poor sensory awareness (pudendal of response to stimulation. nerve latencies), neuromuscular electrical stimulation is indicated. EMG biofeedback Electrical impulses set up an Electromyography (EMG) is the action potential in the pudendal undisputed gold standard of nerve, causing it to fire and biofeedback. Ideally, it shows a contract the PF. This improves range of work over a period of nerve conduction, activates the time, allowing assessment of: neuromuscular junction and • Maximum/minimum contraction stimulates a muscle contraction. It • Maximum/minimum relaxation also promotes synapse formation, • Stability contraction/relaxation protein production and muscle • Speed of initiation/release hypertrophy. • Endurance and fatigue Depending upon the symptoms resistance and aims of treatment, the • Concentric and eccentric control settings are selected according EMG is best performed with a to wavelength and frequency. A shaped vaginal (or anal) electrode. classic ‘fast twitch’ training would It may used across a range of PF include active assisted contractions with the machine (NMS) for speed and strength. A classic ‘slow twitch’ treatment would be passive and would improve sensory conduction, resting tone and normalize bladder reflexes.

Conclusion A neuromuscular stimulation The pelvic floor physiotherapist unit – The Myomed 932 147 has the necessary skills to assess muscle function and dysfunction and rehab according to sound evidence based principles. Highly developed palpation is needed to differentiate between subtle differences in tone and strength. We are, essentially, working blind! Special insight into the psychological implications and management of behaviour make the Pelvic Floor Physio an excellent conservative one-stop-shop.

A clear assessment, with a patient specific programme and regular monitoring of compliance and motivation can yield excellent results; better than standing in the corner doing 100 squeezes per day, but not contracting with a cough!

Physiotherapy for pelvic floor disorders does not compete with medication or surgery. It finds its niche somewhere between patient responsibility and doing the best you can with what you’ve got.

148 Chapter 19 Investigation and management of faecal incontinence

Douglas Stupart

Faecal incontinence is a common same person, if he has a fractured condition, affecting up to 10% femur and cannot move to the of adults, with about 0.5 to 1% bathroom quickly enough, will, having regular symptoms that by definition, experience urge significantly affect their quality incontinence, despite having of life. Unsurprisingly, in view of completely normal anal sphincter the social stigma attached to this function. Also, a patient with problem, it may be underreported, damaged sphincter muscles may and patients often present late. be able to cope for many years until the injury is unmasked by It is important to understand new onset diarrhoea or weakening that faecal incontinence is a of the pelvic muscles with age. symptom, not a diagnosis in itself, The table below summarises and that incontinence is usually the common causes for faecal multifactorial in origin. Adequate incontinence. continence requires higher mental function, intact sensory and motor History taking nerve pathways, an adequate The severity of incontinence, as rectal reservoir and an intact anal well as its impact on the patient’s sphincter complex. In addition, lifestyle should be assessed. the consistency of the stool and Numerous scoring systems for the patient’s general mobility play incontinence exist, but a simple an important part in maintaining and useful classification is simply continence. For example, any to determine if the patient is person who has sufficiently severe incontinent to flatus (least severe), diarrhoea will experience urgency liquid stool (more severe), or solid (having to ‘run to the toilet’). The stool (most severe). One should

149 also ascertain whether the problem as well as any other symptoms is urgency or passive incontinence suggesting bowel cancer or (in which the patient is unaware of inflammatory bowel disease (such the passage of stool). as blood or mucus per rectum or weight loss). The patient should be asked about any general medical conditions, Examination as well as their mobility. Diabetes Apart from a general clinical and many neurological and spinal examination, one should examine

Common causes for facial incontinence Anatomical site Disorders

Anus/ perineum Anal sphincter injury, pudendal neuropathy, rectal prolapse.

Colon and rectum Inadequate rectal reservoir due to e.g. Radia- tion or inflammatory bowel disease.

Stool quality Diarrhoea or mucus production from any cause. This includes inflammatory bowel disease and faecal impaction or colorectal neoplasms with overflow diarrhoea. Numerous medications.

Sensorimotor pathways Diabetes, neurological disorders

Brain Dementia, psychological disturbances

General Impaired mobility diseases can affect pudendal nerve the perineum for signs of rectal and therefore sphincter function. or vaginal prolapse and perineal Obstetric history is especially descent. Examination of the important, particularly any perineum and anus may reveal a history of instrumental deliveries, palpable anal sphincter defect. episiotomies or perineal tears. A digital anal examination is important not only subjectively to One should ask about the patient’s assess sphincter tone (both resting bowel habits and stool consistency and ‘squeeze’), but also to exclude with particular attention to any anorectal neoplasms, and to detect recent change in bowel habits, faecal loading. Where appropriate,

150 a full neurological or cognitive anal sphincter function. One may assessment should be performed. also gain information about the compliance of the rectum, and Investigation the anorectal inhibitory reflex All patients with new onset faecal (which causes the anus to relax incontinence who are over 50 years during defecation). It is unusual, old, or who have experienced however, for this to change the changes in bowel habits should be management of an incontinent referred for a colonoscopy in order patient, and its usefulness is mainly to exclude colorectal neoplasms or in research and in documentation inflammatory bowel disease. for medico legal purposes.

Endo- anal ultrasound is a non- Sacral nerve latency testing aims invasive procedure which allows to detect sacral neuropathy (which visualisation of the anal sphincters, is common in incontinent women, and is indicated in all patients and usually due to obstetric injury). in whom anal sphincter damage The test has poor inter- observer is suspected. It will identify the reproducibility in most operators’ group of patients with isolated hands, and seldom gives results sphincter injuries (almost all of that change management. which are due to obstetric injuries) who may suitable for surgical MRI scanning provides detailed sphincter repair. The illustration imaging of the anal sphincters. below is a typical example of an It can not only detect sphincter obstetric sphincter injury involving injury, but also gives information the anterior part of the external about sphincter muscle atrophy. and internal sphincters. At present it is not widely used in the assessment of anal sphincter Anorectal manometry is commonly injuries, but may become more so performed to document anal in the future. sphincter function. Measuring resting sphincter pressures Management provides information about Treatable specific conditions the function of the internal Patients with sphincter injuries sphincter, while the quality of the should be referred for possible (consciously controlled) ‘squeeze’ repair. Although the long- term pressure is dependant on external results of anal sphincter repairs

151 are disappointing (about 25% stop any with side effects on of patients will be continent for gastrointestinal motility. liquid stool after 10 years), this offers the best hope of cure in this If the patient has loose stools in group of patients. the absence of an identifiable Faecal impaction is common, colorectal pathology (on especially in the elderly, and should colonoscopy), loperamide is the be treated with enemas and oral drug of first choice to firm the laxatives (and manual disimpaction stool and decrease stool frequency. under general anaesthesia if Tricyclic antidepressants may necessary) until the rectum is also have a role in reducing stool empty. frequency. Rectal prolapse may require Rectal washouts may be helpful surgical correction. to motivated patients. They can empty their rectum at a convenient Bowel diseases such as colorectal time, and hopefully not soil neoplasms or inflammatory bowel themselves during the intervening disease should be treated as usual. time.

Conservative management Other surgical options Unfortunately, most patients Patients with incontinence due with faecal incontinence do to pudendal nerve dysfunction not have curable diseases. They or surgically non- repairable anal should initially be treated with sphincter injuries may benefit from conservative measures aimed sacral nerve stimulation. Short at reducing the impact of the term data for this intervention incontinence on the patient’s are encouraging, but long- term lifestyle. outcomes are not well known.

Bowel habits may be improved by Neosphincter construction, modifying fibre intake (some will whether with a prosthetic improve by increasing the fibre sphincter or gracilis muscle in their diet, others by decreasing transposition, are complex it). Reducing caffeine intake may operations with significant decrease bowel frequency. If complications. These should only the patient is receiving chronic be performed in highly specialised medication, one should try to centres.

152 In summary, the management of these patients remains difficult. It is important for the patient and the clinician to realise that the prognosis for cure is poor, and that treatment must be aimed at improving long- term quality of life.

153 Chapter 20 The use of mesh, grafts and kits in Pelvic Organ Prolapse Surgery

Stephen Jeffery

Failure of surgery for pelvic compartments is addressed. In organ prolapse is a reality facing addition there is now evidence to every vaginal surgeon, despite suggest that factors distinctive to a the numerous modifications and specific patient will predispose to innovations to surgical technique a recurrence of the prolapse. This over the past century. As many includes inherent deficiencies in as 29% of women will require an tissue quality or healing, persistent additional operation following increases in intra-abdominal primary prolapse surgery. With pressure and exogenous factors, second and subsequent procedures like steroid use. these figures increase. Despite thorough pre-operative Surgical failure may be the assessment and meticulous surgical attributed to a number of factors. technique, pelvic organ prolapse Surgical technique is rudimentary will recur. In an attempt to and inattention to important improve outcomes, gynaecologists aspects such as tissue handling, involved in reconstructive pelvic correct choice of suture material floor surgery have looked to and strict asepsis will have an the general surgeons, who have important impact on the outcome employed various graft materials of the prolapse repair. Thorough for the correction of abdominal pre-operative assessment is also wall hernias. A wide variety of crucial in ensuring the appropriate synthetic and biological grafts are procedure is performed and currently available. The synthetic support in all three vaginal grafts have shown some promise

154 in the prevention of recurrent and assess the properties of both prolapse but unfortunately have synthetic and biological prostheses a tendency to erode, extrude or employed in reconstructive pelvic become infected. The biological floor surgery and evaluate surgical grafts have been developed to outcomes and peri-operative avoid these complications. The morbidity following the use of autografts, derived from the these materials. patient’s own tissue, unfortunately have the disadvantages associated with harvesting from the thigh, Failure Of Primary vagina or abdominal wall, while the allografts which are harvested And Secondary from cadavers, bring with them Prolapse Procedures the risk of cross-infection. The newest development has been Anterior Compartment the introduction of xenograft (See table 1) materials, derived from animal Ahlfelt in 1909 stated that the only sources, into prolapse surgery. problem in plastic gynaecology These products carry a low left unresolved was the permanent infection risk and, in addition, cure of the cystocele. In 1913 have low erosion rates and do not Kelly described the anterior need to be harvested. There are colporrhaphy, which involved however reservations regarding plication of the urethral muscle. the longevity of these grafts. A number of other procedures advocated for the repair of the The introduction of new prostheses cystocele have subsequently into practice has regrettably been evolved and these include: marketing rather than evidence vaginal para-vaginal repair, driven. It is vital that practitioners colposuspension and abdominal involved in reconstructive pelvic paravaginal repair. The success floor surgery are aware of the rates of anterior colporrhaphy in efficacy, limitations and potential the management of cystoceles morbidity of these products. In this range from 70-100% in chapter we will briefly review the retrospective series. Much higher failure rates following anterior, recurrence rates have, however apical and posterior compartment been reported. In two randomized surgery. In addition, we will classify control trials, Weber et al and

155 Table 1: Failure rates of anterior compartment prolapse repair Procedure Follow-up Failure (variably defined)

Midline fascial placation 1 – 20 yrs 3-58 %

Site-specific fascial repair 6 mths – 2 yrs 10-32 %

Vaginal-paravaginal repair 6 mths – 6 yrs 30-67 %

Abdominal paravaginal repair 6 mths – 6 yrs 20 %

Concomitant sling support 17 mths – 4 yrs 2-57 %

Sand et al reported the anterior related to failure of the initial colporraphy to be successful in procedure to identify and repair all only 42% and 57% respectively. support defects. Adequate support Success rates of the vaginal of the vaginal apex is essential paravaginal repair for cystoceles in ensuring the longevity of an in various case series range from anterior compartment procedure. 1-33%. In addition, this procedure has significant morbidity including Posterior Compartment ureteric ligation, retropubic (See table 2) haemorrhage and abscess Reports of recurrence after formation. Colposuspension has rectocele repair range from 7% a failure rate of up to 33% and to 67%, depending on the type of abdominal paravaginal repair fails operation. Rectocele repair can be in up to 24%. approached vaginally, transanally or abdominally. The vaginal In addition to the traditional risk procedures include: site –specific factors, recurrence of anterior repair, fascial plication and levator compartment prolapse may be plication repair. For the vaginal

156 Table 2: Failure rates of posterior compartment prolapse repair Procedure Failure Persistent POP Dyspareunia symptoms

Levator plication 10-20 % <20 % 27-50 %

Midline fascial 7-13 % 7-20 % 4.2 % plication

Site-specific fascial 10-32 % repair

Trans-anal repair 30-67 % 17-30 %

Laparoscopic 20 % 20 % rectocoele repair approach, failure rates are quoted to apical support is crucial in at between 7-32%. the prevention of posterior and particularly anterior vaginal wall Midline fascial plication during prolapse. the vaginal approach seems to be more successful than site specific A number of procedures; including repair. The transanal repair, the the vaginal, abdominal and colorectal surgeon’s route of laparoscopic approaches are choice, has reported failure rates employed for apical prolapse. of up to 67%. Objective failure rates vary from 24% to 47% in various studies on sacrocolpopexy, bilateral Apical Prolapse iliococcygeus fixation and sacrospinous fixation. The vaginal apex, be it uterus or post –hysterectomy vaginal cuff, is the keystone of pelvic organ support. Appropriate attention

157 Classification And Non-carcinogenic Properties Of Graft Affordable Materials Accessible Easy to handle Prostheses may be derived from Flexible synthetic materials, biological tissues or mixed synthetic and biological grafts. The biological grafts include autologous grafts, Synthetic Grafts which are derived from the individual’s own tissues, allografts Synthetic grafts are durable, easy from human donor tissue and to handle and readily available. xenografts from an animal origin. They do not require harvesting as Recently, a mixed synthetic with the autografts and they do and biological graft has been not carry the infection risks of the produced. The pelvic reconstructive allografts. surgeon needs a working understanding of these grafts. Over the past few years, there Important aspects that should be has been extensive research and considered when selecting a graft development in an attempt to include the inherent strength, identify the properties of an surgical handling, its reaction ideal synthetic prosthesis. A within human tissues and potential number of different grafts have morbidity. The properties of the been manufactured, each with ideal graft for pelvic reconstructive its own properties and in-vivo surgery are listed in table 3. responses. Mesh prostheses have been used to reinforce abdominal Table 3: Properties of the ideal hernia repair by general surgeons graft for a few decades now. When Biocompatible placing mesh through a vaginal incision, additional factors need Inert to be considered in prosthesis Hypoallergenic selection. The risk of infection Hypoinflammatory is four times higher if placed vaginally rather than abdominally. Resistant to mechanical stress The sexual function of the vagina Sterile also needs to be retained and 158 the mesh should therefore be with varying success rates. soft with smooth edges. Erosion The absorbable mesh used is is the greatest risk of synthetic almost exclusively Polyglactin mesh and infection of the graft 910 (Vicryl). Recently, concerns is the most common cause of this have been expressed regarding complication, however it may also the longevity of the absorbable result from inadequate vaginal prostheses and the trend is now closure, superficial placement towards the use of non-absorbable of the graft or vaginal atrophy. products. The most common Injection of local infiltration, non-absorbable materials used which increases tissue volume, may include polypropylene, polyester, also increase the risk of extrusion polytetrafluoroethylene, and by placement of the graft at an polyamide. (Table 5) The in-vivo insufficient tissue depth. The pelvic tissue response to polypropylene reconstructive surgeon therefore appears to be the most favourable. has an important responsibility - Comparative studies have shown since the incorrect choice of mesh the inflammatory response and inappropriate technique elicited by this product to be will doom a woman to possible significantly lower than with dyspareunia, erosion, chronic pain the other materials and it also or recurrence of the prolapse. appears to have a higher resistance to infection. It is the general Classification of Synthetc Mesh surgeon’s mesh of choice and (See table 4) it is now used in more than 1 Synthetic mesh prostheses were million hernia repairs annually. classified by Parvis Amid into 4 It therefore appears to be the Types, based on filament type ideal selection when choosing a and pore size. Based on data synthetic material for pelvic floor drawn from a number of animal repair. and clinically based studies, the following factors need to be Weave and Porosity considered when selecting a Synthetic mesh can be woven, synthetic prosthesis. knitted or non-woven and non- knitted. Microscopically, a woven Material Type mesh would resemble a wicker Absorbable and non-absorbable basket whereas a knitted mesh materials have been used would look like a fishing net.

159 Table 4: Classification Synthetic Grafts Type Component Pore Trade Name Fibre Type Size

Type I Polypropylene Macro Prolene Monofilament Totally (Ethicon,Summerville.NJ) Macroporous Pore size>75um Polypropylene Macro Marlex (Bard,Cranston,RI) Monofilament

Polypropylene Macro Atrium Monofilament (Atrium,Hudson,NH)

Polypropylene Macro Apogee, Perigree (AMS) Monofilament

Polypropylene Macro Prolift ( Gynecare) Monofilament

Polypropylene Macro Posterior IVS (Tyco) Monofilament

Type II Expanded Micro Gore-Tex (Gore, Flagstaff, Multifilament Totally PTFE AZ) Microporous Pore size <10

Type III Polyethylene Micro/ Mersilene (Ethicon, Multifilament Macroporous macro Summerville, NJ) with multifilaments Polypropylene/ Macro Vypro Mono/Multi or microporous Polyglactin (Ethicon,Summerville,NJ) component 910

Polyglactin Macro Vicryl Multifilament 910 (Ethicon,Summerville,NJ)

Type IV Polypropylene submicro Cellgard (not used in Monofilament Submicronic sheet gynae surgery) pore size Pore <1um

Non-woven and non knitted The mean diameter of leukocytes mesh resembles a piece of plastic and macrophages is 9–15 microns sheeting. The structure determines and 16–20 microns respectively the pore size of the mesh. Pore size while the average bacterium is is an extremely important property <1um in size. Selection of a graft of any prosthesis since it influences with a pore size that allows access its susceptibility to infection, the to the leukocytes is therefore flexibility of the graft and the crucial in preventing sepsis and its ability of the graft to become sequelae. incorporated into the surrounding tissue.

160 Table 5 Material Type Example

Polyglactin 910 VICRYL

Polypropylene PROLENE GYNECARE GYNEMESH* PS GYNECARE TVT MARLEX, URETEX SURGIPRO, IVS SPARC

Polyester MERSILENE

Polytetrafluoroethylene GORETEX

Polyamide NYLON

Pore size also determines Filament type angiogenesis and in-growth of Mesh materials are either collagen, which allow adequate mono- or multi- filamentous. incorporation of the graft into Multifilament grafts are made of the native tissue. When these multiple braided strands whereas processes are suboptimal, the in monfilament prostheses the mesh will become encapsulated individual strands of the mesh rather than incorporated into the are solid. As with pore size, the tissues. A pore size of more than interstices between the strands 75um is considered to be ideal play an important role in a graft’s for integration of the graft into predisposition to infection. A the pelvic tissues. Therefore, a distance of less than 10 microns knitted mesh with pores measuring between the strands will allow >75um, as in the Amid Type I, the passage of small bacteria (< is considered to be the optimal 1 micron) but not leukocytes and configuration to prevent infection, hence predispose to infection. promote integration and allow [40] Monofilamentous grafts, flexibility and softness. Table e.g. Amid Types I and III, are 6 summarises the percentage monofilamentous and therefore relative porosity of a number of considered to be a better choice. the commonly available mesh prostheses. Weight and flexibilty The risk of erosion or vaginal

161 irritation is also likely to be Autologous grafts influenced by the stiffness or Autologous grafts may be flexibility of the graft. The latter harvested from the patient’s is influenced by both the fibre and vagina, fascia lata or rectus fascia. pore size. More recently, emphasis The latter options, however, are has been placed on the weight, associated with increased peri- expressed in milligrams per square operative morbidity. Walter et centimeter, of synthetic mesh al reported an incidence of prosthesis. A graft with a lower 4% haematoma or seroma and weight will be softer and more 5% cellulitis following fascia flexible, both desirable qualities lata harvesting in 71 women. In for a vaginal prosthesis. Again addition, 13% of the patients Type I mesh appears to have the reported dissatisfaction with the greatest flexilbity with the newer technique as a result of pain, Type Ib lightweight mesh having cosmesis or both.In addition, the greatest softness and flexibility in women with prolapse, these tissues may be inherently weaker Shrinkage than normal, predisposing to Another clinically relevant property fragmentation and surgical failure. of the synthetic grafts is shrinkage. Excessive contraction of a mesh Allografts leads to erosion and extrusion. Allografts include cadaveric Most grafts will shrink by about derived fascia lata, dura mater 20% and enough excess should and acellular dermal matrix therefore be left when using these (AlloDerm®). These materials materials. have the advantage of avoiding the morbidity of harvesting Biological Grafts autologous tissue and a (see table 7) significantly reduced risk of graft Erosion rates of up to 25% have erosion. Fascia lata and dura been reported for the synthetic mater allografts are harvested grafts. Biological grafts have using an aseptic technique and are therefore been used and industry then soaked in antibiotics. The continues to develop newer grafts grafts are cultured and screened derived from biological tissues, to for HIV, Hepatitis B and C and overcome this problem. T-Lymphocyte virus type 1. The graft is then freeze-dried and

162 sterilized using gamma irradiation matrix provides a template for in keeping with FDA guidelines. revascularization, cell repopulation The freeze-drying process leaves and normal tissue regeneration, a a significant amount of cellular similar principle to the xenograft material on the prostheses and collagen matrices. there is still a small risk of prion or HIV transmission. A newer Xenografts processing technique, the solvent- The most widely used xenografts drying Tutoplast process, involves are porcine and bovine in origin. soaking the graft in sodium They include porcine dermal hydroxide followed by peroxide. grafts (Pelvicol), small intestinal This reduces the risk of viral and submucosa (SIS) and bovine prion transmission significantly pericardium (Veritas). They lack and provides an acellular collagen the ethical implications associated matrix graft. In the older –type with cadaveric grafts and are allografts, where there is residual more readily available. The idea antigenic expression, a ‘host versus behind the use of these prostheses graft’ type immunological reaction is to provide a stable three- may occur resulting in autolysis dimensional structure that ideally of the graft and surgical failure. attracts host cells and acts as an Surgical failure may also arise interactive scaffold for host cell due to intrinsic deficiencies in the migration, neovascularization, and strength of the graft. tissue remodelling. Various animal studies have however shown that The newer acellular dermal matrix this does not always occur and the (AlloDerm®) is derived from implanted graft materials may also human skin tissue. In the USA, undergo either encapsulation with the tissue is supplied by tissue graft fibrosis or breakdown with banks approved by the American loss of support. The manufacturing Association of Tissue Banks (AATB) processes of the graft prior and FDA guidelines. The FDA has to implantation may alter its classified it as banked human structural integrity and the host tissue. The graft is prepared cell may identify the implant as a by a process that removes the foreign body rather than a matrix epidermis and the cells that lead to for remodelling. tissue rejection and graft failure, There are also the religious without damaging the matrix. This implications of using porcine and

163 Table 6: Relative porosity of various synthetic meshes GYNEMESH PS 65,6

MERSILENE 62,7

PROLENE 53,1

GYNECARE TVT 52,1

MARLEX 49,3

IVS 37,7

SURGIPRO 37,7 bovine products. This is, however, strength than pelvicol. open to individual interpretation and the women should obtain Bovine pericardium (Veritas) is counsel from her local religious another acellular product used in leader. prolapse surgery. Recently fetal bovine pericardium (Cytrix) has The two most commonly employed been marketed and is reported xenografts include SIS® and to have no risk of transmission of Pelvicol®. Pelvicol® is a porcine prion disease. dermal collagen. It comprises fibrous acellular collagen and Table 9 and10 summarises some its elastin fibers that are cross- of the differences between the linked by hexamethylene – di- various grafts. isocyanate to resist degradation by the collagenases. It is durable and easy to work with and readily Evidence For The Use available. Recently the product has been modified (Pelvisoft) Of Graft Materials In after a number of reports have Prolapse Surgery suggested that this graft may predispose to encapsulation rather There is regrettably very little than integration. This has involved robust evidence to either support changing the structure to a netting or refute the use of these grafts –type configuration rather than in vaginal prolapse surgery. It is a solid sheet. Another porcine principally based on observational dermal collagen product (InteXen) case series and case-control claims to have up to 25% more studies with limited long-term

164 Table 7: Classification of Biological Mesh Xenograft Porcine SymphaSIS (8-ply) Small Intestinal SurgiSIS (4-ply) Submucosa StrataSIS (Cook, Letchworth, UK)

Porcine dermal Pelvicol collagen Pelvisoft (Bard, Cranston, RI) InteXen (AMS)

Bovine pericardium Veritas Braille biomedical Industria Commercio E representacoes S/A Cytrix (TEI Biosciences)

Allograft Dura Mater

Fascia Lata Suspend (Tutoplast) Mentor Corp Santa Barbara California

Acellular Dermal AlloDerm Matrix Lifecell, Branchberg , NJ Axis Mentor Corp Santa Barbara California Duraderm (Boston Scientific) Replform (Boston Scientific)

Autologous Rectus Sheath

Fascia Lata

Vaginal Mucosa outcome data. Many of these are included women with both retrospective studies and report primary and recurrent prolapse on relatively small numbers in the same cohort. Some reports of patients. Only a few small, compare a mixture of women who randomized control trials have had procedures in addition to graft been performed. In addition, in insertion, e.g. vaginal hysterectomy many of the studies the patient and repair of prolapse in other cohort was heterogenous with compartments. This would have significant confounding variables. impacted on outcomes including For example, many of the studies recurrence and erosion rates. For

165 example, it has been shown that the only randomised controlled performing a vaginal hysterectomy trial on Type I monofilament at the same time as anterior polypropylene mesh (Marlex), 24 insertion of a graft will increase women with recurrent cystocoeles the risk of erosion. (Grade 1) were allocated to anterior colporrhaphy alone or Criteria used to define recurrence reinforcement with the graft. also vary greatly between At 24 month follow-up, the studies, with some authors using success rate was 100% in those validated objective data and who underwent prosthetic others, unvalidated subjective reinforcement, compared observations. to only 66% in those who underwent anterior colporrhaphy There is therefore an urgent need alone. Despite this significant for large, multicentre, randomised improvement in outcomes in the control trials with strict inclusion group having the mesh it was criteria and results based on coupled with a very high erosion objective observations and rate of 25%. validated questionnaires. There have only been an additional three randomised Anterior control trials looking at the use of synthetic mesh in anterior repair Compartment and these have all been done on absorbable mesh Polyglactin 910 Synthetic Materials (Vicryl) with conflicting results. (See tables 11 to 13) Sand performed a study on 161 Prosthetic reinforcement has been women with cystocoeles more than employed in women undergoing grade 1. At 12 months of follow- anterior colporrhaphy for both up, those undergoing fascial primary and recurrent cystocoele. plication alone had a recurrence Most of the studies on grafts and rate of 43%, compared to (p = cystocele repair have investigated 0.2) 25% in those women whose the type 1 polypropylene mesh. repairs were re-inforced with vicryl Julian [45] was the first to mesh. Koduri et al also found publish a clinical study evaluating that the addition of a Polyglactin cystocele repair with prosthetic graft improved outcomes with a re-enforcement in 1996. In this,

166 recurrence rate of 1% in those There have been a large number with the prosthesis compared with of non-randomised studies of 13% in those without. However, polypropylene mesh in anterior in a prospective RCT by Weber compartment prolapse reporting [14], 140 women were assigned recurrence rates ranging from randomly to three different 0-8.4% and erosion rates up to 9%. techniques of anterior repair: There are, however difficulties in standard anterior repair, standard interpreting and comparing these plus polyglactin and ultralateral data. The techniques differed anterior colporrhaphy. After significantly between the studies,

Table 8 MIXED Monofilament Pelvitex (Bard) Monofilament Macro BIOLOGICAL and polypropolene Avaulta Plus SYNTHETIC mesh coated with hydrophilic porcine collagen

Monofilament Ugytex Monofilament Macro polypropolene (Sofradim coated with France) atelocollagen, polyethelene glycol and glycerol follow-up of 83 women (76%) ranging from surgeons who at a median of 23.3 months, sutured the graft firmly in placed the author concluded that the to a tension –free approach. In three techniques for anterior addition, different criteria were colporrhaphy provide similar used to define recurrence and symptomatic and anatomic cure duration of follow-up also varied rates and that the addition of significantly. polyglactin 910 did not confer any advantage over standard Combined absorbable and non- anterior repair. It should also be absorbable prostheses (eg Vypro: mentioned that in the Weber and Polyglactin 910 / Polypropylene) Sand studies, recurrence rates were were introduced in an attempt to particularly high in all the groups. further reduce mesh complications. The results using this graft have

167 Table 9: Biological responses to the different graft materials Prolene SIS (4 ply) Pelvicol

Structural integrity Fully intact at 1 year Not recognisable at Partially recognisable 60 days at 1 year

Collagen Deposition Dense, fibrous Thin layer fibrous Thin layer fibrous At one year organised collagen collagen

Neovascularisation Numerous and wide Smaller and fewer Smaller and fewer calibre

Inflammatory resonse Mononuclear Mononuclear and Mononuclear and High level response to polymorponuclear polymorponuclear 1 year with low level with low level response at 1 year response at 1 year however been disappointing. (Tutoplast) in recurrent cystocele in It is hypothesized that the 153 women. Failure was defined polyglactin component provokes as prolapse of Stage 2 or more an inflammatory reaction leading (Aa or Ba more than or equal to to erosion and poor healing -1). At 12 month follow-up there with resultant recurrence of the was no difference in recurrence prolapse. Denis et al used Vypro between the women who had the to treat prolapse in 106 women. patch (21%) compared with those 50 % of the women experienced that did not have a patch (29%). a recurrence after a mean follow- As with many of these studies, up of only 7.9 months. Moreover, most of women had concomitant there was a very high erosion rate prolapse procedures and this may of 40%. have confounded the results.

Biological materials Other observational studies (Tables 14 and 15) looking at fascia lata have Again there is very little robust reported good outcomes but this evidence for the use of biological was dependant on the criteria used grafts in anterior compartment to define recurrence. Kobashi used prolapse. the outcome measure of prolapse more than Grade 1 and reports Gandhi et al have recently a failure rate of 1.5% after 12 completed a randomised control months. Powell however found trial investigating the use of objective recurrence (>Grade 1) solvent dehydrated fascia lata of 19% versus only 2% subjective

168 Table 10: Properties of Biological vs Synthetic Graft Materials Biological Synthetic

Tensile strength + +++

Antigenicity +++ +

Tissue remodelling +++ +

Erosion + +++

Cost ++++ ++

Consistency of graft strength + +++

Availability - +++

Infection + +++

Stretch + +++

recurrence (ie no symptoms of one preliminary report of a RCT bulge). There was no reported evaluating the efficacy of Pelvicol® erosion with these grafts which in primary cystocele repair. No was very encouraging. significant difference has been detected but follow- up is still only More recently, attention has 6 months. The long term results turned to the use of xenograft of this and other current studies materials in the anterior on the xenografts in the anterior compartment. From the compartment are eagerly awaited. observational studies, they appear Mixed evidence to support the use to have low reported erosion of grafts in women with primary rates but variable recurrence cystocele. rates. Recurrence rates for porcine Grafts should not be used to dermis grafts (Pelvicol ®, Bard ) are compensate for poor surgical between 4 and 19%. The human technique. dermal collagen grafts appear Prosthetic reinforcement appears to have poorer outcomes than to improve short term outcomes in their porcine counterparts. It is recurrent cystocele. also noteworthy that of none of Expert opinion would support the the 21 women that were sexually use of grafts in recurrent cystocele active in Clemons’ study reported and in primary cystocele at high any adverse outcomes. There is risk for recurrence.

169 Summary al performed a sacrospinous suspension with insertion of Posterior Compartment polypropylene mesh in 26 women Synthetic materials (Table 17) with rectoceles. Cure was 92% There has been a justified after 22 months of follow up but reluctance to employ prosthetic again this was coupled with a high material in the posterior erosion rate of 12%. One of the compartment because of the risk 13 sexually active women reported of erosion and concerns regarding increased dysparunia. dyspareunia. A disturbing increase in dyspareunia in 64% of women Adhoute et al [52] reported on the after posterior repair using prolene outcome of 52 non-consecutive mesh was recently reported by women undergoing trans-vaginal Milani et al. Despite very good rectocele and or cystocele repair anatomical outcomes, the authors using polypropylene mesh feel that the prolene prosthesis (Gynemesh®). Depending on should be abandoned. the circumstances, the operation comprised anterior or posterior In another study, de Tayrac et mesh implantation, hysterectomy and TVT insertion. After a mean

Table 11: Anterior compartment grafts Synthetic materials Randomised control Trials Polyglactin 910 Study Prosthesis N Study Type Follow- Recurrence Erosion Type Up

Koduri Polyglactin 125 Prospective 12 months 13% no mesh 910 randomised 1% mesh 2000

Weber [ Polyglactin 140 RCT Mean 23.3 70% (no mesh) 0% (2001) 910 months 58% (Vicryl) ultralateral 54% mesh (non significant)

Sand Polyglactin 161 RCT 12 months 25% (with 0% (2001) 910 Recurrent mesh) (Vicryl) 21 43% Primary 140 (no mesh) p=0.02

170 Table 12: Anterior compartment grafts Synthetic materials Randomised control Trial Polypropylene Study Prosthesis Type N Study Type Follow-Up Recurrence Erosion

Julian Marlex 24 Prospective 24 months 0% (mesh) 25% (1996) (Type1 Monofiliament (recurrent) 34% polypropolene) (no mesh) follow-up of 27 months, the rectocele repair in 43 women using anatomical success was 100% in a dermal allograft to augment site- those who had rectocele repair specific fascial repair. [72] No major and there was no reported erosion. complications were reported. Thirty-three women were available Other studies of synthetic mesh for follow-up (mean 12.9 months) in the posterior compartment are with a 93% surgical cure rate small [69,70] and one revealed a defined by POP-Q evaluation. very high erosion rate. Moore also reports favorable cure and low erosion rates in a Recurrence rates following study looking at 195 women who posterior repair using synthetic received either a porcine or human mesh do appear to be low, dermis graft during a posterior however erosion and dysparunia repair. [73] A further case series are common and the pelvic of 188 women, by Chaudhry et al surgeon should take this into [74], employed a human dermal consideration when choosing allograft (AlloDerm®) for posterior to insert a graft in the posterior repair. They showed some very vaginal compartment. promising results after 18 months of follow up. There was a 5% Biological Materials recurrence and a 0.5% erosion (See table 18) rate. The newer xenografts have a much lower tendency to erode and Most recently Altman et al fibrose. There have been a number assessed quality of life and of recent promising reports on anatomical outcomes following their use in rectocele repair. posterior repair using a collagen Kohli and Miklos in 2003, described allograft. There were significant

171 improvements in several variables with mesh or suture complications associated with quality of life and occurring in 0-12%. Erosion rates no change in sexual function or vary depending on the type of dypareunia rates. The anatomical synthetic material used with the outcomes were however lowest seen with Polypropylenes unsatisfactory. and the highest with Goretex. In a review of 592 operations, The biological grafts appear to Iglesia reports an overall revision have significantly lower rates and removal rate of 2.7%. Sacral of erosion and dysparunia than osteomyelitis and bladder erosion polypropylene mesh when used were rare complications. The in the posterior compartment. procedure involves the placement However anatomical efficacy of numerous sutures around remains to be validated. the vaginal vault and this may predispose to tissue ischemia and resultant prosthetic erosion. Apical Prolapse There have been several small Abdominal or laparoscopic observational studies on sacrocolpopexy appears to be laparoscopic sacrocolpopexy the procedure of choice for vault showing short-term outcomes prolapse. It restores the normal and mesh complication rates vaginal axis whilst maintaining comparable to the abdominal vaginal capacity and coital approach. function. It has the lowest recurrence rate. A number of Due to the low erosion rates prosthetic materials have been and extensive experience with used for this technique. Success the synthetic materials, the rates range from 73-100% at a biological grafts have not been follow-up interval of 1-136 months widely employed in abdominal (Table5) [31-33]. Because the mesh sacrocolpopexy. In addition is being inserted abdominally, the there are concerns regarding risk of infection is significantly the longevity of the biological lower compared to the vaginal grafts. Fitzgerald in 1999 route. The majority of the studies reported on a series of 67 women reported in the literature involve who underwent sacrocolpopexy the use of synthetic prostheses, using donor cadaveric fascia

172 Table13: Anterior compartment grafts Synthetic materials Non Randomised Trials Polypropylene Study Prosthesis N Study Type Follow- Recurrence Erosion Type Up

Adhoute Gynemesh 52 Case series 27 5% cysto 3.8% 2004 + hyste 0% recto cysto (28%) entero (9.5%) recto (28%)

Flood Marlex 142 Retrospective 36 0% 2.1% (1998) (Type1 (primary) months Monofiliament polypropylene) Tension free

Natale Polypropylene 138 recurrent 18 2.2% - (2000) (Tension free) months

Bader Tension-free 40 Observational 16.4 - 7.5% (2004) monofilament polypropylene mesh

Yan Synthetic 30 Observational 6.7 3% 7% (2004) mesh secured (2-12) through obturator foramina

Korushnov Polypropylene 45 RCT <12 Not 14% (2004) months significant (trend towards better cure with mesh

Dwyer Polypropylene 64 Retrospective 6-52 6% Not 2004 (Atrium) review mean 29 stated but 9% for total cohort

de Tayrac Polypropylene 87 Case Series 9-43 8.4% 8.3% 2005 84 mean 24 follow-up

Eglin Polypropylene 103 Case series 18 3% 5% 2003 Transobturator subvesical mesh

173 lata. Recurrent vault prolapse posterior repair and 20% increase was recognised in 8% of women following anterior repair. In a at a follow-up interval of 6-11 further study reporting on the months. Absence or attenuation use of polypropylene, Salvatore of the prosthesis was observed et al describe an increase in in the 7 patients requiring re- dyspareunia from 18 to 78%. operation. This clearly questions Zhongguo et al also report a 64% the use of this allograft for use incidence of dyspareunia following in sacrocolpopexy. Culligan et al, transobturator polypropyle mesh used an acellular human dermal insertion. graft for ASC in 32 patients with follow-up of 1 year. In contrast Role of the Mesh Kits they report no post-operative Pelvic organ prolapse is often complications and acceptable associated with a global weakness outcomes with this newer of support structures and in generation allograft. order to replace this tissue, the new mesh kits have been Overview on complications developed. Three companies have when using mesh in POP launched these devices and they surgery are all available in South Africa. There remains very little Grade 1 They consist of an anterior and evidence for the use of mesh and posterior system. The anterior grafts in POP surgery and more system consists of a central mesh data is emerging regarding the portion and two lateral arms on complications. Sexual function is each side that are placed through often not reported in the literature the obturator foramina. The and those studies that do look at posterior kit has a central mesh this aspect of vaginal function, portion with bilateral arms that usually confine it to a number go through the buttock, traverse of short sentences with very the ischiorectal fossa and enter the little questionnaire-based data. pelvis via the illiococcygeus muscle There are, however, concerning or sacrospinous ligament. The first reports on a rise in dyspareunia of these devices to be launched following repair with synthetic was the Prolift System, marketed mesh. Milani et al report a 63% by Johnson and Johnson. American increase in the number of women Medical Systems, AMS, have reporting dyspareunia following developed an anterior mesh system

174 Table 14: Anterior compartment grafts Biological grafts Fascia lata grafts Study Prosthesis N Study Type Follow- Recurrence Erosion Type Up

Kobashi Cadavaric 132 Observational 12.4 1.5% 0% (2000) Fascia lata study (6-28) (cystocelee) 9.8% (apical)

Groutz Solvent- 21 Observational 20.1 0% 0% dehydrated cadaveric fascia

Powell Fascia lata 58 Case Series 24.7 Objective Not 2004 12-57 19% mentioned subjective 2% Cystocele 4% enteroceles 12% symptomatic rectoceles

Gandhi Solvent 162 RCT 12 21% patch 0% 2005 dehydrated 76 29% no fascia lata patch patch 78 no NS patch called Perigee and a Posterior collagen. Apogee system. Bard have also developed a system called the These products would appear to be Avaulta. The Posterior Avaulta a revolutionary step to improving has two arms on either side. The outcomes in POP surgery. They superior arm is inserted in a similar have, however, been implemented fashion to the Posterior prolift and with very little data to support Apogee but in addition, it also their use. At the time of writing, has two inferior perineal arms. there were six studies on the The Avaulta Solo is polypropylene, Gynecare Prolift system. (See table) similar to the J&J and AMS The maximum follow up time in product but the Avaulta Plus is a these studies was seven months. polypropylene coated with porcine Failure rates ranged from 4-12%.

175 Table 15: Anterior compartment grafts Biological grafts Human and porcine dermal grafts Study Erosion N Study Type Follow- Recurrence Erosion Up

Salomon Porcine 27 Observational 14 19% skin (8-24) collagen implant

Gomelsky Porcine 70 Retrospective 24 Grade 2 – 1 Superficial 2004 dermis 65 sling chart review 8.6% vaginal grafts 50 BIF Grade 3 wound –4.3% separation conservative Mx

Clemons Acellular 33 Observational 18 41 % 64% dermal study objective sexually matrix 6 recurrent II 3% active - (Alloderm) 24 prim + subjective no problems Recur III no erosion 3 Grade IV

Oestergard Pelvicol 31 Observational 6 13% Not 2004 (Porcine Cystocele (Grade 2) mentioned Dermis) >Gr 2

Arya Porcine Porcine 72 Retrospective Cadaveric Cadaveric None 2004 dermal vs Cadaveric repeated 22 69% cadaveric 45 measures (19-28) Porcine dermal study porcine 4% graft 18 (7-22)

Meschia Pelvicol RCT primary 6.5 Optimal Ba 5 % 2004 cystocele months 73% vs 65% defective P0.86 healing

The AMS product features in two in a sexually active patient. These publications with varying failure devices should only be inserted by rates from 7-13%. a skilled pelvic floor surgeon who These devices are associated with has selected the case appropriately. major complications including bladder and bowel injury. There is no data on sexual function pre or post surgery and this fact should deter any wise and prudent surgeon from using these products

176 Table 16: Anterior compartment grafts Synthetic materials Randomised control Trial Polypropylene vs Acellular dermal collagen Study Prosthe- N Study Follow- Ana- Sym- Erosion sis Type Type Up tomical tomatic Failure Failure

Cervigni Pelvicol® 72 RCT 8.8 (Pel- 68% 2.8% 2.7% vs vicol) Pelvicol Pelvicol Pelvicol Prolene 8.1 58% 8% 8.3% soft® (Prolene Prolene Prolene Prolene soft) soft soft soft

Table 17: Posterior Prolapse Synthetics Study Prosthesis N Study Follow- Recur- Erosion Type Type Up rence

Adhoute Gynemesh 52 Observa- Mean 27 Cystocele 3.8% (cys- tional months 5% tocele) Rectocele 0%

Stanton Mersilene 29 Observa- 14 0% of 3% tional stage II and III

De Tay- Gynemesh 26 Observa- 22.7 8% 12% rac** tioinal

177 Table 18: Posterior prolapse Biological Materials Study Prosthesis N Study Follow- Recur- Erosion Type Type Up rence

Kohli and Dermal 43 Prospective 12.9 7% Miklos allograft descriptive months follow-up (2003) in 33 (on POP-Q)

Moore Porcine 195 Retrospec- Porcine Porcine no 2004 dermal porcine tive chart 14.2 1% graft vs 100 review Human Human human 20.9 Human dermal 95 9.6% graft

Chaudhry Alloderm 188 Case series 18 5% 0.5% 2004 3-32 erosion 0.5 % abcess

Altman Collagen 33 Prospective 12 39% none 2005 allograft case series objective Significant improve- ment in QOL scores

178 Table 19: Abdominal sacrocolpopexy – operative outcome and peri- operative morbidity. Author N Prosthesis Follow up Success Complications (months)

Rust [1975] 12 Mersilene 9-42 100% Nil

Symonds[1981] 17 Teflon 60-360 88% Nil

Addison[1985] 56 Mersilene 6-126 89% Nil

Timmons 163 Mersilene 9m – 18 99% Nil years

Drutz[1987] 15 Marlex 3-93 93% 1 sepsis mesh removal

Baker[1990] 59 Prolene 1-45 86% Nil

Snyder[1991] 147 78 Gore -Tex 60 73% 4 mesh erosions 65 Dacron

Creighton[1991] 23 Mersilene 3-91 91% 2 sinuses removal mesh

Van Lindert[1993] 61 Gore-Tex 15-48 ? 1 erosion and fistula

Valaitis[1994] 43 Teflon 3-91 91% 1 sepsis removal mesh

Khohli[1998] 57 47 Marlex 2-50 100% 5 mesh erosions 10 Mersilene 2 suture erosions

Fitzgerald[1999] 67 Fascia lata 12 91% 6 fascial breakdown

Fox[2000] 29 Teflon 6-32 100% 1 sepsis removal mesh

Winters[2000] 20 Marlex 6-27 100% Nil

Visco[2001] 273 269 Mersilene 1-87 ? 15 erosions 4 Gore-Tex

Culligan 2001 32 Acellular hu- 12 satisfac- nil man dermal tory graft

Rocha 32 Abdominal 12 97% 3 % Dysparunia 2003 Fascia

Lindeque 262 Dura mater 16 98.9% 3.8% 2002 (18) Goretex (244)

179 Table 20: Results of Prolift Study N Follow-Up Recurrence Ero- Other Complications sion

Fatton 110 3 months 4.7% 4.7% Bladder injury 1 Haematomas 2

Dalenz 41 7 months Vault 5% 2% Perirectal haematoma 1 Cystocele 2% Erosion 1

Altman 123 2 months Anterior 13% Pelvic organ perforation Posterior 9% 3.2% Total 12% Bladder injury 1 Rectal injury 1

Neumann 100 Not stated 1% 3% Bladder injury 1

Lucioni 12 7 months 8% Enterocele 0

Abdel-fatteh 289 Not Stated 5%

Table 21: Results of Apogee/perigee Study N Follow- Recurrence Erosion Other Up Complications

Garuder-Burmester 110 I3 m 7% of anterior 3% None I6 vault No vault

Shek 46 13%

180 Chapter 21 Management of Third and Fourth degree tears

Stephen Jeffery

Obstetric anal sphincter injuries or at follow up. These so-called (OASI) are unfortunately a occult sphincter injuries have been common event associated with shown to occur in up to 35% of vaginal delivery. If these third primiparous women. and fourth degree tears are not recognised and managed Importance appropriately, these women are Anal spincter tears are associated at high risk for developing a with significant morbidity. Failure number of significant long-term to recognise and repair an anal complications including faecal sphincter injury is one of the top incontinence, perineal pain and four reasons for complaint and dyspareunia. litigation arising in labour ward practice in the UK. The sequelae Incidence of OASI affect women not only The incidence of OASI varies. 40 physically but psychologically as 000 women in the UK develop well. Johanson et al report that faecal incontinence related to only one third of women suffering sphincter injuries in the first year with faecal incontinence sought after birth. The RCOG guideline help. reports an incidence ranging from 0.6-9%, depending not only Risk factors on obstetric practice but also on A large amount of work has been the vigilance exercised in their done in an attempt to more clearly detection. A large number of OASI define risk factors for developing are not clinically apparent but an OASI. Hudelist et al looked at are demonstrated at ultrasound 5044 women delivering vaginally. either immediately post-partum They report that 4.2% of these

181 patients developed a sphincter detected a rectal examination defect. Risk factors emerging must always be performed. If the included low parity, prolonged patient has had a instrumental first and second stage, high birth delivery or if a large episiotomy weight, episiotomy and forceps was performed, she should be delivery. They analysed the same examined by an someone who data, applying multivariate logistic is experienced in the diagnosis progression analysis and only high of sphincter injury. If in doubt, birth weight and forceps delivery it is useful to ask the women to emerged as risk factors. Dandolu contract her anal sphincter while et al later defined this risk using performing gentle PR examination odds ratios, reporting the risk and any loss of tone will suggest associated with forceps to be and underlying sphincter defect. OR 3.84 and for vacuum delivery Another useful manoeuvre is to 2.58. Occiptoposterior postion “pill-roll” the sphincter with the also appears to be associated forefinger in the rectum and the with sphincter injury, with Wu et thumb in the vagina. This will al reporting a fourfold increase enable the clinician to detect compared to occipitoanterior any loss of sphincter bulk – again positions. The relationship suggesting an underlying third or between episiotomy and sphincter fourth degree tear. If there is still a injury remains unclear. Overall, significant amount of uncertainty, 50% of third degree tears are it would be prudent to perform associated with episiotomy and the repair under anaesthesia. midline episiotomy is 50 times more likely to result in third Classification of injuries degree tear. The greater the angle The nomenclature of OASI has the episiotomy makes with the been dogged with inconsistency vertical, the smaller the risk of for many years. Sultan and Thakar sphincter injury. looked at every Obstetric Text in the RCOG library and17% of Recognition and diagnosis the books made no mention of All women following vaginal a classification for OASI and of delivery must be thoroughly those that did, 22% classified a examined with a systematic sphincter injury as a second degree inspection of the vulva, vagina tear. Recently consensus has been and perineum. If any injuries are achieved and internationally OASI

182 are now classified into four grades. 3b: complete tear of the external The standardization of sphincteric sphincter. injury has made it easier to 3c: internal sphincter torn as well. compare data on outcomes and repair techniques. Fourth degree: a third degree tear with disruption of the anal The anal sphincter comprises: epithelium.

External Anal Sphincter Sphincter Rectal mucosal tear (buttonhole) (EAS) without involvement of the anal • Subcutaneous sphincter is rare and not included • Superficial in the above classification. • Deep Internal Anal Sphincter (IAS) • Thickened continuation of Repair of Third and circular smooth muscle of bowel Fourth degree tears The classification of tears is as follows: General Principles All third and fourth degree tear repairs should be done First degree: laceration of the in an operating theatre. This vaginal epithelium or perineal skin recommendation is made for only. a number of reasons. Firstly, in theatre one has access to proper Second degree: involvement of anaesthesia. A general or spinal the vaginal epithelium, perineal anaesthetic makes it much easier skin, perineal muscles and fascia to inspect the tissues and to but not the anal sphincter. adequately visualise the tear. The sphincter is usually more relaxed Third degree: disruption of the which makes it easier to retrieve vaginal epithelium, perineal skin, if the ends are retracted. In perineal body and anal sphincter theatre it is possible to position muscles. This should be further the patient in a more appropriate subdivided into: way. The surgeon also has access 3a: partial tear of the external to better lighting and proper sphincter involving less than 50% instrumentation and often it is thickness. easier to get an assistant if the

183 procedure is being performed in being reduced from 41% to 8%. theatre. In addition to recommending an overlap technique, Monga Inexperience of the operator and Sultan also performed a significantly increases morbidity separate repair of the internal and may also predispose to anal sphincter and this may also litigation. profoundly impact on outcomes. A number of RCT’s comparing Overlap or end to – end repair end-to-end and overlap repair of the Sphincter. have been performed. In a trial by Repair of the sphincter following Fernando et al 24% of women who an acute obstetric injury has had an end-to-end repair reported undergone a significant change faecal incontinence compared over the past decade. Traditionally, to no cases of incontinence the repair was done by an end- in the overlap group. A vastly to-end approximation of the torn underreported complication of sphincter. The outcomes following OASI is long term perineal pain. acute repair of sphincter injuries In the Fernando trial, 20% of the are poor with some studies women who had an end-to-end reporting faecal incontinence repair reported this troublesome rates of up to 37%. (range 15- symptom compared to none in the 59%). Many women later require overlap group. A recent cochrane secondary repair of the sphincter. systematic review addressed the This is usually done by a colo- issue of overlap versus end-to-end rectal surgeon and an overlapping repair of OASI in 279 women. They technique is employed in the report a statistically significant majority of cases. The reported lower incidence in faecal urgency success rates with an overlapping and lower anal incontinence score technique are better, with in the overlap group. The overlap continence outcomes between technique was also associated 74 and 100%. For this reason, with a statistically significant Monga and Sultan performed the lower risk of deterioration of anal first pilot study on an overlapping incontinence symptoms over one technique for acute OASI. In this year. trial, using matched controls, they report significantly improved Specifics of repair outcomes with incontinence rates The anal mucosa is repaired with

184 interrupted vicryl 3-0 sutures with the knots tied in the lumen. After the sphincter has been The torn muscle, including the repaired, the vaginal skin is closed internal and external sphincter, much like one would close an should always be repaired with episiotomy, making every effort to a monofilamentous delayed reconstruct the perineal body. absorbable suture such as PDS or Maxon 3/0. The internal Every woman should be given anal sphincter should first be antibiotics and stool softeners identified and then repaired using following the repair. an interrupted suture. It is not Women sustaining third and fourth possible or necessary to overlap degree tears should always be the IAS and it is adequate to suture offered a follow up appointment this muscle using an end-to-end to assess them for faecal technique. It is often difficult to incontinence, perineal pain and identify the IAS, but usually it is dyspareunia. paler in colour than the external sphincter.

If it is a Grade 3A tear, ie less than 50% of the EAS is torn, the muscle is repaired using and end-to end technique. If it is a 3B, an overlap technique is probably better and this is done as follows: The ends of the torn muscle are identified and clamped using Allis forceps. A double breasted technique is used to approximate these ends. It is important to identify the full length of the sphincter and this can stretch for up to 4-5cm. Whether an end-to-end or overlap technique is used, between three and four sutures are inserted and these are tied following insertion of all the sutures.

185 Chapter 22 Management of Urogenital Fistulae

Suren Ramphal

Urogenital fistulae typically Aetiology And involve a communication between the genital tract (vagina, cervix, Pathophysiology uterus) and the urinary tract In well resourced settings, (ureter, bladder, urethra). They urogenital fistulae occur as a are described by their anatomical consequence of surgery, most location (Table: I) and can be commonly following abdominal classified according to organ hysterectomy and more recently involvement, i.e simple fistulae after laparoscopic hysterectomy. (which involves 2 organs) or In most series, gynaecological complex fistulae (involving 3 surgery is responsible for 70-80% or more organs) (Table: II). The of urogenital fistulae with the majority of urogenital fistulae remainder following urological, occur between the vagina and vascular and colorectal procedures. the bladder (vesicovaginal) with In a study of 303 women with urethrovaginal and ureterovaginal urogenital fistulae from the Mayo occurring less frequently. Clinic, 82% of cases were caused by Communication between the gynaecological surgery, followed lower urinary tract and the uterus by obstetric related fistulae in 8%, or cervix are rare (Figure: 1) 6% related to pelvic radiation and 4% following trauma. The aetiologies of urogenital fistulae are shown in Table III. Most vesicovaginal fistulae (VVF) follow abdominal hysterectomy for benign conditions such as uterine fibroids, endometriosis

186 or pelvic adhesions, with only progressive endarteritis obliterans a few occurring after vaginal leading to tissue fibrosis and hysterectomy. High risk intra- necrosis. Most radiation associated operative scenarios for fistula VVF develop 6 months after formation include excessive completion of therapy. There are bleeding at the angles of the reports of cases presenting many vault, pelvic adhesions, a previous as five years after therapy. It is caesarean section leading to imperative to investigate these difficulty in separating the bladder women for a possible recurrence peritoneum from the uterus, and of the malignancy. Closure of surgery for pelvic malignancies. the fistulae in these cases is particularly technically difficult and Fistula formation is postulated urinary diversion is the procedure to result from unrecognized for these patients, despite the direct injury to the bladder or guarded results of this operation. ureter, devascularization of Fortunately, recent advances in tissue leading to ischaemia and radiation therapy have significantly avascular necrosis, and inadvertent decreased the occurrence of suture placement between the fistulae. bladder and vaginal cuff leading to erosions. Uncommon causes Ureterovaginal fistulae occur most for urogenital fistulae include commonly with laparoscopic or vaginal foreign bodies, trauma abdominal hysterectomy, usually or a bladder calculus. Radiation when removing the adnexae. induced fistulae , especially The pelvic portion of the ureter radiotherapy for cancer of the is most susceptible to injury at cervix, may develop as a result of a number of places including the infundibulo-pelvic ligament TABLE I: Urogenital Genital when the ovarian blood supply is fistulae classified by anatomical ligated, at the cardinal ligament, location as the ureter passes beneath the uterine vessels and at upper Vesicovaginal vagina as the ureter crosses to Vesicouterine enter the bladder base. The Ureterovaginal mechanism for ureterovaginal Ureterourerine fistula formation is similar to that of VVF - unrecognized surgical Urethrovaginal

187 TABLE II: Classification In under-resourced countries, according to organ involvement obstetrics is the leading cause of Simple Fistulae genitourinary fistulae usually as a result of prolonged obstructed Vesicovaginal labour causing ischaemic necrosis. Vesicouterine The exact prevalence is unknown Ureterovaginal but they are particularly common

Ureterourerine in Africa and South Asia. The level at which the fetal head Urethrovaginal becomes impacted during labour Complex Fistulae determines the site of injury and Uretero-vesico-vaginal type of fistula. For example, if

Uretero-vesico-uterine the impaction occurs at the level of the pelvic inlet, the VVF may Vesico-vagino-rectal be intracervical, if the impaction occurs at a lower level, the urethra TABLE III: The Aetiology of will most likely be involved. The Urogenital Fistulae urethra is involved in 28% of cases Surgery of obstetric related fistula with Obstetrical total urethral destruction in 5% of patients. Vesico-uterine fistulae Trauma contributed to 10.5% (4/42) of Malignancy cases in a review of 42 patients Radiation with obstetric fistulae in Durban. Infection

Foreign body Symptoms injury or ligation and tissue necrosis following ischaemia or Symptoms of fistulae vary inflammation. depending on the aetiology. A women who presents with fluid Urethrovaginal fistulae may leaking from her vagina following occur following surgery for pelvic surgery, should be suspected urethral diverticulae, anterior to have a fistula unless proven vaginal prolapse, stress urinary otherwise. Classically, patients incontinence and more rarely, complain of a continuous or radiation therapy. intermittent watery vaginal

188 discharge that smells like urine. but most have continuous leakage Vesicovaginal and ureterovaginal independent of the body posture. fistulae may present in the On the other hand, patients first few days postoperatively. with ureterovaginal fistula have Fistulae that occur as a result intermittent but more profuse of tissue ischaemia, infection, episodes of urinary leakage. devascularization and necrosis typically present later between Women who develop obstetric day 5 and 21. In these women, a fistulae, usually present with foul smelling or persistent vaginal urinary leakage approximately one discharge often precedes the urine week following delivery (range day leakage. Febrile episodes are not 5-21). There is usually a history of common with uncomplicated VVF. a prolonged and difficult labour resulting in a stillbirth. Unlike Ureterovaginal fistulae are also iatrogenic surgical fistulae which not infrequently associated are characterised by a discrete with febrile episodes. If there is injury, the pathophysiological extravasation of urine into the effects of obstructed labour abdominal cavity, patients may are wider and can result in a present with anorexia, nausea, broad range of injuries including vomiting, increasing abdominal neurapraxia, lower bowel pain, abdominal distension and dysfunction, muscle injury and postoperative ileus. Flank pain even rectovaginal fistula. The term should alert the physician not only “field injuries” has been coined to to a possible ureterovaginal fistula, refer to this range of damage. but also to ascending infection complicating the urinary tract injury. Examination

As a general rule, women who Patients with urogenital fistulae later develop an uncomplicated may be relatively well but often VVF, recover uneventfully from the they will present with signs and initial surgery, the only complaint symptoms of acute illness. Fever, being a clear watery discharge that anorexia, nausea, and vomiting smells like urine. The amount of are suggestive of acute sepsis and urine leakage varies depending on peritonitis, and require prompt the size and location of the VVF, admission and investigation. If

189 the patient is not ill, evaluation examination. A tampon is then and diagnostic investigation placed in the vagina and again as an outpatient is acceptable. methylene blue is instilled into Other important findings include the bladder via the catheter. If costovertebral angle tenderness, the tampon turns orange, a associated with ureteric injuries vesicouretric fistula is diagnosed. or infection of the upper urinary If the tampon turns both blue and tract; and abdominal tenderness orange, then a combined VVF and which is suggestive of an vesicouterine fistula should be intraperitoneal urine collection or suspected. sepsis.

The pathognomonic finding is Investigations the observation of urine leaking into the vagina on speculum The aims of the investigations examination. The use of a Sims are as follows:- speculum with downward pressure 1. To confirm the discharge is urine on the posterior wall facilitates 2. To establish that the leakage examination of the anterior is extraurethral rather than vagina and apex. The majority urethral of fistulae following abdominal 3. To locate the site of leakage hysterectomy are located near the 4. To diagnose multiple fistulae vaginal apex and it is therefore difficult to determine clinically whether the origin of the leakage is the bladder or ureter. Following Biochemistry and pelvic examination, the bladder microbiology should be always catheterized and a urine sample sent for microscopy Initial laboratory investigations and culture. The bladder is then for urogenital fistula include:- filled with methylene blue and the 1. Urine for culture and microscopy diagnosis confirmed by observing to rule out infection the leakage of dye-stained urine 2. FBC – to assess the haemoglobin into the vagina. If a ureteric fistula and white cell count (infection) is suspected, the patient should 3. Urea and electrolyte – assess ingest 200mg oral phenazopyridine urea and creatinine level which ( pyridium) 3 hours before may be elevated with ureteric

190 injuries findings are equivocal, contrast 4. If the vaginal discharge is enhanced CT of the pelvis will aid suspicious of urine, then it in the diagnosis of vesicouterine can be analysed for its urea fistula. and creatinine content. If the urea and creatinine level of Retrograde pyelography is a the discharge is greater than reliable way to identify the exact the serum values, it is highly site of a ureterovaginal fistula. suggestive that the discharge is Positive pressure urethrography urine may be needed to diagnose urethrovaginal fistulae, especially those following the insertion of Imaging midurethral tapes.

Cystography is not very helpful if a clinical diagnosis of a Examination Under VVF has been made. It will, Anaesthesia And however, confirm a suspected vesicouavaginal, vesicouterine Cystoscopy or complex fistula. It is good Careful examination under practice to image the upper anaesthesia and cystoscopy urinary tract in all patients with is required to determine the VVF. An intravenous urography following:- (IVU) is usually done to exclude 1. The site of the fistula and the a ureterovaginal fistula and proximity of the fistula to the ureteric obstruction. When the ureteric orifii and bladder neck ureter is involved at the margins 2. To exclude intravesical sutures or of a VVF, an IVU will demonstrate other foreign bodies (stones) a standing coloumn of contrast 3. To assess the bladder mucosa. within the ureter, extravasation of In under-resourced countries contrast around the distal ureter schistosomiasis and tuberculosis or gross hydronephrosis. With should be excluded suspected ureterovaginal fistula, 4. To assess the mobility of the the diagnosis is confirmed by a vaginal tissue and confirm dilatated ureter with extravasation surgical access if planning of dye at the distal end and a vaginal repair normal cystogram. If the IVU

191 5. To inspect the fistula margins prevent soiling of their clothes and consider biopsy if one and to enable them to function suspects a malignancy or socially. Silicone barrier creams infection (schistosomiasis, should be applied to their vulval tuberculosis) skin and perineum to protect 6. To assess whether graft tissue them from urinary dermatitis. The will be required for definitive preoperative use of oestrogen surgery. With bladder neck vaginal cream is recommended in and proximal urethral fistulae, postmenopausal women. These there may be circumferential creams change the vaginal flora loss of the urethral sphincter to aerobic bacteria thus improving mechanism. Usage of a Martius the integrity of the vaginal wall graft at definitive surgery will and promoting vaginal healing. have beneficial effects with Counselling is pivitol in the regard to assisting in urethral management of these patients. continence. It is important to remember that many of these women are healthy At cystoscopy, it may be necessary individuals who entered hospital to digitally occlude the fistula for a routine procedure and by to achieve distension. If the developing a fistula have ended up tissues are necrotic or there is with worse symptoms than their substantial slough or induration, original complaints. then definitive surgery should be delayed. Surgical Management

Preoperative Timing Of Repair Management The timing of the fistula repair is a controversial issue. Surgical success Patients should always be well should not be compromised by informed, especially during operating too early. Advances in the waiting period from fistula antibiotic therapy, suture material diagnosis to repair. The carers and surgical techniques have should always be sympathetic encouraged many surgeons to to these women’s needs which attempt early surgical repair which should always include offering if successful avoids the prolonged them incontinence pads, to morbidity and discomfort of

192 delayed repair. Several published During this period, any evidence series support early attempts of cellulitis should be vigorously at repair. If surgical injury is treated and the patient should recognized within the first 24 maintain optimal nutrition and hours postoperatively, immediate fluid intake to encourage healing. repair can be attempted, Recently, Waaldijk has advocated provided the injury site is not too surgery as soon as the slough oedematous and extravasation of separates, but more studies are urine into the tissues has not been needed to justify this approach.12 too extensive. With previous surgical failures, it is Small VVF discovered within 7 days prudent to wait at least 12 weeks of surgical injury can be treated before re-attempting to repair with continuous bladder drainage the fistula. Surgery for urogenital to facilitate spontaneous closure. fistula should only be undertaken Although the optimal duration of by surgeons with appropriate drainage has not been established, training and skills since the first it is reasonable to allow drainage attempt will give you the best for at least 4 weeks. If closure is results. not achieved, then a concomitant ureterovaginal fistula should be Route Of Repair excluded and surgery planned 12 Surgeons involved in fistula weeks later. management should be skilled in both the abdominal and vaginal With larger fistulae, definitive approach and should have the repair should be planned at 3 surgical expertise and versatility months. This period will allow for to modify their technique based the oedema and inflammation to on the individual case. When resolve and improve the likelihood access is good and the vaginal of a successful repair. tissue sufficiently mobile, the vaginal route is the preferred With obstetric related fistulae, option (less invasive, less morbidity most surgeons suggest waiting than abdominal approach). The a minimum of 3 to 4 months to abdominal route is favoured if the allow the slough to separate and vaginal access is poor, the fistula the induration to settle, before is close to the apex , and the embarking on definitive surgery. ureter is in close proximity to the

193 fistula edge (anticipate ureteric longitudinal incision should be reimplantation.) As a general made around the urethral or rule, most surgical fistula arising midvaginal fistula while vault from abdominal surgery require an fistulas are better managed by abdominal approach, perhaps with a transverse elliptical incision. the help of a skilled urologist. Because of the scarring, dissection close to the fistula is usually Instruments And Sutures:- undertaken with a scalpel or Instruments that make your Potts-De Matel scissors. It must be surgery easier include: appreciated that the actual defect 1. Fine scalpel blade on a number in the bladder may be larger 7 holder than the visible defect because of 2. Potts-De Martel scissors and a the scarring and fibrosis. Wide Chasser Moir 30 degree angle- mobilization of the bladder should on-flat scissors be performed so that the repair 3. Lone star ring retractor for is tension free. Caution should vaginal approach be exercised to avoid excessive 4. Skin hooks to put the tissue on bleeding and this is achieved by torsion during dissection dissecting in the correct plane. 5. Turner – Warwick double curved needle holder Principles Of Fistula Repair 1. Excision of all scar tissue around Absorbable sutures, including the fistula tract polyglactin (vicryl) 2-0 sutures on a 2. Wide mobilization of the 25 mm heavy taper cut needle are bladder preferred for the vagina and a 2-0 3. Tension free layered closure vicryl suture on a round body for 4. Interposing tissue between the the bladder. For ureteric implants, 2 organs a 4-0 polydiaxonone (PDS) on a 13 5. Obtaining a water tight tension mm round bodied needle is the free closure suture of choice. 6. Good haemostasis 7. Complete bladder drainage Dissection postoperatively Great care must be taken over 8. Prophylactic antibiotics the initial dissection. The fistula should be circumscribed in the Vaginal Repair most convenient orientation. A 1. Circumferential incision is

194 made around fistula using a into the foley catheter. size 12 blade. Initial incision 9. Close the vaginal epithelium can be aided by inserting a with interrupted suturing foleys catheter through the along the vertical plane to fistula, inflating the bulb and avoid overlapping of the suture by exerting traction on the repair between the bladder and catheter. It allows for access to vagina. the fistula. 2. Sharp dissection around the Abdominal Approach fistula edges. This can either be transvesical or 3. The bladder is separated transperitoneal. from the vaginal wall and fully mobilised. Potts-De Transvesical Matel scissors are used for the This approach is extraperitoneal. dissection. The cave of Retzius is entered and 4. The fistula edges are trimmed. a vertical incision on the dome of 5. The bladder is sutured the bladder is made. The fistula transversely. The first 2 sutures is identified and the ureters are are inserted at the angles stented. A vaginal probe is inserted using vicryl 2-0. Additional into the vagina and the fistula sutures are inserted towards site is elevated. The fistula tract the centre from both angles is circumscribed and the bladder with interrupted closure. The is mobilised with the Potts De- sutures are usually placed 3 mm Matel scissors. The vagina (VVF) apart (less interference with or uterus (vesicouterine) is sutured vascular supply as compared to with interrupted vicryl through continuous suturing). the bladder and the bladder 6. Avoid penetration of the is then sutured at 90 degrees bladder mucosa during suture (interrupted vicryl) so that the insertion and ensure that the repair sites do not overlap. The knots are secure and cut short. initial bladder cystotomy is then 7. The second layer of sutures repaired with continuous vicryl. A should invert the first layer. This disadvantage of this route is that is also done with interrupted no interposition graft can be used. suturing. 8. Confirm a water tight seal by Transperitoneal instilling methylene blue dye With this approach, the peritoneal

195 cavity is entered. urethral fistula repair to provide Indications are:- bulk to maintain competence of 1. complex fistulae the closure mechanism. 2. if the surgeon anticipates that a ureteric implant may need to With the abdominal approach, be performed (because of close an omental pedicle graft may be proximity of the fistula site to utilised to improve success. It is the ureter) created by dissecting the omentum 3. large/high fistula where there is from the greater curve of the poor vaginal access stomach and rotating it down into the pelvis on the gastro-epiploic With this approach, the cave of artery. It is then secured to the Retzius is entered. A midline split repair site. of the dome of the bladder is performed and extended to the Postoperative Management fistula site resulting in a racquet As a general principle, the shaped incision. The bladder is best postoperative cure is a mobilised and the fistulous tract good intraoperative surgery. excised. Layered closure is then Furthermore, nursing care is performed, first closing the vaginal critical during this period as poor epithelium and then the bladder. nursing care can undermine what has been achieved by the surgical team. Important principles are as Interposition Grafts follows:- 1. Good fluid intake At times, fistula repair may require (approximately 3 litres/24 hours) additional tissue to provide and strict input and output. support, bring in new blood supply 2. Good bladder drainage. Free to the area and to fill dead space. drainage is critical as bladder clots may obstruct the outflow With the vaginal approach, one resulting in distension of the can use either a Martius graft or bladder and disruption of the the Gracillus Muscle Graft. With repair site. the Martius graft, the labial fat 3. The ideal is to have both a pad is passed subcutaneously to suprapubic and urethral catheter cover the vaginal repair. This is with abdominal approaches and particularly useful in bladder neck a urethral 3 way catheter with

196 the vaginal approach. Following postsurgery. surgery, continuous bladder irrigation is instituted. Once the urine clears out with the 3 way foleys, a spigot is used to occlude the irrigation channel and the catheter is left in situ. With the Abdominal approach, the suprapubic is removed and the foleys is strapped to the inner thigh to avoid kinking or dragging of the catheter. 4. Prophylactic urinary antiseptic viz nitrofurantoin 100mg nocte is used as long as the patient has the catheter in situ. 5. Occasionally stool softeners are prescribed if the patient is FIGURE I: Types and locations of constipated. common urogenital fistulae. 6. Patients are advised to be on A: Vesicouterine, B: bed rest during the period of Vesicovaginal, C: Urethrovaginal catheterization and educated on catheter care. 7. With surgical fistula, 14 days of free drainage is recommended while with obstetric fistula, 25 days is recommended.

On removal of the catheter, patients are counselled that they should void more frequently initially and gradually increase the periods between voids aiming to be back to normal by 4 weeks postoperatively. Tampons, douching and penetrating sex must be avoided for at least 3 months

197 Chapter 23 The role of laparoscopy in urogynaecological procedures

Peter de Jong

Introduction There is good evidence that the management of, for example, Ever since the introduction of high- ectopic pregnancy, is superior using fidelity endoscopic equipment the endoscopic route, but this is in the field of gynaecological not necessarily true for the use surgery in the early 1990’s workers of laparoscopy in other fields of have performed traditional gynaecological surgery. gynaecological procedures using minimally invasive routes. It is important that any surgeon Generally, the endoscopic using endoscopic tools: approach allows the surgeon the • Be properly trained in the advantages of: procedure • Excellent surgical view • Enjoy the use of quality • Magnification of anatomical equipment structures • Have recourse to urological and • Bloodless dissection surgical back-up • Precise haemostasis, less blood • Have an excellent appreciation loss of pelvic anatomy • Lower incidence of adhesions • Counsel the patient fully in the • Less post operative pain, shorter spheres of surgical complications hospitalization and the need for emergency • Quicker return to normal laparotomy, otherwise the activities traditional approach is • Small incisions, cosmetic scars preferable • Lower incidence of infection This chapter will consider the

198 role of endoscopy in the fields of early 1990’s, in experienced hands prolapse and incontinence surgery. the para vaginal repair may be performed laparoscopically by means of the placement of sutures Prolapse Surgery with perfectly acceptable results. However it is not for the beginner, Apical Prolapse since suturing in this area is Laparoscopy to repair apical difficult laparoscopically. prolapse is well described and has been practiced for many years. The Similarly, the use of mesh in the procedure is identical to traditional laparoscopic management of sacrocolpopexy with the use of anterior or posterior compartment mesh, and offers the patient prolapse is well described, with the advantages of endoscopy as acceptable long term outcomes, mentioned above. provided the surgeon is well trained and highly experienced in However the operation is this art. technically highly demanding and requires extensive experience in endoscopic surgery. The advanced Urinary Stress endoscopist completes the Incontinence Surgery procedure in around an hour, and in the hands of expert surgeons The use of the laparoscopic such as Wattiez, the outcome Burch procedure was described enjoys comparable results to in the 1990’s with placement standard open sacrocolpopexy. In of sutures similar to the open terms of apical repair, at present route. However it is difficult to the ICS benchmark is still for correctly place the sutures by conventional open sacrocolpopexy laparoscopy, and the endoscopic – but in the hands of trained Burch was beyond the reach of expert endoscopists, laparoscopic most endoscopists. Moreover its sacrocolpopexy using mesh is use was overshadowed by the a well described acceptable introduction in the late 1900’s of alternative procedure. the mid urethral tapes, which were technically far easier to perform. Anterior Compartment Prolapse First described by Vancaille in the Long term results seem to be

199 equivalent to those of the traditional Burch, with equivalent cure and complication rates.

Nowadays the laparoscopic Burch procedure is confined to surgery by laparoscopic experts when performing prolapse operations, when the patient has concomitant stress incontinence.

Traditional Burch laparotomy procedures are similarly confined to cases where the patient undergoes a laparotomy for other reasons (for example, hysterectomy for large fibroids) and has concomitant stress incontinence.

200 Chapter 24 Suture Options in Pelvic Surgery

Peter de Jong

Introduction endothelial chemo-attractants and increases the rate of collagen The gynaecologist is presented synthesis by fibroblasts. By the fifth with a bewildering array of sutures day, fibroblasts are found in high and needles for pelvic surgery and numbers and the formation of a wound closure. The article aims microcirculation begins. After the to narrow the choice to a few second week, although collagen logical options that will meet most synthesis and angiogenesis are surgical requirements. reduced, the pattern of repair is reorganized and the strength of Wound Healing the wound increases, although Healing begins as soon as an never to its original level. Collagen incision is made, when platelets synthesis and lysis are delicately are activated and release a balanced. During the first 12-14 series of growth factors. Within days the rate at which wound minutes, the wound displays strength increases is the same, a mild inflammatory reaction irrespective of the type of tissue. characterised by the migration of Thus, relatively weak tissue, such neutrophils which are attracted as bladder mucosa, may have by degradation products of fibrin regained full strength, whereas and fibrinogen. During this time, fascia will only have recovered and until the proliferative phase by 15%. Moreover, it takes three of healing begins, wound strength months for an aponeurosis to is low. Macrophages peak at 24 recover 70% of its strength and hours and produce lactate. This it probably never regains its full promotes the release of angiogenic strength.

201 Factors Affecting Healing Surgical Principles Many factors influence healing, including age, nutrition, Basic surgical principles influence vascularity, sepsis and hypoxia. the healing process, and the Some medical conditions, such best sutures are useless unless as diabetes, malnutrition, use of meticulous attention to surgical steroids, uraemia, jaundice and detail is observed. There are a anaemia effect healing adversely. number of surgical guidelines Another factor of relevance to the which promote better outcomes of gynaecologist is the menopause, surgery: since it has been shown that oestrogen accelerates cutaneous The incision healing by increasing local A thoughtful surgeon plans the growth factors. Postmenopausal length, direction and position of women having vaginal surgery the incision in such a way as to are therefore advised to use provide maximal exposure and pre-operative topical oestrogen. a good cosmetic result, with a Cigarette smoking can also affect minimum of tissue disruption. healing adversely. Maintenance of a sterile field and With regard to infection, the aseptic technique. main source of contamination Infection deters healing, and the is endogenous, with only about surgeon and theatre team must 5% of infections being airborne. observe all proper precautions Most gynaecological operations to avoid contamination of the are clean (0-2% rate of infection) operative field. Laparoscopic or clean/contaminated when the surgery affords a favorable vagina is incised (2-5% rate of environment to prevent infection). Other surgical factors in contamination by extraneous infection include local trauma from debris and airborne infection. excessive retraction, over-zealous Gentle handling of tissue and diathermy and operations lasting precise dissection causes less tissue more than two hours. damage, with resultant fewer adhesions, and reduced post operative pain.

202 Dissection Technique tissue (secondary to cautery) to A clean incision with minimal reduce the likelihood of scarring , tissue trauma promotes speedy adhesion formation and infection. healing. Avoid careless ripping of tissue planes and extensive cautery Foreign bodies burns. Atraumatic tissue handling Avoid strangulating tissue with is the hallmark of a good surgeon. excessive surgical sutures. These Pressure from retractors devitalizes represent a significant foreign structures, causes necrosis and body challenge and reduce tissue traumatizes tissue and this oxygen tension. Certain sutures predisposes to infection. Swabs are such as chromic gut, provoke more remarkably abrasive, and if used to inflammatory reaction than others, pack off bowel, must be soaked in for example nylon. saline.

Haemostasis Wound closure Good haemostasis allows greater surgical accuracy of dissection, Choice of material prevents haematomas and The appropriate needle and suture promotes better healing. When combination allows atraumatic clamping, tying or cauterizing tension, free tissue approximation, vessels, prevent excessive tissue with minimal reaction, and damage. sufficient tensile strength.

Avoid tissue dessication Elimination of dead space Long procedures may result in Separation of wound edges the tissue surface drying out, permits the collection of fluid with fibrinogen deposition and which promotes infection and ultimately adhesion formation. wound breakdown. Surgical drains Periodic flushing with Ringer’s help reduce fluid collections. lactate solution is a sound surgical principle. Stress on wounds Postoperative activity may Removal of surgical debris stress the wound during the Debride devitalised tissue, and healing phase. Coughing stresses remove blood clots, necrotic debris, abdominal fascia, and careful foreign material, and charred wound closure prevents disruption.

203 Excessive tension causes tissue Minimally reactive to tissue necrosis, oedema and discomfort. Non capillary, non allergenic. The capillary The length of the suture for action of braided material promotes infec- wound closure should be six times tion, as opposed to non-braided sutures length of the incision to prevent Resistant to shrinkage and contraction excessive suture tension. Complete absorption after predictable interval Choice Of Suture Available in desired diameters and lenghth Many surgeons have a personal preference for sutures both as a Available with desired needle sizes result of proficiency in a particular technique and the suitable In general terms, the thinnest handling characteristics of a suture to support the healing suture and needle. Knowledge tissue is best. This limits trauma of the physical characteristics of and, as a minimum of foreign suture material, the requirements material is used, reduces local of wound support, and the type tissue reaction and speeds re- of tissue involved, is important absorption. The tensile strength of to ensure a suture used which the material need not exceed that will retain its strength until of the tissue. the wound heals sufficiently to withstand stress. While most Monofilament vs. braided suture materials cause some tissue material reaction, synthetic materials such Monofilament sutures (for as polyglactin 910 tend to be less example nylon) are made from a reactive than natural fibers like single strand of material, and are silk. less likely to harbor organisms than multifilament braided material Suture Characteristics (table II). The properties and characteristics of the “ideal” suture are listed in Because of its composition Table I monofilament material may have a “memory” and care should be Table I: The Ideal Suture taken when handling and tying monofilament sutures – perhaps Good handling and knotting characteristics a few extra throws on a proper High tensile strength surgical knot would prevent unravelling. 204 Table II: Suture Properties Mate- Prop- Compo- Made Trade Tissue Strength Absorp- rial erty sition from Name Reactiv- Reten- tion ity tion

Natural Absorb- Spun Plain gut Consid- 7-10 70 days able erable days

Chromic Moder- 10-14 90 days gut ate days

Non Braided Silk Acute 6 2 years absorb- Inflam- months able mation

Mono- Stainless Minimal Main- Nil filament steel tained wire

Syn- Absorb- Braided Polygla- Vicryl* Minimal 50% at 70 days thetic able ctin 21 days

Mono- Co-poly- Monocryl* Minimal 40% at 4 filament mer 14 days months

Co-poly- PDS II* Slight 50% at 6 mer 28 days months

Non Braided Polyester Ethibond* Minimal Main- Nil absorb- Mersilene tained able

Mono- Nylon Minimal 20% per Years filament year

Polypro- Prolene* Minimal Main- Nil pylene tained

* Trademark

Minimal=”very little”, Slight=”some”

Avoid nicking or crushing a use in micro-surgery applications, monofilament strand, as this may and slightly heaver grades are create a point of weakness. They appropriate for skin closure. have a smooth surface and so pass easily though tissue. Nylon sutures Multifilament sutures consist of have high tensile strength and very several filaments braided together, low tissue reactivity and degrade in affording greater tensile strength, vivo at 15% per year by hydrolysis. pliability and flexibility with Fine nylon sutures are suitable for good handling as a result. They

205 must be coated to reduce tissue Specific Sutures And resistance and improve handling characteristics. Because of their Applications inherent capillarity they are Surgical gut more susceptible to harbouring Absorbable surgical gut may be organisms than monofilament plain or chromic, and spun from sutures. strands of highly purified collagen. Absorbable vs. non-absorbable The non –collagenous material materials in surgical gut causes the tissue reaction. Ribbons of collagen are Absorbable sutures are prepared spun into polished strands, but from the collagen of animals or most protein-based absorbable from synthetic polymers. Catgut sutures have a tendency to fray is manufactured from sheep when tied. Surgical gut may be submucosa or bovine serosa and used in the presence of infection, may be treated with chromium but will then be more rapidly salts to prolong absorption time. absorbed. Surfaces may be Enzymes degrade the suture, with irregular and so traumatise tissue an inflammatory response. during suturing. The loss of tensile strength and the rate of absorption are separate Plain surgical gut is absorbed phenomena. A suture can lose within 70 days, but tensile strength tensile strength rapidly and yet is maintained for only 7-10 days be absorbed slowly. If a patient is post operation. Chromic gut is febrile or has a protein deficiency, collagen fiber tanned with chrome the suture absorption process may tanning solution before being accelerate, with a rapid loss of spun into strands. Absorbsion is tensile strength. prolonged to over 90 days, with tensile strength preserved for 14 Non-absorbable sutures may be days. Chromic sutures produce processed from single or multiple less tissue reaction than plain gut filaments of synthetic or organic during the early stages of wound fibers rendered into a strand by healing, but are unsuitable for spinning, twisting or braiding. certain procedures , such as in They may be coated or uncoated, fertility surgery. uncoloured or dyed.

Recently, the use of sutures of

206 animal origin has been abandoned approximation where short-term in many countries because of the support is desired, for example for theoretical possibility of prion episiotomy repair. protein transmission, thought to be responsible for Creutzfieldt- Polyglecaprone 25 (i.e. monocryl™) Jakob disease. is a synthetic monofilament co- polymer that is virtually tissue Synthetic absorbable sutures inert, with predictable absorption Synthetic absorbable sutures were completed by 4 months. It has developed to counter the suture high tensile strength initially, antigenicity of surgical gut, with but all strength is lost after one its excess tissue reaction and month. It is useful for subcuticular unpredictable rates of absorption. skin closure and soft-tissue approximation, for example during Polyglactin 910 (i.e. Vicryl) is Caesarean Section. braided copolymer of lactide and glycolide, allowing approximation Polydioxanone (i.e. PDS II™) is of tissue during wound-healing absorbable and also monofilament followed by rapid absorption. composition, but has more tissue At 3 weeks post-surgery 50% of reaction than monocryl. It supports its tensile strength is retained. wounds for up to 6 weeks, and is The sutures may be coated with absorbed by 6 months. Synthetic a lubricant to facilitate better absorbable monofilament sutures handling properties of the are useful for subcutaneous skin material. Absorption is minimal closure since they do not require until day 40, completed about 2 removal. This suture is suitable for months after suture placement, sheath closure at laparotomy. with only a mild tissue reaction. Non absorbable sutures Occasionally it is desirable to have Surgical silk consists of filaments a rapid-absorbing synthetic suture, spun by silkworms, braided into a such as Vicryl Rapide™. The suture suture which is dyed then coated retains 50% of tensile strength with wax or silicone. It loses most at 5 days, and since the knot its strength after a year, and “falls off” in 7 to 10 days, suture disappears after about 2 years. removal is eliminated. It is only Although it has superior handling suitable for superficial soft tissue qualities, it elicits considerable

207 tissue reaction, so is seldom used in minimal tissue reactivity, and gynaecology nowadays. maintain tensile strength. Prolene*, for example, has better Synthetic non absorbable suture handling properties sutures than nylon, and may be used in Nylon sutures consist of a contaminated or infected wounds polyamide monofilament with very to minimize sinus formation and low tissue reactivity. Their strength suture extrusion. They do not degrades at 20% per year, and the adhere to tissue and are easily sutures are absorbed after several removed. years. Because of the «memory» of nylon, more throws of the knot are Topical skin adhesions required to secure a monofilament Where skin edges appose under suture than braided sutures. Nylon low tension, it is possible to glue sutures in fine gauges are suitable edges together with glue, such for micro-surgery because of the as Dermabond™. It is a sterile properties of high tensile strength liquid, and when applied onto and low tissue reactivity. the skin (not into the wound) seals in three minutes. It protects Polyester sutures are composed of and seals out common bacteria, braided fibers in a multifilament commonly associated with wound strand. They are stronger than infections, and promotes a natural fibres and exhibit less favourable, moist, wound healing tissue reaction. Mersilene* environment, speeding the rate synthetic braided sutures last of epithelialisation. The adhesive indefinitely, and Ethibond* is gradually peels off after 5 – 10 coated with an inert covering days with a good cosmetic result. that improves suture handling, Subcutaneous sutures need to minimises tissue reaction and be placed to appose skin edges maintains suture strength. They if topical skin adhesions are to are unsuitable for suturing vaginal be used. It may especially be epithelium, as they are non- used in cases of Laparoscopy to absorbable. close several small skin incisions, Polypropylene monofilament and obviate the need for suture sutures are synthetic polymers that removal. Skin adhesive use are not degraded or weakened eliminates the pain occasionally by tissue enzymes. They exhibit associated with skin sutures, but is

208 unsuitable for vaginal use. Choosing A Surgical

Adhesive Tapes Needle Adhesive tapes are used Fig 1 shows the anatomy of approximating the edge of the needle. A cutting needle is lacerations or to provide increased designed to penetrate tough wound edge support and less tissue such as the sheath or skin. skin tension. This is important Conventional cutting needles if patients tend to form keloids have an inside cutting edge on during scar healing. In this the concave curve of the needle, case, the wound is closed with with the triangular cutting blade monofilament absorbable sutures, changing to a flattened body (See carefully cleaned, and sprayed Fig 2). with surgical spray to promote adhesive tape adhesion to the skin. The curvature of the body is The wound is closed with a sterile flattened in the needle grasping waterproof dressing after adhesive area for stability in the needle tapes are placed to provide skin holder, and longitudinal ridges support. may be present to reduce rocking The dressing is removed after a or twisting in the needle holder. week, but the adhesive tapes are allowed to fall off at a later stage. Reverse cutting needles have a They have minimal tissue reactivity third cutting edge on the outer and yield the lowest infection rates convex curvature of the needle, of any closure method. making for a strong needle able to Tapes do not approximate deeper penetrate very tough skin or tissue tissues, do not control bleeding, (See fig 3). and are unsuitable for use on hairy areas or in the vagina. Apply Taper point needles are round, and them gently to avoid unequal so pierce and spread tissue without distribution of skin tension, which cutting it. The body profile flattens may result in blistering. to an oval or rectangular shape to prevent needle rotation in the needle holder. They are preferred for atraumatic work with the smallest hole being desirable, in easily penetrated tissue, but are

209 not suitable for stitching skin (See for an “eye” in the needle. Eyed Fig 4). needles need to be threaded, and create a larger hole with greater Tapercut needles combine the tissue disruption than a swaged features of the reverse – cutting needle. The swaged end of needle edge tip and taper point needle. is securely crimped over the suture The trochar point readily material, and may be available penetrates tough tissue, with a with the controlled release option. round body, moving smoothly This feature allows rapid suture through tissue without cutting placement and a slight, straight surrounding tissue (See Fig 5). tug will release it from the needle to allow tying. Avoid grasping Blunt point needles have a the needle holder at the swaged rounded, blunt point that does not end. This may be weaker than cut through tissue. They are used the flattened body and cause for general closure of tissue and disintegration of the needle. fascia especially when performing procedures on at-risk patients (See Abdominal wound closure Fig 6). Modern sutures are uniform and strong and wound dehiscence will Tissue trauma is increased if only be due to suture failure in the needle bends during tissue exceptional circumstances, with penetration, and a weak needle improper tying of knots or damage damages structures and may snap. to the suture by instruments. The Reshaping a bent needle may suture can cut through if wide make it less resistant to bending enough bites are not taken and if and breaking. Needles are not the suture is too tight. Premature designed to manipulate tissue or to loss of strength only occurs with be used as retractors to lift tissue. absorbable sutures, especially Ensure the needle is stable in the catgut. grasp of a needle holder. The grasping area is usually flattened, The closure of low transverse and heavier needles are ribbed as incisions is simplified by the well as flattened to resist rotating fact that they generally heal in the needle holder (See Fig 7). well, with a low incidence of Most sutures are attached to dehiscence and hernia whatever swaged needles, without the need suture is used. Closure of midline

210 incisions presents more problems. of the wound to allow for the The integrity of any wound is 30% increase in abdominal completely dependant on the circumference postoperatively. suture until reparative tissue has Permanent sutures should still bridged the wound. First principles be considered where the risk of therefore indicate that rapidly wound failure is particularly high. absorbable sutures will have a greater tendency to fail than non- Closure of the peritoneum was absorbable sutures. Studies have shown in 1977 to be unnecessary, shown that catgut is associated this was confirmed in 1990 by a with an unacceptably high risk of randomised controlled trial. evisceration and incisional hernia and should not be used. Skin closure In gynaecological practice, there Experimental work on rats has are many options for skin closure, shown that mass closure with but cosmesis is more important monofilament nylon significantly than in general surgery where the reduces the dehiscence rate avoidance of infection is more of a compared with braided suture, as concern. Lower transverse incisions bacteria reside in the interstices heal well because of the lack of of infected multifilament sutures. tension. Full-thickness interrupted However, in some patients, stitches must not be too tight as removal of suture material oedema may lead to disfiguring will be required due to sinus crosshatching, particularly formation. Delayed absorbable if infection forms along the sutures have been assessed track. Very thin monofilament for abdominal wound closure absorbable or non-absorbable and it was found that wound sutures are preferable but a dehiscence is similar without the subcuticular stitch leaves less of a problem of sinus formation. A scar (Figure I). Similar assessment randomised controlled trial of of laparoscopy scars suggests that polyglyconate (Maxon™) versus subcuticular polyglactin (Vicryl™) nylon in 225 patients showed that is better than transdermal nylon. polyglyconate was as effective Staples are popular because there at two-year follow-up. Suture is less chance of bacterial migration length should be approximately into the wound, although the risk four times to six times the length of infection in most gynaecological

211 surgery is low. Properly conducted Where cosmetic results are clinical trials have shown the only important, close and prolonged benefit of staples to be speed, skin opposition is desired, so there is more wound pain and a thin, inert material such as nylon worse cosmetic result compared or polypropylene is best. Close with subcuticular sutures. subcutaneously when possible, and use sterile skin closure strips to secure close opposition of skin Hints And Tips edges when circumstances permit. Try to use the finest suture size Personal preference will always commensurate with the inherent play a part in needle and suture tissue strength to be sutured. selection, but the final choice will depend on various factors that influence the healing process, Conclusion the characteristics of the tissue and potential post-operative With a little thought and complications. preparation we should use the suture and needle best suited Close slow-healing tissues (i.e. to the surgery which is being fascia or sheath) with non- performed. It is essential that we absorbable or long-lasting are aware of what is available absorbable material, i.e. Pds or and how it may best be utilized. vicryl. Surgical training should include the characteristics and applications Close fast-healing tissue such as of sutures and needles. a bladder with rapidly absorbed sutures. Non-absorbable sutures such as nylon form a nidus for stone formation. Foreign bodies in potentially contaminated tissue may convert contamination into infection. So avoid multifilament, braided sutures under these circumstances – rather use monofilament material.

212 Chapter 25 Thromboprophylaxis in Urogynaecological Surgery

Barry Jacobson

When the gynaecologist decides gynaecological surgery. Patients that a woman requires surgery should be divided into open versus for prolapse or incontinence, it is laparoscopic surgery. Patients essential that a decision be made undergoing “open” surgery, as to whether she requires peri- including vaginal surgery, should operative thromboprophylaxis. be given low molecular weight heparin prophylaxis routinely. The first decision is based on the The debate arises in laparoscopic risk factors for that particular surgery, which appears to have a patient. Any patient who has had very low risk of VTE. Furthermore a previous venous thromboembolic prescribing anticoagulation to (VTE) event is obviously at high these patients increases the risk of risk. Other important risk factors minor bleeding and this therefore include an underlying malignancy, could potentially increase the rate age more than 76 years, use of an of having to convert a laparoscopic estrogen containing product and procedure to an open procedure. obesity. A relatively simple scoring table promoted by the Southern Although there is little data to African Society of Thrombosis and support the use of intermittent Haemostasis has been devised. pneumatic compression devices, (See attached table). Note that the European Association smoking is not a risk factor. for Endoscopic Surgery has recommended that they be There is a paucity of randomized used routinely for all prolonged data on the risk of thrombosis laparoscopic procedures. The after gynaecological surgery, American guidelines mandated especially non oncological that patients undergoing

213 laparoscopic procedures who do should be offered LMWH as well not have additional risk factors as the graduated compression should not be offered any stockings. thromboprophylaxis other than early and frequent ambulation. So in summary, any patient having a laparotomy ought to receive The Author suggests that the LMWH thromboprophylaxis, European recommendation should generally given 6 hours after be followed. All patients who surgery. have additional VTE risk factors

Thrombosis Risk Factor Assessment

Choose All That Apply Each Risk Factor Represents 1 point Each Risk Represents 3 points

• Age 41 – 60 years • Age > 75 years • Minor surgery planned • History of DVT/PE • History of prior major surgery (< 1 month) • Family history of thrombosis • Varicose veins (large) • Positive factor V Leiden • History of inflammatory bowel disease • Positive prothrombin 20210A • Swollen legs (current) • Positive lupus anticoagulant • Overweight (BMI >25 kg/m2) • Elevated anticardiolipin antibodies • Acute myocardial infarction • Other congenital or acquired thrombophilia • Congestive heart failure (CHF) (<1 month) • Sepsis (< 1 month) • Serious lung disease including pneumonia (<1 month) • Abnormal pulmonary function (COPD) • Medical patient currently at best rest

Risk Factor Score Total Risk Factor Score Incidence of DVT* Risk Level

0 – 1 < 10% Low Risk

2 10 – 20 % Moderate Risk

3 - 4 20 – 40 % High Risk

5 or more 40 – 80 % Highest Risk

214 Prophylaxis Safety Considerations: Check box if answers if “yes” Anticoagulants: Factors Associated with Increased Bleeding

Is patient experiencing any active bleeding?

Does patient have (or had a history of) HIT?

Is patient’s platelet count < 100.000/mm 3?

Is patient taking oral anticoagulants, platelet inhibitors (e.g. NSAIDS, Clopidogrel, salicylates)?

Is patient’s Creatinine clearance abnormal? Please indicate value:

If any of the above boxes are checked, the patient may not be a candidate for anticoagulant therapy and should be considered for alternative prophylactic measure.

Intermittent Pneumatic Compression (IPC)

Does patient have severe peripheral arterial disease?

Does patient have CHF?

Does patient have an acute/superficial DVT?

If any of the above boxes are checked, the patient may not be a candidate for IPC therapy and should be considered for alternative prophylactic measures.

215 Textbook of Urogynaecology

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 Editors: floor dysfunction has also grown extensively. This multi- Stephen Jeffery contributor text, authored by a multi-disciplinary team of Peter de Jong experts from around South Africa, concisely summarises the most up-to-date concepts and management strategies in urogynaecology. It will prove invaluable to gynaecology, urol- ogy and surgery registrars and specialists. Physiotherapists and nurses working in the field of urogynaedcology will also find it extremely useful.