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 Creative Commons Attributive Licence 2010 This publication is part of the CREATIVE COMMONS You are free: to Share – to copy, distribute and transmit the work to Remix – to adapt the work Under the following conditions: Attribution. You must attribute the work in the manner specified by the author or licensor (but not in any way that suggests that they endorse you or your use of the work) Non-commercial. You may not use this work for commercial purposes. Share Alike. If you alter, transform, or build upon this work, you may distribute the resulting work but only under the same or similar license to this one. • For any reuse or distribution, you must make clear to others the license terms of this work. One way to do this is with a link to the license web page: http://creativecommons.org/licenses/by-nc-sa/2.5/za/ • Any of the above conditions can be waived if you get permission from the copyright holder. • Nothing in this license impairs or restricts the authors’ moral rights. • Nothing in this license impairs or restricts the rights of authors whose work is referenced in this document • Cited works used in this document must be cited following usual academic conventions • Citation of this work must follow normal academic conventions http://za.creativecommons.org 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.