UPDATE IN UROGYNAECOLOGY

1
UPDATE IN UROGYNAECOLOGY

• Bernard T. Haylen
• St. Vincents Clinic, Mater
  Randwick Urodynamic Centres, Sydney
• www.bladder.com.au
  

2
UROGYNAECOLOGY

• AREA OF GYNAECOLOGY AND FEMALE
• UROLOGY INVOLVING THE ASSESSMENT
• AND TREATMENT OF LOWER URINARY
• TRACT AND PELVIC FLOOR DYSFUNCTION
• INCLUDING UTERINE AND VAGINAL
• PROLAPSE

3
INCIDENCE OF UROGYNAECOLOGICAL PROBLEMS

• OVERALL
• High
• INCONTINENCE
• 34 Australian women (11 severe)
• PROLAPSE
• 50 of postmenopausal women at routine
  gynaecological examination will have some degree
  of prolapse

4
UROGYNAECOLOGY

• DIAGNOSES

5
UROGYNAECOLOGY - COMMON DIAGNOSES

• URODYNAMIC STRESS INCONTINENCE
• (USI) - 70
• DETRUSOR OVERACTIVITY (DO) 15-40
• VOIDING DIFFICULTIES 14-39
• (Definition dependent)
• UTERINE/VAGINAL PROLAPSE - 65

6
UROGYNAECOLOGY - URODYNAMIC STRESS INCONTINENCE
(USI)

• The diagnosis of USI is urinary incontinence due
  to weakness or incompetence of the bladder neck
  and/or urethral sphincter closure mechanisms that
  normally maintain continence
• The symptom of stress incontinence is the
  involuntary loss of urine with coughing,
  sneezing, running, jumping etc. This is the most
  likely associated symptom of USI.

7
UROGYNAECOLOGY - DETRUSOR OVERACTIVITY (DO)

• Abnormal contractions of the intrinsic bladder
  (detrusor) musculature
• Irritable bladder symptoms such as frequency,
  urgency, urge incontinence and nocturnal enuresis
  are more likely to be present with this condition

8
UROGYNAECOLOGY VOIDING DIFFICULTY

• Abnormally slow or incomplete micturition
• Abnormally slow urine flow rate or high postvoid
  residual urine volume
• If high residual (over 30mls) recurrent urinary
  tract infections can ensue
• May be due to hypotonic or atonic bladder or
  bladder outflow obstruction

9
UROGYNAECOLOGY - UTERINE/VAGINAL PROLAPSE

• Abnormal descent into the vagina of the uterus,
  bladder (cystocoele) vaginal vault (enterocoele)
  or rectum (rectocoele)
• 560 Consecutive urogynaecology patients with
  incidence of
• . Uterine prolapse (15 overall)
• . Cystocoele (57
  overall)
• . Rectocoele (41
  overall)
• . Enterocoele ( 8
  overall)

10
UROGYNAECOLOGY - OTHER DIAGNOSES

• MIXED DIAGNOSES
• Its very common for women to have more than
  one of the most common diagnoses e.g USI/DO,
  USI/prolapse
• Women with prolapse often have USI and may
  also have DO and voiding difficulties
• INTERCURRENT DIAGNOSES
• 8 of urogynaecology patients will have other
  pelvic pathology (e.g. fibroids, ovarian
  pathology) whilst many more will have other
  gynaecological symptomatology.
• OTHER DIAGNOSES
• . Inflammation, Fistula, Urethral Diverticulum

11
UROGYNAECOLOGY RECURRENT URINARY TRACT
INFECTIONS

• One of the most common bacterial infections in
  General Practice.
• 40 women affected sometime in their life
• 27 have a recurrence within 6 to 12 months
• Definition uncertain to date
• 2 or more symptomatic and medically
  documented UTI in the last 12 months

12
UROGYNAECOLOGY RECURRENT URINARY TRACT
INFECTIONS

• 1140 consecutive first visit referrals for
  urogynaecological assessment
• Full history, examination, urodynamics
• Prevalence 18.6
• Main Risk factors
• Nulliparity 3.7x (18-50yrs) 1.8x (over 50)
• Postvoid Residual (PVR) over 30mls

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UROGYNAECOLOGY

• AETIOLOGY
• (for background reading)

14
UROGYNAECOLOGY AETIOLOGY OF URODYNAMIC STRESS
INCONTINENCE

• 1 CHILDBIRTH Number 1 cause by far
• Risk Factors Vaginal delivery heavy baby
  (gt4kg) prolonged 2nd stage labour (gt1hr
  pushing). Caesarean section protective in short
  term.
• 2 MENOPAUSE Mean age for presentation of women
  with urinary tract and pelvic floor dysfunction
  is 55 years.
• 3 HYSTERECTOMY Much incontinence present but
  not discussed at time of hysterectomy. Some new
  dysfunction post-hysterectomy with voiding
  difficulties not uncommon.

15
UROGYNAECOLOGY AETIOLOGY OF DETRUSOR
OVERACTIVITY

• MANY THEORIES
• 1 IDIOPATHIC Absence of inhibitory
  neuro-transmitters or increased spontaneous
  detrusor contractions
• 2 NEUROGENIC Lesions to frontal lobe, pontine
  lesions or lesions above S2-4 give detrusor
  overactivity
• 3 OBSTRUCTIVE Postsurgical or with prolapse
• 4 INFECTIVE

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UROGYNAECOLOGY AETIOLOGY OF PROLAPSE

• 1 CHILDBIRTH
• 2 HYSTERECTOMY
• 3 MENOPAUSE
• 4 PREVIOUS PROLAPSE / INCONTINENCE SURGERY

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UROGYNAECOLOGY AETIOLOGY OF VOIDING DIFFICULTY

• 1 BLADDER OUTFLOW OBSTRUCTION
• Idiopathic . Drugs (e.g
  tricyclics)
• Postoperative . Obstructive effect
  of prolapse
• Psychogenic . Distal urethral
  (ageing) changes
• Infective . External
  pressure (retroversion)
• 2 HYPOTONIC / ATONIC BLADDER
• Postpartum retention
• LMN Lesion (diabetes, peripheral neuropathy)
• Overdistension

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UROGYNAECOLOGY

• ASSESSMENT

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UROGYNAECOLOGY - INITIAL ASSESSMENT - (ALL
PRACTITIONERS)

• 1 HISTORY
• Full history with symptoms of incontinence,
  bladder irritability, prolapse and voiding
  difficulty sought
• 2 EXAMINATION
• General, Clinical Stress Leakage, Sims Speculum
  (prolapse), Bimanual
• 3 MSU
• 4 BLADDER CHART
• 5 POSTVOID RESIDUAL (U/S)/ RENAL TRACT U/S if
  recurrent UTI

20
UROGYNAECOLOGY - COMMON SYMPTOMS

• 1 INCONTINENCE
• Stress, Urge, Coital, Nocturnal
• 2 IRRITATIVE
• Urgency, Frequency (gt 7), Nocturia (gt1)
• 3 VOIDING
• Hesitancy, Poor stream, Sense of incomplete
  emptying, Need to immediately revoid, Strain to
  void
• 4 PROLAPSE
• Pelvic pressure, Vaginal lump, Sacral backache,
• Dyspareunia.
  
• 5 OTHER
• Gynaecological (pelvic pain, menstrual
  dysfunction), Neurological, Diabetes

21
UROGYNAECOLOGY - ROLE OF SYMPTOMS

• MOST WOMEN WITH PELVIC FLOOR
• DYSFUNCTION WILL PRESENT WITH
• MULTIPLE SYMPTOMS SUGGESTIVE OF
• MORE THAN ONE UROGYNAECOLOGICAL
• DIAGNOSIS.

22
UROGYNAECOLOGY COMMON SIGNS

• A CLINICAL STRESS LEAKAGE
• . Bladder FULL, Standing or left lateral
  position
• . Occult stress prolapse reduced to see
  leakage
• B PROLAPSE (UTERINE/VAGINAL)
• . Bladder EMPTY, Left lateral (Sims)
  position
• C INTERCURRENT GYNAE/UROLOGY PATHOLOGY
• . Bimanual pelvic examination
• . Speculum examination
• . Vulval examination
• . Vaginal ultrasound examination ( generally
  
• specialist assessment)

23
FEMALE URINARY INCONTINENCE CLINICAL EXAMINATION

• GRADING OF PELVIC ORGAN PROLAPSE (POP) - ICS
• For each of uterine prolapse, cystocoele,
  rectocoele, enterocoele
• GRADE 0 No prolapse
• GRADE 1 Descent towards vaginal introitus (gt1cm
  above hymen)
• GRADE 2 Descent to vaginal introitus (hymen /-
  1cm from hymen)
• GRADE 3 Descent through introitus (gt 1cm below
  hymen)
• GRADE 4 Prolapse totally outside introitus
• (uterine grade 4
  procidentia)

24
Figure 1 Prolapse staging 0,1,2,3,4 (uterine
by the position of the leading edge of the
cervix) N.B. vaginal eversion in stages 3 4
Symphysis
BH / JL 2007
Position Section 2D (ii/iii)
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Figure 11 Pelvic Organ Prolapse
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UROGYNAECOLOGY ROLE OF MID STREAM URINE

• 33 of women with symptoms of pelvic floor
  dysfunction will have frequency and/or dysuria -
  ? UTI
• UTI might cause or exacerbate symptoms of pelvic
  floor dysfunction
•  Recurrent UTIs might be a reflection of a
  chronic abnormally high postvoid residual (above
  30mls can lead to recurrent UTIs)

27
UROGYNAECOLOGY ROLE OF BLADDER DIARY

• 3 DAYS CHARTING TIME AND AMOUNT OF EACH VOID,
  FLUID INTAKE AND EPISODES OF INCONTINENCE
• Indicator of urinary frequency or nocturia (
  this can be altered by bladder training)
• Indicator of average voided volume (should be
  200-300mls)
• Indicator of severity of incontinence (number of
  leaks)
• Indicator of above average (gt2 litres) or below
  average (under 1 litre) fluid intake

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Figure 2 Bladder Diary
This simple chart allows you to record the fluid
you drink and the urine you pass over 3 days (not
necessarily consecutive) in the week prior to
your clinic appointment. This can provide
valuable information. Please fill in
approximately when and how much fluid you drink,
and the type of liquid. Please fill in the time
and the amount (in mls, or ounces) of urine
passed, and mark with a star if you have leaked
or mark with a P if you have needed to change
your pad. (Please find below an example of how to
complete this form.)
Summary Frequency 9 Nocturia 1 Urine
production / 24 hour 1250 ml Maximum voided
volume 300 ml Average void 125 ml
Position Section 2F (i/ii)
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UROGYNAECOLOGY INITIAL GENERAL MEASURES

• WEIGHT LOSS often reduces symptom of stress
  incontinence
• REDUCED CAFFEINE reduced frequency, bladder
  irritability
• IMPROVE CHEST CONDITIONS or other exacerbating
  factors for stress incontinence
• VAGINAL OESTROGENS May improve frequency,
  nocturia, urgency and condition of the vaginal
  mucosa. Little proven benefit for incontinence
  over placebo
• MEDICATIONS Adverse effect of diuretics,
  Minipress
• PHYSIOTHERAPY Best if incontinence is mild to
  moderate and stress incontinence is the main
  symptom

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UROGYNAECOLOGY

• ? REFERRAL /
• URODYNAMIC TESTING

31
UROGYNAECOLOGY REFERRAL FOR URODYNAMICS

• MIXED SYMPTOMS - Diagnosis uncertain
• SEVERE SYMPTOMS
• FAILURE OF INITIAL MEASURES
• DEFINITIVE TREATMENT ANTICIPATED - Surgery for
  Urodynamic Stress Incontinence
• - Anticholinergics for Detrusor Overactivity

32
UROGYNAECOLOGY AIMS OF URODYNAMICS (a)

• 1 IDENTIFY/ ELIMINATE DETRUSOR OVERACTIVITY
• TEST Cystometry
•  
• 2 IDENTIFY/ ELIMINATE VOIDING DIFFICULTIES
• TESTS Urine flow rate, Residual
  urine, Voiding cystometry
•  

33
UROGYNAECOLOGY AIMS OF URODYNAMICS (b)

• 3 CONFIRM PRESENCE OF URODYNAMIC STRESS
  INCONTINENCE
• TESTS Stress urine leakage, ultrasound
• imaging
•  
• 4 IDENTIFY PRESENCE OF PROLAPSE AND INTERACTION
  WITH OTHER BLADDER DYSFUNCTION
•  
• 5 ASSESS SEVERITY OF ALL DIAGNOSES PRESENT

34
UROGYNAECOLOGY URODYNAMICS WHATS INVOLVED?

• 1 hour assessment Including initial and final
  discussion
• History and Examination
• Vaginal Ultrasound (Bladder neck, postvoid
  residual and pelvic, uterine assessment)
• Uroflowmetry
• Filling and voiding cystometry

35
UROGYNAECOLOGY

• URODYNAMIC TESTING
• - CRITERIA FOR DIAGNOSES
• ( Further Reading)

36
UROGYNAECOLOGY Dx OF GENUINE STRESS
INCONTINENCE

• CLINICAL STRESS LEAKAGE (Examination, Pad Test)
• BLADDER STABLE
• (or stable when leakage occurs)
• IMAGING EVIDENCE
• Bladder neck incompetent

37
Figure 5 Schematic diagram of fillingcystometry
filling cystometry
voiding cystometry
FD
ND
SD
U
CC
Fill volume mls
400
300
200
100
Pves cmH2O
80
60
40
20
80
Pdet cmH2O
60
40
20
80
Pabd cmH2O
60
40
20
40
Flow rate mls/sec
30
20
10
BH / JL 2007
48 year old female with urinary frequency. No
phasic activity during filling. Voided with
normal flowrate at normal detrusor pressure.
Normal study. FD First Desire to Void, ND
Normal desire to void, SD Strong desire to
void, U Urgency, CC Cystometric Capacity
(permission to void given).
Position Section 3C (v vii), Section 3D
(iii/iv)
38
UROGYNAECOLOGY Dx OF DETRUSOR OVERACTIVITY

• CYSTOMETRY
• PRESENCE OF UNSTABLE BLADDER CONTRACTIONS ON
  FILLING OR PROVOCATION ASSOCIATED WITH SYMPTOM OF
  URGENCY

• Bladder Capacity normally 500mls with lt 10cm H20
  pressure rise
• Pressure increases over 15cm H20 abnormal
• Under 400mls capacity is low

39
Figure 9 Schematic diagram of detrusor
overactivity
filling cystometry
voiding cystometry
FD
ND
SD
U
L
L
U
MCC
400
Fill volume ml
300
200
100
80
Pves cmH2O
60
40
20
80
Pdet cmH2O
60
40
20
80
60
Pabd cmH2O
40
20
40
30
Flow rate mls/sec
20
10
BH / JL 2007
52 year old female with urgency and frequency.
Phasic activity during filling. Leakage
associated urgency and detrusor contractions. L
leakage, MCC Maximum Cystometric Capacity.
Position Section 3D (vb) Section 4B (i)
40
UROGYNAECOLOGY Dx OF VOIDING DIFFICULTIES

• SLOW URINE FLOW
• (Under 10th Centile of Liverpool Nomogram)
• HIGH RESIDUAL URINE
• Over 30mls is abnormal. 85 of women have no
  residual
• VOIDING CYSTOMETRY -
• . No Contraction, poor or no flow - Hypotonic
  or atonic
• . Strong Contraction, slow flow - Bladder
  outflow obstruction

41
Figure 4 Liverpool Nomogram for maximum urine
flow rate in women
Equation Ln (Maximum flow rate) 0.511 0.505
x Ln (voided volume) Root mean square error
0.340
Reference 20
Position Section 3A (ix)
42
Figure 10 Voiding difficulty
Example of voiding difficulty Voided volume
250ml Qmax 15mls/sec lt 10th centile on
Liverpool Nomogram and / or Post void residual
(TV USS) 78ml
Reference 20
Height (H4.5)
Pubis
Depth (D3.5)
PVR (H x D) x 5.9 15 X ml PVR (4.5 x
3.5) x 5.9 15 78ml
Reference 23
Vaginal Probe (Ultrasound)
Position Section 4D (i)
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UROGYNAECOLOGY

• URODYNAMIC STRESS
• INCONTINENCE
• - MANAGEMENT

44
UROGYNAECOLOGY CONSERVATIVE TREATMENT OF USI

• PHYSIOTHERAPY
• 50-65 improvement, 20-40 cure if properly
  supervised. 40 Contractions per day for maximal
  compliance.
• AIDS TO PHYSIO
• . Perineometer
• . Vaginal Cones
• . Electrical Stimulation
• MECHANICAL DEVICES
• . Tampons
• . Pessaries

45
UROGYNAECOLOGY SURGICAL TREATMENT OF USI

• SURGERY FOR USI
• Minimally Invasive
• . Tension-free Vaginal
• Tape J J
• . Advantage - Boston
• Traditional
• Colposuspension

46
UROGYNAECOLOGY TENSION-FREE VAGINAL TAPE (TVT)

• Minimally invasive, day-only or overnight surgery
• Inert prolene mesh no rejection or infection
• Most scientifically proven continence surgery in
  the history of Urogynaecology
• Around 800,000 TVTs performed worldwide (20,000
  in Australasia)
• Excellent combination with prolapse surgery
• 90 success rate (Primary USI)

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UROGYNAECOLOGY

• DETRUSOR OVERACTIVITY
• - MANAGEMENT

48
UROGYNAECOLOGY TREATMENT OF DETRUSOR
OVERACTIVITY

• CAN BE DIFFICULT
• 50 response from most treatments versus
  30 for placebo
• MILD/MODERATE Behavioural
• . Bladder Training
• . Maximal electrical stimulation
• . ? Acupuncture/ Hypnosis
• MODERATE/SEVERE Medication
• . Anticholinergics
• . Antidepressant
• . Antidiuretics

49
UROGYNAECOLOGY BLADDER TRAINING FOR DETRUSOR
OVERACTIVITY

• SUPPRESS URGENCY
• INCREASE VOIDED VOLUMES
• DECREASED FREQUENCY
• DECREASED URGENCY

50
UROGYNAECOLOGY DRUG TREATMENT OF DETRUSOR
OVERACTIVITY - DAYTIME

• PROPANTHELINE (Probanthine)
• - (15 - 30mg tds) - anticholinergic
• OXYBUTYNIN (Ditropan) (2.5 - 5mg tds)
  musculotrophic, antispasmodic, anticholinergic
• . Patch form available (Oxytrol)
• TOLTERODINE (Detrusitol) (1 - 2mg BD)
• antispasmodic, antimuscarinic - reduced
  S/E
• SOLIFENACIN (Vesicare) 5 -10mg daily
• - antimuscarinic - probably least S/E

51
UROGYNAECOLOGY DRUG TREATMENT OF DETRUSOR
OVERACTIVITY NIGHT TIME

• IMIPRAMNE (Tofranil) (25-75mg)
• AMITRYPTALINE (Endep) (10-25mg)
• DESMOPRESSIN ACETATE (Minirin) (200mcg ½ - 1
  nocte) - Antidiuretic for enuresis

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UROGYNAECOLOGY

• UTEROVAGINAL PROLAPSE
• - MANAGEMENT

53
UROGYNAECOLOGY TREATMENT OF UTEROVAGINAL
PROLAPSE

• ACONSERVATIVE Future child bearing desired
  younger (under 34) Medically compromised
• physiotherapy
• ring pessary

54
UROGYNAECOLOGY TREATMENT OF UTEROVAGINAL
PROLAPSE

• B Future childbearing
• unlikely under 40 years
• conservative measures
• unsuitable
• Manchester repair sacrospinous hitch
  (St. Vincents Repair)

55
UROGYNAECOLOGY TREATMENT OF UTEROVAGINAL
PROLAPSE

• C No future childbearing
• over 40 years
• vaginal hysterectomy repairs /- sacrospinous
  hitch (easiest effective vaginal vault support)

56
UROGYNAECOLOGY SURGICAL TREATMENT OF PROLAPSE

• 1 UTERINE
• . Family Complete - Vaginal Hysterectomy
• . Family Incomplete - Manchester
• 2 CYSTOCOELE
• . Primary - Anterior Repair
• . Recurrent - Anterior or Paravaginal
  Repair
• 3 RECTOCOELE Posterior Vaginal Repair
• 4 ENTEROCOELE
• . Small Posterior Vaginal Repair
• . Medium/Large Sacrospinous Hitch (90
  Success)

57
UROGYNAECOLOGY

• RECURRENT UTI /
• VOIDING DIFFICULTY
• - MANAGEMENT

58
UROGYNAECOLOGY RECURRENT UTI

• MEDICAL THERAPY
• Milder 1 2 Courses antibiotics then
• Hiprex 1Gm / Vit C 500mg each BD for
• 3 5 months according to no. of UTI
• Stronger Rotating low dose antibiotics
• e.g Keflex 500mg, ½ Triprim, or Macrodantin
  100mg each nocte 2/12 with cranberry tablet mane
• Strongest Long term Noroxin

59
UROGYNAECOLOGY RECURRENT UTI

• SURGICAL THERAPY
• . If many UTIs Cystoscopy
• . Poor flow, High PVR, No prolapse
• Cystoscopy urethral dilatation
• . Poor flow, High PVR, Prolapse
• ? Cystoscopy prolapse repair.

60
UROGYNAECOLOGY TREATMENT OF VOIDING
DIFFICULTIES

• CAUSE
  TREATMENT
• . Uterine/Vaginal Prolapse . Repair
  Prolapse
• . Idiopathic High Residual . Longterm
  UTI Prophylaxis
• (Recurrent UTIs)
  (Hiprex/ Macrodantin)
• . Postoperative, Postpartum .
  Catheterisation
• 
  (Suprapubic/ Self-cath)
• . Distal Urethral Stenosis .
  Urethral dilatation
• 
  Vaginal oestrogens

61
UPDATE IN UROGYNAECOLOGY

• Bernard T. Haylen
• St. Vincents Clinic, Mater
  Randwick Urodynamic Centres, Sydney
• www.bladder.com.au