Urogynaecology Incontinence and Prolapse

Ms C Domoney
Mr M Stafford
Chelsea and Westminster
Hospital

Urinary continence
Learnt phenomenon
Development inhibitory pathways
Intact nerve pathways
Intact lower urinary tract

Urinary Incontinence
A condition in which involuntary loss of
urine is a social or hygienic problem and
is objectively demonstrated.

International Continence Society

Risk factors
Congenital abnormalities
Developmental or behavioural factors
Female
Childbirth
Aging and the menopause
Medical disorders
Surgery or other trauma
Drug therapy
abdominal pressure or pelvic mass

Classification
Urethral
Genuine stress incontinence
Detrusor overactivity
Mixed incontinence
Voiding dysfunction
Congenital
Functional
Extra-urethral
Congenital
Fistula

Classification
Urethral
Genuine stress incontinence
Detrusor overactivity
Mixed incontinence
Voiding dysfunction
Congenital
Functional
Extra-urethral
Congenital
Fistula

History
Urinary frequency - day / night, volume.
Fluid intake - caffeine, alcohol
Urinary urgency - ability to defer, triggers
Incontinence - type, duration, severity
Enuresis - current or previous
Coital incontinence - penetration / orgasm
Voiding difficulties - stream, strains, incomplete
emptying
Irritative, recurrent UTI symptoms, pain

History
Obstetric - Number, type delivery, fetal wt
Gynaecological - fibroids, prolapse
Medical - DM, DI, renal disease
Surgical - previous continence / prolapse ops
Psychiatric - Depression, schizophrenia
Neurological - MS, CVA, Parkinsons
Drugs - Diuretics, cold remedies, prazosin

Examination
General
General mobility, BMI
Respiratory - Asthma, COAD
Abdominal - palpable kidneys, pelvic mass
Neurological - general / direct 2,3,4 roots

Examination
Gynaecological
Genital urinary dermatoses / atrophy

Bladder neck mobility and incontinence on coughing

Bimanual examination
Prolapse grading, vaginal capacity
Vaginal scarring or pain
Anorectal tone

Investigations
Urinary frequency volume diary
MSU - microscopy, culture, cytology
Pad test
Cystometry
Diagnostic cystoscopy
Bladder neck or renal tract ultrasound

Bladder Diary

MSU

Urodynamics
Indications
Failed conservative treatment
Complex symptoms
Surgery considered
Previous or failed continence surgery
Fistula suspected
Neurological signs or symptoms
Voiding dysfunction

Urodynamics
Diagnosis
Normal
Urodynamic stress incontinence
Detrusor overactivity
Neurogenic detrusor overactivity
Voiding disorder

normal pres s ure flow s tudy.gif

Cystoscopy
Indications
Intractable sensory urgency
Recurrent UTIs
Suspected fistula
Suspected interstitial cystitis
Haematuria
Neoplasm ?

Stress Urinary Incontinence

Conservative therapy
Stress urinary incontinence
Fluid restriction (1.5 - 2.0 litres daily)
Reduce exacerbating factors - eg. cough
Pelvic floor exercises
Tampons / foam pessaries
Vaginal cones
Electrical therapy
Biofeedback therapy
Drug therapy

Surgical therapy
Burch colposuspension
Mid urethral slings
retropubic tape Eg TVT
Tranobturator tape TOT

Pubovaginal slings
Cadaveric fascia, harvested slings rectus sheath

Periurethral injectables
Artificial sphincters

Effective surgical therapy

Minimally invasive
Minimal peri-operative morbidity
Short hospital stay
High long term continence rate (>80% at 10 years)

Colposuspension

Colposuspension
Continence rate of 85 90% at 1 year
Falls to 70% at 5 years
Cochrane review most effective treatment for SI
esp. in the long term
Data up to 12 years

Colposuspension
Voiding dysfunction

10.3% (2-27%)

De novo DO

17%

(8-27%)

New prolapse

13.6%

(2.5 26%)

Sling Procedures
Autologous or Synthetic materials

Erosion vs failure
Vaginal Erosion
Urethral Erosion
De novo DO
Voiding Dysfunction

0 - 16%
5%
3.7 66%
10% (2%)

Mid-urethral Slings

TVT
At 3 years
86% cured
11% improved

Approved by NICE
Similar subjective and
objective continence rates to
colposuspension with
shorter hospital stay

Need for long term

data!
Bladder perforation
3.8 %
Voiding Dysfunction
2.3%

Transobturator Tape
NICE Guidelines January 2005
Current evidence on safety and short term
efficacy support the use of the TOT

Trans-urethral Bulking Agents

Medical Therapy for SI

DULOXETINE

( Yentreve)

Blocks the reuptake of serotonin &

noradrenaline in the sacral spinal cord

Believed to increase pudendal nerve activity

increasing sphincter contraction & thus
reducing stress urinary incontinence
symptoms

Medical Therapy for SI

Mild to moderate primary stress incontinence
in a primary care setting
Family not complete
On the waiting list for surgery
To facilitate pelvic floor retraining
Unfit for surgery
Declines surgery
Mixed incontinence

Urge Urinary Incontinence

Urge Urinary Incontinence

Detrsusor Instability (old term)

=
Detrusor Overactivity (new term)

Differential Diagnosis
Severe stress incontinence
Urethral diverticulum
Urinary tract fistula
Cystitis
Bladder foreign body
Bladder tumour
Urethritis

Management
Conservative
Reduce fluid intake
Avoid caffeine and alcohol
Bladder retraining
Biofeedback
Electrical therapy
Drugs

Commonly used drugs

ANTICHOLINERGICS
Oxybutynin: 2.5 mg bd - 5 mg qds and ER/ Patch
NB NICE guidelines 1st line as cheap but Ses +
Tolterodine: 1 mg - 2 mg bd and ER
Fesoterodine: 4-8mg od
Propiverine: 15 mg bd-tds
Trospium chloride: 20 mg bd-tds
Solifenacin 5 10mg od

May be used empirically with fluid restriction and

bladder drill if fails refer for UDS. Success 60 - 70%

Commonly used drugs

OTHERS
Imipramine - 25 - 50 mg nocte
Desmopressin - 100 - 200 mcg nocte

Surgical intervention for DO

Indications
Significant symptoms
Failed conservative and drug therapy
NB Realistic expectations

Surgical intervention
Procedures
Botox into detrusor muscle
Sacral Neuromodulation
Clam cystoplasty
Ileal conduit

Sacral Neuromodulation

Voiding dysfunction

Acute retention
> 6 hours
volume equal to or greater than capacity
usually painful

Chronic retention
Insidious and painless
< 50% bladder capacity

Voiding dysfunction - treatment

Catheterisation
Intermittent self catheterisation (ISC)
Urethral
Suprapubic
Adjuvant
Double or triple voiding
Oestrogen therapy
Antibiotic prophylaxis
Urethrotomy

Prolapse
Anterior compartment
Urethrocele
Cystocele
Miccle compartment
Uterine
Vault
Posterior compartment
Enterocele
Rectocele
Perineum

[ Each site graded 1 - 4 ]

Prolapse Therapy
Conservative
Reduce exacerbating factors
Pelvic floor exercises
Vaginal pessaries (eg. ring or shelf)

Aims of prolapse surgery

Alleviate symptoms
Restore normal anatomy
Restore normal visceral function
Avoid new bladder or bowel symptoms
Preserve sexual function
Avoid surgical complications

Primary genital tract prolapse

Surgery
Uterine - hysterectomy or hysteropexy with vault support
Anterior or Posterior compartment Primary - vaginal repair
Recurrent prolapse - repair + mesh
- repair + sacrospinous fixation

Classification of Surgery for

Apical Prolapse
Abdominal

Vaginal

Laparoscopic

Surgery for apical prolapse

VAGINAL SUSPENSION PROCEDURES
1. Sacrospinous ligament suspension / fixation
2.

Modified McCall culdoplasty

3.

Iliococcygeus fascia suspension

4.

High uterosacral ligament suspension

5.

LeFort partial colpocleisis

6.

Colpectomy and colpocleisis

Surgery for apical prolapse

ABDOMINAL SUSPENSION PROCEDURES
1.

Sacrocolpopexy

2.

Sacrohysteropexy

3.

High uterosacral ligament suspension

LAPAROSCOPIC SUSPENSION PROCEDURES

All of the Abdominal Procedures +/-reinforcement