UROGYNAECOLOGY DR CHO CHO KHIN Associate Professor MBBS, M.Med Sc (OG), MRCOG(UK), Dr.Med.Sc(OG), Dip.Med.ME

Transcription

1 UROGYNAECOLOGY DR CHO CHO KHIN Associate Professor MBBS, M.Med Sc (OG), MRCOG(UK), Dr.Med.Sc(OG), Dip.Med.ME

2 Urinary incontinence Definition Involuntary loss of urine on effort or exertion on sneezing or on coughing. It is a social or hygienic problem.

3

4 Urine storage symptoms Frequency: patient considers he/she voids too often by day. Nocturia: waking at night one or more times to void. Urgency: a sudden compelling desire to pass urine, which is difficult to defer. Urge incontinence: involuntary leakage accompanied by or immediately preceded by urgency. Stress incontinence: involuntary leakage on effort, exertion, sneezing or coughing. Nocturnal enuresis: the loss of urine occurring during sleep.

5 Urine voiding symptoms Slow stream: perception of reduced urine flow. Splitting or spraying: where the stream or urine is not a single flow. Intermittent stream: urine flow that stops and starts. Hesitancy: difficulty in initiating micturition resulting in a delay in the onset of voiding. Terminal dribble: a prolonged final part of micturition, when the flow has slowed to a trickle or dribble

6

7 Anatomy the detrusor muscle is relaxed allowing storage + no increased in pressure bladder capacity is reach sensory signals from stretch receptors in the bladder wall send the sensation of bladder filling sphincter mechanism is closed cortical inhibition of the spinal voiding reflex arc Before voiding begins, this inhibition is removed

8 the pelvic floor and urethral sphincters relax detrusor contraction and bladder emptying muscarinic cholinergic nerves of the parasympathetic nervous system- D m/s contraction noradrenergic neurons of the sympathetic nervous system (sphincter contraction) somatic fibres (voluntary contraction and relaxation) from the pudendal nerves.

9 urethral sphincter mechanism internal (smoothmuscle) + external (striated muscle) sphincters pelvic floor and the pubourethral ligament urethral epithelium ( rich blood supply) acting as a seal

10 Causes of Urinary Incontinence Urodynamic Stress incontinence Detrusor overactivity Overflow incontinence Fistulae (VVF, UVF, UrethroVF) Congenital (ectopic ureter) Urethral diverticulum Others- UTI, fecal impaction, medication Functional ( immobility)

11

12 Urodynamic Stress Incontinence Involuntary leakage of urine when there is increase in intra-abdominal abdominal pressure in the absence of detrusor contraction, (cases of coughing, sneezing, laughing, lifting heavy weight, etc.)

13 Multiparity (particularly vaginal births). Forceps delivery*. Perineal trauma. Long labour*. Epidural analgesia. Birthweight >4 kg. Increasing age. Postmenopause. Obesity Connective tissue disease Chronic cough Doxazocin Risk factors for USI

14 OAB (Detrusor Instability) stress incontinence is due to involuntary detrusor contraction either spontaneously or on provocation, associated with symptoms during the filling phase. It can be objectively diagnosed only after urodynamic study.

15 aetiology of DO is poorly understood obesity Smoking All continence surgery carries a risk of 5 10% of new DO Detrusor overactivity causes increased sensation; leakage only occurs if the contraction pressure exceeds the pelvic floor and sphincter pressure

16 Risk factors for detrusor overactivity Childhood bedwetting Obesity Smoking Previous hysterectomy. Previous continence surgery

17 Urge Incontinence UI is an involuntary loss of urine associated with a strong desire to void. It is due to hyperactive bladder following infections, stones, tumours, etc.

18 Overflow Incontinence Overflow incontinence occurs without any detrusor activity when the bladder is overdistended. It is due to overfilling of bladder,as in cases of atonic bladder following child birth, spinal cord injuries, etc.

19 KEY LEARNING POINTS Stress incontinence is typically a result of a weak urethral sphincter, often as a consequence of childbirth DO causes urgency, frequency and nocturia, but not all patients will have leakage History should include direct questions about faecal leakage or leakage during sexual intercourse

20 Clinical examination should exclude pelvic masses (e.g. fibroid uterus) and assess the patient s ability to contract her pelvic floor muscles and the strength of that contraction. Women with pain, haematuria or recurrent infections should have the renal tract investigated radiologically and by cystoscopy.

21 Fistulae fistulae between genital & urinary tracts. Involuntary loss of urine occurs per vagina. Frequency seven or more times a day, or being awoken from sleep more than once a night to void.

22 detailed history only SI symptoms, only OAB symptoms or mixed symptoms to record measures of severity number of episodes per day of frequency, urgency and leakage continence pads- how many and what size change her underclothes or outer clothes behaviour changes reduced their fluid intake limit their social activities

23 Associated symptoms of prolapse, faecal incontinence -any sexual difficulties medical history to identify potential predisposing factors Comorbidities signs suggesting malignancy such as haematuria, rectal bleeding or significant pain

24 Physical examination GE, Abd and pelvic examination any surgical scars, obesity and any pelvic mass lithotomy position associated prolapse Visible leakage during coughing or Valsalva manoeuvre

25 MSU Investigation Bladder diary 3 days Pad test Provocative test- hand washing, climbing stairs, coughing USG

26 Urodynamic testing to reproduce a micturition cycle (bladder filling and voiding) while recording abdominal and bladder pressure and attempting to reproduce the patient s symptoms, to provide a diagnosis

27

28 Management of Urodynamic stress incontinence Conservative management Pharmacological management Surgical procedures

29 USI: conservative management Tailor the individual advice about fluid balance Reduction of caffeine intake Pelvic floor muscle exercises- cure 50% - improve >75% _ MDT meeting, including a gynaecologist, urologist, continence nurse, physiotherapist and possibly a medicine for the elderly consultant

30

31 Anticholinergic medications Oxybutynin: mg up to three times daily; first-choice medication recommended by the UK National Institute for Health and Care Excellence (NICE); modified release preparation 5 mg once daily; increase weekly by 5 mg up to 20 mg daily. Propiverine: 15 mg one to three times daily. Trospium: 20 mg twice daily.

32 Tolterodine: 2 mg twice daily; reduced to 1 mg in hepatic impairment; modified release preparation 4 mg once daily. Fesoterodine: 4 mg once daily, maximum 8 mg once daily (fesoterodine is related to tolterodine). Solifenacin: 5 mg once daily; can be increased to 10 mg once daily. Darifenacin: 7.5 mg once daily.

33 USI: Surgical procedure Colposuspension Pubovaginal sling Retropubic mid-urethral tape Transobturator sling procedure Urethral bulking agents

34 tension-free vaginal (TVT) transobturator (TOT) midurethral tapes

35 Burch colposuspension colposuspension through a Pfannenstiel incision Voiding difficulty (usually short term) in 2 5%. Bladder perforation during the procedure (2 5%). Onset of new OAB symptoms after surgery (5%).

36

37 Detrusor overactivity Symptom complex of urgency with or without urge incontinence, usually with frequency and nocturia Involuntary contractions of the detrusor muscle during the filling phase of the micturition cycle

38 OAB: Management Conservative management Bladder retraining Antimuscarinic drugs Drugs with mixed action Tricyclic antidepressants Anti-diuretic agents desmopressin Oestrogens

39 OAB: NICE guidelines Bladder retraining first line Oxybutinin effective with significant side effect More specific antimuscarinic agents with fewer side effect Oestrogens frequently prescribed with little evidence

40 a surgical option may be considered as second-line treatment Intravesicle therapy Neuromodulation

41 Key points Surgery for stress incontinence is highly effective with cure rates of 85% or higher. Midurethral tapes and colposuspension are equally effective, but tape surgery is more costeffective due to the short hospital stay and rapid return to normal activities. Patients should be warned of the risk of voiding dysfunction, bladder injury and new OAB symptoms after surgery.

42 Mesh-related complications are uncommon after midurethral tape surgery but can be difficult to treat; patients should be fully informed of the risks, and of the potential for further surgery to deal with these complications. Botulinum toxin and sacral neuromodulation are highly effective second-line treatments for detrusor overactivity

43 The neurotoxin botulinum toxin A Neuromodulation alternative to reconstructive surgery Surgical intervention such as diversion reserved for failed other treatment

44 Treatment Simple measure such as: - exclusion of UTI - modifying medication eg. (diuretics) and treating chronic cough, constipation Prevention of GSI - shortening of the second stage of delivery - reducing traumatic delivery - HRT - pelvic floor exercise before & during 1st pregnancy

45 Conservative management 1. Supervised Pelvic floor muscle training -1 line, 3 months-effective & safe for stress or mixed UI 2. Wearing a tampoon 3. Absorbent pads 4. Electronic vaginal devices 5. Vaginal cones 6. Mechanical devices 7. Continuous indwelling catheter

46 Surgical treatment The aim of surgery are: 1. restoration of the proximal urethra and bladder neck to the zone of intra abdominal pressure transmission. 2. to increase urethral resistance

47 Surgery Burch Colposuspension highest success rate. >95% at 1 yr 78% at 15 yr Endoscopic bladder neck suspension eg. Stamey, Pereyra Anterior colporrhaphy and Kelly s stitch at the level of urethrovesical angle. Cystourethropexy (Marshall- Marchetti-Krantz) Sling procedure Periurethral injection (eg. contigen collagen, macroplastique) Artificial urinary sphincter New development Tension Free Vaginal Tape insertion (TVT) based on theory of suburethral support.

48 OAB Urgency, urge incontinence, frequency, nocturia, stress incontinence, enuresis and sometimes, voiding difficulties. Pathophysiology poorly understood idiopathic, neuropathy, outflow obstruction, smoking Examination- any mass in abdomen, prolapse, vaginal atrophy

49 Treatment of OAB Bladder retraining, biofeedback, kor hypnosis- to increase the interval between voids and inhibit the symptoms of urgency. Lifestyle interventions- caffeine reduction, BMI >30 advice to reduce wt; Medical- anticholinergic ( oxybutynin, tolterodine), imipramine, desmopressin (ADH) Surgery- last measure, bladder augmentation, ureterostomy

50 Retention of urine Inability to pass urine with distension of the bladder. 1. Acute retention (acute / sudden onset) 2. Chronic retention (Insidious onset)

51 Acute retention The sudden onset of painful or painless inability to void over 12 hours, requiring catherization with removal of equal to or greater than normal bladder capicity. Acute retention is usually painfull. It may be painless in the presence of a neurological lesion or following an epidual anaesthesia.

52 Chronic retention Insidious and painless failure of bladder emptying where catherization yields a volume equal to at least 50% of normal bladder capicity.

53 Causes of acute retention of urine Obstetric - pain from episiotomy wound or vulva and vagina haematoma following instrumental delivery. - retroverted gravid uterus Gynaecological uterovaginal prolapse, tumour or cyst in the pelvis obstructing the bladder neck Post-operative operative LSCS, TAH, VH, pelvic floor repair operation (AC & PCP)

54 Neurological suprapontine lesion CVA, Parkinson s d/s cord lesion spinal cord injury, multiple sclerosis peripheral lesion prolapsed intervertebral disc, diabetic autonomic neuropathy, other peripheral autonomic neuropathies. Bladder stone Urethral stricture Inflammatory Around anogenital region Acute urethritis or cystitis, genital herpes, acute vulvovaginitis Rectal constipation Psychogenic Idiopathic Pharmacological Epidual anaesthesia and certain drugs e.g. tricyclic antidepressants, anticholinergic agents, alpha adrenergic stimulants and ganglion-blocking drugs.

55 Treatment Note the amount of urine drain. If more than 500ml, leave indwelling catheter for 48 hrs. If the volume drained is less than 500ml, encourage to void normally. If she fails to void after a further 8 hrs or again earlier if uncomfortable or bladder is obviously distended, a Foley s catheter should be inserted again left indwelling for 48 hrs regardless of volume drain. Treat underlying cause - adequate analgesic for pain. - evacuation of heamatoma. - removal of pelvic tumour etc.

56 Urinary Fistula Definition A urinary fistula is an abnormal opening between the urinary tract and the genital tract.

57 Different types of urinary fistula Vesico-vaginal fistula Fistula between bladder and vagina. Vesico-cervical cervical fistula Fistula between bladder and cervix. Vesico-uterine fistula Fistula between bladder and uterus. Urethro-vaginal Fistula between urethra and vagina. Uretero-vaginal Fistula between ureter and vagina Uretero cervical Fistula between ureter and cervix Uretero uterine Fistula between ureter and uterus.

58

59

60

61

62

63 Causes Obstetric injury - pressure necrosis due to prolonged labour, prolonged second stage. - direct injury from caesarean section, forceps delivery, destructive operation craniotomy or symphysiotomy, ruptured uterus.

64 Gynecological injury clamping, cutting, ligating the uterine arteries, cardinal lig:, uterosacral lig: and vaginal angles (for ureteric fistula) clamping, cutting, ligating the vaginal vault (for vesical fistula) as in cases of TAH,VH, RH. While dissecting the ant: vaginal wall (for urethral fistula & vesical fistula) in cases of anterior repair (AC). Complication of criminal abortion. Traditional surgical practices including circumcision.

65 Infection of the vagina with tissue destruction as in cases of lymphogranuloma venerium, tuberculosis, schitosomiasis. Radiation injury due to direct effect as well as indirect effect from tissue fibrosis. Congenital abnormalities Malignancies of genital or urinary tracts invading neighbouring organs. Deep physical or chemical injuries of the genital tract.

66 Diagnosis History Continuous dribbling of urine No need to void urine in vesical fistula Need to void urine in one sided ureteric fistula Similar to SI in case of urethral fistula. History of difficult delivery / recent operations. Direct injury will give rise to immediate incontinence. Tissue necrosis will give rise to delayed incontinence after about a week.

67 Past History H/O chronic infection H/O radiation treatment to gynaecological cancer or bladder cancer H/O previously treated malignancies of either genital tract or urinary tract. Examination Vaginal examination in Sim s left lateral position or knee chest position.

68 Investigations Three swabs test to differentiate the site of fistulae & small opening not visible with naked eye. IVU Cystoscopy EUA

69 Treatment Conservative treatment Recent onset fistula. continuous drainage of urine by urinary catheter for at least 2 weeks with patient in prone or semi-prone position under aseptic precautions. Operative treatment Surgery can be delayed until tissue inflammation and oedema have resolved at about four weeks

70 Vesico-Vaginal Vaginal Fistula - Sim s saucerization - Sim s flap splitting operation Graft operations for large fistula such as Martius Graft, Ingelmann Sundberg. Urethral Fistula same as above Ureteric Fistula Abdominal approach and repair such as ureteric reimplantation

71