Urogynecology: Evidence-Based Clinical Practice

Urogynecology: Evidence-Based Clinical Practice

Kate H. Moore Urogynecology: Evidence-Based Clinical Practice Second Edition

Kate H. Moore, MBBS, FRCOG, FRANZCOG, MD, CU Department Obstetrics & Gynaecology St George Hospital Kogarah New South Wales Australia ISBN 978-1-4471-4290-4 ISBN 978-1-4471-4291-1 (ebook) DOI 10.1007/978-1-4471-4291-1 Springer London Heidelberg New York Dordrecht Library of Congress Control Number: 2012950313 Springer-Verlag London 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, speci fi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on micro fi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied speci fi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a speci fi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Contents 1 Taking the History............................ 1 History Taking for Incontinent Women............. 1 Incontinence Symptoms...................... 1 Nonincontinent Symptoms of Storage Disorders: Frequency, Urgency, and Nocturia.............. 2 The Frequency Volume Chart (FVC)............... 3 Other Types of Leakage...................... 5 How Bad Is the Problem?........................ 5 History Taking for Voiding Difficulty............... 6 History Taking for Prolapse...................... 8 History Taking for Fecal Incontinence.............. 8 Symptoms of Obstructive Defecation............... 9 Assessing Previous Surgical History in Relation to Urinary Incontinence................... 10 History Taking for Dyspareunia................... 11 History Taking for Recurrent Bacterial Cystitis....... 12 History Taking for Painful Bladder Syndrome/Interstitial Cystitis (IC)........... 12 History of Drug Therapy That May Facilitate Urinary Incontinence............................ 13 General Assessment of the Patient in Relation to Urogynecology........................ 14 2 Physical Examination.......................... 15 Examine the Abdomen.......................... 15 Inspect the Vulva............................... 16 Elicit a Stress Leak........................... 17 v

vi Contents Speculum Examination.......................... 18 Pass a Bivalve Speculum..................... 18 Pass a Sims Speculum....................... 18 POPQ Scoring System of Prolapse................. 20 Perform a Bimanual Examination.............. 21 Assess the Pelvic Floor Muscle Contraction Strength: Oxford Score................... 22 Do All Urogynecology Patients Need a Rectal Examination?.................... 23 Screening Neurological Examination............... 23 References.................................... 24 3 How to Manage the Patient After History and Examination.............................. 25 First, Treat Precipitating Factors................... 25 Second, Obtain All Relevant Old Notes............. 25 Third, Begin a Basic Management Program for Urinary Incontinence.................. 26 Fourth, if Anal Incontinence Is Present............. 27 Fifth, if Prolapse Symptoms Are Present............ 27 If Associated Recurrent Bacterial Cystitis (Urinary Tract Infection, UTI) Is Present...... 27 If Suprapubic Pain, with Severe Frequency, Urgency, and Nocturia, Is Present........... 27 A Few Words About Explaining the Situation to the Patient............................ 28 Urinary Incontinence........................ 28 Anal Incontinence.......................... 28 Prolapse................................ 28 4 How to Conduct Urodynamic Studies: Essentials of a Good Urodynamic Report.......... 31 Who Needs Urodynamic Testing?................. 31 Different Forms of Urodynamic Studies............. 32 Practical Advice About How to Perform Urodynamic Studies...................... 34 Calibration of the Equipment.................. 35

Contents vii General Clinical Guidelines................... 35 Explaining the Test to the Patient............... 36 Uroflowmetry................................. 36 Performance of Cystometry................... 39 Passing the Rectal Catheter................... 40 Twin Channel Cystometry....................... 41 Urodynamic Diagnoses Available from the Filling Phase.................... 42 What Is Sensory Urgency, Now Termed Bladder Oversensitivity?......................... 44 Features of the Atonic Bladder During the Filling Phase......................... 46 Videourodynamics............................. 47 Videourodynamic Testing.................... 47 Value of VCU in Cystocele................... 49 Occult Stress Incontinence..................... 49 Ultrasound.................................... 51 Voiding Cystometry............................ 53 Diagnoses Made After Voiding Cystometry...... 54 Special Urodynamic Tests........................ 57 Urethral Pressure Profilometry................. 57 Abdominal or Valsalva Leak Point Pressure Test.. 57 Triple Lumen (Trantner) Catheter Test for Urethral Diverticulum, Now Replaced by MRI. 59 Note Regarding Diagnostic Tests for Vesicovaginal Fistulae................................ 59 Example of Report............................. 60 Case History, with Example of a Full Urodynamic Report, Illustrating Contribution of Urodynamic Studies to Management................... 60 Urodynamic Result.......................... 61 Comments................................ 62 Diagnosis: Marked Detrusor Overactivity (DO) with Mild Degree of Obstruction; Mild Stress Incontinence Management................. 63 Conclusions................................... 63 References.................................... 63

viii Contents 5 Outcome Measures Used to Assess Response....... 65 Introduction................................. 65 Tests That Measure Patient s Symptoms......... 67 The Wexner Score for Fecal Incontinence........ 67 Tests That Quantify Patients Symptoms............ 67 Bladder Chart................................. 67 The Pad Test.................................. 71 The One-Hour Pad Test...................... 71 The 24-Hour Pad Test....................... 71 Tests That Measure Anatomical and Functional Observations by Doctors.................. 72 Quality of Life for Incontinence................... 72 Quality of Life Tests for Prolapse and Sexual Function............................... 73 Why Do We Need QOL Tests for Prolapse?...... 73 Why Do We Need QOL Tests for Sexual Function?.............................. 74 Socioeconomic Evaluation....................... 74 Conclusions................................... 75 References.................................... 75 6 Conservative Therapy of Urodynamic Stress Incontinence............................ 77 Managing Chronic Cough and Obesity.............. 77 Treatment of Constipation....................... 78 Treatment of Postmenopausal Urogenital Atrophy.... 79 Practical Advice for Patients.................. 80 Starting a Home-Based Pelvic Floor Muscle Training Program............................... 80 The Role of the Nurse Continence Advisor.......... 82 Who Should Be Referred for Physiotherapy?......... 84 What Does the Physiotherapist Do That Increases Efficacy?............................... 85 The Efficacy of Physiotherapy Techniques........... 90 Extracorporeal Electromagnetic Chair Stimulation Therapy...................... 91 What to Do if Conservative Therapy Fails but Patient Does Not Want Surgery.......... 91 Conclusions................................... 93 References.................................... 93

Contents ix 7 Step-by-Step Guide to Treatment of Overactive Bladder (OAB)/Detrusor Overactivity............ 97 Explain the Condition........................... 97 Step-by-Step Guide to Bladder Training............ 100 How Do Anticholinergic Drugs Work?.............. 101 Are Anticholinergic Drugs Effective?............... 104 Role of Topical Estrogens........................ 105 Alternative Therapies for Detrusor Overactivity...... 106 TENS (Transcutaneous Electrostimulation Therapy)............................... 106 Acupuncture............................... 107 SANS Electro-Acupuncture (Stoller Afferent Nerve Stimulator)........................ 107 Hypnotherapy.............................. 108 Electrostimulation.......................... 109 Extracorporeal Electromagnetic Stimulation Therapy............................... 109 Cystodistention............................. 109 Botox Therapy (Botulinum Toxin A Injections)... 110 Intravesical Resiniferatoxin (RTX) Installation.... 111 Clam Cystoplasty........................... 111 Partial Detrusor Myomectomy................. 112 Implantation of S3 Sacral Nerve Root Stimulator......................... 112 Conclusions................................... 113 References.................................... 113 8 Anal Incontinence and Disorders of Obstructive Defecation....................... 117 Basic Physiology of Anal Continence and Defecation for the Gynecologist............ 117 The Act of Defecation........................... 120 Overview of Anal Incontinence................... 122 Treatment of Anal Incontinence................... 124 Overview of the Disorders of Obstructive Defecation............................. 126 Constipation.................................. 127 Assessing the Causes of Constipation............... 127 Overview of Treatment of Disorders of Defecation.... 131 Conclusions................................... 132

x Contents A Note Regarding Obstetric Trauma as a Cause of Anal Incontinence..................... 133 References.................................... 134 9 Surgery for Urodynamic Stress Incontinence...... 137 Introduction.....................................137 Bladder Neck Buttress.......................... 137 Colposuspension............................... 138 Preoperative Consent Discussion............... 140 Postoperative Convalescence.................. 140 The Technique of Colposuspension............. 140 Immediate Complications of Colposuspension.... 142 Long-Term Complications of Colposuspension.... 142 Postoperative Management for Colposuspension.. 143 Double Voiding Technique.................... 143 How to Manage Short-Term Voiding Difficulty.... 143 How to Manage Long-Term Voiding Dysfunction.. 145 The Abdomino-Vaginal Sling..................... 145 Preoperative Consent Discussion............... 146 Historical Note: Stamey Needle Suspension and Raz/Pereyra/Gittes Procedures.......... 148 Paravaginal Repair............................. 150 Laparoscopic Colposuspension.................... 150 The TVT and Transobturator Tape................. 150 Preoperative Consent Advice.................. 151 Is the Cough Test Necessary?................. 153 Postoperative Instructions.................... 154 Outcome Data for the TVT................... 154 The Transobturator Tape..................... 155 The Use of Bulking Agents for USI................ 158 GAX Collagen (Contigen).................... 159 Macroplastique............................. 160 Durasphere................................ 161 Conclusions.................................. 162 References................................... 162 10 Management of Prolapse....................... 167 Nonsurgical Management Options................ 167 Use of Ring Pessary........................ 168

Contents xi Surgery for Cystocele.......................... 171 Anterior Colporrhaphy....................... 171 The Anterior Repair with Extensive Plication (Ultralateral Anterior Colporrhaphy)......... 173 Paravaginal Defect Repair.................... 173 Use of Mesh for Cystocele Repair.............. 174 What Is the Value of Manchester Repair/ Retention of a Nonprolapsed Uterus?........ 176 Preoperative Consent Discussion for Anterior Compartment Repairs..................... 178 Surgery for Rectocele/Deficient Perineum.......... 179 A Repair for Mid Low Rectocele and Deficient Perineum.............................. 180 Surgery for Enterocele......................... 182 Vaginal Sacrospinous Fixation................. 184 Preoperative Consent Discussion for Vaginal Sacrospinous Fixation.................... 186 Abdominal Sacrocolpopexy................... 188 Preoperative Consent Discussion for Abdominal Sacrocolpopexy......................... 190 Conclusions.................................. 191 References................................... 191 11 Recurrent Bacterial Cystitis in Women.......... 195 Guide to Management of Recurrent UTI........... 195 During Examination......................... 196 Investigations for Recurrent UTI................. 196 Treatment................................... 197 At Second Visit............................ 197 What to Look for on Cystoscopy............... 198 References................................... 198 12 Interstitial Cystitis........................... 199 How to Diagnose It............................ 199 Etiology..................................... 200 Treatment................................... 202 References................................... 203 Erratum........................................ E1 Index........................................... 205