GayayatatatatatatatataUrogynecology.pdfg

Ahahgagaga

1. Urogynecology
Dr. Ala’aShallalFarhan
M.B.Ch.B/F.I.C.O.G/C.A.B.O.G

2. Urinaryincontinencehasamajorimpactonthequalityoflifeof
women.Throughignorance,embarrassmentandabeliefthatlossof
bladdercontrolisa‘normal’resultofchildbirthandageing,many
womensufferforyearsbeforeseekinghelp.Anaccuratediagnosiscan
bemadeandmanywomencanbecuredorimprovedbytheuseof
variousmanagementstrategies.
Urinaryincontinenceisdefinedasthecomplaintofanyinvoluntaryloss
ofurine,whereascontinenceistheabilitytoretainurineatalltimes
exceptduringmicturition.Bothcontinenceandmicturitiondependon
astructurallyandfunctionallynormallowerurinarytract.

3. Causes of urinary incontinence in women
Urethralincontinencewilloccurwhenevertheintravesicalpressureinvoluntarilyexceeds
theintraurethralpressure.Thismaybeduetoanincreaseinintravesical(ordetrusor)
pressureorareductioninurethralpressureoracombinationofthetwo.Thus,thefault
whichleadstoincontinencemaylieintheurethraorthebladderorboth.
Urodynamicstressincontinence(urethralsphincterincompetence)
Detrusoroveractivity(neurogenicdetrusoroveractivity)
Retentionwithoverflow
Fistulae:vesicovaginal,ureterovaginal,urethrovaginal,complex
Congenitalabnormalities,e.g.epispadias,ectopicureter,spinabifidaocculta
Urethraldiverticulum
Temporary,e.g.urinarytractinfection,faecalimpaction
Functional,e.g.immobility

4. Urodynamic stress incontinence
Urodynamicstressincontinenceisdefinedastheinvoluntaryleakageofurine
duringincreasedabdominalpressureintheabsenceofadetrusorcontraction.
Inisolation,thesymptomofstressincontinenceisareasonablygoodpredictorof
thepresenceofanincompetenturethralsphincter.Urethralsphincterweaknessin
mostcasesisduetohypermobility,wherethepelvicfloorandligamentscannot
retaintheurethrainpositionanditfallsthroughtheurogenitalhiatusduring
increasesinabdominalpressure,leadingtolossofpressuretransmissiontothe
urethraandhenceleakageofurine.Intrinsicsphincterdeficiency(ISD)isless
commonandoccurswhereurethralclosurepressureislowwithoutanyurethral
mobility.ISDisduetoweaknessofthesphinctermusclesandlossofthecushioning
sealeffectintheurethra.

5. Urethralsphincterweaknessisassociatedstronglywithahistoryof
vaginalchildbirthandvariousrelatedriskfactors,andwithsomenon-
obstetricfactors.Obstetricriskfactorsactbyacombinationeffectof
stretching/damagetothepudendalnervesandoverstretching,oreven
avulsion,ofthepelvicfloormusclesfromtheirinsertionsonthepelvic
sidewall.Directmuscledamageresultsinlossofpelvicfloorsupport
andhenceurethralhypermobility.Pudendalnervedamagecauses
bothweakeningofthepelvicfloormusclesandurethralsphincter.Itis
nowpossibletoidentifylevatormuscledefectsinsymptomaticwomen
by means of magnetic resonance imaging or
transperineal/transvaginal ultrasound. Most risk
factorsmaynotbemodifiable.

6. Risk factors for stress urinary incontinence
Multiparity (particularly vaginal births).
Forceps delivery.
Perineal trauma.
Long labour.
Epidural analgesia.
Birthweight >4 kg.
Increasing age.
Post menopause.
Obesity studies have shown that significant weight loss among obese women is associated with major
improvements in urinary leakage symptoms.
Connective tissue disease.
Chronic cough (e.g. bronchiectasis or chronic obstructive pulmonary disease).
alpha-adrenergic antagonist for hypertension causes relaxation of the urethral sphincter.

7. Causes of urodynamic stress incontinence
•Urethral hypermobility
•Urogenital prolapse
•Pelvic floor damage or denervation
•Parturition
•Pelvic surgery
•Menopause
•Urethral scarring
•Vaginal (urethral) surgery
•Incontinence surgery
•Urethral dilatation or urethrotomy
•Recurrent urinary tract infections
•Radiotherapy
•Raised intra‐abdominal pressure
•Pregnancy
•Chronic cough (bronchitis)
•Abdominal/pelvic mass
•Faecalimpaction
•Ascites
•Obesity

8. Detrusor overactivity
Detrusoroveractivityisdefinedasaurodynamicobservationcharacterizedbyinvoluntarycontractions
duringthefillingphasethatmaybespontaneousorprovoked.Itisthesecondcommonestcauseof
urinaryincontinenceinwomenandaccountsfor30–40%ofcases.
WomenwithDOwilloftencomplainofsymptomsofOAB,butmaynotbeincontinentunlesstheurethral
sphincterfunctioniscompromisedorthedetrusorcontractionsareofveryhighpressureamplitudeand
overcomeurethralresistance.
TheaetiologyofDOispoorlyunderstoodbutlaboratorystudieshaveidentifieddifferencesinsensory
andinterstitialnervesinthebladderwallofpatientscomparedtocontrols,andalterationsinthe
expressionofseveraldifferentneurotransmittersandtheirreceptors.
Theincidenceishigherintheelderlyandafterfailedincontinencesurgery.Thecauseofdetrusor
overactivityremainsuncertainandinthemajorityofcasesitisidiopathic,occurringwhenthereisa
failureofadequatebladdertraininginchildhoodorwhenthebladderescapesvoluntarycontrolinadult
life.Insomecasesdetrusoroveractivitymaybesecondarytoanuppermotorneuronlesion,especially
multiplesclerosis.Insuchcasesitisknownasneurogenicdetrusoroveractivity.Inmen,detrusor
overactivitymaybesecondarytooutflowobstructionandmaybecuredwhentheobstructionisrelieved.
However,outflowobstructioninwomenisrare.

9. Riskfactorsfordetrusoroveractivity:
• Childhood bedwetting.
• Obesity.
• Smoking.
• Previous hysterectomy.
• Previous continence surgery. All continence surgery carries a risk of
5–10% of new DO.

10. Detrusor overactivity and overactive bladder
ThesymptomsofOABareduetoinvoluntarycontractionsofthe
detrusormuscleduringthefillingphaseofthemicturitioncycle
(termeddetrusoroveractivity).
However,OABisnotidenticalwithdetrusoroveractivityastheformer
isasymptom‐baseddiagnosiswhereasthelatterisaurodynamic
diagnosis.Ithasbeenestimatedthat64%ofpatientswithOABhave
urodynamicallyprovendetrusoroveractivityandthat83%ofpatients
withdetrusoroveractivityhavesymptomssuggestiveofOAB.

11. Clinical presentation of urinary incontinence
Symptomsoflowerurinarytractdysfunctionfallintothreemain
groups:(i)incontinence;(ii)overactivebladder(OAB)symptoms;and
(iii)voidingdifficulties.
Stressurinaryincontinence(SUI)isthemostcommoncomplaint.Itmay
beasymptomorasign,butitisnotadiagnosis.Apartfromstress
incontinence,womenmaycomplainofurgeincontinence,dribble
incontinence.Nocturnalenuresis(bedwetting)mayoccuronitsownor
inconjunctionwithothercomplaints.Symptomsofvoidingdifficulty
includehesitancy,apoorstream,strainingtovoidandincomplete
bladderemptying.

12. Clinical assessment of incontinence
Adetailedhistoryshouldbetakentoelicitthepatient’spresentingsymptoms,toidentify
whetherthepatienthasonlystressincontinencesymptoms,onlyOABsymptomsormixed
symptoms.Iftherearemixedsymptoms,anassessmentshouldbemadeastowhich
predominate.Itisusefultorecordmeasuresofseverity,including:thenumberofepisodes
perdayoffrequency,urgencyandleakage;whethercontinencepadsareneeded,andifso
howmanyandwhatsize;whetherthepatientneedstochangeherunderclothesorouter
clothesbecauseofleakage;andwhatbehaviourchangeshavebeenemployed.
Commonly,womenwillhavereducedtheirfluidintakeandmaylimittheirsocialactivities
toplaceswheretheyalreadyknowaboutthepositionandcleanlinessoftoiletfacilities.
Associatedsymptomsofprolapse(seelater),faecalincontinencesymptoms(which
patientsrarelyofferspontaneously)andanysexualdifficultiesshouldbesought,aswellas
adetailedmedicalhistorytoidentifypotentialpredisposingfactorsandtoidentifyany
ongoingmedicalorsurgicalconditionsthatmayimpactontreatment(including
comorbiditiesthatmayincreasetheriskofanaesthesia,orpresentcautionsor
contraindicationstodrugtherapy).Remembertobealertfor‘redflag’signssuggesting
malignancysuchhaematuria,rectalbleedingorsignificantpain.

13. Physicalexaminationshouldincludegeneralexaminationandanabdominal
andpelvicexamination.Abdominalexaminationwillidentifyanysurgical
scars,evidenceofobesityandthepresenceorabsenceofanypelvicmass
thatmaybeafactorinurinaryfrequency.Thepresenceofalargefibroid
uterusorovariancystfillingthepelvisisanuncommonfinding,butwill
causeurinaryfrequencybyoccupyingthespaceinthepelviswherethefull
bladderwouldnormallylie.Insuchcases,surgicalremovalofthemasswill
beindicatedandshouldimprovetheurinarysymptoms.Pelvicexamination
oftheincontinentwomanideallyshouldbedoneinthelithotomyposition
usingaright-angledSimsspeculumtoassesseachvaginalwalladequately
forassociatedprolapse.VisibleleakageduringcoughingorValsalva
manoeuvreshouldbesought,andanassessmentofthepatient’sabilityto
contractandholdthecontractionofherpelvicfloormusclesisessential.

14. Investigations
Midstreamurinesample
Amidstreamurine(MSU)specimenshouldalwaysbesentforculture
andsensitivitypriortofurtherinvestigation.Althoughthepatient’s
symptomsareunlikelytobecausedbyaurinarytractinfection,they
canbealteredbyone.

15. Frequency–volumecharts(Patientbladderdiary)
Itisoftenhelpfultoaskwomentocompleteafrequency–volumechartorurinary
diary.Thisisinformativeforthedoctoraswellasthepatientandmayindicate
excessivedrinkingorbadhabitsasthecauseoflowerurinarytractsymptoms.The
frequency–volumechart(urinaryorbladderdiary)providesanobjective
assessmentofapatient’sfluidinputandurineoutput.Aswellasthenumberof
voidsandincontinenceepisodes,themeanvolumevoidedovera24‐hourperiod
canalsobecalculated,aswellasthediurnalandnocturnalvolumes.Frequency–
volumechartshavetheadvantageofassessingsymptomseverityintheeveryday
situation.Itincludeapatientbladderdiary(for3daysisusuallyadequate)to
recordtheamount,typeandfrequencyofdrinkstakenandtorecordthe
timing,frequencyandvolumeofvoids.Thiscanbeausefulexerciseforthe
patientherselftotakenoteofexactlywhatsheisdrinkingandhervoiding
habits.Thebladderdiarywillalsoallowthepatienttorecordleakage
episodesandurgency.

16. Pad test
Incontinencecanbeconfirmed(withoutdiagnosingthecause)by
performingapadweighingtest.Manydifferenttypesofpadtesthave
beendescribedbasedonthemethodforfillingthebladderorlengthof
thetest.
Itispossibletoobtainanobjectivemeasureofurineleakbyconducting
apadtest.Thisisaninvestigationwherethepatientwearsoneormore
preweighedsanitarypadsforavariablelengthoftime(between1hour
inclinicand24hoursathome)whileperformingspecificprovocation
tests(e.g.handwashing,climbingstairs,coughing)oractivitiesofdaily
living.Thechangeinweight(g)isameasureoftheamountofurinelost
(ml).Onlythe24-hourhomepadtesthasbeenshowntobereliable
andreproducible,andpadtestshavebecomemuchlesscommonly
doneinthelast5–10years.

17. Urodynamics
Urodynamicstudiescompriseseveralinvestigationsthatareemployedto
determinebladderfunction.
Uroflowmetry:
Uroflowmetry,themeasurementofurineflowrate,isasimpletestthatcan
excludethepresenceofoutflowobstructionorahypotonicdetrusor,buton
itsownwillnotdifferentiatebetweenthetwo.Inordertoobtainaflowrate,
thepatientisaskedtovoidontotheflowmeter,inprivate,whenherbladder
iscomfortablyfull.Themaximumflowrateandvolumevoidedarerecorded.
Inwomen,thenormalrecordingisabell‐shapedcurvewithapeakflowrate
ofatleast15mL/sforavolumeof150mLofurinevoided.Areducedflow
rateinanasymptomaticwomanmaybeimportantifsheistoundergo
incontinencesurgeryassheismorelikelytodevelopvoidingdifficultiesin
thepostoperativeperiod.

18. Uroflowmetry

19. Uroflowmetry

20. Cystometry
Cystometry,whichmeasuresthepressure–volumerelationshipwithin
thebladder,candifferentiatebetweenurodynamicstressincontinence
anddetrusoroveractivityinthemajorityofcases.Thebladderisfilled
withphysiologicalsalineviaaurethralcatheter.Duringbladderfilling
theintravesical(totalbladder)pressureandtheintra‐abdominal
pressurearemeasured.Therectal(orvaginal)pressureisrecordedto
representintra‐abdominalpressureandthisissubtractedfromthe
bladder(intravesical)pressuretogivethedetrusorpressure.Thisis
calledsubtractedcystometry.

21. Subtracted cystometry

22. Theinformationobtainedfromasubtractedcystometrogramincludes
sensation,capacity,contractilityandcompliance.Theurinaryresidual
volumeisnormallylessthan50mL,thefirstsensationofdesiretovoidis
normallyat150–250mLandthecystometricbladdercapacityisnormally
400–600mL.Undernormalcircumstances,thedetrusorpressuredoesnot
risebymorethan0.03cmH2Ofor1mLofbladdervolumeandthereareno
detrusorcontractionsduringbladderfilling.
Ideally,thebladderisfilledwiththewomansittingorstandingandthefilling
catheterremovedoncecapacityisreached.Sheisaskedtocoughseveral
timesandtoheelbounceandanyriseindetrusorpressureorleakageper
urethramisrecorded.Sheisthenaskedtopassurineandthedetrusor
pressureismeasuredandanyurinaryresidualvolumecanbenoted.

23. Videocystourethrography
Videocystourethrographywithpressureandflowstudies,which
combinescystometry,uroflowmetryandradiologicalscreeningofthe
bladderandurethra,canbeamostinformativeinvestigation.Itis
relativelyexpensiveandtime‐consumingandisonlyavailablein
tertiaryreferralcenters.Abnormalbladdermorphologycanbe
assessedaswellasthepresenceofvesico‐uretericreflux,trabeculation
ordiverticula.Occasionally,aurethraldiverticulumorvesicovaginal
fistulamaybeidentified.

24. Videocystourethrographyimage show extrinsic compression of
the bladder by uterine fibroids

25. Special investigations
Urethralpressureprofilometry
Therestingurethralpressureprofile(UPP)isagraphicalrecordof
pressurewithintheurethraatsuccessivepointsalongitslength.Of
particularinterestarethemaximumurethralclosurepressureand
functionalurethrallength.Inaddition,stresspressureprofilescanbe
performedifthepatientcoughsrepeatedlyduringtheprocedure.
Urethralinstabilityorrelaxationcanalsobeidentified.Itishelpfulin
womenwhoseincontinenceoperationshavefailedandalsointhose
withvoidingdifficulties.

26. Urethral pressure profilometry

27. Imaging of the urinary tract
Imagingoftheurinarytractismainlythroughultrasound,X‐raysorMRI.Intravenous
urographyhasnowlargelybeenreplacedbyultrasoundoftheupperurinarytract.
However,aCTurogramisimportantincasesofhaematuria.Additionalpathologymaybe
diagnosed,suchasthepresenceofauretericfistula,atransitionalcellcarcinomaorcalculi.
Ultrasoundisnowroutinelyusedforassessingbladdervolumesandassessingtheupper
urinarytracts.Transvaginalultrasounddoesallowclearvisualizationoftheurethraand
urethraldiverticula.Bladderwallthicknessofanemptybladdercanbemeasured
transvaginallygivingareproducibleandsensitivemethodofscreeningfordetrusor
overactivity(ameanbladderwallthickness>5mmgaveapredictivevalueof94%inthe
diagnosisofdetrusoroveractivity).Measurementofbladderwallthicknesshasalsobeen
showntohavearoleasanadjunctivetestinthosewomenwhoselowerurinarytract
symptomsarenotexplainedbyconventionalurodynamicinvestigations..Apelvicand/or
renaltractultrasoundmaybeindicatediftherearesymptomsofpelvicpain,clinical
suspicionofapelvicmass,haematuria,bladderpainorrecurrenturinarytractinfection.
MRIisusefulindiagnosingurethraldiverticulaandimagingthepelvicfloormuscles.

28. Intravenous urogramshowing a right duplex ureter

29. Electromyography
Electromyographycanbeemployedtoassesstheintegrityofthenerve
supplytoamuscle.Theelectricalimpulsestoamusclefiberare
measuredfollowingnervousstimulation.Twomaintypesof
electromyographyareemployedintheassessmentoflowerurinary
tractdysfunction.Thepudendalnerveisstimulatedandpotentials
measuredviatheelectrode.Thisisinaccurateasthemuscularactivity
ofthelevatoraniisnotnecessarilyrepresentativeofthatofthe
rhabdosphincterurethrae.Single‐fiberelectromyographyismore
accurateasitassessesthenervelatencywithinindividualmusclefibers
oftherhabdosphincter.Electromyographymaybeusefulinthe
assessmentofwomenwithneurologicalabnormalitiesorthosewith
voidingdifficultiesandretentionofurine.

30. Ambulatory urodynamics
Allurodynamictestsareunphysiologicalandmostareinvasive.Various
authorshavesuggestedthatlong‐termambulatorymonitoringmaybemore
physiologicalastheassessmenttakesplaceoveraprolongedperiodoftime
andduringnormaldailyactivities.Ambulatoryurodynamicsisdefinedasa
functionaltestofthelowerurinarytractutilizingnaturalfillingand
reproducingthesubject’severydayactivities.Ambulatoryurodynamicsis
usefulincaseswheretheclinicalandconventionalurodynamicdiagnoses
differ,orwhennoabnormalityisfoundonlaboratoryurodynamics.
Ambulatoryurodynamicshasbeenshowntobemoresensitivethan
laboratoryurodynamicsinthediagnosisofdetrusoroveractivitybutless
sensitiveinthediagnosisofurodynamicstressincontinence,althoughits
roleinclinicalpracticeremainscontroversial.

31. Ambulatory urodynamic equipment

32. Treatment of stress incontinence:
Conservative treatment
Conservativetreatmentisindicatedasfirst‐linetherapyifthepatientismedicallyunfitfor
surgeryordoesnotwishtoundergoanoperation,orinwomenwhohavenotyet
completedtheirfamilies.
Pelvicfloormuscletraining:
Individualizedexerciseprogrammesaredevisedforeachpatient,toincreaseboth
thenumberofcontractionsthatcanbeperformedconsecutivelyandalsoto
increasethedurationof‘hold’ofeachcontraction.Thistwo-prongedapproachis
importanttobuildbothstrengthofthemuscle,bothofwhichareessentialto
improvecontinencefunction.Successfuladherencetoaprogrammeofpelvicfloor
exercisescanleadtocureinover50%ofwomenandimprovementin75%or
more.Themajorbarriertosuccessisthewoman’swillingnesstoperseverewith
theexercisesoveraperiodofseveralweeks,inordertoachievemaximumbenefit,
butthemostobviousadvantageisthatacourseofexercisecarriesnoriskof
complications!PelvicfloorexercisesworkforbothstressincontinenceandOAB.In
thelattercase,itislikelythatthebenefitisfromimprovingmusclestrengthtogive
womentheconfidencetoresisttheurgewithoutfearofleakage,andalsobypelvic
floorcontractionhavingareflexinhibitionactionondetrusormusclecontraction.

33. Weighted vaginal cones
Thesearecurrentlyavailableassetsoffiveorthree,allofthesame
shapeandsizebutofincreasingweight(20–90g).Wheninsertedinto
thevagina,aconestimulatesthepelvicfloortocontracttopreventit
fromfallingoutandthisprovides‘vaginalweighttraining’.A60–70%
improvementratehasbeenreportedusingthistechniqueandtwo
studieshaveshownthatconesareaseffectiveasmoreconventional
formsofpelvicfloorre‐educationandrequirelesssupervision.

34. Weighted vaginal cones

35. Maximal electrical stimulation:
Maximalelectricalstimulationcanbecarriedoutusingahomedevicethatutilizesa
vaginalelectrodethroughwhichavariablecurrentispassed.Thewomanisableto
adjustthestrengthofthestimulusherselfandisinstructedtousethedevicefor20
mindailyinitiallyfor1month.Maximumelectricalstimulationhasbeenemployed
inboththemanagementofurodynamicstressincontinenceanddetrusor
overactivity,althoughithasnotgainedpopularity.
Vaginaldevices:
Therearemanywomenwho,forvariousreasons,arenotsuitablefor,orwhodo
notwishtoundergo,activetreatmentoftheirincontinence.However,theydo
requiresomesortof‘containment’oftheirleakageandvaginaldevicesmaybe
suitableforuseduringexerciseonashort‐termbasis.

36. Vaginal electrode for electrical stimulation and vaginal device

37. Medical therapy
Duloxetineisusedveryoccasionallyforincontinence.Itisa
combinedserotoninandnoradrenalinereuptakeinhibitor,and
hasaduallicenceforthetreatmentofdepressioninhigher
doses.Duloxetineactsatthemicturitioncenterinthesacral
spinalcordtoincreasethesympatheticnerveoutputtothe
urethralsphincterandincreasesphinctertone.Randomizedtrials
haveshowna50%improvementormoreinleakagesymptomsin
overone-halfofthepatientstreated.However,theside-effects,
includingnausea,causemanywomentostoptreatment.

38. Surgery
Surgeryisusuallythemosteffectivewayofcuringurodynamicstress
incontinence,anda90%cureratecanbeexpectedforanappropriate,
properlyperformedprimaryprocedure.Traditionalsurgeryfor
urodynamicstressincontinenceaimstosupportthebladderneckand
proximalurethraandinsomecasestoincreasetheoutflowresistance.
Undoubtedly,theresultsofsuprapubicoperationssuchasBurch
colposuspensionortheMarshall–Marchetti–Krantzprocedureare
betterthanthoseforthetraditionalanteriorcolporrhaphywithbladder
neckbuttress.Numerousoperationshavebeendescribedandmany
arestillperformedtoday.

39. Anterior colporrhaphy
Anteriorcolporrhaphyisonlyrarelyperformedforurodynamicstress
incontinence.Althoughitisusuallythebestoperationfora
cystourethrocele,thecureratesforurodynamicstressincontinenceare
poorcomparedwiththosefromsuprapubicprocedures.Asprolapseis
relativelyeasiertocurethanstressincontinence,itisappropriateto
performthebestoperationforincontinencewhenthetwoconditions
coexist.

40. Marshall–Marchetti–Krantz procedure
TheMarshall–Marchetti–Krantzprocedureisasuprapubicoperationin
whichtheparaurethraltissueatthelevelofthebladderneckissutured
totheperiosteumand/orperichondriumoftheposterioraspectofthe
pubicsymphysis.Thisprocedureelevatesthebladderneckbutwillnot
correctanyconcomitantcystocele.Ithasbeenlargelysupersededby
Burchcolposuspensionbecauseitscomplicationsincludeosteitispubis
in2–7%ofcases.

41. Colposuspension
Burchcolposuspensionwastheprimaryprocedureforstressincontinence
formanyyearsbeforethemidurethraltapesweredeveloped.At
colposuspension,theretropubicspaceisopenedviaaPfannenstielincision
intheabdomen,andthebladderreflectedmediallyoneachsidetoallowthe
placementoftwoorthreesutures(eitherabsorbableorpermanent)intothe
paravaginalfasciaoneachsideatthelevelofthebladderneck.These
suturesareplacedthroughthepectinealligamentonthepubicramusonthe
sameside,andthentiedtoprovidesupporttothebladderneckandprevent
descentduringcoughingorstraining.Thecurerateforincontinenceisthe
sameasformidurethraltapes(80–85%),andcomplicationsaresimilar.

42. Burch colposuspension

43. Sling procedures
Slingproceduresarenormallyperformedassecondaryoperations
wherethereisscarringandnarrowingofthevagina.Theslingmaterial
canbeeitherbiological(autologousrectusfascia,porcinedermis,
cadavericfascia)orsynthetic(Prolene).Theslingmaybeinserted
eitherabdominallyorvaginally,orbyacombinationofboth.Sling
proceduresareassociatedwithahigherincidenceofsideeffectsand
complications,especiallyaftertheinsertionofinorganicmaterialbut
mid‐tolong‐termcontinenceoutcomesaresuperiortoopen
colposuspensionbutthereareincreasedratesofirritativesymptoms.

44. Mid‐urethral tape procedures:
Therearenowseveralvariationsofmidurethraltapesavailable,buttheunderlyingprincipleis
the
same.Apermanent,non-absorbablemeshofpolypropylenewovenintoatapeapproximately1
cm wide
isplacedthroughasmallvaginalincisionunderthemidurethraandintoaUshapebehindthe
pubic
symphysis,viatwosmallsuprapubicincisions(aretropubicplacement),orintoahammock
shape behind
theinferiorpubicramiandthroughtheobturatorforamen,viaasmallincisionineachgroin(a
transobturatorplacement).Themidurethraltapeshaveacurerateforstressincontinenceof
80–85%,andthishighsuccessratepersistsinthelongterm(10yearsormore).Complications
specific to
midurethraltapesrelatetothenon-absorbablepolypropylenetheyaremanufacturedfrom.
Thereisalowrateofthetapeinterferingwithvaginalwoundhealing,leadingtoexposureofthe
centralportionoftape,oroflatererosionofthetapethroughthevaginalskinatotherplaces
alongitslength.
Commonoperativecomplicationsinclude:
•Voidingdifficulty(usuallyshortterm)in2–5%.
•Bladderperforationduringtheprocedure(2–5%).
•OnsetofnewOABsymptomsaftersurgery(5%).

45. Tension‐free vaginal tape in situ under the mid‐urethra
and exiting suprapubically

46. Urethral bulking agents
Athirdoptionforsurgeryisperiurethralinjectionsofmaterialthatbulkupthe
bladderneckandcoattheurethralmucosatopreventleakage.Three
productsarewidelyavailable(Macroplastique,DurasphereandBulkamid).
Theseareallsyntheticpolymermaterials.Theprocedureisperformed
underlocalanaestheticandisavailableforwomendeemedtoomedically
unfitorfrailforaformalanaesthetic,orforwomenwithresidualleakage
afteratapeorcolposuspension.Cureratesaftertheseproceduresareof
theorderof60–80%butlongertermcureislesseffective,sosomepatients
requiretwoormoretreatments.High-qualitydatafromrandomizedtrialsof
theseproductsarelacking,somostclinicianswillusetheseasthird-lineor
‘rescue’therapy,althoughinsomesettingswomenarechoosinginjectables
asfirst-linetreatmentinviewofthepossibilityofbeingtreatedinan‘office’
setting.

47. Artificial urinary sphincter
Anartificialsphincterisadevicethatmaybeemployedwhenconventional
surgeryfails.Itisimplantableandconsistsofafluid‐filledinflatablecuffthat
issurgicallyplacedaroundthebladderneck.Areservoircontainingfluidis
sitedintheperitonealcavityandasmallfinger‐operatedpumpissituatedin
theleftlabiummajus.Thethreemajorcomponentsareconnectedviaa
controlvalve.Undernormalcircumstancesthecuffisinflatedandthus
obstructstheurethra.Whenvoidingisdesiredthepumpisutilizedtoempty
thefluidinthecuffbackintotheballoonreservoirsothatvoidingmayoccur.
Thecuffthengraduallyrefillsoverthenextfewminutes.Artificialsphincters
areassociatedwithmanyproblems:theyareexpensive,thesurgeryrequired
toinsertthemiscomplicatedandthetissuesaroundthebladderneck
followingpreviousfailedoperationsmaybeunsuitablefortheimplantation
ofthecuff.Inaddition,mechanicalfailuremayoccur,necessitatingfurther
surgery.However,thereisaplaceforthesedevicesandtheirtechnologyis
likelytoimproveinthefuture.

48. Treatment of detrusor overactivity
Treatmentfordetrusoroveractivityaimstore‐establishcentralcontrol
ortoalterperipheralcontrolviabladderinnervation.Thefactthatso
manydifferenttypesoftreatmentareavailableforthisconditionshows
thatnoneisuniversallysuccessful.

49. Bladder retraining
ForwomenwithOABormixedincontinence,pelvicfloormuscletrainingiscombinedwitha
form of
bladderdrillorbladderretraining.Bladderdrillinvolvesre-educatingthepatient(andher
bladder)toincreasetheintervalbetweenvoids,tore-establishnormalfrequency.Formany
womenwithOAB,theurgencyandassociatedleakage(orfearofleakage)leadsthemto
establishapatternofvoidingwhenevertheyareawareofbladderfillingsensations.An
awarenessofbladderfillingisanormalphysiologicalsignalthatoccursonceormorethan
onceasthebladderfills,butbeforefullbladdercapacityisreached.Bladderretraining(in
conjunctionwithpelvicfloormuscletraining)includesteachingthewomanaboutnormal
bladdersensation,therateofurineproduction(usually1–2ml/min)andnormalbladder
capacity(350–500ml),andthenencouraginghertopracticedelayingvoidingforseveral
minutesbeyondwhenshewouldnormallyvoid.Itisusualdotothisinastepwisefashion,
topushbackvoidingin5or10minutesteps,ratherthantryingtoholdforawholehour.
Bladderretrainingcanbeverysuccessfulinreducingfrequencyandurgency,butlikepelvic
floorexercises,itrequiresperseveranceanddeterminationonthepartofthepatient.

50. Medical treatment
Medicaltreatmentsforurinaryincontinenceareprimarilyaimedat
treatmentofOABsymptomsandDO.Becausetheparasympatheticnerves
stimulatethedetrusormuscletocontract,anticholinergicmedications
havebeenthemainstayofmedicaltreatmentformanyyears.Thereisawide
rangeofdifferentcompoundsandpreparationsavailable.Themainsiteof
actionofanticholinergicdrugsisthemotorendplateoftheneuromuscular
junction,wheretheyantagonizetheactionofacetylcholineatthemuscarinic
receptorsandinhibitdetrusorcontraction.Inthelast5years,ithasbecome
apparentthatacetylcholineisalsoanimportantneurotransmitterinthe
afferent,sensorypathwaysinthebladderandthusthedrugsalso
haveadirecteffectinreducingtheperceivedsensationsofbladderfillingby
inhibitingreceptor-mediatedafferentsignals.

51. Drugsthathaveamixedaction:
OxybutyninTheeffectivenessofoxybutynininthemanagementof
patientswithdetrusoroveractivityiswelldocumented.Adouble‐blind
placebo‐controlledtrialfoundoxybutynintobesignificantlybetterthan
placeboinimprovinglowerurinarytractsymptoms,although80%of
patientscomplainedofsignificantadverseeffects,principallydry
mouthordryskin.Thesecanbemitigatedbyslow‐release
preparationsoralternativemethodsofadministration(e.g.topicalor
intravesical).

52. Anticholinergic medications
1.Oxybutynin:2.5–5mguptothreetimesdaily;first-choicemedicationrecommendedby
theUKNationalInstituteforHealthandCareExcellence(NICE);modifiedrelease
preparation5mgoncedaily;increaseweeklyby5mgupto20mgdaily.
2.Propiverine:15mgonetothreetimesdaily.
3.Trospium:20mgtwicedaily.
4.Tolterodine:2mgtwicedaily;reducedto1mginhepaticimpairment;modifiedrelease
preparation4mgoncedaily.
5.Fesoterodine:4mgoncedaily,maximum8mgoncedaily(fesoterodineisrelatedto
tolterodine).
6.Solifenacin:5mgoncedaily;canbeincreasedto10mgoncedaily.
7.Darifenacin:7.5mgoncedaily.

53. Allanticholinergicdrugshavesimilarefficacy,withpublishedrandomized
studiesdemonstratingadecreaseinurgencyandincontinenceepisodesin
therangeof1–2perday,comparedwithplacebo.Theside-effectprofileis
similaracrossalldrugs,withdrymouth,constipationandblurredvision
beingthemostcommon.Mirabegronisamorerecentlydeveloped
medicationforOAB,whichisabeta3-adrenergicagonist.Mirabegronacts
uponthesympatheticneuronsinnervatingthebladder,toenhance
relaxationofthedetrusor.Thereforeitisactingmoreonthestoragefunction
ofthebladderthandoanticholinergicmedications,whichactbysuppressing
voiding.Mirabegroncanbeusedsimultaneouslywithananticholinergic
drug.

54. Antidepressants
Imipraminehasbeenshowntohavesystemicanticholinergiceffects
andblocksthereuptakeofserotonin.Someauthoritieshavefounda
significanteffectinthetreatmentofpatientswithdetrusoroveractivity,
althoughothersreportlittleeffect.Inlightofthisevidenceandthe
seriousadverseeffectsassociatedwithtricyclicantidepressants,their
roleindetrusoroveractivityremainsofuncertainbenefit,although
theyareoftenusefulinpatientscomplainingofnocturiaorbladder
pain.

55. Antidiuretic agents
Desmopressinisasyntheticvasopressinanalogue.Ithasstrong
antidiureticeffectswithoutalteringbloodpressure.Thedrughasbeen
usedprimarilyinthetreatmentofnocturiaandnocturnalenuresisin
childrenandadults.Desmopressinissafeforlong‐termuse;however,
thedrugshouldbeusedwithcareintheelderlyowingtotheriskof
hyponatraemia.

56. Intravesical therapy
TheneurotoxinbotulinumtoxinA(marketedasBotox)hasbeenshownin
recentrandomizedtrialstobeahighlyeffectivetreatment.Botulinumtoxinis
along-actingmoleculethatpreventsthereleaseofneurotransmittervesicles
fromthemotorend-plateandcausesaflaccidparalysisinthetreated
muscle.Asingleintramuscularinjectioncanlastfor3–6months.Botulinum
toxinisadministeredviaaflexibleorrigidcystoscopeandinjectedin
multiplesitesacrossthedomeofthebladder,toabolishtheinvoluntary
detrusorcontractionsthatcausesymptoms.Reductionofurgencyand
leakageepisodesofover50–80%havebeenreported,andcontinencerates
inexcessof40%.Themajordrawbackofthistreatmentisavoidingdifficulty
rateof8–15%which,ifitoccurs,canpersistforthedurationoftreatment
effectandbetroublesomeforthepatienttomanage.However,many
patientsareabletoself-catheterizewithlittledifficultyandstillfindthatthis
givesthemahighdegreeofsocialindependence,comparedtobefore
treatment.

57. Neuromodulation
Peripheral neuromodulation
ThetibialnerveisamixednervecontainingL4–S3fibersandoriginates
fromthesamespinalcordsegmentsastheinnervationtothebladder
andpelvicfloor.Consequently,peripheralneuromodulationmayhavea
roleinthemanagementofurinarysymptoms.Peripheral
neuromodulationmayofferanalternativetherapeuticoptionforthose
patientswithintractableOABwhohavefailedtorespondtomedical
therapy,althoughitremainslesscost‐effectivethantreatmentwith
antimuscarinicagents.

58. Sacral neuromodulation
Stimulationofthedorsalsacralnerverootusingapermanent
implantabledeviceintheS3sacralforamenhasbeendevelopedfor
useinpatientswithbothidiopathicandneurogenicdetrusor
overactivity.Thesacralnervescontainnervefibersofthe
parasympatheticandsympatheticsystemsprovidinginnervationtothe
bladderaswellassomaticfibersprovidinginnervationtothemuscles
ofthepelvicfloor.Thelatterarelargerindiameterandhencehavea
lowerthresholdofactivation,meaningthatthepelvicfloormaybe
stimulatedselectivelywithoutcausingbladderactivity.
Althoughneuromodulationremainsaninvasiveandexpensive
procedure,itoffersausefulalternativetomedicalandsurgical
therapiesinpatientswithsevereintractabledetrusoroveractivity.

59. Surgery
Forthosewomenwithseveredetrusoroveractivitythatisnottreatablebysimpletypesof
treatment,surgerymaybeemployed.
Clamcystoplasty:
Intheclamcystoplasty,thebladderisbisectedalmostcompletelyandapatchofgut
(usuallyileum)equalinlengthtothecircumferenceofthebisectedbladder(about25cm)
issewninplace.Thisoftencuresthesymptomsofdetrusoroveractivitybyconvertinga
high‐pressuresystemintoalow‐pressuresystem,althoughinefficientvoidingmayresult.
Patientshavetolearntostraintovoid,ormayhavetoresorttocleanintermittent
self‐catheterization,sometimespermanently.Inaddition,mucusretentioninthebladder
maybeaproblem,butthiscanbepartiallyovercomebyingestionof200mLofcranberry
juiceeachdayinadditiontointravesicalmucolyticssuchasacetylcysteine.
Thechronicexposureoftheilealmucosatourinemayleadtomalignantchange.In
addition,metabolicdisturbancessuchashyperchloraemicacidosis,vitaminB12deficiency
andoccasionallyosteoporosissecondarytodecreasedbonemineralizationmayoccur.

60. Clam cystoplasty

61. Urinary diversion
Asalastresortforthosewomenwithseveredetrusoroveractivityor
neurogenicdetrusoroveractivitywhocannotmanageclean
intermittentcatheterization,itmaybemoreappropriatetoperforma
urinarydiversion.Usuallythiswillutilizeanilealconduittocreatean
abdominalstomaforurinarydiversion.Analternativeistoforma
continentdiversionusingtheappendix(Mitrofanoff)orileum(Koch
pouch),whichmaythenbedrainedusingself‐catheterization.

63. Mixed incontinence
Thosewomenwithbothdetrusoroveractivityandurodynamicstress
incontinenceposeadifficultmanagementproblem.Thedetrusor
overactivityisinitiallytreatedwithantimuscarinicagentsbutifthereis
persistentSUIoncetheurgencyandurgencyincontinenceistreated,
thencontinencesurgeryisperformed.However,ifurgeincontinence
stillpredominates,surgerymayaggravatethewoman’ssymptoms.

64. Thank you