- 1. INCONTINENCE OF URINE Dr .Ashraf Fouda Damietta General
Hospital
2. Physiology of Micturition
- somatic, parasympathetic (PSN) and sympathetic (SNS)
- As urine fills the bladder, the detrusor stretches and allows
the bladder to expand
- ~300 ml in bladder before the brain
- recognizes bladder fullness
3. Physiology of Micturition 4.
- Low bladder volumes : SNS is stimulated and PNS is
inhibited
- Bladder full:PNS stimulated (bladder contracts) SNS inhibited
(internal sphincter relaxes)
- Intravesical pressure > resistance within the urethra: urine
flows
- Pudenal nerveinnervates external sphincter
Physiology of Micturition 5. DEFINITION OFINCONTINENCE OF
URINE
- It is involuntary escape of urine
6. TYPES:
- 2 . Falseincontinence (ischuria paradoxica).
- 3.Stressor sphincter incontinence.
- (precipitancy-detrusor instability or detrusor
dyssynergia).
7. 1. True (continuous) incontinence
- In this case, urine escapes continuously by day and by
night.
- (a) Urinary fistulae as vesicovaginal fistula;
8. 2. False incontinence( Overflow incontinence)
- Itis involuntary loss of urine following overdistension of the
bladder .
- Overflow incontinence, usually short-term, can occurafter
vaginal delivery especially ifepidural anesthesia was used.
- Other causes includediabetes, neurological diseases, severe
genital prolapse, and post surgical obstruction.
9. 4. Urgency incontinence(precipitancy-detrusor instability or
detrusor dyssynergia).
- The woman feels the desire to micturate but before she reaches
the bathroom, urine passes involuntarily.
- It is due to irritability of the bladder muscle and so the
patient cannot inhibit it.
- bladder diseases as cystitis, stone or tumour.
10.
- Detrusor instability, also calledoveractive bladder , is a
condition in which the bladder contracts involuntarily in response
to filling.
- It was calleddetrusor dys-synergiain the past.
- It commonly presents as urge incontinenceleakage of urine
associated with a strong desire to void.
- No causeis identified in more than90%of these patients.
- Advancing age is an important risk factor .
Detrusor instability(DI) 11.
- Detrusor instability caused by neurologic diseases such as
cerebrovascular disease, multiple sclerosis, or spinal cord injury
is calleddetrusor hyperreflexia.
- Irritation of the bladder by inflammation(such as urinary tract
infection)or prior pelvic surgery can also cause detrusor
instability.
Detrusor instability(DI) 12. Urge incontinence 13. STRESS
INCONTINENCE ) SPHINCTER INCONTINENCE-GENUINE STRESS INCONTINENCE)
14. DEFINITION
- It is involuntary escape of few drops of urine with increased
intra-abdominal pressure as during straining, sneezing, coughing,
laughing ... etc.
15. DEGREES OF STRESS INCONTINENCE
- Incontinence occurs onlywith severe stress , such as coughing,
sneezing, etc
- Incontinence withmoderate stress , such as rapid movement or
walking up and down stairs
- Incontinence withmild stress , such as standing. The patient is
continent in the supine position
16. PHYSIOLOGICAL ANATOMY
- The bladder neck and upper third or half of the urethra are
above the level of the pelvic floor.
17.
- With increased intra-abdominal pressure,the pressure is equally
transmitted to the bladder and upper urethra andurine will not
escape
PHYSIOLOGICAL ANATOMY 18.
- Is an involuntary muscle which surrounds the bladder neck.
The internal urethral sphincter (= bladder sphincter) 19. The
external urethral sphincter
- is a voluntary muscle found between the superficial and deep
perineal membranes and surrounds the middle part of the
urethra(compessor urethrae muscle).
20.
- It empties the urethra after the act of micturition,
- Interrupts the flow of urine on desireand
- It acts as a secondary defensive mechanism against escape of
urine.
The external urethral sphincter 21.
- At rest the urethra makes an angle of90-100 degreeswith the
base of the urinary bladder called the :posterior urethrovesical
angle .
- The urethra also makesan angle of less than 30 degreeswith the
vertical line.
22. During micturition the followingchanges occur:
- 1. Descent of the bladder neck with complete loss of the
posterior urethrovesical angle(angle becomes 180 degrees).
- 2. Opening(funneling)of the bladder neck and upper
urethra.
- 3. Descent of the urethra leading to increase in the angle
between it and vertical line, so the angle becomes more than 30
degrees.
- .In stress incontinence, one or all of the above changes occur
with increased intra-abdominal pressure.
23. Incidence of Subtypes of Urinary Incontinence in Women
24. TYPES OF STRESS INCONTINENCE
- Type 1: There is complete loss of the posterior urethrovesical
angle.
- Type 2: There is complete loss of the posterior urethrovesical
angle together with increase in the angle between the urethra and
vertical line to be more than 30 degrees.
- This type leads to severe stress incontinence
25. AETIOLOGY
- Weakness of the internal urethral sphincter or
- Descent of bladder neck below the level of the pelvic
floor.
26.
- 1.Congenital weaknessof the internal urethral sphincter, seen
in the young nullipara.
- Short urethra(less than 1 cm),
- Separation of symphysis pubis.
AETIOLOGY 27.
- 3.Traumato the region of the bladder neck due to vaginal
delivery or operation.
- The incidence of stress incontinence increases with parity due
to repeated birth trauma.
AETIOLOGY In fact vaginal delivery is the commonest cause of
stress incontinence. 28.
- 4.Menopause :Lack of oestrogen leads to atrophy of bladder neck
supports.
- 5. Pregnancy and continuous administration of
oestrogen-progestogen preparation to induce psuedopregnancy state
to treat endometriosis.
- The hormonal imbalance with increased progesterone weakens the
internal urethral sphincter.
AETIOLOGY 29.
- If the bladder neck descends below the level of the pelvic
floor, the increased intra-abdominal pressure will be transmitted
to the bladder and not to the upper urethra leading to escape of
urine.
- 7.Organic nervous diseases as disseminated sclerosis.
AETIOLOGY 30. Pathophysiology of Stress Incontinence
- The basic pathology is urethral incompetence.
- This can be either due to:
- A)Urethral hypermobility (80 - 90% of patients)
- B)Intrinsic Sphincter Dysfunction(10 - 20% of patients)
31. A) Urethral hypermobility(80 - 90% of patients)
- This results from loss of the normal pelvic support mechanism
of the bladder and urethra due to:
- Trauma and stretching of vaginal delivery
- Hormonal changes ( Menopause)
32.
- As the bladder neck support is weakened, the increase in
intra-abdominal pressure is no longer transmitted equally to the
bladder outlet, and therefore instantaneous leakage occurs.
A) Urethral hypermobility(80 - 90% of patients) 33. B) Intrinsic
Sphincter Dysfunction(10 - 20% of patients)
- This results from damage to the sphincter due to:
- Multiple prior operations
- Neurogenic disorders including Diabetes Mellitus
- Atrophic changes: lack of estrogen.
34. Diagnosis 35. A. History
- A detailed history differentiates between the different types
of incontinence.
- Stress incontinence and detrusor instability frequently occur
together.
- Gradual onset after menopause suggests oestrogen
deficiency.
- History of vaginal repair or operation in the region of the
bladder neck and history of any neurologic disease.
36. B. Diagnostic Tests 37. 1. Stress Test
- The bladder must be moderately full.
- The patient in the lithotomy position, the two labia are
separated, and the patient is asked to cough.
- If urine escapes , the patient is incontinent.
- If no urine escapes , the test is repeated while the index and
middle fingers in the vagina press on the perineum to abolish
reflex contraction of the levator ani muscles during
straining.
- If still no urine escapes, the test is repeated while the
patient is standing with the legs separated.
38. 2. Bonneytest
- It is indicated in case of a positive stress test associated
with a cystocele.
- To know if incontinence is due to descent of bladder neck or
weakness of the sphincter .
- The index and middle fingers are placed on both sides of the
urethra to elevate the bladder neck upwards.
- If no urine escapes on stressit means that the incontinence
isdue to descent of the bladder neck , but if urine still escapes
it means weakness of the sphincter.
39.
- Indicated in case of anegative stress testassociated with a
large cystocele to diagnose hidden stress incontinence.
- The cystocele is reduced, the cervix is grasped with a
volsellum and pushed upward, then the patient is asked to
cough.
- If urine escapes, it indicates that the patient was continent
because of kinking of the urethra.
3. Yousef Test 40. 4. Examination of Urine
- Urinalysis, culture and sensitivity to exclude cystitis.
41.
- To exclude lesions in the urethra and bladder.
- The bladder neck is examined.
- It should close in response to straining.
- However, it opens in case of stress incontinence.
5. Cystourethroscopy 42.
- A radio-opaque dye is injected by a catheter into the
bladder.
- On straining, the lateral view will showabsence of the
posterior urethrovesical angle in more than 90% of cases.
- Funneling of the bladder neckin theantero-posterior view may be
seen in some cases.
- The procedure is recorded on video tape(video
Cystourethrography)to facilitate diagnosis and for education
purposes.
6. Cystourethrography 43. 7.Urodynamics
- Medical science concerned with the study of urine transport
from kidney to bladder as well as its storage and evacuation
- 1.Cystometrogram ( most important test), Filling Cystometry and
Voiding Cystometry
- 2.Urethral pressure profile
44.
- To measure the intravesical pressure while the bladder is
filled with sterile water or carbon dioxide gas.
- It diagnoses stress incontinence and detrusor instability.
Cystometrogram 45. Cystometrogram
- Involves filling the bladder to measure volume-pressure
relationships.
- As the bladder is filled to its normal capacity of300-500 ml ,
the pressure inside the bladder should remain low.
- The patient usually experiences the first urge to void
at150-200 ml.
46.
- Patients with DI often have reduced bladder capacity(< 300
ml)and demonstrate urinary incontinence that is associated with
involuntary bladder contractions(pressure increase above
baseline)
Cystometrogram 47.
- In patients with GSI, incontinence is demonstrated when the
patients coughs or strains (e.g.,Valsalva maneuver ).
- The intravesical pressure at which leakage is noted(leak point
pressure)is generally< 60 cmof water pressure if intrinsic
sphincter deficiency is present.
Cystometrogram 48. 8. The Cotton-Tip Applicator(Q-Tip) Test
- A sterile applicator with a small piece of cotton at its tip is
introduced to reach the bladder neck.
- The angle between the applicator and the horizontal is
measured.
- The patient then strains maximally using the Valsalva
manoeuvre.
- This causes descent of the bladder neck and upward movement of
the applicator producing a new angle with the horizontal.
49. (Q-Tip) Test
- In normal patientsthe increase in the angle is less than 30
degrees.
- In stress incontinencethe change is more than 30 degrees
indicating poor support and abnormal descent of bladder neck
- The test is positive in more than90%of cases with stress
incontinence .
50.
- To maintain continence, the urethral pressure(100-120 cm
water)must be higher than the intravesical pressure(0-20 cm
water).
- A special catheter; is used which measures the intravesical and
intra-urethral pressure.
9. Measurement of Urethral Pressure 51.
- The urethral closing pressure
- Equals the intraurethral pressure minus the intravesical
pressure(normally 90-100 cm water).
- The length of the urethra along which urethral pressure exceeds
bladder pressure is termedfunctional length of the urethrawhich
is3-4 cm .
- In stress incontinence the urethral closing pressure is reduced
.
52.
- Stress incontinence occurs if the length isless than 1 cm
.
10. Measurement ofUrethral Length 53.
- It records the rate of urine flow through the urethra when the
patient is asked to void spontaneously while sitting on uroflow
chair.
- It is used toevaluate patientswith stress incontinencebefore
surgeryto exclude difficulty in voiding which may be increased by
bladder neck surgery.
11. Uroflowmetry 54.
- The normal female voids by the rule of "20"
- that is urine is passed at a rate of 20 ml/second and the
bladder is emptied in less than 20 seconds.
55.
- It gives information about funneling of the bladder neck,both
at rest and with Valsalva manoeuvre.
12. Sonographic 56. By three-dimension transvaginal
ultrasound
- The continent womenhave a thick wall internal urethral
sphincter which extends from the bladder neck and along 60-80% of
the whole urethra.
- In stress incontinence , the sphincter is torn as proved by
appearance of areas of echolucency.
57.
- When rupture affects theupper partof the sphincter, the urethra
appears"funnel-shaped".
- When damage affects thelower part , the urethra
appears"vase-shaped" .
- When rupture affects thewhole lengthof the sphincter, the
urethra appearsshort and irregular.
By three-dimension transvaginal ultrasound 58. What laboratory
tests are helpful in evaluating incontinence?
- Postvoid residualis an easy initial test to obtain.
- After the patient voids, there should be less than 50 ml of
urine in the bladder.
- Postvoid residualis measured by ultrasound or catheterizing the
patient in the office.
- A patient withan elevated Postvoid residual(repeat measurements
greater than 100-200 ml) may have an underlying neurologic
disorder.
59.
- Catheterization also provides a good opportunity to obtain
urine for analysis and culture.
- Urinalysis and urine culturehelp to diagnose urinary tract
infection.
- Blood workis required only if compromised renal function,
diabetes, syphilis, or other systemic diseases are suspected.
What laboratory tests are helpful in evaluating incontinence?
60. Which tests aremosthelpful in differentiating between GSI and
DI?
- should be performed especially in patients with: irritative
bladder symptoms such as urgency, frequency, and hematuria
61. TREATMENT 62. I. Prophylactic Treatment
- 1. During labour, the bladder should be kept empty.
- 2. Episiotomy is performed if necessary.
- Pelvic floor exercisesare started after delivery.
- These include repeated stoppage of the urinary stream during
micturition and repeated contractions of the pelvic floor
muscles.
63.
- 1. Mildstress incontinence.
- 2.The patient not completed her family as vaginal delivery may
damage a bladder neck repair
- 3.Patient isunfit for surgeryor refuses surgery.
- 4.When stress incontinence iscombined with detrusor
instability.
- The latter should be treated at first before surgery is done
for stress incontinence .
II. Conservative (non-surgical) Treatment 64. Conservative
treatment cures or improves50% of casesand include:
- 1 .Physiotherapy:Kegl perineometer may be used.
- 2 .Faradic current stimulationof the levator ani muscles to
improve their tone.
- A set consists of 5 or 9 cones.
- Weight ranges from 20 to 100 grams.
- Patient inserts the cone in the vagina and keeps it for 15
minutes twice daily.
- If this succeeds she inserts the next cone.
- This improves the tone of the pelvic floor muscles.
65.
- 4. Oestrogen therapy for menopausal patients:
- It causes thickening of the urethral mucosa and engorgement of
the underlying blood vessels thus increasing the urethral pressure
and resistance.
- Oestrogen is given orally or as vaginal cream.
- 5.Alpha-adrenergic stimulants: which stimulate contraction of
the internal urethral sphincter, e.g. ephedrine.
- 6. Large vaginal diaphragms, Hodge pessaryto elevate ' and
support the bladder neck.
Conservative treatment cures or improves 50% of cases and
include: 66.
- 7 .Reduction of weightin obese patients to reduce
intra-abdominal pressure.
- 8 .Stop caffeine(to avoid diuresis)andsmoking(to avoid
coughing)
- 9 .Injection of Teflon or bovine collagenin the submucosal
layer in the region of the bladder neck.
- This leads to narrowing of the urethral lumen and increased
urethral resistance.
Conservative treatment cures or improves 50% of cases and
include: 67. Il. Surgical Treatment
- It is the primary treatment of stress incontinence.
- The operation is done vaginally, abdominally, or
abdominovaginally.
- Almost 200 operations have been described.
68.
- Urehroplasty(Kelly,Kennedy,etc.)
- Urethropexy(Retropubic urethropexy e.g.
Marchall-Marchitti-Krantz, etc.)
- Colposuspension( Burch operation, Preyera , etc.)
- Urethral slings(Aldridge operation, etc..)
- Tension free Vaginal Tape(TVT)
69. A. Vaginal Operations 70.
- It consists of repair of cystocele and/or urethrocele.
- Vertical mattress sutures are then placed to plicate the whole
urethra and bladder neck.
- This gives support to the urethra and restores the normal
posterior urethrovesical angle.
- Operation is done for mild and moderate cases of stress
incontinence.
- Long term success rate is 55-65%.
1.Kelly operation 1914 71. 2.El-Hemaly urethrorrhaphy
operation
- A vertical incision is made in the anterior vaginal wall.
- The torn edges of the internal urethral sphincter are sutured
together to restore its integrity.
- The repair restores the normal urethrovesical angles seen in
continent women.
72. 3.Vaginal tape operation(TVT) 1996
- The tape is made of prolene and has a curved needle at each
end.
- Operation is done using local infiltration anaesthesia.
- Two smalltransverse incisions 5 cm apart are made in the
suprapubic area.
- A vertical incision is made in the anterior vaginal wall.
- The needles of the tape are passed upward behind the pubic bone
and brought out through the suprapubic incisions.
- The tape is made to surround the mid-urethra.
73.
- The cystoscope is used by the assistant to make sure that the
bladder is not pierced by the needle.
- The tape is adjusted by pulling on its ends, and continence is
confirmed by asking the patient to cough.
- The ends of the tape are cut off and left free and not fixed to
the tissues,
- Finally the vaginal and suprapubic incisions are closed.
- When stress occurs ,the recti will contract and pull on the
tape to support the urethra and prevent escape of urine
3.Vaginal tape operation (TVT) 74.
- Simple, easy, relatively safe with short recovery & little
pain.
- Reported cure is 86% & improvement is 11%.
- Operation takes 20-30 minutes.
- Complications: urine retention, parautrethral & paravesical
hemorrhage, infection , bladder &bowel injury.
T ension freeV aginalT ape (TVT) 75. B. Abdominal Operations
76.
- The stitches are placed in the fascia on each side of the
bladder neck and upper half of the urethra and are attached to the
periosteum on the back of the symphysis pubis.
- This restores the normal intra-abdominal position of the
urethra.
- Main complication isosteitis pubis (0.5-5%).
- Nonabsorpable (as mersilene) or delayed absorbable sutures (as
Vicryl or Dexon) are used.
1.Mashall-Marchetti-Krantz1949 77. 2.Burch Operation1968
- Burch colposuspensionis the operation of choice .
- It corrects both stress incontinence and cystocele.
- The stitches are placed in the fascia on each side of the
bladder neck and the base of the bladder and are attached to the
iliopectineal ligaments (Cooper Ligaments),( The pectineal part of
the inguinal ligament)
- Nonabsorpable or delayed absorbable sutures are used.
- Operation can be done through the laparoscope.
78.
- The success rate of the above abdominal operations
is80-90%
79. C. Combined Abdominovaginal Operations 80. 1. Urethral
Slings
- In this condition, there is damage or paralysis of the
sphincteric unit which could even be in a normal position.
- The goal of surgery for Intrinsic Dysfunction is coaptation,
support, and compression of the damaged sphincteric unit.
- Simple suspension of the bladder neck is unlikely to correct
the problem.
- Urethral Sling Procedures is the best to achieve the goal.
81.
- A sling is put around the urethra at the bladder neck and
either fixed around the rectus muscles or to the pubic bone.
- - The sling could be taken from the rectus sheath"Aldridge
operation".
- - A nylon sling may be used"Pereyra operation".
Sling Operations 82.
- An incision is made in the vaginal wall to expose the bladder
neck.
- A nylon suture is placed in the fascia on each side of the
bladder neck.
- The two sutures are passed upward behind the symphysis pubis
and are attached to the anterior rectus sheath.
- The cystoscope is used to be sure that the needle does not pass
through the bladder(endoscopic needle bladder neck
suspension).
2. Needle Bladder NeckSuspension Operations 83.
- An example isStamey operationin which two Dacron tubes (1 cm)
are used to give support to the bladder neck and to avoid the
sutures cutting through the tissues.
2. Needle Bladder NeckSuspension Operations 84. ObTape
transobturator sling
- September 10, 2003new surgical implant for treatment of stress
incontinence in women has been approved by the FDA.
- It was pioneered in 1999 by Emmanuel Delorme in France.
- Soon became popular because the procedure is perceived to be
simpler and faster, with less risk of complications, than
alternative procedures.
- In the last 2 years over 11,000 women have been successfully
treated for stress incontinence with transobturator sling.
85. D. ArtificialUrinary Sphincter 86.
- Indicated when surgery fails to correct stress
incontinence.
- The device consists of a cuff which is placed around the
bladder neck.
- A balloon reservoir, containing fluid is placed in the
peritoneal cavity or under the anterior rectus sheath, and a small
pump is situated in one labium major.
D. Artificial Urinary Sphincter 87.
- Under normal conditions the cuff is full with fluid thus
closing the bladder neck.
- When voiding is desired the pump is pressed to force the fluid
in the cuff to go back into the balloon reservoir so that voiding
can occur.
- The cuff then gradually refills over the next few minutes.
88. DETRUSOR INSTABILITY (DI) 89. DETRUSOR INSTABILITY
- The patient complains of urgency incontinence, frequency and
nocturia.
- Involuntary loss of urine also occurs when the women sits for a
long time and stands to go to the bathroom.
- She may pass urine with thesight or soundof water
90.
- Women typically complain ofurgency followed by a large loss of
urine.
- Cystometryconfirms the diagnosis.
- Involuntary detrusor contractions of 15 cm of water or more
occur during filling of the bladder.
DETRUSOR INSTABILITY (DI) 91. TREATMENT of (DI)
- Bladder retraining drills :
- The patient is asked to pass urine every hour during daytime
and to increase the interval by 15 minutes every week until she
passes urine every 2-3 hours.
92.
- Which inhibit the contractions of detrusor muscle as
anticholinergic drugs, tricyclic antidepressants, and
ephedrine.
- Ephedrinestimulates alpha-adrenergic receptors in the internal
urethral sphincter leading to contraction, and stimulates
beta-adrenergic receptors in the detrusor muscle leading to
relaxation.
TREATMENT of (DI) 93. SURGICAL TREATMENT OF URODYNAMIC STRESS
INCONTINENCE RCOG EVIDENCE BASEDGUIDELINESOCTOBER 2003 94.
- Surgery for stress incontinence of urine has been performed on
women for over a century.
95.
- The anterior vaginal repair was the most popular primary
procedure for stress incontinence up to the1970s,but over thelast
20 yearsthe operation has been criticized because of high
recurrence rates.
96.
- More sustained results are obtained from retropubic
surgery.
97.
- Primary surgery should only be considered aftera period of
conservative treatment froma specialist therapist
98.
- The literature on surgery for stress incontinenceis extensive
but is mainly based oncase series rather than randomized trials
.
99.
- Overall,83%of women reported improvement three months after
continence surgery,5%had no change and8%reported a worsening in
their condition.
100. Surgical procedures 101. Anterior vaginal repair
- Anterior repair is less successful as an operation for
continence than retropubic procedures and has been superseded by
sling procedures.
- Anterior repair still has a role in the treatment of prolapse
without incontinence.
A 102.
- Meta-analyses of heterogeneous studies suggest a continence
rateof between67.872.0%.
Anterior vaginal repair A 103.
- The anterior colporrhaphy procedure remains in use, largely
because of the relativelylow morbidityof the procedure and
itsfamiliarityfor gynecologists as an operation for prolapse.
Anterior vaginal repair A 104.
- The incidence oflong-term voiding disordersfollowing this
procedure approacheszero .
- Long-term results decrease with time , such that a 63%
continence rate at one year of follow up fell to37% at five years
of follow up.
Anterior vaginal repair A 105.
- The view of the American Urological Association is thatanterior
repairsare the least likely of the four major operative
categories(anterior repair, suburethral sling, colposuspension,
long-needle suspension)to be efficacious in the long term.
Anterior vaginal repair A 106.
- Burch colposuspension is the most effective surgical procedure
for stress incontinence, with a continence rate of 8590% at one
year .
- The continence rate falls to 70% at five years; this shows
better longevity than other methods of treatment.
Burch colposuspension A 107.
- Voiding difficultyhas been reported in a mean of 10.3% of women
after colposuspension (range 227%).
- De novodetrusor overactivityhas been described in a mean of 17%
women(range 827%).
- Genitourinary prolapse(enterocele, rectocele) has been reported
in follow up at five years in an average of 13.6% women(range
2.526.7%).
Burch colposuspension A 108.
- Ureteric damagehas been reported.
- There wasno reported mortalityas a direct consequence of the
procedure.
- The continence rate after Burch colposuspension falls if
previous continence surgery has been performed.
- In one study the continence rate fell from 84% for a primary
procedure to 63% for secondary surgery
Burch colposuspension A 109.
- A Cochrane review has examined the place of Burch
colposuspension among other continence procedures and concluded
that :
- open colposuspension is the most effective surgical treatment
for stress incontinence, especially in the long term.
Burch colposuspension A 110.
- Burch colposuspension is more effective than needle suspension
and provides a similar subjective continence rate to laparoscopic
colposuspension (85100% after 618 months of follow-up).
Burch colposuspension A 111. Alternative suprapubic surgery
- The role of other suprapubic operations such as
MarshallMarchetti Krantz , paravaginal repair and laparoscopic
colposuspension, is unclear.
B 112.
- (MMK) retropubic procedure was a common anti-incontinence
procedure between 195090sand Krantz described a personal series of
3861 cases with a follow-up of up to 31 years and a96%subjective
continence rate.
Marshall Marchetti Krantz (MMK) A 113.
- The mortality was 0.2%, with a 22% overall complication
rate.
- This operation has now fallen into disuse.
MarshallMarchettiKrantz (MMK) A 114.
- A characteristic complication of MMK wasosteitis pubis , which
occurs in 2.5% of patients who undergo a MMK procedure.
- The operation was less successful than Burch colposuspension at
correcting a cystocele.
MarshallMarchettiKrantz (MMK) A 115.
- Laparoscopic colposuspension has been the subject of several
case series and cohort studies, which showsimilar continence rates
between laparoscopic and open Burch colposuspension .
Laparoscopic colposuspension A 116.
- There were no significant differences for postoperative
detrusor overactivity or voiding difficulty.
Laparoscopic colposuspension A 117.
- There were trends towards a:
- higher complication rate and
- lower intraoperative blood loss,
- shorter need for catheterization,
- shorter hospital stay and
- earlier return to normal activities
Laparoscopic colposuspension A 118.
- Despite a quicker recovery,the operation takeslonger to perform
, is associated withmore surgical complicationsand is
moreexpensive.
- It is likely to be performed bysurgeons highly skilledin both
continence and laparoscopic techniques.
Laparoscopic colposuspension A 119. Needle suspension
procedures
- Needle suspension procedures should not be performed :initial
success rates are not maintained with time and
- The risk of failure is higher than for retropubic suspension
procedures.
A 120.
- Multiple suspension procedures have been described in the
past.
- The first procedure was described byPeyreraand numerous
procedures have subsequently evolved from this, including theStamey
procedure , using suspending sutures and patch materials.
Needle suspension procedures A 121.
- Long-term follow up of thepercutaneous needle procedure was
only:
- 12% significantly improved and
- 83% considered the operation a failure.
Needle suspension procedures A 122.
- Needle suspensions were more likely tofailthan open retropubic
procedures and there were more perioperative complications in the
needle suspension group(48% compared with 30%).
- Needle suspensions may be as effective as anterior repair but
carry a higher morbidity
Needle suspension procedures A 123. Sling procedures
- Suburethral sling procedures were developed initially in the
1880s.
- Numerous authors have subsequently modified these
procedures.
C 124.
- Aldridgeused rectus sheath strips , thesuccess raterecorded in
the literature would appear to range between64% and 100%,with a
mean continence rate in the region of86%.
Sling procedures C 125.
- Sling procedures, usingautologous or synthetic materials ,
produce a continence rate of approximately 80% and an improvement
rate of 90%, with little reduction in continence over time.
- Only one synthetic sling procedure(tension-free vaginal
tape)has been subjected to randomized study to date.
Sling procedures A 126.
- Numerous materials are available for use in a suburethral
sling.
- As a generalization,autologous material is associated with a
greater continence rate and fewer complicationsthan either
cadaveric material or synthetic materials.
Sling procedures A 127.
- Autologous rectus fascia and fascialata are probably the most
common materials in use.
Sling procedures A 128.
- Synthetic material tends to be associated with a risk of
erosion and sinus formation.
Sling procedures A 129.
- Modifications designed to achieve greater stabilization, such
asanchorage to the pubic bone , are associated with good results in
the short term but carry a long-term risk ofosteomyelitisat the
site of anchorage.
Sling procedures A 130.
- When compared with colposuspension procedures, the suburethral
sling carries a similar success rate.
Sling procedures A 131.
- The intermediate and longer-term results for suburethral slings
suggest that the ten-year continence rate is not dissimilar from
the one-year continence rate.
A Sling procedures 132.
- The American Urological Association considered that Retropubic
suspensions and slings are the most efficacious procedures for
long-term success based upon cure/dry rate .
- However, retropubic suspensions and sling procedures are
associated with slightly higher complication rates, including
postoperative voiding difficulty and longer convalescence.
Sling procedures A 133.
- The Second International Consultation on Incontinence concluded
thatsuburethral slings represented an effective procedure for
genuine stress incontinence in the presence of previous failed
surgery.
Sling procedures A 134.
- The Prolene tension-free vaginal tape (TVT) is relatively new,
although increasing numbers of cohort studies of its use are being
reported.
- The originator of the procedure reports that, at three
years,86%of women werecompletely cured,while a
further11%weresignificantly improved.
TVT A 135.
- The majority of women are potentially treatable without general
anaesthesia and on a day-case basis.
- Between3% and 15%of women developed symptoms compatible with
the onset ofde novodetrusor overactivity.
TVT A 136.
- Short-termvoiding disorderis described in4.3%of women, although
longer term voiding disorder does not appear to be a specific
feature.
TVT A 137.
- There have been a few individual case reports of urethral
erosion, sometimes several years after surgery.
- There is a need for long-term results for this procedure.
TVT A 138.
- Despite being more expensive than colposuspension,the reduction
in hospital stay makes the procedurecost effective
A TVT 139. Injectable agents
- Injectable agents have alower success rate than other
procedures : a short-term continence rate of 48% and an improvement
rate of 76%.
- Long term, there is a continued decline in continence.
B 140.
- The procedure has alow morbidityand may have a role after other
procedures have failed, e.g. when a diagnosis of intrinsic
sphincter deficiency is made.
Injectable agents C 141.
- The bulking agents (collagen, Teflon fat, silicone, Durasphere
) are injected in aretrograde (more common)or antegrade fashion in
the periurethral tissue around the bladder neck and proximal
urethra.
Injectable agents C 142.
- Follow up was between three months and two years,(mean of 12
months).
- Thecure rate , defined as completely dry, was48%.
- Thesuccess rate(defined as dry or improved) was76%.
Injectable agents C 143.
- Forsilicone Radley et al.showed cure or improvement in60%in a
prospective cohort of women withrecurrent stress incontinenceon
a19-month follow-up.
- Detrusor overactivity was an importantcause of failuresin this
study.
Injectable agents C 144.
- RCTs are needed for bulking agents.
- The lack of morbidity associated with the bulking agents leads
some people to believe that they should be more meaningfully
compared with conservative therapy such as pelvic floor
physiotherapy.
Injectable agents C 145. Artificial sphincters
- Artificial sphincters can be successfully used after previous
failed continence surgery but have ahigh morbidity and need for
further surgery (17%).
B 146. Preoperative management
- It is recommended that women undergoing surgery for urodynamic
stress incontinence should have urodynamic investigations prior to
treatment(including Cystometry).
147.
- Prior to performing assess objectively the type of incontinence
and the presence of any complicating factors such as voiding
difficulty or detrusor overactivity, which may affect the surgical
decision
Preoperative management 148.
- Surgery should be performed by a surgeon who has been trained
in the operation and who has a caseload that enables him or her to
provide a suitable level of expertise, especially when any repeat
surgery is considered.
Preoperative management 149. Thank you