"#$%&!'()%!
Philippine Obstetrical and Gynecological Society (POGS), Foundation, Inc.
!
CLINICAL PRACTICE GUIDELINES on UROGYNECOLOGY !
November 2010
Task Force on Clinical Practice Guidelines on Urogynecology ! !
FOREWORD! !
REGTA L. PICHAY, MD President Philippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2010
REGTA L. PICHAY, MD
INTRODUCTION!
EFREN J. DOMINGO, MD, PhD Editor in Chief, Clinical Practice Guidelines, 2010 The Clinical Practice Guidelines on Urogynecology is the First Edition of this Publication, 2010. The Philippine Obstetrical and Gynecological Society, (Foundation), Inc. (POGS), through the Committee on Clinical Practice Guidelines initiated and led to completion the publication of this manual in plenary consultation with the Residency Accredited Training Hospitals’ Chairs and Training Officers, The Regional Board of Directors, The Board of Trustees, The Task Force on Urogynecology and the Committee on Continuing Medical Education (CME). This publication represents the collective effort of the POGS in updating the clinical practice of Obstetrics and Gynecology, specifically on Urogynecology, and making it responsive to the most current and acceptable standard in this procedure. A greater part of the inputs incorporated in this edition are the contributions originating from the day-to-day academic interactions from the faculty of the different Residency-Accredited Hospitals in Obstetrics and Gynecology in the country. This Clinical Practice Guideline on Urogynecology is envisioned to become the handy companion of the Obstetrician-Gynecologist in his/her day-to-day rendition of quality care and decision making in managing the Gynecologic patient. This is also envisioned to provide the academic institutions in the country and in Southeast Asia updated information on Urogynecology as being practiced in the Philippines. Profound gratitude is extended to all the members of the POGS, the Chairs and Training Officers of the Residency-Training Accredited Institutions, the Regional Directors, The Task Force Reviewers/Contributors, The CME Committee members, and the 2010 POGS Board of Trustees.
EFREN J. DOMINGO, MD, PhD
BOARD OF TRUSTEES 2010 OFFICERS Regta L. Pichay, MD President Sylvia delas Alas Carnero, MD Vice President Ditas Cristina D. Decena, MD Secretary Jericho Thaddeus P. Luna, MD Treasurer Gil S. Gonzales, MD Public Relations Officer
BOARD OF TRUSTEES Efren J. Domingo, MD, PhD Virgilio B. Castro, MD Blanca C. de Guia, MD Raul M. Quillamor, MD Rey H. delos Reyes, MD Ma. Cynthia Fernandez-Tan, MD
COMMITTEE ON CLINICAL PRACTICE GUIDELINES ON UROGYNECOLOGY Efren J. Domingo, MD, PhD Editor in Chief MEMBERS Ann Marie C. Trinidad, MD Ma. Victoria V. Torres, MD Lisa T. Prodigalidad-Jabson, MD Christine D. Dizon, MD Rommel Z. Duenas, MD MANAGING EDITOR Ana Victoria V. Dy Echo, MD TECHNICAL STAFF ASSISTANTS Ms. Emiliana C. Enriquez Ms. Jhasmin G. De Guzman TASK FORCE ON UROLOGYNECOLOGY Lisa T. Prodigalidad-Jabson, MD Chair Members Almira J. Amin-Ong, MD Lennette L. Chan, MD Jennifer B. Jose, MD Maria Teresa C. Luna, MD Manuel S. Ocampo, MD Judith M. Sison, MD TASK FORCE REVIEWERS AND PLENARY REVIEWERS Rainerio S. Abad, MD Ruth Jinky Aposaga, MD Ricardo Braganza, MD Grace D. Caras, MD Cherrie Climaco, MD Macrina A. De Guzman, MD Rodante P. Galiza, MD May N. Hipolito, MD Margarette Lavalle, MD Ma. Cecilia Maclang, MD Jocelyn Z. Mariano, MD Suzette Miclat, MD Belen Pantangco-Rajagukguk, MD Sarah Pingol, MD Rico E. Reyes, MD Pura Rodriguez-Caisip, MD Esmarliza Tacud-Luzon, MD Jean Anne B. Toral, MD Faith Villaruiz, MD
Ma. Flores Adiong, MD Prudence V. Aquino, MD Sybil Lizanne R. Bravo, MD Abigail Elsie D. Castro, MD Antonio Cortez, MD Grace D. delos Angeles, MD Gil S. Gonzales, MD Rosemarie R. Hudencial, MD Lourdes Ledesma, MD Marilou Mangubat, MD Rudie Frederick B. Mendiola, MD Cristia S. Padolina, MD Gladys Pelicano, MD Kenet Prado, MD Ricalynn Rivera, MD Alice Salvador, MD Patricia L. Tan, MD Florentina A. Villanueva, MD Marilou Viray, MD Amaryllis Digna A. Yazon, MD
Regional Directors Betha Fe M. Castillo, MD (Region 1) Concepcion P. Argonza, MD (Region 3) Diosdado V. Mariano, MD (Region 4A NCR) Evelyn R. Lacson, MD (Region 6) Fe G. Merin, MD (Region 8) Jana Joy R. Tusalem, MD (Region 10)
Imelda O. Andres, MD Nurlinda Arumpac, MD Maria Nelvez Candilario, MD Ma. Theresa Cedullo, MD Ma. Lara David-Bustamante, MD Lorina Q. Esteban, MD Maribel Hidalgo-Co, MD Humildada Asumpta Igana, MD Jericho Thaddeus P. Luna, MD Corazon B. Mata, MD Marites Mendoza, MD Mary Christine F. Palma, MD Regta L. Pichay, MD Ma. Carmen H. Quevedo, MD Bella G. Rodriguez, MD Jean Marie Salvador, MD Ma. Theresa B. Tenorio, MD Julieta Villanueva, MD Regina P. Vitriolo, MD
Noel C. de Leon, MD (Region 2) Ernesto S. Naval, MD (Region 4) Cecilia Valdes-Neptuno, MD (Region 5) Belinda N. Pañares, MD (Region 7) Cynthia A. Dionio, MD (Region 9) Amelia A. Vega, MD (Region 11)
DISCLAIMER, RELEASE AND WAIVER OF RESPONSIBILITY
• • • •
• •
• • ! ! ! ! ! ! ! ! ! ! ! !
This is the Clinical Practice Guidelines (CPG) on Urogynecology, First Edition, November 2010. This is the publication of the Philippine Obstetrical and Gynecological Society, (Foundation), Inc. (POGS). This is the ownership of the POGS, its officers, and its entire membership. The obstetrician gynecologist, the general practitioner, the patient, the student, the allied medical practitioner, or for that matter, any capacity of the person or individual who may read, quote, cite, refer to, or acknowledge, any, or part, or the entirety of any topic, subject matter, diagnostic condition or idea/s willfully release and waive all the liabilities and responsibilities of the POGS, its officers and general membership, as well as the Committee on the Clinical Practice Guidelines and its Editorial Staff in any or all clinical or other disputes, disagreements, conference audits/controversies, case discussions/critiquing. The reader is encouraged to deal with each clinical case as a distinct and unique clinical condition, which will never fit into an exact location if reference is made into any or all part/s of this CPG. The intention and objective of this CPG is to serve as a guide, to clarify, to make clear the distinction. It is not the intention or objective of this CPG to serve as the exact and precise answer, solution and treatment for clinical conditions and situations. It is always encouraged to refer to the individual clinical case as the one and only answer to the case in question, not this CPG. It is hoped that with the CPG at hand, the clinician will find a handy guide that leads to the a clue, to a valuable pathway that leads to the discovery of clinical tests leading to clinical treatments and eventually recovery. In behalf of the POGS, its Board of Trustees, the Committee on The Clinical Practice Guidelines, 2010, this CPG is meant to make each one of us a perfect image of Christ, the Healer.
!
CPG ON UROGYNECOLOGY TOPICS / CONTENTS / AUTHOR/S!
Introduction ……………………………………………………………… 1 Dr. Lisa T. Prodigalidad-Jabson Definition of Terms (Standardization of Terminology) ………………… Dr. Almira J. Amin-Ong Evaluation of Pelvic Floor Dysfunction and POP-Q Scoring System ….. Dr. Judith M. Sison Conservative Management of Stress Urinary Incontinence ……………… Dr. Almira J. Amin-Ong Surgical Management of Stress Urinary Incontinence ……………………. Dr. Lisa T. Prodigalidad-Jabson Conservative Management of Pelvic Organ Prolapse …………………… Dr. Maria Teresa C. Luna Surgical Management of Pelvic Organ Prolapse ………………………… Dr. Manuel S. Ocampo, Jr and Dr. Lisa T. Prodigalidad-Jabson Fecal Incontinence and Obstetric Anal Sphincter Injuries (OASIS) …….. Dr. Lennette L. Chan Urinary Retention ………………………………………………………... Dr. Jennifer B. Jose Appendix: Level of Evidence and Grade of Recommendations ………….
! !
INTRODUCTION Lisa T. Prodigalidad-Jabson, MD Urogynecology and Reconstructive Pelvic Surgery has long been a recognized specialty in the field of Obstetrics and Gynecology. However, here in the Philippines, Urogynecology is still at its infancy stage and only recently has there been a growing interest in this field of pelvic reconstruction. Pelvic floor disorders such as pelvic organ prolapse (POP), fecal incontinence (FI), and urinary incontinence (UI) are, at present, aspects of women’s health that are frequently neglected or ignored. POP is among the most common indications for benign gynecologic surgery. A review by the National Center for Health Statistics in the United States lists genital prolapse as one of the 3 most common reasons for hysterectomy in women. In the University of the Philippines - Philippine General Hospital alone, over 100 cases of vaginal hysterectomies are performed each year for prolapse. In a recent review by the Women’s Health Initiative, POP was found to be a very common condition in women during menopause and was consistently related to parity.2 This becomes of particular importance in a society such as ours where family planning, although strongly advocated, is not widely practiced. Likewise, female UI is a common problem that is often unrecognised, neglected, or ignored. It is a condition believed to be as natural as pregnancy, childbirth, menopause, and aging. The prevalence of UI is reported to range from 2% to 57% and afflicts both the young and old. The wide range may reflect the difficulty in estimating the incidence of UI, as most women experiencing such symptoms often do not seek medical advice. In a 2001 study by the Asia-Pacific Continence Advisory Board, the prevalence of overactive bladder as a cause of incontinence in Asians was noted to be 51.4%. More specifically, Diokno states a 13% prevalence rate of UI among Filipinos.3 This is in contrast to the incidence of 31% reported by RamosoJalbuena in 1994.4 With recent emphasis on women’s health and quality of life, caring for women with various pelvic floor disorders would become an increasingly important aspect of women’s health care. And, for a rapidly growing and aging population, the demand for such care will inevitably escalate. References 1.
2. 3. 4.
!
Milsom I, Altman D, Lapitan MC, Nelson R, Sillen U, and Thom D. Epidemiology of urinary (UI) and fecal incontinence (FI) and pelvic organ prolapse (POP). In Abrams P, Cardozo L, Khoury S, and Wein A (Eds). Incontinence: WHO–ICUD International Consultation on Incontinence, 4th edition, 2009. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the women’s health initiative: gravity and gravidity. Am J Obstet Gynecol 2002;186(6):1160-6. Lapitan MC and Chye PLH on behalf of the Asia-Pacific Continence Advisory Board. The epidemiology of overactive bladder among females in Asia: A questionnaire survey. Int Urogyn J 2001;12(4):226-31. Ramoso-Jalbuena J. Climacteric filipino women: a preliminary survey in the Philippines. Maturitas 2004;19(3):183-190.
DEFINITION OF TERMS Almira J. Amin-Ong, MD Lower urinary tract symptoms are classified into three major categories namely, storage, voiding and postmicturition symptoms. The following terms are culled from the latest International Continence Society (ICS) Standardization of Terminology for lower urinary tract symptoms published in 2009. The terminologies serve to eliminate confusion and facilitate communication amongst clinicians. I. SYMPTOMS SUGGESTIVE DYSFUNCTION
OF
LOWER
URINARY
TRACT
A. STORAGE SYMPTOMS 1. Urgency – the complaint of a sudden compelling desire to pass urine which is difficult to defer 2. Increased daytime frequency – the complaint of the patient who considers that she voids too often by day; equivalent to pollakisuria used in many countries 3. Nocturia – the complaint that the individual has to wake up at night one or more times to void 4. Stress urinary incontinence (SUI) – the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing 5. Urge UI – the complaint of involuntary leakage accompanied by or immediately preceded by urgency 6. Mixed UI – the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing 7. Nocturnal enuresis – complaint of loss of urine occurring during sleep 8. Continuous urinary leakage – the complaint of continuous leakage 9. Normal bladder sensation – the individual is aware of bladder filling and increasing sensation up to a strong desire to void 10. Increased bladder sensation – the individual feels an early and persistent desire to void 11. Reduced bladder sensation – the individual is aware of bladder filling but does not feel a definite desire to void 12. Absent bladder sensation – the individual reports no sensation of bladder filling or desire to void 13. Non-specific bladder sensation – the individual reports no specific bladder sensation but may perceive bladder filling as abdominal fullness, vegetative symptoms, or spasticity B. VOIDING SYMPTOMS 1. Slow stream – perception of the individual of reduced urine flow, usually compared to previous performance or in comparison with others 2. Splitting or spraying – self-explanatory 3. Intermittent stream (intermittency) – urine flow described as a stop and start flow, on one or more occasions, during micturition 4. Hesitancy – difficulty in initiating micturition resulting in a delay in the onset
of voiding after the individual is ready to pass urine 5. Straining – describes the muscular effort used to either initiate, maintain or improve the urinary stream 6. Terminal dribble – term used when an individual describes a prolonged final part of micturition, when the flow has slowed to a trickle/dribble C. POSTMICTURITION SYMPTOMS 1. Feeling of incomplete emptying – self-explanatory term for a feeling experienced by the individual after passing urine 2. Postmicturition dribble – involuntary loss of urine immediately after the patient has passed urine, or after rising from the toilet D. GENITAL AND LOWER URINARY TRACT PAIN 1. Bladder pain – pain felt suprapubically or retropubically, and usually increases with bladder filling, it may persist after voiding 2. Urethral pain – felt in the urethra and the individual indicates the urethra as the site 3. Vaginal pain – felt internally, above the introitus 4. Perineal pain – felt between the posterior fourchette and the anus 5. Pelvic pain – less well defined than the bladder, urethral or perineal pain and is less clearly related to the micturition cycle or to bowel function and is not localized to any single pelvic organ E. GENITO-URINARY PAIN SYNDROMES 1. Painful bladder syndrome – complaint of suprapubic pain related to bladder filling accompanied by other symptoms such as increased daytime or nighttime frequency, in the absence of a proven urinary infection or other obvious pathology 2. Urethral pain syndrome – occurrence of recurrent episodic urethral pain usually on voiding, with daytime frequency and nocturia, in the absence of a proven infection or other obvious pathology 3. Vulval pain syndrome / Vaginal pain syndrome / Perineal pain syndrome – occurrence of persistent or recurrent episodic vulval, vaginal or perineal pain which is either related to the micturition cycle or associated with symptoms suggestive of urinary tract or sexual dysfunction, with no proven infection or obvious pathology 4. Pelvic pain syndrome – occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual, bowel or gynecological dysfunction, with no proven infection or obvious pathology II. SIGNS SUGGESTIVE OF LOWER URINARY TRACT DYSFUNCTION 1. Daytime frequency – number of voids during waking hour inclusive of the last void before sleep and the first void upon waking in the morning 2. Nocturia – number of voids recorded during a night’s sleep, each void is
preceded and followed by sleep 3. Polyuria – urine production of more than 2.8 liters in 24 hours in adults 4. Nocturnal polyuria – is present when an increased proportion of the 24-hour output occurs at night (> 20% in young adults to > 33% over 65 years) 5. Maximum voided volume – largest recorded volume of urine voided in a single micturition as determined in the bladder diary or frequency/volume chart 6. SUI – observation of involuntary leakage from the urethra, synchronous with exertion/effort, or sneezing or coughing 7. Overactive bladder – characterized by the storage symptoms of urgency with or without urgency incontinence, usually with frequency and nocturia 8. Mixed UI – complaint of involuntary leakage associated with urgency and also with effort, exertion, sneezing and coughing 9. Extraurethral incontinence – observation of urine leakage through channels other than the urethra 10. Uncategorized incontinence – observation of involuntary leakage that cannot be classified into one of the above categories on the basis of signs and symptoms 11. Intravesical pressure – pressure within the bladder 12. Abdominal pressure – pressure surrounding the bladder which is estimated from rectal, vaginal, or less commonly, from extraperitoneal pressure or bowel stoma 13. Detrusor pressure – the component of vesical pressure that is created by forces in the bladder wall, both active and passive. It is estimated by subtracting the abdominal pressure from the intravesical pressure. 14. Filling cystometry – method by which the pressure/volume relationship of the bladder is measured during bladder filling 15. Bladder diary – records the times of micturitions and voided volumes, incontinence episodes, pad usage and other information such as fluid intake, the degree of urgency and the degree of incontinence 16. Detrusor overactivity – a urodynamic investigation characterized by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked 17. Terminal detrusor overactivity – defined as a single, involuntary detrusor contraction, occurring at cystometric capacity, which cannot be suppressed and results in incontinence usually resulting in bladder emptying 18. Detrusor overactivity incontinence – incontinence due to an involuntary detrusor contraction 19. Neurogenic detrusor overactivity – involuntary detrusor contractions occurring in patients with relevant neurological condition 20. Idiopathic detrusor overactivity – no defined cause for the involuntary detrusor contractions 21. Bladder compliance – describes the relationship between change in bladder volume and change in detrusor pressure 22. Cystometric capacity – the bladder volume at the end of the filling cystometrogram when “permission to void” is given. It is the volume voided together with any residual urine. 23. Maximum cystometric capacity – the volume at which a patient with normal sensations feels she can no longer delay micturition (has a strong desire to void). 24. Urodynamic stress incontinence – noted during filling cystometry and is
defined as the involuntary leakage of urine during increased intraabdominal pressure, in the absence of a detrusor contraction. It replaces the term ”genuine stress incontinence”. 25. Abdominal leak point pressure – the intravesical pressure at which urine leakage occurs due to increased abdominal pressure in the absence of a detrusor contraction. 26. Detrusor leak point pressure – the lowest detrusor pressure at which urine leakage occurs in the absence of either a detrusor contraction or increased abdominal pressure 27. Detrusor underactivity – a contraction of reduced strength and/or duration, resulting in a prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span. 28. Acontractile detrusor – one that cannot be demonstrated to contract during urodynamic studies. 29. Bladder outlet obstruction – a generic term for obstruction during voiding and is characterized by increased detrusor pressure and reduced urine flow rate 30. Dysfunctional voiding – characterized by intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the peri-urethral striated muscle during voiding in neurologically normal individuals. 31. Detrusor sphincter dysynergia – a detrusor contraction concurrent with an involuntary contraction of the urethral and/or peri-urethral striated muscle. 32. Non-relaxing urethral sphincter obstruction – occurs in individuals with a neurological lesion and is characterized as non-relaxing, obstructing urethra resulting in reduced urine flow. 33. Pelvic organ prolapse (POP) – defined as the descent of one or more of the anterior vaginal wall, the posterior vaginal wall, and the apex of the vagina (cervix/uterus) or vault (cuff) after hysterectomy. 34. Anterior vaginal wall prolapse – defined as the descent of the anterior vagina so that the urethrovesical junction (a point 3 cm proximal to the external urethral meatus) or any anterior point proximal to this is less than 3 cm above the plane of the hymen 35. Posterior vaginal wall prolapse – defined as any descent of the posterior vaginal wall so that a midline point on the posterior vaginal wall 3 cm above the level of the hymen or any posterior point proximal to this is less than 3 cm above the plane of the hymen 36. Prolapse of the apical segment of the vagina – defined as any descent of the vaginal cuff scar (after hysterectomy) or cervix below a point which is 2 cm less than the total vaginal length above the plane of the hymen 37. Rectal prolapse – defined as the circumferential full thickness rectal protrusion beyond the anal margin 38. Anal incontinence – defined as any involuntary loss of fecal material and/or flatus and maybe divided into: a. Fecal incontinence (FI) – any involuntary loss of fecal material b. Flatus incontinence – any involuntary loss of gas (flatus) 39. Acute retention of urine – defined as a painful, palpable or percussable bladder, when the patient is unable to pass any urine. 40. Chronic retention of urine – defined as a non-painful bladder, which remains palpable or percussable after the patient has passed urine. Such patients may be incontinent.
III. TREATMENT 1. Pelvic floor training – repetitive selective voluntary contraction and relaxation of specific pelvic floor muscles 2. Biofeedback – technique by which information about a normally unconscious physiological process is presented to the patient and/or therapist as a visual, auditory or tactile signal 3. Behavioral modification – the analysis and alteration of the relationship between the patient’s symptoms and her environment for the treatment of maladaptive voiding patterns 4. Electrical stimulation – the application of electrical current to stimulate the pelvic viscera or their nerve supply 5. Catheterization – technique for bladder emptying employing a catheter to drain the bladder or a urinary reservoir 6. Intermittent (in/out) catheterization – defined as drainage or aspiration of the bladder or urinary reservoir with subsequent removal of the catheter a. Intermittent self-catheterization – performed by the patient herself b. Intermittent catheterization – performed by an attendant (e.g., doctor, nurse, or relative) c. Clean intermittent catheterization – use of a clean technique. This implies ordinary washing techniques and use of disposable or cleansed reusable catheters d. Aseptic intermittent catheterization – use of a sterile technique. This implies genital disinfection and use of sterile catheters and instruments/gloves 7. Indwelling catheterization – an indwelling catheter remains in the bladder, urinary reservoir or urinary conduit for a period of time longer than one emptying References 1.
2.
Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, Shull BL, Amith ARB. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-1. Abrams P, Cardozo L, Khoury S, Wein A. Incontinence. 4th International Consultation on Incontinence. 4th ed. 2009.
EVALUATION OF PELVIC FLOOR DYSFUNCTION AND THE POP-Q SCORING SYSTEM Judith M. Sison, MD, MPH I. URINARY INCONTINENCE 1. Patients with urinary incontinence (UI) should undergo a basic evaluation that includes a history1, physical examination2,3, measurement of postvoid residual volume (PVR), urinalysis, and 3-day bladder chart. Standard chemical tests for renal function are recommended in patients with UI and a high probability of renal damage. (Level II-3, Grade A) Summary of Evidence Post-void residual volume A PVR < 50 ml is considered adequate bladder emptying and > 200 ml is considered inadequate.4,5 Routine urinalysis with or without urine culture and sensitivity test To assess for any lower urinary tract infection (UTI), a clean midstream or catheterized urine sample should be obtained for dipstick urinalysis which provides necessary information as a “multi-property” strip should be used.6 It can also screen any urothelial lesion and stone disease.7 Three-day bladder diary (frequency/volume chart) Urinary diaries are highly reproducible and correlated well with urodynamic diagnosis.8 Consistent results have been shown between the first 3-day period and the last 4-day period, suggesting that a 3-day chart may be adequate to document symptoms, thus, improving compliance.9, 10 Standard blood chemistries for renal function The routine use of a battery of common chemical tests in patients with UI appears to be a prudent rule of good practice in the following conditions: a. chronic retention with UI (overflow UI) b. neurogenic lower urinary tract dysfunction c. when surgery is contemplated d. when there is a clinical suspicion 2. Cough stress test strongly suggests a diagnosis of stress urinary incontinence (SUI). Borderline or negative test results should be repeated to maximize its diagnostic accuracy. (Level II-2, Grade B) Summary of Evidence Loss of small amounts of urine in spurts, simultaneous with coughing and in the absence of urge, strongly suggests a diagnosis of SUI.11 Prolonged loss of urine, leaking 5-10 seconds after coughing, or no urine loss with provocation indicates that other causes of incontinence, especially detrusor overactivity, may be present. The inability to demonstrate the sign of SUI
during simple bladder filling and cough stress test correlates highly with the absence of urodynamic stress incontinence.11,12 3. Q-tip or cotton swab test is not useful in differentiating SUI from abnormalities of voiding and detrusor functions. (Level II-3, Grade B) Summary of Evidence Q-tip or cotton swab test refers to placement of a cotton swab in the urethra at the level of the bladder neck and measurement of the axis change (> 30o) to demonstrate urethral mobility. Investigators found that a sizable minority of women with urodynamic diagnosis of SUI did not have a positive Q-tip test and that many women with positive Q-tip test did not have SUI on urodynamic testing. It is now used primarily to assess the results of antiincontinence surgery or to determine whether the degree of urethral hypermobility may influence treatment outcomes.13,14 Other tests, e.g. perineal ultrasonography and magnetic resonance imaging (MRI), can be used for assessment of bladder neck mobility, but these are not commonly used in clinical practice. Modifications of the Bonney’s test require support of the urethrovesical junction during coughing in women who leak during a stress test. These modifications are not reliable in selecting a surgical procedure or in predicting cure.15 4. The standard 1-hour pad test quantifies the volume of urine lost by weighing a perineal pad before and after some type of leakage provocation. A pad weight gain of > 1 g is considered positive for a 1-hour test, and > 4 g for a 24-hour test.16,17 (Level II, Grade B) Summary of Evidence The Committee on Investigations from the 2nd International Consultation on Incontinence concluded that the 1-hour pad test would yield increased accuracy if done with a fixed bladder volume.18,19 It was able to discriminate most of the time between continent and incontinent women. 5. Dye test: The identification of the site of a fistula is best carried out by instillation of methylene blue into the bladder. (Level III, Grade C) Summary of Evidence If leakage of clear fluid continues after dye instillation, a ureteric fistula is most likely and this is most easily confirmed by a 2-dye test, using Phenazopyridine or indigo carmine (or any drug that colors the urine like Nitrofurantoin, in the local setting) to stain the renal urine, and methylene blue to stain the bladder contents.20,21 6. Assessment of pelvic floor muscle strength has practical application in determining whether the patient has nil, weak or good muscles to
effectively carry out passive contraction therapy, an exercise program, or any need for further evaluation. (Level III, Grade C) Summary of Evidence The continence mechanisms imply that integrity of the levator ani and the external urethral sphincter is necessary to maintain continence. It is therefore important to test the contractility of these muscles. A pelvic muscle contraction may be assessed by visual inspection, palpation, electromyography or perineometry. When considering methods/devices used to measure pelvic muscle strength, cost and availability are important considerations.21 This can be qualitatively defined by the tone at rest and the strength of a voluntary contraction as strong, weak, or absent by a validated grading system, e.g. Oxford scale 1-5. Factors to be assessed include strength, duration, displacement, and repeatability.22 The modified Oxford scale has been shown to correlate well with surface electromyography and manometry of pelvic floor muscles.23 7. Urine cytology is recommended in patients with persistent microscopic hematuria in the absence of UTI to exclude bladder neoplasm. (Level III, Grade C) Summary of Evidence Urine cytology should be requested in patients with microscopic hematuria (RBC 2-5/hpf), ! 50 year-old with persistent hematuria or those with acute onset of irritative voiding symptoms in the absence of UTI to exclude bladder neoplasm.24 It is not recommended in the routine evaluation of patients with incontinence.25 8. Cystometric testing is not required in the routine or basic evaluation of UI.26 Whenever objective clinical findings do not correlate with or reproduce the patient’s symptoms, simple cystometry is appropriate for detecting abnormalities of detrusor compliance and contractibility.27 (Level II, Grade B) Summary of Evidence Office cystometry: Retrograde bladder filling provides an assessment of bladder sensation and an estimate of bladder capacity. The definition of normal bladder capacity lacks consensus, with values that range from 300-750 ml. In addition, large bladder capacities are not always pathologic. Researchers showed that 33% of women with bladder capacities > 800 ml. were urodynamically normal, and only 13% had true bladder atony.28 . 9. Minimum urodynamic investigation includes uroflowmetry, pressureflow study of voiding together with one or more of the following, as indicated for the individual patient: abdominal leak point pressure measurement, urethral pressure measurement. (Level II, Grade B)
Indications for urodynamics29: a. Prior to invasive or irreversible treatment or retreatment of all types of incontinence b. Complex incontinence cases whenever there is doubt about the underlying pathophysiology c. Neurogenic bladders as an initial assessment or as part of a long-term surveillance. If possible, videourodynamic testing should be employed. Summary of Evidence There was not enough evidence to show whether women with UI who underwent urodynamics were less likely to be incontinent after treatment than women who did not undergo urodynamic testing.30, 31 10. Urethral pressure profilometry (UPP) and leak point pressure measurements have not proved useful in the evaluation of UI. (Level III, Grade C) Summary of Evidence Researchers found that UPP is not standardized, reproducible, or able to contribute to the differential diagnosis in women with SUI symptoms. Therefore it does not meet the criteria for a useful diagnostic test.32 Leak point pressure measures the amount of increase in intraabdominal pressure that causes stress incontinence, although its usefulness also has not been proved.33 11. Cystoscopy should not be performed routinely in patients with incontinence to exclude neoplasm. (Level II-2, Grade B) Summary of Evidence Indications for cystoscopy in patients with UI include those who have: sterile hematuria or pyuria; irritative voiding symptoms, e.g. frequency, urgency, urge incontinence in the absence of any reversible causes; bladder pain; recurrent cystitis; suburethral mass; and when urodynamic testing fails to duplicate symptoms of UI.34 Bladder lesions are found in < 2% of patients with incontinence35; therefore, cystoscopy should not be performed routinely in patients with incontinence to exclude neoplasm36. 12. Imaging: Ultrasound is not recommended in the primary evaluation of patients with UI and/or POP. It is likewise an optional test in the evaluation of patients with complex or recurrent UI and or POP.37, 29 MRI of the pelvic floor is rapidly gaining field in the evaluation of enteroceles and in the morphological analysis of pelvic floor muscles although the evidence of its clinical benefit is still unclear.29,38 (Level III, Grade C)
Summary of Evidence Transabdominal, perineal or translabial, transrectal, and transvaginal ultrasound is currently used due to its noninvasive nature, ready availability, and absence of distortion. Although ultrasound is rapidly evolving and much progress has been made, it remains optional as evidence of its clinical benefit is still weak.29 MRI provides anatomical detail to the pelvic floor in a single noninvasive study that does not expose the patient to ionizing radiation. Gousse, et. al. reported a sensitivity of 83%, specificity of 100%, positive predictive value of 100%, when comparing dynamic MRI to intraoperative findings. These numbers were similar compared to physical examination alone.39 II. PELVIC ORGAN PROLAPSE AND PELVIC ORGAN PROLAPSE QUANTIFICATION SYSTEM 1. The only symptom specific to prolapse is the awareness of vaginal bulge or protrusion. For all other pelvic symptoms, resolution with prolapse treatment can not be assumed.40 (Level II-3, Grade A) Summary of Evidence Almost half of parous women can be identified as having prolapse by physical examination criteria, most are not clinically affected; the finding is not well correlated with specific pelvic symptoms.41 2. The amount or severity of prolapse in each vaginal segment may be measured and recorded using the pelvic organ prolapse quantification system (POP-Q). (Level III, Grade C) Summary of Evidence The POP-Q system was introduced for use in clinical practice and research. Some have argued that the 9-points of the POP-Q system maybe more detailed than necessary for clinical practice, and it is better suited for clinical research purposes. It often is useful to include a measurement of the extent of protrusion relative to the hymen to better assess change overtime.42 2. Cystoscopy or cystourethroscopy should be performed intraoperatively to assess for bladder or ureteral damage after all prolapse or incontinence procedures during which the bladder or ureters may be at risk of injury.43 (Level II-2, Grade B) Summary of Evidence A recent systematic review of urinary tract injuries during urogynecologic surgical procedures and routine intraoperative cystourethroscopy reported the overall ureteral injury rate was 8.8/1,000
procedures (95% CI 2.3-12.6).43 The overall bladder injury rate after urogynecologic surgical procedures was 16.3 (95% CI 4.3-26.6).44 PELVIC ORGAN PROLAPSE QUANTIFICATION SYSTEM (POP-Q) The POP-Q is the current gold standard for measuring prolapse stage in patients. It offers an objective evaluation that can be communicated between physicians and used to compare pre- and post-surgical intervention examinations. It was developed and adopted by the International Continence Society (ICS) and endorsed by leading international organizations dealing with pelvic floor dysfunction. Stages are based on the maximal extent of prolapse relative to the hymen, in one or more compartments. The hymen is assigned the value of zero; points proximal to the hymen are negative (inside the body) while points distal to the hymen are positive (outside of the body). There are 6 vaginal sites as represented in the POP-Q grid, and 3 additional measurements which always have a positive value namely: a) genital hiatus (Gh) b) perineal body (Pb), and c) total vaginal length (TVL). All measurements, except for TVL, are made while patient is doing Valsalva maneuver. All measurements are made to the nearest 0.5 cm. Both the patient’s position (lithotomy, birthing chair, or standing) during the examination, and the state of her bladder and rectum (full or empty) should be noted. Quantification Definitions and Ranges: POINT Aa Ba C D Ap Bp Gh Pb TVL
MEASUREMENT Anterior vaginal wall 3 cm proximal to hymen Leading-most point of anterior vaginal wall prolapse Most distal edge of cervix or vaginal cuff (if absent cervix) Most distal portion of posterior fornix Post vaginal wall 3 cm proximal to hymen Leading-most point of post vaginal wall prolapse Perpendicular distance from mid-urethral meatus to posterior hymen Perpendicular distance from mid-anal opening to posterior hymen Post vaginal fornix or vaginal cuff (if absent cervix) to the hymen
RANGE -3 to +3 -3 to + TVL - /+ TVL - /+ TVL -3 to +3 -3 to + TVL No limit No limit No limit
The stages of POP are: Stage 0 – No descent of any compartment Stage 1 – Descent of the most prolapsed compartment between perfect support and -1 cm Stage 2 – Descent of the most prolapsed compartment between -1 cm and +1 cm Stage 3 – Descent of the most prolapsed compartment between +1 cm and TVL -2 cm Stage 4 – Descent of the most prolapsed compartment from TVL -2 cm to complete prolapse
Reproduced from: Bump RC, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175: 10-7. 42
III. FECAL INCONTINENCE 1. A simple assessment of possible anorectal dysfunction by history and physical examination should be performed whenever lower urinary tract function is evaluated. (Level III, Grade C) Summary of Evidence Jackson, et. al. evaluated 247 women with either UI or POP. Thirty one percent (31%) of women with UI and 7% with POP had concurrent anal incontinence.45 2. The cheapness and speed of investigation makes endosonography the ideal screening procedure to assess anal sphincter. Manometry may offer little extra information where ultrasound is available. Preoperative assessment in patients with possible atrophy is the main indication for MRI.21 (Level III, Grade C)
Summary of Evidence Anorectal manometry is an optional test that may be used in difficultto-evaluate cases of fecal or anal incontinence. It should be considered if therapy based on simpler assessments fails to yield the desired improvement.46 MRI is superior to ultrasound in diagnosis of perianal sepsis and in quantifying external anal sphincter muscle degeneration.47 References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
Scientific Committee of the First International Consultation on Incontinence. Assessment and treatment of urinary incontinence. Lancet 2000;355:2153-8. Ouslander JG, et al. Incontinence in the nursing home. Ann Intern Med 1995;122:438-49. Blaivas JG, et al. The bulbocavernosus reflex in urology: a prospective study of 299 patients. J Urol 1981;126:197-9. Agency for Health Care Policy and Research. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline, No.2, 1996 Update. AHCPR Publication No. 96-0682. Rockville (MD): AHCPR; 1996. Goode PS, et al. Measurement of postvoid residual urine with portable transabdominal bladder ultrasound scanner and urethral catheterization. Int Urogynecol J Pelvic Floor Dysfunct 2000;11(5):296-300. Semeniuk H, et al. Evaluation of the leukocyte esterase and nitrite urine dipstick screening tests for detection of bacteriuria in women with suspected uncomplicated urinary tract infections. J Clin Microbiol 1999; 37(9):3051-2. European Urinalysis Guidelines. Summary. Scand J Clin Lab Invest 2000;60:1-96. Wyman JF, et al. The urinary diary in evaluation of incontinent women: a test-retest analysis. Obstet Gynecol 1988;71:812-7. Nygaard I, et al. Reproducibility of a 7-day voiding diary in women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2000;11:15-7. Addla S, et al. Assessment of reliability of 1-day, 3-day, and 7-day frequency volume charts. Eur Urol 2004;(Suppl 2):30. Wall LL, et al. Simple bladder filling with a cough stress test compared with subtracted cystometry for the diagnosis of urinary incontinence. Am J Obstet Gynecol 1994;171:1472-7; discussion 1477-9. Swift SE, Ostergard DR. Evaluation of current urodynamic testing methods in the diagnosis of genuine stress incontinence. Obstet Gynecol 1995;86:85-91. Karram MM, Bhatia NN. The Q-tip test: Standardization of the technique and its interpretation in women with urinary incontinence. Obstet Gynecol 1988;71(61):807-11. Walters MD, et al. Q-tip test: a study of continent and incontinent women. Obstet Gynecol 1987;70(2):208-11. Bergman A. Invalidity of Marshall-Marchetti and Bonney stress tests. In: Ostergard D, Bent A, eds. Urogynecology and urodynamics: Theory and practice (2e) Baltimore, MD: Williams and Wilkins, 1991:179-84. Kromann-Andersen B, et al. Pad-weighing tests; A literature survey on test accuracy and reproducibility. Neurourol Urodyn 1989;8(3):237-42. Jorgensen L, Lose G, et al. Diagnosis of mild stress incontinence in females: 24-hour pad weighing test vs. the 1-hour test. Neurourol Urodyn 1987;6:165-6. Kinn AC, Larsson B. Pad test with fixed bladder volume in urodynamic stress incontinence. Acta Obstet Gynecol Scand 1987;66(4): 369-371. Artibani W, et al. Imaging and other investigations. In: Abrams P, Cardozo L, Khoury S, Wein A (eds) Incontinence. Plymouth: Health Publication, 2002:425-77. Raghavaiah N. Double-dye test to diagnose various types of vaginal fistulas. J Urol 1974; 112: 811-2. 4th International Consultation on Incontinence, Paris July 5-8, 2008. Incontinence edited by Abrams, Cardozo, et al. Health Publication Ltd. 4th edition 2009 Laycock J, et al. Pelvic floor assessment: the PERFECT scheme. Physiotherapy 2001;87:63142.
23. Haslam J. Evaluation of pelvic floor muscle assessment: digital, manometric, and surface electromyography in females. M Phil Thesis. University of Manchester, 1999. 24. Cohen RA, et al. Clinical Practice. Microscopic hematuria. N Eng J Med 2003;348:2330-8. 25. Chahal, et al. Is it necessary to perform urine cytology in screening patients with hematuria? Eur Urol 2001;39:283-6. 26. ACOG 2007 Compendium Vol.11 Practice Bulletins pp1115-27. 27. Wall LL, et al. Simple bladder filling with a cough stress test compared with subtracted cystometry for the diagnosis of urinary incontinence. Am J Obstet Gynecol 1994;171:1472-7; discussion 1477-9. 28. Weir J, et al. Large-capacity bladder. A urodynamic survey. Urology 1974;4:544-8. 29. Cardoso A, et. al. (ed). Incontinence. 4th International Consultation on Incontinence Paris July 5-8, 2008. Health Publication Ltd. 4th edition, 2009. 30. Ramsay IN, et al. A randomized controlled trial of urodynamic investigations prior to conservative treatment of urinary incontinence in the female. Int Urogynecol J 1995;6:277 31. Khullar V, Cardozo L, et al. 30th Annual meeting of ICS, Finland 2000. 32. Weber AM. Is urethral pressure profilometry a useful diagnostic test for stress urinary incontinence? Obstet Gynecol Surv 2001;56:720-35. 33. Weber AM. Leak point pressure measurement and stress urinary incontinence. Curr Women’s Health Rep 2001;1:45-52. 34. Association of Professors of Gynecology and Obstetrics. Clinical management of urinary incontinence. Crofton (MD) APGO; 2004. 35. Awad SA, et al. Final diagnosis and therapeutic implications of mixed symptoms of urinary incontinence in women. Urology 1992;39:352-7. 36. Agency for Health Care Policy and Research. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline, No.2, 1996 Update.AHCPR Publication No. 96-0682. Rockville (MD): AHCPR; 1996. 37. Beer-Gabel M, et al. Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders: pilot study. Dis Colon Rectum 2002;45:239-45. 38. Pannu HK, et al. Dynamic MR imaging of pelvic organ prolapse: spectrum of abnormalities. Radiographics 2000;20:1567-82. 39. Gousse AE, et al. Dynamic half fourier acquisition single shot turbo spin-echo magnetic resonance imaging for evaluating the female pelvis. J Urol 2000;164:1606-13. 40. ACOG Compendium of Selected Publications 2009. Clinical Management Guidelines for Obstetrician-Gynecologists #85, September 2007: 417-29. 41. Samuelsson EC, et al. Signs of genital prolapse in a Swedish population of women 20-59 years of age and possible related factors. Am J Obstet Gynecol 1999;180:299-305. 42. Bump RC, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-7. 43. Gustilo-Ashby AM, et al. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for POP. Am J Obstet Gynecol 2006;194:1478-85. 44. Gilmour DT, et al. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol 2006;107:1366-72. 45. Jackson S, Walters M, et al. Fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 1997;89:423-7. 46. De Leeuw JW, et al. Relationship of anal endosonography and manometry to anorectal complaints. Dis Colon Rectum 2002;45:1004-10. 47. Rociu E, et al. Fecal Incontinence: endoanal ultrasound vs endoanal MR imaging. Radiology 1999; 212(2):453-8. 48. Cardozo L, Staskin D (Eds). Textbook of Female Urology and Urogynecology 2006; 2nd edition Volume 1. 49. Chappe C, et. al. Multidisciplinary Management of Female Pelvic Floor Disorders 2006.
CONSERVATIVE MANAGEMENT OF STRESS URINARY INCONTINENCE Almira J. Amin-Ong, MD. Urinary incontinence (UI) affects women not only in the reproductive age but more commonly in the postmenopause. It is often a neglected condition even if the prevalence rate is quite high ranging from 17-55% in older and 12-42% in younger women. Majority do not seek consult but opt to make provisions in their daily routine to hide or live with the disorder thus affecting the overall quality of life. The International Continence Society (ICS) describes three major categories of incontinence – stress, urge and mixed. Differentiating among the three types would help the primary care physician gear management towards that which will be beneficial to the patient. There are several management schemes available for UI. Conservative management alone entails numerous forms of intervention, which are usually low cost and with low adverse effects. With the current crisis putting a strain on the health care of most economies, conservative management is offered as an option especially on the following circumstances: those awaiting or delaying surgery, those in whom existing medical condition precludes any form of surgical intervention, and those whose symptoms are not severe enough for surgical intervention. I. LIFESTYLE INTERVENTION There are very few randomized controlled trials (RCTs) on the field of lifestyle intervention to control, prevent or improve UI. None of those available specifically addresses the impact of age or any other variables on outcome. 1. Women with a body mass index (BMI) of 30 or more should be encouraged weight reduction as this significantly reduces prevalence of UI. (Level II-1, Grade A) Summary of Evidence Obesity is an independent risk factor for UI even after controlling for age and parity. In women with BMI of 30 or higher, the odds of severe urinary incontinence were 3.1 times that of women with BMI between 22 and 241. Another study found a 2.39 fold risk of UI compared with normal weight women.2 A 2005 RCT involving 48 participants showed that women who were put on a liquid diet showed a 60% reduction of weekly incontinent episodes and a weight loss of 15 kgs.3 Another RCT by the same author involving 338 women (the Programme to Reduce Incontinence by Diet and Surgery – [PRIDE]) who underwent a 6-month intensive weight loss program showed a weekly incontinence episode reduction of 70% as compared to 22% in the control group.4 2. Heavy lifting may predispose to development of UI. (Level III, Grade B)
Summary of Evidence There are no RCTs comparing heavy lifting with sedentary activities. The association between heavy lifting and UI should be investigated further, whether heavy exertion is a risk factor for incontinence or whether changing exertions can improve existing incontinence. Present studies are conflicting with one study of 27,936 women in 2003 reporting no difference in UI between women engaged in high impact activities more than 2 hours per week with those who engaged in less than 1 hour of activity per week.5 Nygard, et. al., in a study of 3,364 women reported that UI with physical activity was more common among highly active than less active women (15.9% versus 11.8%; p=0.01).6 3. Smoking increases the risk of more severe UI. (Level III, Grade B) Summary of Evidence There are currently no RCTs regarding the effect of smoking cessation on resolution or promotion of the onset of UI. Current data are conflicting with one in vitro study stating that nicotine produces phasic contraction of the bladder musculature inducing the urge type of incontinence.7 A large study involving 27,936 women found that smoking increases the odds of severe UI (Odds Ratio [OR] 1.4, 95% CI 1.2-1.6). However, smokers were found to have stronger urethral sphincters.5 4. Decreasing caffeine intake improves continence. (Level II-1, Grade B) Summary of Evidence Bryant, et. al. found that decreasing caffeine intake to 96.5 mg had statistically significant reduction in urgency episodes (61% versus 12%) and number of incontinence episodes (55% versus 26%) but this was not statistically significant.8 In the Norwegian EPICONT Study, they found that tea drinkers had higher odds of UI (OR 1.2, 95% CI 1.4-55) for up to 2 cups per day and an OR of 1.3 (95% CI 1.5-19.0) for 3 or more cups compared to none.5 4. Alcoholic beverages do not increase the incidence of UI. (Level II-2, Grade B) Summary of Evidence Large epidemiologic trials using multivariate analyses assessed the effect of alcohol consumption and UI but found no association between the two even after adjusting for age and fluid intake.9 5. Limiting fluid intake to prevent UI should only be reserved to those with abnormally high intake. (Level III, Grade C)
Summary of Evidence It is always the assumption that leakages can very well be controlled by limiting the fluid intake. However, a state of negative fluid balance or poor fluid intake may lead to urinary tract infections (UTIs), constipation or dehydration – conditions that can readily be prevented by maintaining the average daily fluid intake. An RCT that used a small crossover design found that when fluid intake is decreased, women with stress urinary incontinence (SUI) and women with detrusor overactivity had decreased incontinence episodes10. 6. Chronic straining may be a risk factor for development of UI. (Level III, Grade C) Summary of Evidence There are no studies regarding the effect of resolving constipation or regulating bowel function on incontinence. One study reported that women who strain during defecation are more likely to report SUI (OR 1.9, 95% CI 1.3-2.6) and urgency (OR 1.7, 95% CI 1.2-2.4).11 Further research is needed to evaluate the role of constipation or chronic straining in the pathogenesis of UI. 7. Postural changes such as crossing the legs and bending forward might be useful in reducing leakages during coughing or provocation. (Level III, Grade C) Summary of Evidence There was a mean fluid loss of only 1.3 g (95% CI 0.5-2.1, p<0.001) when legs are crossed to prevent leakages compared to the following postural changes: 4.7 g when legs are crossed and body bent forward (95% CI 1.4-7.7, p<0.01); 10.2 g (95% CI 6.5-13.0) when bending forward alone; and 12.3 g (95% CI 8.5-16.1) when standing.12 Further studies on the effectiveness of postural changes as treatment for UI still needed. Addendum Many other lifestyle interventions are anecdotal hence there is currently no evidence to support any of these, specifically, wearing of nonrestrictive clothing, reducing emotional stress, wearing cotton undergarments, use of a bedside commode, decreasing lower extremity edema, treating chronic cough and increasing sexual activity. II. PELVIC FLOOR MUSCLE EXERCISE Pelvic floor muscle training (PFMT) or Kegel’s exercise should be offered as first line treatment for stress or mixed type of incontinence. (Level I, Grade A)
Summary of Evidence Studies regarding PFMT are conflicting because of variations in the technique used. However, the most recent Cochrane systematic review (2003) which included studies of women with urge, stress or mixed type of incontinence found that PFMT was more effective compared to placebo intervention (drug, sham electrical stimulation, sham exercise).13 Compared with vaginal cones, there was a significant reduction in urinary leakage with PFMT alone. There is also no benefit of combining PFMT with biofeedback. PFMT supervised and continued for 3 months is a safe and effective treatment for stress and mixed types of incontinence. III. ELECTRICAL STIMULATION Electrical stimulation for patients with stress or mixed type of incontinence does not offer any benefit in reducing the frequency of incontinent episodes. (Level I, Grade B) Summary of Evidence Electrical stimulation involves delivery of brief electrical impulses via needle or surface electrodes to the sacral nerves to inhibit detrusor overactivity and to improve pelvic floor musculature. A randomized trial of 68 women with urge type of incontinence did not reveal significant improvement at all. For women with stress type of incontinence, a small trial of 26 women showed no changes in urinary leakages per week based on an incontinence impact questionnaire. Combined with PFMT, a recent trial of 200 women showed no significant reduction in the frequency of incontinent episodes.9 IV. MAGNETIC STIMULATION The benefit of magnetic stimulation for treatment of UI has not been established. (Level II-3, Grade D) Summary of Evidence Extracorporeal magnetic stimulation is delivered to the pelvic floor muscles and the sacral nerve roots by sitting on a magnetic chair. The patient’s perineum is centered on the middle of the seat from where the pelvic floor muscles are placed directly on the primary axis of the pulsating magnetic field without any vaginal or anal probes. Usually, the treatment is given for 16 sessions for 6 weeks. There are still no trials regarding primary and secondary prevention of UI. Regarding treatment, magnetic stimulation might be better for both stress and urge type of incontinence.14,15 Further investigation is warranted.
V. VAGINAL CONES Vaginal cones offer subjective cure but do not lead to significant improvement on the number of leakage episodes, pad test or pelvic floor muscle strength. (Level II-1, Grade B) Summary of Evidence Vaginal cones are a set of weighted cylinders that are held in place by contraction of the pelvic floor muscles. Therapy usually starts with the lightest cone then graduated to the heavier ones. It is not readily available in our country. Majority of the trials enrolled women with stress incontinence who had subjective cure from UI.16 Compared with the control group who had other forms of intervention, there were no differences in objective outcomes – leakage episodes, pad test or pelvic floor muscle strength.16,17 VI. BLADDER TRAINING Bladder training combined with pelvic floor muscle training is more effective than either alone. It should be offered as first line treatment for urge or mixed type of incontinence. (Level I, Grade A) Summary of Evidence Bladder training is a technique to increase the time interval between voids using progressive voiding schedules. It is usually advised on patients who have intact cognitive and physical functions and can take months to achieve a cure. There are not too many trials to support bladder training. There were two small trials with 78 patients which showed few subjective cures in patients who had bladder training alone versus those who did not receive any at all (OR for failure, 0.07; 95% CI 0.03-0.19). However, when one combines it with PFMT, it is more effective than a combination of bladder training with drug therapy. There is good evidence though that bladder training is effective for urge or mixed type of incontinence, with fewer adverse effects and lower relapse rates compared to drug treatment with antimuscarinics.13 VII. PHARMACOLOGIC Anticholinergics are effective in the treatment of urge incontinence. (Level 1, Grade A) Summary of Evidence Anticholinergics are drugs prescribed to inhibit involuntary detrusor contractions that could lead to urine leakages. A Cochrane systematic review found that anticholinergics were better than placebo in subjective cure rate and improvement rates (RR 1.41; 95% CI 1.29-1.54) and in improvement in leakages episodes in 24 hours (WMD, -0.56; 95% CI -0.73 to -0.39).18 When
compared with other drugs used to treat urge incontinence, anticholinergics still offer both subjective cure and improvement in leakage episodes. References 1.
2. 3. 4.
5.
6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
16. 17.
18. 19.
Danforth KN, Townsend MK, Lifford K, Curhan GC, Resnick NM, Grodstein F. Risk factors for urinary incontinence among middle-aged women. Am J Obstet Gynecol 2006;194(2):33945. Melville JL, Katon W, Delaney K, Newton K. Urinary incontinence in US women: a population-based study. Arch Intern Med 2005;165(5):537-42. Subak LL, Whitcomb E, Shen HUI, Saxton J, Vittinghoff E, Brwon JS. Weight loss: a novel and effective treatment for urinary incontinence. J Urol 2005;174(1):190-5. Subak LL, Wing R, Smith West D, et al, A behavioral weight loss program significantly reduces urinary incontinence episodes in overweight and obese women [Oral presentation]. American Uroynecologic Society Annual Meeting 2007. Hannestad YS, Rortveit G, Daltveit AK, Hunskaar S. Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPINCONT Study. BJOG 2003;110(3);247-54. Nygaard I, Girts T, Fultz NH, Kinchen K, Pohl G, Sternfeld B. Is urinary incontinence a barrier to exercise in women? Obstet Gynecol 2005;106(2);307-14. Hisayama T, Shinkai M, Takayanagi I, Toyoda T. Mechanism of action of nicotine in isolated urinary bladder of guinea-pig. Br J Pharmacol 1988;95(2):465-72. Bryant CM, Dowell CJ, Fairbrother G. Caffeine reduction education to improve urinary symptoms. Br J Nurs 2002;11(8):560-5. Abrams P, Cardozo L, Kouri S, Wein A: Incontinence. Adult Conservative Management of Urinary Incontinence. 4th International Consultation in Continence July 2009. Swithinbank L, Hashim H, Abrams P. The effect of fluid intake on urinary symptoms in women. J Urol 2005l;174(1):187-9. Moller L, Lose G, Jorgensen T: Risk factors for lower urinary tract symptoms in women 40 to 60 years of age. Obstet Gynecol 2000;96(3):446-51. Norton PA, Baker JE: Postural changes can reduce leakage in women with stress urinary incontinence. Obstet Gynecol 1994;85(5):770-4. Hay-Smith EJ, Bo K, Berghmans LC, et al. Pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev 2003, Issue 1. But I, Faganelj M, Sostaric S: Functional magnetic stimulation for mixed urinary incontinence. J Urol 2005;173(5):1644-46. Morris AR, O’Sullivan R, Dunkley P, Moore KH. Extracorporeal magnetic stimulation is of limited clinical benefit to women with idiopathic detrusor overactivity: A randomized sham controlled trial. Eur Urol 2007;52:876-83. Herbison P, Plevnik S, Mantle J. Weighted vaginal cones for urinary incontinence. Cochrane Database Syst Rev 2003, Issue 1. Williams KS, Assassa RP, Gilleis CL, Abrams KR, Turner DA, Shaw C, et al. A randomized controlled trial of the effectiveness of pelvic floor therapies for urodynamic stress and mixed incontinence. BJU Int 2006;98(5):1043-50. Hay-Smith J, Herbison P, Ellis G, Moore K. Anticholinergic drugs versus placebo for overactive bladder syndrome in adults. Cochrane Database Syst Rev 2003, Issue 1. Holroyd-Leduc JM, Straus S. Management of urinary incontinence in women: scientific review. JAMA 2004;291(8):986-95.
SURGICAL MANAGEMENT OF STRESS URINARY INCONTINENCE Lisa T. Prodigalidad–Jabson, MD Stress urinary incontinence (SUI), or urodynamic stress incontinence (USI), is believed to result from either poor anatomic support associated with bladder neck and urethral motion (referred to as urethral hypermobility) or a combination of defects of the urethral sphincteric mechanism that may also result in decreased urethral resistance (referred to as intrinsic sphincter deficiency). There have been over a hundred procedures described for the surgical correction of SUI. With a better understanding of the etiology of SUI, many surgical procedures have been developed, and/or abandoned, to improve success rate and to minimize morbidity. Selecting the type of surgical procedure would depend on the individual patient’s characteristics (assessment of bladder neck mobility and urethral sphincter function), urodynamic evaluation, and the inherent risks/complications attendant to the type of procedure. Other factors to consider include pelvic organ prolapse (POP), previous failed abdominal surgery, previous radiation therapy or radical pelvic surgery. I. ANTERIOR COLPORRHAPHY Anterior colporrhaphy should NOT be used in the management of SUI. (Level II-2, Grade A) Summary of Evidence Ten randomized trials compare anterior colporrhaphy with pelvic floor muscle training (PFMT), colposuspension, needle suspension, MarshallMarchetti-Krantz (MMK) or tension-free vaginal tape (TVT). In these studies, 967 women were included with 346 undergoing anterior colporrhaphy. Reported cure rates range from 31% to 88%, with anterior colporrhaphy consistently showing statistically and clinically poorer outcomes. In the few trials that report follow-up beyond 12 months, subjective outcomes fell from 80% at 1 year to 60% at 5-7 years in one study, and combined subjective and objective cure rates fell from 80% at 3 months to 63% at 1 year and 37% at 5 years in another study. One randomized trial compared anterior colporrhaphy with the TVT in 50 women with at least a stage II anterior wall prolapse and “occult SUI”. Meschia, et. al. found both subjective (96% vs 64%) and objective (92% vs 56%) cure rates to be significantly higher following TVT.1 The Cochrane review of anterior vaginal repair reported that there was evidence to indicate that anterior vaginal repair was less effective than open retropubic suspension in the treatment of primary urodynamic stress incontinence. Likewise, the recent National Institute of Health and Clinical Excellence (NICE) guidance recommends that anterior colporrhaphy should not be used for the treatment of SUI.
II. OPEN BURCH COLPOSUSPENSION 1. Open retropubic colposuspension can be recommended as an effective treatment for primary SUI, which has longevity. (Level I, Grade A) Summary of Evidence Randomized trials comparing the open colposuspension with anterior colporrhaphy, the MMK procedure, needle suspension procedures, abdominal paravaginal repair, traditional sling procedures, the TVT, the transobturator tape, and laparoscopic colposuspension include 4161 women with 1900 randomized to colposuspension. Analysis shows objective cure rates ranging from 59% to 100% (median 80%) and subjective cure rates from 71% to 100% (median 88%). The results from these studies show that the open colposuspension has objective and subjective outcomes comparable to both traditional sling procedures and to newer minimally-invasive mid-urethral sling procedures. However, the colposuspension had better outcomes compared to the anterior colporrhaphy, the MMK, bladder neck needle suspension, and paravaginal repair. 2. Although open colposuspension has to some extent been replaced by less invasive mid-urethral slings, it should still be considered for those women in whom an open abdominal procedure is required concurrently with surgery for SUI. (Level I, Grade A) Summary of Evidence Abdominal retropubic urethropexy or colposuspension procedures, particularly the Burch colposuspension, have become the gold standard for treatment of primary or recurrent SUI. Main indications include primary and secondary urethral sphincter incompetence, with or without a cystourethrocele, but with adequate vaginal mobility and capacity. The paravaginal tissues on either side of the bladder neck and bladder base are sutured and attached to the ipsilateral iliopectineal ligament. The colposuspension is most successful in patients with pure SUI with hypermobility of the urethrovesical junction. The colposuspension had better outcomes compared to the anterior colporrhaphy, the MMK, bladder neck needle suspension, and paravaginal repair. 3. The MMK procedure is not recommended for the treatment of SUI. (Level I, Grade A) Summary of Evidence Randomized trials comparing the open colposuspension with anterior colporrhaphy, the MMK procedure, needle suspension procedures, abdominal paravaginal repair, traditional sling procedures, the TVT, the transobturator tape, and laparoscopic colposuspension include 4161 women with 1900 randomized to colposuspension. The studies showed that colposuspension had
better outcomes compared to the anterior colporrhaphy, the MMK, bladder neck needle suspension, and paravaginal repair. 4. Bladder neck needle suspension procedures are not recommended for the treatment of SUI. (Level I-II Grade A) Summary of Evidence Randomized trials comparing the open colposuspension with anterior colporrhaphy, the MMK procedure, needle suspension procedures, abdominal paravaginal repair, traditional sling procedures, the TVT, the transobturator tape, and laparoscopic colposuspension include 4161 women with 1900 randomized to colposuspension. The studies showed that colposuspension had better outcomes compared to the anterior colporrhaphy, the MMK, bladder neck needle suspension, and paravaginal repair. 5. Paravaginal defect repair is not recommended for the treatment of SUI alone. (Level II-1, Grade A) Summary of Evidence Randomized trials comparing the open colposuspension with anterior colporrhaphy, the MMK procedure, needle suspension procedures, abdominal paravaginal repair, traditional sling procedures, the TVT, the transobturator tape, and laparoscopic colposuspension include 4161 women with 1900 randomized to colposuspension. The studies showed that colposuspension had better outcomes compared to the anterior colporrhaphy, the MMK, bladder neck needle suspension, and paravaginal repair. III. LAPAROSCOPIC BURCH COLPOSUSPENSION 1. Laparoscopic colposuspension is not recommended for the routine surgical treatment of SUI in women. (Level I-II, Grade A) Summary of Evidence The laparoscopic approach has been compared to the standard open Burch colposuspension and the more recent mid-urethral slings, in particular the TVT. Since 1997, there have been 10 randomized controlled trials (RCTs) comparing laparoscopic colposuspension with the open colposuspension and 8 with the mid-urethral slings. Although studies included in the Cochrane review had various lengths of follow-up (majority had follow-up of 6-18 months), subjective cure rates ranged from 58% to 96% in the open technique and 62% to 100% in the laparoscopic approach, with a nonsignificant 5% lower relative subjective cure rate for laparoscopic colposuspension (RR 0.95, 95% CI 0.90-1.00). The objective cure rate, as determined by cough stress testing or pad test within 18 months, was statistically lower following the laparoscopic technique (RR 0.91, 95% CI 0.86-0.96). Following urodynamic testing,
however, the open colposuspension had significantly higher success rates (RR 0.91, 95% CI 0.85- 0.99). Studies comparing laparoscopic colposuspension with minimally invasive mid-urethral slings (TVT) show no statistically significant difference in subjective cure rates within 18 months (RR 0.91, 95% CI 0.80 to 1.02). The overall objective cure rate, however, was higher for mid-urethral slings. A systematic review on laparoscopic colposuspension and TVT showed evidence to favor the mid-urethral sling as the minimal-access technique of choice for USI. 2. Laparoscopic colposuspension may be considered for the treatment of SUI in women who also require concurrent laparoscopic surgery for other reasons. (Level I-II, Grade B) 3. Laparoscopic colposuspension should only be carried out by surgeons with specific training, expertise, and appropriate workload in laparoscopic surgery and with expertise in the assessment and management of UI in women. (Level I, Grade A) IV. TRADITIONAL SLING PROCEDURE 1. Autologous fascial sling is recommended as an effective long-lasting treatment for SUI. (Level I, Grade A) Summary of Evidence Trials on suburethral slings have compared this procedure with open abdominal retropubic suspension (MMK and Burch colposuspension), needle suspension, and even the TVT. Studies comparing different sling materials are also numerous. In comparison with open colposuspension, the objective cure rate from sling operations was not significantly different within the first year (Relative Risk [RR] 0.19; 95% CI 0.02-1.53) or on longer follow-up (RR 0.49; 95% CI 0.17-1.42). In the largest RCT study done by Albo, et. al. comparing colposuspension and fascial sling, the combined subjective and objective outcome in terms of any incontinence (38% vs 47%, p=0.01) and SUI (49% vs 66%, p=<0.001) was significantly better from the sling procedure.10 Although adverse events and voiding difficulty were also more common in the sling group, 47% vs 63% and 14% vs 2% respectively. Studies comparing autologous rectus fascial sling with TVT involve a total of 284 patients from 3 RCTs.11,13,14 Cure rates at 12 months range from 83% to 88% after TVT and 81% to 93% after fascial sling. 2. Autologous fascial sling may be more effective than biological and synthetic slings. (Level II) Summary of Evidence Pubovaginal sling procedures have traditionally been recommended for SUI caused by intrinsic sphincter deficiency (ISD). Sling materials vary and
may be synthetic or biological. The autologous sling may be harvested from either the rectus fascia (as initially described by Aldridge in 1942) or fascia lata. Recently, sling procedures have been done using allograft material (cadaveric fascia or dura mater), xenograft (porcine dermis and small intestinal mucosa or bovine fascia) or synthetic material (such as merselene or prolene). The sling is placed at the level of the bladder neck and proximal urethra (in contrast to the minimally invasive mid-urethral slings) thru a combined vaginal and abdominal route. Complications include vaginal erosion (0-16%), urethral erosion (0-15%), de novo detrussor instability (3.7-66%), and voiding difficulties (10.8%).5 Studies comparing autologous rectus fascial sling with TVT involve a total of 284 patients from 3 RCTs.11,13,14 Cure rates at 12 months range from 83% to 88% after TVT and 81% to 93% after fascial sling. 3. Further high quality research is required to clarify the place of traditional sling procedures in relation to other procedures and to establish the optimum sling materials. V. MID-URETHRAL SLINGS 1. Retropubic mid-urethral slings (TVT) are recommended as an effective treatment for SUI. (Level I-II, Grade B) Summary of Evidence Mid-urethral slings are performed via the retropubic approach (e.g. TVT, IVS, and SPARC) or via the transobturator approach (e.g. transobturator tape [TOT] and tension-free vaginal tape-obturator [TVT-O]). The TVT is a modification of the traditional sling procedure that was introduced by Ulmsten, et. al. in 1996.15 The procedure, initially described to be performed in an ambulatory setting, has been compared to more traditional surgical procedures (such as burch colposuspension and traditional sling procedure) and is seemingly the new “standard” to which other mid-urethral slings are compared. 2. TVT is equally effective as colposuspension and traditional sling procedures. (Level I-II) Summary of Evidence Several randomized trials and cohort studies show that there is no significant difference in the cure rates for the TVT procedure compared to the Burch colposuspension and the fascial sling. Available literature suggests that the TVT has short- and medium-term efficacy (cure rate of 63% to 97%) similar to the open Burch colposuspension but is associated with shorter operating time and hospital stay, less postoperative voiding dysfunction, and quicker recovery. The TVT however appears to have significantly more bladder perforations (6% versus 1%, RR 4.24, 95% CI 1.71-10.52) compared to the open retropubic colposuspension. The TVT is also equally effective as
the traditional fascial sling procedures. Significantly higher objective and subjective cure rates are seen however in the TVT compared to laparoscopic colposuspension. 3. Transobturator mid-urethral slings (TOT or TVT-O) may be used for the treatment of SUI. (Level I-II Grade B) Summary of Evidence The TOT is another modification of the pubovaginal sling procedure and of the TVT. This relatively new technique was introduced in 2001 by Delorme.16 A helical needle/trocar is used to pass a synthetic suburethral sling thru the superomedial aspect of the obturator foramen and behind the ischiopubic ramus (Monarc/ObTape; “outside-in” technique) via an incision at the labio-crural fold. This procedure presumably reduces the risk of bladder and vascular/visceral injuries attributed to the TVT. In 2003, De Leval described another modification to the TOT - the “inside-out” technique to the transobturator approach, the TVT-O.16 Since the technique involved passage of the needle away from the urinary tract, risk of urinary tract injury should significantly decrease. Unlike the TVT, limited data exists comparing the efficacy of the TOT to other standard surgical procedures. Although long-term studies are also not available, reported cure rates of the transobturator approach in various case series range from 59% to 97%. A meta-analysis by Latthe, et. al. comparing the transobturator (TOT or TVT-O) and retropubic (TVT) approaches showed no significant difference in subjective or objective cure rates and in complication rates for a follow-up period of 2 to 12 months.18 VI. BULKING AGENTS 1. If urethral bulking agents are to be used, women should be made aware that repeat injections are likely to be required to achieve efficacy, that efficacy diminishes with time, and is inferior to conventional surgical techniques. (Level I-II, Grade B) Summary of Evidence Urethral bulking agents, injected transurethrally or periurethrally, have long been used for the treatment of SUI. Various substances have been used for this purpose (including bovine collagen, porcine dermal implant, carboncoated beads, autologous fat, etc) but no ideal bulking agent has yet been identified. Likewise, there are no defined standards for optimal location for injection, volume of agent used, injection technique or route, and number of re-injections required. Based on limited data and evidence, benefit from urethral bulking agents appears to be short-term. The Cochrane review includes 12 RCTs with periurethral injection therapy being compared to open surgery, bladder neck suspension, pubovaginal sling procedure, or Burch colposuspension. Numerous studies also compare different bulking agents or the injection
techniques (periurethral or transurethral). However, the group felt that the studies were small and of moderate quality such that meta-analysis was not appropriate. Currently, greater subjective improvement was observed after conventional surgery. Studies comparing bulking agents with non-surgical therapy or minimal access surgery are lacking. 2. Women should be made aware of alternative minimally invasive procedures. References 1.
2. 3. 4. 5.
6. 7. 8. 9. 10. 11. 12. 13.
14. 15. 16. 17.
Meschia M, Pifarotti P, Spennacchio M, Buonaguidi A, Gattei U, and Somigliana E. A randomized comparison of tension-free vaginal tape and endopelvic fascia plication in women with genital prolapse and occult stress urinary incontinence. Am J Obstet Gynecol 2004;190:609-613. Glazener CMA and Cooper K. Anterior vaginal repair for urinary incontinence in women. Cochrane Database Syst Rev 2001, Issue 1. Burch J. Urethrovaginal fixation to Cooper’s ligament for stress incontinence, cystocele, and prolapse. Am J Obstet Gynecol 1961;81:281-290. Lapitan MC, Cody DJ, and Grant AM. Open retropubic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev 2005, Issue 3. ! Bidmead J, Toozs-Hobson P, Cardozo L, Robinson D, Bailey J. Randomised comparison of Burch colposuspension versus anterior colporrhaphy for patients with stress urinary incontinence (letter). BJOG 2001;108:128-129"! Colombo M, Vitobello D, Proietti F and Milani R. Randomised comparison of Burch colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and anterior vaginal wall prolapse. BJOG 2000; 107: 544-551. Dean NM, Ellis G, Wilson PD, and Herbison GP. Laparoscopic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev 2006, Issue 3. Su TH, Wang KG, Hsu CY, Wei HJ, Hong BK. Prospective comparison of laparoscopic and traditional colposuspensions in the treatment of genuine stress incontinence. Acta Obstet Gynecol Scand 1997;76:576-582. Dean NM, Herbison P, Ellis G, Wilson D. Laparoscopic colposuspension and tension-free vaginal tape: a systematic review. BJOG 2006;113:1345-1353. Albo ME, et al and Urinary Incontinence Treatment Network. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. NEJM 2007;356:2143-2155. Bai SW, Jeon JD, Chung KA, Kim JY, Kim S, Park KH. The effectiveness of modified 6 corner suspension in patients with paravaginal defect and stress urinary incontinence. Int Urogyne J 2002;13:303-307. Bezerra CA, Bruschini H, Cody DJ. Traditional suburethral sling operations for urinary incontinence in women. Cochrane Database Syst Rev 2005, Issue 3. Lucas M, Emery S, Alan W, Kathy W. Failure of porcine xenograft sling in a randomized control trial of three sling materials in surgery for stress incontinence. Joint meeting of International Continence Society & International Urogynecological Association. Paris, France, 2004. Wadie BS, Edwan A, Nabeeh AM. Autologous fascial sling vs polypropylene tape at shortterm follow up: a prospective randomized study. J Urol 2005;174: 990-993. Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia for the treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunc 1996;7: 81-86. Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women. Prog Urol 2001;11:1306-13. De Leval J. Novel surgical technique for the treatment of female stress urinary incontinence: transobturator vaginal tape inside-out. Eur Urol 2003;44:724-730.
18. Latthe PM, Foon R, Toozs-Hobson P. Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications. BJOG 2007;114: 522-31. 19. Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev 2009, Issue 4. 20. Keegan PE, Atiemo K, Cody JD, McClinton S, Pickard R. Periurethral injection therapy for stress urinary incontinence in women. Cochrane Database Syst Rev 2007, Issue 3. 21. NICE Guidance on Urinary Incontinence. National Collaborating Center for Women’s and Children’s Health, 2006, National Institute for Health and Clinical Excellence, 2006b. 22. Smith ARB, Dmochowski R, Hilton P, Rovner E, Nilsson CG, Reid FM, Chang D. Surgery for urinary incontinence in women. In: Abrams P, Cardozo L, Khoury S, and Wein A (Eds) Incontinence: WHO – ICUD International Consultation on Incontinence, 4th edition, 2009.
CONSERVATIVE MANAGEMENT OF PELVIC ORGAN PROLAPSE Maria Teresa C. Luna, MD I. VAGINAL PESSARY A vaginal pessary is a removable device placed into the vagina. It is designed to support different sites of pelvic organ prolapse (POP). Available pessaries are either made of silicone or latex rubber. 1. Pessaries can be fitted in most women with prolapse, regardless of prolapse stage or site of predominant prolapse. (Level III, Grade A) Summary of Evidence Vaginal pessaries are the standard nonsurgical treatment for POP. A vaginal pessary can be properly fitted in 78% of patients with approximately 50% of those properly fitted continuing to use a pessary a year later.1-3 Pessaries are most often used when the patient has a strong preference for nonsurgical management of POP or when the patient’s health status confers a significant risk for surgical morbidity and mortality. 4 2. Clinicians should discuss the option of pessary use with all women who have prolapse that warrants treatment based on symptoms. In particular, pessary use should be considered before surgical intervention in women with symptomatic prolapse. (Level III, Grade B) Summary of Evidence Patient factors that determine the type of pessary to be used are sexual activity, site of POP and stage of POP. If the patient is fitted with the correct pessary size, she is not aware of its presence when she wears it, she can void readily, freely and completely and the pessary stays in place (while seated on a toilet bowl and during ambulation). If the patient is fitted with the correct pessary type, no site of defect protrudes when the pessary is in place. Vaginal atrophy should be treated before and concomitant with pessary initiation. Serious complications such as erosions to adjacent organs are rare with proper use and usually result only after a long time of neglect. Pessary complications are rare occurrences in medically compliant patients. The most common side effects of vaginal pessaries are vaginal discharge and odor. Other complications include vaginal bleeding, pelvic/vulvar/vaginal discomfort/pain, pessary expulsion, urinary incontinence (UI), and rectal pain, depending on the type of pessary. Rarely, vaginal pessaries can cause major urinary, rectal and genital complications including fistula, fetal impaction, hydronephrosis and urosepsis.5 The vaginal pessary is removed nightly, washed with soap and water and replaced the next morning. After initial pessary placement, the patient is advised to come back for check-up after 1 week, during which time, the
vagina is inspected for erosions, abrasions, ulcerations, granulation tissue formation and infection. Scheduling of subsequent visits is individualized.6 Vaginal estrogen is generally recommended to patients who, at the time of their initial fitting or at subsequent follow up, are noted to have vaginal atrophy or areas of ulceration or abrasions from pessary use. 7 3. Currently there is no evidence from randomized controlled trials (RCT) upon which to base treatment of women with POP through the use of mechanical devices/pessaries.8 There is no consensus on the use of different types of device, the indications, nor the pattern of replacement and follow-up care. (Level III, Grade B) II. PELVIC FLOOR MUSCLE EXERCISE Despite of the lack of high quality scientific evidence supporting pelvic floor muscle exercise for prevention and treatment of POP, it poses no risk and cost to the patient. It is offered to all patients who are asymptomatic or mildly symptomatic and are interested in preventing the progression of the condition and who decline other treatments. There is some encouragement from a feasibility study that pelvic floor muscle training (PFMT), delivered by a physiotherapist to symptomatic women in an outpatient setting, may reduce severity of prolapse.10 (Level II-3, Grade B) Summary of Evidence The muscles of the pelvic floor help support the abdominal and pelvic contents from below, help control bowel and bladder function and play a role in sexual response. Pelvic floor muscle exercise helps in reducing the progression of POP. The pelvic floor muscle exercise, also known as the Kegel exercise, has been thought to offer a number of benefits to the patient. Firstly, the patient learns to consciously contract before and during increases in abdominal pressure. Secondly, the pelvic floor muscle exercise builds permanent muscle volume and structure support.9 III. PATIENT EDUCATION AND LIFESTYLE MODIFICATION Patients with POP should be counseled on the importance of various lifestyle modifications that may prevent or improve their symptoms of prolapse. (Level III, Grade C) Summary of Evidence Maintaining an ideal body weight limits the pressure that the abdominal content places on the pelvic floor. Any activity that engages the pelvic floor such as walking or gardening can help strengthen the muscles. Patients should be instructed to contract their pelvic floor muscles when lifting
or straining. Patient education should also include bowel movement retraining. This will teach a passing motion without straining the pelvic floor muscles. Advising women on correct posture will in aid in preventing strain on the pelvic floor muscles.11 References 1.
Wu V, Farrel SA, Baskett TF, Flowerdew G. A simplified protocol for pessary management. Obstet Gynecol 1997;90:990-994. 2. Sulak PJ, Kuehl TJ, Shull BL. Vaginal pessaries and their use in pelvic relaxation. J Reprod Med 1993;38:919-923. 3. Clemons JL, et al. Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse. Am J Obstet Gynecol 2004; 190(4): 1025–1029. 4. Rodriguez E, Trowbridge MD and Fenner DE. Conservative management of pelvic organ prolapse. Clin Obstet Gynecol 2005;48(3):668-681. 5. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007;369:1027-1038. 6. Farrell SA. Practice advice for ring pessary fitting and management. J SOGC 1997;19:625. 7. Poma PA. Management of incarcerated vaginal pessaries. J Am Geriatr Soc 1981;29:325-327. 8. Hagen S, Stark D, et al. Conservative management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2006, Issue 4. 9. Bo K. Pelvic floor muscle training is effective in treatment of stress urinary incontinence, but how does it work? Int Urogynecol J 2004;15:76. 10. Hagen S, Stark D, Maher C, et al. Conservative management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2:CD003882, 2004. 11. Rodriguez E, Trowbridge MD, Fenner DE. Conservative management of pelvic organ prolapse. Clin Obstet Gynecol 2005;48(3):668-681.
SURGICAL MANAGEMENT OF PELVIC ORGAN PROLAPSE Manuel S. Ocampo Jr., MD and Lisa T. Prodigalidad-Jabson, MD Previous to the latter half of the twentieth century, the concept of prolapse surgery was based on fascial weakness and defects and so procedures were done to attenuate or strengthen ligaments or fascia supporting the pelvic organs. The work of anatomists in the 1970’s resulted in discovering “breaks in the continuity of support within the endopelvic fascia”. This thinking redirected how pelvic reconstructive surgery is currently performed. This fulfilled the first goal of pelvic organ prolapse (POP) repair that is to “restore normal anatomy”.1 In 2005, The Surgery for Pelvic Organ Prolapse Committee of the World Health Organization (WHO)’s 3rd International Consultation on Incontinence (ICI) made a comprehensive review of POP surgery studies and published its recommendations based on the strength of evidence using the Oxford System.2 Among the Level I conclusions are : o Overall outcomes indicate that abdominal and vaginal surgeries are equivalent. o Abdominal surgery has higher short term morbidity.2 o The recommendation for the use of autologous and non-autologous materials in pelvic floor reconstruction is guarded until more randomized controlled trials (RCTs) are presented and sources of these meshes have “confirmed their efficacy and safety”.3 I. ANTERIOR PROLAPSE)
COMPARTMENT
(ANTERIOR
VAGINAL
WALL
1. Options for repair include the traditional vaginal anterior colporrhaphy, retropubic paravaginal defect repair, vaginal paravaginal defect repair. (Level III, Grade A) Summary of Evidence Traditional vaginal anterior colporrhaphy has cystocele recurrence rates up to 20% when done alone. Large studies on retropubic paravaginal repair have cystocele recurrence rates from 3-5%.4 There are no published studies comparing the traditional vaginal and retropubic approaches. Vaginal paravaginal defect repairs have a 7% recurrence rate.4 2. Transvaginal permanent mesh placement may reduce the incidence of recurrent cystocele but this has unacceptably a high rate of postoperative complications. These would include erosion, infection, sepsis, and dyspareunia. (Level I, Grade B) Summary of Evidence Introduction of mesh or graft inlays together with the anterior repair may decrease the incidence of recurrent cystocele.5 Three RCTs comparing anterior colporrhaphy alone and with a polyprolene mesh were reviewed, examining populations from 76- 202 women and examined after 12 months.
Anterior colporrhaphy alone had recurrent cystocele rates from 34.4-45%. When a mesh was added, the lower recurrence rates were from 6.7-19%. However, vaginal erosion rates for the mesh groups were 5.6-17.3%.6-8 Laparoscopic repair studies are few. A laparoscopic paravaginal defect repair study of 212 consecutive women showed a recurrence rate of 24%. Addition of a graft with anterior colporrhaphy decreased recurrence to 16%.9 3. Options for symptomatic diverticulae are diverticulectomy, partial ablation, and marsupialisation. (Level III, Grade B) Summary of Evidence It is estimated that up to 8% of adult women are diagnosed with a urethral diverticulum. Only women with symptomatic diverticulae should be operated on. There is a paucity of published reports on urethral diverticulae surgery. There have been no studies comparing the different techniques and so “the choice of procedure is driven by the patient’s presentation and the unique anatomy as well as the surgeon’s choice”. Options for symptomatic diverticulae are diverticulectomy, partial ablation, and marsupialisation.1 II. MIDDLE / APICAL COMPARTMENT (UTEROVAGINAL / VAGINAL VAULT PROLAPSE) Because there are few RCTs comparing procedures and most are uncontrolled retrospective studies, there is no gold standard to speak of. Because of this, the choice of surgery would depend on the specific fascial defects. Additionally the patient's age, co-morbidities, activity level, desire for future fertility, history of prior prolapse surgery in other compartments, patient preference, as well as the skill and comfort level of the surgeon with the particular surgery are to be considered.10 Options for uterine preservation are the Manchester procedure, sacrospinous hysteropexy, and the abdominal/laparoscopic hysteropexy. The most common procedures for post-hysterectomy vaginal vault prolapse include sacrospinous ligament fixation, McCall culdoplasty, uterosacral ligament suspension, iliococcygeus fascia suspension, and colpocleisis. The route of hysterectomy will depend on multiple factors to be considered. Options include vaginal, abdominal, and laparoscopic hysterectomy. Laparoscopic hysterectomy approaches are divided into laparoscopic assisted vaginal hysterectomy with or without uterine artery release and total laparoscopic vaginal hysterectomy that includes vault closure laparoscopically. MANCHESTER PROCEDURE The Manchester procedure can be recommended for a patient who is desirous of maintaining her uterus. It has a high middle compartment success rate. The addition of uterosacral ligament plication increases the success rate. (Level II-3, Grade B)
Summary of Evidence This procedure is indicated for a patient with an elongated cervix, an anterior vaginal wall prolapse, with a desire of maintaining her uterus. A retrospective study of 187 consecutive patients with a majority having a stage 3 uterine prolapse underwent a Manchester procedure. Early post-operative complications were urinary retention (22.05%) and cervical stenosis (11.27%). Follow-up after 3 years revealed almost 4% had undergone surgery for prolapse recurrence and urinary incontinence.11 A comparison of a Modified Manchester procedure with the addition of a uterosacral ligament plication versus a vaginal hysterectomy with a high uterosacral ligament plication showed similar anterior and posterior compartments prolapse recurrences (50%). After a one-year follow-up, the Modified Manchester had no recurrent middle compartment prolapse compared to 4% for the vaginal hysterectomy with a high uterosacral plication group.12 SACROSPINOUS HYSTEROPEXY AND ABDOMINAL / LAPAROSCOPIC HYSTEROPEXY The American College of Obstetrics and Gynecology (ACOG) released Bulletin 85, recommendations are:15 1. Alternative operations for uterine preservation in women with prolapse include uterosacral or sacrospinous ligament fixation by the vaginal approach or sacral hysteropexy by the abdominal approach. (Level II-3, Grade B) Summary of Evidence These procedures use suture or mesh to attach the cervix/uterus to the sacrospinous ligament or the sacrum. Few studies are available for sacrospinous and abdominal hysteropexy. One observational study for sacrospinous fixation involved 133 women where 84% of women were highly satisfied. No serious complications were noted. The uterine prolapse recurrence rate that needed reoperation was 2.3%. Cystocele recurrence was 35%.13 A review by Ridgeway, et. al. concluded that “favorable postoperative outcomes range from 62-100% and additional data show improved quality of life and sexual function. Anatomic outcomes appear to be comparable to vaginal hysterectomy with sacrospinous ligament vault suspension.”14 The open or laparoscopic sacrohysteropexy has similar results when compared with sacrospinous fixation, with cure rates ranging from 91-100%. Several studies favoring sacrohysteropexy also showed improvements in quality of life and sexual function.14 2. Hysteropexy should not be performed by using the ventral abdominal wall for support because of the high risk for recurrent prolapse, particularly enterocele. (Level II, Grade B)
3. Round ligament suspension is not effective in treating uterine or vaginal prolapse. (Level II, Grade B) HYSTERECTOMY 1. Because of equal or significantly better outcomes on all parameters, vaginal hysterectomy should be performed in preference to abdominal hysterectomy where possible. (Level I, Grade B) Summary of Evidence Hysterectomy is an option for middle compartment prolapse. The route of hysterectomy depends on multiple factors, which include the stage of uterine prolapse, the gynecologist’s training and comfort with the route of hysterectomy, the patient’s condition, and the patient’s preference. A vaginal or laparoscopic route is favorable if the uterus is less than 12 weeks size and accessible vaginally, size reduction is possible during surgery, the pathology is limited to the uterus, the extra-uterine pathology is mild, the cul de sac is accessible, and there is an absence of severe endometrioses and severe adhesions. Otherwise an abdominal hysterectomy is the safer choice. Figure 1 is a pathway for choosing the route of hysterectomy for benign disease.1 2. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy may avoid the need for abdominal hysterectomy. (Level I, Grade B) Summary of Evidence In an analysis of multiple RCTs comparing vaginal, abdominal, and laparoscopic hysterectomies, it was found that recovery was fastest in vaginal and laparoscopic than in abdominal routes, there were more urinary tract complications in laparoscopic than abdominal hysterectomy, there was no advantage of laparoscopic hysterectomy over vaginal hysterectomy, and that the differences between laparoscopic assisted vaginal hysterectomy over total laparoscopic hysterectomy were a shorter operation time, fewer febrile episodes, and unspecified infections.16,17 3. The surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon in light of the relative benefits and hazards. (Level I, Grade B) SACROSPINOUS LIGAMENT FIXATION LAPAROSCOPIC SACROCOLPOPEXY
AND
ABDOMINAL
/
The ACOG released Bulletin 85, recommendations are: 1. Cadaveric fascia should not be used as graft material for abdominal sacral colpopexy because of a substantially higher risk of recurrent prolapse than with synthetic mesh. (Level I, Grade A)
()*+,-,.+/0)! %&7%.#+,7!:/-! ;,&%$&!<%*,#*,! #$%! ()$*+%!,--$%%./0$! )*,1%2,3.1,004! !&'!
!&'!
#$%! ()$*+%!B!CDE!3!F0$%%! )6,1!GC!8$$H%!%.A$I!
56.%!70'8!-6,*)!.%!1')! ,99*'9*.,)$!7'*!:$-.%.'1! %+99'*)"!
!&'!
@.A$!*$:+-).'1! 9'%%./0$!
#$%!
!&'! ! 567/0%&#'! ()*+,-,.+/0)!
;,)6'0'34!,99$,*%! -'17.1$:!)'!)6$!+)$*+%! !&'!
! 4#2#-/*./2%.! 89#0%&#+%/&!
!#$%!
! "#$%&#'! ()*+,-,.+/0)
<=)*,+)$*.1$! 9,)6'0'34! ,/%$1)!'*!>.0:!
!
! 12,-#+%3,! 4#2#-/*./2)
!
#$%!
!&'! !&'!
?+0!:$!@,-! .1,--$%%./0$!
@$2$*$!,:6$%.'1%! !&'!
!&'!
#$%!
Figure 1. Determining the route of hysterectomy
@$2$*$! $1:'>$)*.'%.%!
2. For stress-continent women planning abdominal sacral colpopexy, regardless of the results of preoperative stress testing, the addition of the Burch procedure substantially reduces the likelihood of postoperative stress incontinence without increasing urgency symptoms or obstructed voiding. (Level I, Grade A) 3. Compared with vaginal sacrospinous ligament fixation, abdominal sacral colpopexy has less apical failure and less postoperative dyspareunia and stress incontinence, but is also associated with more complications. (Level II, Grade B) Summary of Evidence The 3rd ICI reported that sacrospinous-based vaginal procedures have a higher anterior and apical anatomical recurrence rate than sacrocolpopexybased abdominal repairs.2 Sacrospinous ligament fixation has post-operative risks for temporary buttock pain in 6% of patients, cystocoele in 8%, dyspareunia in 2.7%, and de novo stress urinary incontinence in 2.6%.18 In a recent study by Benedito de Castro, the sacrospinous fixation cure rate was 93.1%. Preoperative and postoperative evaluation of the anterior vaginal compartment was respectively: stage 1 (5.2%; 48.3%). De novo cystocele occurred in 87.9% of cases.19 Abdominal sacrocolpopexy without paravaginal defect repair showed a 26.9% recurrence of cystocele.20 Laparoscopic sacrocolpopexy results from >1000 patients in 11 series were reviewed by Ganatra, et. al. and found a 6.2% prolapse reoperation rate and a 2.7% mesh erosion rate. They concluded that laparoscopic sacrocolpopexy is comparable to abdominal sacrocolpopexy.21 McCALL CULDOPLASTY McCall’s culdoplasty, high uterosacral ligament suspension, iliococcygeus fascia suspension may be performed with success rates above 80%. (Level II-III, Grade B) Summary of Evidence The goal of endopelvic fascia repair (or modified McCall culdoplasty) is to suspend the vaginal vault to the endopelvic fascia. A study by Chene, et. al. used a modified McCall procedure where 185 patients underwent vaginal hysterectomy. The 2-year follow-up showed the absence of apical prolapse in 89.2% and a 10% incidence of stage 1 vaginal vault prolapse that did not require re-operation. About eighty one percent (81.2%) of patients had satisfactory sexual function.22 A history of macrosomic infant delivery, indicating pelvic floor damage, was linked to failure of the modified McCall culdoplasty and resulted in 44.4% post operative apical prolapse.23
HIGH UTEROSACRAL LIGAMENT SUSPENSION McCall’s culdoplasty, high uterosacral ligament suspension, iliococcygeus fascia suspension may be performed with success rates above 80%. (Level II-III, Grade B) Summary of Evidence This aims to suspend the prolapsed vaginal vault bilaterally to the uterosacral ligaments. This is similar to the McCall’s culdoplasty. The vault suspension sutures suspend the vagina deep into the pelvis, up to the level of the ischial spines. High uterosacral ligament suspension carries a risk of ureteral injury or kinking. Intra-operative cystoscopy is an option. Silva, et. al. presented a high uterosacral vault suspension over an average of 5 years follow-up of 110 patients. They only had a 2.8% recurrence of an apical prolapsed.24 A meta-analysis of uterosacral ligament suspension by Marquiles, et. al. showed that uterosacral suspension was most favorable for the apical compartment with a pooled rate of 98.3%, followed by the posterior compartment (87.4%), and the anterior compartment (81.2%).25 ILIOCOCCYGEUS FASCIA SUSPENSION McCall’s culdoplasty, high uterosacral ligament suspension, iliococcygeus fascia suspension may be performed with success rates above 80%. (Level II-III, Grade B) Summary of Evidence The purpose of iliococcygeus fascia suspension is to suspend the vaginal vault to the fascia of the iliococcygeus muscle in patients with weak uterosacral ligaments. There are few recent studies on this procedure. A study comparing McCall’s culdoplasty alone and with iliococcygeus fascia suspension showed that 8.3% had postoperative vaginal defects in the combined group and 33.3% were observed in the group undergoing McCall culdeplasty alone.26 COLPOCLEISIS For women who are at high-risk for complications with reconstructive procedures and who no longer desire vaginal intercourse, colpocleisis can be offered. (Level III, Grade B) Summary of Evidence Total colpocleisis procedures are performed for patients with posthysterectomy vaginal vault prolapse. Colpocleisis carries a risk for postoperative de novo stress urinary incontinence (SUI). Published data were reviewed by Fitzgerald, et. al. and their conclusions were: 1) Colpocleisis for
POP is successful in almost 100% of patients in recent studies. 2) The data is incomplete with regards reoperation rates for stress incontinence. 3) Concomitant elective hysterectomy does not improve outcomes. 4) Pelvic symptoms were not usually assessed by the studies.27 Colpocleisis is an option for women who have a high risk for complications with reconstructive procedures and are not desirous of intercourse.27
III.POSTERIOR PROLAPSE)
COMPARTMENT
(POSTERIOR
VAGINAL
WALL
1. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach.15 (Level II-1, Grade B). 2. Posterior colporrhapy has a greater success rate compared to site-specific rectocele repair with or without a graft. (Level I, Grade A) Summary of Evidence In a study by Paraiso, et. al., 3 different rectocele repair techniques were compared where 106 women with stage II or greater posterior vaginal wall prolapse were randomly assigned to either posterior colporrhaphy, sitespecific rectocele repair, or site-specific rectocele repair augmented with a porcine small intestinal submucosa graft. Results after one year follow-up showed that those who received graft augmentation had a significantly greater anatomic failure rate (46%) than those who received site-specific repair alone (22%) or posterior colporrhaphy (14%). Overall postoperative sexual function had significantly improved in all groups postoperatively. Posterior colporrhaphy and site-specific rectocele repair had similar anatomic and functional outcomes. Addition of a porcine-derived graft did not improve anatomic results.28 The same groups were followed one year postoperatively and assessed for bowel symptoms and were found to have less straining and less of a feeling of incomplete emptying.29 References 1. 2. 3. 4. 5. 6.
Kovac SR, Zimmerman C. Advances in reconstructive surgery. Lippincott Williams & Wilkins 2007;187-88. Atiemo H, Griebling T, Daneshgari F. Advances in geriatric female pelvic surgery. BJU Int 2006;98(Suppl 1):92-93. Cardozo L. Editorial comment: The use of synthetic mesh in female pelvic reconstructive surgery. BJU Int 2006;98(Suppl 1):77. Stanton S, Zimmern P. Female pelvic reconstructive surgery. Springer-Verlag London Ltd 2003. Maher C, Baessler K, Glazener CM, Adams EJ, Hagen S. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2007 Jul;18(3):CD004014. Carey M, Higgs P, Goh J, Lim J, Leong A, Krausse H, Cornish A. Vaginal repair with mesh versus colporrhaphy for prolapsed: a randomized controlled trial. BJOG 2009; 116(10):13806.
7. 8. 9. 10. 11. 12.
13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
23. 24. 25. 26.
27. 28.
Nguyen JN, Burchette RJ. Outcome after anterior vaginal prolapse repair: a randomized controlled trial. Obstet Gynecol 2008 Apr;111(4):891-8. Hiltunen R, Nieminen K, Takala T, Heiskanen E, Merikari M, Niemi K, Heinonen PK. Lowweight polypropylene mesh for anterior vaginal wall prolapse: a randomized controlled trial. Obstet Gynecol 2007;110(2 Pt 2):455-62. Behnia-Willison F, Seman El, Cook JR, O’Shea Rt, Keirse MJ. Laparoscopic paravaginal repair of anterior compartment prolapse. Minim Invasive Gynecol 2007;14(4):475-80. Park AJ, Paraiso MF. Surgical management after uterine prolapsed. Minerva Ginecol 2008 Dec;60(6):493-507. Ayhan A, Esin S,Guven S, Salman C, Ozyunco O. The Manchester operation for uterine prolapsed. Int J Gynaecol Obstet 2006 Mar;92(3):228-33. De Boer TA, Milani AL, Kluivers KB, Withagen MI, Vierhout ME. The effectiveness of surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication (modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication. Int Urogynecol J Pelvic Floor Dysfunct 2009 Nov;20(11):1313-9. Dietz V, de Jong J, Huisman M, Schraffordt Koops S, Heintz P, van der Vaart H. The effectiveness of the sacrospinous hysteropexy for the primary treatment of uterovaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2007 Nov;18(11):1271-6. Ridgeway B, Frick AC, Walter MD. Hysteropexy: A review. Minerva Ginecol 2008 Dec;60(6):509-28. ACOG Practice Bulletin No. 85. Pelvic organ prolapse. American College of Obstetricians and Gynecologists (ACOG). Washington (DC) Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BW, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009 Jul 8;(3):CD003677. Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ 2005 Jun 25;330(7506):1478. Lovatsis D, Drutz HP. Safety and efficacy of sacrospinous vault suspension. Int Urogynecol J Pelvic Floor Dysfunct 2002;13(5):308-13. Benedito de Castro E, Palma P, Riccetto C, Herrmann V, Bigozzi MA, Olivares JM. Impact of sacrospinous vaginal vault suspension on the anterior compartment. Actas Urol Esp 2010 Jan;34(1):106-10 Shippey SH, Quiroz LH, Sanses TV, Knoepp LR, Cundiff GW, Handa VL. Anatomic outcomes of abdominal sacrocolpopexy with or without paravaginal repair. Int Urogynecol J Pelvic Floor Dysfunct 2010 Mar;21(3):279-83. Ganatra AM, Rozet F, Sanchez-Salas R, Barret E, Galiano M, Cathelineau X, Vallancien G. The current status of laparoscopic sacrocolpopexy: a review. Eur Urol 2009 May;55(5):1089103. Chene G, Tardieu AS, Savary D, Krief M, Boda C, Anton-Bousquet MC, Mansoor A. Anatomical and functional results of McCall culdoplasty in the prevention of enteroceles and vaginal vault prolapse after vaginal hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct 2008 Jul;19(7):1007-11. Cam C, Karateke A, Asoglu MR, Selcuk S, Namazov A, Aran T, Celik C, Tug N. Possible cause of failure after McCall culdoplasty. Arch Gynecol Obstet 2010 Mar 16. Silva WA, Pauls RN, Segal JL, Rooney CM, Kleeman SD, Karram MM. Uterosacral ligament vault suspension: five-year outcomes. Obstet Gynecol 2006 Aug;108(2):255-63 Margulies RU, Rogers MA, Morgan DM. Outcomes of transvaginal uterosacral ligament suspension: systematic review and metaanalysis. Am J Obstet Gynecol. 2010 Feb;202(2):12434. Koyama M, Yoshida S, Koyama S, Ogita K, Kimura T, Shimoya K, Murata Y, Nagata I. Surgical reinforcement of support for the vagina in pelvic organ prolapse: concurrent iliococcygeus fascia colpopexy (Inmon technique). Int Urogynecol J Pelvic Floor Dysfunct. 2005 May-Jun;16(3):197-202. FitzGerald MP, Richter HE, Siddique S, Thompson P, Zyczynski H. Colpocleisis: a review. Int Urogynecol J Pelvic Floor Dysfunct. 2006 May;17(3):261-71. Paraiso MF, Barber MD, Muir TW, Walters MD. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol 2006 Dec;195(6):1762-71.
29. Gustilo-Ashby AM, Paraiso MF, Jelovsek JE, Walters MD, Barber MD. Bowel symptoms 1 year after surgery for prolapse: further analysis of a randomized trial of rectocele repair. Am J Obstet Gynecol 2007 Jul;197(1):76.e1-5.
FECAL INCONTINENCE AND OBSTETRIC ANAL SPHINCTER INJURIES Lennette L. Chan, MD I. NON-OPERATIVE TREATMENT 1. Non-operative therapy is the initial management to improve the symptoms of fecal incontinence (FI). Patient education is important. (Level III, Grade C) 2. Attempt should be done to establish a bowel routine. (Level III, Grade C) Summary of Evidence Expert opinion supports the use of general health education, patient teaching about bowel function and advice on lifestyle modification.2-4 3. Treat reversible causes of diarrhea. Antidiarrheal agents, such as adsorbents or opium derivatives, may reduce FI. (Level II, Grade C) Summary of Evidence Diarrhea or loose stools is consistently found to be a risk factor for FI. Potentially preventable causes of diarrhea include drugs, dietary supplements, and some foods. There is some evidence that loperamide may decreased stool frequency, improve stool consistency, and reduce side effects in patients with FI.5-7 4. A trial of soluble dietary fiber is recommended for the management of FI associated with loose stool. (Level I, Grade B) Summary of Evidence Dietary fiber supplementation appears to be a safe and tolerable intervention for fecal incontinence. In Bliss study, subjects were communityliving adults with incontinence of loose or liquid stools given supplementation with one of two soluble dietary fibers compared to placebo resulted in reduced rate of FI in patients with loose stool.8 On the other hand, there are reports that dietary fiber may exacerbate FI in some patients. Some patients with FI benefit from moderating their intake of foods containing largely insoluble fiber.9 Another study reported that treating constipation in elderly immobile people with a supplement of insoluble fiber and bran, resulted in FI in half of them.10,11 Fiber supplements appear to benefit diarrhea-associated but not constipation associated FI. 5. Enemas, laxatives, and suppositories may help to promote more complete bowel emptying in appropriate patients and minimize further post defecation leakage and treat constipation associated FI. (Level II, Grade C)
Summary of Evidence For constipation-associated FI, daily or more frequent oral laxative regimens may be effective.12 6. Pelvic floor muscle exercises are recommended in patients who have not responded to simple dietary modification or medication. (Level III, Grade C) 7. The use of biofeedback as a treatment for FI is recommended after other behavioral and medical management have been tried if inadequate symptom relief is obtained. (Level III, Grade C) Summary of Evidence National Institute of Health and Clinical Excellence (NICE) clinical guidelines consensus statement regarding and the use of biofeedback for FI. “Given the numerous positive outcomes from uncontrolled trials, limitations in the current randomized controlled trials (RCTs) and low morbidity associated with its application the use of pelvic floor muscle exercises and biofeedback, as treatment for fecal incontinence, is recommended as possibly effective and currently unproven and can be used after other behavioral and medical management has been tried.” 8. Patients who failed conservative therapy or not be candidates for conservative therapy due to severe anatomic, physiologic or neurologic dysfunction are referred for surgical management. II. DIAGNOSTIC TESTS PRIOR TO SURGICAL MANAGEMENT 1. Endoanal ultrasonography has the largest diagnostic value to detect morphological integrity of the anal sphincter complex in patients with FI. (Level III, Grade C). 2. Ancillary tests: Anal manometry, electromyography (EMG) and defecography may be helpful in guiding management. (Level III, Grade C) Summary of Evidence Endoanal ultrasound is helpful in defining the extent of anal sphincter injury. Preoperative physiologic testing may be helpful in the overall management of patients with FI. However, the value of anal manometry and pelvic floor electrophysiological assessment as prognostic indicators for outcome following sphincteroplasty is controversial. There are no established parameters that reliably predict outcome following sphincteroplasty.17,18 15
3. In case of failed conservative management, the surgical approach to the patient depends on the presence and magnitude of an anatomic sphincter defect. If no sphincter defect is present, the patient should undergo initial
percutaneous nerve evaluation (PNE), which, if successful, should lead to sacral nerve stimulation (SNS). It has the unique advantage of allowing a therapeutic trial prior to permanent stimulator implantation. (Level III Grade B) Summary of Evidence SNS was primarily used it in patients with neurologic origin of fecal incontinence without sphincteric defects.19 A report by Rosen, et. al. highlights the effect of SNS in a cohort of patients, 75% of whom suffered from FI of neurologic origin.20 Frequency of incontinence episodes/week was reduced from 6 to 2 at 15 months follow-up. The technique is safe, minimally invasive, and has the unique advantage of allowing a therapeutic trial prior to permanent stimulator implantation.21-23 4. If sphincter loss is < 180 degrees, sphincteroplasty is recommended. Due to increasing evidence that sphincteroplasty deteriorates with time, SNS for sphincter defect may be used for most patients with clinically significant incontinence with sphincter defect. (Level III, Grade B) Summary of Evidence Most patients improve after overlapping sphincteroplasty, but outcomes deteriorate over time. A number of studies have looked at long term outcomes after repair of a 3rd or 4th degree tears and all have shown an increasing prevalence of continence disorders with age.24-28,30,31 In the largest study reported to date, Bravo Gutierrez, et. al. found that only 6% of patients retained full continence 10 years following anal sphincteroplasty.32 Long-term atrophy of the sphincters may be relevant.30 There is now an increasing body of evidence indicates that SNS may also be a treatment option for patients with sphincter defects, unrepaired or after attempted anatomic reconstruction. The presence of an internal anal sphincter defect on endoanal sonography is reportedly unrelated to the success of permanent SNS.33 Three of five patients with ultrasound evidence of sphincter disruption measuring 25-33% of the circumference benefited from chronic SNS.34 In 20 patients with unrepaired obstetric trauma, SNS resulted in significant improvement of incontinent episodes with a minimum follow-up of 4 years.35 In patients with an unrepaired external or internal anal sphincter or both, the frequency of incontinent episodes per week decreased from 1.3 to 0.3 and the Cleveland Clinical Score (CCS) improved (from 15 to 3.5) with a follow-up of 12-97 months.36 SNS in 6 of 8 patients presenting with fecal incontinence related to obstetric full thickness anal sphincter lesions ranging from > 30-150 degree resulted at a median follow-up of 26.5 months in improved frequency of incontinent episodes per week from 5.5 to 1.5 clinical function37, improved ability to postpone bowel emptying and improved American Society of Colon and Rectal Surgeons (ASCRS) quality of life scores. Melenhorst, et. al. showed that the primary use of SNS in patients with a sphincter gap 17-33% of the circumference appeared to result in an outcome similar to its use after failed sphincter repair.38
5. For patients who remain incontinent following sphincteroplasty, repeat endoanal ultrasound should be done to reassess the status of the repair. If there is a persistent sphincter defect, repeat anal sphincter repair could be considered. (Level II, Grade C) Summary of Evidence Initial success of sphincteroplasty is related to whether the anal sphincter defect is corrected.39 Early failure is usually associated with a persisting defect, identifiable using endoanal ultrasound.40 This may be amenable to a further attempt at repair.39,42 6. For patients with sphincter defects of greater than 180 degrees or major perineal tissue loss, individualized treatment is indicated. Initial pelvic floor reconstruction can be performed. (Level III, Grade C) Summary of Evidence Deen, et. al.43 in an RCT comparing three procedures in 36 women with neuropathic FI, found that complete continence was achieved in 42% of patients after postanal repair, 33% after anterior levatorplasty, and 67% after total pelvic floor repair while van Tets, et. al.44 conducted an RCT comparing postanal repair and total pelvic floor repair in 20 women with neurogenic FI. Complete continence to solid or liquid stool was achieved in 27% of patients after postanal repair and in 22% after total pelvic floor repair. Studies with a median follow-up of more than 5 years revealed that continence after pelvic floor reconstruction deteriorated with time. Possible explanations for deterioration of continence following initial improvement included unrecognized denervation and/or muscular injury of the sphincter and pelvic floor musculature and the presence of occult anal sphincter disruption. These reports of increasingly poor outcomes have diminished the popularity of this procedure significantly. 7. For patients with persistent incontinence after pelvic reconstruction, alternative management includes stimulated muscle transposition, artificial anal sphincter implantation, or SNS. (Level II, Grade B) Summary of Evidence Stimulated muscle transposition involves the transposition of the gracilis muscle to reconstruct the anal sphincter, which was then electrically stimulated transforming type II into type I muscle fibers. Stimulated muscle transposition has been shown to have reasonable success but is associated with significant morbidity such as disturbed evacuation, infection, pain, pulse generator displacement, and anorectal perforation.47 It remains a useful technique in selected patients with significant perineal tissue loss and in those who have failed other treatments.45-47 8. For patients who remain incontinent despite an anatomically satisfactory sphincteroplasty, SNS is recommended. (Level III, Grade B)
Summary of Evidence A cohort study reports on the effect of permanent SNS in 53 patients presenting with either an intact external anal sphincter (N=32 [37.5% after sphincter repair]) or an external anal sphincter lesion (N=21 [81% after prior sphincter repair]) of < 90° (N=11) or 90-120° (N=10).48 Improvement of symptoms and quality of life was achieved in all groups. Outcome after 12 months was statistically not significantly different between those patients with an intact sphincter complex and those without. Chan and Tjandra reviewed 53 consecutive patients who underwent SNS for FI.49 There was no significant difference in outcomes between those with and without an external sphincter defect. SNS is an effective therapy for most patients with clinically significant incontinence who fail conservative management.50 9. Patients with sphincter defect who have failed SNS, sphincteroplasty can be considered. Other alternatives include stimulated muscle transposition and implantation of an artificial anal sphincter (AAS). (Level II, Grade B) Summary of Evidence The device (Acticon Neosphincter®, American Medical Systems, Minnesota, USA) is a totally implantable system consisting of 3 parts: an inflatable occlusive cuff that is implanted around the native sphincter, a pressure-regulating balloon that is implanted in the prevesical space, and a control pump that is implanted in the labia majora. AAS has been shown to have reasonable success. Most of the patients (78-100%) with a functioning device were continent to solid stool, 56-95% were continent to solid and liquid stool, and 22-67% were completely continent. The success rate in patients with a functioning device was 44-100%, and the intention-to-treat success rate was 41-83%. Overall complication rate varied between 11-87% but no mortality rate was reported. Surgical site infections (9-58%) and erosion of the adjacent skin (6-32%) were common. Up to 46% of patients underwent revisional surgery, and the proportion of patients with a functioning device after follow-up of between 6 and 34 months ranged between 24-100%. Sixty seven percent patients have their devices explanted. The AAS is a useful technique in carefully selected patients, particularly those who have failed other treatments. 10. Patients with passive FI to liquid or solid stool who had failed conventional therapy, the use of injectable biomaterials report reasonable short and midterm term success rate. (Level III, Grade C) Summary of Evidence Shafik in 1993 began treating patients with FI (7 of whom had internal sphincterotomy and 4 idiopathic incontinence) using injectable biomaterials of polytetrafluoroethylene paste into the anal submucosa.57 Sixty four percent reported complete cure and 36% had partial improvement. There is only one report of long-term results for injectable agents. Maeda, et. al. reported the 5year outcome of 6 patients injected with Bioplastique.58 One patient had
undergone a colostomy. However, four of the remaining five patients reported subjective improvement in their incontinence and quality of life scores. Most series of injectable biomaterials report reasonable success rates though with short-term efficacy. 11. Patients who fail surgical therapy for FI, or who do not wish to undergo extensive pelvic reconstruction, should consider placement of an end sigmoid colostomy. (Level III, Grade C) Summary of Evidence A permanent colostomy is usually performed as a last resort for severe FI when all other interventions have failed. It restores dignity and allows patients to regain social function. An age- and gender-adjusted regression analysis of the FI Quality of Life score revealed significantly higher scores in the coping, embarrassment, and lifestyle scales in the colostomy group compared to the FI group.61 It also could be the most cost-effective in the short to medium term, compared to more complicated surgical procedures such as artificial anal sphincter and dynamic graciloplasty. Colostomy should not be regarded as a treatment failure but rather a reasonable treatment option for patients whose lives are restricted by FI that is not amenable to other therapies. III. PREVENTION OF FECAL INCONTINENCE 1. Treat reversible causes of diarrhea. (Level II, Grade C) Summary of Evidence Diarrhea or loose stools is consistently found to be a risk factor for FI. Potentially preventable causes of diarrhea include drugs, dietary supplements, and some foods such as lactose, fructose and sorbitol and natural foods such as prunes. Drugs known to cause diarrhea as a side effect include antibiotics, especially the erythromycin analogs; orlistat, the serotonin reuptake inhibitor class of antidepressants; digoxin; and laxatives. Chronic laxative dependence or abuse may cause frequent diarrhea. There is some evidence that loperamide may decreased stool frequency, improved stool consistency, and reduced side effects in patients with fecal incontinence.5-7 Fiber supplements appear to benefit diarrhea-associated but not constipation associated FI. 2. There is no convincing evidence of role for preventive cesarean section for FI. (Level III, Grade A) Summary of Evidence Cesarean delivery before the onset of the second stage of labor was found to be protective64, however, in a systematic review, Nelson, et. al.65 found that pregnancy rather than delivery was a more important indicator of post partum continence.
3. Avoid midline episiotomy. (Level I, Grade A) 4. Restrictive rather than liberal episiotomy protocols. (Level II, Grade A) Summary of Evidence Midline episiotomy is associated with higher incidence of anal sphincter injury.66 The angle of mediolateral episiotomy may also influence perineal outcome. In a prospective case–control study there was a 50% relative reduction in risk of sustaining third-degree tear observed for every 6 degrees away from the perineal midline that an episiotomy was cut.67 A policy of restrictive use of episiotomy may reduce the incidence of anal sphincter injury.68 5. All women having a vaginal delivery with evidence of genital tract trauma should be examined systematically to assess the severity of damage prior to suturing. (Level I, Grade C) Summary of Evidence With increased awareness and training there appears to be an increase in the detection of obstetric anal sphincter injuries. One observational study showed that increased vigilance about anal sphincter injury can double the detection rate.69 In another study where endoanal ultrasound was used immediately following delivery, the detection rate of anal sphincter injury was not significantly increased compared to clinical examination alone.70 6. Primary overlapping sphincter repair performed by a fully trained surgeon in obstetric anal sphincter injuries (OASIS) repair is indicated. (Level I, Grade B) Summary of Evidence Primary repair of an obstetrical tear is usually performed by the obstetrician immediately after delivery most commonly in the delivery room under local or epidural anesthetic. Results of the four RCTs71-74 and one metaanalysis75 that have investigated different techniques of immediate primary repair of the external anal sphincter following obstetric injury points to a trend towards better outcome with an overlap repair. Inexperienced attempts at anal sphincter repair may contribute to maternal morbidity, especially subsequent FI. Training may be improved by the implementation of surgical skills workshops with the use of models and audiovisual material. A report on the effect of hands-on training workshops on repair of third- and fourth-degree perineal tears showed that there is increased awareness of perineal anatomy and recognition of anal sphincter injury following attendance at hands-on training workshops.76,77 7. Discourage the use of internal anal sphincter division for treatment of anal fissure and hemorrhoids. (Level II-3, Grade A)
Summary of Evidence A persistent defect in the internal anal sphincter was found to be an important determinant of FI.78 Patients with chronic anal fissure or hemorrhoids may be offered internal anal sphincterotomy (slit in the internal anal sphincter for 50-60% of its length to reduce anal canal pressures). In a large series of 585 patients with a chronic anal fissure treated in this fashion at the Mayo Clinic, 11% developed FI.79 References 1.
Norton C, Whitehead WE, Bliss DZ, Metsola P, Tries J. Conservative and pharmacological management of faecal incontinence in adults. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence. Plymouth: Health Publications; 2005. p. 1521-63. 2. Norton C, Thomas L, Hill J. Management of faecal incontinence in adults: summary of NICE guidelines. BMJ 2007;334:1370-1. 3. Norton C, Chelvanayagam S. Bowel continence nursing. Beaconsfield: Beaconsfield Publishers; 2004. 4. Whitehead WE, Wald A, Norton N. Treatment options for fecal incontinence: consensus conference report. Dis Colon Rectum 2001;44:131-44. 5. Cheetham M, Brazzelli M, Norton C, Glazener CM. Drug treatment for faecal incontinence in adults. Cochrane Database Syst Rev 2003;(3):CD002116. 6. Hanauer SB. The role of loperamide in gastrointestinal disorders. Rev Gastroenterol Disord 2008 Winter;8(1):15-20. 7. Bischoff A, Levitt MA, Bauer C, Jackson L, Holder M, Peña A. Treatment of fecal incontinence with a comprehensive bowel management program. Pediatr Surg 2009 Jun;44(6):1278-83;discussion 1283-4. 8. Bliss DZ, Jung H, Savik K, Lowry AC, LeMoine M, Jensen L, et al. Supplementation with dietary fiber improves fecal incontinence. Nursing Research 2001;50(4):203-13. 9. Norton C, Chelvanayagam S. Conservative management of faecal incontinence in adults. In: Norton C, Chelvanayagam S, editors. Bowel continence nursing. Beaconsfield: Beaconsfield Publishers; 2004. p. 114-31. 10. Ardron ME, Main ANH. Management of constipation. BMJ 1990;300:1400. 11. Bode C, Bode JC. Effect of alcohol consumption on the gut. Best Pract Res Clin Gastroenterol 2003;17:575-92 12. Ryan D, Wilson A, Muir TS, Judge TG. The reduction of faecal incontinence by the use of “Duphalac” in geriatric patients. Curr Med Res Opin 1974;2:329-33. 13. Byrne CM, Solomon MJ, Rex J, Young JM, Heggie D, Merlino C.Telephone vs. face-to-face biofeedback for fecal incontinence: comparison of two techniques in 239 patients. Dis Colon Rectum 2005 Dec;48(12):2281-8. 14. Boselli AS, Pinna F, Cecchini S, Costi R, Marchesi F, Violi V, Sarli L, Roncoroni L. Biofeedback therapy plus anal electrostimulation for fecal incontinence: prognostic factors and effects on anorectal physiology. World J Surg 2010 Apr;34(4):815-21. 15. Williams AB, Bartram CI, Halligan S, Spencer JA, Nicholls RJ, Kmiot WA. Anal sphincter damage after vaginal delivery using three-dimensional endosonography. Obstet Gynecol 2001;97(5 Pt 1):770-5. 16. Mortele KJ, Fairhurst J. Dynamic MR defecography of the posterior compartment: Indications, techniques and MRI features. Eur J Radiol 2007;61(3):462-72. 17. Gearhart S, Hull T, Floruta C, Schroeder T, Hammel J. Anal manometric parameters: predictors of outcome following anal sphincter repair? J Gastrointest Surg 2005;9(1):115-20. 18. Maslekar S, Gardiner AB, Duthie GS. Anterior anal sphincter repair for fecal incontinence: Good long term results are possible. J Am Coll Surg 2007;204(1):40-6. 19. Matzel KE, Stadelmaier U, Hohenfellner M, Gall FP. Electrical stimulation of sacral spinal nerves for treatment of faecal incontinence. Lancet 1995;346(8983):1124-7. 20. Rosen HR, Urbarz C, Holzer B, Novi G, Schiessel R. Sacral nerve stimulation as a treatment for fecal incontinence. Gastroenterology 2001;121(3):536-41. 21. Matzel KE, Schmidt RA, Tanagho EA. Neuroanatomy of the striated muscular anal continence
mechanism. Implications for the use of neurostimulation. Dis Colon Rectum 1990;33(8):66673. 22. Matzel KE, Stadelmaier U, Hohenberger W. Innovations in fecal incontinence: sacral nerve stimulation. Dis Colon Rectum 2004;47(10):1720-8 23. Tjandra JJ, Lim JF, Matzel K. Sacral nerve stimulation: an emerging treatment for faecal incontinence. ANZ J Surg 2004;74(12):1098-106. 24. Nygaard IE, Rao SS, Dawson JD. Anal incontinence after anal sphincter disruption: a 30-year retrospective cohort study. Obstet Gynecol 1997;89(6):896-901. 25. Faltin DL, Otero M, Petignat P, Sangalli MR, Floris LA, Boulvain M, Irion O. Women’s health 18 years after rupture of the anal sphincter during childbirth: I. Fecal incontinence. Am J Obstet Gynecol 2006;194(5):1255-9. 26. Bollard RC, Gardiner A, Duthie GS, Lindow SW. Anal sphincter injury, fecal and urinary incontinence: a 34-year follow-up after forceps delivery. Dis Colon Rectum 2003;46(8):10838. 27. Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm MA. Long- term results of overlapping anterior anal sphincter repair for obstetric trauma. Lancet 2000;355:260–5 28. Evans C, Davis K, Kumar D. Overlapping anal sphincter repair and anterior levatorplasty: effect of patient’s age and duration of follow-up. Int J Colorectal Dis 2006;21(8):795-801. 29. Mous M, Muller SA, de Leeuw JW. Long-term effects of anal sphincter rupture during vaginal delivery: faecal incontinence and sexual complaints. BJOG 2008;115(2):234-8. 30. Dudding TC, Vaizey CJ, Kamm MA. Obstetric anal sphincter injury: incidence, risk factors, and management. Ann Surg 2008;247(2):224-37. 31. Madoff RD. Surgical treatment options for fecal incontinence. Gastroenterology 2004;126(1 Suppl 1):S48-54. 32. Bravo Gutierrez A, Madoff RD, Lowry AC, Parker SC, Buie WD, Baxter NN. Long-term results of anterior sphincteroplasty. Dis Colon Rectum 2004;47(5):727-31; discussion 731-2. 33. Dudding TC, Pares D, Vaizey CJ, Kamm MA. Predictive factors for successful sacral nerve stimulation in the treatment of faecal incontinence: a 10-year cohort analysis. Colorectal Dis 2008;10(3):249-56. 34. Conaghan P, Farouk R. Sacral nerve stimulation can be successful in patients with ultrasound evidence of external anal sphincter disruption. Dis Colon Rectum 2005;48(8):1610-4. 35. Maslekar SK, Gardiner A, Duthie GS. Sacral nerve stimulation as primary treatment for faecal incontinence secondary to obstetric anal sphincter damage: medium and long-term results [abstract]. Dis Colon Rectum 2006;49(5):730. Abstract 38 36. Ratto C. Sacral nerve stimulation in fecal incontinence due to anal sphincter lesions. Paper presented at: European Society of Coloproctology 2nd Annual Scientific Meeting; September 27, 2007; Malta 37. Jarrett ME, Dudding TC, Nicholls RJ, Vaizey CJ, Cohen CR, Kamm MA. Sacral nerve stimulation for fecal incontinence related to obstetric anal sphincter damage. Dis Colon Rectum 2008;51(5):531-7. 38. Melenhorst J, Koch SM, Uludag O, van Gemert WG, Baeten CG. Is a morphologically intact anal sphincter necessary for success with sacral nerve modulation in patients with faecal incontinence? Colorectal Dis 2008;10(3):257-62. 39. Pinedo G, Vaizey CJ, Nicholls RJ, Roach R, Halligan S, Kamm MA. Results of repeat anal sphincter repair. Br J Surg 1999;86(1):66-9. 40. Nielsen MB, Dammegaard L, Pedersen JF. Endosonographic assessment of the anal sphincter after surgical reconstruction. Dis Colon Rectum 1994;37(5):434-8. 41. Giordano P, Renzi A, Efron J, Gervaz P, Weiss EG, Nogueras JJ, Wexner SD. Previous sphincter repair does not affect the outcome of repeat repair. Dis Colon Rectum 2002;45(5):635- 40. 42. Vaizey CJ, Norton C, Thornton MJ, Nicholls RJ, Kamm MA. Long-term results of repeat anterior anal sphincter repair. Dis Colon Rectum 2004;47(6):858-63. 43. Deen KI, Oya M, Ortiz J, Keighley MR. Randomized trial comparing three forms of pelvic floor repair for neuropathic faecal incontinence. Br J Surg 1993;80(6):794-8. 44. van Tets WF, Kuijpers JH. Pelvic floor procedures produce no consistent changes in anatomy or physiology. Dis Colon Rectum 1998;41(3):365-9. 45. Rongen MJ, Uludag O, El Naggar K, Geerdes BP, Konsten J, Baeten CG. Long-term followup of dynamic graciloplasty for fecal incontinence. Dis Colon Rectum 2003;46(6):716- 21. 46. Tillin T, Gannon K, Feldman RA, Williams NS. Third-party prospective evaluation of patient outcomes after dynamic graciloplasty. Br J Surg 2006;93(11):1402-10.
47. Thornton MJ, Kennedy ML, Lubowski DZ, King DW. Long- term follow-up of dynamic graciloplasty for faecal incontinence. Colorectal Dis 2004;6(6):470-6. 48. Matzel KE, Stadelmaier U, Hohenfellner M, Hohenberger W. Chronic sacral spinal nerve stimulation for fecal incontinence: long term results with foramen and cuff electrodes. Dis Colon Rectum 2001 Jan;44(1):59-66. 49. Tjandra JJ, Chan MK, Yeh CH, Murray-Green C. Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study. Dis Colon Rectum 2008;51(5):494-502. 50. Chan MK, Tjandra JJ. Sacral nerve stimulation for fecal incontinence: external anal sphincter defect vs. intact anal sphincter. Dis Colon Rectum 2008;51(7):1015-24; discussion 1024-5. 51. O’Brien PE, Dixon JB, Skinner S, Laurie C, Khera A, Fonda D. A prospective, randomized, controlled clinical trial of placement of the artificial bowel sphincter (Acticon Neosphincter) for the control of fecal incontinence. Dis Colon Rectum 2004;47(11):1852-60. 52. Ortiz H, Armendariz P, DeMiguel M, Solana A, Alos R, Roig JV. Prospective study of artificial anal sphincter and dynamic graciloplasty for severe anal incontinence. Int J Colorectal Dis 2003;18(4):349-54. 53. Wong WD, Congliosi SM, Spencer MP, Corman ML, Tan P, Opelka FG, et al. The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study. Dis Colon Rectum 2002;45(9):1139-53. 54. Mundy L, Merlin TL, Maddern GJ, Hiller JE. Systematic review of safety and effectiveness of an artificial bowel sphincter for faecal incontinence. Br J Surg 2004;91(6):665- 72. 55. Belyaev O, Muller C, Uhl W. Neosphincter surgery for fecal incontinence: a critical and unbiased review of the relevant literature. Surg Today 2006;36(4):295-303. 56. Altomare DF, Binda GA, Dodi G, La Torre F, Romano G, Rinaldi M, Melega E. Disappointing long-term results of the artificial anal sphincter for faecal incontinence. Br J Surg 2004;91(10):1352-3. 57. Shafik A. Polytetrafluoroethylene injection for the treatment of partial fecal incontinence. Int Surg 1993;78(2):159-61. 58. Maeda Y, Vaizey CJ, Kamm MA. Long-term results of perianal silicone injection for faecal incontinence. Colorectal Dis 2007;9(4):357-61. 59. Shafik A. Perianal injection of autologous fat for treatment of sphincteric incontinence. Dis Colon Rectum 1995;38(6):583-7. 60. Vaizey CJ, Kamm MA. Injectable bulking agents for treating faecal incontinence. Br J Surg 2005;92(5):521-7. 61. Colquhoun P, Kaiser R, Jr., Efron J, Weiss EG, Nogueras JJ, Vernava AM, 3rd, Wexner SD. Is the quality of life better in patients with colostomy than patients with fecal incontience? World J Surg 2006;30(10):1925-8. 62. Norton C, Burch J, Kamm MA. Patients’views of a colostomy for fecal incontinence. Dis Colon Rectum 2005;48(5):1062- 9. 63. Catena F, Wilkinson K, Phillips RK. Untreatable faecal incontinence: colostomy or colostomy and proctectomy? Colorectal Dis 2002;4(1):48-50. 64. Fynes M, Donnelly VS, O’Connell PR, O’Herlihy C. Caesarean delivery and anal sphincter injury. Obstet Gynecol 1998;92(4 Pt 1):496-500. 65. Nelson RL, Westercamp M, Furner SE. A systematic review of the efficacy of caesarean section in the preservation of anal continence. Dis Colon Rectum 2006;49(10):1587-95. 66. Fenner DE, Genberg B, Brahma P, Marek L, DeLancey JO. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol 2003 Dec;189(6):1543-9. 67. Eogan M, Daly L, O’Connell PR, O’Herlihy C. Does the angle of episiotomy affect the incidence of anal sphincter injury? BJOG 2006;113(2):190-4. 68. Clemons JL, Towers GD, McClure GB, O’Boyle AL. Decreased anal sphincter lacerations associated with restrictive episiotomy use. Am J Obstet Gynecol 2005;192(5):1620-5. 69. Groom KM, Paterson-Brown S. Can we improve on the diagnosis of third degree tears? Eur J Obstet Gynecol Reprod Biol 2002;101:19–21. 70. Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injuries: myth or reality? BJOG 2006;113:195–200. 71. Fitzpatrick M, Behan M, O’Connell PR, O’Herlihy C. A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears. Am J Obstet Gynecol 2000;183(5):1220-4. 72. Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, O’Brien PM. Repair techniques for
obstetric anal sphincter injuries: a randomized controlled trial. Obstet Gynecol 2006;107(6):1261-8. 73. Williams A, Adams EJ, Tincello DG, Alfirevic Z, Walkinshaw SA, Richmond DH. How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial. BJOG 2006;113(2):201-7. 74. Garcia V, Rogers RG, Kim SS, Hall RJ, Kammerer-Doak DN. Primary repair of obstetric anal sphincter laceration: a randomized trial of two surgical techniques. Am J Obstet Gynecol 2005;192(5):1697-701. 75. Fernando R, Sultan AH, Kettle C, Thakar R, Radley S. Methods of repair for obstetric anal sphincter injury. Cochrane Database Syst Rev 2006;3:CD002866 76. Fernando RJ, Sultan AH, Radley S, Jones PW, Johanson RB. Management of obstetric anal sphincter injury- A systematic review and national practice survey. BMC Health Serv Res 2002;2:9. 77. Thakar R, Sultan AH, Fernando R, Monga A, Stanton S. Can workshops on obstetric anal sphincter rupture change practice? Int Urogynecol J 2001;12:S5. 78. Mahony R, Behan M, Daly L, Kirwan C, O’Herlihy C, O’Connell PR. Internal anal sphincter defect influences continence outcome following obstetric anal sphincter injury. Am J Obstet Gynecol 2007;196(3):217 e1-5. 79. Nyam DC, Pemberton JH. Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum 1999 Oct;42(10):1306-10.
URINARY RETENTION Jennifer Marie B. Jose, MD Background Voiding dysfunction or lower urinary tract dysfunction is a term used to describe various problems related to the bladder’s ability to store and empty urine. Urinary retention is the inability to complete the voiding phase of the micturition cycle and, often times, represent the end stage of voiding dysfunction. Physiologically, a problem may be present with either the bladder, the outlet or both. Voiding dysfunction is manifest clinically in lower urinary tract symptoms (LUTS) which may be characterized as storage symptoms (frequency, urgency, nocturia and urge incontinence) or emptying symptoms (decreased force of stream, incomplete emptying, hesitancy straining to void and urinary retention). Symptoms do not always correlate with the underlying pathology, and numerous conditions may exist that can have similar presentations. Distinguishing neurogenic from non-neurogenic voiding dysfunction is important. The latter category is often caused by bladder outlet obstruction and this may be functional, as in the case of dysfunctional voiding and primary bladder neck obstruction or anatomic as in the case of pelvic floor prolapse or post surgical obstruction.1 The standardization of terminology of lower urinary tract dysfunction, published by the International Continence Society (ICS), has recently defined LUTS in relation to voiding difficulty and retention.2 • Acute retention of urine is defined as a painful, palpable or percussable bladder, when the patient is unable to pass any urine. • Chronic retention of urine is defined as a non-painful bladder, which remains palpable or percussable after the patient has passed urine. Such patients may be incontinent. Recommendations 1. Acute retention should be managed with an indwelling catheter and evaluation and management of possible precipitant and contributory factors, followed by a voiding trial after about 1 week (perhaps longer for retention volumes over 1 liter).3 If the voiding trial fails, then further urodynamic investigation is needed (including sphincter electromyography [EMG]). If prolonged catheterization is necessary, suprapubic catheterization should be considered because of its lower risk of catheter associated infection and urethral trauma.4 (Level I, Grade A) Summary of Evidence Short term use of an indwelling catheter is commonly used to manage acute urinary retention. In most cases, continous drainage by foley catheter is necessary until bladder function normalizes, usually within 48 to 72 hours.5
2. Intermittent self-catheterization as a nonsterile procedure is now the principal treatment for chronic urinary retention. It allows women to lead independent lives with efficient bladder emptying and low rates of urinary tract infection when performed properly.5 (Level I, Grade A) Summary of Evidence Clean intermittent straight catheterization is the procedure performed in many voiding difficulties. Continuous bladder drainage is best avoided in cases of urinary retention because of the high complication rate from the infection, ulcerations, calculi, malignancies and bladder spasms. 6 I. PHARMACOTHERAPY 1. Cholinergic agents - for example, betanechol chloride and distigmine bromide (an anti-cholinesterase) - and intra vesical prostaglandin E2 and F2 have been advocated for treatment of urinary retention, however there is no real evidence of clinical benefits.6 (Level III, Grade C) Summary of Evidence Bethenacol has been used as treatment for retention caused by detrusor contractility, but it has not been used for women with sphincteric overactivity. Its treatment value is therefore unknown.7 2. Although adrenergic blocking agents (e.g. phenoxybenzamine, prazocin and indoramine) have proven benefit in women, they are useful in men with urodynamically proven bladder neck obstruction. Anxiolytic agents such as diazepam may help with postoperative voiding problems. In women with combined urge incontinence and retention, anticholinergic agents such as tolterodine maybe used effectively in conjunction with clean intermittent straight catheterization (CISC) if required, but the incidence of this is reassuringly low due to the site of action of anticholinergics in their current doses.6 (Level III, Grade C) Summary of Evidence Adrenergic blocking agents, like prazocin hydrochloride and phenoxybenzamine, have been used to decrease the contractility of the smooth muscle component of the urethral sphincter. Diazepam can be used to decrease urethral resistance.7 4. Voiding difficulties following pelvic and particularly continence surgery and delivery are important causes of patient morbidity and litigation. Strict protocols on the management of patients before and after surgery and delivery need to be defined.6 (Level III, Grade C)
Summary of Evidence If voiding difficulty is due to urethral stenosis, urethral dilatation using Hegar dilators or preferably the Otis urethrotome is an appropriate option. The place of bladder neck incision in patients with outflow obstruction should never be performed unless diagnosis is confirmed by pressure/ flow videourodynamics. Partial cystectomy has been performed for treating the myogenic decompensated bladder and excessive residual urine. However, the results are disappointing. Urinary diversion using appendix or fallopian tube, colocystoplasty, latissimus dorsi myoplasty and vesical cap operation with ileal seomuscular patch grafts have all been tried with variable success.9 III. BLADDER TRAINING Bladder training should be guided by patients’ bladder capacity, symptoms and fluid intake. A general guide for adults is to do CISC often enough to maintain catheterized volumes at 500 ml or less (every 4 to 6 hours). (Level III, Grade C) Summary of Evidence There are no randomized trials comparing CISC and clamping the foley catheter intermittently for bladder training. One main advantage of CISC is that the voiding trials can be done before self-catheterization. In addition, it can be implemented as a one-time treatment repeatedly over a short period of time, on an occasional basis, or may be life-long for persons with chronic bladder emptying disturbances. It is often preferred to indwelling catheters, because it can result in a better quality of life for the patient has less complications, such as urinary tract infections (UTI), urethral stricture, compared to indwelling catheters. The evaluation, management and treatment of female patients with voiding dysfunction and urinary retention is often complex and must take multiple factors into consideration, including the degree to which the patients symptoms is bothersome and whether the upper tracts are in jeopardy. A patient specific diagnostic approach is recommended, depending on symptoms, degree of bother and whether there is a history of suspicion of neurologic disease. In certain cases, empirical treatment is appropriate. However, when a formal diagnosis is indicated, specific therapy can be directed based on urodynamics and other basic tests.8
III. NEUROGENIC VOIDING DYSFUNCTION 1. CISC is the mainstay of therapy for neurogenic voiding dysfunction. The same is true for retention secondary to impaired contractility. (Level I, Grade A) Summary of Evidence The ideal treatment for detrusor external sphincter dyssynergia (DESD) is anticholinergics with CISC.1 The management of multiple sclerosis includes anticholinergics with or without CISC and behavioral therapy.15 Urinary retention for cauda equine syndrome resolves within months, with one CISC to facilitate emptying.1 2. In some cases, a catheterizable stoma can facilitate independence when neurologic disease is advanced and urethral catheterization cannot be performed independently. (Level I, Grade A) 3. Botulinum toxin has been injected transurethrally for the treatment of detrusor internal sphincter dyssynergia (DISD). (Level I, Grade A) Summary of Evidence Botulinum A toxin injections do have therapeutic value in urethral spasticity, but larger, controlled trials are necessary to establish their role.12 4. Chronic indwelling catheters are generally not recommended for treatment of chronic retention but may be used as a last resort in select patients. (Level I, Grade A) 5. In situations in which chronic indwelling catheters desirable and necessary, appropriate catheter care and frequent changing of the catheter is recommended.7 (Level I, Grade A) IV.NON-NEUROGENIC VOIDING DYSFUNCTION / DYSFUNCTIONAL VOIDING 1. The use of CISC is considered satisfactory management. (Level I, Grade A) Summary of Evidence CISC is the mainstay of therapy. All management strategies are directed at successful bladder emptying.1 2. Biofeedback and behavioral modification has become the recommended treatment for women with dysfunctional voiding. (Level I, Grade A)
Summary of Evidence Behavioral and biofeedback treatments are safe, noninvasive, and effective interventions that are useful in the management of idiopathic urinary retention. Behavioral changes enlighten patients about their fluid intake and voiding behavior. Biofeedback involves surface or internal (vaginal or rectal) electrodes that transducer muscle potentials into auditory or visual signals. This helps the patient learn to increase or decrease voluntary muscle activity.17 3. Diazepam was reported to be successful to be used in treatment. (Level II1, Grade B) Summary of Evidence Diazepam relaxes the pelvic floor striated musculature during bladder contraction, or that such relaxation removes an inhibitory stimulus to reflex bladder activity.1 4. Amitryptyline was reported to be successful. (Level III, Grade A) 5. Endoscopic and transperineal injection of botulinum toxin has been performed in women with dysfunctional voiding. (Level III, Grade A) 6. Sacral neuromodulation is effective for restoring voiding in patients with idiopathic retention (Fowler’s syndrome).7 (Level III, Grade A) Summary of Evidence Dagupta and colleagues provided long term results of sacral nerve stimulation in women with Fowler’s syndrome. The retrospective study included 26 women who were followed for more than 6 years. Seventy-seven percent were voiding successfully more than 5 years post operatively: 54% required revision surgery. The study supported effectiveness of sacral nerve stimulation (SNS) for at least 5 years after implantation.18 Shaker and Hassouna treated 20 patients, with idiopathic, nonobstructing, chronic urinary retention dependent on CISC who had at least 50% improvement on percutaneous nerve evaluation screening. The patients were followed for a mean of 15.2 months and had significant improvement in voiding function, pelvic pain, and sensation of emptiness after voiding. The study authors emphasize that the lack of change in cystomyography after SNS implantation indicates that the cause of the problem is not the bladder but the pelvic floor musculature.19
V. PRIMARY BLADDER NECK OBSTRUCTION 1. The treatment options for primary bladder neck obstruction (PBNO) include watchful waiting, pharmacotherapy and surgical intervention. (Level III, Grade A) Summary of Evidence Inflammatory processes, such as bladder neck fibrosis, urethral stricture, meatal stenosis, urethral caruncle, Skene’s cyst or abscess, and urethral diverticulum are associated with anatomic obstruction. Management usually involves treatment of the offending infection and surgical excision of the obstructing lesion.22 2. PBNO can be treated surgically with transurethral incision of the bladder neck.8 (Level III, Grade A) Summary of Evidence The management for primary bladder neck obstruction is medical and surgical. Surgical options include transurethral incision of the bladder neck and Y-V-plasty of the bladder neck. Care is taken to avoid injury to the external sphincter, which can lead to stress incontinence.9 VI. PELVIC ORGAN PROLAPSE 1. Voiding dysfunction caused by pelvic organ prolapse (POP) can be treated by pessary or surgical repair.9 (Level I, Grade A) Summary of Evidence After the diagnosis of the prolapse, a pessary or packing can be used to reduce the prolapse and confirm the diagnosis. This helps predict the outcome of prolapse repair. Treatment of symptomatic prolapse is usually surgical. In case of significant morbidity and age, a pessary alone may be used.10 VII. IATROGENIC POST SURGICAL OBSTRUCTION 1. Treatment is dictated by degree of bother of postoperative symptom. An obstructed patient will opt for conservative management with CISC.7 (Level I, Grade A) Summary of Evidence Treatment of postoperative retention begins with catheter decompression and management of contributory factors, such as constipation. If these measures fail, then CISC and or surgical repair (urethrolysis, sling
release) are recommended.14 2. The role of urethral dilatation is not known. (Level III, Grade C) Summary of Evidence Urethral dilatation leads to post-dilatation bleeding or urine extravasation into periurethral tissue, causing scarring of the urethral wall and periurethral fibrosis.14 3. Urethrolysis or sling incision is the most definitive treatment available whether retropubic, transvaginal or supreameatal approach. (Level I, Grade A) Summary of Evidence Bladder neck surgery, tension free vaginal tape placement (TVT), and collagen injection are recognized causes of compression and voiding difficulty. Postoperative factors contributing to retention may include failure of the sphincter to relax, edema surrounding the vesical neck and urethra, pelvic floor spasm, and obstruction from bladder neck elevation. Age, higher preoperative urethral resistance, straining during voiding, and magnetic resonance imaging (MRI) evidence of greater bladder neck elevation and urethral compression have been associated with the number of days of voiding dysfunction after colposuspension.19 4. The cholinergic agent bethenacol is not effective.10 (Level I, Grade A) Summary of Evidence Bethenacol has been used as treatment of retention caused by detrusor acontractility, but it has not been used in women with sphincteric overactivity. Its treatment value is unknown.14 5. The use of botolinum toxin injection into the urethral sphincter for retention after anti-incontinence surgery is under investigation.11 (Level III, Grade C) Summary of Evidence Phelan and colleagues were the first to report successful outcomes with a botulinim A injections in women and in non neurogenic voiding dysfunction. They studies 21 patients (13 women) with impaired bladder emptying who were dependent on catheterization. All except one were able to void spontaneously after the injection of 80-100 units of botulinum toxin.20 Kuo and associates repeated this study in 20 patients with urinary retention and dysuria due to detrusor hypocontractility and non relaxing urethral sphincter who who were refractory to conservative therapy. This
study clearly showed that botulinum toxin is effective in decreasing urethral sphincter resistance and improving voiding dysfunction. Botulinum A toxin injections do have therapeutic value in urethral spasticity, but larger, controlled trials are necessary to establish value. 21 VIII. IMPAIRED DETRUSOR CONTRACTION 1. CISC is the mainstay for patients with significant retention. (Level I, Grade A) Summary of Evidence Impaired neuromuscular transmission at the detrusor and/or myopathic processes are proposed causes of the decreased contractility. Urodynamics is essential for diagnosis. CISC is the mainstay of therapy.14 3. Pharmacotherapy with cholinergic agonists such as bethenacol has not proven to be successful.7 (Level III, Grade C) Summary of Evidence Bethenacol chloride is cholinesterase resistant and causes a contraction of smooth muscle from the bladder, bladder neck and urethra, thus preventing coordinated and complete bladder emptying. It is no longer considered to be effective to facilitate voiding.14 IX. POSTPARTUM URINARY RETENTION There is no standardized definition that qualifies postpartum urinary retention. A commonly used symptom-based definition is the absence of spontaneous voiding of urine within 6 hours of delivery. After caesarian section, if a catheter is used, retention is defined as “no spontaneous voiding within 6 hours after removal of the indwelling catheter”. Another commonly used definition is based on the post-void residual bladder volume as estimated by ultrasound or catheterization. Although most experts agree that residual volumes of less than 50 ml are normal and more than 200 ml are abnormal, little agreement exist on the intervening grey zone. Postpartum urinary retention can be classified into covert and overt forms. The covert form is asymptomatic and recognized by demonstrating an elevated post-void residual measurement of more than or equal to 150 ml; with either ultrasound scanning or catheterization. Clinically overt postpartum urinary retention refers to the inability to void spontaneously after delivery. There is no concensus of opinion on the management of postpartum urinary retention and various treatment regimen have been described. The treatment includes general measures such as administration of oral analgesia,
helping the woman to mobilize, and ensuring privacy during voiding and having a warm bath. None of the pharmacologic drugs have been studied systematically in postpartum women, as most women would be breastfeeding. If conservative measures fail, it is advisable to insert a urethral catheter and remove it after the bladder has been emptied. If spontaneous voiding fails to occur within 4 hours or if the voided volume is less than 150 ml and/or the post void residual urine is more than 150 ml, a foley catheter should be inserted. A trial without catheter can be attempted after 24-28 hours. The duration of catheterization is empirical, and no standard has been agreed to. If trial without catheter fails, the woman can be taught intermittent self-catheterization every 4-6 hours until she is able to void and then until the residual is less than 150 ml. If this is not feasible, send her home with an indwelling catheter for 48 hours and repeat the voiding trial. Overdistention bladder injury in the postpartum period can be avoided by strict vigilance in ensuring that voiding occurs regularly. Women with potential risk factors, e.g. regional anesthesia, instrumental delivery, obstetric anal sphincter trauma or severe perineal tears should be catheterized during labor and delivery. There are very few studies on the sequelae of postpartum urinary retention but published data suggest that this condition returns to normal within a short period and specific treatment is not necessary.21- 24 References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Cardozo L, Statskin D. Textbook of Female Urology and Urogynecology, 2nd ed. Informa Healthcare; 2006. Abrams P, Cardozo L, Fall M, et al. The standardization of terminology of lower urinary tract function: report from the Standardization Sub- committee of the International Continence Society: Neurourol Urodyn 2002;21(2):167-78. Djavan B, Shariat S, Omar M, et al. Does prolonged catheter drainiage improve the chance of recovering voluntary voiding after acute retention of urine? Eur Urol 1998;33:110. Agency for Healthcare Policy and research. Making healthcare safer, a critical analysis of patient safety practices. Available online at www. Ahcpr.gov/clinic/ptsafety/chap15b.htm. Wyndaele J, Maes D. Clean intermittent self-catheterization: a 12-year follow-up. J Urol 1990;143906-8. Recommendations arising from the 42nd Study Group: Incontinence in Women. In: Maclean AB, Cardozo L, editors. Incontinence in Women. London: Royal College of Obstetrician and Gynecology Press; 2002;443-441. Walters M, Karram M. Urogynecology and Reconstructive Pelvic Surgery. (Third edition) Chapter on Voiding Dysfunction and Urinary Retention. Philadelphia, Mosby Inc.,2007 Kumar A, Mandhani A, Gogoi S, Srivastava A. Management of functional bladder neck obstruction in women: use of alpha blockers and pediatric resectoscope for bladder neck incision. J Urol 1999;162:2061 Romanzi L, Blaivas JG. The effect of genital prolapsed on voiding. J Urol 1999;161:581 Hindley RG, Brierly RD, Thiomas PJ. Prostaglandin E2 and Bethenacol in combination for treating detrusor underactivity . BJU Int 2004;93:89-92. Smith CP, O’Leary M, Erickson J, Somogy GT, Chancellor MB. Botulinum toxin urethral sphincter injection resolves urinary retention after pubovaginal sling operation. Int Urogynecol J 2002;13:55-56. Royal Women’s Hospital Clinical Practice Guidelines Kermans, G, Wyndaele JJ, Thiery M, De SW. Puerperal urinary retention. Acta Urol Belg 1986; 54(4): 376-85. Yip SK, Sahota, D, Pang MW, Day L. Postpartum urinary retention. Obstet Gynecol 2005; 106(3); 602-6
Figure 1. Algorithm for the Management of Acute Urinary Retention
G" C" U"
"#$%&!$'()"'*!'&%&)%(+)! &')!9,%%$:!+*.1$!8.)6.1
