a new approach to managing atrophic vaginitis a new approach to managing atrophic vaginitis
TRANSCRIPT
Dr. Angelika BorozdinaMBBS. PhD. FRANZCOG
Obstetrician and Gynaecologist
CVOGS
ABC OF PROLAPSE AND INCONTINENCE
A New Approach to Managing Atrophic Vaginitis
URINARY INCONTINENCE
Defi nition:
Involuntary urine leakage during activity (eff ort/exertion).
Occurs with loss of normal rise in urethral closure pressure in response to rising abdominal pressure.
Anatomic and physiologic factors result in disordered pressure transmission.
Distinguished from URGE Incontinence
.
Urge incontinence is the strong, sudden need to urinate due to bladder spasms or contractions5
Stress incontinence is an involuntary loss of urine that occurs during physical activity, such as coughing, sneezing, laughing, or exercise5
Mixed incontinence is the combination of both urge and stress incontinence6
THREE COMMON TYPES OF URINARY INCONTINENCE
Urge
Stress
Mixed
Of the 1 in 3 adult women who have urinary incontinence7:
URGE VS. STRESS VS. MIXED INCONTINENCE
Urge 11%
Mixed
36%
SUI 50%
SUI: 4 TYPES OF ETIOLOGIC RISK FACTORS
Intervene• Behavioral
• Pharmacologic• Devices• Surgical
Predispose• Female Gender• Race, Culture and
Environment• Anatomy• Neurologic
Incite • Vaginal childbirth• Nerve Damage• Muscle Damage • Radiation
Promote• Constipation• Physical work• Obesity• Smoking• Menopause• Fluid Intake• Toilet Habits
Decompensate• Aging
• Comorbid disease• Dementia
• Medications• Environment
Continent
Incontinent
COMPONENTS OF SUI PATHOPHYSIOLOGY
1. Loss of anatomic urethral supportUrethral Hypermobility (UH) - weakness of pelvic structures that support urethral compression during increased abdominal pressure
2. Intrinsic Sphincter Deficiency (ISD) Deficiency of urethral intrinsic closing
mechanism
INCONTINENCE EVALUATION
Incontinence on Physical Activity
• History and Physical examination: abdominal, pelvic, neurological• Assess effect on quality of life • Bladder diary• MSU, if UTI treat• Assess for pelvic organ mobility / prolapse• Ultrasound of detrusor muscle, bladder neck and residual volume of urine post void • Urodynamics
HISTORY
CLINICAL ASSESSMENT
Pelvic Examination
• Prolapse may mask incontinence
• Pelvic floor muscle tone • Voluntary pelvic floor
contraction• Perineal skin condition• Palpation of anterior vaginal
wall and urethra• Determine degree of
estrogenization• May observe leakage on
coughing
SUI Assessment
.
Urinalysis1
Tests of detrusor function• Postvoid residual (PVR) volume1
• Flow rate1
• Filling cystometrogram (CMG)1
Tests of urethral sphincter function• Valsalva leak point pressure (VLPP)2
• Maximum urethral closure pressure (MUCP)1
SUI Assessment (continued)
1. Abrams P, et al. he Standardisation of Terminology of Lower Urinary Tract Functioning: Report from the Standardisation Sub-committee of the Int’l Continence Society. Neurourol Urodyn. 2002;21:167-178.
2. Blaivas JG, Groutz A. In: Retik AB, Vaughan ED Jr, Wein AJ, et al, eds. Urinary Incontinence: Pathophysiology, Evaluation, and Management Overview. Philadelphia, Pa: WB Saunders; 2002:1027–1052.
SUI MANAGEMENT
Incontinence on physical activity
History and urodynamic study confirm Stress incontinence
•Pelvic floor muscle training•Oestrogen therapy of vagina•Pessary management•Sling operation or vaginal prolapse surgery• Lifestyle interventions
TREATMENT
HISTORY/
Clinical
examination
SUI SURGICAL TREATMENTS
vs.
Modern
Integral Theory’ of urinary incontinence*
1. Control of urethra depends: • pubourethral ligaments• suburethral vaginal
hammock• pubococcygeus muscle
1. Elevate bladder neck and proximal urethra
2. Support bladder neck and prevent funnelling
3. Increase outflow resistance
Traditional
NON SURGICAL TREATMENT
Neotonus MR Chair
Based on Extracorporeal Technology produces highly focused pulsing magnetic fields
MID-URETHRAL SLINGS
Goals1. Restore and/or reinforce the pubourethral ligaments at the mid-urethra2. Restore and/or reinforce the suburethral vaginal hammock at the mid-
urethra3. Reinforce the paraurethral connective tissue
pubourethralligament
urethropelvicligament
ADVANTAGES OF MID-URETHRAL SLINGS
1. Easily reproducible
2. Long-term successful clinical results
3. Minimal complication risk
4. Minimally invasive
5. Minimal tissue dissection
6. Can be performed under regional, or general anesthesia
7. Most patients can be discharged the same day w/o catheter
8. Shorter patient recovery than traditional open procedure
Patient and Physician Benefits
Studies show that most patients are continent following the sling procedure and can resume normal, non-strenuous activities within a few days .
SUCCESS RATE
85-94%
Clinical data on AMS slings shows:19-22
*In a MiniArc study 90% of patients had negative cough stress test and 85% had a 1-hour pad weight test less than 1 gm at 1 year.
*In a MiniArc study 94% of patients had significant improvement in pad use at 1 year.
*In a Monarc study 90% of patients had a negative cough stress test and improvement in pad use at 1 year follow-up.
*In a SPARC study 88% of patients had significantly reduced symptoms according to the Kings Health Questionnaire at 1 year.
Known risks of surgical procedures for the treatment of urinary incontinence include:
• Pain/Discomfort/Irritation• Inflammation (redness, heat, pain, or swelling resulting from surgery)• Infection• Mesh erosion (presence of suture or mesh materials within the organs surround
the vagina)• Mesh extrusion (presence of suture or mesh material within the vagina)• Fistula formation (a hole/passage that develops between organs or anatomic
structures that is repaired by surgery)• Foreign body (allergic) reaction to mesh implant• Adhesion formation (scar tissue)• Urinary incontinence (involuntary leaking of urine)
WARNINGS AND PRECAUTIONS
Known risks of surgical procedures for the treatment of urinary incontinence include:
• Urinary retention/obstruction (involuntary storage of urine/blockage of urine flow)
• Voiding dysfunction (difficulty with urination or bowel movements)• Contracture (mesh shortening due to scar tissue)• Wound dehiscence (opening of the incision after surgery)• Nerve damage• Perforation (or tearing) of vessels, nerves, bladder, ureter, colon, and
other pelvic floor structures • Hematoma (pooling of blood beneath the skin)• Dyspareunia (pain during intercourse)
WARNINGS AND PRECAUTIONS
NOTE: Some of these adverse reactions are specific to procedures involving mesh repair (e.g. mesh extrusion).
Involuntary loss of urine associated with a sudden, strong desire to void.
Urge Incontinence ( bladder muscle problem )Life style changes, bladder retraining Reduce caffeine , Vaginal Estrogen Magnetic chair Anticholinergic medication( SE) Neuromodulators
DETRUSOR OVERACTIVITY INCONTINENCE
50% of parous women (Swift 2000, DeLancey 1993,
Beck 1991)
30 – 40% of women in general population (Slieker-
tenHove 2004,
Samuelsson 1999)
Only 8.8% symptomatic (McLennan 2000)
11.1% lifetime risk of surgical repair
29 – 40% reoperation within 3 years (Clark 2003,
Olson 1997)
Basic Prolapse Stats
Pelvic organ prolapse (PLP) a common condition among female population ~ 60%
Life time risk of surgery for POP 19% in WA (Smith FJ et al., 2010) higher than USA( 11%)
Recurrence surgery 50%
Prolapse surgery challenging
- Multifunctionality of the vagina
PROLAPSEHERNIATION OF URO-GENITAL TRACT
Pelvic organ prolapse (PLP) is a common condition among female population.
Life time risk of surgery for POP was estimated to be 19% in the Western Australia (Smith FJ et al., 2010) which is higher than 11-12% reported from US.
TYPES OF PELVIC ORGAN PROLAPSE
Cystocele Bladder prolapses or protrudes into the vagina
Enterocele Small bowel prolapses or protrudes into the vagina
Rectocele Rectum prolapses or protrudes into the vagina
Uterine Prolapse Uterus prolapses or protrudes into the vagina
Vaginal Vault Prolapse
Vaginal vault occurs when the upper portion of the vagina (the apex) descends into the vaginal canal
White 1910
History
So let’s POP-Q this (hymen = 0):
• Aa = -3• Ba = -3• C = -6• D = -10• Ap = -3• Bp= -3Simply put, this vagina receives a POPQ of:-3, -3,-3, -3, -6, -10 (Aa, Ba, Ap, Bp, C, D)One line – loads of information
Aa
Ba
Ap
Bp
DC
So, what is this?
• Here’s a hint• Here’s the answer:
+3, 0, -1, -3, -6, -9
• It’s a cystocele
• Reconstructive surgical options include24
– Vaginal colporrhaphy and apical suspensions using native tissue
– Sacrocolpopexy– Transvaginal mesh (TVM) repair
systems
SURGICAL TREATMENT OPTIONS
Elevate® is designed to:
Offer a minimally invasive solutionMinimize tissue traumaRestore normal anatomy with a faster recovery than open abdominal approachesMinimize pain compared to more invasive procedures
ELEVATE® PROLAPSE REPAIR SYSTEM
Typically, procedures to correct prolapse take place on an in-patient basis and are performed under general anesthesia.
In clinical studies, 91-96% of patients felt their prolapse symptoms were some or a lot improved following surgery with Elevate.28 ,29
ELEVATE PROLAPSE REPAIR SYSTEM
91-96%
WARNINGS AND PRECAUTIONS
Known risks of surgical procedures for the treatment of POP including the following:• Mesh extrusion (presence of suture or mesh
material within the vagina)• Mesh migration• Nerve damage• Obstruction of ureter• Pain/Discomfort/Irritation• Perforation (or tearing) of vessels, nerves, bladder,
ureter, colon, and other pelvic floor structures • Urinary tract infection• Vaginal contracture (tightening of the vagina)• Voiding dysfunction• Wound dehiscence (opening of the incision after
surgery)
On October 20, 2008, the FDA issued a PHN regarding serious complications associated with transvaginal placement (meaning placement through the vagina) of transvaginal surgical mesh to treat POP and SUI.
From Jan. 2008 to Dec. 2010 there were 2, 874 reports of complications associated with surgical mesh devices
FDA NOTIFICATION: TRANSVAGINAL MESH 2 3
1,503 POP 1,371 SUI
In July of 2011, the FDA issued an update to the PHN and provided physicians the following recommendations:Seek specialized training in transvaginal mesh
proceduresAdvise their patients about the potential for serious
complications associated with these procedures Be vigilant for potential complications from the
mesh
In 2012, the TGA(Therapeutic Guidelines Australia) released a statement³² which in summary stated: Since 2006, the TGA has received 63 adverse event
reports for all Uro-gynaecological surgical meshes. The Uro-gynaecological Society of Australia (UGSA)
reinforced their view that the issues were about the use of these meshes rather than the meshes themselves. In light of this, the Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) and UGSA are advising that surgeons should have special training on performing these procedures and patient selection.
TGA AND SOCIETY RESPONSES
The TGA urges any patients with mesh implants who are concerned to contact their surgeon.
UGSA has released a statement supporting the use of mid-urethral slings for SUI.
Urodynamic study
Quality of life assessment (POP-Q)
Sexual function assessment(PISQ-12)
HOMEWORK BEFORE THE OPERATION
Who needs urodynamic work-up ?
Why do they get this work-up ?
Can we obtain that information ?
less cost
less effort
less discomfort less site dependent
incontinence surgery severe prolapse
pre-operatively
detect occultincontinence
detect detrusor
or voidingproblems
aimsdiffer
detect occultincontinence
detect detrusor
or voidingproblems
theissue
is
standardised history
examination
questionnaire
24-hour-pad test
pelvic ultrasound
urinary flow-metry
bladder diary
Can these be detected in any other way ?
standardised history
examination
questionnaire
24-hour-pad test
pelvic ultrasound
urinary flow-metry
bladder diary
Can these be detected in another way?
Quality of life assessment (POP-Q)
“Stage of complete physical, mental and social well-being and not merely the absence of infirmity and disease.”
WHO DEFINITION OF HEALTH
QOL IS PERCEPTION OF:
Emotional and
sexual wellbeing
Physical Well-being
Material Well-being
Self Determination
Sexual responseexcitementplateau
Orgasmresolution
MALE AND FEMALE SEXUAL FUNCTIONBY MASTER AND JOHNSON
Sexual responseexcitementplateauOrgasmresolution
Three times per week don’t feel like it, do it anyway – Working , washing
A matter of health more than pleasure Heart protection - 30% less heart attack for men and women
IS SEX A MATTER OF HEALTH ??
Pessaries used for treatment since beginning of recorded history
1800BC Kahun Papyrus Ebers Papyrus (1500 B.C.) which portrayed the uterus as an independent animal, usually a tortoise, newt or crocodile, capable of movement within its host.
Hippocrates – halved pomegranite soaked in wine! Hippocrates perpetuated this animalistic concept stating that the uterus often went wild when deprived of male semen
1625- Stromayr’s Practica Coposium – sponge and twine
Latex products-1800’sSilicon now used
PELVIC ORGAN PROLAPSE (POP) & PESSARIES
Pt preferenceMedical comorbiditiesDelayed surgeryRecurrenceVaginal ulcerationPOP in pregnancyDesiring future fertility
INDICATIONS
Vaginal/pelvic infectionMesh exposureNoncompliance
CONTRAINDICATIONS
FOLLOW UP EVERY 3 MONTHS EROSION AND INFECTION
Vaginal repair +/_ hysterectomyNative tissue repair( midline, site
specific)Biological mesh repairSynthetic mesh repair ( Elevate Mesh kit)Laproscopic pelvic floor repairMesh scaro-hysteropexySuture hysteropexy+/_ vaginal repair
PROLAPSE REPAIR
Abdominal sacral colpopexy was associated with a lower
rate of recurrent vault prolapse and less dyspareunia
than the vaginal sacrospinous colpopexy
Use of mesh or graft inlays at the time of anterior
vaginal wall repair reduces risk of objective recurrence
Posterior repair better performed vaginally
No evidence to suggest that the addition of any graft
material at the posterior compartment repair results in
improved outcomes
Value of adding a continence procedure is uncertain
TAKE HOME MESSAGES
ATROPHIC VAGINA
The upper 2/3 of Vagina is Mullerian origin
The lower 1/3 is urogenital foldVaginal skin is estrogen and
progesterone dependentEstrogen thickens the skin and
progesterone thins the skinThe lower 1/3 is less estrogen sensitive
VAGINAL SKIN
Passage of blood flow during the periodsBirth canalSupports function and position of bladderSupports function and position of bowelConnects the abdominal cavity with
outside via cervixVaginal lubricationSexual activityReproduction
VAGINAL FUNCTION
No vaginal glandsParacervical glands and Bart gland provide discharge at the time of orgasm
Vaginal epithelium stratified squamous epithelium and responsible for lubrication
Balancing vaginal flora and pHAvoiding possible infection eg thrush
VAGINAL LUBRICATION
Decrease in Oestrogen after menopauseUp to 40% of postmenopausal women suffer
from Atrophic Vaginitis1
Decreased quality of life and direct impact on women’s sex life
- Vaginal dryness, painful sex, low libido, sluggish orgasm, urinary problems, vaginal infection
ATROPHIC VAGINITIS
Decrease in oestrogen levels Less Connective TissueLess capacity to retain waterIncreased risk of fissuring &ulceration3
Decrease in glycogen in vagina tissueChange in vaginal floraChange in vagina pHIncreased risk of UTI& thrush
ATROPHIC VAGINITIS
ATROPHIC VAGINITIS
Normal Pap Smear• Abundant
Cytoplasm• Low Nuclear
Cytoplasmic Ratio
Atrophic Vaginitis Pap Smear• Enlarged Nuclei• Inflammatory Exudate• Amorphous Basophillic
Structurs (Blue Bulbs)• Loss of Gylcogen in
the Squamous Cells
Oestrogen Replacement4
Systemic or LocalCan reverse or prevent symptoms
Moisturizers and LubricantsCan be independently or with oestrogen replacement therapy
Sexual Activity- 3 times per week
CURRENT BEST PRACTICE
Oestrogen Replacement10-25% of women do not respond5
Physical limitation in older womenSmall increase risk of endometrial caOestrogen therapy in ER+ Breast cancer!
Moisturizers and LubricantsShort term benefit
Sexual ActivityNo firm understanding of mechanism
CURRENT BEST PRACTICE DRAWBACKS
Platelet Rich Plasma Therapy - 27 gauge needle and vaginal gelV2 LR Laser Therapy - using a vaginal probe
NON-SURGICAL, NON-HORMONAL OPTIONS
High concentration of plateletsIncreased release of growth factors from platelets
Promotes regeneration of connective tissue
Suggested applications in Dentistry, Maxillofacial Surgery, Plastic Surgery, and Orthopaedic Surgery.
PLATELETS RICH PLASMA
LASER - Light Amplification by Stimulated Emission of RadiationAn intense beam of lightHighly directionalA single wavelength or colour
WHAT IS A LASER?
Pump some energy into it – electrically or with lightThe material naturally emits light (of a characteristic colour)
Feedback (between the mirrors) build the intensity
Light ‘leaks’ out a partially reflecting mirror
HOW DOES IT WORK?
Laser materialMirrorMirror
Energy in
excited
Light Laser beam
1. Greendale GA, Judd HL. The menopause: health impl icat ions and cl in ical management. J Am Ger iatr Soc . 1993;41:426–362. Pandit L , Ouslander JG. Postmenopausal vaginal atrophy and atrophic vaginit is . Am J Med Sci . 1997;314:228–31.3. R igg LA. Estrogen replacement therapy for atrophic vaginit is . Int J Fert i l . 1986;31:29–34.4. Handa VL, Bachus KE, Johnston WW, Robboy SJ , Hammond CB. Vaginal administrat ion of low-dose conjugated estrogens: systemic absorpt ion and eff ects on the endometr ium. Obstet Gynecol . 1994;84:215–8.5. Smith RN, Studd JW. Recent advances in hormone replacement therapy. Br J Hosp Med . 1993;49:799–808.6. Robert E Marx, DDS , a , Er ic R Car lson, DMD b , Ralph M Eichstaedt , DDS c , Steven R Schimmele, DDS d , James E Strauss, DMD e , Karen R Georgeff f (RN) P latelet -r ich plasma: Growth factor enhancement for bone grafts, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology Vol 85, Issue 6, June 1998, 638-6467. Eppley, Barry L. M.D. , D.M.D. ; Pietrzak, Wi l l iam S. Ph.D. ; B lanton, Matthew M.D. , P latelet -Rich Plasma: A Review of Bio logy and Appl icat ions in P last ic Surgery, P last ic and Reconstruct ive Surgery. Nov 2006 Vol 118 Issue 6 147-1598. T i m o t h y E . F o s t e r , M D † * , B r i a n L . P u s k a s , M D † , B e r t R . M a n d e l b a u m , M D ‡ , M i c h a e l B . G e r h a r d t , M D ‡ a n d
S c o t t A . R o d e o , M D Platelet-Rich Plasma9From Basic Science to Clinical Applications, The American Journal of Sports Medicine Nov 2009 Vol 37 no 11 2259-2272
REFERENCES