Download - Stress Urinary Incontinence & Cytoceles
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Christopher W. Wagener MDAffinity Medical Group
Obstetrics and Gynecology
Stress Urinary Incontinence & Cytoceles
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Overview• Stress Incontinence
– What is it?– What causes it?– How is it treated?
• Cystocele– What is it?– What causes it?– How is it treated?– What’s new and what should you be aware of?
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Incontinence
• International Continence Society (ICS)• (2002) The complaint of any involuntary leakage
of urine.• It increases with age, but is not normal and
treatment is available.
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Incontinence• Stress incontinence 50%• Overactive bladder syndrome 25%• Mixed incontinence 25%• Overflow incontinence• Fistulae• Urethral diverticulum• Functional• Reversible causes
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How the Urinary System Works
Ureter
Bladder
Bladderneck
Urinarysphincter
Urethra
Kidney
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Stress Incontinence
• Involuntary leakage of urine on effort or exertion, or on sneezing or coughing
• Usually small amounts• Pressure in the bladder
exceeds the urethral pressure
• No bladder contraction
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Stress Incontinence• Causes
– Pregnancy/Childbirth– Age– Obesity
• BMI 25-30, 2x increase• BMI >40, 66%
– Chronic cough• ACE inhibitors• Smoking
– Genetics
• Evaluation– History– Physical exam
• Cough stress test• Urethral mobility• Assess for prolapse
– Urine test– Possibly urodynamic
testing
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Stress IncontinenceTreatment
• Weight loss, treatment of chronic cough• Physiotherapy
– Pelvic floor muscle training– Vaginal cones– Biofeedback
• Pessary with incontinence knob• Midurethral sling• Periurethral bulking agents
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Tension-Free Vaginal Tape Sling• Indicated when conservative treatment fails• Child bearing is complete• Restores the urethral support• 85 to 90 % success rate• Minimally invasive• 6 weeks of restrictions, recommend 2 weeks off work• Risks
– Bleeding, infection, bladder or other organ injury– Mesh erosion, urinary retention, overactive bladder symptoms
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TVT Sling
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Bulking Agents• Minimally invasive• Consider for patients with non-mobile urethra, prior
unsuccessful incontinence procedures, significant health problems
• 40- 60 % success rate• No restrictions after surgery• May take more than one procedure• No long term studies to show it is long lasting• Risks: Urinary tract infection, retention, discomfort
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Bulking Agents
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Cystocele• Protrusion of the bladder into the vagina (hernia)• Also called a dropped bladder/prolapsed bladder• May be associated with uterine prolapse,
rectocele, or enterocele• May notice a vaginal bulge or pressure• Urinary symptoms including incomplete bladder
emptying
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Cystocele
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Cystocele• Causes
– Childbirth– Age– Genetics– Occupation– Medical conditions
• COPD, cough• Obesity• Constipation
• Evaluation– History
• Symptoms• Incontinence
– Pelvic exam• Stage prolapse• Strain or bear down• Check uterus and
ovaries• +/- Cough stress test
– +/- Urine test
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Natural History• Prospective observational study• 259 postmenopausal women, with a uterus• Over 3 years
– Maximal descent increased by >2 cm in 11.0%– Maximal descent decreased by >2 cm in 2.7%
• Obesity and grandmultiparity were risk factors for worsening prolapse
Bradley, Obstet. and Gyn. 2007; 109:848
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Cystocele Treatment: Pessary
• Appointment to fit • Trial • May not work for certain
patients• Side effects
– Discharge– Pressure sores– UTI
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Surgery
• Cystocele repair• Anterior repair• Anterior
colporrhaphy
• Without grafts– Suture repair
• With grafts– Biological grafts– Synthetic grafts
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Cystocele Treatment
Symptom likely to resolve
Questionable if symptom will resolve
• Bulge • Pressure
• Urinary • Gastrointestinal• Sexual function• Pelvic and back pain• Consider pessary trial
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Grafts• Lower rate of failure• Fewer hysterectomies with graft use
– Patient acceptance– Possible risk factor for incontinence– Minimize risks of intra-abdominal
complications• Complications
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Graft supporting bladder and uterus
21
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Risks of Synthetic Grafts• Erosion 3-8 %• Infection• Rejection of mesh• Dyspareunia (pain with sex) 10%• Injury to adjacent structures
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FDA Public Health Notification• October 2008• Over 1000 reports of complications in a
3-year period• Specific characteristics of the patients at risk
have not been determined• Complications of erosion through the vaginal
epithelium, infection, pain and urinary problems
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Recommendations for Physicians• Obtain specialized training for each mesh placement technique, and
be aware of its risks. • Be vigilant for potential adverse events from the mesh, especially
erosion and infection. • Watch for complications associated with the tools used in
transvaginal placement, especially bowel, bladder and blood vessel perforations.
• Inform patients that implantation of surgical mesh is permanent, and that some complications associated with the implanted mesh may require additional surgery that may or may not correct the complication.
• Inform patients about the potential for serious complications and their effect on quality of life, including pain during sexual intercourse, scarring, and narrowing of the vaginal wall (in POP repair).
• Provide patients with a written copy of the patient labeling from the surgical mesh manufacturer, if available.
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Grafts• Consider for patients with recurrences• Paravaginal defects• Severe prolapse or poor native tissue• Weigh risks and benefits
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The Future
• Robotically assisted prolapse surgery• Minimally invasive• Vaginal apex prolapse