Overactive Bladder Symptoms (OAB) cured by surgery Cerrahi ile tedavi edilen aşırı aktif mesane...
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Overactive Bladder Symptoms (OAB) cured by surgery Cerrahi ile tedavi edilen aırı aktif mesane semptomlar A. Gunnemann 13. Ulusal Jinekoloji ve Obstetrik Kongresi Belek/Antalya 12.05.2015
Overactive Bladder Symptoms (OAB) cured by surgery Cerrahi ile tedavi edilen aşırı aktif mesane semptomlar A. Gunnemann 13. Ulusal Jinekoloji ve Obstetrik
Overactive Bladder Symptoms (OAB) cured by surgery Cerrahi ile
tedavi edilen asr aktif mesane semptomlar A. Gunnemann 13. Ulusal
Jinekoloji ve Obstetrik Kongresi Belek/Antalya 12.05.2015
Slide 2
OLD DEFINITION OAB symptoms: -associated with the unstable
bladder ( bladder contracting involuntarily during the filling
phase of a cystometrogram) -detrusor hyperreflexia (if neurological
disease was present) -detrusor instability (if the cause was
unknown or non-neurogenic).
Slide 3
CURRENT DEFINITION: The overactive bladder syndrome (OAB) is
defined as urinary urgency, usually with urinary frequency and
nocturia, with or without urgency urinary incontinence
International Continence Society (ICS) Standardisation of
Terminology of Lower Urinary Tract Symptoms and the joint ICS and
International Urogynecological Association (IUGA) report on the
Terminology for Female Pelvic Floor Dysfunction
Treatment of non neurogenic Urgency Incontinence (ICS):
antimuscarinic and anticholinergic drugs: darifenacin,
fesoterodine, oxybutynin, propiverine, solifenacin, tolterodine,
trospium and Beta3 agonists None of the drugs are an ideal
first-line treatment for all OAB/DO patients: treatment
individualisation patients comorbidities, concomitant medications
and pharmacologic profiles of different drugs. BUT large
metanalyses show clearly that the drugs provide a significant
benefit
Slide 6
Anticholinergic therapy: do the patients take the pills
prescribed Jundt et al. 2011 After 12 months at least (N = 132) 38
% (N = 51) take the drug furthermore N = 23 (17 %) continent, much
improved and satisfied N = 17 only few improved und unsatisfied N =
11 not improved 62 % (N = 81) withdraw the drug
Slide 7
For different reasons, stress and urge derive mainly from
laxity in the vagina or its supporting ligaments, a result of
altered collagen/elastin www.integraltheory.org P. Petros, U.
Ulmsten 1990
Slide 8
Connective tissue at the pelvic floor which can be loose and
surgically be repaired (Petros) Anterior Zone (Meatus urethrae to
bladder neck) pubourethral ligament hammock extraurethral ligament
Middle Zone (bladder neck to anterior cervix) Arcus tendineus
fasciae pelvis pubocervical fascia cervical ring Posterior Zone
(posterior cervix to anal canal) uterosacral ligament rectovaginal
fascia perineal body Tethered vagina: contracted vaginal scar at
bladder neck
Slide 9
The stretch receptors N Transient Receptor Potential channels
(TRPs) in the urothelium TRPs are sensitive to pressure. They
release chemicals such NO (nitrous oxide) and ATP which stimulate
afferent nerve fibres (NF), smooth muscle cells (SMC) and
interstitial cells (ICC). From Everaerts et al 2008
Trampolinanalogy
Slide 10
STRAINING The anterior vaginal wall acts like a trampoline
beneath the bladder
Slide 11
DYNAMIC ANATOMY OF STRESS URINARY CONTINENCE the key role of
the pubourethral ligament
Slide 12
Nocturia causation - patient lying supine in bed Empty
bladder-dark green enclosed by red broken lines G USL A weak
uterosacral ligament ( USL) cannot support the filling bladder
which is stretched downward by gravity G . Stretch receptors N Send
afferent impulses to cortex perceived as urgency which wakens the
patient (nocturia).
Slide 13
De Boer et al. 2010
Slide 14
Community-based studies NFrequency of OAB Symptoms in women
with POPwithout POPRR (POP/no POP) Tegerstedt et al. 20055.48922,5
% (454)2,9 % (5.035)5,8 Lawrence et al. 20084.10336,8 % (239)9,1 %
(3.799)4,0 Miedel et al. 2008 22852,0 % (223)25,0 % (44)2,1 Fritel
et al. 20092.64034,4 % (96)16,2 % (2.544) 2,1 Prevalence of OAB
Symptoms in Relation to Symptoms and Signs of POP In
Community-Based Studies (Boer et al. 2010)
Slide 15
Author:NFollow-upFrequency of OAB symptoms
monthspreoperativepostoperativeRR (pre/post) Stanton et al.
1991442427,3 %4,2 % 6,5 Jrgensen et al. 1987163787,5 %63 % 1,4
Chaikin et al. 2000104740 %20 % 2,0 Nguyen, Bhatia 200138100 %36,8
% 2,7 Weber et al. 2001 822353,3 %13,3 % 7,0 Sivaslioglu et al.
2005301653,3 %13,3 % 4,0 Farnsworth 20045918,441 %15,5 % 2,6
Farnsworth 20042419,4 62,5 %21,7 % 2,9 Milani et al. 2005321750 %40
% 1,3 Salvatore et al. 2005649375,3 %16,3 % 4,6 Brubaker et al.
2006165328,1 %11,9 % 2,4 Digesu et al. 2007931262,3%17,2 % 3,7
Natale et al. 200727944,4 %14,8 % 3,0 Basu et al. 2009492,5100
%46,7 % 2,1 Li Marzi et al. 20065117,737,2 %5,8 % 6,4 Miedel et al.
20081111227,9 %18 % 1,6 Natale et al. 20082726046,7 %22,1 % 2,1
Siviasloglu et al. 2009851224,7 %2,4 %10,3 Prevalence of OAB
Symptoms Before and After POP Surgery without Concomitant
Incontincene Surgery (de Boer et al. 2010)
Pessary treatment for pelvic organ prolapse and health-related
quality of life: a review Lamers BHC, Broekman BMW, Milani AL. Int
Urogynecol J 2011;22:637-644
Slide 26
Folie - 26 - Cystocele
Slide 27
Folie - 27 - simulated operation by inserting a tampon
(temporary pessary)
Slide 28
Summary Urge incontinence can be caused by pelvic organ
prolapse Surgery can cure female urge incontinence in up to 80 % by
careful anatomical pelvic floor reconstruction Special case:
Tethered vagina Syndrom
Slide 29
Slide 30
31,6 % 71,7 % 72,0 % 72,7 % PFDI Question 17: do you urinate
usually very often ? P < 0,01
Slide 31
PFDI question 19 Do you loose urine while have a strong feeling
of urgency? 42,7 % 74,1 % 75,7 % 75,6 % P < 0,01
Slide 32
PFDI question 27 Does urgency wake you up during the night?
31,0 % 58,3 % 57,4 % 55,8 % P < 0,01