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Dr. Wagener explains what stress urinary incontinence and cytoceles are. He also looks at causes and treatment options.
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Christopher W. Wagener MDAffinity Medical Group
Obstetrics and Gynecology
Stress Urinary Incontinence & Cytoceles
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?
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.
Incontinence• Stress incontinence 50%• Overactive bladder syndrome 25%• Mixed incontinence 25%• Overflow incontinence• Fistulae• Urethral diverticulum• Functional• Reversible causes
How the Urinary System Works
Ureter
Bladder
Bladderneck
Urinarysphincter
Urethra
Kidney
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
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
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
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
TVT Sling
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
Bulking Agents
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
Cystocele
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
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
Cystocele Treatment: Pessary
• Appointment to fit • Trial • May not work for certain
patients• Side effects
– Discharge– Pressure sores– UTI
Surgery
• Cystocele repair• Anterior repair• Anterior
colporrhaphy
• Without grafts– Suture repair
• With grafts– Biological grafts– Synthetic grafts
Cystocele Treatment
Symptom likely to resolve
Questionable if symptom will resolve
• Bulge • Pressure
• Urinary • Gastrointestinal• Sexual function• Pelvic and back pain• Consider pessary trial
Grafts• Lower rate of failure• Fewer hysterectomies with graft use
– Patient acceptance– Possible risk factor for incontinence– Minimize risks of intra-abdominal
complications• Complications
Graft supporting bladder and uterus
21
Risks of Synthetic Grafts• Erosion 3-8 %• Infection• Rejection of mesh• Dyspareunia (pain with sex) 10%• Injury to adjacent structures
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
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.
Grafts• Consider for patients with recurrences• Paravaginal defects• Severe prolapse or poor native tissue• Weigh risks and benefits
The Future
• Robotically assisted prolapse surgery• Minimally invasive• Vaginal apex prolapse