3 Hannestad YS, Rortveit G, Sandvik H, et al. (2000) A community-based epidemiological surv ey of female urinary incontinence: The Norwegian EPINCONT Study. J Clin Epidemiol 53:1150 \200\2237. 4 Blaivas JG, Olsson CA (1988) Stress incontinence: classi \201 cation and surgical approa ch. J Urol 139:727 \200\22331 5 Hirasing RA, van Leerdam FJM, Bolk-Bennink L, et al. (1997) Enuresis nocturna in adults. Scan J Urol Nephrol 31:533 \200\2236. 6 Abrams P, Cardozo L, Khoury S, Wein A (2009) Epidemiology of Urinary and Fecal Incontinen ce and Pelvic Organ Prolapse. 4th International Consultation on Incontinence, pp 39 \200 \22341. London: Health Publications Ltd. 7 BT Haylen, D de Ridder, RM Freeman, et al. (2010) An International Urogynecological Assoc iation (IUGA)/International Continence Society (ICS) joint report on the terminology for fe male pelvic \202 oor dysfunction. Int Urogynecol J 21:5 \200\22326. CHAPTER 5 Incontinence and female urology 130 Incontinence: causes and pathophysiology General risk factors for UI Predisposing factors - - - - Gender (female > males). Race (Caucasian > Afro-Caribbean). Genetic predisposition. Neurolo gical disorders (spinal cord injury ( sclerosis, Parkinson \200\231s disease). Anatomical d isorders (vesicovaginal \201 stula, ectopic ureter in girls, urethral diverticulum, ureth ral \201 stula, bladder exstrophy, epispadias) Childbirth (vaginal delivery, increasing p arity) and pregnancy. Anomalies in collagen subtype. Pelvic, perineal, and prostate surgery (radical hysterectomy, prostatectomy, TURP), leading to pelvic muscle and nerve injury. Ra dical pelvic radiotherapy. Diabetes. SCI), stroke, multiple - Promoting factors - - - - - - - - - - Smoking (causing chronic cough and raised intra-abdominal pressure). Obesity. Infection ( I ncreased \202 uid intake. Medications (i.e. alpha blockers in women). Poor nutrition. Age ing. Cognitive de \201 cits. Poor mobility. Estrogen de \201 ciency. UTI). Pathophysiology Urodynamic studies can help determine the underlying etiology for UI. Bladder abnormalities Detrusor overactivity: a urodynamic observation characterized by invo l- untary bladder muscle (detrusor) contractions during the \201 lling phase of the bladd er, which may be spontaneous or provoked and can consequent- ly cause UI. The underlying ca use may be neuropathic where there is a relevant neurological condition or idiopathic where there is no de \201 ned cause. It leads to the symptoms of urgency incontinence and overa ctive bladder (OAB). The pathogenesis of detrusor overactivity is most likely to be multifac- torial. Theories include: - Myogenic hypothesis: increased excitability and activity betwee n muscle cells.1 Neurogenic hypothesis: muscle cells.2 partial detrusor denervation, leading to disruption of primary neural control in INCONTINENCE: CAUSES AND PATHOPHYSIOLOGY 131 detrusor muscle is arranged in modules Integrative hypothesis: which are thought to be controlled by a peripheral myovesical plexu s composed of intramural ganglia and interstitial cells. Detrusor overactivity results from abnormal or exaggerated peripheral autonomic activity (within this plexus).3 Low bladder compliance: characterized by a decreased volume-to-pres- sure relationship wher e there is a high increase in bladder pressure during \201 lling due to alterations in el astic properties of the bladder wall or changes in muscle tone (secondary to myelodysplasia , SCI, radical hysterectomy, interstitial or radiation cystitis). Urethral and sphincter abnormalities In females, there may be functional abnormalities of u rethral hypermobility and/or ISD. These are the main causes of SUI. Urethral hypermobility: due to a weakness of pelvic \202 oor support, caus- ing a rotatio nal descent of the bladder neck and proximal urethra during increases in intra-abdominal pr essure. If the urethra opens concomitantly, there will be urinary leaking. Intrinsic sphincter de \201 ciency: describes an intrinsic malfunction of the sphincter, r egardless of its anatomical position, which is responsible for type III SUI (described by M cGuire). Causes include inadequate urethral compression (previous urethral surgery, ageing, menopause, radical pelvic surgery, anterior spinal artery syndrome) or de \201 cient uret hral support (pelvic \202 oor weakness, childbirth, pelvic surgery, menopause). In males, the urethral sphincter may be damaged after prostatic or pelvic surgery (TURP, radical pro statectomy) or radiotherapy. Theories for the pathogenesis of SUI include: Integral theory: ligaments, causing bladder neck hypermobility.4 Hammock hypothesis: fascia and vaginal wal l.5 laxity of anterior vaginal wall and pubourethral failure of support of urethra by the endopelvic 1 Brading AF (1997) A myogenic basis for the overactive bladder. Urology 50:57 \200\22367 2 De Groat WC (1997) A neurological basis for the overactive bladder. Urology 50:36 \200 \22352. 3 Drake MJ, Mills IW, Gillespie JI (2001) Model of peripheral autonomous modules and a myo- vesical plexus in normal and overactive bladder function. Lancet 358:401 \200\2233. 4 Petros PE, Ulmsten UI (1990) An integral theory of female urinary incontinence. Experimen tal and clinical considerations. Acta Obstet Gynecol Scand Suppl. 153:7 \200\22331. 5 DeLancey JO (1994) Structural support of the urethra as it relates to stress urinary inco nti- nence: the hammock hypothesis. Am J Obstet Gynecol 170:1713 \200\22320. CHAPTER 5 Incontinence and female urology 132 Incontinence: evaluation History Aim: to establish the type of incontinence (stress, urgenc y or mixed). Enquire about LUTS (storage or voiding symptoms); triggers for inconti- nence (cough, sneezing, exercise, position, urgency); frequency, severity, and degree of bother o f symptoms. Establish risk factors (abdominal/pelvic surgery or radiotherapy, neurological disorders, obstetric and gynaecol- ogy history, medications). Enquire about bowel function and symptoms of sexual dysfunction and pelvic organ prolapse in women (see b p. 170) A vali dated patient-completed questionnaire is helpful to assess initial symp- toms and patient-r eported outcome following intervention (ICIQ-UI short form,1,5 ICIQ-FLUTS,2 ICIQ-MLUTS,3 SF 36 QoL4) (Fig. 5.1). \200\230Red \202 ag \200\231 symptoms which require further speci \201 c investigation are incontinence associated with pain, haematuria, recurrent UTI, signi \201 cant voiding or obstructive symptoms, and a previous history of pelvic surgery/ radiotherapy. Physical examination Women Perform a chaperoned pelvic examination in the supine, standing, and left lateral position with a Sim \200\231s speculum. Ask the patient to cough or strai n and inspect for anterior and posterior vaginal wall prolapse, uterine or vaginal vault de scent, and urinary leakage (stress test). Internal pelvic ex- amination can be performed to assess the strength of voluntary pelvic \202 oor muscle strength and for bladder neck mo bility. Inspect the vulva for estrogen de \201 ciency (causing vaginal atrophy), which may require topical estrogen treatment. Calculate of body mass index (BMI) as a tool to counse l patients as higher BMIs are associated with incontinence. Both sexes Examine the abdomen for a palpable bladder (indicating urinary reten- tion if th e patient has recently passed urine). A neurological examination should include assessment of gait, anal re \202 ex, perineal sensation, and lower limb function. DRE should be perfo rmed to exclude constipation, a rectal mass, and to test anal tone. \200\230Red \202 ag \200\231 signs requiring further investigation include (new) neurolo gi- cal de \201 cit, haematuria, urethral, bladder or pelvic masses, and suspected \201 stula. INCONTINENCE: EVALUATION 133 Many people leak urine some of the time. We are trying to find out how many people leak uri ne, and how much this bothers them. We would be grateful if you could answer the following ques- tions, thinking about how you have been, on average, over the PAST FOUR WEEKS. 1 Please write in your date of birth: DAY MONTH YEAR Female Male 2 Are you (tick one): 3 How often do you leak urine? (Tick one box) 0 1 never about once a week or less often 2 two or three times a week 3 4 5 week once a day several times a day all the time 4 We would like to know how much urine you think leaks. How much urine do you usually leak (whether you wear protection or not)? (Tick one box) 0 2 none a small amount 4 a moderate amount 6 a large amount 5 Overall, how much does leaking urine interfere with your everyday life? Please ring a num ber between 0 (not at all) and 10 (a great deal) 7 0 1 2 3 4 5 6 8 9 10 not at all a great deal ICIQ score: sum scores 3+4+5 6 When does urine leak? (Please tick all that apply to you) never \200\223 urine does not leak leaks before you can get to the toilet leaks when you cough or sneeze leaks when you are asleep leaks when you are physically active/exercising leaks when you have finished urinating and are dressed leaks for no obvious reason leaks all the time Thak you very much for answering these questions. Fig. 5.1 International Consultation on Incontinence Modular Questionnaire, ICIQ UI SF (shor t form). Reproduced with permission from: Abrams P, Cardozo L, Khoury S, Wein A. (eds) (200 9) 4th International Consultation on Incontinence. International Consultation on Incontinen ce Modular Questionnaire (ICIQ) UI SF (short form). London: Health Publications Ltd. Basic investigation Bladder diaries: record \202 uid intake, the frequency and volume of urine voided, incontinent episodes, pad usage, and degree of urgency over a 3-day period. U rinalysis 9 culture: treat any infection and reassess symptoms. CHAPTER 5 Incontinence and female urology 134 Flow rate and post-void residual (PVR) volume: patients need to void 150mL of urine for an accurate result. A reduced \202 ow rate suggests BOO or reduced bladder contractility. Th e volume of urine remaining in the bladder after voiding (PVR) is also informative (<50mL i s normal; >200mL is abnormal; 50 \200\223200mL requires clinical correlation). PVR is measu red with transabdominal USS. Pad testing: weighing of perineal pads to estimate urine loss after a speci \201 c time or provocation test. It is performed with a full bladder. A pad weight gain >1g is positive for a 1h test and a pad weight gain >4g is positive for a 24h t est. This is not standardized and not always reliable. Further investigation Blood tests, imaging (USS) and cystoscopy: indicated for complicated cas- es with persistent or severe symptoms, haematuria, bladder pain, voiding dif \201 cul ties, recurrent UTI, abnormal neurology, previous pelvic surgery or radiation therapy, or s uspected extraurethral incontinence. Urodynamics (see b p. 68) - Multichannel cystometry measures bladder and bladder outlet behavior during \201 lling an d voiding, including incontinence episodes. In SUI, it measures the minimal pressure at whi ch leakage occurs on straining (abdominal leak point pressure). Pressures >90 \200\223100cm H2O suggest hypermobility, <60cmH2O suggest ISD. Detrusor overactivity is manifest as detru sor contractions during \201 lling or an abnormal detrusor pressure rise with position ch ange (lying to standing). Poor bladder compliance is seen as a persistent gradual rise in d etrusor pressure during bladder \201 lling. Ambulatory urodynamics are thought to be a mo re physiological and accurate diagnostic test. Videourodynamics and bladder neck with \201 lling or provocation and identify risk factors for the development of upper tract dete rioration (i.e. DSD, vesicoureteric re \202 ux). can visualize movement of the proximal urethra Sphincter electromyography (EMG): measures electrical activity from stri- ated muscles of t he urethra or perineal \202 oor and provides information on synchronization between the b ladder muscle (detrusor) and external urethral sphincter. 1 men and women, to assess symptom score and quality of life (see Fig. 5.1). ICIQ-UI short form: International Consultation on Incontinence Questionnaire (short form) f or 2 of symptoms relating to incontinence and other urinary symptoms in females. ICIQ-FLUTS: ICIQ on Female Lower Urinary Tract Symptoms. Assesses occurrence and bother 3 ICIQ-MLUTS: ICIQ Male Lower Urinary Tract Symptoms. 4 SF36 QOL: Short Form 36 health survey questionnaire. Assesses health status in persons wi th incontinence. 5 Avery K, Donovan J, Peters TJ, et al. (2004) ICIQ: a brief and robust measure for evaluat ing the symptoms and impact of urinary incontinence. Neurourol Urodyn 23:322 \200\22330. This page intentionally left blank CHAPTER 5 Incontinence and female urology 136 Stress and mixed urinary incontinence Stress urinary incontinence (SUI) This accounts for u p to 50% of reported UI in women and causes the symptoms of involuntary urinary leakage on effort (e.g. lifting), exertion (e.g. running), sneezing, and coughing. It is associated wi th an intrinsic loss of urethral strength and/or urethral hypermobility. Speci \201 c risk factors for female SUI - - - - - Childbirth (increased risk with vaginal delivery, forceps delivery). Ageing. Estrogen withd rawal. Previous pelvic surgery. Obesity. Speci \201 c risk factors for male SUI External urethral sphincter damage (from pelvic fra cture, prostatectomy, pelvic surgery, or radiotherapy). Other risk factors Neurological disorders causing sphincter weakness (SCI, multiple sclero- sis, spina bi \201 da). Investigation of SUI (also see b p. 132) Women - Stress test: positive test. Pad test: Pelvic exam: an existing anterior wall prolapse will unmask any occult sphincter incompetence in those who are continent as a result of obstruct ion caused by the prolapse. Assess estrogen status and requirement for topical estrogen tre atments. Q-tip test: measure of urethral mobility in women. With the patient in lithotomy p osition and the bladder comfortably full, a well lubricated sterile cotton-tipped applicato r is gently inserted through the urethra into the bladder. Once in the bladder, the applica tor is withdrawn to the point of resistance which is at the level of the bladder neck. The resting angle from the horizontal is recorded. The patient is then asked to strain and the degree of rotation is assessed. Hypermobility is de \201 ned as a resting or straining ang le of greater than 30* from the horizontal. Urethral pressure pro \201 le are mounted in a catheter that is placed into the bladder, then slowly withdrawn, measuring intraluminal ur ethral pressures. A measure of urethral closure pressure can be obtained. Urodynamics: \200 There is suspicion of concomitant detrusor overactivity. \200 History of previous s urgery for SUI or anterior compartment a leakage of urine from the urethra on cough denotes a number and weight of pads used to estimate urine loss. check for pelvic organ prolapse (POP ). Elevation of although not performed routinely, the Q-tip angle is a (selected cases only): microtransducers recommended for women before SUI surgery if:1 prolapse. Symptoms of voiding dysfunction. STRESS AND MIXED URINARY INCONTINENCE 137 Men - - - - - Abdominal exam to detect a palpable bladder. External genitalia exam to assess for penile a bnormalities. DRE Flow rate and Consider imaging of upper tracts if evidence of . PVR. BOO. Conservative treatment - Pelvic \202 oor muscle training ( PFMT): for a minimum of 3 months is the \201 rst-line treatment, performing at least eight contractions, three times per day. PMFT improve sympt oms in 30% of women with mild SUI. Lifestyle modi \201 cation: modify \202 uid intake. B iofeedback: strength of pelvic \202 oor muscle contraction is presented back to the patie nt as a visual, auditory, or tactile signal. Patients may also be helped by the perineomete r which measures pelvic \202 oor contraction. Medication: and noradrenaline. It is given orally 20 \200\22340mg twice daily and acts to increase sphincteric muscle activity during bladder \201 lling. Recommended as an alternative to surgery rather than \201 rst-line treatment due to adverse effects.1 Extracorporal magnetic innervation: involves sitting the patient in a chair and using a pulsed magnetic \201 eld to stimulate the nerves of the s phincter and pelvic \202 oor. Possible bene \201 t in mixed incontinence. High frequency electrical stimulation: pelvic \202 oor (35 \200\22350Hz). No proven therapeutic bene \201 t in SUI. weight loss, stop smoking, avoid constipation, the technique by which information on ability and duloxetine inhibits the reuptake of both serotonin produces contraction of the Surgical treatment - - - - b p. 138). b p. 140). Urethral bulking agents (see Retropubic suspension (see b p. 142). Suburethral slings (see Arti \201 cial urinary sphincters (see b p. 146). Mixed urinary incontinence Approximately 30% of women will report symptoms of MUI, with inv olun- tary urinary leakage associated with urgency and also with exertion, effort, sneezing , or coughing. The underlying aetiologies and evaluation remain the same as for SUI and UUI , but also consider further investigation to rule out pathologies such as bladder cancer, s tones, and interstitial cystitis. The aim of management is to treat the predominant symptom s \201 rst. 1 National Institute for Health and Clinical Excellence (2006) Urinary Incontinence: the ma nage- ment of urinary incontinence in women [online]. Available from: M http://www.nice.org .uk/CG40. CHAPTER 5 Incontinence and female urology 138 Surgery for stress incontinence: injection therapy Indications The injection of bulking mat erials into bladder neck and periurethral mus- cles is a minimally invasive surgical techni que used to increase outlet re- sistance (Table 5.2). The main indication is for female str ess incontinence secondary to demonstrable ISD in the presence of normal bladder muscle fun ction. There is also evidence of bene \201 t in urethral hypermobility. Table 5.2 Periurethral bulking agents Product Material Macroplastique Silicone (polydimethyl siloxane elastomer) Bulkamid Polyacrylamide hydrogel Durasphere Carbon-coated zirconium beads Te \202 on Polytetra \202 uoroethylene paste (PTFE) Coaptite Calcium hydroxylapatite Permacol Porcine dermal implant Autologous fat Adipose tissue Of note, several products are either no longer available for clinical use or have been with drawn. These includes Contigen \200\224cross-linked GAX bovine collagen; Zuidex \200 \224 hyaluronic acid and dextranomer microspheres; Tegress \200\224ethylene vinyl alcohol copolymer in DMSO. Contraindications - Active infection ( - Untreated bladder overactivity. - Bladder neck ste nosis. UTI). Injection techniques - Under local anesthetic ( injected submucosally under endoscopic guidance. In women, a periu rethral (percutaneous) technique can be used with endoscopic or ultrasound guidance. A \200\230blind \200\231 mid-urethral technique using available to administer Macroplastique and Bulkamid . LA) block or general anesthesia, agents are LA and an instillation device is The aim is to achieve urethral muscosal apposition and closure of the lumen. In women, 2 \200\2234 injections are recommended (depending on agent) while in men, 3 \200\2234 circumf erential injections are administered. Overall suc- cess rates are variable, depending on bo th the agent and patient selection (reported in ranges of 50 \200\22380%).1 \200\2234 Resul ts tend to deteriorate with time and repeat treatments are often needed. SURGERY FOR STRESS INCONTINENCE: INJECTION THERAPY 139 Complications - - - - - Temporary urinary retention (2 \200\22315%). De novo urgency incontinence (6 \200\22312%). Uncomplicated Haematuria (5%). Distant migration of the injected particles ( and risk of gr anuloma formation (PTFE), although no adverse consequences are reported. UTI (5%). PTFE, Macroplastique ) Outcomes Overall success rates are variable, depending on both the agent and patient select ion, with reported ranges of 10 \200\22380%.1-5 Results tend to deteriorate with time (i.e. the success of Durasphere decreases from 80% at 1y to 12% at 3y).5 Patients should be co unseled on outcomes and the need for repeat treatments. As the results are not durable, per iurethral bulking agents are not commonly used as a \201 rst-line intervention. 1 Koelbl H, Saz V, Doer \202 er D, et al. (1998) Transurethral injection of silicone micro implants for intrinsic urethral sphincter de \201 ciency. Obstet Gynaecol 92:332 \200\2236 . 2 Appell RA (1994) Collagen injection therapy for urinary incontinence. Urol Clin N Am 21: 177 \200\22382. 3 Dmochowski R, Apell RA, Klimberg I, et al. Initial clinical results from coaptite injecti ons for stress urinary incontinence, comparative clinical study. Program of the Internation al Continence Society, 2002. Heidelberg, Germany, August 2002. 4 Lighter D, Calvosa C, Andersen R, et al. (2001) A new injectable bulking agent for treatm ent of stress urinary incontinence: results of a multicentre, randomized, controlled, doubl e-blind study of DurasphereTM. Urology 58:12 \200\2235. 5 PE Keegan, K Atiemo, J Cody, S McClinton, R Pickard (2007) Urethral injection therapy for urinary incontinence in women, Cochrane Database Syst Rev 3:CD003881. CHAPTER 5 Incontinence and female urology 140 Surgery for stress incontinence: retropubic suspension Retropubic suspension procedures are used to treat female stress in- continence predominantly caused by urethral hypermobility. The aim of surgery is to elevate and \201 x the bladder neck and proximal urethra in a r etropubic position in order to support the bladder neck and regain continence. There is a l ower chance of clinical bene \201 t in the presence of signi \201 cant ISD. Types of surgery Surgery is considered after conservative methods have failed. There are th ree main operations, all of which can be performed open via a Pfannenstiel or lower midline abdominal incision to approach the bladder neck and develop the retropubic space. Burch co lposuspension can also be performed laparoscopically. Better results are seen in patients w ith pure stress incontinence and primary repair (as opposed to \200\230re-do \200\231 sur- gery). Burch colposuspension This is the most widely used technique with the best durability. Pati ents that are selected require good vaginal mobility as the vaginal wall is ele- vated and attached to the lateral pelvic wall where the formation of adhe- sions over time will secur e its position. It is also considered an option for patients with concurrent SUI and anteri or vaginal wall prolapse. This oper- ation involves exposing the paravaginal fascia and app roximating it to the iliopectineal (Cooper \200\231s) ligament of the superior pubic rami. Initial success rates for open repair are about 85 \200\22390% at 1y and 70% at 5y.1 Succes s rates when used for recurrent incontinence are 83% at 1y.2 Overall success rates are slig htly higher for open repair over the laparoscopic approach.3,4 Open repair has a shorter op erating time and the laparoscopic approach is more costly, but has a shorter hospital stay. Complications of Burch colposuspension - - - Posterior compartment prolapse (10 \200\22325%). De novo urgency incontinence (15%). Voidin g dysfunction (10%). Vagino-obturator shelf/paravaginal repair A variant of the Burch procedure. Sutures are pla ced by the vaginal wall and paravaginal fascia and then passed through the obturator fascia to at- tach to part of the parietal pelvic fascia below the tendinous arch (arcus tendoneu s fascia). It aims to disperse tension on the paravesical tissues laterally to reduce the r isk of prolapse. Cure rates are up to 85%, although it is considered less effective than th e Burch colposuspension. SURGERY FOR STRESS INCONTINENCE: RETROPUBIC SUSPENSION 141 Marshall \200\223Marchetti \200\223Krantz (MMK) procedure Sutures are placed on ither side of the urethra around the level of the bladder neck and then tied to the hyaline cartilage of the pubic symphysis. Short-term success is about 90%,1 however, this declines over time and is now considered less effective than the Burch procedure. Complications include a 3% r isk of osteitis pubis which typically presents up to 8 weeks post-operatively with pubic pa in radiating to the thigh. Treatment is with simple analgesia, bed rest, and steroids. 1 Lapitan MCM, Cody JD, Grant A (2009) Open retropubic colposuspension for urinary inconti- nence in women. Cochrane Database Syst Rev 2:CD002912. 2 Jarvis CG (1994) Surgery for genuine stress incontinence. Br J Obstet Gynaecol 101:371 \200 \2234. 3 Moehrer B, Carey M, Wilson D (2003) Laparoscopic colposuspenion: a systematic review. BJO G 110:230 \200\2235. 4 Ankardal M, Ekerydh A, Crafoord K, et al. (2004) A randomized trial comparing open Burch col- posuspension using sutures with laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence. BJOG 111:974 \200\22381. CHAPTER 5 Incontinence and female urology 142 Surgery for stress incontinence: suburethral tapes and slings Types of sling* (Figs. 5.2, 5 .3) - Synthetic tapes: polypropylene mesh. Examples include: \200 Retropubic tape, i.e. tension -free vaginal tape (TVT); Lynx . \200 Transobturator tape (TOT), i.e Monarc Subfascial H ammock; TVT type I (>75 m pores), soft, mono \201 lamentous obturator system (TVTO); Obtryx . Autologous: Non-autologous: rectus fascia, fascia lata (from the thigh), vaginal wall slings. allograft fascia lata fro m donated cadaveric tissue. Synthetic tapes Widely practiced \201 rst-line surgical treatment for female SUI. Tapes c an be inserted under general or local anesthetic as day cases. They are less in- vasive tha n colposuspension with fewer complications. They are placed via a retropubic route (TVT) or a transobturator route (TOT, TVTO). The bladder should be empty and catheterized. All tech niques use cystoscopy to detect bladder perforation during sling placement. Post-operativel y, pa- tients may temporarily require CISC until post-void residuals are less than 100 \200 \223150mL. Retropubic tapes A small midline anterior vaginal incision is made over the mid-urethra. Th e TVT tape has long trocars on each end. These are inserted either side of the urethra and perforate through the endopelvic fascia. They are then pushed up behind the symphysis pubis and out onto the lower abdominal wall in the midline, just above the pubic bone (i.e. troc ar passes from bot- tom upwards). Once the tape is positioned loosely (tension-free) over t he mid-urethra, its covering is removed and the ends cut \202 ush to the abdomen. Vaginal epithelium is closed over the top. Outcomes - TVT - TVT Ward and Hilton studies have not detected a statistically signi \201 cant difference between TVT and colposuspension for the cure of SUI at 6 months, 2 or 5y fo llow-up.2,3 At 2y, 63% of patients were dry with TVT vs 51% with colposuspension.2 At 5y, t hey still have equivalent cure rates, but the TVT group have lower OAB symptoms and prolaps e (1.8% vs 7.5% with colposuspension).3 : success rates at 1y are up to 90% and at 5y are up to 80%.1 vs colposuspension: although there is a trend in favor of TVT, Transobturator tapes A midline anterior vaginal incision is made for dissection around the ure- thra. Two small incisions are made lateral to the labia majora at the level of the cli toris. In the Monarc Subfascial Hammock (AMS), the curved han- dle device is placed through the skin incision and turned downwards, pass- ing through the anterior part of the obturat or foramen and exiting along- side the urethra on each side (i.e. trocar passes from outsid e to inside). The tape is attached to the end of each handle and brought back out to SUBURETHRAL TAPES AND SLINGS 143 the skin surface. It is positioned loosely around the mid-urethra and the ends cut \202 u sh with the skin. In TVTO, the tape is passed in a reverse route (i.e. trocar passes from i nside to outside). Outcomes - TOT vs TVT: TOT has equivalent subjective cure rates to TVT at 1y, but objective cure rates are slightly lower (84% vs 88%).4 TOT has less voiding dysfunction, blood loss, bladder perforation, and a shorter operating time as compared to TVT.4 Bladder perforation and voiding dif \201 culties are lower in TOT compared to TVT.4,5 Vaginal injuries/ erosi on and pain in the groin/thigh is higher with TOT.5 De novo urgency and frequency symptoms were the same in both groups.5 TVTO rate to TVT in randomized control trials (81% vs 86%, r espectively), but signi \201 cantly increased risk of leg pain.6 vs TVT: TVTO has reported statistically similar objective cure Mini tapes (Fig. 5.4) Examples of self-retaining mini tapes inserted via a single vaginal i ncision are the MiniArc (AMS) and GYNECARE TVT SECURTM. The short-term success rates are around 80 \200\22390%,7,8 although results may not be sustained over time.8 General complications of tapes - - - - Voiding dysfunction (urinary retention, Vaginal, urethra, and bladder perforation or erosio ns. Pain (groin/thigh with transobturator route). Damage to bowel or blood vessels (rare). de novo bladder overactivity). Pubovaginal (autologous) slings Most commonly, a segment of rectus fascia measuring 10 \200 \22320cm in length is harvested via a Pfannenstiel approach and non-absorbable long sutures placed on both ends. The sling is placed under the mid-urethral and the sutures placed thr ough the endopelvic fascia up to the remaining rectus fascia where the su- ture ends are ti ed using the minimal amount of tension needed to prevent urethral movement. Autologous slin gs have been shown to have a better out- come as compared to colposuspension, but at the ex pense of higher complica- tions (UTI, voiding dysfunction, and urge incontinence).9 Autolog ous retropu- bic slings are not commonly used as \201 rst-line surgical procedures for SU I. Male tapes There are many new male continence slings and devices available, but fol- low-up data are limited. Examples include: - TM Male Sling System (AMS): indications include mild to AdVance moderate SUI (<3 \200\2234 pads per day) with some residual sphincter function. A small incision is made in the perine um and two further incisions in each groin. The sling is passed through the obturator foram ina and positioned over the bulbar urethra to support and slightly elevate the urethra. Suc cess rates at 1y are 60 \200\22380%. InVance bone by three titanium screws on both sides to compress the bulbar urethra. Success rates at 3 \200\2234y are 70 \200\22380%. TM Male Sling System (AMS): mesh is attached to the pubic CHAPTER 5 Incontinence and female urology 144 (a) (b) Fig. 5.2 (a) GYNECARE TVTTM retropubic system tension-free support for incontinence. (b) GY NECARE TVTTM obturator system. Reproduced with permission, courtesy of ETHICON, Inc. (a) (b) Fig. 5.3 (a)Trocar handles for the Monarc Subfascial Hammock (TOT). (b) AdVanceTM Male Sl ing System. (Reproduced with permission, courtesy of American Medical Systems.) SUBURETHRAL TAPES AND SLINGS 145 Fig. 5.4 GYNECARE TVT SECURTM system. Reproduced with permission, courtesy of ETHICON, Inc. * Of note, many other products are available. Full product names: Retropubic tapes: Lynx Suprapubic Mid-urethral Sling System (Boston Scienti \201 c); GYNECARE TVTTM Retropubic S ystem Tension-free Support for Incontinence (Ethicon) Transobturator tapes: Monarc Subfas cial Hammock (AMS); ObtryxTM Transobturator Mid-Urethral Sling (Boston Scienti \201 c); GY NECARE TVTTM Obturator System (Ethicon) Mini-tapes: **GYNECARE TVT SECURTM System (Ethicon) ; MiniArc Single Incision Sling System (AMS) 1 Chene G, Amblard J, Tardieu AS, et al. (2007) Long-term results of tension-free vaginal t ape (TVT) for the treatment of female urinary stress incontinence. Eur J Obstet Gynaecol Re prod Biol 134:87 \200\22394. 2 Ward K, Hilton P (2006) Multicentre randomized trial of tension-free vaginal tape and col posuspen- sion for primary urodynamic stress incontinence: \201 ve year follow up. Neurou rol Urodyn 25:568 \200\2239. 3 Ward KL, Hilton P (2008) Tension-free vaginal tape versus colposuspension for primary uro dy- namic stress incontinence: 5-year follow up. BJOG 115:226 \200\22333. 4 Latthe PM, Foon R, Toozs-Hobson P (2007) Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of effectiveness and co mplications. BJOG 114:522 \200\22331. 5 Ogah J, Cody JD, Rogerson L (2009) Minimally invasive synthetic suburethral sling operati ons for stress urinary incontinence in women. Cochrane Database Syst Rev 4:CD006375. 6 Teo R, Moran P, Mayne C, Tincello D (2011) Randomized trial of tension-free vaginal tape and tension-free vaginal tape-obturator for urodynamic stress urinary incontinence in women . J Urol 185:135 \200\2235. 7 Oliveira R, Botelho F, Silva P, et al. (2001) Single-incision sling system as primary tre atment of stress urinary incontinence: prospective 12 months data from a single institution . BJU Int 108:1616 \200\22321. 8 Cornu JN, S be P, Peyrat L, et al. (2010) Midterm prospective evaluation of TVT-Secur re veals high failure rate. Eur Urol 58:157 \200\22361. 9 Albo ME, Richter HE, Brubaker L, et al. (2007) Burch colposuspension versus fascial sling to reduce stress urinary incontinence. N Engl J Med 356:2143 \200\22355. Of note, as of June 2012, GYNECARE TVT SECURTM System has been withdrawn. CHAPTER 5 Incontinence and female urology 146 Surgery for stress incontinence: arti \201 cial urinary sphincter The arti \201 cial urin ary sphincter (AUS) (AMS800TM; Fig. 5.5) is a closed pres- surized system with three compon ents. The in \202 atable cuff is commonly placed around the bulbar urethra or alternativel y, the bladder neck (in both women and men). A pressure-regulating balloon is placed extrap - eritoneally in the abdomen. An activating pump is placed in the scrotum or labia majora. The cuff provides a constant circumferential pressure to compress the urethra. To void, the pump is squeezed, which transfers \202 uid to the reservoir balloon, thereby de \202 at ing the cuff. The cuff then au- tomatically re \201 lls within 3min. Voiding takes place i n the interval taken for the cuff to re \201 ll. The reservoir balloon pressure can be 61 \200\22370mmHg for bulbar urethral placement or 71 \200\22380mmHg for bladder neck placemen t. Indications and patient selection Used for moderate to severe SUI, secondary to urethral sp hincter de \201 - ciency in patients with normal bladder capacity and compliance. In men, it is used for sphincter damage due to radical prostatectomy, TURP, pelvic radiotherapy, pe lvic fracture, and following complicated urethral recon- struction. In women, it is used af ter other treatments for incontinence have failed. It can be used for neuropathic sphincter weakness (e.g. SCI, spina bi \201 da). If there is combined bladder overactivity and sphi ncter weak- ness, treat the bladder \201 rst (i.e. lower bladder pressures with anticho- linergics, intravesical botulinum injections, augmentation), which, in some cases, will be enough to achieve continence. If incontinence persists, pro- ceed with AUS at a later date. Contraindications to AUS: bladder neck stenosis, poor patient man- ual dexterity or cogniti on, active infection. Patient evaluation Patients should undergo urodynamics, cystoscopy, and upper tract imag- i ng to evaluate voiding function and identify anatomical abnormalities that might affect the ef \201 cacy of the AUS. Good manual dexterity is required to manipulate the pump and suf \201 cient cognitive function to operate the AUS themselves several times daily. Results AUS can function well for many years ((cid:2)10y). Overall long-term success (conti nued continence, no device malfunction) is 70 \200\22390%; revision rates are 20 \200\22330 %.1 Complications Recurrent incontinence due to: - \200\230Urethral atrophy \200\231 underneath the cuff (10% in the \201 rst 5y). Thought not to be true atrophy, but due to the formation of a constricting sheath of tissue over th e urethra. Mechanical failure (of the pump or slow leak of \202 uid from the system). Ure thral erosion (essentially a pressure sore in the urethra due to chronic pressure from the cuff). ARTIFICIAL URINARY SPHINCTER 147 Bladder overactivity or reduced compliance. Investigate recurrent incontinence by cystoscop y (to exclude erosion), X-ray to determine leaks from the system (the balloon loses its rou nd shape), and urodynamics (to detect high bladder pressures). Erosion: occurs in 5%, most commonly at 3 \200\2234 months, with 75% occurring in the \201 rst year. Presents with pain and swelling of scrotum, labia or perineum, incontinence, and bloody discharge. Increased risk after pelvic radiotherapy. Infection: primary implant infection rates are 1 \200\2235%. With infection or ero- sion, r emove the entire device and wait 3 \200\2236 months before reinsertion. Other: haematoma (scrotum or labia); late urinary retention which may signify obstruction f rom urethral stricture or bladder neck contracture (higher risk with previous pelvic irradi ation). Always ensure that the AUS is deactivated (i.e. the cuff is de \202 ated) prior to urethral instrumentation or catheterization. Fig. 5.5 AMS 800TM Urinary Control System Arti \201 cial Urinary Sphincter. (Reproduced wi th permission. Courtesy of American Medical Systems Inc., Minnesota.) 1 Lai HH, Hsu EI, Teh BS, et al. (2007) 13y of experience with arti \201 cial urinary sphi ncter implanta- tion at Baylor College of Medicine. J Urol 177:1021 \200\2235. CHAPTER 5 Incontinence and female urology 148 Overactive bladder: conservative and medical treatment De \201 nition Overactive bladder ( OAB) is a symptom syndrome that includes urgency, with or without urge incontinence, usuall y with frequency and nocturia. The symptoms are usually caused by bladder (detrusor) overac tivity, but can be due to other forms of voiding dysfunction (Fig. 5.6). Seventeen per- cen t of the population aged >40y in Europe have symptoms of OAB.1 The prevalence increases wit h age. Conventional treatment Conservative Patient management involves a multidisciplinary team ap proach (urolo- gists, urogynaecologists, continence nurse specialists, physiotherapists, an d community-based health care workers). Pelvic \202 oor muscle train- ing (PFMT), biofeed back, acupuncture, and electrical stimulation thera- py (which strengthens the pelvic \202 oor and sphincter by increasing tone through sacral neural feedback systems) may provi de some bene \201 t. Behavioral modi \201 cation This involves modifying \202 uid intake, avoiding stimulants (caffeine, alcohol), and bladder training (delayed micturition for increasing periods of t ime by inhibiting the desire to void). If this fails, consider medication.