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 Of note, as of June 2012, GYNECARE TVT SECURTM System has been withdrawn.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. Anticholinergic medication Acetylcholine acts on muscarinic receptors (M3 9 M2 subtypes) on the bladder smooth muscle (detrusor) to cause involuntary contractions and provoke the sym ptoms of bladder overactivity. These receptors are the targets of anticholinergic (antimusc arinic) drugs which inhibit contractions and increase bladder capacity. Approximately 50% o f patients will bene \201 t from medication. - Oxybutynin: muscle relaxation). It is avail able as immediate or extended release (ER) tablets, transdermal patch, gel preparations, an d can be given intravesically. It is very effective, but has a high rate of side effects, r educing patient compliance. Solifenacin: STAR trial2 compared solifenacin to tolterodine ER and found higher improvements in urgency, urge incontinence, and overall incontinence with solifenacin (59% became continent vs 49%). The number of patients discontinuing treatment due to side effects was similar (3 \200\2233.5%). Tolterodine: 5-hydroxymethyl tolterodine (5-HMT). Extended release formulation has demonstrated good ef \201 cacy and tolerability. 3 Fesoterodine: metabolite. Superior to tolerodine in reducing UUI, improving bladder mixed action (antimuscarinic, local anesthetic, and direct selective antimuscarinic antagonist (M3 > M2). The bladder selective antimuscarinic, metabolized to non-selective antimuscarinic with 5-HMT active OVERACTIVE BLADDER: CONSERVATIVE AND MEDICAL TREATMENT 149 capacity and continence (64% dry vs 57% with tolterodine) with the added bene \201 t of a \202 exible dosing regimen.4 Darifenacin: highly selective M3 antagonist. Achieves signi \201 cant reduction in urinary frequency, urgency, incontinence episodes (77% with 15mg do se).5 It is well tolerated (2.1% discontinued 15mg treatment due to side effects). Trospium : non-selective for muscarinic receptors. Minimal passage across the blood brain barrier wi th the theoretical bene \201 t of fewer cognitive effects. Extended release formula has go od long-term results.6 Propiverine: non-selective for muscarinic receptors. Contraindications to anticholinergics Uncontrolled narrow angle glaucoma, myasthenia gravis , BOO, bowel disorders (i.e. active ulcerative colitis, bowel obstruction). Common side effects of anticholinergics Dry mouth, constipation, blurred vision, urinary re tention, cognitive impairment, skin rash with transdermal patches. Other drugs used for OAB - Topical estrogen: frequency, and nocturia in post-menopausal women.7 Relative contraindicat ion is a history of breast cancer. can provide improvement urgency, UUI, 1 Milsom I, Abrams P, Cardozo L, et al. (2001) How widespread are the symptoms of an overac tive bladder and how are they managed? A population-based prevalence study. BJU Int 87:760 \200\2236. 2 Chapple CR, Martinez-Garcia R, Selvaggi L, et al. (2005) A comparison of the ef \201 cac y and tolerability of solifenacin succinate and extended release tolterodine at treating ov eractive bladder syndrome: results of the STAR trial. Eur Urol 48:464 \200\22370. 3 Swift S, Garely A, Dimp \202 T, et al. (2003) Tolterodine Study Group. A new once daily formula- tion of tolterodine provides superior ef \201 cacy and is well tolerated in women with overactive bladder. Int Urogynecol J Pelvic Floor Dysfunct 14:50 \200\2234. 4 Herschorn S, Swift S, Guan Z, et al. (2009) Comparison of fesoterodine and tolterodine ex tended release for the treatment of overactive bladder: a head to head placebo-controlled t rial. BJU Int 105:58 \200\22366. 5 Chapple C, Steers W, Norton P, et al. (2005) A pooled analysis of three phase III studies to investigate the ef \201 cacy, tolerability and safety of darifenacin, a muscarinic M3 selective receptor antagonist, in the treatment of overactive bladder. BJU Int 95:993 \200 \2231001. 6 Zinner NR, Dmochowski RR, Staskin DR, et al. (2011) Once-daily trospium chloride 60 mg ex tended-release provides effective, long-term relief of overactive bladder syndrome symptoms . Neurourol Urodyn 30:1214 \200\2239. 7 Cardozo L, Lose G, McClish D, et al. (2004) A systematic review of the effects of oestrog ens for symptoms suggestive of overactive bladder. Acta Obstet Gynecol Scand 83:892 \200 \2237. CHAPTER 5 Incontinence and female urology 150 Overactive bladder: options for failed conventional therapy Neuromodulation (see also b p. 624) Sacral nerve stimulation involves electrical stimulation of the bladder \200\231s nerv e supply to suppress re \202 exes responsible for involuntary bladder muscle (detrusor) co ntraction.* - The Interstim device (Medtronic) stimulates the S3 afferent nerve, which then inhibits detr usor activity at the level of the sacral spinal cord. An initial percutaneous nerve evaluat ion is performed, followed by surgical implantation of permanent electrode leads into the s acral foramen, with a pulse generator which is programmed externally. TM (Stoller Afferent Nerve Stimulator) is a minimally invasive SANS technique, which is applied near the posteri or tibial nerve above the medial malleolus on the ankle. Surgery The aim is to increase functional bladder capacity, decrease maximal detrusor press ure, and protect the upper urinary tract (also see b pp. 602 \200\2237). Augmentation enter ocystoplasty ( \200\230Clam \200\231 ileocystoplasty): relieves intrac- table frequency, ur ge, and UUI in 90% of patients. The bladder dome is cut open (bivalved) and a detubularized segment of ileum is anastomosed, creating a larger bladder volume. Autoaugmentation (detru sor myectomy): detrusor muscle is excised from the entire dome of bladder, leaving the unde rlying bladder endothelium intact. A large epithelial bulge is created which augments bladd er capacity. Less commonly performed now as limited long-term ef \201 cacy. Most bene \201 t in patients with idiopathic detrusor overactivity. Urinary diversion: a non-continen t urinary outlet, reserved for intractable cases only. Typically, both ureters are anastomo sed and connected to a short ileal pouch which is brought out cutaneously as a stoma. Intravesical pharmacotherapy Botulinum toxin-A (BTX-A): injected at multiple sites as a ble b under the bladder mucosa or into detrusor, sparing the trigone (see b pp. 152 \200\2233; 604 \200\2237; 590 \200\2231). This treatment is off license. Sacral nerve stimulation has National Institute of Excellence (NICE) approval for women wit h detrusor overactivity who have failed conservative treatments. This page intentionally left blank CHAPTER 5 Incontinence and female urology 152 Overactive bladder: intravesical botulinum toxin-A therapy Botulinum toxin-A (BTX-A) Botuli num toxin (BTX) is a neurotoxin produced by a Gram-positive, rod- shaped, anaerobic bacteri um, Clostridium botulinum. There are seven sub- types. Subtypes A and B are used in urology ; however, BTX-A is the more potent with longer duration of action. Main applications for treatment in the urinary tract - - - NDO).1 Neurogenic detrusor overactivity ( Idiopathic detrusor overactivity ( Detrusor sphincter dy ssynergia ( IDO).2,3 DSD).4 Children with NDO associated with myelomeningocele5 and with IDO6 have been safely and succ essfully treated with BTX-A. There is also emerging, but limited, evidence for a role in sy mptomatic benign prostatic enlargement and chronic pelvic pain syndromes (BPS/IC). Mechanism of action BTX-A acts by inhibiting the release of acetylcholine (ACh) and other n eurotransmitters from presynaptic cholinergic nerve terminals, resulting in regionally decr eased muscle contractility and muscle atrophy at the site of BTX-A injection. The chemical dennervation that results is a reversible process. Adult dosing regimen for detrusor overactivity - - - BTX-A (Botox , Allergan), 100 \200\223300 units. American English Botox BTX-A (Dysport , Ipsen), up to 1000 units 300 is roughly equivalent to 900 units of Dysport . Method of intravesical administration - Techniques include rigid cystoscopy under general anesthetic ( GA) using a \202 exible ne edle or LA \202 exible cystoscopy using a shealth and ultra- \201 ne 4mm needle. BTX-A s aline). Twenty random sites on the bladder wall are injected (i.e. Botox ) per injection s ite). BTX-A General practice is usually to avoid injecting the trigone (trigone sparing)*. is diluted in normal saline (i.e. 100IU Botox diluted in 20mL 71mL (5IU can be injected directly into detrusor muscle or submucosally. Outcome - - A response is seen within 7 days (maximal response may take 30 days). Effects last approxim ately 6 \200\2239 months and repeat injections are required. Tolerance to the drug appears unchanged with repeated applications. INTRAVESICAL BOTULINUM TOXIN-A THERAPY 153 Contraindications to treatment - - Myasthenia gravis. Aminoglycosides/drugs interfering with neuromuscular transmission, which may enhance effects of BTX-A. Eaton \200\223Lambert syndrome.** Breastfeeding and pregnanc y. Bleeding disorders (hemophilia, hereditary clotting factor de \201 ciency). - Side effects - NDO compared to IDO (770% vs Urinary retention. Higher risk in 720%).7 Risk higher (in IDO) with higher dose of BTX-A.3 Haematuria. UTI Bladder pain. General muscle weakness (Dysport Dysphagia. Diplopia, blurred vision. - - - - . ). A trigone sparing technique has been used to prevent the theoretical risk of iatrogenic ves i- coureteric re \202 ux, although there is no evidence to support this. Eaton \200\223Lambert syndrome: small cell bronchial carcinoma associated with defective ACh release at the neuromuscular junction causing proximal muscle weakness. 1 Schurch B, De Seze M, Denys P, et al. (2005) Botulinum toxin type is a safe and effective treat- ment for neurogenic incontinence: results of a single treatment, randomized, placeb o controlled 6-month study. J Urol 174:196 \200\223200. 2 Schmid DM, Suermann P, Werner M, et al. (2006) Experience with 100 cases treated with bot ulinum-A toxin injections in the detrusor for idiopathic overactive bladder syndrome refrac tory to anticholinergics. J Urol 176:177 \200\22385. 3 Dmochowski R, Chapple C, Nitti VW, e t al. (2010) Ef \201 cacy and safety of onabotulinumtoxinA for idiopathic detrusor overact ivity: a double blind, placebo controlled, randomized, dose ranging trial. J Urol 184:2416 \200\22322. 4 Dykstra DD, Sidi AA, Scott AB, et al. (1998) Effects of botulinum A toxin on detrusor-sph incter dyssynergia in spinal cord injury patients. J Urol 139:919 \200\22322. 5 Riccabona M, Koen M, Schinder M, et al. (2004) Botulinum-A toxin injection into the detru sor: a safe alternative in the treatment of children with myelomeningocele with detrusor hy perre \202 exia. J Urol 171:845 \200\2238. 6 Verleyen P, Hoebeke P, Raes A, et al. (2004) The use of botulinum toxin A in children wit h a non-neurogenic overactive bladder: a pilot study. BJU Int 93:69. 7 Popat R, Apostolidis A, Kalsi V, et al. (2005) A comparison between the response of patie nts with idiopathic detrusor overactivity and neurogenic detrusor overactivity to the \201 rst intradetrusor injection of botulinum toxin-A. J Urol 174:984 \200\2239. CHAPTER 5 Incontinence and female urology 154 Post-prostatectomy incontinence Incidence UI occurs in <1% after TURP and 0.5% after open p rostatectomy (OP) performed for benign prostate disease.1 Following radical prostatectomy ( RP) for malignant disease, UI tends to improve over 12 \200\22318 months post- surgery.2 Th e overall incidence in open RP is 710 \200\22315%,2,3 with similar risks reported for lapar oscopic RP.4 Early results from robotic-assisted laparo- scopic RP suggest slightly earlier recovery of continence and improved overall continence rates.5 Risk factors for UI after RP - - - Increasing age. Pre-existing bladder dysfunction. Previous radiotherapy ( of UI). Prior Adv anced stage of disease and surgical technique. TURP following brachytherapy has a 40% risk TURP. Earlier recovery of continence after open RP is achieved using a perineal approach, nerve s paring techniques, and sphincter and bladder neck pre- serving procedures. Pathophysiology The main cause of post-radical prostatectomy incontinence is sphincter dysf unction. The proximal sphincter mechanism is removed at prosta- tectomy (TURP, OP, RP). Pos t-prostatectomy continence, therefore, requires a functioning distal (external) urethral sp hincter mechanism and low bladder pressure during bladder \201 lling. Direct damage to th e external sphincter can occur during prostatectomy (at TURP, it occurs particularly during resection between 11 and 2 o \200\231clock positions when the reference point for the posi tion of the distal sphincter, the verumontanum, cannot be seen). Damage to the innervation of the sphincter can also occur dur- ing prostatectomy. Urodynamic studies before and after RP show that maximal urethral closure pressure (MUCP) and functional urethral length (the length of urethra over which the sphincter functions to maintain high pressures) are lower. Nerve-sparing RP (where the neurovascular bundles are speci \201 cally identi \201 ed an d preserved) produces better continence rates and longer functional urethral lengths and MU CPs. A substantial proportion of men also have OAB before prostatectomy and this may remain so after surgery, contributing to UI. Evaluation Wait for up to 12 months for spontaneous improvement. Act sooner if symptoms are severe. - History: position) suggests sphincter dysfunction. Examination: Tests: PVR measurement on U SS (to exclude retention with over \202 ow); (video)urodynamic studies allow the determina tion of stress-induced leakage (cough, standing from a sitting observe for leakage on coughing. POST-PROSTATECTOMY INCONTINENCE 155 bladder and sphincter function; cystoscopy allows the identi \201 cation of strictures (pa rticularly important if arti \201 cial urinary sphincter implantation is contemplated). Treatment PFMT does not appear to convey bene \201 t. In the Men After Prostate Surgery (M APS) study, four sessions of PFMT administered by a trained physiotherapist or continence n urse over a 3-month period had no impact on continence* or QALY 12 months post-prostatectom y when compared with no intervention. In the radical prostatectomy group, 76% of inconti- n ent men receiving PFMT remained wet compared with 77% not receiving such training; in the T URP group, 65% of incontinent men receiving PFMT remained wet compared with 62% not receivi ng such training.6 Treatment for sphincter dysfunction - Bulbourethral sling or tapes to compress or elevate the urethra (InVanceTM and AdVanceTM ma le tapes) (see b p. 143). Best results in mild to moderate incontinence (requiring <3 \200 \2234 pads per day). Arti \201 cial urinary sphincter. Insertion is usually deferred until 1y post- prostatectomy and it is the most effective long-term treatment (80% success rates ). Treatment for bladder dysfunction - Conservative treatment for bladder overactivity includes behavioral therapy and anticholine rgic medication. Surgery for intractable cases includes intravesical botulinum toxin inject ion, augmentation cystoplasty, or urinary diversion. Catheterization may be considered in t he older patient. Continence was assessed by the International Consultation on Incontinence Questionnaire (IC IQ) \200\224Urinary Incontinence Short Form). 1 Agency for Health Care Policy and Research (AHCPR) (1994) Benign Prostatic Hyperplasia: d iagnosis and treatment, Clinical Practice Guidelines No.8 [online]. Available from: M www.n cbi. nlm.nih.gov. 2 Benoit RM, Naslund MJ, Cohen JK (2000) Complications after radical prostatectomy in the m edicare population. Urology 56:116 \200\22320. 3 Catalona WJ, Carvalhal GF, Mager DE, et al. (1999) Potency, continence and complication r ates in 1,870 consecutive radical retropubic prostatectomies. J Urol 162:433 \200\2238. 4 Eden CG, Moon DA (2006) Laparoscopic radical prostatectomy: minimum 3-year follow-up of t he \201 rst 100 patients in the UK. BJU Int 97:981 \200\2234. 5 Patel VR, Thaly R, Shah K (2007) Robotic radical prostatectomy: outcomes of 500 cases. BJ U Int 99:1109 \200\22312. 6 Glazener C, Boachie C, Buckley B, et al . (2011) Urinary incontinence in men after formal one- to-one pelvic- \202 oor muscle training following radical prostatectomy or transuret hral resection of the prostate (MAPS): two parallel randomized controlled trials. Lancet 37 8:328 \200\22337. CHAPTER 5 Incontinence and female urology 156 Vesicovaginal \201 stula (VVF) VVF is an abnormal communication between the bladder and v agina. In 10%, there is a coexisting ureterovaginal \201 stula. Etiology In developing countries, the majority are due to obstructed or prolonged childbirt h, causing tissue pressure necrosis between the vagina and blad- der. In developed countrie s, 75% follow hysterectomy (0.1 \200\2230.2% risk; Fig. 5.6).1,2 Other causes include pelvi c surgery or radiotherapy, pessary ero- sion, advanced pelvic malignancy (cervical carcinom a), pelvic endometri- osis, in \202 ammatory bowel disease, trauma, childbirth (5%), low e strogen states, infection (urinary TB), and congenital abnormalities. Symptoms Immediate or delayed onset of urinary leakage from the vagina post- operatively; a bdominal pain or distension; prolonged bowel ileus (due to leak of urine into the peritonea l cavity as well as through the vagina); suprapubic pain; haematuria. Assessment - - Pelvic examination may demonstrate \200\2303-swab test \200\231: give oral phenazopyridine which turns the urine orange. After 1h, place three swabs into the vagina and instill meth ylene blue into the bladder. If the proximal swab turns blue, it indicates VVF; if it is or ange, it suggests ureterovaginal \201 stula. Cystoscopy may directly identify the \201 stula tract and help determine its proximity to the ureteric ori \201 ces. Biopsy the trac t if history of malignancy. VVF. IVU- and/or bilateral retrograde pyelograms to assess ureteric involvement or coexisting injury. Cystogram (or micturating cystourethrogram ( identifying bladder \201 stula. Contrast enhanced malignancy. MCUG)): best test for CT or MRI if history of previous radiotherapy or Management Small, uncomplicated VVF may resolve with urethral catheterization (9 anticholin ergics and antibiotics) or electrocoagulation of the tract (9 \201 brin sealant). A coexi sting ureterovaginal \201 stula will require ureteric stent or catheter. Most cases proce ed to surgery. Surgery Overall surgical success for simple VVF repair is 90%. Early repair (with- in 2 \200\2233 weeks) is advocated in selected cases, but traditionally, surgery is delayed 3 \200\2236 months (or 6 \200\22312 months following radiation therapy). The main principles are to excise the \201 stula, tension-free closure, and interpo- sition of healthy tissue . Transvaginal approach: most commonly used. The vaginal \202 ap technique involves incis ion of the \201 stula tract and closure with two layers of sutures. VESICOVAGINAL FISTULA (VVF) 157 Interpositional tissue grafts may be mobilized between the bladder and vagina (Martius fat pad graft from labia majora; peritoneal \202 ap; gracilis \202 ap) prior to the advance ment of a vaginal \202 ap and closure of the vaginal wall. Abdominal approach: more often used for complex cases, patients with a VVF high in the vagina or associated ureteric inju ry. The bladder is bisected to the level of the \201 stula tract which is then completely excised. The blad- der is closed and an interpositional (omental) graft created. In comple x cases, urinary diversion procedures may be needed. Suprapubic and urethral catheters are placed for 2 weeks and MCUG performed prior to cathet er removal. Offer estrogen replacement to post-menopausal women. Avoid tampons or sexual in tercourse for 3 months. Post-operative complications: vaginal bleeding; infection; bladder pain; dys- pareunia due to vaginal stenosis; graft ischaemia; ureteric injury; \201 stula recurrence. Bladder Vagina Fig. 5.6 Cystogram (lateral view) showing leak of contrast from the bladder and into the va gina due to a VVF. This followed a hysterectomy. 1 TancermL (1992) Observations on prevention and management of vesicovaginal \201 stula a fter total hysterectomy. Surg Gynaecol Obstet 175:501 \200\2236. 2 Harris WJ (1995) Early complications of abdominal and vaginal hysterectomy. Obstet Gynaec ol Survey 50:795 \200\223805. CHAPTER 5 Incontinence and female urology 158 Incontinence in elderly patients Prevalence UI steadily increases with advancing age (parti cularly \211 70y). It affects about 10 \200\22320% of women and 7 \200\22310% of men >65y old and living at home. These \201 gures escalate if older people are institutionalized. Prevalence for both sexes: residential home, 25%; nursing home, 40%; long-stay hospital war d, 50 \200\22370%.1 Transient causes of UI ( \200\230DIAPPERS \200\231) Delirium. Infection. Atrophic vaginitis or urethritis. Pharmaceuticals (opiates and calcium antagonists cause urinary retention an d constipation; anticholinergics cause increased PVR and retention; A-adrenergic antagonist cause reduced urethral resistance in women). Psychological problems (depression; neurosis; anxiety). Excess \202 uid input or output (diuretics; congestive cardiac failure (CCF); nocturnal polyuria). Restricted mobility. Stool impaction (constipation). Established UI This is unrelated to comorbid illness and persists over time. There are sev- eral types, including UUI, SUI, and incontinence associated with impaired bladder emptying (due to underactive bladder, urethral or bladder outlet obstruction). In addition, functio nal incontinence is associated with factors outside of the urinary tract such as permanent immobility, cognitive im- pairment, and environmental changes. History Seek out any transient causes and correct before arranging complex as- sessment and investigation. This can immediately improve function and quality of life and may be suf \201 cient to restore continence, even if there is coexisting urinary tract dysfunction. El icit full drug history; comorbid conditions; psychological, cognitive, functional, social, and environmental status. Examination Include mini-mental state evaluation and direct observation of patient dex- ter ity and mobility (Barthel Index). Include abdominal assessment (dis- tended bladder), DRE ( impacted feces), vulval inspection (POP; atrophic vaginitis), and neurological testing. Investigations - - - - Measure serum creatinine. Frequency volume chart. Bladder Urinalysis (screen for infection, haematuria, glycosuria, proteinuria). USS for PVR volume. INCONTINENCE IN ELDERLY PATIENTS 159 Stress test. Evaluation of the home environment and assess the need for modi \201 cations (occupational therapist and district nurse visits). Urodynamics should be reserved for patients considered \201 t for surgery and where the r esults will alter clinical treatment. Renal tract USS can be undertaken where clinically in dicated (i.e. large PVR, impaired renal func- tion, haematuria, UTI). Management Conservative Biofeedback, electrical stimulation of pelvic \202 oor, and behav ioral meth- ods are appropriate only if cognition is intact. PFMT (good results if used in conjunction with anticholinergics). Treat any atrophic vaginitis (0.01% estriol cream topic ally). Optimize mobility and bring the toilet closer to the bed. Try timed and prompted voi ding. Absorbent appliances include bed pads and body worn pad products (disposable or reuse able); body worn external urine collection devices (close \201 tting penile sheath); pess a- ry for POP; indwelling catheters where UI is due to obstruction and/or no alternative in tervention suitable. Medical therapy Ensure that BOO and signi \201 cant post-void bladder residuals are adequa te- ly treated before considering treatment of OAB symptoms. Antimuscarinic drugs with fewe r effects on cognitive function and good ef \201 cacy in older patients include solifenaci n and trospium chloride. Surgery Where conservative treatments have failed, surgery can be considered for selected c ases. - In women, options include colposuspension (particularly if associated with anterior compart ment prolapse), suburethral slings/tapes or periurethral bulking agents for SUI, and surger y for POP. In men, sphincter incompetence can be treated with bulbourethral tapes and arti \201 cial urinary sphincter in appropriately selected cases. 1 Royal College of Physicians (1995) Incontinence: causes, management and provision of serv ices, Report of a working party. London: RCP 1995 [online]. Available from: M www.rcplondon .ac.uk. 1 6 0 Initial management of urinary incontinence in women C H A P T E R 5 Initial Management of Urinary Incontinence in Women Incontinence with mixed symptoms Incontinence on physical activity Incontinence / frequency with urgency Complicated incontinence \200 Recurrent incontinence \200 Incontinence associated with: I n c o n t i n e n c e HISTORY Pain - Hematuria - Recurrent infection - Significant voiding General assessment (see relevant chapter) \200 Urinary symptom assessment (including freq uency- volume chart and questionnaire) Assess quality of life and desire for treatment \200 Physical examination: abdominal, pel vic and perineal \200 Cough test to demonstrate stress incontinence if appropriate \200 Urinalysis urine culture -> if infected, treat and reassess symptoms Pelvic irradiation - Radical pelvic surgery - Suspected fistula CLINICAL ASSESSMENT If appropriate Assess estrogen status and treat as appropriate \200 Assess voluntary pelvic floor muscle contraction \200 Assess post-void residual urine a n d f e m a l e PRESUMED DIAGNOSIS OAB -with or without URGENCY INCONTINENCE presumed due to detrusor overactivity STRESS INCONTINENCE presumed due to sphincteric incompetence MIXED INCONTINENCE (treat most bothersome symptom first) If other abnormality found e.g. \200 Significant post void residual \200 Significant pelvic organ prolapse Life style interventions. \200 Pelvic floor muscle training for SUI or OAB \200 Bladder retraining for OAB \200 Duloxetine* (SUI) or antimuscarinic (OAB urgency incontinence ) u r o l o g y Pelvic mass MANAGEMENT Other adjuncts, such as electrical stimulation \200 Vaginal devices, urethral inserts Subject to local Failure regulatory approval (see black box worning). SPECIALIZED MANAGEMENT Fig. 5.7 International Continence Society (ICS) recommendations. Reproduced with permission from 4th International Consultation on Incontinence. Incontinence, 4th edition 2009. Ed. A brams P, Cardozo L, Khoury S, Wein A. Health Publications Ltd 2009, p. 1785. Specialized management of urinary incontinence in women Specialized Management of Urinary Incontinence in Women M A N A G E M E N T O F Incontinence with mixed symptoms Incontinence on physical activity Incontinence with urgency / frequency HISTORY/ SYMPTOM ASSESSMENT \200\234Complicated \200\235 incontinence: \200 Recurrent incontinence \200 Incontinen ce associated with: - Pain - Hematuria - Recurrent infection - Voiding symptoms - Pelvic irradiation - Ra dical pelvic surgery - Suspected fistula Assess for pelvic organ mobility / prolapse \200 Consider imaging of the UT/ pelvic floor \200 Urodynamics (see notes) CLINICAL ASSESSMENT U R N A R Y I INCONTINENCE associated with poor bladder emptying DETRUSOR OVERACTIVITY INCONTINENCE (DOI) MIXED INCONTINENCE (USI/DOI) (Treat. most bother- some symptom first) URODYNAMIC STRESS INCONTINENCE (USI) Consider: \200 Urethrocystoscopy \200 Further imaging \200 Urodynamics I N C O N T N E N C E DIAGNOSIS Underactive detrusor Bladder outlet obstruction Lower urinary tract anomaly / pathology I Correct anatomic bladder outlet obstruction (e.g. genito-urinary prolapse) \200 Intermitt ent TREATMENT If initial therapy fails : \200 Stress incontinence If initial therapy fails : \200 Botulinum toxin \200 Neuromodulation \200 Bladder aug mentation I surgery N W O M E N bulking agents - tapes and slings - colposuspension Correct anomaly \200 Treat pathology catheterization Fig. 5.8 International Continence Society (ICS) recommendations. Reproduced with permission from 4th International Consultation on Incontinence. Incontinence, 4th edition 2009. Ed. A brams P, Cardozo L, Khoury S, Wein A. Health Publications Ltd 2009, p. 1787. 1 6 1 1 6 2 Initial management of urinary incontinence in men C H A P T E R 5 Initial Management of Urinary Incontinence in Men Incontinence on physical activity (usually post- prostatectomy) Urgency / frequency, with or with- out urgency incontinence Post- micturition dribble I n c o n t i n e n c e \200\234Complicated \200\235 incontinence \200 Recurrent or \200\234total \200\235 Incontinence with mixed symptoms HISTORY incontinence Incontinence associated with: - Pain - Hematuria - Recurrent infection - Prostate irradiation - Radical pelvic surg ery General assessment (see relevant chapter) \200 Urinary Symptom Assessment and symptom sco re (including frequency-volume chart and questionnaire) CLINICAL ASSESSMENT Assess quality of life and desire for treatment \200 Physical examination: abdominal, rec tal, sacral, neurological \200 Urinalysis urine culture -> if infected, treat and reas sess \200 Assessment of pelvic floor muscle function \200 Assess post-void residual uri ne a n d Any other abnormality detected e.g. significant post void residual f e m a l e STRESS INCONTINENCE presumed due to sphincteric incompetence MIXED INCONTINENCE (treat most bothersome symptom first) URGENCY INCONTINENCE presumed due to detrusor overactivity PRESUMED DIAGNOSIS DISCUSS TREATMENT OPTIONS WITH THE PATIENT \200 Lifestyle interventions \200 Pelvic flo or muscle training biofeedback \200 Scheduled voiding (bladder training) \200 Incont inence products \200 Antimuscarinics (OAB urgency incontinence) and -adrenergic anta gonists (if also bladder outlet obstruction) Urethral milking u r o l o g y Pelvic floor MANAGEMENT muscle contraction Failure SPECIALIZED MANAGEMENT Fig. 5.9 International Continence Society (ICS) recommendations. Reproduced with permission from 4th International Consultation on Incontinence. Incontinence, 4th edition 2009. Ed. A brams P, Cardozo L, Khoury S, Wein A. Health Publications Ltd 2009, p.1781. Specialized management of urinary incontinence in men Specialized Management of Urinary Incontinence in Men Incontinence with urgency / frequency \200\234Complicated \200\235 Incontinence : \200 Recurrent incontinence \200 Incontine nce associated with: - Prostate or pelvic irradiation - Radical pelvic surgery Post-prostatectomy incontinence HISTORY/ SYMPTOM ASSESSMENT M A N A G E M E N T O F Consider urodynamics and imaging of the urinary tract \200 Urethrocystoscopy (if indicate d) CLINICAL ASSESSMENT Consider: \200 Urethrocystoscopy \200 Further imaging \200 Urodynamics U R N A R Y URGENCY INCONTINENCE due to detrusor overactivity (during filling) MIXED INCONTINENCE Treat major component first STRESS INCONTINENCE due to sphincteric incompetence I DIAGNOSIS I N C O N T N E N C E with coexisting underactive detrusor (during voiding) with coexisting bladder outlet obstruction Lower urinary tract anomaly/ pathology -blockers, 5ARI \200 Correct anatomic bladder outlet obstruction \200 Antimuscarinics I If initial therapy fails: \200 Artificial urinary sphincter \200 Male sling (see chapte r) If initial therapy fails: \200 Neuromodulation Intermittent catheteri- sation \200 Antimus- carinics Correct anomaly \200 Treat pathology TREATMENT