Gynecology_Novak

Gynecology_Novak. In the industrialized world, the most common causes of genitourinary fistulas are surgery, malignancy, and radiation therapy, alone or in combination. Most often a vesicovaginal fistula develops after an otherwise uncomplicated vaginal or abdominal hysterectomy in which a small portion of the bladder was inadvertently trapped in a surgical clamp or was transfixed by a suture. These fistulas most often occur at the vaginal apex and are no larger than 1 to 2 mm. The amount of urine that can leak through a fistula of any size, however, is enormous. Figure 26.3 shows a cystoscopic view of three small vesicovaginal fistulae, lined up where the cuff suture line would have been. With traditional vaginal and abdominal hysterectomy, many surgeons recommend universal cystoscopy at the completion of the surgical case to assess for urinary tract injury and potentially decrease the incidence of urinary tract fistula. A review of 839 patients undergoing hysterectomy for benign disease followed by


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Gynecology_Novak. the surgical case to assess for urinary tract injury and potentially decrease the incidence of urinary tract fistula. A review of 839 patients undergoing hysterectomy for benign disease followed by universal cystoscopy at completion of the procedure revealed lower urinary tract injury in 4.3%, including bladder injury in 2.9% and ureteral injury in 1.8% (21).


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Gynecology_Novak. With the increase in minimally invasive techniques for pelvic surgery, including hysterectomy, the use of electrocautery devices is commonplace. This more frequent use of electrocautery for ligation of vessels and the resulting thermal spread increases concern about the possibility of ureteral damage that may lead to ureterovaginal fistula. When significant urine leakage occurs, often 10 to 14 days following a laparoscopic hysterectomy, ureterovaginal fistula should be strongly considered in the differential diagnosis. As with abdominal and vaginal surgery, careful attention to the location of the ureter, especially in proximity to the uterine arteries, must be a standard precaution. The incidence of ureterovaginal fistula after laparoscopic hysterectomy appears to be 1% to 4% (22).


Gynecology_Novak

Gynecology_Novak. Although rare, vesicouterine fistulas are increasing in incidence as the rate of cesarean deliveries increases. Such fistulas are almost always associated with repeat cesarean deliveries. The classic triad of vaginal urinary leakage, cyclic hematuria, and amenorrhea is known as Youssef’s syndrome (23).


Gynecology_Novak

Gynecology_Novak. Nocturia Nocturia is the number of voids recorded during a night’s sleep; each void is preceded and followed by sleep. To sort out whether nocturia results from heightened urine production at night, the nocturnal urinary volume can be assessed from a bladder chart. Nocturnal urinary volume is defined as the total volume of urine passed between the time the woman goes to bed with the intention of sleeping and the time of waking with the intention of rising. Thus, it excludes the last void before going to bed but includes the first void after rising in the morning. Nocturia can be the result of nocturnal polyuria potentially related to delayed mobilization of ﬂuid especially in the elderly, sleep problems (e.g., sleep apnea), or low volume voids. Nocturnal polyuria is present when an increased proportion of the 24-hour output occurs at night.


Gynecology_Novak

Gynecology_Novak. Most of the data about risk factors for urinary incontinence come from clinical trials or cross-sectional studies using survey design. Some risk factors were more rigorously studied than others. Thus, the information available is limited in its general applicability and one cannot infer causality from it. Despite these limitations, there is some evidence that age, pregnancy, childbirth, obesity, functional impairment, and cognitive impairment are associated with increased rates of incontinence or incontinence severity (16). Some factors pertain more to certain age groups than others. For example, in studies of older women, childbirth no longer increases the risk of incontinence, possibly because of the presence of comorbidities and other factors that promote incontinence. Medical diagnoses that were associated with urinary incontinence include diabetes, strokes, and spinal cord injuries. Other factors about which less is known or findings are contradictory include hysterectomy,


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Gynecology_Novak. that were associated with urinary incontinence include diabetes, strokes, and spinal cord injuries. Other factors about which less is known or findings are contradictory include hysterectomy, constipation, occupational stressors, smoking, and genetics.


Gynecology_Novak

Gynecology_Novak. Pregnancy and delivery predispose women to stress urinary incontinence, at least during their younger years. Of women who have not borne children, those who are pregnant leak more often than their nonpregnant counterparts; about half of women report symptoms of stress urinary incontinence during pregnancy, but in most, the symptom resolves after delivery. In a prospective study, 32% of 305 primiparas developed stress urinary incontinence during pregnancy and 7% after delivery. By 1 year, only 3% reported stress urinary incontinence (24). However, 5 years later, 19% of women with no symptoms after the first delivery had stress urinary incontinence. Of women reporting stress urinary incontinence 3 months postpartum (in most of whom it had resolved by 1 year), 92% had such leakage 5 years later. Transient postpartum leakage may be a marker for future incontinence.


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Gynecology_Novak. Various changes happen after delivery that may predispose women to stress urinary incontinence. Levator ani muscle strength decreases (25). About 20% of women develop a visible defect in the levator ani muscles after vaginal delivery (26). The bladder neck descends, and the pelvic muscles undergo partial denervation with pudendal neuropathy (27). In most studies, parity is strongly associated with urinary incontinence in younger women (28). In studies of women 60 years and older, parity is no longer an independent risk factor for incontinence (29). The reason for this is not well elucidated, but it may be because the changes in muscle, nerve, connective tissue, and hormonal function that occur with aging make other women “catch up” to those who developed incontinence at a younger age because of delivery trauma. Alternately, it may be that medical problems more common in older women account for a larger proportion of incontinence risk as women age.


Gynecology_Novak

Gynecology_Novak. Obesity deserves special mention for its role in causing or exacerbating stress incontinence. Many researchers report an association (that remains after adjusting for age and parity) between increased weight and body mass index (BMI) and urinary incontinence. For example, a dose–response relationship between BMI and severe urinary incontinence was described (30). Compared with women with a BMI less than 25 kg/m2, odds ratios (OR) for the following BMI groups were: 25 to 29, OR 2.0 (range 1.7–2.3); 30 to 34, OR 3.1 (2.6–3.7); 35 to 39, OR 4.2 (3.3–5.3); 40+ 5.0 (3.4–7.3). A prospective randomized study evaluating overweight and obese women with at least 10 urinary incontinence episodes per week undergoing an intensive 6-month weight-loss program versus structured education program found that women in the weight-loss program had a mean weight loss of 8.0% and decreased their leakage episodes by 47% compared to mean weight loss of 1.6% and 28% reduction in leakage episodes in the


Gynecology_Novak

Gynecology_Novak. that women in the weight-loss program had a mean weight loss of 8.0% and decreased their leakage episodes by 47% compared to mean weight loss of 1.6% and 28% reduction in leakage episodes in the education program group (31).


Gynecology_Novak

Gynecology_Novak. Initial Evaluation The initial evaluation of patients with incontinence requires a systematic approach to consider possible causes. The basic evaluation should include the following items: history (including assessment of quality of life and degree of bother from symptoms), physical examination, and simple primary care level tests. Most women can begin nonsurgical treatment after this basic evaluation.


Gynecology_Novak

Gynecology_Novak. History A thorough medical history should be obtained from every incontinent patient. The history should include a review of symptoms, general medical history, review of past surgery, and current medications. The woman’s most troubling symptoms must be ascertained—how often she leaks urine, how much urine she leaks, what provokes urine loss, what improves or worsens the problem, and what treatment (if any) she had in the past. It is essential to keep the patient’s chief symptom at the forefront to avoid inappropriate management. Consider, for example, a woman whose chief concern is that once a month, while leading a business seminar, she has a sudden, overwhelming urge to void followed by complete bladder emptying. She finds this leakage devastating and is considering quitting her job because of her acute embarrassment. On occasion, she leaks a few drops of urine during exercise, but this minor leakage does not bother her. During the evaluation, urodynamics reveal minimal stress


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Gynecology_Novak. because of her acute embarrassment. On occasion, she leaks a few drops of urine during exercise, but this minor leakage does not bother her. During the evaluation, urodynamics reveal minimal stress urinary incontinence at capacity during strong coughing. No detrusor overactivity is seen. The patient is offered, and undergoes, a surgical procedure for her documented urodynamic stress incontinence. Not surprisingly, her chief symptom is not improved and she is devastated.


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Gynecology_Novak. The general medical history may reveal systemic illnesses that have a direct bearing on urinary incontinence, such as diabetes mellitus (which produces osmotic diuresis if glucose control is poor), vascular insufficiency (which can lead to incontinence at night when peripheral edema is mobilized into the vascular system, resulting in increased diuresis), chronic pulmonary disease (which can lead to stress incontinence from chronic coughing), or a wide variety of neurologic conditions that can affect the neurourologic axis at any point from the cerebral cortex to the peripheral nervous system. Medications that may affect the lower urinary tract are summarized in Table 26.3 (32–35).


Gynecology_Novak

Gynecology_Novak. Quality-of-Life Measures Physicians caring for incontinent women should ask them about the way the incontinence specifically affects their lives and to what degree the incontinence bothers them. There often is discord between the objective symptom severity and subjective bother. Only by understanding each woman’s situation can treatment be appropriately planned and response evaluated. Some women may be completely satisfied if they are able to sit through a movie without running to the bathroom, even if they leak urine at other times. Others may be satisfied only if they are 100% dry. Given that the latter is likely an unrealistic goal, knowing that the patient feels this way gives the provider the opportunity to educate her about the likely outcome of treatment.


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Gynecology_Novak. Physicians may use one of several well-designed, validated quality-of-life measures. An expert summary of the literature in this area conducted for the International Consultation on Incontinence recommended the instruments summarized in Table 26.4. These instruments were found to be valid, reliable, and responsive to change following standard psychometric testing. Table 26.3 Medications that May Affect the Urinary Tract 1. Sedatives such as the benzodiazepines may cause confusion and secondary incontinence, particularly for elderly patients. 2. Alcohol may have similar effects to benzodiazepines and also impairs mobility and causes diuresis. 3. Anticholinergic drugs may impair detrusor contractility and may lead to voiding difficulty and overﬂow incontinence. Drugs with anticholinergic properties are widespread and include antihistamines, antidepressants, antipsychotics, opiates, antispasmodics, and drugs used to treat Parkinson’s disease. 4.


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Gynecology_Novak. 4. α-Agonists, which are often found in over-the-counter cold remedies, increase outlet resistance and may lead to voiding difficulty. 5. α-Blockers, sometimes used to treat hypertension (e.g., prazosin, terazosin), may decrease urethral closure pressure and lead to stress incontinence. 6. Calcium-channel blockers may reduce bladder smooth muscle contractility and lead to voiding problems or incontinence; they may also cause peripheral edema, which may lead to nocturia or nighttime urine loss. 7. Angiotensin-converting enzyme inhibitors may result in a chronic and bothersome cough that can result in increasing stress urinary incontinence in an otherwise asymptomatic patient. Table 26.4 Questionnaires to Assess Urinary Incontinence The following questionnaires have been recommended by the International Consultation on Incontinence to assess symptoms of incontinence and impact of incontinence on quality of life in women.a Urogenital Distress Inventory.


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Gynecology_Novak. Urogenital Distress Inventory. Shumaker SA, Wyman JF, Uebersax JS, et al. Health-related quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Qual Life Res 1994;3:291–306. Urogenital Distress Inventory (UDI)-6 (short form). Uebersax JS, Wyman JF, Shumaker SA, et al. Short forms to assess life quality and symptom distress for urinary incontinence in women: the incontinence impact questionnaire and the urogenital distress inventory. Neurourol Urodyn 1995;14:131–139. Urge-UDI. Lubeck DP, Prebil LA, Peebles P, et al. A health related quality of life measure for use in patient with urge urinary incontinence: a validation study. Qual Life Res 1999;1999: 337–344. King’s Health Questionnaire. Kelleher CJ, Cardozo LD, Khullar V, et al. A new questionnaire to assess the quality of life of urinary incontinent women. Br J Obstet Gynaecol 1997;104:1374–1379. Incontinence Severity Index.


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Gynecology_Novak. Kelleher CJ, Cardozo LD, Khullar V, et al. A new questionnaire to assess the quality of life of urinary incontinent women. Br J Obstet Gynaecol 1997;104:1374–1379. Incontinence Severity Index. Sandvik H, Hunskaar S, Seim A, et al. Validation of a severity index in female urinary incontinence and its implementation in an epidemiological survey. J Epidemiol Community Health 1993;47:497–499. Quality of Life Quality of life in persons with urinary incontinence (I-QOL). Wagner TH, Patrick DL, Bavendam TG, et al. Quality of life of persons with urinary incontinence: development of a new measure. Urology 1996;47:67–72. Incontinence Impact Questionnaire. Wyman JF, Harkins SW, Taylor JR, et al. Psychosocial impact of urinary incontinence in women. Obstet Gynecol 1987;70:378–381. Incontinence Impact Questionnaire (IIQ)-7 (short form).


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Gynecology_Novak. Wyman JF, Harkins SW, Taylor JR, et al. Psychosocial impact of urinary incontinence in women. Obstet Gynecol 1987;70:378–381. Incontinence Impact Questionnaire (IIQ)-7 (short form). Uebersax JS, Wyman JF, Shumaker SA, et al. Short forms to assess life quality and symptom distress for urinary incontinence in women. The incontinence impact questionnaire and the urogenital distress inventory. Neurourol Urodyn 1995;14:131–139. Urge-IIQ. Lubeck DP, Prebil LA, Peebles P, et al. A health related quality of life measure for use in patient with urge urinary incontinence: a validation study. Qual Life Res 1999;1999: 337–344. a Donovan JL, Badia X, Corcos J, et al. Symptom and quality of life assessment. In: Abrams P, Cardozo L, Khoury J, et al., eds. Incontinence. Plymouth, UK: Plymbridge Distributors, 2002.


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Gynecology_Novak. Physical Examination The physical examination of the patient with incontinence should focus on general medical conditions that may affect the lower urinary tract and problems related to urinary incontinence. Such conditions include cardiovascular insufficiency, pulmonary disease, occult neurologic processes (e.g., multiple sclerosis, stroke, Parkinson’s disease, and anomalies of the spine and lower back), abdominal masses, and mobility. Key factors to assess during the physical examination are summarized in Table 26.5. A cotton swab test has poor predictive value for determining either stress urinary incontinence diagnosis or predicting treatment success (36). It is used by some clinicians to determine movement of the anterior vaginal wall with Valsalva. A woman with a fixed nonmobile urethra is a poor candidate for a surgery (such as a Burch colposuspension) designed to elevate the urethra. It is not possible to increase support for an already well-supported urethra.


Gynecology_Novak

Gynecology_Novak. Table 26.5 Physical Examination of a Woman with Lower Urinary Tract Dysfunction Levator muscle palpation (symmetry, ability to squeeze) Test of urethral mobility (e.g., cotton swab test) Simple (Primary Care It is important to realize that formal urodynamics tests are neither the only nor the most important Level) Tests tests of bladder function. Other simple tests that can be performed in the primary care setting provide useful information to guide patient care.


Gynecology_Novak

Gynecology_Novak. Voiding Diary A frequency/volume bladder chart (often termed a “bladder diary”) is an invaluable aid in the evaluation of patients with urinary incontinence. A frequency/volume chart is a voiding record kept by the patient for several days. Patients are instructed to write down the time of every void on the chart and measure the amount of urine voided. The time of any incontinent episodes, and the specific activities associated with urine loss, should be recorded. If desired, the patient can be instructed to keep a record of ﬂuid intake. Although the type of intake may guide management suggestions, in most cases volume of intake can be estimated with some accuracy from the amount of urine produced.


Gynecology_Novak

Gynecology_Novak. A frequency/volume bladder chart provides vital information about bladder function that is not provided by formal urodynamics studies: 24-hour urinary output, the total number of daily voids, number of nighttime voids, the average voided volume, and the functional bladder capacity (largest volume voided in normal daily life). This information allows the clinician to confirm reports of urinary frequency with objective data and to determine whether part of the patient’s problem is an abnormally high (or low) urinary output. The chart can be used to calculate the volume of urine generated in nighttime hours versus daytime hours. Nighttime volume is calculated by adding output from voids that occur after the woman has fallen asleep for the night and the first morning void on awakening for the day. Older women sometimes have a marked shift in urine production, with more than half of their urine output generated during sleeping hours (Fig. 26.4). Demonstrating this on the voiding diary may


Gynecology_Novak

Gynecology_Novak. day. Older women sometimes have a marked shift in urine production, with more than half of their urine output generated during sleeping hours (Fig. 26.4). Demonstrating this on the voiding diary may lead to further treatment options.


Gynecology_Novak

Gynecology_Novak. Urinalysis Examination of the urine by dipstick testing and microscopy is done to exclude infection, hematuria, and metabolic abnormalities. Hematuria cannot be diagnosed on the results of a dipstick test alone; confirmation by microscopic evaluation is mandatory. Figure 26.4 Voiding diary (also called bladder chart). Daytime frequency is seven. The patient has nocturia (gets up to void two times during sleeping hours) and also has nocturnal polyuria (an increased proportion of the 24-hour output occurs at night; note that nighttime urine output excludes the last void before sleep but includes the first void of the morning). She has urge incontinence, likely caused by the relatively larger bladder volumes voided at night, which in turn may be related to her greater ﬂuid, caffeine, and alcohol consumption in the evening.


Gynecology_Novak

Gynecology_Novak. If a urinary tract infection is documented by microscopy or culture, it is reasonable to see whether urinary tract symptoms improved with eradication of bacteriuria. Occasionally, a simple urinary tract infection causes the onset or exacerbation of urinary incontinence. Some women, particularly older ones, have asymptomatic bacteriuria that truly is asymptomatic; thus, if attempted treatment of a woman with bacteriuria but without classic urinary tract infection symptoms (such as dysuria, urgency, or frequency) does not improve incontinence, further antibacterial treatment is generally unnecessary.


Gynecology_Novak

Gynecology_Novak. If hematuria and bacteriuria are found, the urine should be rechecked after eradication of the bacteriuria. Hematuria found in the absence of bacteriuria may need further evaluation to rule out kidney or bladder tumors; the necessity for and extent of the evaluation depends on concomitant risk factors and the clinical presentation. If malignancy is suspected, bladder biopsy should be performed by the surgeon who would treat the patient in the event a malignancy is discovered. Routine urinary cytology is not helpful, but testing may be of value in women older than 50 years with irritative urinary tract symptoms, particularly if those symptoms are of sudden onset.


Gynecology_Novak

Gynecology_Novak. Routine urinary cytology is not helpful, but testing may be of value in women older than 50 years with irritative urinary tract symptoms, particularly if those symptoms are of sudden onset. Postvoid Residual Volume Incomplete bladder emptying may cause incontinence. Patients with a large postvoid residual (PVR) urine volume have a diminished functional bladder capacity because of the dead space occupied in the bladder by retained urine. This stagnant pool of urine is a source of urinary tract infections because the major defense of the bladder against infection is frequent, nearly complete emptying.


Gynecology_Novak

Gynecology_Novak. A large PVR volume can contribute to urinary incontinence in two ways. If the bladder is overdistended, increases in intra-abdominal pressure can force urine past the urethral sphincter, causing stress incontinence (sometimes termed “overﬂow incontinence” in the context of a large PVR volume). In some cases, bladder overdistention may provoke an uninhibited contraction of the detrusor muscle, leading to incontinence. These conditions may coexist, further complicating the problem.


Gynecology_Novak

Gynecology_Novak. The PVR volume can be assessed by either direct catheterization or ultrasonography. Although sufficiently accurate for clinical purposes, ultrasonography measurements of PVR volume have a standard error of 15% to 20%. It is reasonable to confirm an elevated PVR volume detected on ultrasound with a catheterized volume (37). It is important to perform this test within 10 minutes of a void to avoid an artificially elevated result because of diuresis. It is agreed that a PVR level less than 50 mL is normal and greater than 200 mL is abnormal, but there is much debate about values in the midrange. Because many women are unable to void well during an anxiety-ridden first visit, it is helpful to recheck the PVR volume at a future visit before embarking on further diagnostic tests. The value of assessing bladder emptying in neurologically normal women who do not have pelvic organ prolapse or symptoms of voiding dysfunction has not been demonstrated.


Gynecology_Novak

Gynecology_Novak. Urodynamics At its most basic level, a urodynamic study is anything that provides objective evidence about lower urinary tract function (38). In this sense, measurement of a patient’s voided urine volume and catheterization to determine her PVR volume are urodynamic studies. A frequency/volume chart is also a valuable urodynamic study. Obtaining clinically valuable information does not always require the use of expensive, complex technology. After basic testing, further testing is recommended in the following circumstances: the diagnosis is uncertain (for example, because of major discrepancies between the history, the voiding diary, and symptom scales); surgery is being considered; an elevated PVR volume, a neurologic condition that may complicate treatment (such as multiple sclerosis), marked pelvic organ prolapse, or numerous prior surgical attempts at correction. Bladder and kidney imaging should be considered if the patient has hematuria in the absence of an infection. Current


Gynecology_Novak

Gynecology_Novak. marked pelvic organ prolapse, or numerous prior surgical attempts at correction. Bladder and kidney imaging should be considered if the patient has hematuria in the absence of an infection. Current urodynamic definitions are summarized in Table 26.6.


Gynecology_Novak

Gynecology_Novak. To assess voiding function, urodynamic testing usually begins with uroﬂowmetry, a study in which the volume of urine voided is plotted over time. Flow time, peak ﬂow rate, and time to peak ﬂow usually increase as the voided volume increases.


Gynecology_Novak

Gynecology_Novak. Cystometry is done to assess bladder and urethral function during bladder filling. Simple (or single-channel) cystometry is performed when bladder pressure only is measured during filling. Because the bladder is an intra-abdominal organ, the pressure recorded in the bladder is a combination of several other pressures, most notably the pressure created by the activity of the detrusor muscle itself and the pressure exerted on the bladder by the weight of the surrounding intra-abdominal contents (e.g., uterus, intestines, straining, or exertion). For this reason, the technique of complex (also called multichannel or subtracted) cystometry is used to try to approximate the actual pressure exerted in the bladder by the activity of the detrusor muscle alone. The detrusor pressure (Pdet) is obtained by measuring Table 26.6 Urodynamic Definitions I. Bladder sensation Table 26.6 (Continued )


Gynecology_Novak

Gynecology_Novak. Table 26.6 Urodynamic Definitions I. Bladder sensation Table 26.6 (Continued ) From Abrams P, Cardozo L, Fall M, et al. The standardization of terminology of lower urinary tract function: report from the Standardization Sub-committee of the International Continence Society. Neurourol Urodyn 2002;21:167–178, with permission. total intravesical pressure (Pves) with a bladder pressure catheter, approximating intra-abdominal pressure (Pabd) with a rectal or vaginal catheter, and then electronically subtracting the latter from the former: Pdet = Pves − Pabd.


Gynecology_Novak

Gynecology_Novak. Pdet = Pves − Pabd. Measurements can be obtained using electronic microtip transducer pressure catheters, ﬂuid-filled pressure lines, fiberoptic catheters, or air-charged catheters. All are acceptable for clinical use, but it is important to realize that when different types of catheters are used, the correlation between numbers is imperfect. Other technical factors that inﬂuence cystometry results include the choice of distending medium, filling rate, and patient position. The steps involved in a multichannel urodynamic study are outlined in Table 26.7. Normal cystometric values for women are shown in Table 26.8.


Gynecology_Novak

Gynecology_Novak. An example of detrusor overactivity seen during complex cystometry is shown in Figure 26.5. Surface or needle electromyography may be performed during filling and voiding to assess muscle activity of the urethral sphincter or pelvic ﬂoor. Electromyography as generally performed did not prove useful in neurologically intact women with symptoms of only stress urinary incontinence, and is not required in this patient population. Both false-positive and false-negative results can occur with urodynamic studies. False-positive results occur in patients with asymptomatic detrusor overactivity, detrusor overactivity Table 26.7 Steps in Conducting a Multichannel Urodynamic Study 1. Insert pressure and filling catheter into bladder (may be two catheters or dual catheter) to measure intravesical pressure and to fill bladder. Insert pressure catheter into upper vagina or rectum to approximate abdominal pressure. 2.


Gynecology_Novak

Gynecology_Novak. 2. Infuse ﬂuid (usually sterile water or saline, sometimes radiographic contrast dye) at a rate of 50 to 100 mL/min. Record the volume infused and the pressure measurements continuously. The patient’s bladder may be filled with her lying supine, in a modified lithotomy position, sitting, or standing. When possible, do cystometry in the standing position as most patients with incontinence report this problem more when they are erect. 3. Note the point at which any leakage occurs. 4. During filling, record the first desire to void (that is, the feeling that would lead her to void at the next convenient moment, but voiding can be delayed if necessary) and the strong desire to void (that is, the persistent desire to void without the fear of leakage). The maximum cystometric capacity, in women with normal sensation, is the volume at which the woman can no longer delay micturition; filling should not be continued to the point of pain or severe discomfort.


Gynecology_Novak

Gynecology_Novak. 5. If no detrusor overactivity is noted during filling, have the patient do provocative maneuvers at maximum capacity, such as coughing, heel-bouncing, and listening to the sound of running water to provoke uninhibited detrusor contractions, which may be the cause of the patient’s symptoms. that is irrelevant to the symptom, or detrusor overactivity that is situational (e.g., caused by test anxiety). False-negative results can occur because a 20-to 40-minute cystometrogram is not always an accurate measure of 24-hour bladder activity. Looking for detrusor overactivity with such a test is like looking for an episodic cardiac arrhythmia using 12-lead electrocardiography, as opposed to looking for the arrhythmia using a 24-hour Holter monitor. The sensitivity of the latter test is far greater than that of the former. Ambulatory urodynamics can be performed and are more likely to detect detrusor overactivity than office-based studies. Tests of Urethral Function


Gynecology_Novak

Gynecology_Novak. Tests of Urethral Function Several tests of urethral function, including urethral pressure profilometry, Valsalva leak-point pressures, and the ﬂuoroscopic and cystoscopic assessment of the bladder neck, are used in attempts to guide therapy in women with stress urinary incontinence. Women with poor urethral function, evidenced by low Valsalva leak-point pressures, low maximal urethral closure pressures, or a visualized open bladder neck, are thought to be at higher risk of treatment Table 26.8 Approximate Normal Values of Female Bladder Function First desire to void occurs between 150 and 250 mL infused Strong desire to void does not occur until after 250 mL No uninhibited detrusor contractions during filling, despite provocation No stress or urge incontinence demonstrated, despite provocation Voiding occurs as a result of a voluntarily initiated and sustained detrusor contraction Flow rate during voiding is >15 mL/sec with a detrusor pressure of <50 cm H2O


Gynecology_Novak

Gynecology_Novak. Voiding occurs as a result of a voluntarily initiated and sustained detrusor contraction Flow rate during voiding is >15 mL/sec with a detrusor pressure of <50 cm H2O From Wall LL, Norton P, Delancey J. Practical urogynecology. Baltimore, MD: Williams & Wilkins, 1993, with permission. Figure 26.5 Detrusor overactivity on filling cystometrography. The patient begins to sense urgency, accompanied by an unstable bladder contraction, when 88 mL of water are instilled into the bladder. The detrusor pressure rises, and when 96 mL of water are instilled, she leaks. Pabd, abdominal pressure; Pves, vesical pressure; Pdet, detrusor pressure.


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Gynecology_Novak. failure using standard retropubic urethropexy (Fig. 26.6). Cutoff values for these tests are poorly defined and remain controversial. Although women with stress urinary incontinence have, on average, significantly lower maximal urethral closure pressures than those without incontinence, there is wide overlap in the values between such women, and no lower limit of urethral closure pressure or leak point pressure is established that diagnoses stress urinary incontinence. The urethral pressure profile is a test designed to measure urethral closure. Because continence requires the pressure in the urethra to be higher than the pressure in the bladder, it was believed that measuring the pressure differential between the two would provide useful clinical information. The urethral pressure profile is determined by slowly pulling a pressure-sensitive catheter through the urethra from the bladder.


Gynecology_Novak

Gynecology_Novak. The urethral closure pressure (Pclose) is the difference between the urethral pressure (Pure) and the bladder pressure: (Pves): Pclose = Pure − Pves. It was suggested that women with stress incontinence with low urethral closure pressure (<20 cm H2O) have a poorer prognosis for surgical outcome than women who do not have this condition; however, this area is the subject of considerable debate (3,39,40). Because stress incontinence, by definition, occurs during increases in intra-abdominal pressure that are generated by some kind of physical activity, it is not obvious why measurement of resting urethral pressure should be relevant to stress-related leakage, which is a dynamic event. One review concluded that urethral pressure profilometry is not a useful diagnostic test for stress incontinence in women and that its use in clinical management is unsupported by current evidence (41).


Gynecology_Novak

Gynecology_Novak. Leak-point pressure (LPP) is a urodynamic measure of the minimum intra-abdominal or intravesical pressure required to cause incontinence during abdominal strain or cough. Figure 26.6 Open and scarred bladder neck in an elderly woman who has undergone three anterior colporrhaphies for stress urinary incontinence in the past. There is no consensus about whether it should be measured from the resting supine baseline (generally near 0) or from the standing resting baseline (which increases depending on body mass). Other factors that may affect the results include the catheter’s type, caliber, and placement (vaginal, rectal, or intravesical), the bladder volume at which the measurement is obtained, the mechanism by which intra-abdominal pressure is increased (coughing versus straining), and patient position (42).


Gynecology_Novak

Gynecology_Novak. Leak point pressure measurements often are performed at a bladder volume of 200 or 300 mL. Patients are asked to cough with gradually increasing force (cough leak-point pressure) and finally to strain slowly (Valsalva) to increase intravesical pressure gradually. The lowest pressure at which leakage occurs is recorded as the cough or the Valsalva leak-point pressure (Fig. 26.7). If leakage is not demonstrated, the highest pressure that was obtained can be recorded with the notation “no leakage” to the specified pressure as measured in centimeters of water pressure. Many clinicians use a cutoff point of 60 cm water pressure to separate women who have intrinsic sphincter deficiency from those who do not. This is problematic for two reasons: (i) the marked variability of results that depend on all the aforementioned factors and (ii) the lack of prospective studies that demonstrate the predictive value of leak point pressure values on surgical outcomes. Results from this and other


Gynecology_Novak

Gynecology_Novak. depend on all the aforementioned factors and (ii) the lack of prospective studies that demonstrate the predictive value of leak point pressure values on surgical outcomes. Results from this and other urodynamics tests must be evaluated as one piece of the patient’s puzzle, along with the history, physical examination, voiding diary, and other tests. Medicare guidelines require that when bulking agents, such as collagen, are considered to treat stress incontinence, the intra-abdominal leak point pressure when the bladder has been filled with at least 150 mL of ﬂuid must be less than 100 cm H2O.


Gynecology_Novak

Gynecology_Novak. Fluoroscopy and cystourethroscopy were used to visualize the bladder neck because many clinicians and investigators believe that a closed bladder neck is important in maintaining continence. However, studies of continent women reveal that many individuals with normal urethral function show evidence of bladder neck opening with physical stress (43). Neither test is recommended in the routine evaluation of women with straightforward incontinence. Figure 26.7 Leak point pressure. The abdominal leak point pressure (LPP) is 114 cm H2O (the abdominal pressure at which the patient leaked urine).


Gynecology_Novak

Gynecology_Novak. Figure 26.7 Leak point pressure. The abdominal leak point pressure (LPP) is 114 cm H2O (the abdominal pressure at which the patient leaked urine). Urodynamic testing usually concludes with an instrumented voiding study (also known as a pressure-ﬂow study or voiding cystometrogram), in which the vesical, abdominal, and urethral pressures are measured simultaneously during bladder emptying (Fig. 26.8). Various studies identified Valsalva voiding, low preoperative ﬂow rate, and high preoperative detrusor pressures during voiding as risk factors for postoperative voiding dysfunction; however, findings often are contradictory.


Gynecology_Novak

Gynecology_Novak. Imaging Tests The role of imaging techniques in studying female urinary incontinence is not yet established. Researchers are evaluating the potential roles of ultrasonography, ﬂuoroscopy, functional neuroimaging, and magnetic resonance imaging (MRI). These tests should not be done routinely but are useful in certain conditions. If the patient’s symptoms (easily remembered by the three Ds: dysuria, dribbling, and dyspareunia) or examination suggests a urethral diverticulum, MRI is the test of choice (44).


Gynecology_Novak

Gynecology_Novak. Neurophysiologic Tests The neuromuscular function of the pelvic ﬂoor is dependent on the integrity of the nervous system. Injury can theoretically occur anywhere along these nerves, from the cell body located in Onuf’s nucleus in the ventral part of the spinal cord, along its axon, to the neuromuscular junction. Pelvic ﬂoor neurophysiology utilizes techniques applied to nerves and skeletal muscles elsewhere in the body to document neuromuscular integrity or evidence of injury. These tests are not routinely used in the clinical evaluation of most incontinent women. Figure 26.8 Voiding cystometrogram. This patient voids in an uninterrupted ﬂow pattern by means of a prolonged bladder contraction. She does not strain to void, with the exception of minimal straining toward the end of the ﬂow.


Gynecology_Novak

Gynecology_Novak. The pudendal nerve terminal motor latency (PNTML) indirectly assesses the integrity and patency of the terminal portion of the pudendal nerve, its neuromuscular junction, and the muscle it serves. Using a specialized electrode affixed over the index finger, the pudendal nerve is electrically stimulated near the ischial spine (either transrectally or transvaginally), and the resulting muscular response is measured. The response, termed a compound muscle action potential (CMAP), is detected at the anal sphincter. The interval between the stimulation and the onset of the CMAP is measured. A prolonged latency is noted with injury to large and heavily myelinated axons. The latency time may be within the normal range when only smaller nerve fibers are affected; thus, neurologic dysfunction may exist in the presence of a normal latency time.


Gynecology_Novak

Gynecology_Novak. Only the distal efferent arm of the pudendal nerve is analyzed in the PNTML. Similar to the clinically obtained anal wink or bulbocavernosus reﬂex, electrically induced sacral reﬂexes can gather information about both the afferent and efferent arc in the pelvic nerves. A short train of dual impulses delivered next to the clitoris and measured at the anal sphincter is termed the clitoroanal reﬂex and provides information about the integrity of the afferent and efferent arm of the somatic pudendal nerve. A stimulating electrode placed in the bladder sends these signals along the visceral, autonomic fibers to the spinal cord, and a reﬂex signal will return along the pudendal nerve to the anal sphincter.


Gynecology_Novak

Gynecology_Novak. Normal pelvic ﬂoor and pelvic organ function ultimately is controlled by higher centers in the central nervous system, including the cerebral cortex. Recording electrodes located on the scalp near the motor cortex allow the signal transmission speed between a skeletal muscle and the brain to be measured. Repeated electrical stimuli, called somatosensory evoked potentials, at a muscle of interest are used to assess the integrity of the central afferent limb. In a reverse fashion, electrical or magnetically induced stimuli can be delivered at the motor cortex (or along the spine), and the induced muscle action potentials can be detected. Prolonged latencies not attributable to the peripherally studied nerves (such as with a PNTML or sacral reﬂex) are evidence of a central nervous system conduction ﬂaw.


Gynecology_Novak

Gynecology_Novak. Electromyography (EMG) assesses the inherent electrical potentials generated during neuronal activation of skeletal muscle. It can be performed using surface electrodes or needle electrodes. Surface EMG measures the summation of muscle activity in the general area of the applied electrode. It is best used for simply describing the pattern and coordination of muscle activity but is less useful in providing more specific assessments. Needle EMG of the pelvic ﬂoor can “map” the anatomic location of muscles but is mostly replaced by ultrasonography. The major value of needle EMG is its ability to assess nerve injury and determine whether the injury is acute and ongoing or chronic. Single-fiber EMG can quantify the ratio of muscle fibers to nerve fibers (the so-called fiber density). An increase in fiber density is evidence of previous nerve injury with successful reinnervation. Concentric needle EMG is more widely available and allows for further neurophysiologic evaluation. Abnormal


Gynecology_Novak

Gynecology_Novak. in fiber density is evidence of previous nerve injury with successful reinnervation. Concentric needle EMG is more widely available and allows for further neurophysiologic evaluation. Abnormal electrical activity associated with acute injury may be seen, and motor unit action potentials (MUAPs) can be assessed and quantified. Following nerve injury and reinnervation, MUAP parameters—such as duration, amplitude, number of phases, and turns—are typically larger.


Gynecology_Novak

Gynecology_Novak. Positron emission tomography and functional magnetic resonance imaging studies are yielding preliminary insights into the neural control of continence; these technologies are used in the research setting only. Physical Therapy Medical evidence from well-designed randomized clinical trials shows that supervised pelvic ﬂoor muscle training (Kegel exercises) is an effective treatment for stress urinary incontinence. The Cochrane Incontinence Group concluded that pelvic ﬂoor muscle training is consistently better than no treatment or placebo treatment for stress incontinence and should be offered as first-line conservative management to women. Intensive training sessions that include personal contact with a health care professional to teach and supervise pelvic ﬂoor muscle training may be more beneficial than standard care. Biofeedback provides no added benefit over pelvic ﬂoor muscle training alone in women with stress urinary incontinence (46).


Gynecology_Novak

Gynecology_Novak. Several factors improve the likelihood that pelvic muscle training will relieve stress urinary incontinence. The woman must do the exercises correctly, regularly, and for an adequate duration. Based on exercise training of skeletal muscles elsewhere in the body, many physical therapists recommend training sessions three to four times per week, with three repetitions of eight to ten sustained contractions each time. Electrical stimulation therapy was used to treat incontinence by delivering low levels of current via a probe placed in the vagina or rectum. When compared with sham devices and pelvic ﬂoor exercises, electrostimulation produced mixed results in the treatment of stress urinary incontinence but may be more helpful in women with overactive bladders (47–50). Further research is needed to determine what niche this treatment may fill for women with urinary incontinence.


Gynecology_Novak

Gynecology_Novak. Bladder training focuses on modifying bladder function by changing voiding habits. Behavioral therapy focuses on improving voluntary control rather than bladder function (51). The key component to bladder training is a scheduled toileting program. After reviewing the patient’s voiding diary, an initial voiding interval is chosen that represents the longest interval between voiding that is comfortable. She is instructed to empty her bladder when she awakes, and then every time during the day that the interval is reached (for example, every 30 to 60 minutes). When the patient feels the urge to void during that interval, she is instructed to use urge-suppression strategies, such as distraction or relaxation techniques, until she gets to the stated interval. Effective distraction strategies include mental exercises (such as mathematical problems), deep breathing, or “singing” the words to a song silently. The main goal is to avoid running to the bathroom at the moment of severe urgency.


Gynecology_Novak

Gynecology_Novak. include mental exercises (such as mathematical problems), deep breathing, or “singing” the words to a song silently. The main goal is to avoid running to the bathroom at the moment of severe urgency. Another strategy is to quickly contract the pelvic muscle several times in a row (“freeze and squeeze”), which often lessens urgency. Gradually, the interval is increased (usually weekly) until the patient voids every 2 to 3 hours. Bladder training is most effective when women record every void and check in (by telephone or in person) with a health care provider weekly. This program lasts for about 6 weeks. Bladder training is effective; in a trial in which bladder training was compared with treatment with oxybutynin, 73% of women in the bladder training group were clinically cured (52).


Gynecology_Novak

Gynecology_Novak. The primary technique of behavioral training is pelvic ﬂoor muscle training, as described previously, but with a focus on urge inhibition. Mastering voluntary pelvic ﬂoor muscle contractions helps to strengthen the outlet (decreasing leakage) and inhibit detrusor contractions. Other components of therapy may include voiding schedules, urge-inhibitions strategies, and ﬂuid management.


Gynecology_Novak

Gynecology_Novak. Patients with neurogenic detrusor overactivity, rather than idiopathic detrusor overactivity, do not respond as well to behavioral therapy because the problem is actually one of neural pathway destruction rather than the need to reestablish cortical control mechanisms. Frequently, these patients have a trigger volume of urine that sets off a contraction that they cannot control voluntarily. They may benefit from a timed schedule in which they void at regular intervals (such as every 2 hours) to keep their bladder volume below the trigger point. Attempting to lengthen the interval between voids often does not work well. Less-intensive treatments also decrease incontinence episodes. In a randomized trial, the guidance of a simple self-help booklet was only somewhat less effective in reducing leakage (mean reduction in leakage episodes 43%) than behavioral training (mean reduction 69%) or behavioral training plus electrical stimulation (mean reduction 72%) (53).


Gynecology_Novak

Gynecology_Novak. Vaginal devices (pessaries) and urethral inserts are available for treating stress urinary incontinence. In a tertiary care population, approximately two-thirds of women with stress urinary incontinence offered a trial of vaginal devices chose to undergo pessary fitting (54). Most (89%) achieved a successful fit. Of those who took a pessary home to manage their stress urinary incontinence, approximately one-half used it for more than 6 months. Women who stopped using the pessary generally did so within the first month. In an intent-to-treat analysis of a recent large multisite randomized trial, 3 months after beginning either pessary or behavioral therapy, 40% of those randomized to pessary and 49% of those doing behavioral therapy were “very much” or “much” better. By 12 months there were no group differences in outcomes and patient satisfaction was greater than 50% for each group (55). Some women are pleased to be able to avoid surgery or to use a “crutch” while waiting for the


Gynecology_Novak

Gynecology_Novak. were no group differences in outcomes and patient satisfaction was greater than 50% for each group (55). Some women are pleased to be able to avoid surgery or to use a “crutch” while waiting for the effect of pelvic muscle training; others prefer a treatment option (like surgery) that does not require daily intervention. Examples of some vaginal devices are shown in Figure 26.9.


Gynecology_Novak

Gynecology_Novak. Urethral inserts are sterile inserts placed into the urethra by the patient and removed before a void, after which a new sterile insert is placed. Such inserts are appropriate for women with Figure 26.9 Vaginal incontinence pessaries: (clockwise from top): A: Suarez ring (Cook Urological, Spencer, IN), B: PelvX ring (DesChutes Medical Products, Bend, OR), C: Incontinence dish (Milex Inc., Chicago, IL), D: Incontinence dish with support (Mentor Corp., Santa Barbara, CA), E: Introl prosthesis (was Johnson and Johnson; currently not available), F: Incontinence ring with support (Milex Inc., Chicago, IL), (middle): G: Incontinence dish with support (Milex Inc., Chicago, IL).


Gynecology_Novak

Gynecology_Novak. relatively pure stress incontinence, no history of recurrent urinary tract infections, and no serious contraindications to bacteriuria (e.g., artificial heart valves). The FemSoft device was U.S. Food and Drug Administration (FDA) approved in 1997 and is the only urethral insert that is available in the United States. Several other urethral inserts and urethral occlusion devices were marketed with good effectiveness but were withdrawn from the market. In a 5-year, multicenter trial involving 150 women with a mean follow-up of 15 months, a statistically significant reduction in incontinence episodes and pad weight were observed with 93% of the women having a negative pad test at 12 months. However, urinary tract infections were common and found in 31.3% of the subjects (56). Urethral inserts have not developed a widespread acceptance but may offer a viable treatment option for some select patients.


Gynecology_Novak

Gynecology_Novak. The tone of the urethra and bladder neck is maintained in large part by α-adrenergic activity from the sympathetic nervous system. For this reason, many pharmacologic agents are used with varying degrees of success to treat stress incontinence. These drugs include imipramine (which has a concomitant relaxing effect on the detrusor), ephedrine, pseudoephedrine, phenylpropanolamine, and norepinephrine. Many of these compounds increase vascular tone and may, therefore, lead to problems with hypertension, a condition that afﬂicts many postmenopausal women with stress incontinence. There is an increased risk for hemorrhagic cerebral vascular accident in women taking phenylpropanolamine, and while the risk is very low, it is not possible to predict who is at risk for this complication (57). The use of these agents in the treatment of stress urinary incontinence appears to be more limited than originally thought (58). No drugs are cleared by the FDA to treat stress incontinence.


Gynecology_Novak

Gynecology_Novak. Based on a biologic rationale, it was thought that estrogen could effectively treat urinary incontinence, given the presence of estrogen receptors in the bladder, urethra, and levator muscles.


Gynecology_Novak

Gynecology_Novak. In early uncontrolled case series, women using various estrogen preparations experienced less incontinence. However, in several large randomized trials, women assigned to receive estrogen and progesterone did not have less leakage, and were more likely to experience the onset of incontinence or worsening of baseline symptoms (59). In over 23,000 women enrolled in the Women’s Health Initiative double-blind, placebo-controlled, randomized clinical trial, use of menopausal hormone therapy (conjugated estrogen alone in women with a prior hysterectomy, conjugated estrogen and medroxyprogesterone acetate in women with a uterus) increased the incidence of all types of urinary incontinence at 1 year among women who were continent at baseline (60). Among women who reported urinary incontinence at baseline, both frequency and severity of incontinence worsened at 1 year in women taking either hormone preparation compared with those in the placebo group. Thus, conjugated estrogen with or without


Gynecology_Novak

Gynecology_Novak. baseline, both frequency and severity of incontinence worsened at 1 year in women taking either hormone preparation compared with those in the placebo group. Thus, conjugated estrogen with or without progestin should not be prescribed for the prevention or relief of urinary incontinence.


Gynecology_Novak

Gynecology_Novak. The drugs used for treating detrusor overactivity can be grouped into different categories according to their pharmacologic characteristics; these drugs are anticholinergic agents that exert their effects on the bladder by blocking the activity of acetylcholine at muscarinic receptor sites. All of these drugs have side effects, the most common of which are dry mouth resulting from decreased saliva production, increased heart rate because of vagal blockade, feelings of constipation resulting from decreased gastrointestinal motility, and occasionally, blurred vision caused by blockade of the sphincter of the iris and the ciliary muscle of the lens of the eye. Medications commonly used to treat these conditions are listed in Table 26.9. The introduction of several new drugs for overactive bladder resulted in significant attention being given to urinary incontinence in the media.


Gynecology_Novak

Gynecology_Novak. The newer drugs have some advantages over oxybutynin, which was available for decades. These advantages include once-(or sometimes twice-) daily dosing, rather than three to four times per day and, to some degree, a less severe side-effect profile. The latter results from changes in the delivery system and to more selectivity of muscarinic receptors (so that, for example, the bladder may be targeted more than the salivary glands). In addition, quaternary amines (such as trospium chloride) are not distributed into the central nervous system because of their large molecular size and hydrophilicity. The primary disadvantage of the newer agents is cost.


Gynecology_Novak

Gynecology_Novak. In 2009, the Agency for Healthcare Research and Quality carried out an evidence-based review of the large body of literature on pharmacologic therapies for urinary urgency incontinence and overactive bladder (61). Estimates from their meta-analysis models suggest that immediate-release forms of medications (oxybutynin, short-acting tolterodine) decreased incontinence episodes and voids by 1.46 and 2.16 per day, respectively. Extended-release forms of medications (tolterodine, trospium chloride, solifenacin, oxybutynin) decreased incontinence episodes and voids by 1.78 and 2.24 per day, respectively. However, placebo also impacted continence, decreasing incontinence episodes and voids by 1.08 and 1.48 per day, respectively. Whether or not the improvements observed with medication are clinically significant depends on patients’ perceptions and initial level of severity. In the randomized trials reviewed, baseline episodes of incontinence ranged from 1.6 to 5.3; decreasing this by one or


Gynecology_Novak

Gynecology_Novak. significant depends on patients’ perceptions and initial level of severity. In the randomized trials reviewed, baseline episodes of incontinence ranged from 1.6 to 5.3; decreasing this by one or two may or may not constitute a successful outcome for a given patient.


Gynecology_Novak

Gynecology_Novak. When initiating therapy with generic oxybutynin, it is best to start with a lower dose (particularly for elderly patients) and increase it as needed to a higher, more frequent dosage. Patients should be encouraged to titrate their medication to their symptoms and to vary the dosage (within acceptable limits) according to their needs. If this is not effective, the next step is to move to one of the other anticholinergic agents. Some women may respond better to one agent than another. A 2-week trial is sufficient to determine effectiveness. It is helpful to ask patients to record daily episodes of incontinence or urgency before and during therapy so effectiveness can be more accurately determined.


Gynecology_Novak

Gynecology_Novak. Patients should be warned of the side effects of anticholinergic agents. Patients should be particularly advised about the symptom of a dry mouth and told that this is not caused by thirst. Some patients increase their ﬂuid intake to combat this problem, with a subsequent worsening of their incontinence. If dry mouth is a problem, patients should relieve it by chewing gum, sucking on a piece of hard candy, or eating a piece of moist fruit. Table 26.9 Commonly Used Medications for Urge Incontinence tid, three times a day; qid, four times a day; qd, every day; bid, twice a day. aAvailable as generic.bWatson Pharmaceuticals. cPfizer. dAllergan. eAstellas Pharmaceuticals. f 7.5 or 15 mg by mouth Medications that treat nocturia and nocturnal enuresis have one of three aims: (i) to reduce urine output, (ii) to increase bladder capacity and reduce unstable bladder contractions, and (iii) to act centrally on sleep and micturition centers.


Gynecology_Novak

Gynecology_Novak. An analogue of arginine vasopressin, DDAVP, is used extensively to treat children with nocturnal enuresis. Some studies suggest that it may be useful in adults (62,63). It is available as a nasal spray and as an oral preparation. When taken orally, the dose required is approximately 10 times greater because of the increased availability of the nasal preparation. Complications associated with the DDAVP include hyponatremia, particularly in patients with excessive ﬂuid intake; therefore, it is essential in higher-risk patients to measure serum sodium levels periodically. There are few clinical trials that specifically investigate the use of anticholinergic medications to treat nocturia or nocturnal enuresis. Anecdotal evidence supports a trial of a long-acting or extended-release form of an anticholinergic, taken approximately 1 hour before bedtime.


Gynecology_Novak

Gynecology_Novak. The most extensively studied medications for the treatment of nocturnal enuresis are tricyclic antidepressants, particularly imipramine. These agents may work by altering the sleep mechanism, by providing anticholinergic or antidepressant effects, or by affecting antidiuretic hormone excretion. The typical starting dose of imipramine is 25 mg at bedtime, which may be increased to as high as 75 mg. In the elderly, imipramine should be used cautiously because it increases the risk of hip fracture, presumably related to the potential side effect of orthostatic hypertension (64).


Gynecology_Novak

Gynecology_Novak. In a randomized, placebo-controlled study comparing nighttime doses of placebo and 1 mg of bumetanide (a loop diuretic), bumetanide decreased nocturia episodes by 25% compared with placebo (65). Patients who produce half of their total urine at night often benefit from the use of a diuretic (e.g., 20 mg furosemide) in the late afternoon to move ﬂuid through the system and decrease their nighttime urine production. Historically, the body of literature concerning surgical therapy for stress urinary incontinence, while large, is hampered by poor methods, short follow-up, biased outcome observations, and little attention paid to the patients’ perceptions of symptoms and quality of life (66). Over the past decade, scientific research in this area evolved; while much of the literature continues to reﬂect small short-term case series, randomized trials with rigorous follow-up are becoming more common.


Gynecology_Novak

Gynecology_Novak. Several shifts occurred in recommendations regarding surgical therapy in the past generation. In 1997, the American Urological Association convened a clinical guidelines panel to analyze published outcomes data on surgical procedures to treat female stress urinary incontinence and to produce practice recommendations to guide surgical decision making (67). The panel concluded that colposuspension (e.g., Burch, Marshall-Marchetti-Krantz [MMK]) and slings were more effective than transvaginal needle suspensions or anterior repairs for longterm success (48-month cure/dry rates). The median probability estimates for cure/dry rates at 48 months and longer were 84% (95% confidence interval [CI], 79%–88%) for colposuspension and 83% (95% CI, 75%–88%) for sling procedures, compared with 67% (95% CI, 53%–79%) for transvaginal needle suspensions and 61% (95% CI, 47%–72%) for anterior repairs. Thus, the latter two procedures are no longer recommended as adequate treatments for stress urinary


Gynecology_Novak

Gynecology_Novak. CI, 53%–79%) for transvaginal needle suspensions and 61% (95% CI, 47%–72%) for anterior repairs. Thus, the latter two procedures are no longer recommended as adequate treatments for stress urinary incontinence.


Gynecology_Novak

Gynecology_Novak. Historical Perspective Anterior vaginal repair (also termed anterior colporrhaphy) was described by Howard Kelly in 1914, and this operation remained the standard first approach to stress incontinence until the middle of the 20th century (68). Many different operations are lumped together under the term anterior colporrhaphy, including simple plication of the bladder neck, elevation of the bladder neck by plicating the fascia under the urethra, and elevation and fixation of the bladder neck by passing sutures lateral to the urethra and driving the needles anteriorly into the back of the pubic symphysis for fixation. As noted previously, the problem with most techniques of anterior colporrhaphy is that they do not hold up well over time (69–71). In essence, this operation attempts to take weak support from below and push it back up from below, with hope that these structures will maintain their strength and position over time. Although there were excellent longterm results shown with


Gynecology_Novak

Gynecology_Novak. weak support from below and push it back up from below, with hope that these structures will maintain their strength and position over time. Although there were excellent longterm results shown with anterior colporrhaphy, most of these cases involve specific techniques requiring skillful dissection of the endopelvic fascia, deep bold bites of suture, and fixation of permanent sutures to the pubic bone from below: in essence, a transvaginal retropubic bladder neck suspension (72,73). Most surgical series that evaluated techniques of anterior colporrhaphy for stress incontinence show long-term success rates of only 35% to 65%, a figure that most would regard as unacceptably low. Anterior colporrhaphy should be reserved primarily for patients requiring cystocele repair who do not have significant stress incontinence.


Gynecology_Novak

Gynecology_Novak. Needle suspension procedures are so named because they suspend the urethra and bladder neck through a technique that involves passage of sutures between the vagina and anterior abdominal wall using a specially designed long needle carrier. Although initial cure rates are between 70% to 90%, rates decrease significantly over time in many series, with 5-year success rates of 50% or less (67,74–77). Therefore, these operations are no longer recommended.


Gynecology_Novak

Gynecology_Novak. The modern era of retropubic surgery for stress incontinence began in 1949, when Marshall et al. described their technique for urethral suspension in a man with postprostatectomy incontinence (78). A variety of modifications of this operation were described, all of which share at least two characteristics: They are performed through an open low abdominal incision or with laparoscopically assisted exposure of the space of Retzius, and they all involve attachment of the periurethral or perivesical endopelvic fascia to some other supporting structure in the anterior pelvis (Fig. 26.10). In the MMK operation, the periurethral fascia is attached to the back of the pubic symphysis. Another approach, the Burch colposuspension, involves the attachment of the fascia at the level of the bladder neck to the iliopectineal ligament (Cooper’s ligament) (79,80). With the paravaginal repair, the lateral endopelvic fascia along the urethra and bladder is reattached to the arcus tendineus fascia pelvis


Gynecology_Novak

Gynecology_Novak. to the iliopectineal ligament (Cooper’s ligament) (79,80). With the paravaginal repair, the lateral endopelvic fascia along the urethra and bladder is reattached to the arcus tendineus fascia pelvis (81,82). In the Turner-Warwick vagino-obturator shelf procedure, the endopelvic fascia, vagina, or both are attached to the fascia of the obturator internus muscle (83,84).


Gynecology_Novak

Gynecology_Novak. Figure 26.10 Points of reattachment of the endopelvic fascia during retropubic bladder neck suspensions. A: Arcus tendineus fascia pelvis (for paravaginal repair). B: Periosteum of pubic symphysis (for Marshall-Marchetti-Krantz procedure). C: Ileopectineal, or Cooper’s, ligament (for Burch colposuspension). D: Obturator internus fascia (also used for paravaginal, or obturator shelf, repair). A 2009 Cochrane review found that 69% to 88% of women treated with Burch colposuspension were largely continent, and 5 years after surgery the continence rate remained high at 70%. Twelve trials were available that compared colposuspension with various forms of suburethral slings; there were no significant differences in failure rates between slings and colposuspension at any time interval studied (85).


Gynecology_Novak

Gynecology_Novak. The long-term success of laparoscopic colposuspension is unclear, but there is limited evidence to suggest the results are less favorable than with open colposuspension, although this may reﬂect a learning effect and be unreliable in isolation (86).


Gynecology_Novak

Gynecology_Novak. Sling operations traditionally were performed using a combined vaginal and abdominal approach (Fig. 26.11). The anterior vagina is opened, the space of Retzius is dissected on each side of the bladder neck, and a sling is passed around the bladder neck and urethra and then attached to the anterior rectus fascia or some other structure to cradle the urethra in a supporting hammock. This supports the urethra and allows it to be compressed during periods of increased intra-abdominal pressure (87–97). The sling can be made of organic or inorganic materials. Organic materials can be autologous tissues harvested from the patient (e.g., fascia lata, rectus fascia, tendon, round ligament, rectus muscle, vagina), processed allografts from human donors (e.g., fascia lata, dermis), or heterologous tissues harvested from another species and processed for surgical use (e.g., ox dura mater, porcine dermis). Synthetic materials (e.g., Silastic, Gore-Tex, Marlex) are popular because of their


Gynecology_Novak

Gynecology_Novak. tissues harvested from another species and processed for surgical use (e.g., ox dura mater, porcine dermis). Synthetic materials (e.g., Silastic, Gore-Tex, Marlex) are popular because of their consistent strength and availability, but historically these substances were plagued by problems with erosion and infection when used around the urethra (67,98,99).


Gynecology_Novak

Gynecology_Novak. The multicenter Urinary Incontinence Treatment Network conducted a randomized clinical trial comparing Burch colposuspension and fascial pubovaginal sling in 655 women with stress urinary incontinence (100). The primary outcome, success, was rigorously defined as a negative pad test, no urinary incontinence (as recorded in a 3-day diary), a negative cough and Valsalva stress test, no self-reported symptoms, and no retreatment for the condition. At 24 months, success rates were higher for women who underwent the sling procedure than for those who underwent the Burch procedure for the overall category of success (47% vs. 38%; p = .01). However, more women who underwent the sling procedure later had urinary tract infections, difficulty voiding, and postoperative urge incontinence. This study highlights the wide range in success depending on how it is defined: for example, based on a cough stress test, success rates were 71% in the Burch group and 87% in the sling group, while based on a


Gynecology_Novak

Gynecology_Novak. highlights the wide range in success depending on how it is defined: for example, based on a cough stress test, success rates were 71% in the Burch group and 87% in the sling group, while based on a pad test, rates were 84% and 85%, respectively.


Gynecology_Novak

Gynecology_Novak. Figure 26.11 A completed traditional suburethral sling procedure with the fascia located at the bladder neck with the ends of the sling tied to or above the rectus fascia. The classic procedure uses autologous fascia; however, some surgeons use allograft or xenograft tissue performed in a similar fashion. (Redrawn from original by Jasmine Tan.) Minimally Invasive Sling In the 1990s, various orthopedic bone anchors were marketed to implant into the pubic bone to suspend the urethra with sutures or slings. Despite a lack of medical evidence to support either the bone anchor or the allograft use, bone anchor systems became the quick and minimally invasive method to suspend allograft slings (101). Although bone anchors were not superior to standard fixation techniques, their use led to increased complications in several series.


Gynecology_Novak

Gynecology_Novak. In 1996, Falconer et al. described the tension-free vaginal tape (TVT) for correcting stress urinary incontinence (102). In this technique, polypropylene mesh is placed under the midurethra with minimal tension (Fig. 26.12 A, B). To perform this operation, a small midurethral incision is made in the vaginal epithelium mucosa. A 40-by 1-cm mesh tape covered by a plastic sheath and attached to two 5-mm curved trocars is passed lateral to the urethra and through the endopelvic fascia into the retropubic space. The trocar is passed along the back of the pubic bone, through the rectus fascia, and into two small suprapubic skin incisions. The tension on the tape is adjusted, the sheath is removed, and the remaining tape is cut off at the level of the skin. This technique has the advantage of being performed quickly using limited anesthesia (fewer than 30 minutes in experienced hands). The procedure requires the use of a catheter guide to deviate the urethra and cystoscopy to ensure that


Gynecology_Novak

Gynecology_Novak. being performed quickly using limited anesthesia (fewer than 30 minutes in experienced hands). The procedure requires the use of a catheter guide to deviate the urethra and cystoscopy to ensure that bladder or urethral perforations are recognized immediately because the trocar is passed blindly.


Gynecology_Novak

Gynecology_Novak. Numerous modifications of the TVT were proposed and marketed. Such devices generally circumvent the stringent regulatory control provided by the FDA by gaining approval through a Premarket Notification 510(k). This mechanism is a submission to the FDA demonstrating that a new device is substantially equivalent either to a legally marketed or “predicate” device introduced before 1976 in the United States or to one approved by the FDA through the 510(k)


Gynecology_Novak

Gynecology_Novak. Figure 26.12 Midurethral synthetic slings involve the use of large pore, monofilament polypropylene mesh placed after minimal dissection at the midurethra followed by placement of a trocar through the retropubic route. Some surgeons prefer placing the trocar by a suprapubic route beginning with a small abdominal incision. A: The trocar is guided into the previously performed midurethral incision with care to place the trocar against the pubic bone to avoid entry into the peritoneal cavity. The trocar handle has been removed in this view after perforation through the abdominal incision. B: The synthetic sling should rest in the midurethra location and is brought through two stab incisions above the pubic symphysis. (Redrawn from original by Jasmine Tan.) process itself. Substantial equivalence means the new device has the same intended use as the predicate device and has the same technological characteristics or different technological characteristics, but it is as safe and effective


Gynecology_Novak

Gynecology_Novak. means the new device has the same intended use as the predicate device and has the same technological characteristics or different technological characteristics, but it is as safe and effective as the predicate device. Surgeons should be aware that most new devices for urinary incontinence are not tested in clinical trials before they are marketed.


Gynecology_Novak

Gynecology_Novak. Since its introduction, there were scores of articles published suggesting that TVT is effective and safe and similar in effectiveness to colposuspension. Larger, multicenter trials provide the most realistic look at outcomes of a surgical procedure performed by many surgeons with varying experience on a wide array of patients. A report of the 2-year follow-up of 344 women with urodynamic stress incontinence enrolled from 14 centers in a multicenter randomized clinical trial compared TVT and open Burch colposuspension. The objective cure rates (defined as a negative 1-hour pad test) ranged from 63% to 85% for the TVT procedure and 51% to 87% for open colposuspension, depending on how missing data were handled, leading the authors to conclude that “TVT may be better, worse, or the same as open colposuspension in the cure of stress incontinence” (103). Subjectively, only 43% of women in the TVT group and 37% of women in the open colposuspension group reported cure of their stress


Gynecology_Novak

Gynecology_Novak. as open colposuspension in the cure of stress incontinence” (103). Subjectively, only 43% of women in the TVT group and 37% of women in the open colposuspension group reported cure of their stress leakage. Women undergoing the TVT were more likely to have a cystocele after surgery, whereas those undergoing the Burch colposuspension were more likely to have apical prolapse. Two years after the index procedure, seven women (4.8%) in the Burch colposuspension group underwent surgery for pelvic organ prolapse, compared with no women in the TVT group. There was no difference in the number of women that underwent repeat surgery for stress incontinence (1.8% in the TVT group and 3.4% in the Burch group). Women who underwent TVT were less likely to have voiding disorders requiring intermittent self-catheterization than those who underwent colposuspension (0% vs. 2.7%).


Gynecology_Novak

Gynecology_Novak. Another form of minimally invasive sling is the transobturator tape procedure (also known as a TOT) or transobturator suburethral tape. This modification was designed to reduce complications associated with retropubic needle passage. Inserting the trocar through the obturator space theoretically lessens the risk of bladder, bowel, or vascular injury because the procedure involves passing the polypropylene midurethral sling through the obturator membrane along its ischiorectal fossa path, bypassing the pelvic cavity altogether (104,105). In a multicenter trial, 183 women from seven sites underwent a transobturator tape procedure for stress and mixed urinary incontinence. At 1-year follow-up 80.5% patients were cured (defined as absence of subjective report of stress urine leakage and negative cough stress test). Perioperative complications included one bladder perforation, two urethral perforations, and one lateral vaginal perforation. Tape erosion necessitating removal occurred in


Gynecology_Novak

Gynecology_Novak. cough stress test). Perioperative complications included one bladder perforation, two urethral perforations, and one lateral vaginal perforation. Tape erosion necessitating removal occurred in five cases (three vaginal and two urethral) (106).


Gynecology_Novak

Gynecology_Novak. A 2009 Cochrane review identified 62 trials with over 7,000 women in which minimally invasive sling was studied in at least one arm (107). Most were of poor to moderate quality with short follow-up. Minimally invasive synthetic suburethral sling operations appeared to be as effective as traditional suburethral slings but with shorter operating time and less postoperative voiding dysfunction and de novo urgency symptoms. Similarly, minimally invasive synthetic suburethral slings were as effective as open retropubic colposuspension with fewer perioperative complications, less postoperative voiding dysfunction, shorter operative time and hospital stay, but significantly more bladder perforations (6% vs. 1%). A retropubic bottom-to-top route was more effective than top-to-bottom route and was associated with significantly less voiding dysfunction, fewer bladder perforations, and tape erosions. At the time of this review, 17 trials comprising 2,434 women compared the transobturator route


Gynecology_Novak

Gynecology_Novak. associated with significantly less voiding dysfunction, fewer bladder perforations, and tape erosions. At the time of this review, 17 trials comprising 2,434 women compared the transobturator route with the retropubic route of sling placement. The transobturator route had a slightly lower objective cure rate (84% vs. 88%) but had less voiding dysfunction, blood loss, bladder perforation, and shorter operating time.


Gynecology_Novak

Gynecology_Novak. After the publication of this Cochrane review, the largest (597 women) randomized equivalence trial to date comparing retropubic and transobturator sling approaches was published by the Urinary Incontinence Treatment Network (108). Women were randomized in the operating room and were followed for 1 year. The primary outcome was treatment success at 12 months according to both objective criteria (a negative stress test, a negative pad test, and no retreatment) and subjective criteria (self-reported absence of symptoms, no leakage episodes recorded, and no retreatment). Objective success rates were 80.8% and 77.7% and subjective success rates were 62.2% and 55.8%, in the retropubic and transobturator groups, respectively. Women in the retropubic group had more voiding dysfunction (2.7% vs. 0%), while those in the transobturator group had a higher rate of neurologic symptoms (9.4% vs. 4.0%). There were no significant differences between groups in postoperative urge incontinence,


Gynecology_Novak

Gynecology_Novak. vs. 0%), while those in the transobturator group had a higher rate of neurologic symptoms (9.4% vs. 4.0%). There were no significant differences between groups in postoperative urge incontinence, satisfaction with the results of the procedure, or quality of life.


Gynecology_Novak

Gynecology_Novak. A third generation of minimally invasive slings was developed, the so-called minislings. Insertion of the minisling requires only a single vaginal incision, less dissection, and the potential to be placed in a clinic setting. Data are mixed, with some finding equivalent success rates and others up to eightfold higher failure rates in the minisling group than in the full-length synthetic sling (109,110).


Gynecology_Novak

Gynecology_Novak. Bulking Agents Injectable (so-called bulking) agents are less invasive than surgery, and although they are less likely than surgery to result in cure, they relieve symptoms in many women. In the United States, glutaraldehyde cross-linked bovine collagen (Contigen), carbon beads (Durasphere), cross-linked polydimethylsiloxane (Macroplastique), and calcium hydroxylapatite (Coaptite) are approved for use to treat stress urinary incontinence and can be injected either peri-or transurethrally. The newer agents were studied primarily by transurethral injection. Injecting a material around the periurethral tissues facilitates coaptation of the urethra under conditions of increased intra-abdominal pressure (111–116). In a 15-article review, the short-term cure or improvement rate was 75% (117). Contigen can be passed easily through small-bore needles under local anesthesia but requires preoperative skin testing to check for possible allergic reactions (3%). Durasphere is nonantigenic (thus no


Gynecology_Novak

Gynecology_Novak. can be passed easily through small-bore needles under local anesthesia but requires preoperative skin testing to check for possible allergic reactions (3%). Durasphere is nonantigenic (thus no skin testing is required) and does not migrate. As compared with collagen, Durasphere appears to have similar reduction in leakage episodes and is more likely to require only a single injection (112). This bulking agent does require a larger-gauge needle for injection and is somewhat more difficult to inject than collagen. Macroplastique is approved for use in the United States. This material appears to offer better outcomes as defined by improvement and cure rates than Contigen at 12 months (113). A follow-up 24-month study revealed that 84% of patients maintained improvement from the 12-month assessment (114). A recent prospective randomized trial of Coaptite versus Contigen revealed similar improvement and safety profile at 12 months when compared Contigen. Coaptite required less material per


Gynecology_Novak

Gynecology_Novak. (114). A recent prospective randomized trial of Coaptite versus Contigen revealed similar improvement and safety profile at 12 months when compared Contigen. Coaptite required less material per injection (4 mL vs. 6.6 mL) and was more likely to require only a single injection (115). These techniques may require several injections to achieve continence, and the long-term success of these operations remains poorly studied.


Gynecology_Novak

Gynecology_Novak. Complications In choosing surgical management, surgeons must weigh the chance of cure against the chance of severe complications. In the aforementioned randomized trial comparing TVT and Burch, women undergoing TVT were more likely to experience a bladder perforation than those undergoing the Burch procedure (9% vs. 2%, respectively) but less likely to have a fever (1% vs. 5%) or prolonged catheterization more than 29 days (3% vs. 13%) (118). Less common complications require a large sample size to detect differences. Severe complications reported on the FDA manufacturer and user facility device experience (MAUDE) database include vascular injuries, bowel injuries, and patient deaths after retropubic midurethral slings and groin and leg pain, visceral injuries, and severe infections from transobturator approaches (119). Even though these serious life-threatening complications are rare, surgeons must be cognizant of the risks and use intraoperative safety measures to prevent their


Gynecology_Novak

Gynecology_Novak. transobturator approaches (119). Even though these serious life-threatening complications are rare, surgeons must be cognizant of the risks and use intraoperative safety measures to prevent their occurrence.


Gynecology_Novak

Gynecology_Novak. Actual complication rates are often difficult to discern because denominators often are not available. In a nationwide analysis of 367 complications associated with 1,455 TVT procedures performed in Finland, there was a 1.9% rate (95% CI, 1.2–2.7) of blood loss over 200 mL, a 1.9% rate (95% CI, 1.2–2.7) of retropubic hematoma, a 0.5% rate (95% CI, 0.2–1.0) of hematoma outside the retropubic area, a 0.1% rate (95% CI, 0.0–0.4) of injury to the epigastric vessel, a 0.1% rate (95% CI, 0.0–0.4) of injury to the obturator nerve, and a 3.8% rate (95% CI, 2.9–5.0) of bladder perforation (120).


Gynecology_Novak

Gynecology_Novak. A prospective, randomized trial of retropubic versus transobturator slings (the TOMUS trial) involving 597 patients revealed more bladder perforations in the retropubic group (15 vs. 0), more patients with elevated PVR volume (>100 mL at time of discharge), and higher rate of sling release or catheterization for voiding dysfunction after 6 weeks (8 vs. 0). The transobturator group had more vaginal perforations (13 vs. 6) and neurologic symptoms including lower extremity weakness and numbness found immediately following surgery to 6 weeks (31 vs. 15). Otherwise, serious adverse events were similar in both groups (108).


Gynecology_Novak

Gynecology_Novak. Erosion is unique to surgeries in which a graft is placed, and the rate depends largely on the type of graft used. Tension-free vaginal tape is associated with a low rate of graft erosion, compared with a much higher rate of erosion with certain synthetics previously used for pubovaginal slings. Most midurethral synthetic slings used at this time are made of polypropylene; the main differences in the character of the mesh involve elasticity and rigidity and not the material itself. In the randomized trial comparing TVT to TOT described above, of the 597 women who underwent a sling procedure, 1.8% of the patients were noted to have a mesh erosion or exposure (108).


Gynecology_Novak

Gynecology_Novak. In the randomized trial comparing TVT to TOT described above, of the 597 women who underwent a sling procedure, 1.8% of the patients were noted to have a mesh erosion or exposure (108). The most common adverse events (5% to 10% rate for each) after all surgeries for stress urinary incontinence include urinary tract infection, failure to cure, new onset detrusor overactivity, voiding dysfunction, genital prolapse, and bladder perforation. When new onset detrusor overactivity occurs after surgery for incontinence, cystoscopy should be considered to rule out a foreign body in the bladder (Fig. 26.13). Less common events (2% to 5% for each) include excessive blood loss, wound infection, pain, or nerve injury. Events such as sinus tracts and fistulae are rare. Erosion rates depend on the material implanted and, as noted previously, are rare for the midurethral slings. In addition, medical events, such as thromboembolic, cardiac, or pulmonary events, are rare.


Gynecology_Novak

Gynecology_Novak. As midurethral slings largely replace pubovaginal slings and retropubic urethropexies as the primary procedure for stress urinary incontinence, the comparison of complications of these procedures becomes more important. Given the debate on the effectiveness of the different approaches for midurethral slings, the severity and incidence of complications for midurethral slings will become more important when determining the best primary procedure for stress urinary incontinence. Likewise, the uncommon occurrence of intraoperative and long-term complications of these procedures and underreporting of complications demonstrates the need for reliable large registries for midurethral slings and other promising procedures to assess the safety of these procedures. Figure 26.13 Cystoscopic view of encrusted suture penetrating bladder wall following sling urethropexy.


Gynecology_Novak

Gynecology_Novak. Neuromodulation Even with the development of newer anticholinergic medications with fewer side effects, there continues to be a select group of patients with overactive bladders who remain refractory to standard medical and behavioral treatment. Surgical treatment of this condition traditionally involved substantial morbidity and major urinary denervation, reconstruction, or both to achieve therapeutic benefits. The development of implantable sacral nerve root stimulators led to FDA approval of sacral root neuromodulation in patients with refractory urinary urgency and frequency, urge incontinence, and voiding dysfunction. This therapy offers patients with severe symptoms an alternative to urinary augmentation or diversion. Sacral nerve stimulation therapy is performed in two phases. In the first phase, a percutaneous nerve evaluation test is performed to determine which patients respond to this type of therapy. Those who respond are implanted with a permanent electrode lead adjacent


Gynecology_Novak

Gynecology_Novak. first phase, a percutaneous nerve evaluation test is performed to determine which patients respond to this type of therapy. Those who respond are implanted with a permanent electrode lead adjacent to the third sacral nerve root connected to a pulse generator.


Gynecology_Novak

Gynecology_Novak. A multicenter prospective study demonstrated that 63% of test patients responded to the initial procedure. After implantation, 47% of patients became completely dry, and 77% were successful in eliminating “heavy” leakage episodes. Despite substantial success in nearly 80% of patients who received implants, 30% of patients required further surgical revision because of pain or other complications at the generator or implant site. No permanent injuries or nerve damage was reported in the initial trials (121,122).


Gynecology_Novak

Gynecology_Novak. In a group of 96 patients with implants (who responded favorably during the test stimulation period), reductions in urge incontinence episodes and severity were still seen at an average of 31 months after implantation. The device was removed in 11 of the 96 patients because of lack of efficacy, pain, or bowel dysfunction. There were no permanent injuries (123). The technique for this procedure evolved to include the location of a generation implant site on the back and the performance of the procedure in two stages with initial percutaneous implantation of a quadpolar instead of a unipolar stimulator. These modifications may improve success rates and decrease the morbidity associated with these procedures. A recent systematic review evaluating eight randomized trials concluded that continuous sacral neural stimulation offers benefits for carefully selected patients with overactive bladder and urinary retention in the absence of obstruction, but many implants did not work or required


Gynecology_Novak

Gynecology_Novak. sacral neural stimulation offers benefits for carefully selected patients with overactive bladder and urinary retention in the absence of obstruction, but many implants did not work or required revisions. The review recommended trials to assess effectiveness directly compared to other treatment options (124).


Gynecology_Novak

Gynecology_Novak. Percutaneous tibial nerve stimulation (PTNS) was first described in 1987 to treat lower urinary tract symptoms and FDA approved in 2000 for overactive bladder. This therapy uses peripheral neurostimulation technique with small (34-gauge) needle electrode inserted at a 60-degree angle approximately 5 cm cephalad to the medial malleolus and slightly posterior to the tibia. The treatment course typically consists of a weekly 30-minute session for 12 weeks. A multicenter, double-blind, randomized control trial involved 220 women with overactive bladder symptoms randomized 1:1 to 12 weeks of treatment with weekly PTNS or sham therapy. The PTNS treatment group achieved statistically significant improvement in bladder symptoms, with 55% reporting moderate to marked improvement compared to 21% in the sham arm compared to baseline (125). The OrBIT (Overactive Bladder Innovative Therapy) trial compared PTNS to extended-release tolterodine in the treatment of OAB and found similar improvements


Gynecology_Novak

Gynecology_Novak. the sham arm compared to baseline (125). The OrBIT (Overactive Bladder Innovative Therapy) trial compared PTNS to extended-release tolterodine in the treatment of OAB and found similar improvements in both groups (126). A large portion of responders in this trial (96%) had sustained improvement in OAB symptoms at 12-month follow-up when receiving periodic treatments (127,128). PTNS may represent a viable treatment option for patients who cannot tolerate side effects from anticholinergic medications, who do not responded to behavioral therapy, or who decline implantable neurostimulators.


Gynecology_Novak

Gynecology_Novak. Botox Injections Botulinum toxin A (BtxA), a neurotoxin produced by the anaerobic bacteria Clostridium botulinum, acts on peripheral cholinergic nerve endings to inhibit calcium-mediated release of acetylcholine vesicles at the presynaptic neuromuscular junctions. In a report from a multicenter study, a 73% continence rate occurred in 180 patients with neurogenic detrusor overactivity incontinence who underwent cystoscopic Botox injections (129). A recent prospective placebo-controlled trial in patients with refractory idiopathic urge incontinence demonstrated a 60% clinical response using the Patient Global Impression of Improvement score of 4 or greater with a median duration of response of 373 days. The Botox group did experience an increase in postvoid residual in 75% of the subjects (130). The off-label use of Botulinum A cystoscopic detrusor injections to treat refractory urge incontinence in women with and without neurologic impairment is gaining popularity. The procedure is


Gynecology_Novak

Gynecology_Novak. (130). The off-label use of Botulinum A cystoscopic detrusor injections to treat refractory urge incontinence in women with and without neurologic impairment is gaining popularity. The procedure is done via cystoscopy and involves injecting 15 to 30 different detrusor muscle sites under direct visualization, sparing the bladder trigone and ureteral orifices.


Gynecology_Novak

Gynecology_Novak. Surgery to replace the function of a diseased bladder has been done for more than a century and over the past several decades has gained some popularity in treating people with intractable detrusor overactivity not responsive to any other form of management. These surgical options include (i) conduit diversion (creation of various intestinal conduits to the skin) or continent diversion (which includes a rectal reservoir or continent cutaneous diversion), (ii) bladder reconstruction, or (iii) replacement of the bladder with various intestinal segments. For a discussion of these techniques, both historical and current, the interested reader is referred to a review by Greenwell et al. (131). A Cochrane review found only two randomized trials that were of sufficient quality to include and concluded that there were no major differences in outcomes between the techniques and that higher quality research was needed (132). With the advent of sacral neuromodulation and cystoscopic injection


Gynecology_Novak

Gynecology_Novak. that there were no major differences in outcomes between the techniques and that higher quality research was needed (132). With the advent of sacral neuromodulation and cystoscopic injection with Botulinum A, these procedures are done much less often to treat women with detrusor overactivity.


Gynecology_Novak

Gynecology_Novak. Surgical Treatment of A wide variety of techniques are available for fistula repair (133,134). Traditionally, fistula repair


Gynecology_Novak

Gynecology_Novak. Fistulae was performed after a waiting period to allow the resolution of inﬂammation and formation of scar tissue. This is particularly important in the case of obstetric fistulas, in which the extent of the vascular injury to the soft tissues of the pelvis may not be apparent for many weeks. However, there is a recent trend toward early closure of small gynecologic fistulas (135). The keys to closure of a vesicovaginal fistula include wide mobilization of tissue planes so that the fistula edges can be approximated without any tension, close approximation of tissue edges, closure of the fistula in several layers, and meticulous attention to postoperative bladder drainage for 10 to 14 days. The closure of large fistulas will be enhanced by the use of tissue grafts (e.g., Martius labial fat-pad grafts, gracilis muscle ﬂaps) that provide an additional blood supply to nourish an area that has sustained vascular injury. The Latzko procedure used to close a vesicovaginal fistula is shown in


Gynecology_Novak

Gynecology_Novak. grafts, gracilis muscle ﬂaps) that provide an additional blood supply to nourish an area that has sustained vascular injury. The Latzko procedure used to close a vesicovaginal fistula is shown in Figure 26.14.


Gynecology_Novak

Gynecology_Novak. Cystoscopy Scientific evidence does not support routine cystoscopy in women with stress urinary incontinence in the absence of other pathologies (136). Cystoscopy cannot be used to predict intrinsic sphincteric deficiency, stress incontinence, or detrusor overactivity. Cystoscopy can be considered in the following circumstances: (i) in women with urge incontinence to rule out other disorders, especially in women with microscopic hematuria, (ii) in the evaluation of vesicovaginal fistulae, and (iii) intraoperatively to evaluate possible ureteral or vesical injury.