THE OFFICIAL NEWSLETTER Volume 1, Issue 2

SA UROGYNAECOLOGICAL ASSOSCIATION

NOVEMBER 2013

LETTER FROM THE EDITOR A great big thank you to Bettina Vizirgianakis, for collating this Edition of SAUGA Newsletter. The last Edition, collected by Steve Jeffery, was very well received: in fact, some pharmaceutical firms have approached me to sponsor our newsletter. This edition has been kindly sponsored by BOSTON SCIENTIFIC. We have a fair spread of articles this edition: all with a practical slant. I hope you enjoy reading this wide variety of papers. PETER DE JONG

Letters to the Editor Dear Editor I read in this issue of the Newsletter, Prof Philip Tooze—Hobson’s paper on voiding dysfunction, that animal models have been used to demonstrate the effects of ischaemia on the bladder (see page 3). I strongly object to the use of beagle dogs in animal experiments to demonstrate urinary dysfunction. Yours, Dr Winer

Dear Dr Winer Thank you for your interest, Dr Winer. I fully agree. Recently I acquired 2 beagle puppies (see pic). Sadly, it appears that these 2 puppies were the very dogs used experimentally by Prof Tooze-Hobson to demonstrate uncontrolled voiding dysfunction. They also have uncontrolled bowel dysfunction, a fact he appears to have inexplicably overlooked. Regards Editor

Picture: Beagle puppies show voiding dysfunction. Note urine on newspaper

SAU GA N E WS L E T T E R Volume 1, Issue 2

SA UROGYNAECOLOGICAL ASSOSCIATION

EDITORIAL : P. DE JONG

HERBAL MEDICINE— how safe is it? Herbs and plants have been used for

aissance period and beyond. It

from the truth, since there are

medicinal purposes from ancient

sought to disprove superstitions

many “natural” agents that inter-

times. It was ancient Greece that

and rituals

accreted around the

fere with bleeding and haemosta-

bequeathed herbal knowledge to

collecting of plants. For example, it

sis during surgery. Patients often

both the Western and Islamic

was believed that when the man-

also not declare use of herbs dur-

world. Antique herbals were origi-

drake was pulled up, it screamed

ing a medical history, erroneously

nally conceived as codices of sim-

and whoever heard it would die.

assuming herbs to be, by their

ples, medicines or medicaments

The custom was to tie a dog to the

very nature innocuous. The fol-

consisting of only one constituent,

plant and let the dog pull it out

lowing “natural” agents have been

especially one herb or plant. Aris-

whilst the people ran away so as

implicated in disturbing thrombo-

totle, Crateuas, Theophrastes and

not to hear the screaming.

sis and haemostasis, and patients

Pliny, philosophers from the classical Greek period, were all interested in and wrote about plants and herbal medicine. But it was a Greek doctor,

Pedanios

Dioskurides,

Two mandrake plants (Mandragora autumnalis) showing the Arabic illustrative style copied perhaps in Baghdad. Reproduced with permission from the Bodleian Library, Oxford University

aught to be interrogates as to their use prior to surgery:  Ginseng  Garlic

knownt to us by his Latin name

 Omega 3

Dioscorides, who was to become the

 Ginca Bulova

most influential.

 Ginger  St John’s Wort

Born in 40 AD in Asia Minor, Dioscorides studied in Alexandria and

 Black Cohosh

worked as a doctor with the army of

 Arnica

the Roman Empire which gave him

 Spirulina

the opportunity to observe the local flora of the Mediterranean. In 77

However it has become apparent

AD he wrote, in Greek, his great

that despite widespread use of

work De Materia Medica in five volumes, which was to become the

herbs for various Maladies, they

most authoritative work on medici-

which make some downright dan-

nal plants for 1500 years.

gerous. Many women use sero-

Dioscorides described 600 medical simples which included a description of the plant, its origin, habitat, preparation of the simple and its medical effect. De Materia Medica was accepted as the authority throughout Western Europe and much of central Asia up to the Ren-

do have unwanted side effects

tonin—inducers to combat depression. The use Black Cohosh and St John’s Wort for this purpose is common, but the affects of these agents

remains

unresearched,

since they are perceived to be harmless due to the very nature of their composition. This is far

 Cinnamon This list is incomplete: as a general rule, suspend use of all herbs before surgery. I have on 2 occasions had to “re-laparotmise” women after being caught out by their use of herbs. Our MCC is careful to scrutinize medicines, but allows medicinal use of herbs with gay abandon. (pictures and some of the text reproduced from Veld & Flora, Sept 2013)

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in damage. Voiding dysfunction has been recently defined by the ICS and IUGA as a diagnosis by symptoms and urodyamic investigation and is defined as abnormally slow and /or incomplete mucurition. Abnormal slow urine flow rates and abnormally high post void residuals are the basis of this diagnosis. This diagnosis should be based on a repeated measurement to confirm abnormality. Short term injuries may be reversible or result in damage, depending on whether the bladder tissue stretches past its elastic limit into plastic deformity. This in turn causes the bladder to empty inefficiently. There is a reduction of the oxygen supply once the intravesical pressure rises beyond 7-10mm Hg, resulting in ischaemia and tissue damage.

Dr Philip Toozs-Hobson MD FRCOG, Fidan Israfil-Bayli MBBS PhD

FEMALE VOIDING DYSFUNCTION AFTER SURGERY

The bladder is a compliant organ which can distend dramatically with little observable pressure change. Over-distention may result

Animal models have demonstrated two effects of ischaemia. Firstly, that the bladder loses its ability to empty completely (although this will usually recover with time). Secondly there is evidence that reperfusion may add a second layer of injury onto the bladder and as a result of this oxidative stress, the ability of the bladder to produce nerve growth factor is reduced after repeated insults and also an increase in the muscle provides more sensitivity to the neurotransmitters. The changes in the bladder’s nerve supply leads to an increase in the so called “nonadrenergic noncholinergic” fibres, otherwise known as the adrenergic fibres. Normally the bladder is protected as a result of sensory fibres which alert an individual to the bladder filling and the need to void. However, alteration in sensation post operatively may lead to the loss of sensation and as a result patients may be unaware that they have developed voiding problems. Three aspects of voiding dysfunction are discussed.

Childbirth During childbirth, mode of delivery and anaesthetic affect immediate sensation, with return of bladder sensation being delayed by up to 12 hours after Caesarean section. In childbirth, up to 85% of women will have evidence of nerve injury leading to loss of normal nerve function.

Pelvic Surgery Female voiding dysfunction may occur as a result of detrusor hypotonia or bladder outlet obstruction. The most common cause of hypotonia is bladder overdistention and the effects are outlined above. Other causes of dysfunction include pain from infective, allergic or chemical damage of urogenital tissues. Bladder outlet obstruction can be intraluminal but is most commonly extra-luminal as a result of anatomical changes relating to surgery. A third pathophysiology for obstruction is dyssynergia which may be neurogenic, iatrogenic (pharmalogical or pain) or psychogenic.

Continence Surgery One of the challenges of pelvic floor medicine is predicting voiding difficulties, and managing patients expectation. Urodynamics have repeatedly been investigated but there has been a failure to identify a reliable predictor of post— operative voiding dysfunction. A meta-analysis of vaginal tapes for stress incontinence suggests that obturator tapes may have a slightly lower incidence of voiding dysfunction. Management of voiding dysfunction has been controversial with traditionalists managing women conservatively with in-dwelling catheters or intermittent self catheterization. Our data suggests only 3% have a long term problem. Additionally if the tape is subsequently cut 80% will then resolve with only 20% having a return of symptoms. Another area of surgery result in voiding dysfunction is intravesical injection of botulinum toxin. The RELAX study showed a 16% CISC rate (v 4% in placebo)

Management Management is usually practical and symptom-based and involves draining the bladder. This may be initially by resting the bladder with free drainage and subsequently (or if picked up immediately) by self catheterization. Drug modification, treating infection and constipation as aggravating factors, is also important. In refractory cases either peripheral nerve stimulation or sacral nerve stimulation my be appropriate.

Presented at the SAMS Menopause Update 2013

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PESSARIES FOR PROLAPSE - WHY NOT! Pelvic organ prolapse occurs in up to 50% of parous women. 77% of clinicians in the United Kingdom use pessaries as first line therapy, yet in South Africa their use is limited and often only used by practitioners who are perceived as experts in fitting pessarys.

There are several reasons why one would choose to use a pessary over surgery. They are particularly appropriate for women whom still desire fertility or who are not fit for surgery due to medical reasons. They give immediate relief of symptoms with minimal risk. Not all women desire surgery, given a success rate of around 60%. When choosing a pessary, silicone causes less odorous discharge and are more durable than Latex. For prolapsed, either a ring with support or a gellhorn pessary would be appropriate as first line choices. The cube should be reserved for patients with procedentia or for patients where the ring type pessaries fall out. Most patients maybe taught to remove and insert the pessary themselves, but patients whom are frail or not willing to change them must be seen regularly. The primary goal when fitting a pessary is that the prolapse is prevented from bulging beyond the introtius. The ring with support, and gellhorn pessary tends to rest just inside the introitus when the patient is upright. It is important to council the patient that it is not falling out. In general, patients with an intoitus more than 4 cm in diameter are less likely to retain the device insitu. For sizing, 2 fingers are placed in the vagina and spread apart as if assessing dilatation, and then measured in cm to gauge width and size of pessary. A ring with support should be used as the first choice. Estrogen cream should be used in conjunction with a pessary, for those patients with atrophy . Complications are usually related to neglect and consist of erosions, abrasions and discharge. If this does occur they should have a break from the pessary for 3 weeks and use daily vaginal estrogen for 2 weeks. In a recent Cochrane review in 2013 there was only 1 randomized controlled trial that compared the ring to the gellhorn. Both were effective in 60% of cases with varying degrees of prolapse. There is however no good randomized controlled trial comparing surgery to pessary use.

PRACTICE POINT Pessaries are however cheap, safe ,effective alternatives to surgery and require very little training in order to use them, and possibly should be our first choice for patients with prolapse.

A PESSARY - WHY NOT TRY?

PROF TRUDY SMITH

A pessary is a mechanical device that is designed to support the vagina. They come in various shapes and sizes and have different functions. They are made of silicone or plastic. There are 2 broad groups of pessaries: Space occupying pessariesi.e. a cube or a doughnut, and support devices such as rings.

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DR KENDALL BROUARD

IS THERE A ROLE FOR URODYNAMICS BEFORE SURGERY FOR STRESS INCONTINENCE? At the International Urogynaecology Association (IUGA) conference earlier this year I attended a debate between Charles Nager and Dudley Robinson on the value of Urodynamics (UDS) before surgery for Stress urinary incontinence (SUI). In a recent publication, Charles Nager laid out most of the points that he made in the debate and I have summarised them below.In his article he also compared the predictive ability of urodynamic prolapse reduction stress testing with office-based prolapse reduction stress testing for detecting postoperative SUI in women without SUI undergoing prolapse surgery. I have not included that in this article, but it makes for interesting reading(1).

UDS are essentially designed to measure the bladders ability to store and void urine. They should supplement, not replace the clinical assessment which consists of history, physical examination and side room investigations (urinalysis and post voiding residual). In order for the patient to benefit from UDS, the tests should be done with the aim of answering a specific clinical question. Ideally the answer to this question should then guide our decision making with regard to management, and result in a better outcome for the patient.

The IUGA and the International Consultation for Incontinence recommend UDS before invasive treatment (surgery) for SUI(2,3). However, the National Institute of Clinical Excellence states that routine UDS are not recommended before surgery in women with a clearly defined clinical diagnosis of pure SUI(4). Despite this, 66% of specialists in the United Kingdom consider UDS to be essential preoperatively in a patient with pure demonstrable SUI(5). Reasons for this include the need to confirm the diagnosis of SUI, evaluate urethral function, evaluate for detrusor overactivety (DO)and evaluate bladder emptying. But is there evidence that these pre-operative urodynamic findings are useful in guiding our management and consequently improving patient outcomes?(1)

The TOMUS trial (Trial Of MidUrethral Slings) was a trial of 597 women with a positive cough test and preoperative UDS who then randomly received either a retropubic or transobturator midurethral sling (6). The ValUE (Value of Urodynamic Evaluation) trial was a randomised trial of UDS before surgery for stress incontinence. 630 women were randomised and 315 received UDS pre-operatively while the other group only had office evaluation(7). In these two large Urinary Incontinence Treatment Network (UITN) studies which included women with predominant SUI symptoms and positive office cough test, the finding of Urodynamic stress urinary incontinence was confirmed in 86% and 97% respectively (1,6,7). Surgical outcomes were not improved in the group of women that had confirmation of their SUI on UDS (1). In women with SUI symptoms but a negative office stress test, UDS is indicated.If these women do not demonstrate USI, the catheter needs to be removed as it has been shown that more than 50% of these women will then demonstrate stress incontinence(8). This would not diagnose USI, but confirm SUI.

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Studies by Miller et al and Schierlitz et al suggested a higher failure rate of transobturator tapes versus retropubic tapes in women with Intrinsic Sphincter Deficiency (ISD) (9). As a result some surgeons use results of urethral function studies (Valsalva leak point pressure – VLPP and maximum urethral closure pressure – MUCP) to predict failure or decide on management, i.e. perform a retropubic rather than a transobturator tape in women with lower urethral function test results.It should be mentioned, however, that in the Schierlitz study the objective failure and re-operation rate was higher in the group of women who had transobturator tapes, but there was no difference in pad test, and patient reported quality of life (1,9). In the TOMUS study where the surgeons were blinded to the urodynamic results, women with lower MUCP or lower VLPP values had twofold higher objective failure rates with either retropubic or transobturator midurethral sling. No urodynamic measure was associated with subjective failure (10). MUCP values have poor reproducibility and it can be argued that there is no biological rationale for cut-off or threshold values (1). The most recent IUGA / ICS joint report on the terminology for female pelvic floor dysfunction does not include the diagnosis of ISD (11). If your surgery of choice for SUI is a retropubic midurethral sling, then urethral function studies do not provide any additional information to change management. If your aim is to improve the patient’s symptoms and quality of life, then neither the TOMUS nor Schierlitz studies suggest that urethral function studies are of value in determining route of surgery (1). Using data from the ValUE study, 113 UDS need to be done to prevent one objective failure if the aim of the UDS is to decide between transobturator and retropubic sling(1). Some clinicians perform pre-operative UDS in women with SUI or mixed UI in order to determine if there is detrusor overactivity (DO), and if so, offer alternative conservative or medical therapy first. It should be remembered though that urge incontinence is a clinical diagnosis; irrespective of whether DO is evident on UDS. In the TOMAS study, 9-14% of women with predominant SUI symptoms and a positive stress test had DO on UDS. The failure rate in this group was not significantly higher than in the group without DO (6). A recent systematic review and meta-analysis by Jain et al. which included 13 studies on the effectiveness of midurethral slings in mixed incontinence found that there were good cure rates (85-97%) of the stress component and 30-85% cure rates for urgency urinary incontinence. There was no apparent significant difference in the overall subjective and UUI cure rate between retropubic and transobturator tapes (12). There is no good evidence that a midurethral sling should not be performed in patients with DO, or that the presence of DO should dictate the route of the tape (1). Urodynamic bladder emptying studies (non-invasive uroflowmetry or pressure flow studies) are sometimes performed before SUI surgery with the idea that the results could predict possible post-operative voiding dysfunction and consequently guide management (placing the tape ‘looser’ or selecting transobturator tape over retropubic tape)(1). Recent studies have questioned previous findings that low peak flow rates were associated with delayed voiding after pubovaginal sling particularly in women with normal post void residuals (13). The SISTEr trial was a randomised trial of women with symptoms of SUI and a positive stress test who underwent UDS before either Burch or pubovaginal sling. Fifty seven of 655 women met the definition of post-operative voiding dysfunction (need for surgical revision or catheterisation beyond 6 weeks); however, no preoperative UDS findings were associated with an increases risk of voiding dysfunction(14). In the TOMUS trial voiding dysfunction rates at 6 weeks were negligible; however, UDS did not even predict the 24% of women who required a second voiding trial (6).

PRACTICE POINT Recent good quality evidence suggests that women with predominant stress symptoms, no previous surgery, a positive stress test, a normal residual and no prolapse do not require UDS before surgery for SUI. The Medical, Epidemiological, and Social Aspects of Aging (MESA) score is a useful tool to determine whether stress or urgency incontinence is the predominant symptom. In more complicated patients UDS can provide helpful information about bladder function in order to guide management of the patient.

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REFERENCES 1.

Nager CW. Role of Urodynamics in the Evaluation of Urinary Incontinence and Prolapse. Curr Obstet Gynaecol Rep. 2013;2:139-146

2.

Ghoniem G et al. Evaluation and outcome measures in the treatment of female urinary incontinence: International Urogynaecological Association (IUGA) guidelines for research and clinical practice. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(1):533

3.

Abrams P et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse and fecal incontinence. Neurourol Urodyn. 2010;29(1):213-40

4.

NICE. Urinary incontinence. The management of urinary incontinence in women National Institute for Health and Clinical Excellence (NICE), 2006. NICE clinical guidance 40: p. 1-36

5.

Hilton P et al. Assessing professional equipoise and views about a future clinical trial of invasive urodynamics prior to surgery for stress urinary incontinence in women: a survey within a mixed methods feasibility study. Neurourol Urodyn. 2012;31 (8):1223-30

6.

Richter HE et al. Retropubic versus transobturator midurethral slings for stress incontinence. N Engl J Med. 2010;362 (22):2066-76

7.

Nager CW et al. A randomised trial of urodynamic testing before stress incontinence surgery. N Engl J Med. 2012;366 (21):1987-97

8.

Maniam P, Goldman HB. Removal of transurethral catheter during urodynamics may unmask stress urinary incontinence. J Urol. 2002;167(5):2080-2

9.

Schierlitz L et al. Effectiveness of tension free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency: a randomised controlled trial. Obstet Gynecol. 2008;112(6):1253-61

10.

Nager CW et al. Baseline urodynamic predictors of treatment failure 1 year after midurethral sling surgery. J Urol. 2011;186 (2):597-603

11.

Swift S. Intrinsic sphincter deficiency; what is it and does it matter anymore? Int Urogynecol J. 2012

12.

Jain P et al. Effectiveness of midurethral slings in mixed urinary incontinence: a systematic review and meta-analysis. Int Urogynecol J. 2011;22(8):923-32

13.

McLennan MT, Melick CF, Bent AE. Clinical and urodynamic predictors of short-term voiding after fascia lata suburethral sling. Obstet Gynecol. 1998;92(4 pt 1):608-12

14.

Albo ME et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med. 2007;356 (21):2143-55

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WHAT PHYSIOTHERAPY CAN AND CANNOT DO FOR PROLAPSE! The prevalence of symptomatic POP is reported to be between 3-28% with prolapse symptoms such as vaginal Prolapse recurrence after surgery can be up to 58%.(Braekken et al, 2010). The role of physiotherapy as a conservative and preventative treatment option is thus of interest. The theoretical rationale for pelvic floor muscle training (PFMT) for POP is based on DeLancey’s “boat in dry dock theory”. The ship is analogous to the pelvic organs, the ropes to the ligaments and fascia and the water to the supportive layer of the pelvic floor muscles (PFMs). DeLancey argues that as long as the PFMs function normally, the ligaments and fascia are under normal tension. If the PFMs relax or are damaged, the connective tissue support of the organs fail and hence pelvic organ descent. This underpins the concept of strength training and therefore elevation of the PFM and closure of the levator hiatus as important elements in conservative management of POP. This is achieved in clinical practice by asking women to earn to consciously contract before and during increased abdominal pressure (known as ‘The Knack’), the second being a strength training program to build up structural support over time. (Bo, 2012) Bo’s 2012 review reported findings of 5 RCTs with all being in favour of PFMT for POP. Braekken et al (2010), found a significant and huge increase in strength in the PFMT group, statistically significant increases in muscle volume, constriction of the levator hiatus and lifting of the bladder neck and rectal ampulla and subsequently a strong effect on patients’ POP symptoms including associated bladder and bowel symptoms. The recent POPPY Trial, a multicentre RCT, showed significant improvement in prolapse symptoms at 6 and 12 months. The intervention group showed greater self-reported change and were less likely to seek further treatment.PFM contractile strength increased significantly and found the intervention to be cost-effective. There were only marginally significant changes in prolapse severity. Based on the principles of exercise science, in order for muscle training to be effective, the muscle needs to be intact both at its origin and insertion. We therefore would assume that puborectalis avulsion injuries may not respond as well to PFMT. In more recent studies there has been interest in whether PFMT decreases the POPQ stage. It is yet inconclusive but there is a certain percentage of patients that decrease their POP-Q stage with PFMT. Patients however need to appreciate that PFMT will not ‘take their prolapse away’ but merely attempt to improve prolapse symptoms and in so doing delay the need for further intervention. Aside from the idea of strength training for patients with POP, PFM co-ordination training is also a critical component of pelvic floor rehabilitation, especially when managing posterior compartment prolapse. Slieckerten-Hove (2009) found a significant correlation between posterior compartment prolapse and bowel disorders especially obstructive defaecation. Functional as well as structural abnormalities frequently co-exist and this is especially true in patients complaining of symptoms of obstructive defaecation(Muller-Lissner 2011). PFM coordination training, biofeedback and defaecation retraining have proven successful in patients with obstructive defaecation with or without structural defects.

PRACTICE POINT Sufficient high quality data has been obtained in the last few years and it therefore makes us able to conclude that PFMT is effective with no adverse side effects as well as cost saving, hence, a recommended first line management

BETTINA VIZIRGIANAKIS

bulging and heaviness being the most common. It is based on these symptoms that surgery is indicated.