Transcript - urogynaecology.co.za


Stephen T Jeffery
University of Cape Town, South Africa
Urogynaecology and laparoscopy clinic
www.urogynaecology.co.za
Impact of Pelvic Floor Dysfunction
 Very different from the experience in well resourced
settings.
 Heaviest burden is in the prevailing problem of
obtsetric fistula.
Let’s kick off with a few typical cases
Case 1
• 56 year old
• Complains of urgency, urgency incontinence
daily episodes
• Also incontinence with coughing, laughing
and sneezing
• On exam – obvious stress leak with cough
Case 1
 Options?
Case 1: If she was living in Chicago / London / Paris
For the urgency incontinence
 Bladder retraining by specialist continence nurse
 Pelvic floor exercises by women’s health physiotherapist
 Trial of anticholinergic therapy including tolteridine,
solifenacin, oxybutynin slow realease, mirabregnon
 Possibly Intradetrusor Botox
 Poterior tibial nerve stimulation
 Sacral Nerve Stimulation
Case 1: If she was living in Chicago / London / Paris
For the stress incontinence
 Tension –free vaginal or transobturator tape
Case 1: If she was living in Accra / Kathmandu/
For the urgency incontinence
 May have some advice about PFE / Bladder drill / Fluid advice
 May get some Oxybutynin
Case 1: If she was living in Accra / Kathmandu/
For the stress incontinence
 Depends on training
 Possibly have a Burch / Pubovaginal sling
 No option of a TVT or TOT
Case 1: If she was living in Accra / Kathmandu/
AND would she even have sought help for this problem?
Case 2
 21 year old
 Constant urinary leakage
 Delivered a macerated, dead baby at home 6 months ago
Case 2
Case 3: Only likely to see in resource constrained setting
Case 4:
Prolapse
Urinary
Incontinence
Fecal
Incontinence
Other common referral problems
•
Hematuria
•
Recurrent UTIs
•
Bladder pain syndrome
•
Sexual dysfunction/dyspareunia
•
Pelvic pain
•
Defecatory difficulty
•
Obstructed defecation
The most staggering statistics are the
related to fistula
Pelvic Floor Health in Resource
Constrained Settings
 Under-reported
 Under-diagnosed
 Undertreated
 Significant direct and indirect costs
First of all – get the basics right
Approach
• Important symptoms: Urinary incontinence
Stress
Urgency / urgency incontinence
Nocturia
Leakage with sex
How many pads
Symptoms of voiding dysfunction
Medications: Look for diuretics and Beta blockers
Approach
• Red flag symptoms
– Voiding difficulties
– Haematuria
– Severe bladder pain
Prolapse related queries
Does the bulge protrude through the introitus?
How big is it in relation to known objects such as a
golf ball, egg, lemon, orange?
How exactly is the problem BOTHERING her?
What are her fears about the bulge?
What are her expectations for treatment?
Approach
Faecal symptoms
Faecal Urgency
Faecal Incontinence
Defaecatory difficulty
Change in bowel habit
Bleeding
Straining and digitation
Distinguishing between flatus
and solid stool
Rectal prolapse
Approach
Sexual Dysfunction
Approach
• General Medical History
– Multiple sclerosis
– Parkinsons
– Stroke
– Risk factors for surgery
Approach
•Surgical History
– Previous incontinence/ prolapse surgery?
– Does she still have a uterus?
– Previous gynaecological surgery?
Neuro Exam
 S2, S3, S4 nerves – peri-anal skin
 Decreased ankle reflexes – SCI or Cauda Equina
Abdomen
 Ileal disease – RLQ (Crohns)
 Abdominal mass
Don’t only zoom in on the vagina
Fistula
Skin Irritation
Digital Rectal Exam
 Squeeze
 Some correlation with
manometry
Case
•
45 year old with Stage III
vaginal vault and rectal
prolapse. She is sexually
active.
•
Total Vaginal Length is 8
cm
•
What options would you
present to this patient?
Urine dipstix
• Pyuria
UTI is an important cause of
urgency
• Glycosuria
DM – Peripheral autonomic
neurop, UTI
• Haematuria
Bladder Ca
Bladder diary
Don’t forget the
bladder diary
Don’t forget the
bladder diary
Check Urine Residual
 Catheter
Or
 Ultrasound
Cheap “cystometry”
(acknowledgements to Lauri Romanzi)
Cheap “cystometry”
(acknowledgements to Lauri Romanzi)
1
Position patient in lithotomy, with head raised if
possible
2
Separate labia, STAND TO THE SIDE, as pt strains,
then coughs – note presence/absence SUI, record
data
3
Clean meatus with Betadine
4
Insert red rubber catheter use lubricant
5
Empty bladder, record volume
Cheap “cystometry”
(acknowledgements to Lauri Romanzi)
6
Evaluate urine for infection (dipstick, visual inspection) &
record findings – defer filling if infected
7
Invert catheter & attach 60 ml catheter tip syringe
8
Fill bladder via gravity in 50 ml increments using normal
saline
9
Note volume at which patient reports 1st urge, moderate
fullness, total fullness
10 Evaluate filling phase for presence/absence involuntary
bladder contractions (detrusor instability) record
findings
Cheap “cystometry”
(acknowledgements to Lauri Romanzi)
⑪ At capacity, remove catheter and have patient
strain (Valsalva) & cough again – record
presence/absence SUI
⑫ If patient does not demonstrate SUI supine, repeat
strain & cough in standing position, record presence
absence SUI
⑬ Have patient void into container – record audible
characteristics of flow, volume voided, & calculate
post-void residual (PVR)
Treatment options for
stress and urge urinary incontinence, prolapse
Supporting
Pelvic floor physiotherapy
• pessaries, tampon
• Pelvic floor reeducation
• incontinence pads
• Kegel exercises
• Biofeedback
Behavioral intervention
• reducing fluid intake
Surgical therapy
• prevent intoxications (coffee etc)
• mid-urethral slings
• bladder training
• colposuspension
• cough technique
• bulking agents
• reduction of weight
• prevent psychological and somatic
stress situations
• Prolapse surgery
Drug therapy
No therapy
• Anti-cholinergics, α-sympaticomimetics
• ???
• Fistula surgery
• Estrogen
55
Inexpensive treatment options
Basic fluid advice
Group physio therapy sessions
Anticholinergics
 Always worth trying Oxybutynin
 If you can’t afford second line anticholinergic
therapy, don’t worry – most of them don’t really
work!
Persistence on Specific Medications for OAB Based on
Prescription Data
Cheap posterior Tibial Nerve Stimulation
Pessaries
Pessaries
 Follow up 6 monthly
 Clean and re-insert each time
 No need to replace with new one
Other essential tools of the trade

Identify keen doctors and support them
 Don’t underestimate the power of energy and
enthusiasm!
Training, training, training!
Identify your specific challenges
 Lack of training
 Lack of resources
 No patients
 Anaesthesia
 Radiological investigations
 Competing interests
 Oncology
 Obstetrics
 Emergency gynae
Build your team
 Urologist
 Colo-rectal
 Physio
 Nurses

www.urogynaecology.co.za
www.urogynaecology.co.za