Stephen T Jeffery

University of Cape Town, South AfricaUrogynaecology and laparoscopy clinicwww.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

• 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

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

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 1: If she was living in Accra / Kathmandu/

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

• Important symptoms: Urinary incontinenceStress

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

Approach

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?

Faecal symptomsFaecal 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?

Approach

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?

• PyuriaUTI is an important cause of urgency

• GlycosuriaDM – Peripheral autonomic neurop, UTI

• HaematuriaBladder Ca

Urine dipstix

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)

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)

Cheap “cystometry”(acknowledgements to Lauri Romanzi)

Treatment options for stress and urge urinary incontinence, prolapse

55

Supporting• pessaries, tampon

• incontinence pads

Behavioral intervention• reducing fluid intake

• prevent intoxications (coffee etc)

• bladder training

• cough technique

• reduction of weight

• prevent psychological and somatic stress situations

Drug therapy• Anti-cholinergics, α-sympaticomimetics• Estrogen

Pelvic floor physiotherapy• Pelvic floor reeducation • Kegel exercises• Biofeedback

Surgical therapy• mid-urethral slings• colposuspension • bulking agents

• Prolapse surgery• Fistula surgery

No therapy• ???

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

Download these slides for free at

www.urogynaecology.co.za

Download these slides for free at

www.urogynaecology.co.za