Christopher W. Wagener MDAffinity Medical Group

Obstetrics and Gynecology

Stress Urinary Incontinence & Cytoceles

Overview• Stress Incontinence

– What is it?– What causes it?– How is it treated?

• Cystocele– What is it?– What causes it?– How is it treated?– What’s new and what should you be aware of?

Incontinence

• International Continence Society (ICS)• (2002) The complaint of any involuntary leakage

of urine.• It increases with age, but is not normal and

treatment is available.

Incontinence• Stress incontinence 50%• Overactive bladder syndrome 25%• Mixed incontinence 25%• Overflow incontinence• Fistulae• Urethral diverticulum• Functional• Reversible causes

How the Urinary System Works

Ureter

Bladder

Bladderneck

Urinarysphincter

Urethra

Kidney

Stress Incontinence

• Involuntary leakage of urine on effort or exertion, or on sneezing or coughing

• Usually small amounts• Pressure in the bladder

exceeds the urethral pressure

• No bladder contraction

Stress Incontinence• Causes

– Pregnancy/Childbirth– Age– Obesity

• BMI 25-30, 2x increase• BMI >40, 66%

– Chronic cough• ACE inhibitors• Smoking

– Genetics

• Evaluation– History– Physical exam

• Cough stress test• Urethral mobility• Assess for prolapse

– Urine test– Possibly urodynamic

testing

Stress IncontinenceTreatment

• Weight loss, treatment of chronic cough• Physiotherapy

– Pelvic floor muscle training– Vaginal cones– Biofeedback

• Pessary with incontinence knob• Midurethral sling• Periurethral bulking agents

Tension-Free Vaginal Tape Sling• Indicated when conservative treatment fails• Child bearing is complete• Restores the urethral support• 85 to 90 % success rate• Minimally invasive• 6 weeks of restrictions, recommend 2 weeks off work• Risks

– Bleeding, infection, bladder or other organ injury– Mesh erosion, urinary retention, overactive bladder symptoms

TVT Sling

Bulking Agents• Minimally invasive• Consider for patients with non-mobile urethra, prior

unsuccessful incontinence procedures, significant health problems

• 40- 60 % success rate• No restrictions after surgery• May take more than one procedure• No long term studies to show it is long lasting• Risks: Urinary tract infection, retention, discomfort

Bulking Agents

Cystocele• Protrusion of the bladder into the vagina (hernia)• Also called a dropped bladder/prolapsed bladder• May be associated with uterine prolapse,

rectocele, or enterocele• May notice a vaginal bulge or pressure• Urinary symptoms including incomplete bladder

emptying

Cystocele

Cystocele• Causes

– Childbirth– Age– Genetics– Occupation– Medical conditions

• COPD, cough• Obesity• Constipation

• Evaluation– History

• Symptoms• Incontinence

– Pelvic exam• Stage prolapse• Strain or bear down• Check uterus and

ovaries• +/- Cough stress test

– +/- Urine test

Natural History• Prospective observational study• 259 postmenopausal women, with a uterus• Over 3 years

– Maximal descent increased by >2 cm in 11.0%– Maximal descent decreased by >2 cm in 2.7%

• Obesity and grandmultiparity were risk factors for worsening prolapse

Bradley, Obstet. and Gyn. 2007; 109:848

Cystocele Treatment: Pessary

• Appointment to fit • Trial • May not work for certain

patients• Side effects

– Discharge– Pressure sores– UTI

Surgery

• Cystocele repair• Anterior repair• Anterior

colporrhaphy

• Without grafts– Suture repair

• With grafts– Biological grafts– Synthetic grafts

Cystocele Treatment

Symptom likely to resolve

Questionable if symptom will resolve

• Bulge • Pressure

• Urinary • Gastrointestinal• Sexual function• Pelvic and back pain• Consider pessary trial

Grafts• Lower rate of failure• Fewer hysterectomies with graft use

– Patient acceptance– Possible risk factor for incontinence– Minimize risks of intra-abdominal

complications• Complications

Graft supporting bladder and uterus

21

Risks of Synthetic Grafts• Erosion 3-8 %• Infection• Rejection of mesh• Dyspareunia (pain with sex) 10%• Injury to adjacent structures

FDA Public Health Notification• October 2008• Over 1000 reports of complications in a

3-year period• Specific characteristics of the patients at risk

have not been determined• Complications of erosion through the vaginal

epithelium, infection, pain and urinary problems

Recommendations for Physicians• Obtain specialized training for each mesh placement technique, and

be aware of its risks. • Be vigilant for potential adverse events from the mesh, especially

erosion and infection. • Watch for complications associated with the tools used in

transvaginal placement, especially bowel, bladder and blood vessel perforations.

• Inform patients that implantation of surgical mesh is permanent, and that some complications associated with the implanted mesh may require additional surgery that may or may not correct the complication.

• Inform patients about the potential for serious complications and their effect on quality of life, including pain during sexual intercourse, scarring, and narrowing of the vaginal wall (in POP repair).

• Provide patients with a written copy of the patient labeling from the surgical mesh manufacturer, if available.

Grafts• Consider for patients with recurrences• Paravaginal defects• Severe prolapse or poor native tissue• Weigh risks and benefits

The Future

• Robotically assisted prolapse surgery• Minimally invasive• Vaginal apex prolapse