CPG Urogynecology

"#$%&!'()%!Philippine Obstetrical and Gynecological Society (POGS), Foundation, Inc. ! CLINICAL PRACTICE GUIDELINES on UROGYNECOLOGY ! November 2010 Task Force on Clinical Practice Guidelines on Urogynecology ! ! FOREWORD! ! REGTA L. PICHAY, MD President Philippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2010 REGTA L. PICHAY, MD INTRODUCTION! EFREN J. DOMINGO, MD, PhD Editor in Chief, Clinical Practice Guidelines, 2010 The Clinical Practice Guidelines on Urogynecology is the First Edition of this Publication, 2010. The Philippine Obstetrical and Gynecological Society, (Foundation), Inc. (POGS), through the Committee on Clinical Practice Guidelines initiated and led to completion the publication of this manual in plenary consultation with the Residency Accredited Training Hospitals’ Chairs and Training Officers, The Regional Board of Directors, The Board of Trustees, The Task Force on Urogynecology and the Committee on Continuing Medical Education (CME). This publication represents the collective effort of the POGS in updating the clinical practice of Obstetrics and Gynecology, specifically on Urogynecology, and making it responsive to the most current and acceptable standard in this procedure. A greater part of the inputs incorporated in this edition are the contributions originating from the day-to-day academic interactions from the faculty of the different Residency-Accredited Hospitals in Obstetrics and Gynecology in the country. This Clinical Practice Guideline on Urogynecology is envisioned to become the handy companion of the Obstetrician-Gynecologist in his/her day-to-day rendition of quality care and decision making in managing the Gynecologic patient. This is also envisioned to provide the academic institutions in the country and in Southeast Asia updated information on Urogynecology as being practiced in the Philippines. Profound gratitude is extended to all the members of the POGS, the Chairs and Training Officers of the Residency-Training Accredited Institutions, the Regional Directors, The Task Force Reviewers/Contributors, The CME Committee members, and the 2010 POGS Board of Trustees. EFREN J. DOMINGO, MD, PhD MD Ma. Luna. MD Treasurer Gil S. MD President Sylvia delas Alas Carnero. Castro. Cynthia Fernandez-Tan. MD Public Relations Officer BOARD OF TRUSTEES Efren J. MD . Quillamor. delos Reyes. PhD Virgilio B.BOARD OF TRUSTEES 2010 OFFICERS Regta L. MD Secretary Jericho Thaddeus P. Pichay. MD Vice President Ditas Cristina D. MD. MD Blanca C. Decena. de Guia. MD Rey H. MD Raul M. Domingo. Gonzales. Lacson. MD (Region 4A NCR) Evelyn R. De Guzman. PhD Editor in Chief MEMBERS Ann Marie C. MD Abigail Elsie D. Prodigalidad-Jabson. Reyes. MD Jericho Thaddeus P. MD Regina P. Torres. MD Sarah Pingol. Hudencial. MD (Region 9) Amelia A. Dy Echo. MD Lennette L. MD (Region 3) Diosdado V. Victoria V. Trinidad. MD (Region 7) Cynthia A. Mariano. MD Gil S. MD MANAGING EDITOR Ana Victoria V. MD Corazon B. Caras. MD Grace D. MD (Region 8) Jana Joy R. MD Ricardo Braganza. MD Rommel Z. Esteban. MD Jean Marie Salvador. Tan. MD Maribel Hidalgo-Co. Domingo. Duenas. MD Antonio Cortez. MD Suzette Miclat. MD (Region 6) Fe G. MD Maria Teresa C. MD Macrina A. MD Lorina Q. MD Marilou Viray. Mariano. Rodriguez. MD TECHNICAL STAFF ASSISTANTS Ms. MD TASK FORCE REVIEWERS AND PLENARY REVIEWERS Rainerio S. Merin. MD Margarette Lavalle. delos Angeles. MD Lisa T. MD Esmarliza Tacud-Luzon. MD Ma. MD May N. Luna. MD Regta L. Tusalem. Castillo. MD Alice Salvador. Quevedo. MD Ma. Prodigalidad-Jabson. Pañares. MD (Region 4) Cecilia Valdes-Neptuno. Dizon. MD Sybil Lizanne R. MD Rico E. MD Jean Anne B. MD. MD Marilou Mangubat. Padolina. Jose. MD (Region 1) Concepcion P. Toral. MD (Region 10) Imelda O. MD Bella G. Ocampo.COMMITTEE ON CLINICAL PRACTICE GUIDELINES ON UROGYNECOLOGY Efren J. Yazon. MD Marites Mendoza. MD Manuel S. MD Florentina A. Luna. MD (Region 2) Ernesto S. de Leon. Vega. MD Rodante P. MD Mary Christine F. MD Ma. Amin-Ong. MD Cristia S. MD Faith Villaruiz. MD Julieta Villanueva. Enriquez Ms. Andres. MD Lourdes Ledesma. MD Ma. Theresa B. Villanueva. MD Rudie Frederick B. Argonza. MD Chair Members Almira J. MD Noel C. MD Regional Directors Betha Fe M. Sison. MD Christine D. Palma. MD (Region 5) Belinda N. MD Ma. MD Ma. Gonzales. Emiliana C. Abad. MD Pura Rodriguez-Caisip. Naval. MD Maria Nelvez Candilario. Galiza. MD Ma. De Guzman TASK FORCE ON UROLOGYNECOLOGY Lisa T. Lara David-Bustamante. Pichay. Carmen H. MD Cherrie Climaco. Tenorio. MD Rosemarie R. Dionio. MD Ricalynn Rivera. Mendiola. Vitriolo. MD Patricia L. Chan. MD Prudence V. Cecilia Maclang. MD Judith M. MD Gladys Pelicano. MD Amaryllis Digna A. Theresa Cedullo. Bravo. MD Belen Pantangco-Rajagukguk. Hipolito. MD Jennifer B. MD (Region 11) . MD Ruth Jinky Aposaga. MD Jocelyn Z. Aquino. Flores Adiong. MD Kenet Prado. MD Humildada Asumpta Igana. Castro. Jhasmin G. MD Grace D. MD Nurlinda Arumpac. Mata. 2010. its Board of Trustees. It is not the intention or objective of this CPG to serve as the exact and precise answer. this CPG is meant to make each one of us a perfect image of Christ. and its entire membership. any capacity of the person or individual who may read. The reader is encouraged to deal with each clinical case as a distinct and unique clinical condition. to make clear the distinction. subject matter. cite. or acknowledge. or for that matter. quote. not this CPG. to clarify. Inc. its officers. The obstetrician gynecologist. the general practitioner. case discussions/critiquing. the student. to a valuable pathway that leads to the discovery of clinical tests leading to clinical treatments and eventually recovery. conference audits/controversies. November 2010. solution and treatment for clinical conditions and situations. the clinician will find a handy guide that leads to the a clue. the patient. the allied medical practitioner.DISCLAIMER. This is the ownership of the POGS. which will never fit into an exact location if reference is made into any or all part/s of this CPG. the Committee on The Clinical Practice Guidelines. The intention and objective of this CPG is to serve as a guide. its officers and general membership. (Foundation). In behalf of the POGS. First Edition. any. the Healer. diagnostic condition or idea/s willfully release and waive all the liabilities and responsibilities of the POGS. disagreements. RELEASE AND WAIVER OF RESPONSIBILITY • • • • • • • • ! ! ! ! ! ! ! ! ! ! ! ! This is the Clinical Practice Guidelines (CPG) on Urogynecology. refer to. It is always encouraged to refer to the individual clinical case as the one and only answer to the case in question. (POGS). as well as the Committee on the Clinical Practice Guidelines and its Editorial Staff in any or all clinical or other disputes. or the entirety of any topic. or part. This is the publication of the Philippine Obstetrical and Gynecological Society. It is hoped that with the CPG at hand. . Jennifer B. Jose Appendix: Level of Evidence and Grade of Recommendations …………. Lisa T... Lisa T. Judith M. Prodigalidad-Jabson Fecal Incontinence and Obstetric Anal Sphincter Injuries (OASIS) ……. Lisa T. Dr. Lennette L. Sison Conservative Management of Stress Urinary Incontinence ……………… Dr. Prodigalidad-Jabson Conservative Management of Pelvic Organ Prolapse …………………… Dr. Luna Surgical Management of Pelvic Organ Prolapse ………………………… Dr.! CPG ON UROGYNECOLOGY TOPICS / CONTENTS / AUTHOR/S! Introduction ……………………………………………………………… 1 Dr. Chan Urinary Retention ………………………………………………………. Ocampo. Jr and Dr.. Maria Teresa C. Dr. Amin-Ong Evaluation of Pelvic Floor Dysfunction and POP-Q Scoring System …. Dr. Almira J. Prodigalidad-Jabson Definition of Terms (Standardization of Terminology) ………………… Dr. Manuel S. Almira J.. Dr. ! ! . Amin-Ong Surgical Management of Stress Urinary Incontinence ……………………. Khoury S. the demand for such care will inevitably escalate. fecal incontinence (FI). In a 2001 study by the Asia-Pacific Continence Advisory Board. childbirth.Philippine General Hospital alone. and urinary incontinence (UI) are.INTRODUCTION Lisa T. Nelson R. Altman D. Am J Obstet Gynecol 2002. Epidemiology of urinary (UI) and fecal incontinence (FI) and pelvic organ prolapse (POP). Nygaard I.2 This becomes of particular importance in a society such as ours where family planning. MD Urogynecology and Reconstructive Pelvic Surgery has long been a recognized specialty in the field of Obstetrics and Gynecology. Prodigalidad-Jabson. 4. More specifically. for a rapidly growing and aging population. the prevalence of overactive bladder as a cause of incontinence in Asians was noted to be 51. The epidemiology of overactive bladder among females in Asia: A questionnaire survey. Pelvic floor disorders such as pelvic organ prolapse (POP). 3. female UI is a common problem that is often unrecognised. Likewise.3 This is in contrast to the incidence of 31% reported by RamosoJalbuena in 1994. as most women experiencing such symptoms often do not seek medical advice. POP is among the most common indications for benign gynecologic surgery. over 100 cases of vaginal hysterectomies are performed each year for prolapse. is not widely practiced. at present. 2009. Int Urogyn J 2001. although strongly advocated. In Abrams P. In the University of the Philippines . or ignored. Clark A. Diokno states a 13% prevalence rate of UI among Filipinos.4 With recent emphasis on women’s health and quality of life. A review by the National Center for Health Statistics in the United States lists genital prolapse as one of the 3 most common reasons for hysterectomy in women. neglected. References 1. Lapitan MC and Chye PLH on behalf of the Asia-Pacific Continence Advisory Board. Incontinence: WHO–ICUD International Consultation on Incontinence. Hendrix SL. And. and aging. It is a condition believed to be as natural as pregnancy.4%. The wide range may reflect the difficulty in estimating the incidence of UI. Sillen U. Cardozo L. Lapitan MC. Maturitas 2004. . Barnabei V.12(4):226-31. Urogynecology is still at its infancy stage and only recently has there been a growing interest in this field of pelvic reconstruction. and Thom D. and Wein A (Eds). Ramoso-Jalbuena J. Climacteric filipino women: a preliminary survey in the Philippines. However. The prevalence of UI is reported to range from 2% to 57% and afflicts both the young and old. here in the Philippines. Aragaki A. caring for women with various pelvic floor disorders would become an increasingly important aspect of women’s health care. POP was found to be a very common condition in women during menopause and was consistently related to parity. McTiernan A.186(6):1160-6. 4th edition. In a recent review by the Women’s Health Initiative.19(3):183-190. menopause. Pelvic organ prolapse in the women’s health initiative: gravity and gravidity. ! Milsom I. aspects of women’s health that are frequently neglected or ignored. 2. Increased daytime frequency – the complaint of the patient who considers that she voids too often by day. Continuous urinary leakage – the complaint of continuous leakage 9. The terminologies serve to eliminate confusion and facilitate communication amongst clinicians. Normal bladder sensation – the individual is aware of bladder filling and increasing sensation up to a strong desire to void 10. storage. STORAGE SYMPTOMS 1. Mixed UI – the complaint of involuntary leakage associated with urgency and also with exertion. vegetative symptoms. usually compared to previous performance or in comparison with others 2. sneezing or coughing 7. Urge UI – the complaint of involuntary leakage accompanied by or immediately preceded by urgency 6.DEFINITION OF TERMS Almira J. during micturition 4. Amin-Ong. or on sneezing or coughing 5. Reduced bladder sensation – the individual is aware of bladder filling but does not feel a definite desire to void 12. equivalent to pollakisuria used in many countries 3. Slow stream – perception of the individual of reduced urine flow. Increased bladder sensation – the individual feels an early and persistent desire to void 11. Hesitancy – difficulty in initiating micturition resulting in a delay in the onset . on one or more occasions. Nocturia – the complaint that the individual has to wake up at night one or more times to void 4. Splitting or spraying – self-explanatory 3. The following terms are culled from the latest International Continence Society (ICS) Standardization of Terminology for lower urinary tract symptoms published in 2009. Stress urinary incontinence (SUI) – the complaint of involuntary leakage on effort or exertion. I. MD Lower urinary tract symptoms are classified into three major categories namely. Absent bladder sensation – the individual reports no sensation of bladder filling or desire to void 13. or spasticity B. Intermittent stream (intermittency) – urine flow described as a stop and start flow. voiding and postmicturition symptoms. Urgency – the complaint of a sudden compelling desire to pass urine which is difficult to defer 2. Nocturnal enuresis – complaint of loss of urine occurring during sleep 8. VOIDING SYMPTOMS 1. SYMPTOMS SUGGESTIVE DYSFUNCTION OF LOWER URINARY TRACT A. Non-specific bladder sensation – the individual reports no specific bladder sensation but may perceive bladder filling as abdominal fullness. effort. Painful bladder syndrome – complaint of suprapubic pain related to bladder filling accompanied by other symptoms such as increased daytime or nighttime frequency. Urethral pain – felt in the urethra and the individual indicates the urethra as the site 3. urethral or perineal pain and is less clearly related to the micturition cycle or to bowel function and is not localized to any single pelvic organ E. sexual. Bladder pain – pain felt suprapubically or retropubically. Terminal dribble – term used when an individual describes a prolonged final part of micturition. Urethral pain syndrome – occurrence of recurrent episodic urethral pain usually on voiding. Postmicturition dribble – involuntary loss of urine immediately after the patient has passed urine. Feeling of incomplete emptying – self-explanatory term for a feeling experienced by the individual after passing urine 2. in the absence of a proven infection or other obvious pathology 3. vaginal or perineal pain which is either related to the micturition cycle or associated with symptoms suggestive of urinary tract or sexual dysfunction. Vaginal pain – felt internally. bowel or gynecological dysfunction. SIGNS SUGGESTIVE OF LOWER URINARY TRACT DYSFUNCTION 1. Daytime frequency – number of voids during waking hour inclusive of the last void before sleep and the first void upon waking in the morning 2. GENITAL AND LOWER URINARY TRACT PAIN 1.of voiding after the individual is ready to pass urine 5. above the introitus 4. it may persist after voiding 2. with no proven infection or obvious pathology 4. Vulval pain syndrome / Vaginal pain syndrome / Perineal pain syndrome – occurrence of persistent or recurrent episodic vulval. Pelvic pain – less well defined than the bladder. Pelvic pain syndrome – occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract. when the flow has slowed to a trickle/dribble C. Nocturia – number of voids recorded during a night’s sleep. Perineal pain – felt between the posterior fourchette and the anus 5. Straining – describes the muscular effort used to either initiate. in the absence of a proven urinary infection or other obvious pathology 2. with no proven infection or obvious pathology II. each void is . or after rising from the toilet D. with daytime frequency and nocturia. GENITO-URINARY PAIN SYNDROMES 1. POSTMICTURITION SYMPTOMS 1. and usually increases with bladder filling. maintain or improve the urinary stream 6. Mixed UI – complaint of involuntary leakage associated with urgency and also with effort. or less commonly. from extraperitoneal pressure or bowel stoma 13. Idiopathic detrusor overactivity – no defined cause for the involuntary detrusor contractions 21. Maximum voided volume – largest recorded volume of urine voided in a single micturition as determined in the bladder diary or frequency/volume chart 6. Detrusor overactivity – a urodynamic investigation characterized by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked 17. Terminal detrusor overactivity – defined as a single. Abdominal pressure – pressure surrounding the bladder which is estimated from rectal. incontinence episodes. Overactive bladder – characterized by the storage symptoms of urgency with or without urgency incontinence.8 liters in 24 hours in adults 4. Detrusor overactivity incontinence – incontinence due to an involuntary detrusor contraction 19. It is estimated by subtracting the abdominal pressure from the intravesical pressure. 24. Intravesical pressure – pressure within the bladder 12. Polyuria – urine production of more than 2. 23.preceded and followed by sleep 3. the degree of urgency and the degree of incontinence 16. Filling cystometry – method by which the pressure/volume relationship of the bladder is measured during bladder filling 15. Maximum cystometric capacity – the volume at which a patient with normal sensations feels she can no longer delay micturition (has a strong desire to void). vaginal. usually with frequency and nocturia 8. 14. exertion. Extraurethral incontinence – observation of urine leakage through channels other than the urethra 10. both active and passive. SUI – observation of involuntary leakage from the urethra. Detrusor pressure – the component of vesical pressure that is created by forces in the bladder wall. which cannot be suppressed and results in incontinence usually resulting in bladder emptying 18. Urodynamic stress incontinence – noted during filling cystometry and is . pad usage and other information such as fluid intake. Uncategorized incontinence – observation of involuntary leakage that cannot be classified into one of the above categories on the basis of signs and symptoms 11. synchronous with exertion/effort. Neurogenic detrusor overactivity – involuntary detrusor contractions occurring in patients with relevant neurological condition 20. sneezing and coughing 9. Nocturnal polyuria – is present when an increased proportion of the 24-hour output occurs at night (> 20% in young adults to > 33% over 65 years) 5. Cystometric capacity – the bladder volume at the end of the filling cystometrogram when “permission to void” is given. Bladder diary – records the times of micturitions and voided volumes. or sneezing or coughing 7. occurring at cystometric capacity. Bladder compliance – describes the relationship between change in bladder volume and change in detrusor pressure 22. It is the volume voided together with any residual urine. involuntary detrusor contraction. 26. Dysfunctional voiding – characterized by intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the peri-urethral striated muscle during voiding in neurologically normal individuals. palpable or percussable bladder. 29. Abdominal leak point pressure – the intravesical pressure at which urine leakage occurs due to increased abdominal pressure in the absence of a detrusor contraction. which remains palpable or percussable after the patient has passed urine. 34. 31. Acontractile detrusor – one that cannot be demonstrated to contract during urodynamic studies. the posterior vaginal wall. and the apex of the vagina (cervix/uterus) or vault (cuff) after hysterectomy. Bladder outlet obstruction – a generic term for obstruction during voiding and is characterized by increased detrusor pressure and reduced urine flow rate 30. Anterior vaginal wall prolapse – defined as the descent of the anterior vagina so that the urethrovesical junction (a point 3 cm proximal to the external urethral meatus) or any anterior point proximal to this is less than 3 cm above the plane of the hymen 35. Pelvic organ prolapse (POP) – defined as the descent of one or more of the anterior vaginal wall. Detrusor sphincter dysynergia – a detrusor contraction concurrent with an involuntary contraction of the urethral and/or peri-urethral striated muscle. 40. Posterior vaginal wall prolapse – defined as any descent of the posterior vaginal wall so that a midline point on the posterior vaginal wall 3 cm above the level of the hymen or any posterior point proximal to this is less than 3 cm above the plane of the hymen 36. Chronic retention of urine – defined as a non-painful bladder. Such patients may be incontinent. Detrusor leak point pressure – the lowest detrusor pressure at which urine leakage occurs in the absence of either a detrusor contraction or increased abdominal pressure 27. Anal incontinence – defined as any involuntary loss of fecal material and/or flatus and maybe divided into: a. obstructing urethra resulting in reduced urine flow. Rectal prolapse – defined as the circumferential full thickness rectal protrusion beyond the anal margin 38. 33. Detrusor underactivity – a contraction of reduced strength and/or duration. 32. Prolapse of the apical segment of the vagina – defined as any descent of the vaginal cuff scar (after hysterectomy) or cervix below a point which is 2 cm less than the total vaginal length above the plane of the hymen 37. Flatus incontinence – any involuntary loss of gas (flatus) 39. 25. in the absence of a detrusor contraction. resulting in a prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span. Non-relaxing urethral sphincter obstruction – occurs in individuals with a neurological lesion and is characterized as non-relaxing. It replaces the term ”genuine stress incontinence”. Acute retention of urine – defined as a painful. 28.defined as the involuntary leakage of urine during increased intraabdominal pressure. Fecal incontinence (FI) – any involuntary loss of fecal material b. when the patient is unable to pass any urine. . Brubaker LP.g. Abrams P. Cardozo L. Mattiasson A. Khoury S. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Electrical stimulation – the application of electrical current to stimulate the pelvic viscera or their nerve supply 5. Incontinence. 4th International Consultation on Incontinence. Clean intermittent catheterization – use of a clean technique. Bo K. Intermittent self-catheterization – performed by the patient herself b.175:10-1. 2009. 4th ed. DeLancey JOL. auditory or tactile signal 3. Shull BL. This implies genital disinfection and use of sterile catheters and instruments/gloves 7. Behavioral modification – the analysis and alteration of the relationship between the patient’s symptoms and her environment for the treatment of maladaptive voiding patterns 4. This implies ordinary washing techniques and use of disposable or cleansed reusable catheters d. or relative) c. Amith ARB. Catheterization – technique for bladder emptying employing a catheter to drain the bladder or a urinary reservoir 6. doctor. . Pelvic floor training – repetitive selective voluntary contraction and relaxation of specific pelvic floor muscles 2. Aseptic intermittent catheterization – use of a sterile technique. Intermittent catheterization – performed by an attendant (e. TREATMENT 1. nurse. Intermittent (in/out) catheterization – defined as drainage or aspiration of the bladder or urinary reservoir with subsequent removal of the catheter a.III. urinary reservoir or urinary conduit for a period of time longer than one emptying References 1. Indwelling catheterization – an indwelling catheter remains in the bladder. Bump RC. 2.. Am J Obstet Gynecol 1996. Wein A. Biofeedback – technique by which information about a normally unconscious physiological process is presented to the patient and/or therapist as a visual. Klarskov P. especially detrusor overactivity. may be present. measurement of postvoid residual volume (PVR).3. Borderline or negative test results should be repeated to maximize its diagnostic accuracy.EVALUATION OF PELVIC FLOOR DYSFUNCTION AND THE POP-Q SCORING SYSTEM Judith M.7 Three-day bladder diary (frequency/volume chart) Urinary diaries are highly reproducible and correlated well with urodynamic diagnosis. MPH I. The inability to demonstrate the sign of SUI . physical examination2.9. or no urine loss with provocation indicates that other causes of incontinence.8 Consistent results have been shown between the first 3-day period and the last 4-day period. (Level II-3. leaking 5-10 seconds after coughing. when surgery is contemplated d. and 3-day bladder chart.4. MD.5 Routine urinalysis with or without urine culture and sensitivity test To assess for any lower urinary tract infection (UTI). a clean midstream or catheterized urine sample should be obtained for dipstick urinalysis which provides necessary information as a “multi-property” strip should be used. Sison. improving compliance. Standard chemical tests for renal function are recommended in patients with UI and a high probability of renal damage. strongly suggests a diagnosis of SUI. simultaneous with coughing and in the absence of urge. chronic retention with UI (overflow UI) b. thus.6 It can also screen any urothelial lesion and stone disease. urinalysis. neurogenic lower urinary tract dysfunction c. when there is a clinical suspicion 2. URINARY INCONTINENCE 1. (Level II-2. Grade A) Summary of Evidence Post-void residual volume A PVR < 50 ml is considered adequate bladder emptying and > 200 ml is considered inadequate. Grade B) Summary of Evidence Loss of small amounts of urine in spurts.11 Prolonged loss of urine. suggesting that a 3-day chart may be adequate to document symptoms. 10 Standard blood chemistries for renal function The routine use of a battery of common chemical tests in patients with UI appears to be a prudent rule of good practice in the following conditions: a. Patients with urinary incontinence (UI) should undergo a basic evaluation that includes a history1. Cough stress test strongly suggests a diagnosis of stress urinary incontinence (SUI). can be used for assessment of bladder neck mobility. Q-tip or cotton swab test is not useful in differentiating SUI from abnormalities of voiding and detrusor functions.21 6. weak or good muscles to . Grade B) Summary of Evidence The Committee on Investigations from the 2nd International Consultation on Incontinence concluded that the 1-hour pad test would yield increased accuracy if done with a fixed bladder volume. (Level II-3. and methylene blue to stain the bladder contents. Dye test: The identification of the site of a fistula is best carried out by instillation of methylene blue into the bladder.17 (Level II.g. perineal ultrasonography and magnetic resonance imaging (MRI).19 It was able to discriminate most of the time between continent and incontinent women. but these are not commonly used in clinical practice. a ureteric fistula is most likely and this is most easily confirmed by a 2-dye test. and > 4 g for a 24-hour test. in the local setting) to stain the renal urine.during simple bladder filling and cough stress test correlates highly with the absence of urodynamic stress incontinence. Modifications of the Bonney’s test require support of the urethrovesical junction during coughing in women who leak during a stress test. Grade C) Summary of Evidence If leakage of clear fluid continues after dye instillation. 5. e.12 3.18.11.14 Other tests. using Phenazopyridine or indigo carmine (or any drug that colors the urine like Nitrofurantoin. Assessment of pelvic floor muscle strength has practical application in determining whether the patient has nil. Investigators found that a sizable minority of women with urodynamic diagnosis of SUI did not have a positive Q-tip test and that many women with positive Q-tip test did not have SUI on urodynamic testing.20. These modifications are not reliable in selecting a surgical procedure or in predicting cure. Grade B) Summary of Evidence Q-tip or cotton swab test refers to placement of a cotton swab in the urethra at the level of the bladder neck and measurement of the axis change (> 30o) to demonstrate urethral mobility. The standard 1-hour pad test quantifies the volume of urine lost by weighing a perineal pad before and after some type of leakage provocation. (Level III. It is now used primarily to assess the results of antiincontinence surgery or to determine whether the degree of urethral hypermobility may influence treatment outcomes. A pad weight gain of > 1 g is considered positive for a 1-hour test.13.15 4.16. palpation. Oxford scale 1-5. A pelvic muscle contraction may be assessed by visual inspection. an exercise program. (Level II. or absent by a validated grading system.26 Whenever objective clinical findings do not correlate with or reproduce the patient’s symptoms. or any need for further evaluation.27 (Level II. Grade B) . displacement. simple cystometry is appropriate for detecting abnormalities of detrusor compliance and contractibility. 9. It is therefore important to test the contractility of these muscles. electromyography or perineometry.23 7.28 . pressureflow study of voiding together with one or more of the following. Grade C) Summary of Evidence Urine cytology should be requested in patients with microscopic hematuria (RBC 2-5/hpf). as indicated for the individual patient: abdominal leak point pressure measurement.effectively carry out passive contraction therapy. were urodynamically normal. The definition of normal bladder capacity lacks consensus. weak. Cystometric testing is not required in the routine or basic evaluation of UI.24 It is not recommended in the routine evaluation of patients with incontinence. When considering methods/devices used to measure pelvic muscle strength. duration. e. cost and availability are important considerations. In addition.22 The modified Oxford scale has been shown to correlate well with surface electromyography and manometry of pelvic floor muscles. (Level III. Minimum urodynamic investigation includes uroflowmetry. ! 50 year-old with persistent hematuria or those with acute onset of irritative voiding symptoms in the absence of UTI to exclude bladder neoplasm. Researchers showed that 33% of women with bladder capacities > 800 ml. large bladder capacities are not always pathologic.g. Grade B) Summary of Evidence Office cystometry: Retrograde bladder filling provides an assessment of bladder sensation and an estimate of bladder capacity. and only 13% had true bladder atony.21 This can be qualitatively defined by the tone at rest and the strength of a voluntary contraction as strong.25 8. Factors to be assessed include strength. with values that range from 300-750 ml. (Level III. urethral pressure measurement. Urine cytology is recommended in patients with persistent microscopic hematuria in the absence of UTI to exclude bladder neoplasm. and repeatability. Grade C) Summary of Evidence The continence mechanisms imply that integrity of the levator ani and the external urethral sphincter is necessary to maintain continence. therefore. although its usefulness also has not been proved. Therefore it does not meet the criteria for a useful diagnostic test.Indications for urodynamics29: a. videourodynamic testing should be employed. urge incontinence in the absence of any reversible causes.29. Summary of Evidence There was not enough evidence to show whether women with UI who underwent urodynamics were less likely to be incontinent after treatment than women who did not undergo urodynamic testing. suburethral mass. Urethral pressure profilometry (UPP) and leak point pressure measurements have not proved useful in the evaluation of UI. e. recurrent cystitis. Neurogenic bladders as an initial assessment or as part of a long-term surveillance. (Level III. Imaging: Ultrasound is not recommended in the primary evaluation of patients with UI and/or POP. (Level II-2. reproducible.38 (Level III. Grade C) . Complex incontinence cases whenever there is doubt about the underlying pathophysiology c. bladder pain.32 Leak point pressure measures the amount of increase in intraabdominal pressure that causes stress incontinence. Grade C) Summary of Evidence Researchers found that UPP is not standardized. 12. If possible. Cystoscopy should not be performed routinely in patients with incontinence to exclude neoplasm.37. Grade B) Summary of Evidence Indications for cystoscopy in patients with UI include those who have: sterile hematuria or pyuria. 31 10. irritative voiding symptoms.33 11.30. urgency. and when urodynamic testing fails to duplicate symptoms of UI. cystoscopy should not be performed routinely in patients with incontinence to exclude neoplasm36. 29 MRI of the pelvic floor is rapidly gaining field in the evaluation of enteroceles and in the morphological analysis of pelvic floor muscles although the evidence of its clinical benefit is still unclear. It is likewise an optional test in the evaluation of patients with complex or recurrent UI and or POP. frequency. Prior to invasive or irreversible treatment or retreatment of all types of incontinence b.34 Bladder lesions are found in < 2% of patients with incontinence35. or able to contribute to the differential diagnosis in women with SUI symptoms.g. Grade A) Summary of Evidence Almost half of parous women can be identified as having prolapse by physical examination criteria.43 (Level II-2. and absence of distortion. reported a sensitivity of 83%. perineal or translabial. Grade C) Summary of Evidence The POP-Q system was introduced for use in clinical practice and research. For all other pelvic symptoms. al.000 .Summary of Evidence Transabdominal. et. specificity of 100%.41 2. it remains optional as evidence of its clinical benefit is still weak. ready availability.39 II.8/1. positive predictive value of 100%.42 2. Some have argued that the 9-points of the POP-Q system maybe more detailed than necessary for clinical practice. transrectal. when comparing dynamic MRI to intraoperative findings. resolution with prolapse treatment can not be assumed. Cystoscopy or cystourethroscopy should be performed intraoperatively to assess for bladder or ureteral damage after all prolapse or incontinence procedures during which the bladder or ureters may be at risk of injury.29 MRI provides anatomical detail to the pelvic floor in a single noninvasive study that does not expose the patient to ionizing radiation. These numbers were similar compared to physical examination alone.40 (Level II-3. Gousse. It often is useful to include a measurement of the extent of protrusion relative to the hymen to better assess change overtime. and it is better suited for clinical research purposes. the finding is not well correlated with specific pelvic symptoms. and transvaginal ultrasound is currently used due to its noninvasive nature. Although ultrasound is rapidly evolving and much progress has been made. The amount or severity of prolapse in each vaginal segment may be measured and recorded using the pelvic organ prolapse quantification system (POP-Q). most are not clinically affected. The only symptom specific to prolapse is the awareness of vaginal bulge or protrusion. (Level III. PELVIC ORGAN PROLAPSE AND PELVIC ORGAN PROLAPSE QUANTIFICATION SYSTEM 1. Grade B) Summary of Evidence A recent systematic review of urinary tract injuries during urogynecologic surgical procedures and routine intraoperative cystourethroscopy reported the overall ureteral injury rate was 8. birthing chair.and post-surgical intervention examinations.procedures (95% CI 2. points proximal to the hymen are negative (inside the body) while points distal to the hymen are positive (outside of the body). in one or more compartments./+ TVL .3-12.44 PELVIC ORGAN PROLAPSE QUANTIFICATION SYSTEM (POP-Q) The POP-Q is the current gold standard for measuring prolapse stage in patients. and the state of her bladder and rectum (full or empty) should be noted.5 cm. Stages are based on the maximal extent of prolapse relative to the hymen. All measurements are made to the nearest 0. All measurements. It offers an objective evaluation that can be communicated between physicians and used to compare pre. are made while patient is doing Valsalva maneuver.3-26.3 (95% CI 4. and c) total vaginal length (TVL).6). The hymen is assigned the value of zero. It was developed and adopted by the International Continence Society (ICS) and endorsed by leading international organizations dealing with pelvic floor dysfunction. and 3 additional measurements which always have a positive value namely: a) genital hiatus (Gh) b) perineal body (Pb).43 The overall bladder injury rate after urogynecologic surgical procedures was 16. Quantification Definitions and Ranges: POINT Aa Ba C D Ap Bp Gh Pb TVL MEASUREMENT Anterior vaginal wall 3 cm proximal to hymen Leading-most point of anterior vaginal wall prolapse Most distal edge of cervix or vaginal cuff (if absent cervix) Most distal portion of posterior fornix Post vaginal wall 3 cm proximal to hymen Leading-most point of post vaginal wall prolapse Perpendicular distance from mid-urethral meatus to posterior hymen Perpendicular distance from mid-anal opening to posterior hymen Post vaginal fornix or vaginal cuff (if absent cervix) to the hymen RANGE -3 to +3 -3 to + TVL .6)./+ TVL -3 to +3 -3 to + TVL No limit No limit No limit The stages of POP are: Stage 0 – No descent of any compartment Stage 1 – Descent of the most prolapsed compartment between perfect support and -1 cm Stage 2 – Descent of the most prolapsed compartment between -1 cm and +1 cm Stage 3 – Descent of the most prolapsed compartment between +1 cm and TVL -2 cm Stage 4 – Descent of the most prolapsed compartment from TVL -2 cm to complete prolapse . except for TVL. There are 6 vaginal sites as represented in the POP-Q grid. or standing) during the examination. Both the patient’s position (lithotomy. Manometry may offer little extra information where ultrasound is available. Am J Obstet Gynecol 1996. 42 III. The cheapness and speed of investigation makes endosonography the ideal screening procedure to assess anal sphincter. FECAL INCONTINENCE 1. Grade C) . al. Thirty one percent (31%) of women with UI and 7% with POP had concurrent anal incontinence. evaluated 247 women with either UI or POP.21 (Level III. 175: 10-7. (Level III. Preoperative assessment in patients with possible atrophy is the main indication for MRI. et.Reproduced from: Bump RC. A simple assessment of possible anorectal dysfunction by history and physical examination should be performed whenever lower urinary tract function is evaluated.45 2. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. et al. Grade C) Summary of Evidence Jackson. 7. 16. 4. Imaging and other investigations. 1996. Acta Obstet Gynecol Scand 1987. Swift SE. In: Abrams P. Khoury S. Urogynecology and urodynamics: Theory and practice (2e) Baltimore. 3-day. et al. Assessment of reliability of 1-day.60:1-96. Am J Obstet Gynecol 1994. Goode PS. Ostergard DR. et al. Semeniuk H. Wall LL. Incontinence edited by Abrams. Kromann-Andersen B. Jorgensen L. et al. 14. 2002:425-77. Summary. J Urol 1981. Raghavaiah N. Bhatia NN.Summary of Evidence Anorectal manometry is an optional test that may be used in difficultto-evaluate cases of fecal or anal incontinence.66(4): 369-371. A literature survey on test accuracy and reproducibility. et al. Paris July 5-8. The bulbocavernosus reflex in urology: a prospective study of 299 patients. Neurourol Urodyn 1989. Scientific Committee of the First International Consultation on Incontinence. 10. Obstet Gynecol 1987. Obstet Gynecol 1988. Invalidity of Marshall-Marchetti and Bonney stress tests. Int Urogynecol J Pelvic Floor Dysfunct 2000. 11. Evaluation of current urodynamic testing methods in the diagnosis of genuine stress incontinence. Pad test with fixed bladder volume in urodynamic stress incontinence. The urinary diary in evaluation of incontinent women: a test-retest analysis. Addla S. Larsson B.71(61):807-11. Q-tip test: a study of continent and incontinent women. eds.87:63142. 37(9):3051-2. 96-0682. Rockville (MD): AHCPR. European Urinalysis Guidelines.71:812-7. 4th International Consultation on Incontinence. 3. MD: Williams and Wilkins. 22.126:197-9. 5. Plymouth: Health Publication. the 1-hour test. 15. 1996 Update. Simple bladder filling with a cough stress test compared with subtracted cystometry for the diagnosis of urinary incontinence. 20. et al. Pelvic floor assessment: the PERFECT scheme.355:2153-8. 4th edition 2009 Laycock J. Measurement of postvoid residual urine with portable transabdominal bladder ultrasound scanner and urethral catheterization. 19. Blaivas JG. Diagnosis of mild stress incontinence in females: 24-hour pad weighing test vs. Clinical Practice Guideline. 8. 18. It should be considered if therapy based on simpler assessments fails to yield the desired improvement.6:165-6.8(3):237-42.122:438-49. In: Ostergard D. Wyman JF.70(2):208-11. 21. Health Publication Ltd. Assessment and treatment of urinary incontinence. 1991:179-84. et al. Kinn AC.11(5):296-300.11:15-7. 6. Cardozo L. Lose G. . Neurourol Urodyn 1987. Nygaard I. Pad-weighing tests. 9. Scand J Clin Lab Invest 2000. Physiotherapy 2001. Eur Urol 2004. Int Urogynecol J Pelvic Floor Dysfunct 2000. Lancet 2000. No. et al. Urinary incontinence in adults: acute and chronic management. Walters MD. Bent A. 2008.86:85-91.2. et al. 17. et al. Double-dye test to diagnose various types of vaginal fistulas. Artibani W. and 7-day frequency volume charts. Agency for Health Care Policy and Research. Bergman A. Evaluation of the leukocyte esterase and nitrite urine dipstick screening tests for detection of bacteriuria in women with suspected uncomplicated urinary tract infections. et al. Obstet Gynecol 1988. J Urol 1974.171:1472-7. Reproducibility of a 7-day voiding diary in women with stress urinary incontinence. Cardozo. Obstet Gynecol 1995. et al. et al. 112: 811-2. discussion 1477-9. 13. Ouslander JG. 2. The Q-tip test: Standardization of the technique and its interpretation in women with urinary incontinence.(Suppl 2):30. et al. J Clin Microbiol 1999. Incontinence in the nursing home. AHCPR Publication No. et al.47 References 1.46 MRI is superior to ultrasound in diagnosis of perianal sepsis and in quantifying external anal sphincter muscle degeneration. Wein A (eds) Incontinence. Ann Intern Med 1995. 12. Karram MM. Dynamic half fourier acquisition single shot turbo spin-echo magnetic resonance imaging for evaluating the female pelvis. Obstet Gynecol 2006. 27. 34.348:2330-8. Association of Professors of Gynecology and Obstetrics. Radiology 1999. 1996 Update. Radiographics 2000. et al. Dynamic MR imaging of pelvic organ prolapse: spectrum of abnormalities. Rockville (MD): AHCPR. et al. 2004. 41.6:277 31. et al. et al. Crofton (MD) APGO. Textbook of Female Urology and Urogynecology 2006. Am J Obstet Gynecol 2006. Chahal.194:1478-85. 29. 30.171:1472-7. 46. Staskin D (Eds). 4th International Consultation on Incontinence Paris July 5-8.39:283-6.164:1606-13. Large-capacity bladder. 44. Beer-Gabel M. Jackson S. Haslam J. Cohen RA. No. 2008. Weber AM. Samuelsson EC. 36. University of Manchester. et al.175:10-7. 2009. Am J Obstet Gynecol 1996. Clinical Practice.1:45-52. Agency for Health Care Policy and Research. ACOG 2007 Compendium Vol. Wall LL. September 2007: 417-29. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for POP. 40. Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders: pilot study. 42. Int Urogynecol J 1995. Walters M. discussion 1477-9. 45. Incontinence. Finland 2000. Dis Colon Rectum 2002. Simple bladder filling with a cough stress test compared with subtracted cystometry for the diagnosis of urinary incontinence.45:1004-10. . Clinical Practice Guideline. Cardoso A. 2nd edition Volume 1. Health Publication Ltd.23. 96-0682. 43. A randomized controlled trial of urodynamic investigations prior to conservative treatment of urinary incontinence in the female.56:720-35. Urology 1974. (ed). Obstet Gynecol 1997. et al. Fecal Incontinence: endoanal ultrasound vs endoanal MR imaging. Relationship of anal endosonography and manometry to anorectal complaints. De Leeuw JW. Chappe C. 30th Annual meeting of ICS. et al. 28. Awad SA. et. Clinical Management Guidelines for Obstetrician-Gynecologists #85. 39. 49. et al. al. ACOG Compendium of Selected Publications 2009. et al. Cardozo L. et al. Ramsay IN. Is it necessary to perform urine cytology in screening patients with hematuria? Eur Urol 2001. et al.39:352-7. Final diagnosis and therapeutic implications of mixed symptoms of urinary incontinence in women.2. 35. Leak point pressure measurement and stress urinary incontinence.45:239-45. Signs of genital prolapse in a Swedish population of women 20-59 years of age and possible related factors.11 Practice Bulletins pp1115-27. Gilmour DT. M Phil Thesis. 37. et al. and surface electromyography in females. Cardozo L.107:1366-72. 38. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Clinical management of urinary incontinence. Microscopic hematuria. Weber AM. 32. 33. Rociu E. 1999. et al. Evaluation of pelvic floor muscle assessment: digital.89:423-7. Bump RC. 47. Am J Obstet Gynecol 1999. et al. et al. Khullar V. Is urethral pressure profilometry a useful diagnostic test for stress urinary incontinence? Obstet Gynecol Surv 2001. manometric. Dis Colon Rectum 2002. N Eng J Med 2003. Multidisciplinary Management of Female Pelvic Floor Disorders 2006. Gustilo-Ashby AM. 4th edition. 25. Weir J. et al. Urology 1992.180:299-305. 24. 1996. 212(2):453-8. et al. 26. J Urol 2000. et. Am J Obstet Gynecol 1994.20:1567-82. A urodynamic survey. 48.4:544-8. Gousse AE. Urinary incontinence in adults: acute and chronic management. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Curr Women’s Health Rep 2001.AHCPR Publication No. Pannu HK. al. Fecal incontinence in women with urinary incontinence and pelvic organ prolapse. prevent or improve UI. and those whose symptoms are not severe enough for surgical intervention.4 2. There are several management schemes available for UI. the odds of severe urinary incontinence were 3. I. Conservative management alone entails numerous forms of intervention. In women with BMI of 30 or higher. None of those available specifically addresses the impact of age or any other variables on outcome. With the current crisis putting a strain on the health care of most economies. It is often a neglected condition even if the prevalence rate is quite high ranging from 17-55% in older and 12-42% in younger women. urge and mixed. Heavy lifting may predispose to development of UI.39 fold risk of UI compared with normal weight women. (Level II-1. LIFESTYLE INTERVENTION There are very few randomized controlled trials (RCTs) on the field of lifestyle intervention to control.CONSERVATIVE MANAGEMENT OF STRESS URINARY INCONTINENCE Almira J. Urinary incontinence (UI) affects women not only in the reproductive age but more commonly in the postmenopause. conservative management is offered as an option especially on the following circumstances: those awaiting or delaying surgery. Grade B) . Another study found a 2. those in whom existing medical condition precludes any form of surgical intervention. MD. Amin-Ong. Differentiating among the three types would help the primary care physician gear management towards that which will be beneficial to the patient. Women with a body mass index (BMI) of 30 or more should be encouraged weight reduction as this significantly reduces prevalence of UI.2 A 2005 RCT involving 48 participants showed that women who were put on a liquid diet showed a 60% reduction of weekly incontinent episodes and a weight loss of 15 kgs.1 times that of women with BMI between 22 and 241. Majority do not seek consult but opt to make provisions in their daily routine to hide or live with the disorder thus affecting the overall quality of life.3 Another RCT by the same author involving 338 women (the Programme to Reduce Incontinence by Diet and Surgery – [PRIDE]) who underwent a 6-month intensive weight loss program showed a weekly incontinence episode reduction of 70% as compared to 22% in the control group. The International Continence Society (ICS) describes three major categories of incontinence – stress. 1. (Level III. which are usually low cost and with low adverse effects. Grade A) Summary of Evidence Obesity is an independent risk factor for UI even after controlling for age and parity. Alcoholic beverages do not increase the incidence of UI. whether heavy exertion is a risk factor for incontinence or whether changing exertions can improve existing incontinence.9% versus 11. Limiting fluid intake to prevent UI should only be reserved to those with abnormally high intake. (Level II-2. 95% CI 1.5 4. Smoking increases the risk of more severe UI.Summary of Evidence There are no RCTs comparing heavy lifting with sedentary activities. smokers were found to have stronger urethral sphincters.6 3. found that decreasing caffeine intake to 96.5 4. Grade C) . al.5-19.0) for 3 or more cups compared to none. However.3 (95% CI 1. (Level II-1. Grade B) Summary of Evidence Bryant.936 women in 2003 reporting no difference in UI between women engaged in high impact activities more than 2 hours per week with those who engaged in less than 1 hour of activity per week.8%. Grade B) Summary of Evidence Large epidemiologic trials using multivariate analyses assessed the effect of alcohol consumption and UI but found no association between the two even after adjusting for age and fluid intake.364 women reported that UI with physical activity was more common among highly active than less active women (15. The association between heavy lifting and UI should be investigated further. (Level III. Decreasing caffeine intake improves continence. al. they found that tea drinkers had higher odds of UI (OR 1.936 women found that smoking increases the odds of severe UI (Odds Ratio [OR] 1.01)..7 A large study involving 27.4-55) for up to 2 cups per day and an OR of 1.9 5.2-1.5 mg had statistically significant reduction in urgency episodes (61% versus 12%) and number of incontinence episodes (55% versus 26%) but this was not statistically significant. Current data are conflicting with one in vitro study stating that nicotine produces phasic contraction of the bladder musculature inducing the urge type of incontinence. in a study of 3. Grade B) Summary of Evidence There are currently no RCTs regarding the effect of smoking cessation on resolution or promotion of the onset of UI. Present studies are conflicting with one study of 27.8 In the Norwegian EPICONT Study.6). 95% CI 1.4.5 Nygard. et. p=0. (Level III.2. et. 1.Summary of Evidence It is always the assumption that leakages can very well be controlled by limiting the fluid intake.5-13. Addendum Many other lifestyle interventions are anecdotal hence there is currently no evidence to support any of these.2-2.5-16. II. Grade C) Summary of Evidence There are no studies regarding the effect of resolving constipation or regulating bowel function on incontinence.7. 95% CI 1. However. p<0.4-7. women with stress urinary incontinence (SUI) and women with detrusor overactivity had decreased incontinence episodes10. Chronic straining may be a risk factor for development of UI. An RCT that used a small crossover design found that when fluid intake is decreased. and 12.1) when standing. One study reported that women who strain during defecation are more likely to report SUI (OR 1.7. specifically. treating chronic cough and increasing sexual activity. (Level III.11 Further research is needed to evaluate the role of constipation or chronic straining in the pathogenesis of UI.4).12 Further studies on the effectiveness of postural changes as treatment for UI still needed. 6. wearing of nonrestrictive clothing. wearing cotton undergarments.3-2. PELVIC FLOOR MUSCLE EXERCISE Pelvic floor muscle training (PFMT) or Kegel’s exercise should be offered as first line treatment for stress or mixed type of incontinence. p<0. a state of negative fluid balance or poor fluid intake may lead to urinary tract infections (UTIs). (Level I.9.6) and urgency (OR 1. reducing emotional stress. 7.3 g (95% CI 8. 95% CI 1. Postural changes such as crossing the legs and bending forward might be useful in reducing leakages during coughing or provocation. constipation or dehydration – conditions that can readily be prevented by maintaining the average daily fluid intake. 10. (Level III.3 g (95% CI 0.7 g when legs are crossed and body bent forward (95% CI 1.2 g (95% CI 6. decreasing lower extremity edema.001) when legs are crossed to prevent leakages compared to the following postural changes: 4. use of a bedside commode. Grade C) Summary of Evidence There was a mean fluid loss of only 1.0) when bending forward alone. Grade A) .5-2.01). stress or mixed type of incontinence found that PFMT was more effective compared to placebo intervention (drug. There is also no benefit of combining PFMT with biofeedback. MAGNETIC STIMULATION The benefit of magnetic stimulation for treatment of UI has not been established. Usually. III. magnetic stimulation might be better for both stress and urge type of incontinence. (Level II-3. Grade D) Summary of Evidence Extracorporeal magnetic stimulation is delivered to the pelvic floor muscles and the sacral nerve roots by sitting on a magnetic chair.9 IV. Combined with PFMT. there was a significant reduction in urinary leakage with PFMT alone. The patient’s perineum is centered on the middle of the seat from where the pelvic floor muscles are placed directly on the primary axis of the pulsating magnetic field without any vaginal or anal probes.15 Further investigation is warranted. For women with stress type of incontinence. sham electrical stimulation. . A randomized trial of 68 women with urge type of incontinence did not reveal significant improvement at all. the treatment is given for 16 sessions for 6 weeks. However. the most recent Cochrane systematic review (2003) which included studies of women with urge. Grade B) Summary of Evidence Electrical stimulation involves delivery of brief electrical impulses via needle or surface electrodes to the sacral nerves to inhibit detrusor overactivity and to improve pelvic floor musculature. ELECTRICAL STIMULATION Electrical stimulation for patients with stress or mixed type of incontinence does not offer any benefit in reducing the frequency of incontinent episodes.Summary of Evidence Studies regarding PFMT are conflicting because of variations in the technique used. a small trial of 26 women showed no changes in urinary leakages per week based on an incontinence impact questionnaire. There are still no trials regarding primary and secondary prevention of UI. a recent trial of 200 women showed no significant reduction in the frequency of incontinent episodes. sham exercise). PFMT supervised and continued for 3 months is a safe and effective treatment for stress and mixed types of incontinence. Regarding treatment. (Level I.14.13 Compared with vaginal cones. It should be offered as first line treatment for urge or mixed type of incontinence. However. There were two small trials with 78 patients which showed few subjective cures in patients who had bladder training alone versus those who did not receive any at all (OR for failure.03-0. A Cochrane systematic review found that anticholinergics were better than placebo in subjective cure rate and improvement rates (RR 1. there were no differences in objective outcomes – leakage episodes. It is usually advised on patients who have intact cognitive and physical functions and can take months to achieve a cure. Grade A) Summary of Evidence Bladder training is a technique to increase the time interval between voids using progressive voiding schedules. 0. Therapy usually starts with the lightest cone then graduated to the heavier ones. -0. Grade A) Summary of Evidence Anticholinergics are drugs prescribed to inhibit involuntary detrusor contractions that could lead to urine leakages.73 to -0. it is more effective than a combination of bladder training with drug therapy.54) and in improvement in leakages episodes in 24 hours (WMD. 95% CI 0. Grade B) Summary of Evidence Vaginal cones are a set of weighted cylinders that are held in place by contraction of the pelvic floor muscles. VAGINAL CONES Vaginal cones offer subjective cure but do not lead to significant improvement on the number of leakage episodes. pad test or pelvic floor muscle strength. There are not too many trials to support bladder training. pad test or pelvic floor muscle strength. (Level II-1.17 VI. 95% CI 1. Majority of the trials enrolled women with stress incontinence who had subjective cure from UI.29-1.41.18 When .07.13 VII.V. 95% CI -0.56. with fewer adverse effects and lower relapse rates compared to drug treatment with antimuscarinics.39). It is not readily available in our country. There is good evidence though that bladder training is effective for urge or mixed type of incontinence. (Level 1.19). BLADDER TRAINING Bladder training combined with pelvic floor muscle training is more effective than either alone. (Level I.16.16 Compared with the control group who had other forms of intervention. PHARMACOLOGIC Anticholinergics are effective in the treatment of urge incontinence. when one combines it with PFMT. American Uroynecologic Society Annual Meeting 2007. Brwon JS. Cochrane Database Syst Rev 2003. Wing R. . Fultz NH. J Urol 2005. Cochrane Database Syst Rev 2003. Shinkai M. et al. The effect of fluid intake on urinary symptoms in women. Melville JL. Risk factors for urinary incontinence among middle-aged women. Fairbrother G. Cochrane Database Syst Rev 2003. J Urol 2005. Shen HUI. 10. Delaney K. Arch Intern Med 2005. Br J Pharmacol 1988. 18. Townsend MK.194(2):33945. Dowell CJ. Obstet Gynecol 1994. Cardozo L. Berghmans LC. 11. Wein A: Incontinence. Hashim H. Ellis G. 19. 16. A behavioral weight loss program significantly reduces urinary incontinence episodes in overweight and obese women [Oral presentation]. Adult Conservative Management of Urinary Incontinence. Pelvic floor muscle training for urinary incontinence in women. JAMA 2004. Subak LL. BJOG 2003.106(2). Moller L. Morris AR. Bo K. Pohl G. et al. Takayanagi I. Lose G.174(1):190-5. Gilleis CL. A randomized controlled trial of the effectiveness of pelvic floor therapies for urodynamic stress and mixed incontinence. Katon W. Issue 1. Jorgensen T: Risk factors for lower urinary tract symptoms in women 40 to 60 years of age. Abrams P. Moore K.291(8):986-95.98(5):1043-50.173(5):1644-46. 6. Am J Obstet Gynecol 2006. Dunkley P. Grodstein F. Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPINCONT Study. Subak LL. Faganelj M. Plevnik S. Lifford K. anticholinergics still offer both subjective cure and improvement in leakage episodes.compared with other drugs used to treat urge incontinence. Sostaric S: Functional magnetic stimulation for mixed urinary incontinence.52:876-83. 17. Shaw C. Swithinbank L.110(3). J Urol 2005l. 2. Curhan GC. Whitcomb E. Holroyd-Leduc JM. BJU Int 2006. 14. Moore KH. 4. Mechanism of action of nicotine in isolated urinary bladder of guinea-pig. Hay-Smith EJ. Rortveit G.85(5):770-4. Williams KS. Obstet Gynecol 2000. et al. Mantle J. Newton K. Herbison P. Toyoda T. Nygaard I. Herbison P. Caffeine reduction education to improve urinary symptoms. 12. Girts T. Bryant CM. Sternfeld B.307-14. Urinary incontinence in US women: a population-based study. Daltveit AK. Vittinghoff E. Management of urinary incontinence in women: scientific review. 13.95(2):465-72. Hisayama T.174(1):187-9. Anticholinergic drugs versus placebo for overactive bladder syndrome in adults. Extracorporeal magnetic stimulation is of limited clinical benefit to women with idiopathic detrusor overactivity: A randomized sham controlled trial. Turner DA. 3. Weight loss: a novel and effective treatment for urinary incontinence. But I. Hunskaar S. Danforth KN. Saxton J. Straus S. Hay-Smith J. Weighted vaginal cones for urinary incontinence. Abrams P.247-54.165(5):537-42. 8. 4th International Consultation in Continence July 2009. Norton PA. Assassa RP. Kouri S. 5. 9. Resnick NM. Kinchen K. 15. Smith West D. Issue 1. Baker JE: Postural changes can reduce leakage in women with stress urinary incontinence. Abrams KR.11(8):560-5. Br J Nurs 2002. Is urinary incontinence a barrier to exercise in women? Obstet Gynecol 2005. O’Sullivan R. Issue 1. Hannestad YS. 7.96(3):446-51. References 1. Eur Urol 2007. Meschia. found both subjective (96% vs 64%) and objective (92% vs 56%) cure rates to be significantly higher following TVT. In the few trials that report follow-up beyond 12 months. . al. Grade A) Summary of Evidence Ten randomized trials compare anterior colporrhaphy with pelvic floor muscle training (PFMT). Selecting the type of surgical procedure would depend on the individual patient’s characteristics (assessment of bladder neck mobility and urethral sphincter function). In these studies. et. or urodynamic stress incontinence (USI). With a better understanding of the etiology of SUI. MD Stress urinary incontinence (SUI). (Level II-2. and/or abandoned.SURGICAL MANAGEMENT OF STRESS URINARY INCONTINENCE Lisa T. subjective outcomes fell from 80% at 1 year to 60% at 5-7 years in one study. previous failed abdominal surgery. colposuspension. many surgical procedures have been developed. ANTERIOR COLPORRHAPHY Anterior colporrhaphy should NOT be used in the management of SUI. Reported cure rates range from 31% to 88%. previous radiation therapy or radical pelvic surgery. needle suspension. the recent National Institute of Health and Clinical Excellence (NICE) guidance recommends that anterior colporrhaphy should not be used for the treatment of SUI. with anterior colporrhaphy consistently showing statistically and clinically poorer outcomes. Likewise. Other factors to consider include pelvic organ prolapse (POP). There have been over a hundred procedures described for the surgical correction of SUI. is believed to result from either poor anatomic support associated with bladder neck and urethral motion (referred to as urethral hypermobility) or a combination of defects of the urethral sphincteric mechanism that may also result in decreased urethral resistance (referred to as intrinsic sphincter deficiency). and combined subjective and objective cure rates fell from 80% at 3 months to 63% at 1 year and 37% at 5 years in another study. to improve success rate and to minimize morbidity. Prodigalidad–Jabson. and the inherent risks/complications attendant to the type of procedure. MarshallMarchetti-Krantz (MMK) or tension-free vaginal tape (TVT). urodynamic evaluation. I. 967 women were included with 346 undergoing anterior colporrhaphy. One randomized trial compared anterior colporrhaphy with the TVT in 50 women with at least a stage II anterior wall prolapse and “occult SUI”.1 The Cochrane review of anterior vaginal repair reported that there was evidence to indicate that anterior vaginal repair was less effective than open retropubic suspension in the treatment of primary urodynamic stress incontinence. and paravaginal repair. The colposuspension is most successful in patients with pure SUI with hypermobility of the urethrovesical junction. have become the gold standard for treatment of primary or recurrent SUI. Although open colposuspension has to some extent been replaced by less invasive mid-urethral slings. which has longevity. traditional sling procedures. the TVT. (Level I. bladder neck needle suspension. 3. Analysis shows objective cure rates ranging from 59% to 100% (median 80%) and subjective cure rates from 71% to 100% (median 88%). the TVT. abdominal paravaginal repair. the MMK. (Level I. Grade A) Summary of Evidence Randomized trials comparing the open colposuspension with anterior colporrhaphy. particularly the Burch colposuspension. The studies showed that colposuspension had . the MMK. the transobturator tape. the transobturator tape. it should still be considered for those women in whom an open abdominal procedure is required concurrently with surgery for SUI. needle suspension procedures. However. The MMK procedure is not recommended for the treatment of SUI. the MMK procedure. with or without a cystourethrocele. 2. OPEN BURCH COLPOSUSPENSION 1.II. and paravaginal repair. Main indications include primary and secondary urethral sphincter incompetence. the MMK procedure. The colposuspension had better outcomes compared to the anterior colporrhaphy. and laparoscopic colposuspension include 4161 women with 1900 randomized to colposuspension. needle suspension procedures. Open retropubic colposuspension can be recommended as an effective treatment for primary SUI. Grade A) Summary of Evidence Randomized trials comparing the open colposuspension with anterior colporrhaphy. (Level I. but with adequate vaginal mobility and capacity. The paravaginal tissues on either side of the bladder neck and bladder base are sutured and attached to the ipsilateral iliopectineal ligament. The results from these studies show that the open colposuspension has objective and subjective outcomes comparable to both traditional sling procedures and to newer minimally-invasive mid-urethral sling procedures. traditional sling procedures. the colposuspension had better outcomes compared to the anterior colporrhaphy. and laparoscopic colposuspension include 4161 women with 1900 randomized to colposuspension. Grade A) Summary of Evidence Abdominal retropubic urethropexy or colposuspension procedures. bladder neck needle suspension. abdominal paravaginal repair. (Level I-II Grade A) Summary of Evidence Randomized trials comparing the open colposuspension with anterior colporrhaphy. 5. as determined by cough stress testing or pad test within 18 months. and paravaginal repair. LAPAROSCOPIC BURCH COLPOSUSPENSION 1.better outcomes compared to the anterior colporrhaphy.95.91. abdominal paravaginal repair. Grade A) Summary of Evidence Randomized trials comparing the open colposuspension with anterior colporrhaphy.90-1. with a nonsignificant 5% lower relative subjective cure rate for laparoscopic colposuspension (RR 0. needle suspension procedures. Although studies included in the Cochrane review had various lengths of follow-up (majority had follow-up of 6-18 months). The studies showed that colposuspension had better outcomes compared to the anterior colporrhaphy. (Level I-II. the MMK. Grade A) Summary of Evidence The laparoscopic approach has been compared to the standard open Burch colposuspension and the more recent mid-urethral slings. traditional sling procedures. the MMK procedure. (Level II-1. the transobturator tape. needle suspension procedures. Laparoscopic colposuspension is not recommended for the routine surgical treatment of SUI in women. 95% CI 0.00). abdominal paravaginal repair. Paravaginal defect repair is not recommended for the treatment of SUI alone. and laparoscopic colposuspension include 4161 women with 1900 randomized to colposuspension. The studies showed that colposuspension had better outcomes compared to the anterior colporrhaphy. Bladder neck needle suspension procedures are not recommended for the treatment of SUI. and laparoscopic colposuspension include 4161 women with 1900 randomized to colposuspension. traditional sling procedures. III. bladder neck needle suspension. the TVT. The objective cure rate. in particular the TVT. 4. there have been 10 randomized controlled trials (RCTs) comparing laparoscopic colposuspension with the open colposuspension and 8 with the mid-urethral slings. Since 1997. was statistically lower following the laparoscopic technique (RR 0. . and paravaginal repair.96). the TVT. subjective cure rates ranged from 58% to 96% in the open technique and 62% to 100% in the laparoscopic approach. the MMK procedure. bladder neck needle suspension. 95% CI 0. the MMK. Following urodynamic testing. the MMK.86-0. the transobturator tape. and paravaginal repair. bladder neck needle suspension. Studies comparing autologous rectus fascial sling with TVT involve a total of 284 patients from 3 RCTs. Grade B) 3. Grade A) Summary of Evidence Trials on suburethral slings have compared this procedure with open abdominal retropubic suspension (MMK and Burch colposuspension). the objective cure rate from sling operations was not significantly different within the first year (Relative Risk [RR] 0. expertise. Autologous fascial sling may be more effective than biological and synthetic slings. 95% CI 0. 95% CI 0. (Level I-II. needle suspension.53) or on longer follow-up (RR 0.99). (Level I.85. p=0. A systematic review on laparoscopic colposuspension and TVT showed evidence to favor the mid-urethral sling as the minimal-access technique of choice for USI. The overall objective cure rate. Laparoscopic colposuspension may be considered for the treatment of SUI in women who also require concurrent laparoscopic surgery for other reasons.02-1.91. Studies comparing laparoscopic colposuspension with minimally invasive mid-urethral slings (TVT) show no statistically significant difference in subjective cure rates within 18 months (RR 0.01) and SUI (49% vs 66%. al. the combined subjective and objective outcome in terms of any incontinence (38% vs 47%.80 to 1.42). TRADITIONAL SLING PROCEDURE 1.however.02). Grade A) IV. 95% CI 0. and even the TVT. and appropriate workload in laparoscopic surgery and with expertise in the assessment and management of UI in women.49.19.91. Autologous fascial sling is recommended as an effective long-lasting treatment for SUI. Studies comparing different sling materials are also numerous.14 Cure rates at 12 months range from 83% to 88% after TVT and 81% to 93% after fascial sling. 2.0.13. 95% CI 0.001) was significantly better from the sling procedure. 47% vs 63% and 14% vs 2% respectively.10 Although adverse events and voiding difficulty were also more common in the sling group. Sling materials vary and . however. In comparison with open colposuspension. was higher for mid-urethral slings. Laparoscopic colposuspension should only be carried out by surgeons with specific training.17-1. comparing colposuspension and fascial sling.11. In the largest RCT study done by Albo. p=<0. (Level I. 2. the open colposuspension had significantly higher success rates (RR 0. et. (Level II) Summary of Evidence Pubovaginal sling procedures have traditionally been recommended for SUI caused by intrinsic sphincter deficiency (ISD). and SPARC) or via the transobturator approach (e. Further high quality research is required to clarify the place of traditional sling procedures in relation to other procedures and to establish the optimum sling materials. has been compared to more traditional surgical procedures (such as burch colposuspension and traditional sling procedure) and is seemingly the new “standard” to which other mid-urethral slings are compared. Retropubic mid-urethral slings (TVT) are recommended as an effective treatment for SUI.52) compared to the open retropubic colposuspension. 3. initially described to be performed in an ambulatory setting. The TVT is a modification of the traditional sling procedure that was introduced by Ulmsten. RR 4. al. The TVT however appears to have significantly more bladder perforations (6% versus 1%. The sling is placed at the level of the bladder neck and proximal urethra (in contrast to the minimally invasive mid-urethral slings) thru a combined vaginal and abdominal route. and quicker recovery. The autologous sling may be harvested from either the rectus fascia (as initially described by Aldridge in 1942) or fascia lata. IVS. TVT is equally effective as colposuspension and traditional sling procedures.71-10. V.may be synthetic or biological.and medium-term efficacy (cure rate of 63% to 97%) similar to the open Burch colposuspension but is associated with shorter operating time and hospital stay.g. 95% CI 1. (Level I-II. Available literature suggests that the TVT has short.5 Studies comparing autologous rectus fascial sling with TVT involve a total of 284 patients from 3 RCTs.8%). Grade B) Summary of Evidence Mid-urethral slings are performed via the retropubic approach (e.14 Cure rates at 12 months range from 83% to 88% after TVT and 81% to 93% after fascial sling.7-66%). MID-URETHRAL SLINGS 1. 2.g. TVT.11. (Level I-II) Summary of Evidence Several randomized trials and cohort studies show that there is no significant difference in the cure rates for the TVT procedure compared to the Burch colposuspension and the fascial sling.15 The procedure. et. Recently. urethral erosion (0-15%). and voiding difficulties (10. in 1996. less postoperative voiding dysfunction.13. The TVT is also equally effective as . de novo detrussor instability (3. Complications include vaginal erosion (0-16%).24. xenograft (porcine dermis and small intestinal mucosa or bovine fascia) or synthetic material (such as merselene or prolene). sling procedures have been done using allograft material (cadaveric fascia or dura mater). transobturator tape [TOT] and tension-free vaginal tape-obturator [TVT-O]). carboncoated beads. risk of urinary tract injury should significantly decrease.16 Since the technique involved passage of the needle away from the urinary tract. bladder neck suspension. BULKING AGENTS 1. Unlike the TVT.the “inside-out” technique to the transobturator approach. porcine dermal implant. Although long-term studies are also not available. In 2003. autologous fat. Transobturator mid-urethral slings (TOT or TVT-O) may be used for the treatment of SUI. Likewise. De Leval described another modification to the TOT . injected transurethrally or periurethrally. benefit from urethral bulking agents appears to be short-term. The Cochrane review includes 12 RCTs with periurethral injection therapy being compared to open surgery. volume of agent used. the TVT-O. al. women should be made aware that repeat injections are likely to be required to achieve efficacy. and is inferior to conventional surgical techniques. Numerous studies also compare different bulking agents or the injection . comparing the transobturator (TOT or TVT-O) and retropubic (TVT) approaches showed no significant difference in subjective or objective cure rates and in complication rates for a follow-up period of 2 to 12 months. pubovaginal sling procedure. “outside-in” technique) via an incision at the labio-crural fold. If urethral bulking agents are to be used. that efficacy diminishes with time.16 A helical needle/trocar is used to pass a synthetic suburethral sling thru the superomedial aspect of the obturator foramen and behind the ischiopubic ramus (Monarc/ObTape. etc) but no ideal bulking agent has yet been identified.the traditional fascial sling procedures. This relatively new technique was introduced in 2001 by Delorme. injection technique or route. limited data exists comparing the efficacy of the TOT to other standard surgical procedures. Significantly higher objective and subjective cure rates are seen however in the TVT compared to laparoscopic colposuspension. (Level I-II. Grade B) Summary of Evidence Urethral bulking agents. and number of re-injections required. (Level I-II Grade B) Summary of Evidence The TOT is another modification of the pubovaginal sling procedure and of the TVT. Based on limited data and evidence. Various substances have been used for this purpose (including bovine collagen. This procedure presumably reduces the risk of bladder and vascular/visceral injuries attributed to the TVT. A meta-analysis by Latthe. 3. et. there are no defined standards for optimal location for injection. have long been used for the treatment of SUI. or Burch colposuspension. reported cure rates of the transobturator approach in various case series range from 59% to 97%.18 VI. Anterior vaginal repair for urinary incontinence in women. 2. 10. Chung KA. A randomized comparison of tension-free vaginal tape and endopelvic fascia plication in women with genital prolapse and occult stress urinary incontinence.174: 990-993.11:1306-13. Bai SW. An ambulatory surgical procedure under local anesthesia for the treatment of female urinary incontinence. Jeon JD. Buonaguidi A. J Urol 2005. Dean NM. 2004. 14. Ulmsten U.44:724-730. Women should be made aware of alternative minimally invasive procedures.81:281-290. Issue 1.113:1345-1353. France. Lucas M. Cody DJ. Cardozo L. ! Bidmead J. 15. Burch J. The effectiveness of modified 6 corner suspension in patients with paravaginal defect and stress urinary incontinence. 12. 7.356:2143-2155. Edwan A. Johnson P. Delorme E. Laparoscopic colposuspension for urinary incontinence in women. Henriksson L. and Somigliana E. Currently. Novel surgical technique for the treatment of female stress urinary incontinence: transobturator vaginal tape inside-out. Ellis G. Bailey J. 17. the group felt that the studies were small and of moderate quality such that meta-analysis was not appropriate. Park KH. Issue 3. Meschia M. Randomised comparison of Burch colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and anterior vaginal wall prolapse. BJOG 2006. Proietti F and Milani R. Bruschini H.13:303-307. Hsu CY. Wei HJ. Am J Obstet Gynecol 2004. 8. Cody DJ. Cochrane Database Syst Rev 2001. Int Urogyne J 2002. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women. Wilson D. Prog Urol 2001. De Leval J. Gattei U. et al and Urinary Incontinence Treatment Network.76:576-582.techniques (periurethral or transurethral). Wang KG.108:128-129"! Colombo M. and Grant AM. Hong BK.190:609-613. and Herbison GP. Spennacchio M. NEJM 2007. However. Cochrane Database Syst Rev 2005. Nabeeh AM. Kathy W. 4. and prolapse. Toozs-Hobson P. Failure of porcine xenograft sling in a randomized control trial of three sling materials in surgery for stress incontinence. Herbison P. 13. 16. cystocele. Int Urogynecol J Pelvic Floor Dysfunc 1996. Emery S. Am J Obstet Gynecol 1961. . Wadie BS. greater subjective improvement was observed after conventional surgery. Urethrovaginal fixation to Cooper’s ligament for stress incontinence. Glazener CMA and Cooper K. Issue 3. Kim JY. Cochrane Database Syst Rev 2005. Ellis G. Studies comparing bulking agents with non-surgical therapy or minimal access surgery are lacking. Kim S. Autologous fascial sling vs polypropylene tape at shortterm follow up: a prospective randomized study. Lapitan MC. Open retropubic colposuspension for urinary incontinence in women. Varhos G. 11. Alan W.7: 81-86. Bezerra CA. Traditional suburethral sling operations for urinary incontinence in women. Wilson PD. Cochrane Database Syst Rev 2006. Pifarotti P. Albo ME. Prospective comparison of laparoscopic and traditional colposuspensions in the treatment of genuine stress incontinence. References 1. BJOG 2000. Laparoscopic colposuspension and tension-free vaginal tape: a systematic review. 2. BJOG 2001. 5. Robinson D. Eur Urol 2003. 107: 544-551. Randomised comparison of Burch colposuspension versus anterior colporrhaphy for patients with stress urinary incontinence (letter). Joint meeting of International Continence Society & International Urogynecological Association. Su TH. 3. 9. Vitobello D. Paris. Dean NM. 6. Issue 3. Acta Obstet Gynecol Scand 1997. 2009. Khoury S. National Institute for Health and Clinical Excellence.114: 522-31. Issue 3. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. In: Abrams P. Cochrane Database Syst Rev 2007. NICE Guidance on Urinary Incontinence. Atiemo K. Surgery for urinary incontinence in women. . and Wein A (Eds) Incontinence: WHO – ICUD International Consultation on Incontinence. Rovner E. Chang D. National Collaborating Center for Women’s and Children’s Health. Toozs-Hobson P. Ogah J. Rogerson L. Keegan PE. 20. Issue 4. Pickard R. Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications. Cardozo L. Periurethral injection therapy for stress urinary incontinence in women. 19. BJOG 2007. 21. Cody JD. Cochrane Database Syst Rev 2009. Hilton P. Reid FM. Nilsson CG. Dmochowski R. Cody JD. McClinton S.18. Foon R. Smith ARB. 4th edition. 22. Latthe PM. 2006b. 2006. regardless of prolapse stage or site of predominant prolapse. urinary incontinence (UI). Pessary complications are rare occurrences in medically compliant patients. Luna. Grade A) Summary of Evidence Vaginal pessaries are the standard nonsurgical treatment for POP. freely and completely and the pessary stays in place (while seated on a toilet bowl and during ambulation). 4 2. The most common side effects of vaginal pessaries are vaginal discharge and odor. Grade B) Summary of Evidence Patient factors that determine the type of pessary to be used are sexual activity. and rectal pain. It is designed to support different sites of pelvic organ prolapse (POP). 1. pelvic/vulvar/vaginal discomfort/pain. VAGINAL PESSARY A vaginal pessary is a removable device placed into the vagina.CONSERVATIVE MANAGEMENT OF PELVIC ORGAN PROLAPSE Maria Teresa C. Serious complications such as erosions to adjacent organs are rare with proper use and usually result only after a long time of neglect. A vaginal pessary can be properly fitted in 78% of patients with approximately 50% of those properly fitted continuing to use a pessary a year later. If the patient is fitted with the correct pessary type. during which time. the . (Level III. hydronephrosis and urosepsis. vaginal pessaries can cause major urinary. no site of defect protrudes when the pessary is in place. Other complications include vaginal bleeding. Available pessaries are either made of silicone or latex rubber.1-3 Pessaries are most often used when the patient has a strong preference for nonsurgical management of POP or when the patient’s health status confers a significant risk for surgical morbidity and mortality. she can void readily. fetal impaction. pessary expulsion. (Level III. pessary use should be considered before surgical intervention in women with symptomatic prolapse. site of POP and stage of POP. washed with soap and water and replaced the next morning. the patient is advised to come back for check-up after 1 week. If the patient is fitted with the correct pessary size. MD I.5 The vaginal pessary is removed nightly. Vaginal atrophy should be treated before and concomitant with pessary initiation. she is not aware of its presence when she wears it. Clinicians should discuss the option of pessary use with all women who have prolapse that warrants treatment based on symptoms. Pessaries can be fitted in most women with prolapse. depending on the type of pessary. After initial pessary placement. In particular. rectal and genital complications including fistula. Rarely. The pelvic floor muscle exercise. delivered by a physiotherapist to symptomatic women in an outpatient setting. the indications. it poses no risk and cost to the patient. Patients should be instructed to contract their pelvic floor muscles when lifting . There is some encouragement from a feasibility study that pelvic floor muscle training (PFMT). the pelvic floor muscle exercise builds permanent muscle volume and structure support. are noted to have vaginal atrophy or areas of ulceration or abrasions from pessary use. ulcerations. (Level III. help control bowel and bladder function and play a role in sexual response.9 III.vagina is inspected for erosions. also known as the Kegel exercise. (Level III. Secondly. Pelvic floor muscle exercise helps in reducing the progression of POP. has been thought to offer a number of benefits to the patient. may reduce severity of prolapse.8 There is no consensus on the use of different types of device. Scheduling of subsequent visits is individualized. 7 3. the patient learns to consciously contract before and during increases in abdominal pressure. abrasions. Firstly.6 Vaginal estrogen is generally recommended to patients who. PATIENT EDUCATION AND LIFESTYLE MODIFICATION Patients with POP should be counseled on the importance of various lifestyle modifications that may prevent or improve their symptoms of prolapse.10 (Level II-3. Grade C) Summary of Evidence Maintaining an ideal body weight limits the pressure that the abdominal content places on the pelvic floor. nor the pattern of replacement and follow-up care. Grade B) Summary of Evidence The muscles of the pelvic floor help support the abdominal and pelvic contents from below. Currently there is no evidence from randomized controlled trials (RCT) upon which to base treatment of women with POP through the use of mechanical devices/pessaries. granulation tissue formation and infection. Any activity that engages the pelvic floor such as walking or gardening can help strengthen the muscles. at the time of their initial fitting or at subsequent follow up. It is offered to all patients who are asymptomatic or mildly symptomatic and are interested in preventing the progression of the condition and who decline other treatments. Grade B) II. PELVIC FLOOR MUSCLE EXERCISE Despite of the lack of high quality scientific evidence supporting pelvic floor muscle exercise for prevention and treatment of POP. Trowbridge MD and Fenner DE. Clemons JL.48(3):668-681. Hagen S. Issue 4. Wu V. 9. J Reprod Med 1993. et al.19:625. Barber MD.48(3):668-681. Conservative management of pelvic organ prolapse in women. Patient education should also include bowel movement retraining. Trowbridge MD. . Flowerdew G. 8. 6. Advising women on correct posture will in aid in preventing strain on the pelvic floor muscles. Practice advice for ring pessary fitting and management. Stark D. Vaginal pessaries and their use in pelvic relaxation. 7. Maher C. Baskett TF. Maher C. Stark D. Cochrane Database Syst Rev 2:CD003882. 2. Clin Obstet Gynecol 2005.38:919-923. Kuehl TJ. Obstet Gynecol 1997. et al.15:76.90:990-994. Clin Obstet Gynecol 2005. Hagen S. 4. Conservative management of pelvic organ prolapse in women. 3.29:325-327. Management of incarcerated vaginal pessaries. Farrel SA. Lancet 2007.or straining. Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse. Rodriguez E. Rodriguez E. Conservative management of pelvic organ prolapse. 5. J Am Geriatr Soc 1981. J SOGC 1997. Jelovsek JE. A simplified protocol for pessary management. et al. Bo K.11 References 1. 190(4): 1025–1029. 11. Pelvic organ prolapse. This will teach a passing motion without straining the pelvic floor muscles. Farrell SA. but how does it work? Int Urogynecol J 2004.369:1027-1038. 2004. Pelvic floor muscle training is effective in treatment of stress urinary incontinence. Fenner DE. 10. Am J Obstet Gynecol 2004. Shull BL. Sulak PJ. Conservative management of pelvic organ prolapse. Cochrane Database Syst Rev 2006. Poma PA. These would include erosion. ANTERIOR PROLAPSE) COMPARTMENT (ANTERIOR VAGINAL WALL 1. o Abdominal surgery has higher short term morbidity. MD Previous to the latter half of the twentieth century.1 In 2005.3 I. The work of anatomists in the 1970’s resulted in discovering “breaks in the continuity of support within the endopelvic fascia”.5 Three RCTs comparing anterior colporrhaphy alone and with a polyprolene mesh were reviewed. retropubic paravaginal defect repair.2 Among the Level I conclusions are : o Overall outcomes indicate that abdominal and vaginal surgeries are equivalent. and dyspareunia. Grade B) Summary of Evidence Introduction of mesh or graft inlays together with the anterior repair may decrease the incidence of recurrent cystocele. Ocampo Jr. Prodigalidad-Jabson. . Grade A) Summary of Evidence Traditional vaginal anterior colporrhaphy has cystocele recurrence rates up to 20% when done alone. sepsis.SURGICAL MANAGEMENT OF PELVIC ORGAN PROLAPSE Manuel S. Vaginal paravaginal defect repairs have a 7% recurrence rate.. the concept of prolapse surgery was based on fascial weakness and defects and so procedures were done to attenuate or strengthen ligaments or fascia supporting the pelvic organs. (Level I. This thinking redirected how pelvic reconstructive surgery is currently performed.2 o The recommendation for the use of autologous and non-autologous materials in pelvic floor reconstruction is guarded until more randomized controlled trials (RCTs) are presented and sources of these meshes have “confirmed their efficacy and safety”. (Level III.4 There are no published studies comparing the traditional vaginal and retropubic approaches. infection.202 women and examined after 12 months. MD and Lisa T.4 2. Options for repair include the traditional vaginal anterior colporrhaphy. This fulfilled the first goal of pelvic organ prolapse (POP) repair that is to “restore normal anatomy”. Large studies on retropubic paravaginal repair have cystocele recurrence rates from 3-5%. The Surgery for Pelvic Organ Prolapse Committee of the World Health Organization (WHO)’s 3rd International Consultation on Incontinence (ICI) made a comprehensive review of POP surgery studies and published its recommendations based on the strength of evidence using the Oxford System. examining populations from 76. Transvaginal permanent mesh placement may reduce the incidence of recurrent cystocele but this has unacceptably a high rate of postoperative complications. vaginal paravaginal defect repair. abdominal. Because of this. (Level II-3.9 3. There have been no studies comparing the different techniques and so “the choice of procedure is driven by the patient’s presentation and the unique anatomy as well as the surgeon’s choice”. vaginal erosion rates for the mesh groups were 5. the lower recurrence rates were from 6. the choice of surgery would depend on the specific fascial defects. When a mesh was added. Options for symptomatic diverticulae are diverticulectomy.6-8 Laparoscopic repair studies are few. Options for symptomatic diverticulae are diverticulectomy. Options include vaginal. and marsupialisation.4-45%. iliococcygeus fascia suspension. The route of hysterectomy will depend on multiple factors to be considered. desire for future fertility. history of prior prolapse surgery in other compartments. partial ablation. and laparoscopic hysterectomy. The addition of uterosacral ligament plication increases the success rate. MANCHESTER PROCEDURE The Manchester procedure can be recommended for a patient who is desirous of maintaining her uterus. there is no gold standard to speak of. A laparoscopic paravaginal defect repair study of 212 consecutive women showed a recurrence rate of 24%.Anterior colporrhaphy alone had recurrent cystocele rates from 34.6-17. Laparoscopic hysterectomy approaches are divided into laparoscopic assisted vaginal hysterectomy with or without uterine artery release and total laparoscopic vaginal hysterectomy that includes vault closure laparoscopically. There is a paucity of published reports on urethral diverticulae surgery. Addition of a graft with anterior colporrhaphy decreased recurrence to 16%.10 Options for uterine preservation are the Manchester procedure. and the abdominal/laparoscopic hysteropexy. McCall culdoplasty. co-morbidities. (Level III.7-19%. Grade B) Summary of Evidence It is estimated that up to 8% of adult women are diagnosed with a urethral diverticulum. It has a high middle compartment success rate. and marsupialisation. Additionally the patient's age.1 II. uterosacral ligament suspension. Grade B) . MIDDLE / APICAL COMPARTMENT (UTEROVAGINAL / VAGINAL VAULT PROLAPSE) Because there are few RCTs comparing procedures and most are uncontrolled retrospective studies. activity level. patient preference. sacrospinous hysteropexy. and colpocleisis. partial ablation. Only women with symptomatic diverticulae should be operated on. The most common procedures for post-hysterectomy vaginal vault prolapse include sacrospinous ligament fixation. as well as the skill and comfort level of the surgeon with the particular surgery are to be considered. However.3%. concluded that “favorable postoperative outcomes range from 62-100% and additional data show improved quality of life and sexual function. Hysteropexy should not be performed by using the ventral abdominal wall for support because of the high risk for recurrent prolapse.05%) and cervical stenosis (11.14 2.11 A comparison of a Modified Manchester procedure with the addition of a uterosacral ligament plication versus a vaginal hysterectomy with a high uterosacral ligament plication showed similar anterior and posterior compartments prolapse recurrences (50%). with cure rates ranging from 91-100%. recommendations are:15 1. (Level II-3. Few studies are available for sacrospinous and abdominal hysteropexy. Grade B) Summary of Evidence These procedures use suture or mesh to attach the cervix/uterus to the sacrospinous ligament or the sacrum. After a one-year follow-up. with a desire of maintaining her uterus. Grade B) .”14 The open or laparoscopic sacrohysteropexy has similar results when compared with sacrospinous fixation. Follow-up after 3 years revealed almost 4% had undergone surgery for prolapse recurrence and urinary incontinence. Several studies favoring sacrohysteropexy also showed improvements in quality of life and sexual function.27%). Early post-operative complications were urinary retention (22. A retrospective study of 187 consecutive patients with a majority having a stage 3 uterine prolapse underwent a Manchester procedure.Summary of Evidence This procedure is indicated for a patient with an elongated cervix. et.3%. Anatomic outcomes appear to be comparable to vaginal hysterectomy with sacrospinous ligament vault suspension. particularly enterocele. an anterior vaginal wall prolapse. the Modified Manchester had no recurrent middle compartment prolapse compared to 4% for the vaginal hysterectomy with a high uterosacral plication group.13 A review by Ridgeway. (Level II. No serious complications were noted. al. One observational study for sacrospinous fixation involved 133 women where 84% of women were highly satisfied. The uterine prolapse recurrence rate that needed reoperation was 2. Alternative operations for uterine preservation in women with prolapse include uterosacral or sacrospinous ligament fixation by the vaginal approach or sacral hysteropexy by the abdominal approach.12 SACROSPINOUS HYSTEROPEXY AND ABDOMINAL / LAPAROSCOPIC HYSTEROPEXY The American College of Obstetrics and Gynecology (ACOG) released Bulletin 85. Cystocele recurrence was 35%. Because of equal or significantly better outcomes on all parameters. (Level I. Figure 1 is a pathway for choosing the route of hysterectomy for benign disease. Grade A) . (Level I. recommendations are: 1.1 2. (Level II. and the patient’s preference. and unspecified infections. Grade B) HYSTERECTOMY 1. Round ligament suspension is not effective in treating uterine or vaginal prolapse. there were more urinary tract complications in laparoscopic than abdominal hysterectomy.3. and that the differences between laparoscopic assisted vaginal hysterectomy over total laparoscopic hysterectomy were a shorter operation time. the patient’s condition. fewer febrile episodes. the gynecologist’s training and comfort with the route of hysterectomy. the extra-uterine pathology is mild. laparoscopic hysterectomy may avoid the need for abdominal hysterectomy. A vaginal or laparoscopic route is favorable if the uterus is less than 12 weeks size and accessible vaginally. size reduction is possible during surgery. it was found that recovery was fastest in vaginal and laparoscopic than in abdominal routes. Cadaveric fascia should not be used as graft material for abdominal sacral colpopexy because of a substantially higher risk of recurrent prolapse than with synthetic mesh. Grade B) SACROSPINOUS LIGAMENT FIXATION LAPAROSCOPIC SACROCOLPOPEXY AND ABDOMINAL / The ACOG released Bulletin 85.16. Grade B) Summary of Evidence In an analysis of multiple RCTs comparing vaginal. and there is an absence of severe endometrioses and severe adhesions. and laparoscopic hysterectomies. (Level I.17 3. The route of hysterectomy depends on multiple factors. vaginal hysterectomy should be performed in preference to abdominal hysterectomy where possible. Where vaginal hysterectomy is not possible. there was no advantage of laparoscopic hysterectomy over vaginal hysterectomy. (Level I. The surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon in light of the relative benefits and hazards. which include the stage of uterine prolapse. Otherwise an abdominal hysterectomy is the safer choice. abdominal. the cul de sac is accessible. the pathology is limited to the uterus. Grade B) Summary of Evidence Hysterectomy is an option for middle compartment prolapse. /%$1)!'*!>.! 89#0%&#+%/&! !#$%! ! "#$%&#'! ()*+.1$! 9.+/0)! ./0$! #$%! !&'! ! 567/0%&#'! ()*+.#+..'1! 9'%%./2) ! #$%! !&'! !&'! ?+0!:[email protected]$%%.1..'%.0:! ! ! 12.:6$%.1$:!)'!)6$!+)$*+%! !&'! ! 4#2#-/*.%! ..1%2..! 4#2#-/*.+)$*.7!:/-! .! #$%! ()$*+%!.'1%! !&'! !&'! #$%! Figure 1.%.-.99*'9*.99$./2%.*%! -'17.%!70'8!-6.+/0)! %&7%.004! !&'! !&'! #$%! ()$*+%!B!CDE!3!F0$%%! )6.+/0) <=)*.-! .1!GC!8$$H%!%. Determining the route of hysterectomy @$2$*$! $1:'>$)*..1.)6'0'34! .#*.*)!.-#+%3./0$! @$2$*$!.'1! %+99'*)"! !&'! @.()*+.3.&%$&!<%*.--$%%.)$!7'*!:$-.-..A$I! 56.%!1')! .A$!*$:+-).-./0$! )*.)6'0'34!. Preoperative and postoperative evaluation of the anterior vaginal compartment was respectively: stage 1 (5. the sacrospinous fixation cure rate was 93. et. They concluded that laparoscopic sacrocolpopexy is comparable to abdominal sacrocolpopexy. and found a 6.1%. regardless of the results of preoperative stress testing.23 . The 2-year follow-up showed the absence of apical prolapse in 89. About eighty one percent (81. Grade A) 3.6%.4% post operative apical prolapse. indicating pelvic floor damage.7% mesh erosion rate. and de novo stress urinary incontinence in 2. iliococcygeus fascia suspension may be performed with success rates above 80%.2% prolapse reoperation rate and a 2. al. abdominal sacral colpopexy has less apical failure and less postoperative dyspareunia and stress incontinence. (Level I. A study by Chene.20 Laparoscopic sacrocolpopexy results from >1000 patients in 11 series were reviewed by Ganatra. the addition of the Burch procedure substantially reduces the likelihood of postoperative stress incontinence without increasing urgency symptoms or obstructed voiding.19 Abdominal sacrocolpopexy without paravaginal defect repair showed a 26. but is also associated with more complications.7%. Grade B) Summary of Evidence The 3rd ICI reported that sacrospinous-based vaginal procedures have a higher anterior and apical anatomical recurrence rate than sacrocolpopexybased abdominal repairs.22 A history of macrosomic infant delivery.9% of cases. De novo cystocele occurred in 87.2%) of patients had satisfactory sexual function. Grade B) Summary of Evidence The goal of endopelvic fascia repair (or modified McCall culdoplasty) is to suspend the vaginal vault to the endopelvic fascia.21 McCALL CULDOPLASTY McCall’s culdoplasty.2% and a 10% incidence of stage 1 vaginal vault prolapse that did not require re-operation. et. (Level II-III. high uterosacral ligament suspension. (Level II.2%. 48. dyspareunia in 2.9% recurrence of cystocele. cystocoele in 8%. For stress-continent women planning abdominal sacral colpopexy. Compared with vaginal sacrospinous ligament fixation. al.3%).18 In a recent study by Benedito de Castro.2 Sacrospinous ligament fixation has post-operative risks for temporary buttock pain in 6% of patients. used a modified McCall procedure where 185 patients underwent vaginal hysterectomy.2. was linked to failure of the modified McCall culdoplasty and resulted in 44. et. They only had a 2. al. Intra-operative cystoscopy is an option. iliococcygeus fascia suspension may be performed with success rates above 80%.26 COLPOCLEISIS For women who are at high-risk for complications with reconstructive procedures and who no longer desire vaginal intercourse. Colpocleisis carries a risk for postoperative de novo stress urinary incontinence (SUI).4%). al. There are few recent studies on this procedure. et.2%). Silva. The vault suspension sutures suspend the vagina deep into the pelvis. Grade B) Summary of Evidence The purpose of iliococcygeus fascia suspension is to suspend the vaginal vault to the fascia of the iliococcygeus muscle in patients with weak uterosacral ligaments. followed by the posterior compartment (87. and their conclusions were: 1) Colpocleisis for . iliococcygeus fascia suspension may be performed with success rates above 80%.HIGH UTEROSACRAL LIGAMENT SUSPENSION McCall’s culdoplasty. This is similar to the McCall’s culdoplasty. showed that uterosacral suspension was most favorable for the apical compartment with a pooled rate of 98. (Level II-III. et. high uterosacral ligament suspension. Grade B) Summary of Evidence This aims to suspend the prolapsed vaginal vault bilaterally to the uterosacral ligaments. (Level II-III. up to the level of the ischial spines.24 A meta-analysis of uterosacral ligament suspension by Marquiles. high uterosacral ligament suspension. colpocleisis can be offered. A study comparing McCall’s culdoplasty alone and with iliococcygeus fascia suspension showed that 8. presented a high uterosacral vault suspension over an average of 5 years follow-up of 110 patients.3% had postoperative vaginal defects in the combined group and 33. al.25 ILIOCOCCYGEUS FASCIA SUSPENSION McCall’s culdoplasty. Published data were reviewed by Fitzgerald.3%.8% recurrence of an apical prolapsed. Grade B) Summary of Evidence Total colpocleisis procedures are performed for patients with posthysterectomy vaginal vault prolapse. High uterosacral ligament suspension carries a risk of ureteral injury or kinking. and the anterior compartment (81. (Level III.3% were observed in the group undergoing McCall culdeplasty alone. Zimmern P. Carey M. 2) The data is incomplete with regards reoperation rates for stress incontinence. 6. For posterior vaginal wall prolapse. (Level I. Grade A) Summary of Evidence In a study by Paraiso. Krausse H. Leong A. Baessler K. 3) Concomitant elective hysterectomy does not improve outcomes. Higgs P. Cardozo L. Grade B). Results after one year follow-up showed that those who received graft augmentation had a significantly greater anatomic failure rate (46%) than those who received site-specific repair alone (22%) or posterior colporrhaphy (14%). Glazener CM. Surgical management of pelvic organ prolapse in women. Addition of a porcine-derived graft did not improve anatomic results. Cornish A. Overall postoperative sexual function had significantly improved in all groups postoperatively. Cochrane Database Syst Rev 2007 Jul.98(Suppl 1):92-93. Hagen S. Vaginal repair with mesh versus colporrhaphy for prolapsed: a randomized controlled trial. 2. 5. Griebling T. Springer-Verlag London Ltd 2003. al. 2.27 Colpocleisis is an option for women who have a high risk for complications with reconstructive procedures and are not desirous of intercourse.. the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach. Adams EJ. Lippincott Williams & Wilkins 2007. Lim J.28 The same groups were followed one year postoperatively and assessed for bowel symptoms and were found to have less straining and less of a feeling of incomplete emptying.POSTERIOR PROLAPSE) COMPARTMENT (POSTERIOR VAGINAL WALL 1. 3.15 (Level II-1. Zimmerman C. Posterior colporrhaphy and site-specific rectocele repair had similar anatomic and functional outcomes. 4. 116(10):13806. Goh J. Advances in geriatric female pelvic surgery. . Maher C. BJOG 2009. et. Female pelvic reconstructive surgery.187-88.POP is successful in almost 100% of patients in recent studies. Stanton S.27 III. 4) Pelvic symptoms were not usually assessed by the studies. BJU Int 2006. 3 different rectocele repair techniques were compared where 106 women with stage II or greater posterior vaginal wall prolapse were randomly assigned to either posterior colporrhaphy. BJU Int 2006.98(Suppl 1):77. Posterior colporrhapy has a greater success rate compared to site-specific rectocele repair with or without a graft. sitespecific rectocele repair. Editorial comment: The use of synthetic mesh in female pelvic reconstructive surgery. Atiemo H.29 References 1. Kovac SR. Advances in reconstructive surgery. or site-specific rectocele repair augmented with a porcine small intestinal submucosa graft. Daneshgari F.18(3):CD004014. Surgical reinforcement of support for the vagina in pelvic organ prolapse: concurrent iliococcygeus fascia colpopexy (Inmon technique). 18. Shimoya K. 25. Handa VL. Seman El. Surgical approach to hysterectomy for benign gynaecological disease. BMJ 2005 Jun 25. Murata Y. Obstet Gynecol 2007. Withagen MI. 28. Sanses TV. 85.17(3):261-71. Knoepp LR. Tavender E. Am J Obstet Gynecol. Am J Obstet Gynecol 2006 Dec. Selcuk S.7. 14. 17. Cundiff GW.34(1):106-10 Shippey SH. Yoshida S. Surgical management after uterine prolapsed. Outcome after anterior vaginal prolapse repair: a randomized controlled trial. 24. Siddique S.111(4):891-8. Int Urogynecol J Pelvic Floor Dysfunct. Int Urogynecol J Pelvic Floor Dysfunct 2010 Mar. 11. Int Urogynecol J Pelvic Floor Dysfunct 2002. Frick AC. Schraffordt Koops S. Celik C. The effectiveness of the sacrospinous hysteropexy for the primary treatment of uterovaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct. Rooney CM. Silva WA. Behnia-Willison F. Int Urogynecol J Pelvic Floor Dysfunct. FitzGerald MP. Outcomes of transvaginal uterosacral ligament suspension: systematic review and metaanalysis. Boda C. 22. Merikari M. Chene G.18(11):1271-6. Rogers MA. Esin S. Hiltunen R. 23.Guven S. Paraiso MF. Keirse MJ. Pelvic organ prolapse. Tardieu AS. Koyama S. Benedito de Castro E. Garry R. Zyczynski H. O’Shea Rt. Krief M. Colpocleisis: a review. Possible cause of failure after McCall culdoplasty.(3):CD003677. Tavender E. Savary D. Cathelineau X. Kleeman SD. Walter MD. Heinonen PK. Minerva Ginecol 2008 Dec. 12. Obstet Gynecol 2008 Apr. Olivares JM. Ridgeway B. Niemi K. The Manchester operation for uterine prolapsed. Kimura T. 8. Riccetto C. 10. Asoglu MR. Koyama M. Takala T. Paraiso MF. 2007 Nov. Lowweight polypropylene mesh for anterior vaginal wall prolapse: a randomized controlled trial. Sanchez-Salas R. Int Urogynecol J Pelvic Floor Dysfunct 2009 Nov. De Boer TA. 20. 2010 Feb. Garry R.21(3):279-83.330(7506):1478.110(2 Pt 2):455-62. Richter HE.60(6):509-28. Dietz V.16(3):197-202. Nagata I. Eur Urol 2009 May. Heiskanen E. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials.13(5):308-13. Johnson N. Kluivers KB. 21. Nguyen JN. de Jong J.108(2):255-63 Margulies RU. Cook JR.55(5):1089103.19(7):1007-11. Muir TW.92(3):228-33. Burchette RJ. Curr E. Vallancien G. Ozyunco O. Bigozzi MA. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation.20(11):1313-9. ACOG Practice Bulletin No. Milani AL. van der Vaart H.202(2):12434. Nieminen K. Tug N. Karram MM. Morgan DM. Uterosacral ligament vault suspension: five-year outcomes. Palma P. Ganatra AM. van Voorst S. 26. Walters MD. Curr L. Int Urogynecol J Pelvic Floor Dysfunct 2008 Jul. Quiroz LH. . Hysteropexy: A review. Barber MD. Int J Gynaecol Obstet 2006 Mar. Thompson P. Lethaby A. 9. Aran T. Mol BW. Actas Urol Esp 2010 Jan. The current status of laparoscopic sacrocolpopexy: a review. Drutz HP. Karateke A. Rozet F. Ayhan A. Anatomical and functional results of McCall culdoplasty in the prevention of enteroceles and vaginal vault prolapse after vaginal hysterectomy. Cochrane Database Syst Rev 2009 Jul 8. Mansoor A. 2006 May. 15. Lethaby A. Park AJ. Impact of sacrospinous vaginal vault suspension on the anterior compartment. Safety and efficacy of sacrospinous vault suspension. The effectiveness of surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication (modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication. Arch Gynecol Obstet 2010 Mar 16. Heintz P. Laparoscopic paravaginal repair of anterior compartment prolapse. 19. Segal JL. Salman C. Pauls RN. 16.60(6):493-507. Anatomic outcomes of abdominal sacrocolpopexy with or without paravaginal repair. Namazov A. Ogita K. Kluivers KB. Vierhout ME. Obstet Gynecol 2006 Aug. 2005 May-Jun. Herrmann V. Galiano M. Anton-Bousquet MC. Washington (DC) Nieboer TE. American College of Obstetricians and Gynecologists (ACOG). Minim Invasive Gynecol 2007.195(6):1762-71. 13. Johnson N. Minerva Ginecol 2008 Dec. Huisman M. 27. Barret E.14(4):475-80. Cam C. Barlow D. Lovatsis D. 29. Gustilo-Ashby AM, Paraiso MF, Jelovsek JE, Walters MD, Barber MD. Bowel symptoms 1 year after surgery for prolapse: further analysis of a randomized trial of rectocele repair. Am J Obstet Gynecol 2007 Jul;197(1):76.e1-5. FECAL INCONTINENCE AND OBSTETRIC ANAL SPHINCTER INJURIES Lennette L. Chan, MD I. NON-OPERATIVE TREATMENT 1. Non-operative therapy is the initial management to improve the symptoms of fecal incontinence (FI). Patient education is important. (Level III, Grade C) 2. Attempt should be done to establish a bowel routine. (Level III, Grade C) Summary of Evidence Expert opinion supports the use of general health education, patient teaching about bowel function and advice on lifestyle modification.2-4 3. Treat reversible causes of diarrhea. Antidiarrheal agents, such as adsorbents or opium derivatives, may reduce FI. (Level II, Grade C) Summary of Evidence Diarrhea or loose stools is consistently found to be a risk factor for FI. Potentially preventable causes of diarrhea include drugs, dietary supplements, and some foods. There is some evidence that loperamide may decreased stool frequency, improve stool consistency, and reduce side effects in patients with FI.5-7 4. A trial of soluble dietary fiber is recommended for the management of FI associated with loose stool. (Level I, Grade B) Summary of Evidence Dietary fiber supplementation appears to be a safe and tolerable intervention for fecal incontinence. In Bliss study, subjects were communityliving adults with incontinence of loose or liquid stools given supplementation with one of two soluble dietary fibers compared to placebo resulted in reduced rate of FI in patients with loose stool.8 On the other hand, there are reports that dietary fiber may exacerbate FI in some patients. Some patients with FI benefit from moderating their intake of foods containing largely insoluble fiber.9 Another study reported that treating constipation in elderly immobile people with a supplement of insoluble fiber and bran, resulted in FI in half of them.10,11 Fiber supplements appear to benefit diarrhea-associated but not constipation associated FI. 5. Enemas, laxatives, and suppositories may help to promote more complete bowel emptying in appropriate patients and minimize further post defecation leakage and treat constipation associated FI. (Level II, Grade C) Summary of Evidence For constipation-associated FI, daily or more frequent oral laxative regimens may be effective.12 6. Pelvic floor muscle exercises are recommended in patients who have not responded to simple dietary modification or medication. (Level III, Grade C) 7. The use of biofeedback as a treatment for FI is recommended after other behavioral and medical management have been tried if inadequate symptom relief is obtained. (Level III, Grade C) Summary of Evidence National Institute of Health and Clinical Excellence (NICE) clinical guidelines consensus statement regarding and the use of biofeedback for FI. “Given the numerous positive outcomes from uncontrolled trials, limitations in the current randomized controlled trials (RCTs) and low morbidity associated with its application the use of pelvic floor muscle exercises and biofeedback, as treatment for fecal incontinence, is recommended as possibly effective and currently unproven and can be used after other behavioral and medical management has been tried.” 8. Patients who failed conservative therapy or not be candidates for conservative therapy due to severe anatomic, physiologic or neurologic dysfunction are referred for surgical management. II. DIAGNOSTIC TESTS PRIOR TO SURGICAL MANAGEMENT 1. Endoanal ultrasonography has the largest diagnostic value to detect morphological integrity of the anal sphincter complex in patients with FI. (Level III, Grade C). 2. Ancillary tests: Anal manometry, electromyography (EMG) and defecography may be helpful in guiding management. (Level III, Grade C) Summary of Evidence Endoanal ultrasound is helpful in defining the extent of anal sphincter injury. Preoperative physiologic testing may be helpful in the overall management of patients with FI. However, the value of anal manometry and pelvic floor electrophysiological assessment as prognostic indicators for outcome following sphincteroplasty is controversial. There are no established parameters that reliably predict outcome following sphincteroplasty.17,18 15 3. In case of failed conservative management, the surgical approach to the patient depends on the presence and magnitude of an anatomic sphincter defect. If no sphincter defect is present, the patient should undergo initial if successful. al.35 In patients with an unrepaired external or internal anal sphincter or both. et. (Level III.19 A report by Rosen. Bravo Gutierrez.36 SNS in 6 of 8 patients presenting with fecal incontinence related to obstetric full thickness anal sphincter lesions ranging from > 30-150 degree resulted at a median follow-up of 26.30. SNS resulted in significant improvement of incontinent episodes with a minimum follow-up of 4 years. If sphincter loss is < 180 degrees. SNS for sphincter defect may be used for most patients with clinically significant incontinence with sphincter defect.30 There is now an increasing body of evidence indicates that SNS may also be a treatment option for patients with sphincter defects. et.24-28. (Level III Grade B) Summary of Evidence SNS was primarily used it in patients with neurologic origin of fecal incontinence without sphincteric defects. Grade B) Summary of Evidence Most patients improve after overlapping sphincteroplasty.38 . unrepaired or after attempted anatomic reconstruction. should lead to sacral nerve stimulation (SNS). showed that the primary use of SNS in patients with a sphincter gap 17-33% of the circumference appeared to result in an outcome similar to its use after failed sphincter repair.32 Long-term atrophy of the sphincters may be relevant.5 clinical function37. Melenhorst. al. 75% of whom suffered from FI of neurologic origin. which. al. sphincteroplasty is recommended.34 In 20 patients with unrepaired obstetric trauma.3 and the Cleveland Clinical Score (CCS) improved (from 15 to 3. found that only 6% of patients retained full continence 10 years following anal sphincteroplasty.3 to 0. The technique is safe. A number of studies have looked at long term outcomes after repair of a 3rd or 4th degree tears and all have shown an increasing prevalence of continence disorders with age. improved ability to postpone bowel emptying and improved American Society of Colon and Rectal Surgeons (ASCRS) quality of life scores. minimally invasive. but outcomes deteriorate over time. the frequency of incontinent episodes per week decreased from 1.33 Three of five patients with ultrasound evidence of sphincter disruption measuring 25-33% of the circumference benefited from chronic SNS.5 to 1. highlights the effect of SNS in a cohort of patients.20 Frequency of incontinence episodes/week was reduced from 6 to 2 at 15 months follow-up.percutaneous nerve evaluation (PNE). The presence of an internal anal sphincter defect on endoanal sonography is reportedly unrelated to the success of permanent SNS.5 months in improved frequency of incontinent episodes per week from 5. and has the unique advantage of allowing a therapeutic trial prior to permanent stimulator implantation.31 In the largest study reported to date. Due to increasing evidence that sphincteroplasty deteriorates with time. It has the unique advantage of allowing a therapeutic trial prior to permanent stimulator implantation.5) with a follow-up of 12-97 months. et.21-23 4. Studies with a median follow-up of more than 5 years revealed that continence after pelvic floor reconstruction deteriorated with time. Initial pelvic floor reconstruction can be performed. SNS is recommended. For patients who remain incontinent following sphincteroplasty. 7. alternative management includes stimulated muscle transposition. For patients with persistent incontinence after pelvic reconstruction. identifiable using endoanal ultrasound.44 conducted an RCT comparing postanal repair and total pelvic floor repair in 20 women with neurogenic FI. Grade C) Summary of Evidence Deen. and anorectal perforation. Grade B) . (Level III. which was then electrically stimulated transforming type II into type I muscle fibers. infection. Complete continence to solid or liquid stool was achieved in 27% of patients after postanal repair and in 22% after total pelvic floor repair. repeat endoanal ultrasound should be done to reassess the status of the repair. These reports of increasingly poor outcomes have diminished the popularity of this procedure significantly. individualized treatment is indicated. If there is a persistent sphincter defect. (Level III. Stimulated muscle transposition has been shown to have reasonable success but is associated with significant morbidity such as disturbed evacuation. Grade C) Summary of Evidence Initial success of sphincteroplasty is related to whether the anal sphincter defect is corrected.39. pulse generator displacement. Possible explanations for deterioration of continence following initial improvement included unrecognized denervation and/or muscular injury of the sphincter and pelvic floor musculature and the presence of occult anal sphincter disruption. artificial anal sphincter implantation. pain.42 6. and 67% after total pelvic floor repair while van Tets. al.45-47 8.39 Early failure is usually associated with a persisting defect. et. For patients with sphincter defects of greater than 180 degrees or major perineal tissue loss.47 It remains a useful technique in selected patients with significant perineal tissue loss and in those who have failed other treatments. For patients who remain incontinent despite an anatomically satisfactory sphincteroplasty.5. al. (Level II.40 This may be amenable to a further attempt at repair. repeat anal sphincter repair could be considered. 33% after anterior levatorplasty. or SNS. et.43 in an RCT comparing three procedures in 36 women with neuropathic FI. Grade B) Summary of Evidence Stimulated muscle transposition involves the transposition of the gracilis muscle to reconstruct the anal sphincter. found that complete continence was achieved in 42% of patients after postanal repair. (Level II. 49 There was no significant difference in outcomes between those with and without an external sphincter defect. Outcome after 12 months was statistically not significantly different between those patients with an intact sphincter complex and those without. SNS is an effective therapy for most patients with clinically significant incontinence who fail conservative management. Minnesota. Up to 46% of patients underwent revisional surgery. a pressure-regulating balloon that is implanted in the prevesical space. et. Grade C) Summary of Evidence Shafik in 1993 began treating patients with FI (7 of whom had internal sphincterotomy and 4 idiopathic incontinence) using injectable biomaterials of polytetrafluoroethylene paste into the anal submucosa. Overall complication rate varied between 11-87% but no mortality rate was reported. There is only one report of long-term results for injectable agents.50 9. Grade B) Summary of Evidence The device (Acticon Neosphincter®.Summary of Evidence A cohort study reports on the effect of permanent SNS in 53 patients presenting with either an intact external anal sphincter (N=32 [37. Chan and Tjandra reviewed 53 consecutive patients who underwent SNS for FI. al. Surgical site infections (9-58%) and erosion of the adjacent skin (6-32%) were common.58 One patient had .5% after sphincter repair]) or an external anal sphincter lesion (N=21 [81% after prior sphincter repair]) of < 90° (N=11) or 90-120° (N=10). and 22-67% were completely continent. USA) is a totally implantable system consisting of 3 parts: an inflatable occlusive cuff that is implanted around the native sphincter. Patients with passive FI to liquid or solid stool who had failed conventional therapy. 10. reported the 5year outcome of 6 patients injected with Bioplastique. American Medical Systems. (Level II. Most of the patients (78-100%) with a functioning device were continent to solid stool. The success rate in patients with a functioning device was 44-100%. the use of injectable biomaterials report reasonable short and midterm term success rate. AAS has been shown to have reasonable success. particularly those who have failed other treatments.57 Sixty four percent reported complete cure and 36% had partial improvement. Patients with sphincter defect who have failed SNS. Sixty seven percent patients have their devices explanted.48 Improvement of symptoms and quality of life was achieved in all groups. The AAS is a useful technique in carefully selected patients. Maeda. sphincteroplasty can be considered. Other alternatives include stimulated muscle transposition and implantation of an artificial anal sphincter (AAS). and the proportion of patients with a functioning device after follow-up of between 6 and 34 months ranged between 24-100%. 56-95% were continent to solid and liquid stool. (Level III. and the intention-to-treat success rate was 41-83%. and a control pump that is implanted in the labia majora. 61 It also could be the most cost-effective in the short to medium term. however.65 found that pregnancy rather than delivery was a more important indicator of post partum continence. Nelson. Colostomy should not be regarded as a treatment failure but rather a reasonable treatment option for patients whose lives are restricted by FI that is not amenable to other therapies. There is no convincing evidence of role for preventive cesarean section for FI. should consider placement of an end sigmoid colostomy. and laxatives. four of the remaining five patients reported subjective improvement in their incontinence and quality of life scores. et. digoxin. al. the serotonin reuptake inhibitor class of antidepressants. Patients who fail surgical therapy for FI. Grade C) Summary of Evidence Diarrhea or loose stools is consistently found to be a risk factor for FI. 11. PREVENTION OF FECAL INCONTINENCE 1. Drugs known to cause diarrhea as a side effect include antibiotics. in a systematic review. Chronic laxative dependence or abuse may cause frequent diarrhea. embarrassment. fructose and sorbitol and natural foods such as prunes. improved stool consistency.and gender-adjusted regression analysis of the FI Quality of Life score revealed significantly higher scores in the coping. (Level II. However. III. It restores dignity and allows patients to regain social function.5-7 Fiber supplements appear to benefit diarrhea-associated but not constipation associated FI. especially the erythromycin analogs. An age. Treat reversible causes of diarrhea. and lifestyle scales in the colostomy group compared to the FI group. or who do not wish to undergo extensive pelvic reconstruction. (Level III. dietary supplements. (Level III. 2.undergone a colostomy. There is some evidence that loperamide may decreased stool frequency. Grade A) Summary of Evidence Cesarean delivery before the onset of the second stage of labor was found to be protective64. Grade C) Summary of Evidence A permanent colostomy is usually performed as a last resort for severe FI when all other interventions have failed. Potentially preventable causes of diarrhea include drugs. Most series of injectable biomaterials report reasonable success rates though with short-term efficacy. . compared to more complicated surgical procedures such as artificial anal sphincter and dynamic graciloplasty. orlistat. and reduced side effects in patients with fecal incontinence. and some foods such as lactose. All women having a vaginal delivery with evidence of genital tract trauma should be examined systematically to assess the severity of damage prior to suturing. Avoid midline episiotomy. Grade A) .70 6.3. Grade A) Summary of Evidence Midline episiotomy is associated with higher incidence of anal sphincter injury. (Level I. Grade C) Summary of Evidence With increased awareness and training there appears to be an increase in the detection of obstetric anal sphincter injuries. Grade B) Summary of Evidence Primary repair of an obstetrical tear is usually performed by the obstetrician immediately after delivery most commonly in the delivery room under local or epidural anesthetic.and fourth-degree perineal tears showed that there is increased awareness of perineal anatomy and recognition of anal sphincter injury following attendance at hands-on training workshops.66 The angle of mediolateral episiotomy may also influence perineal outcome. Restrictive rather than liberal episiotomy protocols. the detection rate of anal sphincter injury was not significantly increased compared to clinical examination alone. Inexperienced attempts at anal sphincter repair may contribute to maternal morbidity.76. One observational study showed that increased vigilance about anal sphincter injury can double the detection rate.77 7. Results of the four RCTs71-74 and one metaanalysis75 that have investigated different techniques of immediate primary repair of the external anal sphincter following obstetric injury points to a trend towards better outcome with an overlap repair. (Level I. Training may be improved by the implementation of surgical skills workshops with the use of models and audiovisual material. Primary overlapping sphincter repair performed by a fully trained surgeon in obstetric anal sphincter injuries (OASIS) repair is indicated. (Level I. Discourage the use of internal anal sphincter division for treatment of anal fissure and hemorrhoids. A report on the effect of hands-on training workshops on repair of third. (Level II.68 5.69 In another study where endoanal ultrasound was used immediately following delivery.67 A policy of restrictive use of episiotomy may reduce the incidence of anal sphincter injury. In a prospective case–control study there was a 50% relative reduction in risk of sustaining third-degree tear observed for every 6 degrees away from the perineal midline that an episiotomy was cut. Grade A) 4. especially subsequent FI. (Level II-3. Brazzelli M. Spencer JA. Nursing Research 2001. Drug treatment for faecal incontinence in adults.(3):CD002116.346(8983):1124-7.9(1):115-20. Jung H. Gardiner AB. Gall FP.Telephone vs. p.discussion 1283-4. Wein A.Summary of Evidence A persistent defect in the internal anal sphincter was found to be an important determinant of FI. Williams AB. Rev Gastroenterol Disord 2008 Winter. Duthie GS. Byrne CM. Thomas L. Young JM. Treatment options for fecal incontinence: consensus conference report. World J Surg 2010 Apr. Rosen HR.34(4):815-21. Schmidt RA. Bliss DZ. Boselli AS. 2004. techniques and MRI features. Biofeedback therapy plus anal electrostimulation for fecal incontinence: prognostic factors and effects on anorectal physiology. Savik K. Rex J. LeMoine M.204(1):40-6. Solomon MJ. Gastroenterology 2001. The reduction of faecal incontinence by the use of “Duphalac” in geriatric patients. Beaconsfield: Beaconsfield Publishers. Bischoff A. Holzer B. Main ANH. Jackson L. Schiessel R. Kmiot WA. 5. Effect of alcohol consumption on the gut. Anal sphincter damage after vaginal delivery using three-dimensional endosonography. Matzel KE.61(3):462-72.2:329-33. Bowel continence nursing. Bode JC. Norton C. 8. Bowel continence nursing. Norton C.17:575-92 12. Pinna F.97(5 Pt 1):770-5. Chelvanayagam S. Tanagho EA. Holder M.300:1400. Dynamic MR defecography of the posterior compartment: Indications. Merlino C. Judge TG. 20. Matzel KE. Muir TS.44:131-44. Conservative and pharmacological management of faecal incontinence in adults. 114-31. Fairhurst J. Incontinence. Management of faecal incontinence in adults: summary of NICE guidelines. Ardron ME.121(3):536-41. Supplementation with dietary fiber improves fecal incontinence. Nicholls RJ. p. Hull T. Whitehead WE. Levitt MA. Maslekar S. 14. Marchesi F. 2005. Whitehead WE. The role of loperamide in gastrointestinal disorders. Lowry AC. 18. Hohenfellner M. 19. 6. Dis Colon Rectum 2001. Neuroanatomy of the striated muscular anal continence . Best Pract Res Clin Gastroenterol 2003. 11. Norton C. Treatment of fecal incontinence with a comprehensive bowel management program. 21. Pediatr Surg 2009 Jun. Cardozo L. 15. Cheetham M. Tries J. Wald A. Bode C. Hammel J. Bliss DZ. et al. Schroeder T. 4. Chelvanayagam S. 1521-63. 10. Jensen L. Khoury S. Conservative management of faecal incontinence in adults. Dis Colon Rectum 2005 Dec. 3.50(4):203-13.334:1370-1. Eur J Radiol 2007. Novi G. Violi V. Wilson A. 16. Norton C. face-to-face biofeedback for fecal incontinence: comparison of two techniques in 239 patients. Bauer C. In a large series of 585 patients with a chronic anal fissure treated in this fashion at the Mayo Clinic. Beaconsfield: Beaconsfield Publishers.44(6):1278-83. Glazener CM. Lancet 1995. Anal manometric parameters: predictors of outcome following anal sphincter repair? J Gastrointest Surg 2005. Electrical stimulation of sacral spinal nerves for treatment of faecal incontinence. Heggie D. Cochrane Database Syst Rev 2003. 2. Hanauer SB. Cecchini S. Bartram CI. Norton C. Management of constipation. Stadelmaier U. 9. Hill J. Curr Med Res Opin 1974. 2004. Roncoroni L. editors. Ryan D. Costi R. Obstet Gynecol 2001. Peña A.79 References 1. BMJ 1990. Chelvanayagam S. 13. Sacral nerve stimulation as a treatment for fecal incontinence. J Am Coll Surg 2007. Mortele KJ. Plymouth: Health Publications. Metsola P. Halligan S. In: Norton C. Norton N. editors. In: Abrams P. 7. Sarli L. Anterior anal sphincter repair for fecal incontinence: Good long term results are possible. Floruta C.78 Patients with chronic anal fissure or hemorrhoids may be offered internal anal sphincterotomy (slit in the internal anal sphincter for 50-60% of its length to reduce anal canal pressures). Urbarz C. BMJ 2007. 11% developed FI. Gearhart S.48(12):2281-8. 17.8(1):15-20. Dis Colon Rectum 2004.115(2):234-8. Dudding TC. Norton CS. Dis Colon Rectum 2008. Sacral nerve stimulation can be successful in patients with ultrasound evidence of external anal sphincter disruption. September 27. 44. 2007. Previous sphincter repair does not affect the outcome of repeat repair. Nicholls RJ. Predictive factors for successful sacral nerve stimulation in the treatment of faecal incontinence: a 10-year cohort analysis. 43. Gannon K. ANZ J Surg 2004. Vaizey CJ. Halligan S. Dammegaard L. Overlapping anal sphincter repair and anterior levatorplasty: effect of patient’s age and duration of follow-up. Fecal incontinence. 30. Results of repeat anal sphincter repair. Cohen CR. Hohenberger W. 40. Dawson JD. Dudding TC. Sacral nerve stimulation as primary treatment for faecal incontinence secondary to obstetric anal sphincter damage: medium and long-term results [abstract]. Faltin DL. Obstet Gynecol 1997. Conaghan P. Lindow SW. Williams NS. Dis Colon Rectum 2002.247(2):224-37. van Tets WF. Lowry AC.80(6):794-8. Kumar D. Nogueras JJ. Sacral nerve stimulation for fecal incontinence related to obstetric anal sphincter damage. Obstetric anal sphincter injury: incidence. Pedersen JF.51(5):531-7. Kamm MA. Uludag O. Anal incontinence after anal sphincter disruption: a 30-year retrospective cohort study. Kamm MA. Matzel K. 39. Dis Colon Rectum 2006. Paper presented at: European Society of Coloproctology 2nd Annual Scientific Meeting. Roach R. Farouk R.45(5):635. Petignat P. Malta 37.21. Long-term effects of anal sphincter rupture during vaginal delivery: faecal incontinence and sexual complaints. Am J Obstet Gynecol 2006. Wexner SD. Renzi A. discussion 731-2. Dudding TC.126(1 Suppl 1):S48-54. BJOG 2008. Madoff RD. Ratto C. 25. 31. Weiss EG. Vaizey CJ. Malouf AJ. Otero M. Madoff RD. 35. Endosonographic assessment of the anal sphincter after surgical reconstruction. Efron J. Nielsen MB. Nicholls RJ. 45. Anal sphincter injury. Ann Surg 2008. 29. Nicholls RJ. Kamm MA. Giordano P. Matzel KE. Dis Colon Rectum 1998. 41. de Leeuw JW. Duthie GS.40. Pelvic floor procedures produce no consistent changes in anatomy or physiology. Dis Colon Rectum 2003. Implications for the use of neurostimulation.47(10):1720-8 23. Nicholls RJ. Muller SA. Davis K. Geerdes BP.37(5):434-8. 46. 33.46(8):10838. Gervaz P. Tillin T. Kamm MA. Sacral nerve stimulation in fecal incontinence due to anal sphincter lesions. Dis Colon Rectum 1994. Lancet 2000.47(5):727-31. Rongen MJ. risk factors. Surgical treatment options for fecal incontinence. Gardiner A. Vaizey CJ. Bravo Gutierrez A. Keighley MR. Gastroenterology 2004. Deen KI. Nygaard IE. Third-party prospective evaluation of patient outcomes after dynamic graciloplasty. Thornton MJ. Long.33(8):66673. Innovations in fecal incontinence: sacral nerve stimulation. Rao SS.86(1):66-9. El Naggar K. Dis Colon Rectum 2004. Engel AF.mechanism. 24. Is a morphologically intact anal sphincter necessary for success with sacral nerve modulation in patients with faecal incontinence? Colorectal Dis 2008. Long-term results of anterior sphincteroplasty. 38.term results of overlapping anterior anal sphincter repair for obstetric trauma. Sacral nerve stimulation: an emerging treatment for faecal incontinence. and management.49(5):730. Br J Surg 2006. Bollard RC. Vaizey CJ. Dis Colon Rectum 1990. Stadelmaier U. Kuijpers JH. Br J Surg 1993.355:260–5 28. Ortiz J. Buie WD. Randomized trial comparing three forms of pelvic floor repair for neuropathic faecal incontinence. Boulvain M. Long-term results of repeat anterior anal sphincter repair. Women’s health 18 years after rupture of the anal sphincter during childbirth: I. Dis Colon Rectum 2004. Int J Colorectal Dis 2006. Abstract 38 36. Long-term followup of dynamic graciloplasty for fecal incontinence. Tjandra JJ. Lim JF. Irion O. Mous M. 32. Melenhorst J. Dis Colon Rectum 2005. 27.10(3):249-56. Jarrett ME. 42. van Gemert WG.21(8):795-801. 26. . fecal and urinary incontinence: a 34-year follow-up after forceps delivery. Baxter NN. Sangalli MR. Koch SM. Duthie GS. Dis Colon Rectum 2003. Baeten CG. Norton C.194(5):1255-9. Vaizey CJ. Br J Surg 1999. Kamm MA. Kamm MA. Evans C. 34. Uludag O. Oya M. 22.74(12):1098-106.46(6):716. Colorectal Dis 2008. Pares D. Pinedo G. Konsten J. Floris LA.47(6):858-63. Feldman RA.48(8):1610-4.41(3):365-9. Parker SC.93(11):1402-10.10(3):257-62. Baeten CG. Gardiner A.89(6):896-901. Maslekar SK. O’Connell PR. Dis Colon Rectum 2005. Kamm MA.6(6):470-6.92(5):521-7. Skinner S.47(11):1852-60. O’Brien PE. Lubowski DZ.. 58. intact anal sphincter. La Torre F. Corman ML. Daly L. 48. Chan MK.4(1):48-50. Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized.113(2):190-4. 52. Fonda D. Congliosi SM. Efron J. 3rd. Matzel KE. O’Herlihy C. Catena F. Chronic sacral spinal nerve stimulation for fecal incontinence: long term results with foramen and cuff electrodes. Fenner DE. 49.44(1):59-66. Sultan AH. Rinaldi M. Binda GA. Dis Colon Rectum 2006. Behan M. 65. et al. Tan P.18(4):349-54. 51. Long-term results of perianal silicone injection for faecal incontinence. Tjandra JJ. Hohenfellner M.51(5):494-502. Phillips RK. Sultan AH. Nelson RL. Can we improve on the diagnosis of third degree tears? Eur J Obstet Gynecol Reprod Biol 2002. Jr. O’Boyle AL. Kamm MA.47. Caesarean delivery and anal sphincter injury. 62. Eogan M. Shafik A. 53.49(10):1587-95. Kamm MA. Andrews V. Fernando RJ. Norton C. Dixon JB. Prospective study of artificial anal sphincter and dynamic graciloplasty for severe anal incontinence. Dis Colon Rectum 1995.192(5):1620-5. Vaizey CJ. 67. Belyaev O. Vaizey CJ. Int Surg 1993. A prospective. DeMiguel M. Romano G. Am J Obstet Gynecol 2003 Dec.101:19–21. Merlin TL. Laurie C. Opelka FG. King DW. Br J Surg 2004. Maddern GJ. 57. Thakar R. Hohenberger W. The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study. Patients’views of a colostomy for fecal incontinence. Systematic review of safety and effectiveness of an artificial bowel sphincter for faecal incontinence.9. Untreatable faecal incontinence: colostomy or colostomy and proctectomy? Colorectal Dis 2002. Kennedy ML.9(4):357-61. Groom KM. Ortiz H. Br J Surg 2004. Kettle C. controlled clinical trial of placement of the artificial bowel sphincter (Acticon Neosphincter) for the control of fecal incontinence. Thornton MJ. 50.91(6):665. O’Brien PM. Murray-Green C. Injectable bulking agents for treating faecal incontinence.91(10):1352-3.183(5):1220-4. 70.30(10):1925-8. O’Connell PR. Paterson-Brown S.189(6):1543-9. Colorectal Dis 2007. Wexner SD. Roig JV. Does the angle of episiotomy affect the incidence of anal sphincter injury? BJOG 2006. 55. Long. Weiss EG. Fynes M. Solana A. Is the quality of life better in patients with colostomy than patients with fecal incontience? World J Surg 2006. 66. Uhl W. O’Connell PR. 54. A systematic review of the efficacy of caesarean section in the preservation of anal continence. Vernava AM. Genberg B. O’Herlihy C.51(7):1015-24. Spencer MP. Tjandra JJ. Wong WD. Br J Surg 2005.36(4):295-303. Mundy L. Decreased anal sphincter lacerations associated with restrictive episiotomy use. McClure GB. Kaiser R. Polytetrafluoroethylene injection for the treatment of partial fecal incontinence. Burch J. Dis Colon Rectum 2001 Jan.45(9):1139-53. discussion 1024-5. Yeh CH. 68. 69. Muller C. Melega E. Wilkinson K. Maeda Y. Armendariz P.48(5):1062. Am J Obstet Gynecol 2005. Colorectal Dis 2004. Hiller JE. 64. Dis Colon Rectum 2008. 59.term follow-up of dynamic graciloplasty for faecal incontinence. DeLancey JO. Dis Colon Rectum 2004. Radley S. Clemons JL. Altomare DF. Sacral nerve stimulation for fecal incontinence: external anal sphincter defect vs. Dis Colon Rectum 2008. Am J Obstet Gynecol 2000. Perianal injection of autologous fat for treatment of sphincteric incontinence. Jones P. Marek L. A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Neosphincter surgery for fecal incontinence: a critical and unbiased review of the relevant literature. 72. Int J Colorectal Dis 2003.113:195–200.92(4 Pt 1):496-500. 61. Furner SE. controlled study. 63. Dis Colon Rectum 2002. Occult anal sphincter injuries: myth or reality? BJOG 2006. Surg Today 2006.38(6):583-7. randomized. Obstet Gynecol 1998. 60. 56. Khera A. Stadelmaier U. Shafik A. Donnelly VS. O’Herlihy C.72. Colquhoun P. Chan MK. Disappointing long-term results of the artificial anal sphincter for faecal incontinence. Jones PW. Dodi G. Nogueras JJ. Towers GD. 71. Brahma P.78(2):159-61. Westercamp M. Fitzpatrick M. Repair techniques for . Alos R. Radley S. Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum 1999 Oct. Monga A.192(5):1697-701. Kim SS. Fernando R. 78. Fernando RJ. Daly L. BMC Health Serv Res 2002. O’Connell PR. Primary repair of obstetric anal sphincter laceration: a randomized trial of two surgical techniques. Mahony R. Internal anal sphincter defect influences continence outcome following obstetric anal sphincter injury. Johanson RB. Cochrane Database Syst Rev 2006. Stanton S. Sultan AH. Am J Obstet Gynecol 2005.113(2):201-7. Adams EJ. How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial. Can workshops on obstetric anal sphincter rupture change practice? Int Urogynecol J 2001.obstetric anal sphincter injuries: a randomized controlled trial. Sultan AH. Thakar R. Tincello DG. . Kammerer-Doak DN. Obstet Gynecol 2006. Rogers RG. Fernando R. Jones PW.12:S5. Richmond DH. 77. Kirwan C. Kettle C. Thakar R.196(3):217 e1-5. Alfirevic Z.42(10):1306-10. Nyam DC.107(6):1261-8. Management of obstetric anal sphincter injury. 74. Sultan AH. Garcia V. Radley S. Walkinshaw SA. Methods of repair for obstetric anal sphincter injury. 79.3:CD002866 76. Pemberton JH.A systematic review and national practice survey. Williams A. 75. Behan M.2:9. Am J Obstet Gynecol 2007. 73. O’Herlihy C. BJOG 2006. Hall RJ. Urinary retention is the inability to complete the voiding phase of the micturition cycle and. Jose. incomplete emptying. Distinguishing neurogenic from non-neurogenic voiding dysfunction is important. suprapubic catheterization should be considered because of its lower risk of catheter associated infection and urethral trauma. usually within 48 to 72 hours. followed by a voiding trial after about 1 week (perhaps longer for retention volumes over 1 liter). • Chronic retention of urine is defined as a non-painful bladder. MD Background Voiding dysfunction or lower urinary tract dysfunction is a term used to describe various problems related to the bladder’s ability to store and empty urine. Recommendations 1. has recently defined LUTS in relation to voiding difficulty and retention. Grade A) Summary of Evidence Short term use of an indwelling catheter is commonly used to manage acute urinary retention. palpable or percussable bladder. a problem may be present with either the bladder. The latter category is often caused by bladder outlet obstruction and this may be functional. nocturia and urge incontinence) or emptying symptoms (decreased force of stream. Voiding dysfunction is manifest clinically in lower urinary tract symptoms (LUTS) which may be characterized as storage symptoms (frequency. Symptoms do not always correlate with the underlying pathology. urgency. when the patient is unable to pass any urine.4 (Level I. the outlet or both. and numerous conditions may exist that can have similar presentations.2 • Acute retention of urine is defined as a painful. represent the end stage of voiding dysfunction.1 The standardization of terminology of lower urinary tract dysfunction. In most cases. hesitancy straining to void and urinary retention). Such patients may be incontinent. continous drainage by foley catheter is necessary until bladder function normalizes. often times. which remains palpable or percussable after the patient has passed urine. published by the International Continence Society (ICS). then further urodynamic investigation is needed (including sphincter electromyography [EMG]). Acute retention should be managed with an indwelling catheter and evaluation and management of possible precipitant and contributory factors.3 If the voiding trial fails. as in the case of dysfunctional voiding and primary bladder neck obstruction or anatomic as in the case of pelvic floor prolapse or post surgical obstruction. Physiologically.URINARY RETENTION Jennifer Marie B.5 . If prolonged catheterization is necessary. It allows women to lead independent lives with efficient bladder emptying and low rates of urinary tract infection when performed properly. but the incidence of this is reassuringly low due to the site of action of anticholinergics in their current doses. ulcerations. prazocin and indoramine) have proven benefit in women. Diazepam can be used to decrease urethral resistance.7 2. they are useful in men with urodynamically proven bladder neck obstruction. In women with combined urge incontinence and retention. 6 I. PHARMACOTHERAPY 1. betanechol chloride and distigmine bromide (an anti-cholinesterase) . Cholinergic agents .g.6 (Level III. Grade C) Summary of Evidence Adrenergic blocking agents. Continuous bladder drainage is best avoided in cases of urinary retention because of the high complication rate from the infection. Grade A) Summary of Evidence Clean intermittent straight catheterization is the procedure performed in many voiding difficulties. malignancies and bladder spasms.2. Although adrenergic blocking agents (e. have been used to decrease the contractility of the smooth muscle component of the urethral sphincter.and intra vesical prostaglandin E2 and F2 have been advocated for treatment of urinary retention.5 (Level I. however there is no real evidence of clinical benefits. like prazocin hydrochloride and phenoxybenzamine. Grade C) Summary of Evidence Bethenacol has been used as treatment for retention caused by detrusor contractility. Its treatment value is therefore unknown.7 4.6 (Level III. calculi. Strict protocols on the management of patients before and after surgery and delivery need to be defined. Anxiolytic agents such as diazepam may help with postoperative voiding problems. phenoxybenzamine. anticholinergic agents such as tolterodine maybe used effectively in conjunction with clean intermittent straight catheterization (CISC) if required. but it has not been used for women with sphincteric overactivity.6 (Level III. Voiding difficulties following pelvic and particularly continence surgery and delivery are important causes of patient morbidity and litigation. Intermittent self-catheterization as a nonsterile procedure is now the principal treatment for chronic urinary retention.for example. Grade C) . The place of bladder neck incision in patients with outflow obstruction should never be performed unless diagnosis is confirmed by pressure/ flow videourodynamics. latissimus dorsi myoplasty and vesical cap operation with ileal seomuscular patch grafts have all been tried with variable success. the results are disappointing. In addition. because it can result in a better quality of life for the patient has less complications. It is often preferred to indwelling catheters. However. Partial cystectomy has been performed for treating the myogenic decompensated bladder and excessive residual urine. it can be implemented as a one-time treatment repeatedly over a short period of time. Grade C) Summary of Evidence There are no randomized trials comparing CISC and clamping the foley catheter intermittently for bladder training.Summary of Evidence If voiding difficulty is due to urethral stenosis. A patient specific diagnostic approach is recommended. empirical treatment is appropriate. including the degree to which the patients symptoms is bothersome and whether the upper tracts are in jeopardy. symptoms and fluid intake. (Level III. such as urinary tract infections (UTI).8 . In certain cases. or may be life-long for persons with chronic bladder emptying disturbances. Urinary diversion using appendix or fallopian tube. management and treatment of female patients with voiding dysfunction and urinary retention is often complex and must take multiple factors into consideration. urethral dilatation using Hegar dilators or preferably the Otis urethrotome is an appropriate option. degree of bother and whether there is a history of suspicion of neurologic disease. BLADDER TRAINING Bladder training should be guided by patients’ bladder capacity. specific therapy can be directed based on urodynamics and other basic tests. The evaluation. urethral stricture. colocystoplasty. compared to indwelling catheters. on an occasional basis. A general guide for adults is to do CISC often enough to maintain catheterized volumes at 500 ml or less (every 4 to 6 hours).9 III. depending on symptoms. when a formal diagnosis is indicated. One main advantage of CISC is that the voiding trials can be done before self-catheterization. However. (Level I. Botulinum toxin has been injected transurethrally for the treatment of detrusor internal sphincter dyssynergia (DISD). Grade A) Summary of Evidence Botulinum A toxin injections do have therapeutic value in urethral spasticity. (Level I. appropriate catheter care and frequent changing of the catheter is recommended. (Level I.III. but larger. CISC is the mainstay of therapy for neurogenic voiding dysfunction.NON-NEUROGENIC VOIDING DYSFUNCTION / DYSFUNCTIONAL VOIDING 1. with one CISC to facilitate emptying. (Level I. All management strategies are directed at successful bladder emptying. Biofeedback and behavioral modification has become the recommended treatment for women with dysfunctional voiding. Grade A) .1 2.12 4. controlled trials are necessary to establish their role. The same is true for retention secondary to impaired contractility.1 The management of multiple sclerosis includes anticholinergics with or without CISC and behavioral therapy. Grade A) Summary of Evidence CISC is the mainstay of therapy. a catheterizable stoma can facilitate independence when neurologic disease is advanced and urethral catheterization cannot be performed independently.7 (Level I. In situations in which chronic indwelling catheters desirable and necessary. NEUROGENIC VOIDING DYSFUNCTION 1. Chronic indwelling catheters are generally not recommended for treatment of chronic retention but may be used as a last resort in select patients.1 2. (Level I. In some cases. (Level I. The use of CISC is considered satisfactory management. Grade A) 3. Grade A) IV.15 Urinary retention for cauda equine syndrome resolves within months. Grade A) Summary of Evidence The ideal treatment for detrusor external sphincter dyssynergia (DESD) is anticholinergics with CISC. Grade A) 5. Amitryptyline was reported to be successful. Sacral neuromodulation is effective for restoring voiding in patients with idiopathic retention (Fowler’s syndrome).Summary of Evidence Behavioral and biofeedback treatments are safe. Diazepam was reported to be successful to be used in treatment. chronic urinary retention dependent on CISC who had at least 50% improvement on percutaneous nerve evaluation screening. (Level III. The retrospective study included 26 women who were followed for more than 6 years. Grade A) 5. Endoscopic and transperineal injection of botulinum toxin has been performed in women with dysfunctional voiding. (Level II1. The study authors emphasize that the lack of change in cystomyography after SNS implantation indicates that the cause of the problem is not the bladder but the pelvic floor musculature. The patients were followed for a mean of 15. The study supported effectiveness of sacral nerve stimulation (SNS) for at least 5 years after implantation. and effective interventions that are useful in the management of idiopathic urinary retention.7 (Level III. with idiopathic. or that such relaxation removes an inhibitory stimulus to reflex bladder activity. and sensation of emptiness after voiding. Behavioral changes enlighten patients about their fluid intake and voiding behavior.1 4. noninvasive.17 3. This helps the patient learn to increase or decrease voluntary muscle activity. Biofeedback involves surface or internal (vaginal or rectal) electrodes that transducer muscle potentials into auditory or visual signals.2 months and had significant improvement in voiding function. nonobstructing. Seventy-seven percent were voiding successfully more than 5 years post operatively: 54% required revision surgery. Grade A) 6.19 . Grade A) Summary of Evidence Dagupta and colleagues provided long term results of sacral nerve stimulation in women with Fowler’s syndrome. pelvic pain.18 Shaker and Hassouna treated 20 patients. (Level III. Grade B) Summary of Evidence Diazepam relaxes the pelvic floor striated musculature during bladder contraction. such as bladder neck fibrosis. Treatment is dictated by degree of bother of postoperative symptom. Care is taken to avoid injury to the external sphincter. An obstructed patient will opt for conservative management with CISC. Skene’s cyst or abscess. such as constipation. Grade A) Summary of Evidence After the diagnosis of the prolapse. Grade A) Summary of Evidence Inflammatory processes. urethral caruncle.7 (Level I. Grade A) Summary of Evidence Treatment of postoperative retention begins with catheter decompression and management of contributory factors. The treatment options for primary bladder neck obstruction (PBNO) include watchful waiting. PRIMARY BLADDER NECK OBSTRUCTION 1. Treatment of symptomatic prolapse is usually surgical. PELVIC ORGAN PROLAPSE 1. which can lead to stress incontinence. and urethral diverticulum are associated with anatomic obstruction. PBNO can be treated surgically with transurethral incision of the bladder neck. pharmacotherapy and surgical intervention. Management usually involves treatment of the offending infection and surgical excision of the obstructing lesion. a pessary alone may be used. meatal stenosis. In case of significant morbidity and age. sling .22 2.10 VII.V. Grade A) Summary of Evidence The management for primary bladder neck obstruction is medical and surgical. then CISC and or surgical repair (urethrolysis. Surgical options include transurethral incision of the bladder neck and Y-V-plasty of the bladder neck. If these measures fail. Voiding dysfunction caused by pelvic organ prolapse (POP) can be treated by pessary or surgical repair. a pessary or packing can be used to reduce the prolapse and confirm the diagnosis.9 (Level I.8 (Level III. IATROGENIC POST SURGICAL OBSTRUCTION 1.9 VI. This helps predict the outcome of prolapse repair. urethral stricture. (Level III. 20 Kuo and associates repeated this study in 20 patients with urinary retention and dysuria due to detrusor hypocontractility and non relaxing urethral sphincter who who were refractory to conservative therapy. Grade C) Summary of Evidence Urethral dilatation leads to post-dilatation bleeding or urine extravasation into periurethral tissue. edema surrounding the vesical neck and urethra. All except one were able to void spontaneously after the injection of 80-100 units of botulinum toxin. (Level III. transvaginal or supreameatal approach. Its treatment value is unknown. The cholinergic agent bethenacol is not effective. Urethrolysis or sling incision is the most definitive treatment available whether retropubic. The use of botolinum toxin injection into the urethral sphincter for retention after anti-incontinence surgery is under investigation. and obstruction from bladder neck elevation.14 2. This . (Level I. and magnetic resonance imaging (MRI) evidence of greater bladder neck elevation and urethral compression have been associated with the number of days of voiding dysfunction after colposuspension. causing scarring of the urethral wall and periurethral fibrosis. tension free vaginal tape placement (TVT). higher preoperative urethral resistance. They studies 21 patients (13 women) with impaired bladder emptying who were dependent on catheterization.release) are recommended. but it has not been used in women with sphincteric overactivity.10 (Level I. Grade A) Summary of Evidence Bladder neck surgery.19 4. straining during voiding. The role of urethral dilatation is not known. Grade C) Summary of Evidence Phelan and colleagues were the first to report successful outcomes with a botulinim A injections in women and in non neurogenic voiding dysfunction.11 (Level III. Postoperative factors contributing to retention may include failure of the sphincter to relax. Grade A) Summary of Evidence Bethenacol has been used as treatment of retention caused by detrusor acontractility. pelvic floor spasm. and collagen injection are recognized causes of compression and voiding difficulty.14 5.14 3. Age. but larger. IMPAIRED DETRUSOR CONTRACTION 1. . retention is defined as “no spontaneous voiding within 6 hours after removal of the indwelling catheter”. A commonly used symptom-based definition is the absence of spontaneous voiding of urine within 6 hours of delivery. Botulinum A toxin injections do have therapeutic value in urethral spasticity. CISC is the mainstay for patients with significant retention. There is no concensus of opinion on the management of postpartum urinary retention and various treatment regimen have been described. controlled trials are necessary to establish value. The treatment includes general measures such as administration of oral analgesia. The covert form is asymptomatic and recognized by demonstrating an elevated post-void residual measurement of more than or equal to 150 ml.7 (Level III. bladder neck and urethra. Postpartum urinary retention can be classified into covert and overt forms. It is no longer considered to be effective to facilitate voiding. thus preventing coordinated and complete bladder emptying. Another commonly used definition is based on the post-void residual bladder volume as estimated by ultrasound or catheterization. if a catheter is used. CISC is the mainstay of therapy. 21 VIII. Grade C) Summary of Evidence Bethenacol chloride is cholinesterase resistant and causes a contraction of smooth muscle from the bladder. little agreement exist on the intervening grey zone.14 IX. After caesarian section. Pharmacotherapy with cholinergic agonists such as bethenacol has not proven to be successful. Although most experts agree that residual volumes of less than 50 ml are normal and more than 200 ml are abnormal. with either ultrasound scanning or catheterization. Urodynamics is essential for diagnosis. Clinically overt postpartum urinary retention refers to the inability to void spontaneously after delivery. (Level I. Grade A) Summary of Evidence Impaired neuromuscular transmission at the detrusor and/or myopathic processes are proposed causes of the decreased contractility.study clearly showed that botulinum toxin is effective in decreasing urethral sphincter resistance and improving voiding dysfunction. POSTPARTUM URINARY RETENTION There is no standardized definition that qualifies postpartum urinary retention.14 3. Walters M. regional anesthesia.2007 Kumar A..143906-8. 11. Pang MW. D. Urogynecology and Reconstructive Pelvic Surgery. Day L. Cardozo L. e. 14. 3. Erickson J.gov/clinic/ptsafety/chap15b. Sahota. O’Leary M. 13. BJU Int 2004. 6. Yip SK. J Urol 1990. Incontinence in Women. G. a foley catheter should be inserted. Obstet Gynecol 2005.21(2):167-78. and no standard has been agreed to. Women with potential risk factors. 2002. Int Urogynecol J 2002. Blaivas JG. If conservative measures fail. Wyndaele J. 2006. Agency for Healthcare Policy and research. Thiery M. Botulinum toxin urethral sphincter injection resolves urinary retention after pubovaginal sling operation. Textbook of Female Urology and Urogynecology.21. There are very few studies on the sequelae of postpartum urinary retention but published data suggest that this condition returns to normal within a short period and specific treatment is not necessary. London: Royal College of Obstetrician and Gynecology Press.htm. 2nd ed. et al. 106(3). 5. 602-6 .committee of the International Continence Society: Neurourol Urodyn 2002. Clean intermittent self-catheterization: a 12-year follow-up. The effect of genital prolapsed on voiding. the woman can be taught intermittent self-catheterization every 4-6 hours until she is able to void and then until the residual is less than 150 ml. J Urol 1999. Statskin D. a critical analysis of patient safety practices. J Urol 1999. 9. Mosby Inc. Making healthcare safer. 8.443-441. Management of functional bladder neck obstruction in women: use of alpha blockers and pediatric resectoscope for bladder neck incision. The standardization of terminology of lower urinary tract function: report from the Standardization Sub.g. Karram M. Shariat S. Djavan B. If trial without catheter fails. 10. and ensuring privacy during voiding and having a warm bath. 7. Royal Women’s Hospital Clinical Practice Guidelines Kermans.162:2061 Romanzi L. Abrams P. obstetric anal sphincter trauma or severe perineal tears should be catheterized during labor and delivery. (Third edition) Chapter on Voiding Dysfunction and Urinary Retention. Maes D. Acta Urol Belg 1986. If spontaneous voiding fails to occur within 4 hours or if the voided volume is less than 150 ml and/or the post void residual urine is more than 150 ml. it is advisable to insert a urethral catheter and remove it after the bladder has been emptied. Cardozo L. Ahcpr. Informa Healthcare. Puerperal urinary retention.helping the woman to mobilize. et al. 12.161:581 Hindley RG.93:89-92. Fall M. If this is not feasible. Thiomas PJ. In: Maclean AB. Recommendations arising from the 42nd Study Group: Incontinence in Women. Cardozo L. The duration of catheterization is empirical. Somogy GT. Smith CP. 54(4): 376-85. De SW. 2. Chancellor MB.24 References 1.13:55-56. Does prolonged catheter drainiage improve the chance of recovering voluntary voiding after acute retention of urine? Eur Urol 1998. editors.33:110. as most women would be breastfeeding. instrumental delivery. Philadelphia. Wyndaele JJ. Srivastava A. 4. Gogoi S. send her home with an indwelling catheter for 48 hours and repeat the voiding trial. Available online at www. Brierly RD. None of the pharmacologic drugs have been studied systematically in postpartum women. Prostaglandin E2 and Bethenacol in combination for treating detrusor underactivity . Overdistention bladder injury in the postpartum period can be avoided by strict vigilance in ensuring that voiding occurs regularly. Mandhani A. A trial without catheter can be attempted after 24-28 hours. Omar M. Postpartum urinary retention. 1.0!! WN! L.)6$)$*!7'*!K0.7)$*!CSTSD!6'+*%! J7!*$%.0!+*.0!!B!GEE!>0! WN! @9'1).13!5*.)6$)$*!*$>'2.0!.))$1)!@$07T-.2$*4!'*!.1![!6'+*%!.:!*$%.0O! (1%.::$*!:.-!<=..::$*[email protected]$!BPEE!>0O!*$>'2$!Q'0$4!-.13!+*$)6*.13!)*.7)$*!-..1$!RPEE!>0O!*$>'2$!Q'0$4!-.::$*!N$%)O! • • • J7!*$%.:+..'%)T2'.1$'+%!2'./0$O!J1%$*)!.1$!8.)6.1! J1%$*)!5*.7)$*!:$0.1%+*$)6*.:+.0!R!GEE!>0!!! ?0$.1$!R!GEEE!>0O!*$>'2$!Q'0$4!-.:+.3$MK0.A.7)$*! -.0!+*.>'+1)%!'7!+*.)6$)$*!.).7)$*!UTP!:.13!7*$\+$1)!%>.)6$)$*!*$>'2.%%.%.-)'*4!V'.1!J1)$*>.1:!*$9$.1$!B!GEE!>0! J7!?J@?!1')!7$.0!+*.:!!R!CEE!>0! Y&L! &'!%9'1).1$'+%!2'.:!*$%.1:!*$%.:.:.0!+*.'1! F?J@?I!\ST[!6'+*%!+1).)6$)$*!! J7!*$%.%-'>7'*)!:+$!)'!/0.1$'+%!2'.1$'+%!2'.0!%9'1).:+.1:8$00.%%$:!+*.2#-.>!M!K0.7)$*!CSTSD! 6'+*%! ! =-.0!?.'%)T2'.:+.7!6)!4%*#!>?!=-/7%$#'%7#7!@!A#6*/&B!C<B!D=1EF! ! .%)$1)..:! R!CEE!>0!.4%! ! ! VWJLJ&X!5NJYZ! @.0O! • @9'1). Algorithm for the Management of Acute Urinary Retention G" C" U" "#$%&!$'()"'*!'&%&)%(+)! &')!9.::$*!L*.)!2'.:!B!CEE!>0! .-)'*4!V'.'1!WN!! .).1$!F2'.)6$)$*!.%7.:![!6'+*%!.$02.:$:!2'0+>$!B!GPE>0I! .).00!.13!5*.0!! • ..%7.0! -.)6$)$*.:.Figure 1.:+.)6$)$*!. 430-3. Am J Obstet Gynecol 2002. Webb MJ. Ramin KD et al. Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery. Lesnick TG. . Carley ME.15.187(2). Vasdev G. Carley JM.