Dr. Angelika BorozdinaMBBS. PhD. FRANZCOG

Obstetrician and Gynaecologist

CVOGS

ABC OF PROLAPSE AND INCONTINENCE

A New Approach to Managing Atrophic Vaginitis

URINARY INCONTINENCE

Defi nition:

Involuntary urine leakage during activity (eff ort/exertion).

Occurs with loss of normal rise in urethral closure pressure in response to rising abdominal pressure.

Anatomic and physiologic factors result in disordered pressure transmission.

Distinguished from URGE Incontinence

.

Urge incontinence is the strong, sudden need to urinate due to bladder spasms or contractions5

Stress incontinence is an involuntary loss of urine that occurs during physical activity, such as coughing, sneezing, laughing, or exercise5

Mixed incontinence is the combination of both urge and stress incontinence6

THREE COMMON TYPES OF URINARY INCONTINENCE

Urge

Stress

Mixed

Of the 1 in 3 adult women who have urinary incontinence7:

URGE VS. STRESS VS. MIXED INCONTINENCE

Urge 11%

Mixed

36%

SUI 50%

SUI: 4 TYPES OF ETIOLOGIC RISK FACTORS

Intervene• Behavioral

• Pharmacologic• Devices• Surgical

Predispose• Female Gender• Race, Culture and

Environment• Anatomy• Neurologic

Incite • Vaginal childbirth• Nerve Damage• Muscle Damage • Radiation

Promote• Constipation• Physical work• Obesity• Smoking• Menopause• Fluid Intake• Toilet Habits

Decompensate• Aging

• Comorbid disease• Dementia

• Medications• Environment

Continent

Incontinent

COMPONENTS OF SUI PATHOPHYSIOLOGY

1. Loss of anatomic urethral supportUrethral Hypermobility (UH) - weakness of pelvic structures that support urethral compression during increased abdominal pressure

2. Intrinsic Sphincter Deficiency (ISD) Deficiency of urethral intrinsic closing

mechanism

INCONTINENCE EVALUATION

Incontinence on Physical Activity

• History and Physical examination: abdominal, pelvic, neurological• Assess effect on quality of life • Bladder diary• MSU, if UTI treat• Assess for pelvic organ mobility / prolapse• Ultrasound of detrusor muscle, bladder neck and residual volume of urine post void • Urodynamics

HISTORY

CLINICAL ASSESSMENT

Pelvic Examination

• Prolapse may mask incontinence

• Pelvic floor muscle tone • Voluntary pelvic floor

contraction• Perineal skin condition• Palpation of anterior vaginal

wall and urethra• Determine degree of

estrogenization• May observe leakage on

coughing

SUI Assessment

.

Urinalysis1

Tests of detrusor function• Postvoid residual (PVR) volume1

• Flow rate1

• Filling cystometrogram (CMG)1

Tests of urethral sphincter function• Valsalva leak point pressure (VLPP)2

• Maximum urethral closure pressure (MUCP)1

SUI Assessment (continued)

1. Abrams P, et al. he Standardisation of Terminology of Lower Urinary Tract Functioning: Report from the Standardisation Sub-committee of the Int’l Continence Society. Neurourol Urodyn. 2002;21:167-178.

2. Blaivas JG, Groutz A. In: Retik AB, Vaughan ED Jr, Wein AJ, et al, eds. Urinary Incontinence: Pathophysiology, Evaluation, and Management Overview. Philadelphia, Pa: WB Saunders; 2002:1027–1052.

SUI MANAGEMENT

Incontinence on physical activity

History and urodynamic study confirm Stress incontinence

•Pelvic floor muscle training•Oestrogen therapy of vagina•Pessary management•Sling operation or vaginal prolapse surgery• Lifestyle interventions

TREATMENT

HISTORY/

Clinical

examination

SUI SURGICAL TREATMENTS

vs.

Modern

Integral Theory’ of urinary incontinence*

1. Control of urethra depends: • pubourethral ligaments• suburethral vaginal

hammock• pubococcygeus muscle

1. Elevate bladder neck and proximal urethra

2. Support bladder neck and prevent funnelling

3. Increase outflow resistance

Traditional

NON SURGICAL TREATMENT

Neotonus MR Chair

Based on Extracorporeal Technology produces highly focused pulsing magnetic fields

MID-URETHRAL SLINGS

Goals1. Restore and/or reinforce the pubourethral ligaments at the mid-urethra2. Restore and/or reinforce the suburethral vaginal hammock at the mid-

urethra3. Reinforce the paraurethral connective tissue

pubourethralligament

urethropelvicligament

ADVANTAGES OF MID-URETHRAL SLINGS

1. Easily reproducible

2. Long-term successful clinical results

3. Minimal complication risk

4. Minimally invasive

5. Minimal tissue dissection

6. Can be performed under regional, or general anesthesia

7. Most patients can be discharged the same day w/o catheter

8. Shorter patient recovery than traditional open procedure

Patient and Physician Benefits

Studies show that most patients are continent following the sling procedure and can resume normal, non-strenuous activities within a few days .

SUCCESS RATE

85-94%

Clinical data on AMS slings shows:19-22

*In a MiniArc study 90% of patients had negative cough stress test and 85% had a 1-hour pad weight test less than 1 gm at 1 year.

*In a MiniArc study 94% of patients had significant improvement in pad use at 1 year.

*In a Monarc study 90% of patients had a negative cough stress test and improvement in pad use at 1 year follow-up.

*In a SPARC study 88% of patients had significantly reduced symptoms according to the Kings Health Questionnaire at 1 year.

Known risks of surgical procedures for the treatment of urinary incontinence include:

• Pain/Discomfort/Irritation• Inflammation (redness, heat, pain, or swelling resulting from surgery)• Infection• Mesh erosion (presence of suture or mesh materials within the organs surround

the vagina)• Mesh extrusion (presence of suture or mesh material within the vagina)• Fistula formation (a hole/passage that develops between organs or anatomic

structures that is repaired by surgery)• Foreign body (allergic) reaction to mesh implant• Adhesion formation (scar tissue)• Urinary incontinence (involuntary leaking of urine)

WARNINGS AND PRECAUTIONS

Known risks of surgical procedures for the treatment of urinary incontinence include:

• Urinary retention/obstruction (involuntary storage of urine/blockage of urine flow)

• Voiding dysfunction (difficulty with urination or bowel movements)• Contracture (mesh shortening due to scar tissue)• Wound dehiscence (opening of the incision after surgery)• Nerve damage• Perforation (or tearing) of vessels, nerves, bladder, ureter, colon, and

other pelvic floor structures • Hematoma (pooling of blood beneath the skin)• Dyspareunia (pain during intercourse)

WARNINGS AND PRECAUTIONS

NOTE: Some of these adverse reactions are specific to procedures involving mesh repair (e.g. mesh extrusion).

Involuntary loss of urine associated with a sudden, strong desire to void.

Urge Incontinence ( bladder muscle problem )Life style changes, bladder retraining Reduce caffeine , Vaginal Estrogen Magnetic chair Anticholinergic medication( SE) Neuromodulators

DETRUSOR OVERACTIVITY INCONTINENCE

50% of parous women (Swift 2000, DeLancey 1993,

Beck 1991)

30 – 40% of women in general population (Slieker-

tenHove 2004,

Samuelsson 1999)

Only 8.8% symptomatic (McLennan 2000)

11.1% lifetime risk of surgical repair

29 – 40% reoperation within 3 years (Clark 2003,

Olson 1997)

Basic Prolapse Stats

Pelvic organ prolapse (PLP) a common condition among female population ~ 60%

Life time risk of surgery for POP 19% in WA (Smith FJ et al., 2010) higher than USA( 11%)

Recurrence surgery 50%

Prolapse surgery challenging

- Multifunctionality of the vagina

PROLAPSEHERNIATION OF URO-GENITAL TRACT

Pelvic organ prolapse (PLP) is a common condition among female population.

Life time risk of surgery for POP was estimated to be 19% in the Western Australia (Smith FJ et al., 2010) which is higher than 11-12% reported from US.

TYPES OF PELVIC ORGAN PROLAPSE

Cystocele Bladder prolapses or protrudes into the vagina

Enterocele Small bowel prolapses or protrudes into the vagina

Rectocele Rectum prolapses or protrudes into the vagina

Uterine Prolapse Uterus prolapses or protrudes into the vagina

Vaginal Vault Prolapse

Vaginal vault occurs when the upper portion of the vagina (the apex) descends into the vaginal canal

White 1910

History

So let’s POP-Q this (hymen = 0):

• Aa = -3• Ba = -3• C = -6• D = -10• Ap = -3• Bp= -3Simply put, this vagina receives a POPQ of:-3, -3,-3, -3, -6, -10 (Aa, Ba, Ap, Bp, C, D)One line – loads of information

Aa

Ba

Ap

Bp

DC

So, what is this?

• Here’s a hint• Here’s the answer:

+3, 0, -1, -3, -6, -9

• It’s a cystocele

• Reconstructive surgical options include24

– Vaginal colporrhaphy and apical suspensions using native tissue

– Sacrocolpopexy– Transvaginal mesh (TVM) repair

systems

SURGICAL TREATMENT OPTIONS

Elevate® is designed to:

Offer a minimally invasive solutionMinimize tissue traumaRestore normal anatomy with a faster recovery than open abdominal approachesMinimize pain compared to more invasive procedures

ELEVATE® PROLAPSE REPAIR SYSTEM

Typically, procedures to correct prolapse take place on an in-patient basis and are performed under general anesthesia.

In clinical studies, 91-96% of patients felt their prolapse symptoms were some or a lot improved following surgery with Elevate.28 ,29

ELEVATE PROLAPSE REPAIR SYSTEM

91-96%

WARNINGS AND PRECAUTIONS

Known risks of surgical procedures for the treatment of POP including the following:• Mesh extrusion (presence of suture or mesh

material within the vagina)• Mesh migration• Nerve damage• Obstruction of ureter• Pain/Discomfort/Irritation• Perforation (or tearing) of vessels, nerves, bladder,

ureter, colon, and other pelvic floor structures • Urinary tract infection• Vaginal contracture (tightening of the vagina)• Voiding dysfunction• Wound dehiscence (opening of the incision after

surgery)

On October 20, 2008, the FDA issued a PHN regarding serious complications associated with transvaginal placement (meaning placement through the vagina) of transvaginal surgical mesh to treat POP and SUI.

From Jan. 2008 to Dec. 2010 there were 2, 874 reports of complications associated with surgical mesh devices

FDA NOTIFICATION: TRANSVAGINAL MESH 2 3

1,503 POP 1,371 SUI

In July of 2011, the FDA issued an update to the PHN and provided physicians the following recommendations:Seek specialized training in transvaginal mesh

proceduresAdvise their patients about the potential for serious

complications associated with these procedures Be vigilant for potential complications from the

mesh

In 2012, the TGA(Therapeutic Guidelines Australia) released a statement³² which in summary stated: Since 2006, the TGA has received 63 adverse event

reports for all Uro-gynaecological surgical meshes. The Uro-gynaecological Society of Australia (UGSA)

reinforced their view that the issues were about the use of these meshes rather than the meshes themselves. In light of this, the Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) and UGSA are advising that surgeons should have special training on performing these procedures and patient selection.

TGA AND SOCIETY RESPONSES

The TGA urges any patients with mesh implants who are concerned to contact their surgeon.

UGSA has released a statement supporting the use of mid-urethral slings for SUI.

Urodynamic study

Quality of life assessment (POP-Q)

Sexual function assessment(PISQ-12)

HOMEWORK BEFORE THE OPERATION

Who needs urodynamic work-up ?

Why do they get this work-up ?

Can we obtain that information ?

less cost

less effort

less discomfort less site dependent

incontinence surgery severe prolapse

pre-operatively

detect occultincontinence

detect detrusor

or voidingproblems

aimsdiffer

detect occultincontinence

detect detrusor

or voidingproblems

theissue

is

standardised history

examination

questionnaire

24-hour-pad test

pelvic ultrasound

urinary flow-metry

bladder diary

Can these be detected in any other way ?

standardised history

examination

questionnaire

24-hour-pad test

pelvic ultrasound

urinary flow-metry

bladder diary

Can these be detected in another way?

Quality of life assessment (POP-Q)

“Stage of complete physical, mental and social well-being and not merely the absence of infirmity and disease.”

WHO DEFINITION OF HEALTH

QOL IS PERCEPTION OF:

Emotional and

sexual wellbeing

Physical Well-being

Material Well-being

Self Determination

Sexual responseexcitementplateau

Orgasmresolution

MALE AND FEMALE SEXUAL FUNCTIONBY MASTER AND JOHNSON

Sexual responseexcitementplateauOrgasmresolution

Three times per week don’t feel like it, do it anyway – Working , washing

A matter of health more than pleasure Heart protection - 30% less heart attack for men and women

IS SEX A MATTER OF HEALTH ??

Pessaries used for treatment since beginning of recorded history

1800BC Kahun Papyrus Ebers Papyrus (1500 B.C.) which portrayed the uterus as an independent animal, usually a tortoise, newt or crocodile, capable of movement within its host.

Hippocrates – halved pomegranite soaked in wine! Hippocrates perpetuated this animalistic concept stating that the uterus often went wild when deprived of male semen

1625- Stromayr’s Practica Coposium – sponge and twine

Latex products-1800’sSilicon now used

PELVIC ORGAN PROLAPSE (POP) & PESSARIES

Pt preferenceMedical comorbiditiesDelayed surgeryRecurrenceVaginal ulcerationPOP in pregnancyDesiring future fertility

INDICATIONS

Vaginal/pelvic infectionMesh exposureNoncompliance

CONTRAINDICATIONS

FOLLOW UP EVERY 3 MONTHS EROSION AND INFECTION

Vaginal repair +/_ hysterectomyNative tissue repair( midline, site

specific)Biological mesh repairSynthetic mesh repair ( Elevate Mesh kit)Laproscopic pelvic floor repairMesh scaro-hysteropexySuture hysteropexy+/_ vaginal repair

PROLAPSE REPAIR

Abdominal sacral colpopexy was associated with a lower

rate of recurrent vault prolapse and less dyspareunia

than the vaginal sacrospinous colpopexy

Use of mesh or graft inlays at the time of anterior

vaginal wall repair reduces risk of objective recurrence

Posterior repair better performed vaginally

No evidence to suggest that the addition of any graft

material at the posterior compartment repair results in

improved outcomes

Value of adding a continence procedure is uncertain

TAKE HOME MESSAGES

ATROPHIC VAGINA

The upper 2/3 of Vagina is Mullerian origin

The lower 1/3 is urogenital foldVaginal skin is estrogen and

progesterone dependentEstrogen thickens the skin and

progesterone thins the skinThe lower 1/3 is less estrogen sensitive

VAGINAL SKIN

Passage of blood flow during the periodsBirth canalSupports function and position of bladderSupports function and position of bowelConnects the abdominal cavity with

outside via cervixVaginal lubricationSexual activityReproduction

VAGINAL FUNCTION

No vaginal glandsParacervical glands and Bart gland provide discharge at the time of orgasm

Vaginal epithelium stratified squamous epithelium and responsible for lubrication

Balancing vaginal flora and pHAvoiding possible infection eg thrush

VAGINAL LUBRICATION

Decrease in Oestrogen after menopauseUp to 40% of postmenopausal women suffer

from Atrophic Vaginitis1

Decreased quality of life and direct impact on women’s sex life

- Vaginal dryness, painful sex, low libido, sluggish orgasm, urinary problems, vaginal infection

ATROPHIC VAGINITIS

Decrease in oestrogen levels Less Connective TissueLess capacity to retain waterIncreased risk of fissuring &ulceration3

Decrease in glycogen in vagina tissueChange in vaginal floraChange in vagina pHIncreased risk of UTI& thrush

ATROPHIC VAGINITIS

ATROPHIC VAGINITIS

Normal Pap Smear• Abundant

Cytoplasm• Low Nuclear

Cytoplasmic Ratio

Atrophic Vaginitis Pap Smear• Enlarged Nuclei• Inflammatory Exudate• Amorphous Basophillic

Structurs (Blue Bulbs)• Loss of Gylcogen in

the Squamous Cells

Oestrogen Replacement4

Systemic or LocalCan reverse or prevent symptoms

Moisturizers and LubricantsCan be independently or with oestrogen replacement therapy

Sexual Activity- 3 times per week

CURRENT BEST PRACTICE

Oestrogen Replacement10-25% of women do not respond5

Physical limitation in older womenSmall increase risk of endometrial caOestrogen therapy in ER+ Breast cancer!

Moisturizers and LubricantsShort term benefit

Sexual ActivityNo firm understanding of mechanism

CURRENT BEST PRACTICE DRAWBACKS

Platelet Rich Plasma Therapy - 27 gauge needle and vaginal gelV2 LR Laser Therapy - using a vaginal probe

NON-SURGICAL, NON-HORMONAL OPTIONS

High concentration of plateletsIncreased release of growth factors from platelets

Promotes regeneration of connective tissue

Suggested applications in Dentistry, Maxillofacial Surgery, Plastic Surgery, and Orthopaedic Surgery.

PLATELETS RICH PLASMA

LASER - Light Amplification by Stimulated Emission of RadiationAn intense beam of lightHighly directionalA single wavelength or colour

WHAT IS A LASER?

Pump some energy into it – electrically or with lightThe material naturally emits light (of a characteristic colour)

Feedback (between the mirrors) build the intensity

Light ‘leaks’ out a partially reflecting mirror

HOW DOES IT WORK?

Laser materialMirrorMirror

Energy in

excited

Light Laser beam

1. Greendale  GA, Judd  HL.  The menopause: health impl icat ions and cl in ical management.   J Am Ger iatr Soc .  1993;41:426–362. Pandit  L , Ouslander   JG.  Postmenopausal vaginal atrophy and atrophic vaginit is .  Am J Med Sci .  1997;314:228–31.3. R igg  LA.  Estrogen replacement therapy for atrophic vaginit is .   Int J Fert i l .  1986;31:29–34.4. Handa  VL, Bachus  KE, Johnston  WW, Robboy  SJ , Hammond  CB.  Vaginal administrat ion of low-dose conjugated estrogens: systemic absorpt ion and eff ects on the endometr ium.  Obstet Gynecol .  1994;84:215–8.5. Smith  RN, Studd   JW.  Recent advances in hormone replacement therapy.   Br J Hosp Med .  1993;49:799–808.6. Robert E Marx, DDS , a , Er ic R Car lson, DMD b , Ralph M Eichstaedt , DDS c , Steven R Schimmele, DDS d , James E Strauss, DMD e , Karen R Georgeff f (RN) P latelet -r ich plasma: Growth factor enhancement for bone grafts, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology Vol 85, Issue 6, June 1998, 638-6467. Eppley, Barry L. M.D. , D.M.D. ; Pietrzak, Wi l l iam S. Ph.D. ; B lanton, Matthew M.D. , P latelet -Rich Plasma: A Review of Bio logy and Appl icat ions in P last ic Surgery, P last ic and Reconstruct ive Surgery. Nov 2006 Vol 118 Issue 6 147-1598. T i m o t h y E . F o s t e r , M D † * , B r i a n L . P u s k a s , M D † , B e r t R . M a n d e l b a u m , M D ‡ , M i c h a e l B . G e r h a r d t , M D ‡ a n d

S c o t t A . R o d e o , M D Platelet-Rich Plasma9From Basic Science to Clinical Applications, The American Journal of Sports Medicine Nov 2009 Vol 37 no 11 2259-2272

REFERENCES