Prolapse and incontinence in the community

1. Prolapse and incontinence in the community May 2012 Judith ten Hof

2. What’s ‘new’ • Terminology related to incontinence • Use of meshes in prolapse surgery • Transvaginal tape procedures • Pharmaceutical treatments • Development of urogynaecology as subspecialty

3. Pelvic organ prolapse • Relaxation of pelvic structures, which may lead to discomfort and a protrusion of tissue from the vagina • Due to weakness of the supporting tissues and deficientperineal body • Types: • Anterior vagina:- urethrocele - cystocele - cysto-urethrocele • Uterine prolapse / vaginal vault • Posterior vagina:- enterocele - rectocele • Deficient perineal body

4. Pelvic organ prolapse • 50% parous women prolapse • 10-20% symptomatic • Gynae surgery waiting list • 20% of women • 59% of elderly women • 2% prolapse in nulliparous women

5. What causes prolapse? • Multifactorial • Increased abdominal pressure • Obesity • Chronic coughing • Constipation or straining to defecate • Work or lifestyle that requires heavy lifting or abdominal straining • Pregnancy & childbirth • Pelvic masses like uterine fibroids or ovarian masses; rare but can occur • Weak/damaged pelvic floor • Neuropathy / nerve damage due to age and childbirth • Inherited weakness of pelvic floor collagen, fascia or muscle • Postmenopausal status • Oestrogen deficiency may be a risk factor • Previous prolapse surgery • Perinealdamage

6. What problems does prolapse cause? • None at all • Worse later in the day • Uterine prolapse • Lump / bulge / something coming down • heaviness or dragging sensation • Backache / pelvic pain • Vaginal irritation/dryness/ulcers • Need to push the vagina back especially after straining (defecation) • Sexual Intercourse impossible/embarrassing/ decrease in sexual satisfaction

7. What problems does prolapsecause? • Bladder symptoms : • Urinary frequency and urgency • Stress urinary incontinence • Voiding difficulties • Inability to pass urine without reducing the prolapse back into the vagina • Recurrent cystitis • Obstruction due to kinking of the ureters that drain kidneys to bladder • Bowel problems : • Incomplete bowel emptying • Obstruction at defecation due to faeces lodging in the rectocele • Constipation • Digitation (Insert finger in the vagina to reduce prolapse) to empty the bowel • Faecal incontinence

8. Prolapse in primary care • History • Is prolapse a problem for the patient? • Urinary / bowel symptoms incl constipation • Sexually active • Pre-/postmenopausal/contraception • Aetiological factors: obstetric history, cough, increased abdo pressure • Past medical history • Drug history

9. Prolapse in primary care • Examination: • General: patient fit for surgery? • BMI • Abdominal: palpable mass / bladder • Pelvic examination: • Bimanual • Speculum / Sims speculum • Vaginal mucosa: lacerations / ulcerations / atrophy • Pelvic organ prolapse • Pelvic floor strength

10. Grading of the prolapse

11. Treatment • Conservative • Lifestyle • Mechanical treatment: pessary • Surgical treatment • Vaginal hysterectomy +/- repairs • uterus conserved – Manchester repair • sacrospinal fixation • Mesh repairs

12. Pessary treatment Benefits: -no need surgery -improvement symptoms -50-80% patients happy with pessary Risks: -vaginal discharge/ulcerations -may interfere with sexual activity -longterm 3-6monthly follow-up -complications neglected pessary Cochrane review 2009 to determine the effects of mechanical devices for pelvic organ prolapse: ‘No eligible, completed, published or unpublished randomised controlled studies were found, therefore no data collection or analysis was possible’.

13. Pessary treatment

14. Surgical correction • Risk intra-/postoperative complications • Urinary symptoms may not improve/get worse • 30% risk of future prolapse • New: primary mesh repair (Prospect study)

15. Anterior repair Posterior repair

16. Use of mesh Cystocele repair Vault prolapse laparoscopicsacrocolpopexy

17. Prolapse in primary care • If patient requests treatment: • Lifestyle advice: • Weight loss • Constipation advice • Advice regarding urinary symptoms • pelvic floor exercise with physiotherapist • vaginal oestrogen/lubricans or moisturisers • Mechanical treatment • Pessary • Issues: • It is a’ lump’ but not cancer • It is never ‘too late’ to have surgery

18. Urinary incontinence • NICE clinical guideline 40 Age group (years) Prevalence of incontinence by age group and severity

19. Terminology • Overactive bladder: • Urgency with or without urgency incontinence, usually with increased daytime frequency and nocturia • Overactive bladder syndrome: • UrgencyA sudden, compelling desire to pass urine which is difficult to defer • Urgency incontinenceAny involuntary leakage of urine associated with urgency • Increased daytime frequency Voiding too often during the day (typically >8 voids/24h) • Nocturia Waking one or more times at night to void • Stress urinary incontinence: • involuntary leakage on effort, exertion, sneezing or coughing (International Continence Society, ICS) (2006)

21. Urinary incontinence

22. Urinary incontinence in primary care • Initial assessment • Full history • Categorise UI as stress UI, mixed UI, or urge UI/OAB • Urine analysis +/- MSU • Bladder diary/frequency-volume chart • 3 days • Post void residue by scan/catheter (if symptoms voiding dysfunction/rec UTI)

23. Urinary incontinence in primary care • Urgent referral: • haematuria • suspected malignancy urinary tract. • Consider referral • persisting bladder or urethral pain • prolapse beyond introitus • pelvic masses • faecal incontinence • suspected neurological disease • voiding difficulty • suspected urogenital fistulae • previous continence/cancer surgery or radiation therapy

24. Urinary incontinence in primary care • Examination: • Assessment pelvic floor • Vaginal atrophy • Assessment of prolapse

25. Conservative management • All patients should have conservative management prior to medication/ referral secondary care • Initial treatment based on symptom category. • In mixed UI, treatment predominant symptom. • Can be referred to District Nurse Continence Clinic or Continence advisory service

26. Conservative management • Lifestyle advice: • Modify fluid intake • Avoid caffeine • Weight loss, smoking cessation, exercise • Constipation advice • Pelvic floor excercises: • ‘supervised’ • Bladder retraining • min 6 wks • Intravaginaloestrogens for postmenopausal women with OAB symptoms • Review after 3 months • Improved continue • Ongoing problems  drug therapy

27. Drug therapy OAB/mixed • For OAB/mixed : anti-muscarinic medication • Oxybutinin: • >60yrs 2.5mg BD • < 60 yrs 5mg BD • Alternative: transdermaloxybutinin • Review 4-8 wks • If side effects/ lack or efficacy try 2nd line: • Darifenacin (enablex) • Fesoterodine (Toviaz) • Solifenacin (Vesicare) • Tolteridine (Detrusitol) • Trospium (Regurin) • Review 4-8 wks: • If side effects/ lack or efficacy refer Urogynae

28. Urinary stress incontinence • Surgical: • Retropubic sling TVT • Transobturator tape • Bulking agents • Repeated injections, • Less effective than tape

29. Case 1: AJ 43yrs • ‘Lump down below’ • P2, 2x VD, 1st forceps • Constipation and digitates • No urinary symptoms • Sexually active, husband had vasectomy • BMI 41 • Moderate rectocele • No cystocele, min uterine descent

30. Case 2: JD 54yrs • Routine smear, speculum difficult. • Prolapse noticed • Menopause 49yrs, no PV bleeding • Can feel it • No urinary symptoms apart from minimal stress incontinence • Bowels reg 1x/2days • Not sexually active

31. Case 3: KB 56yrs • Incontinence • P4, 3xVD, 1x CS • Menopause, no bleeding • Lap sterilisation • BMI 34 • Passes urine 10x/day, night 2-3x • Urgency and occ urgency incontinence • Minimal stress incontinence • O/E: grade 1 ant wall prolapse, no rectocele

32. Case 4: BG 37 yrs • Urinary loss when running since delivery • P1, VD, 1.5 yrs ago • On COCP reg withdrawal • No bowel problems • BMI 23 • Gynae exam normal findings, no prolapse, well healed perineum • Reasonable pelvic floor tone, no control