Case Presentation Ahmed S. El-Azab, MD Associate Professor of - PowerPoint PPT Presentation

Case Presentation Ahmed S. El-Azab, MD Associate Professor of Urology Section of Female Urology & NeuroUrology Asyut University Urology and Nephrology Hospital

Case # 1  Ms. M. I., a 48 yr old ♀ , teacher, menstruating. no history of diabetes or other medical condition  CC: Urine leakage on activities as sneezing, coughing, episodes of urgency and UI, bothered  P/E:  Assess urethral support and mobility  Stress maneuver (cough Vs. Valsalva)  Assess pelvic organ prolapse.  SUI obvious, stage I AVWP, ureth hypermobility  What is Next?!

Preop. Assessment  Voiding diary  U/A  VCUG  Pad test  Q-tip test  Urodynamics ― Indications of Urodynamics in SUI

Q-tip ip test

Pad Test  Length of the test:  Office Vs Home:  Pyridium:  Stress Vs. Rest: Inter erpreta etatio ion

Cost Effectiveness of Urodynamics 1. Mixed incontinence, Significant urge component 2. Before surgery 3. Previous failed incontinence surgery 4. Known or suspected neurologic disease 5. History of urinary retention 6. High PVR 7. Elderly patient (ie, >65 y) 8. Pelvic organ prolapse 9. Diabetes (bladder neuropathy) 10. Nocturnal enuresis 11. Nulliparous woman with stress incontinence

Urodynamics

What operation?  Mid-urethral sling; TVT vs TOT  Same outcome!!  Prolene mesh vs. autologous midurethral sling  TOT easier to put but more difficult to remove  Pain after TOT:  Obturator n. damage  rare as it is far from trocars  Irritation to bone (more common)

TVT Needles Bladder

Pubic Prolene Mesh Symphysis Sling Picture courtesy of M. Walters

Surgery  TOT  On 2 nd postop day  What if she could not void? For how long you keep on CIC before you institute urethrolysis? — Immediate, 2 weeks, 4 weeks, 3 months

 On 2 nd postop day catheter was removed and trial of voiding …. She voided with only 50 mL PVR  She was discharged home

Follow up  1 month later: — she reported No SUI, but complains of urgency and few episodes of urge incontinence — What is next?

Follow up  1 month later: — she reported No SUI, but complains of urgency and few episodes of urge incontinence — What is next? — Timed voiding — Behavioral modifications — Anticholinergics

Follow up  6 month later: — she reported No SUI, but still bothered by the storage symptoms of urgency and urge incontinence. She reported that treatment did not work that much to improve her symptoms — what is next?

Follow up  1 month later: — she reported No SUI, but complains of urgency and few episodes of urge incontinence, still bothered — Differential diagnosis:

Follow up — What is next? — History — P/E — PVR  85 mL — U/A  free — Voiding diary — Urodynamics — Cysto?

Qmax: 10 mL/sec Pdet@Qmax 64cmH2O

Question to the panel  How would you diagnose bladder outlet obstruction in women? — could be difficult, no definite criteria!! — Women may not be able to void at all for a urodynamic study, and thus we do not have access to pressure flow data  Importance of the initial noninvasive uroflow

Asyut Experience — Most accepted nomograms use PdetQmax ≥ 20 – 25 cmH 2 O — Abnormal Qmax ≤ 11 - 15 ml/s — free flow is more representative!! — At our institute: — PdetQmax >20 cm of water when the Qmax is ≤ 12 ml/s or — PdetQmax >30 cm of water when the Qmax is 12-15 ml/s.

Urethrolysis  This woman was scheduled for urethrolysis  Optimal time after sling insertion:

Expert Opinions in Female Urology Prof. Hassan Abdelatif Abolella MD, Professor of Urology, Assiut University .

Case Number (1) OAB and small capacity:  A 65 year – old, gravid 3, para3, Woman with history of overactive bladder (OAB) symptoms , present with refractory OAB to 3 medications that did not work. She stopped all medications after 3 months with no benefit. She describes her incontinence as mostly urge type .She had history of a motor car accident (MCA) and had local surgery for disc herniation for instability after MCA.

 She has had therapy with percutaneous tibial nerve stimulation (PTNS) before her currently referral with no benefit after several sessions of PTNS.  On examination:- No stress incontinence with full bladder.- An attempt to fill her bladder with saline reveals that she can only tolerate a small amount of fluid of less than 65 ml.- PVR is 35 ml, and her urine analysis is negative . # How would you proceed with this patient ?

 This patient suffers from detrusor overactivity incontinence with small bladder capacity and high pressure voiding and increased EMG activity during voiding.  Firstly, a second filling cycle at slow filling rate, instruct the patient to void without voluntarily contracting pelvic floor

 This patient wishes to avoid major surgery : Augmentation cystoplasty or urinary diversion. # The first option is: Intradetrusor injection of 100U Onabotulinum toxin A. # The second option is Sacral neuromodulation.

ICI 2009 - 4th International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and Treatment of Urinary Incontinence, Pelvic Organ Prolapse and Faecal Incontinence

Case Number (2)  Urethral diverticulum A 27 year-old, gravid 3, para 3, woman presents with several years’ history of vaginal pain and voiding symptoms. Her lower urinary tract symptoms include difficulty, urgency, frequency and feeling of incomplete emptying. She has had culture documented infections every 2 months for at least the last 12 months.

She also describes a history of stress urinary incontinence occurring at least 2-3 times a day. She had a past history of 3 vaginal deliveries . Her physical examination revealed palpable suburethral mass extended proximally to the level of bladder neck. Her urinalysis is negative and post-void residual urine is 95 ml. How would you proceed with her therapy ?

Culture specific antibiotic therapy. # An inverted U – shaped incision. Incise the periurethral fascia transversely to raise proximal and distal flaps. Dissection and excision of the diverticulum. Harvest the autologous fascia and perforate the endopelvic fascia lateral to the periurethral fascia . Longitudinal closure of the urethral defect over urethral catheter, transverse closure of periurethral fascia. Midurethral sling fixed without tension to the rectus sheath. Foly catheter is left indwelling for10-14 days. # synthetic sling is contraindicated.

Case Number (3) Stress incontinence and intrinsic sphincter deficiency  A 59 – year- old, gravid 4, para 3, active woman presents for management of symptomatic and fairly severe urinary incontinence.  She wears about 7 pads a day for protection and has tried anticholinergics with no improvement. She describes mainly stress incontinence and no overt urge symptoms although she states she leaks all the time when standing or walking.

She has no nocturnal leakage. Her past history is significant for some vaginal atrophy and a pervious abdominal hystrectomy for benign disease at which time she had a mini-sling performed for urinary incontinence. Her examination demonstrates easy stress incontinence (urethral mobility 20-30 degrees). She has no prolapse. How would you proceed ? Do you think she needs to have her sling incised / cut if one is performing another sling ? if so, what type of sling ? What would you recommened ?

# Minority of patients with SUI would be classified as predominantly having ISD (10-15%). # Most patients presenting with SUI due to moderate or severe ISD ,defined for discussion purposes as an abdominal leak point pressure ( ALPP ) less than 100 cm at low bladder filling volumes with or without further decreasing ALPP with increasing bladder volume testing. # Mid urethral retropubic sling procedures allow passive extrinsic compression of the urethra to induce increased circumferential urethral resistance without any degree of tension applied to the sling arms at the time of fixation .

Pathophysiology of Stress Urinary Incontinence • Urethral Hypermobility – Displacement of urethra during sudden increase in abdominal pressure – Decreases pressure transmission

Pathophysiology of Stress Urinary Incontinence • Intrinsic Sphincter Deficiency (ISD) – Urethra is unable to generate enough Normal Abnormal outlet resistance to Closure Closure keep the urethra closed at rest or with minimal physical activity

SUI Occurs When; Bladder Pressure > Urethral Pressure • Any factor that pushes Cough the equation towards control, weight loss a positive urethral pressure gradient has the potential to be Surgery effective Exercises, medication .