Documente Academic
Documente Profesional
Documente Cultură
November 2010
FOREWORD!
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REGTA L. PICHAY, MD
President
Philippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2010
REGTA L. PICHAY, MD
INTRODUCTION!
BOARD OF TRUSTEES
Efren J. Domingo, MD, PhD
Virgilio B. Castro, MD
Blanca C. de Guia, MD
Raul M. Quillamor, MD
Rey H. delos Reyes, MD
Ma. Cynthia Fernandez-Tan, MD
Regional Directors
Betha Fe M. Castillo, MD (Region 1)
Concepcion P. Argonza, MD (Region 3)
Diosdado V. Mariano, MD (Region 4A NCR)
Evelyn R. Lacson, MD (Region 6)
Fe G. Merin, MD (Region 8)
Jana Joy R. Tusalem, MD (Region 10)
Imelda O. Andres, MD
Nurlinda Arumpac, MD
Maria Nelvez Candilario, MD
Ma. Theresa Cedullo, MD Ma.
Lara David-Bustamante, MD
Lorina Q. Esteban, MD
Maribel Hidalgo-Co, MD
Humildada Asumpta Igana, MD
Jericho Thaddeus P. Luna, MD
Corazon B. Mata, MD
Marites Mendoza, MD
Mary Christine F. Palma, MD
Regta L. Pichay, MD
Ma. Carmen H. Quevedo, MD
Bella G. Rodriguez, MD
Jean Marie Salvador, MD
Ma. Theresa B. Tenorio, MD
Julieta Villanueva, MD
Regina P. Vitriolo, MD
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CPG ON UROGYNECOLOGY
TOPICS / CONTENTS / AUTHOR/S!
Introduction 1
Dr. Lisa T. Prodigalidad-Jabson
Definition of Terms (Standardization of Terminology)
Dr. Almira J. Amin-Ong
Evaluation of Pelvic Floor Dysfunction and POP-Q Scoring System ..
Dr. Judith M. Sison
Conservative Management of Stress Urinary Incontinence
Dr. Almira J. Amin-Ong
Surgical Management of Stress Urinary Incontinence .
Dr. Lisa T. Prodigalidad-Jabson
Conservative Management of Pelvic Organ Prolapse
Dr. Maria Teresa C. Luna
Surgical Management of Pelvic Organ Prolapse
Dr. Manuel S. Ocampo, Jr and Dr. Lisa T. Prodigalidad-Jabson
Fecal Incontinence and Obstetric Anal Sphincter Injuries (OASIS) ..
Dr. Lennette L. Chan
Urinary Retention ...
Dr. Jennifer B. Jose
Appendix: Level of Evidence and Grade of Recommendations .
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INTRODUCTION
Lisa T. Prodigalidad-Jabson, MD
Urogynecology and Reconstructive Pelvic Surgery has long been a recognized
specialty in the field of Obstetrics and Gynecology. However, here in the Philippines,
Urogynecology is still at its infancy stage and only recently has there been a growing
interest in this field of pelvic reconstruction. Pelvic floor disorders such as pelvic
organ prolapse (POP), fecal incontinence (FI), and urinary incontinence (UI) are, at
present, aspects of womens health that are frequently neglected or ignored.
POP is among the most common indications for benign gynecologic surgery.
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. In the
University of the Philippines - Philippine General Hospital alone, over 100 cases of
vaginal hysterectomies are performed each year for prolapse. In a recent review by
the Womens Health Initiative, POP was found to be a very common condition in
women during menopause and was consistently related to parity.2 This becomes of
particular importance in a society such as ours where family planning, although
strongly advocated, is not widely practiced.
Likewise, female UI is a common problem that is often unrecognised, neglected,
or ignored. It is a condition believed to be as natural as pregnancy, childbirth,
menopause, and aging. The prevalence of UI is reported to range from 2% to 57% and
afflicts both the young and old. The wide range may reflect the difficulty in
estimating the incidence of UI, as most women experiencing such symptoms often do
not seek medical advice. In a 2001 study by the Asia-Pacific Continence Advisory
Board, the prevalence of overactive bladder as a cause of incontinence in Asians was
noted to be 51.4%. More specifically, Diokno states a 13% prevalence rate of UI
among Filipinos.3 This is in contrast to the incidence of 31% reported by RamosoJalbuena in 1994.4
With recent emphasis on womens health and quality of life, caring for women
with various pelvic floor disorders would become an increasingly important aspect of
womens health care. And, for a rapidly growing and aging population, the demand
for such care will inevitably escalate.
References
1.
2.
3.
4.
Milsom I, Altman D, Lapitan MC, Nelson R, Sillen U, and Thom D. Epidemiology of urinary
(UI) and fecal incontinence (FI) and pelvic organ prolapse (POP). In Abrams P, Cardozo L,
Khoury S, and Wein A (Eds). Incontinence: WHOICUD International Consultation on
Incontinence, 4th edition, 2009.
Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse
in the womens health initiative: gravity and gravidity. Am J Obstet Gynecol
2002;186(6):1160-6.
Lapitan MC and Chye PLH on behalf of the Asia-Pacific Continence Advisory Board. The
epidemiology of overactive bladder among females in Asia: A questionnaire survey. Int
Urogyn J 2001;12(4):226-31.
Ramoso-Jalbuena J. Climacteric filipino women: a preliminary survey in the Philippines.
Maturitas 2004;19(3):183-190.
DEFINITION OF TERMS
Almira J. Amin-Ong, MD
Lower urinary tract symptoms are classified into three major categories
namely, storage, voiding and postmicturition symptoms. The following terms are
culled from the latest International Continence Society (ICS) Standardization of
Terminology for lower urinary tract symptoms published in 2009. The terminologies
serve to eliminate confusion and facilitate communication amongst clinicians.
I. SYMPTOMS SUGGESTIVE
DYSFUNCTION
OF
LOWER
URINARY
TRACT
A. STORAGE SYMPTOMS
1. Urgency the complaint of a sudden compelling desire to pass urine which is
difficult to defer
2. Increased daytime frequency the complaint of the patient who considers that
she voids too often by day; equivalent to pollakisuria used in many countries
3. Nocturia the complaint that the individual has to wake up at night one or
more times to void
4. Stress urinary incontinence (SUI) the complaint of involuntary leakage on
effort or exertion, or on sneezing or coughing
5. Urge UI the complaint of involuntary leakage accompanied by or
immediately preceded by urgency
6. Mixed UI the complaint of involuntary leakage associated with urgency and
also with exertion, effort, sneezing or coughing
7. Nocturnal enuresis complaint of loss of urine occurring during sleep
8. Continuous urinary leakage the complaint of continuous leakage
9. Normal bladder sensation the individual is aware of bladder filling and
increasing sensation up to a strong desire to void
10. Increased bladder sensation the individual feels an early and persistent
desire to void
11. Reduced bladder sensation the individual is aware of bladder filling but does
not feel a definite desire to void
12. Absent bladder sensation the individual reports no sensation of bladder
filling or desire to void
13. Non-specific bladder sensation the individual reports no specific bladder
sensation but may perceive bladder filling as abdominal fullness, vegetative
symptoms, or spasticity
B. VOIDING SYMPTOMS
1. Slow stream perception of the individual of reduced urine flow, usually
compared to previous performance or in comparison with others
2. Splitting or spraying self-explanatory
3. Intermittent stream (intermittency) urine flow described as a stop and start
flow, on one or more occasions, during micturition
4. Hesitancy difficulty in initiating micturition resulting in a delay in the onset
III. TREATMENT
1. Pelvic floor training repetitive selective voluntary contraction and relaxation
of specific pelvic floor muscles
2. Biofeedback technique by which information about a normally unconscious
physiological process is presented to the patient and/or therapist as a visual,
auditory or tactile signal
3. Behavioral modification the analysis and alteration of the relationship
between the patients symptoms and her environment for the treatment of
maladaptive voiding patterns
4. Electrical stimulation the application of electrical current to stimulate the
pelvic viscera or their nerve supply
5. Catheterization technique for bladder emptying employing a catheter to
drain the bladder or a urinary reservoir
6. Intermittent (in/out) catheterization defined as drainage or aspiration of the
bladder or urinary reservoir with subsequent removal of the catheter
a. Intermittent self-catheterization performed by the patient herself
b. Intermittent catheterization performed by an attendant (e.g., doctor,
nurse, or relative)
c. Clean intermittent catheterization use of a clean technique. This
implies ordinary washing techniques and use of disposable or cleansed
reusable catheters
d. Aseptic intermittent catheterization use of a sterile technique. This
implies genital disinfection and use of sterile catheters and
instruments/gloves
7. Indwelling catheterization an indwelling catheter remains in the bladder,
urinary reservoir or urinary conduit for a period of time longer than one
emptying
References
1.
2.
Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, Shull BL, Amith
ARB. The standardization of terminology of female pelvic organ prolapse and pelvic floor
dysfunction. Am J Obstet Gynecol 1996;175:10-1.
Abrams P, Cardozo L, Khoury S, Wein A. Incontinence. 4th International Consultation on
Incontinence. 4th ed. 2009.
during simple bladder filling and cough stress test correlates highly with the
absence of urodynamic stress incontinence.11,12
3. Q-tip or cotton swab test is not useful in differentiating SUI from
abnormalities of voiding and detrusor functions. (Level II-3, 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. 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. 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.13,14
Other tests, e.g. perineal ultrasonography and magnetic resonance
imaging (MRI), can be used for assessment of bladder neck mobility, but these
are not commonly used in clinical practice.
Modifications of the Bonneys test require support of the urethrovesical junction during coughing in women who leak during a stress test.
These modifications are not reliable in selecting a surgical procedure or in
predicting cure.15
4. 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. A pad weight gain of > 1 g is considered positive for a 1-hour
test, and > 4 g for a 24-hour test.16,17 (Level II, 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.18,19 It was able to
discriminate most of the time between continent and incontinent women.
5. Dye test: The identification of the site of a fistula is best carried out by
instillation of methylene blue into the bladder. (Level III, Grade C)
Summary of Evidence
If leakage of clear fluid continues after dye instillation, a ureteric
fistula is most likely and this is most easily confirmed by a 2-dye test, using
Phenazopyridine or indigo carmine (or any drug that colors the urine like
Nitrofurantoin, in the local setting) to stain the renal urine, and methylene blue
to stain the bladder contents.20,21
6. Assessment of pelvic floor muscle strength has practical application in
determining whether the patient has nil, weak or good muscles to
Summary of Evidence
Transabdominal, perineal or translabial, transrectal, and transvaginal
ultrasound is currently used due to its noninvasive nature, ready availability,
and absence of distortion. Although ultrasound is rapidly evolving and much
progress has been made, it remains optional as evidence of its clinical benefit
is still weak.29
MRI provides anatomical detail to the pelvic floor in a single noninvasive study that does not expose the patient to ionizing radiation. Gousse,
et. al. reported a sensitivity of 83%, specificity of 100%, positive predictive
value of 100%, when comparing dynamic MRI to intraoperative findings.
These numbers were similar compared to physical examination alone.39
II. PELVIC ORGAN PROLAPSE AND PELVIC ORGAN PROLAPSE
QUANTIFICATION SYSTEM
1. The only symptom specific to prolapse is the awareness of vaginal bulge
or protrusion. For all other pelvic symptoms, resolution with prolapse
treatment can not be assumed.40 (Level II-3, Grade A)
Summary of Evidence
Almost half of parous women can be identified as having prolapse by
physical examination criteria, most are not clinically affected; the finding is
not well correlated with specific pelvic symptoms.41
2. The amount or severity of prolapse in each vaginal segment may be
measured and recorded using the pelvic organ prolapse quantification
system (POP-Q). (Level III, Grade C)
Summary of Evidence
The POP-Q system was introduced for use in clinical practice and
research. Some have argued that the 9-points of the POP-Q system maybe
more detailed than necessary for clinical practice, and it is better suited for
clinical research purposes. It often is useful to include a measurement of the
extent of protrusion relative to the hymen to better assess change overtime.42
2. 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.43 (Level II-2, 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 8.8/1,000
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
- /+ TVL
- /+ TVL
-3 to +3
-3 to + TVL
No limit
No limit
No limit
Reproduced from: Bump RC, et al. The standardization of terminology of female pelvic organ prolapse
and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175: 10-7. 42
Summary of Evidence
Anorectal manometry is an optional test that may be used in difficultto-evaluate cases of fecal or anal incontinence. It should be considered if
therapy based on simpler assessments fails to yield the desired improvement.46
MRI is superior to ultrasound in diagnosis of perianal sepsis and in
quantifying external anal sphincter muscle degeneration.47
References
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2.
3.
4.
5.
6.
7.
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22.
23. Haslam J. Evaluation of pelvic floor muscle assessment: digital, manometric, and surface
electromyography in females. M Phil Thesis. University of Manchester, 1999.
24. Cohen RA, et al. Clinical Practice. Microscopic hematuria. N Eng J Med 2003;348:2330-8.
25. Chahal, et al. Is it necessary to perform urine cytology in screening patients with hematuria?
Eur Urol 2001;39:283-6.
26. ACOG 2007 Compendium Vol.11 Practice Bulletins pp1115-27.
27. Wall LL, et al. Simple bladder filling with a cough stress test compared with subtracted
cystometry for the diagnosis of urinary incontinence. Am J Obstet Gynecol 1994;171:1472-7;
discussion 1477-9.
28. Weir J, et al. Large-capacity bladder. A urodynamic survey. Urology 1974;4:544-8.
29. Cardoso A, et. al. (ed). Incontinence. 4th International Consultation on Incontinence Paris July
5-8, 2008. Health Publication Ltd. 4th edition, 2009.
30. Ramsay IN, et al. A randomized controlled trial of urodynamic investigations prior to
conservative treatment of urinary incontinence in the female. Int Urogynecol J 1995;6:277
31. Khullar V, Cardozo L, et al. 30th Annual meeting of ICS, Finland 2000.
32. Weber AM. Is urethral pressure profilometry a useful diagnostic test for stress urinary
incontinence? Obstet Gynecol Surv 2001;56:720-35.
33. Weber AM. Leak point pressure measurement and stress urinary incontinence. Curr Womens
Health Rep 2001;1:45-52.
34. Association of Professors of Gynecology and Obstetrics. Clinical management of urinary
incontinence. Crofton (MD) APGO; 2004.
35. Awad SA, et al. Final diagnosis and therapeutic implications of mixed symptoms of urinary
incontinence in women. Urology 1992;39:352-7.
36. Agency for Health Care Policy and Research. Urinary incontinence in adults: acute and
chronic management. Clinical Practice Guideline, No.2, 1996 Update.AHCPR Publication
No. 96-0682. Rockville (MD): AHCPR; 1996.
37. Beer-Gabel M, et al. Dynamic transperineal ultrasound in the diagnosis of pelvic floor
disorders: pilot study. Dis Colon Rectum 2002;45:239-45.
38. Pannu HK, et al. Dynamic MR imaging of pelvic organ prolapse: spectrum of abnormalities.
Radiographics 2000;20:1567-82.
39. Gousse AE, et al. Dynamic half fourier acquisition single shot turbo spin-echo magnetic
resonance imaging for evaluating the female pelvis. J Urol 2000;164:1606-13.
40. ACOG Compendium of Selected Publications 2009. Clinical Management Guidelines for
Obstetrician-Gynecologists #85, September 2007: 417-29.
41. Samuelsson EC, et al. Signs of genital prolapse in a Swedish population of women 20-59
years of age and possible related factors. Am J Obstet Gynecol 1999;180:299-305.
42. Bump RC, et al. The standardization of terminology of female pelvic organ prolapse and
pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-7.
43. Gustilo-Ashby AM, et al. The incidence of ureteral obstruction and the value of intraoperative
cystoscopy during vaginal surgery for POP. Am J Obstet Gynecol 2006;194:1478-85.
44. Gilmour DT, et al. Rates of urinary tract injury from gynecologic surgery and the role of
intraoperative cystoscopy. Obstet Gynecol 2006;107:1366-72.
45. Jackson S, Walters M, et al. Fecal incontinence in women with urinary incontinence and
pelvic organ prolapse. Obstet Gynecol 1997;89:423-7.
46. De Leeuw JW, et al. Relationship of anal endosonography and manometry to anorectal
complaints. Dis Colon Rectum 2002;45:1004-10.
47. Rociu E, et al. Fecal Incontinence: endoanal ultrasound vs endoanal MR imaging. Radiology
1999; 212(2):453-8.
48. Cardozo L, Staskin D (Eds). Textbook of Female Urology and Urogynecology 2006; 2nd
edition Volume 1.
49. Chappe C, et. al. Multidisciplinary Management of Female Pelvic Floor Disorders 2006.
Summary of Evidence
There are no RCTs comparing heavy lifting with sedentary activities.
The association between heavy lifting and UI should be investigated further,
whether heavy exertion is a risk factor for incontinence or whether changing
exertions can improve existing incontinence. Present studies are conflicting
with one study of 27,936 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.5 Nygard, et.
al., in a study of 3,364 women reported that UI with physical activity was
more common among highly active than less active women (15.9% versus
11.8%; p=0.01).6
3. Smoking increases the risk of more severe UI. (Level III, 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. 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.7 A large study
involving 27,936 women found that smoking increases the odds of severe UI
(Odds Ratio [OR] 1.4, 95% CI 1.2-1.6). However, smokers were found to
have stronger urethral sphincters.5
4. Decreasing caffeine intake improves continence. (Level II-1, Grade B)
Summary of Evidence
Bryant, et. al. found that decreasing caffeine intake to 96.5 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.8 In the Norwegian EPICONT Study, they found that
tea drinkers had higher odds of UI (OR 1.2, 95% CI 1.4-55) for up to 2 cups
per day and an OR of 1.3 (95% CI 1.5-19.0) for 3 or more cups compared to
none.5
4. Alcoholic beverages do not increase the incidence of UI. (Level II-2, 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.9
5. Limiting fluid intake to prevent UI should only be reserved to those with
abnormally high intake. (Level III, Grade C)
Summary of Evidence
It is always the assumption that leakages can very well be controlled
by limiting the fluid intake. However, a state of negative fluid balance or poor
fluid intake may lead to urinary tract infections (UTIs), constipation or
dehydration conditions that can readily be prevented by maintaining the
average daily fluid intake. An RCT that used a small crossover design found
that when fluid intake is decreased, women with stress urinary incontinence
(SUI) and women with detrusor overactivity had decreased incontinence
episodes10.
6. Chronic straining may be a risk factor for development of UI. (Level III,
Grade C)
Summary of Evidence
There are no studies regarding the effect of resolving constipation or
regulating bowel function on incontinence. One study reported that women
who strain during defecation are more likely to report SUI (OR 1.9, 95% CI
1.3-2.6) and urgency (OR 1.7, 95% CI 1.2-2.4).11 Further research is needed
to evaluate the role of constipation or chronic straining in the pathogenesis of
UI.
7. Postural changes such as crossing the legs and bending forward might be
useful in reducing leakages during coughing or provocation. (Level III,
Grade C)
Summary of Evidence
There was a mean fluid loss of only 1.3 g (95% CI 0.5-2.1, p<0.001)
when legs are crossed to prevent leakages compared to the following postural
changes: 4.7 g when legs are crossed and body bent forward (95% CI 1.4-7.7,
p<0.01); 10.2 g (95% CI 6.5-13.0) when bending forward alone; and 12.3 g
(95% CI 8.5-16.1) when standing.12 Further studies on the effectiveness of
postural changes as treatment for UI still needed.
Addendum
Many other lifestyle interventions are anecdotal hence there is currently no
evidence to support any of these, specifically, wearing of nonrestrictive clothing,
reducing emotional stress, wearing cotton undergarments, use of a bedside commode,
decreasing lower extremity edema, treating chronic cough and increasing sexual
activity.
II. PELVIC FLOOR MUSCLE EXERCISE
Pelvic floor muscle training (PFMT) or Kegels exercise should be offered
as first line treatment for stress or mixed type of incontinence. (Level I,
Grade A)
Summary of Evidence
Studies regarding PFMT are conflicting because of variations in the
technique used. However, the most recent Cochrane systematic review (2003)
which included studies of women with urge, stress or mixed type of
incontinence found that PFMT was more effective compared to placebo
intervention (drug, sham electrical stimulation, sham exercise).13 Compared
with vaginal cones, there was a significant reduction in urinary leakage with
PFMT alone. There is also no benefit of combining PFMT with biofeedback.
PFMT supervised and continued for 3 months is a safe and effective treatment
for stress and mixed types of incontinence.
III. 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. (Level I, 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. A randomized trial of 68 women
with urge type of incontinence did not reveal significant improvement at all.
For women with stress type of incontinence, a small trial of 26 women showed
no changes in urinary leakages per week based on an incontinence impact
questionnaire. Combined with PFMT, a recent trial of 200 women showed no
significant reduction in the frequency of incontinent episodes.9
IV. MAGNETIC STIMULATION
The benefit of magnetic stimulation for treatment of UI has not been
established. (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. The patients
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. Usually, the treatment is given for 16
sessions for 6 weeks. There are still no trials regarding primary and secondary
prevention of UI. Regarding treatment, magnetic stimulation might be better
for both stress and urge type of incontinence.14,15 Further investigation is
warranted.
V. 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. (Level II-1, 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. Therapy usually starts with the lightest
cone then graduated to the heavier ones. It is not readily available in our
country. Majority of the trials enrolled women with stress incontinence who
had subjective cure from UI.16 Compared with the control group who had
other forms of intervention, there were no differences in objective outcomes
leakage episodes, pad test or pelvic floor muscle strength.16,17
VI. BLADDER TRAINING
Bladder training combined with pelvic floor muscle training is more
effective than either alone. It should be offered as first line treatment for
urge or mixed type of incontinence. (Level I, Grade A)
Summary of Evidence
Bladder training is a technique to increase the time interval between
voids using progressive voiding schedules. It is usually advised on patients
who have intact cognitive and physical functions and can take months to
achieve a cure. There are not too many trials to support bladder training. 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, 0.07; 95% CI 0.03-0.19). However, when one combines
it with PFMT, it is more effective than a combination of bladder training with
drug therapy. There is good evidence though that bladder training is effective
for urge or mixed type of incontinence, with fewer adverse effects and lower
relapse rates compared to drug treatment with antimuscarinics.13
VII. PHARMACOLOGIC
Anticholinergics are effective in the treatment of urge incontinence. (Level
1, Grade A)
Summary of Evidence
Anticholinergics are drugs prescribed to inhibit involuntary detrusor
contractions that could lead to urine leakages. A Cochrane systematic review
found that anticholinergics were better than placebo in subjective cure rate and
improvement rates (RR 1.41; 95% CI 1.29-1.54) and in improvement in
leakages episodes in 24 hours (WMD, -0.56; 95% CI -0.73 to -0.39).18 When
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
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Danforth KN, Townsend MK, Lifford K, Curhan GC, Resnick NM, Grodstein F. Risk factors
for urinary incontinence among middle-aged women. Am J Obstet Gynecol 2006;194(2):33945.
Melville JL, Katon W, Delaney K, Newton K. Urinary incontinence in US women: a
population-based study. Arch Intern Med 2005;165(5):537-42.
Subak LL, Whitcomb E, Shen HUI, Saxton J, Vittinghoff E, Brwon JS. Weight loss: a novel
and effective treatment for urinary incontinence. J Urol 2005;174(1):190-5.
Subak LL, Wing R, Smith West D, et al, A behavioral weight loss program significantly
reduces urinary incontinence episodes in overweight and obese women [Oral presentation].
American Uroynecologic Society Annual Meeting 2007.
Hannestad YS, Rortveit G, Daltveit AK, Hunskaar S. Are smoking and other lifestyle factors
associated with female urinary incontinence? The Norwegian EPINCONT Study. BJOG
2003;110(3);247-54.
Nygaard I, Girts T, Fultz NH, Kinchen K, Pohl G, Sternfeld B. Is urinary incontinence a
barrier to exercise in women? Obstet Gynecol 2005;106(2);307-14.
Hisayama T, Shinkai M, Takayanagi I, Toyoda T. Mechanism of action of nicotine in isolated
urinary bladder of guinea-pig. Br J Pharmacol 1988;95(2):465-72.
Bryant CM, Dowell CJ, Fairbrother G. Caffeine reduction education to improve urinary
symptoms. Br J Nurs 2002;11(8):560-5.
Abrams P, Cardozo L, Kouri S, Wein A: Incontinence. Adult Conservative Management of
Urinary Incontinence. 4th International Consultation in Continence July 2009.
Swithinbank L, Hashim H, Abrams P. The effect of fluid intake on urinary symptoms in
women. J Urol 2005l;174(1):187-9.
Moller L, Lose G, Jorgensen T: Risk factors for lower urinary tract symptoms in women 40 to
60 years of age. Obstet Gynecol 2000;96(3):446-51.
Norton PA, Baker JE: Postural changes can reduce leakage in women with stress urinary
incontinence. Obstet Gynecol 1994;85(5):770-4.
Hay-Smith EJ, Bo K, Berghmans LC, et al. Pelvic floor muscle training for urinary
incontinence in women. Cochrane Database Syst Rev 2003, Issue 1.
But I, Faganelj M, Sostaric S: Functional magnetic stimulation for mixed urinary
incontinence. J Urol 2005;173(5):1644-46.
Morris AR, OSullivan R, Dunkley P, Moore KH. Extracorporeal magnetic stimulation is of
limited clinical benefit to women with idiopathic detrusor overactivity: A randomized sham
controlled trial. Eur Urol 2007;52:876-83.
Herbison P, Plevnik S, Mantle J. Weighted vaginal cones for urinary incontinence. Cochrane
Database Syst Rev 2003, Issue 1.
Williams KS, Assassa RP, Gilleis CL, Abrams KR, Turner DA, Shaw C, et al. A randomized
controlled trial of the effectiveness of pelvic floor therapies for urodynamic stress and mixed
incontinence. BJU Int 2006;98(5):1043-50.
Hay-Smith J, Herbison P, Ellis G, Moore K. Anticholinergic drugs versus placebo for
overactive bladder syndrome in adults. Cochrane Database Syst Rev 2003, Issue 1.
Holroyd-Leduc JM, Straus S. Management of urinary incontinence in women: scientific
review. JAMA 2004;291(8):986-95.
however, the open colposuspension had significantly higher success rates (RR
0.91, 95% CI 0.85- 0.99).
Studies comparing laparoscopic colposuspension with minimally
invasive mid-urethral slings (TVT) show no statistically significant difference
in subjective cure rates within 18 months (RR 0.91, 95% CI 0.80 to 1.02). The
overall objective cure rate, however, was higher for mid-urethral slings.
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.
2. Laparoscopic colposuspension may be considered for the treatment of
SUI in women who also require concurrent laparoscopic surgery for
other reasons. (Level I-II, Grade B)
3. Laparoscopic colposuspension should only be carried out by surgeons
with specific training, expertise, and appropriate workload in
laparoscopic surgery and with expertise in the assessment and
management of UI in women. (Level I, Grade A)
IV. TRADITIONAL SLING PROCEDURE
1. Autologous fascial sling is recommended as an effective long-lasting
treatment for SUI. (Level I, Grade A)
Summary of Evidence
Trials on suburethral slings have compared this procedure with open
abdominal retropubic suspension (MMK and Burch colposuspension), needle
suspension, and even the TVT. Studies comparing different sling materials are
also numerous. In comparison with open colposuspension, the objective cure
rate from sling operations was not significantly different within the first year
(Relative Risk [RR] 0.19; 95% CI 0.02-1.53) or on longer follow-up (RR 0.49;
95% CI 0.17-1.42). In the largest RCT study done by Albo, et. al. comparing
colposuspension and fascial sling, the combined subjective and objective
outcome in terms of any incontinence (38% vs 47%, p=0.01) and SUI (49% vs
66%, p=<0.001) was significantly better from the sling procedure.10 Although
adverse events and voiding difficulty were also more common in the sling
group, 47% vs 63% and 14% vs 2% respectively.
Studies comparing autologous rectus fascial sling with TVT involve a
total of 284 patients from 3 RCTs.11,13,14 Cure rates at 12 months range from
83% to 88% after TVT and 81% to 93% after fascial sling.
2. Autologous fascial sling may be more effective than biological and
synthetic slings. (Level II)
Summary of Evidence
Pubovaginal sling procedures have traditionally been recommended for
SUI caused by intrinsic sphincter deficiency (ISD). Sling materials vary and
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18. Latthe PM, Foon R, Toozs-Hobson P. Transobturator and retropubic tape procedures in stress
urinary incontinence: a systematic review and meta-analysis of effectiveness and
complications. BJOG 2007;114: 522-31.
19. Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling operations for
stress urinary incontinence in women. Cochrane Database Syst Rev 2009, Issue 4.
20. Keegan PE, Atiemo K, Cody JD, McClinton S, Pickard R. Periurethral injection therapy for
stress urinary incontinence in women. Cochrane Database Syst Rev 2007, Issue 3.
21. NICE Guidance on Urinary Incontinence. National Collaborating Center for Womens and
Childrens Health, 2006, National Institute for Health and Clinical Excellence, 2006b.
22. Smith ARB, Dmochowski R, Hilton P, Rovner E, Nilsson CG, Reid FM, Chang D. Surgery
for urinary incontinence in women. In: Abrams P, Cardozo L, Khoury S, and Wein A (Eds)
Incontinence: WHO ICUD International Consultation on Incontinence, 4th edition, 2009.
Wu V, Farrel SA, Baskett TF, Flowerdew G. A simplified protocol for pessary management.
Obstet Gynecol 1997;90:990-994.
2. Sulak PJ, Kuehl TJ, Shull BL. Vaginal pessaries and their use in pelvic relaxation. J Reprod
Med 1993;38:919-923.
3. Clemons JL, et al. Patient satisfaction and changes in prolapse and urinary symptoms in
women who were fitted successfully with a pessary for pelvic organ prolapse. Am J Obstet
Gynecol 2004; 190(4): 10251029.
4. Rodriguez E, Trowbridge MD and Fenner DE. Conservative management of pelvic organ
prolapse. Clin Obstet Gynecol 2005;48(3):668-681.
5. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007;369:1027-1038.
6. Farrell SA. Practice advice for ring pessary fitting and management. J SOGC 1997;19:625.
7. Poma PA. Management of incarcerated vaginal pessaries. J Am Geriatr Soc 1981;29:325-327.
8. Hagen S, Stark D, et al. Conservative management of pelvic organ prolapse in women.
Cochrane Database Syst Rev 2006, Issue 4.
9. Bo K. Pelvic floor muscle training is effective in treatment of stress urinary incontinence, but
how does it work? Int Urogynecol J 2004;15:76.
10. Hagen S, Stark D, Maher C, et al. Conservative management of pelvic organ prolapse in
women. Cochrane Database Syst Rev 2:CD003882, 2004.
11. Rodriguez E, Trowbridge MD, Fenner DE. Conservative management of pelvic organ
prolapse. Clin Obstet Gynecol 2005;48(3):668-681.
COMPARTMENT
(ANTERIOR
VAGINAL
WALL
Summary of Evidence
This procedure is indicated for a patient with an elongated cervix, an
anterior vaginal wall prolapse, with a desire of maintaining her uterus. A
retrospective study of 187 consecutive patients with a majority having a stage
3 uterine prolapse underwent a Manchester procedure. Early post-operative
complications were urinary retention (22.05%) and cervical stenosis (11.27%).
Follow-up after 3 years revealed almost 4% had undergone surgery for
prolapse recurrence and urinary incontinence.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%). After a one-year follow-up, the Modified Manchester had no recurrent
middle compartment prolapse compared to 4% for the vaginal hysterectomy
with a high uterosacral plication group.12
SACROSPINOUS HYSTEROPEXY AND ABDOMINAL / LAPAROSCOPIC
HYSTEROPEXY
The American College of Obstetrics and Gynecology (ACOG) released Bulletin
85, recommendations are:15
1. 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. (Level II-3,
Grade B)
Summary of Evidence
These procedures use suture or mesh to attach the cervix/uterus to the
sacrospinous ligament or the sacrum. Few studies are available for
sacrospinous and abdominal hysteropexy. One observational study for
sacrospinous fixation involved 133 women where 84% of women were highly
satisfied. No serious complications were noted. The uterine prolapse
recurrence rate that needed reoperation was 2.3%. Cystocele recurrence was
35%.13 A review by Ridgeway, et. al. concluded that favorable postoperative
outcomes range from 62-100% and additional data show improved quality of
life and sexual function. Anatomic outcomes appear to be comparable to
vaginal hysterectomy with sacrospinous ligament vault suspension.14 The
open or laparoscopic sacrohysteropexy has similar results when compared
with sacrospinous fixation, with cure rates ranging from 91-100%. Several
studies favoring sacrohysteropexy also showed improvements in quality of life
and sexual function.14
2. Hysteropexy should not be performed by using the ventral abdominal
wall for support because of the high risk for recurrent prolapse,
particularly enterocele. (Level II, Grade B)
AND
ABDOMINAL
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III.POSTERIOR
PROLAPSE)
COMPARTMENT
(POSTERIOR
VAGINAL
WALL
1. For posterior vaginal wall prolapse, the vaginal approach was associated
with a lower rate of recurrent rectocele and/or enterocele than the
transanal approach.15 (Level II-1, Grade B).
2. Posterior colporrhapy has a greater success rate compared to site-specific
rectocele repair with or without a graft. (Level I, Grade A)
Summary of Evidence
In a study by Paraiso, et. al., 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, sitespecific rectocele repair, or site-specific rectocele repair augmented with a
porcine small intestinal submucosa graft. 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%). Overall postoperative sexual function
had significantly improved in all groups postoperatively. Posterior
colporrhaphy and site-specific rectocele repair had similar anatomic and
functional outcomes. Addition of a porcine-derived graft did not improve
anatomic results.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.29
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
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21.
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24.
25.
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28.
Nguyen JN, Burchette RJ. Outcome after anterior vaginal prolapse repair: a randomized
controlled trial. Obstet Gynecol 2008 Apr;111(4):891-8.
Hiltunen R, Nieminen K, Takala T, Heiskanen E, Merikari M, Niemi K, Heinonen PK. Lowweight polypropylene mesh for anterior vaginal wall prolapse: a randomized controlled trial.
Obstet Gynecol 2007;110(2 Pt 2):455-62.
Behnia-Willison F, Seman El, Cook JR, OShea Rt, Keirse MJ. Laparoscopic paravaginal
repair of anterior compartment prolapse. Minim Invasive Gynecol 2007;14(4):475-80.
Park AJ, Paraiso MF. Surgical management after uterine prolapsed. Minerva Ginecol 2008
Dec;60(6):493-507.
Ayhan A, Esin S,Guven S, Salman C, Ozyunco O. The Manchester operation for uterine
prolapsed. Int J Gynaecol Obstet 2006 Mar;92(3):228-33.
De Boer TA, Milani AL, Kluivers KB, Withagen MI, Vierhout ME. The effectiveness of
surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication
(modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication.
Int Urogynecol J Pelvic Floor Dysfunct 2009 Nov;20(11):1313-9.
Dietz V, de Jong J, Huisman M, Schraffordt Koops S, Heintz P, van der Vaart H. The
effectiveness of the sacrospinous hysteropexy for the primary treatment of uterovaginal
prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2007 Nov;18(11):1271-6.
Ridgeway B, Frick AC, Walter MD. Hysteropexy: A review. Minerva Ginecol 2008
Dec;60(6):509-28.
ACOG Practice Bulletin No. 85. Pelvic organ prolapse. American College of Obstetricians
and Gynecologists (ACOG). Washington (DC)
Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BW,
Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane
Database Syst Rev 2009 Jul 8;(3):CD003677.
Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy:
systematic review and meta-analysis of randomised controlled trials. BMJ 2005 Jun
25;330(7506):1478.
Lovatsis D, Drutz HP. Safety and efficacy of sacrospinous vault suspension. Int Urogynecol J
Pelvic Floor Dysfunct 2002;13(5):308-13.
Benedito de Castro E, Palma P, Riccetto C, Herrmann V, Bigozzi MA, Olivares JM. Impact of
sacrospinous vaginal vault suspension on the anterior compartment. Actas Urol Esp 2010
Jan;34(1):106-10
Shippey SH, Quiroz LH, Sanses TV, Knoepp LR, Cundiff GW, Handa VL. Anatomic
outcomes of abdominal sacrocolpopexy with or without paravaginal repair. Int Urogynecol J
Pelvic Floor Dysfunct 2010 Mar;21(3):279-83.
Ganatra AM, Rozet F, Sanchez-Salas R, Barret E, Galiano M, Cathelineau X, Vallancien G.
The current status of laparoscopic sacrocolpopexy: a review. Eur Urol 2009 May;55(5):1089103.
Chene G, Tardieu AS, Savary D, Krief M, Boda C, Anton-Bousquet MC, Mansoor A.
Anatomical and functional results of McCall culdoplasty in the prevention of enteroceles and
vaginal vault prolapse after vaginal hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct
2008 Jul;19(7):1007-11.
Cam C, Karateke A, Asoglu MR, Selcuk S, Namazov A, Aran T, Celik C, Tug N. Possible
cause of failure after McCall culdoplasty. Arch Gynecol Obstet 2010 Mar 16.
Silva WA, Pauls RN, Segal JL, Rooney CM, Kleeman SD, Karram MM. Uterosacral ligament
vault suspension: five-year outcomes. Obstet Gynecol 2006 Aug;108(2):255-63
Margulies RU, Rogers MA, Morgan DM. Outcomes of transvaginal uterosacral ligament
suspension: systematic review and metaanalysis. Am J Obstet Gynecol. 2010 Feb;202(2):12434.
Koyama M, Yoshida S, Koyama S, Ogita K, Kimura T, Shimoya K, Murata Y, Nagata I.
Surgical reinforcement of support for the vagina in pelvic organ prolapse: concurrent
iliococcygeus fascia colpopexy (Inmon technique). Int Urogynecol J Pelvic Floor Dysfunct.
2005 May-Jun;16(3):197-202.
FitzGerald MP, Richter HE, Siddique S, Thompson P, Zyczynski H. Colpocleisis: a review.
Int Urogynecol J Pelvic Floor Dysfunct. 2006 May;17(3):261-71.
Paraiso MF, Barber MD, Muir TW, Walters MD. Rectocele repair: a randomized trial of three
surgical techniques including graft augmentation. Am J Obstet Gynecol 2006
Dec;195(6):1762-71.
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.
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
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 [37.5% 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).48 Improvement of
symptoms and quality of life was achieved in all groups. Outcome after 12
months was statistically not significantly different between those patients with
an intact sphincter complex and those without. Chan and Tjandra reviewed 53
consecutive patients who underwent SNS for FI.49 There was no significant
difference in outcomes between those with and without an external sphincter
defect. SNS is an effective therapy for most patients with clinically significant
incontinence who fail conservative management.50
9. Patients with sphincter defect who have failed SNS, sphincteroplasty can
be considered. Other alternatives include stimulated muscle transposition
and implantation of an artificial anal sphincter (AAS). (Level II, Grade B)
Summary of Evidence
The device (Acticon Neosphincter, American Medical Systems,
Minnesota, USA) is a totally implantable system consisting of 3 parts: an
inflatable occlusive cuff that is implanted around the native sphincter, a
pressure-regulating balloon that is implanted in the prevesical space, and a
control pump that is implanted in the labia majora. AAS has been shown to
have reasonable success. Most of the patients (78-100%) with a functioning
device were continent to solid stool, 56-95% were continent to solid and liquid
stool, and 22-67% were completely continent. The success rate in patients
with a functioning device was 44-100%, and the intention-to-treat success rate
was 41-83%. Overall complication rate varied between 11-87% but no
mortality rate was reported. Surgical site infections (9-58%) and erosion of the
adjacent skin (6-32%) were common. Up to 46% of patients underwent
revisional surgery, and the proportion of patients with a functioning device
after follow-up of between 6 and 34 months ranged between 24-100%. Sixty
seven percent patients have their devices explanted. The AAS is a useful
technique in carefully selected patients, particularly those who have failed
other treatments.
10. Patients with passive FI to liquid or solid stool who had failed
conventional therapy, the use of injectable biomaterials report reasonable
short and midterm term success rate. (Level III, 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.57 Sixty four percent
reported complete cure and 36% had partial improvement. There is only one
report of long-term results for injectable agents. Maeda, et. al. reported the 5year outcome of 6 patients injected with Bioplastique.58 One patient had
Summary of Evidence
A persistent defect in the internal anal sphincter was found to be an
important determinant of FI.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). In a
large series of 585 patients with a chronic anal fissure treated in this fashion at
the Mayo Clinic, 11% developed FI.79
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31. Madoff RD. Surgical treatment options for fecal incontinence. Gastroenterology 2004;126(1
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32. Bravo Gutierrez A, Madoff RD, Lowry AC, Parker SC, Buie WD, Baxter NN. Long-term
results of anterior sphincteroplasty. Dis Colon Rectum 2004;47(5):727-31; discussion 731-2.
33. Dudding TC, Pares D, Vaizey CJ, Kamm MA. Predictive factors for successful sacral nerve
stimulation in the treatment of faecal incontinence: a 10-year cohort analysis. Colorectal Dis
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34. Conaghan P, Farouk R. Sacral nerve stimulation can be successful in patients with ultrasound
evidence of external anal sphincter disruption. Dis Colon Rectum 2005;48(8):1610-4.
35. Maslekar SK, Gardiner A, Duthie GS. Sacral nerve stimulation as primary treatment for faecal
incontinence secondary to obstetric anal sphincter damage: medium and long-term results
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36. Ratto C. Sacral nerve stimulation in fecal incontinence due to anal sphincter lesions. Paper
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27, 2007; Malta
37. Jarrett ME, Dudding TC, Nicholls RJ, Vaizey CJ, Cohen CR, Kamm MA. Sacral nerve
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38. Melenhorst J, Koch SM, Uludag O, van Gemert WG, Baeten CG. Is a morphologically intact
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39. Pinedo G, Vaizey CJ, Nicholls RJ, Roach R, Halligan S, Kamm MA. Results of repeat anal
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40. Nielsen MB, Dammegaard L, Pedersen JF. Endosonographic assessment of the anal sphincter
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41. Giordano P, Renzi A, Efron J, Gervaz P, Weiss EG, Nogueras JJ, Wexner SD. Previous
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42. Vaizey CJ, Norton C, Thornton MJ, Nicholls RJ, Kamm MA. Long-term results of repeat
anterior anal sphincter repair. Dis Colon Rectum 2004;47(6):858-63.
43. Deen KI, Oya M, Ortiz J, Keighley MR. Randomized trial comparing three forms of pelvic
floor repair for neuropathic faecal incontinence. Br J Surg 1993;80(6):794-8.
44. van Tets WF, Kuijpers JH. Pelvic floor procedures produce no consistent changes in anatomy
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45. Rongen MJ, Uludag O, El Naggar K, Geerdes BP, Konsten J, Baeten CG. Long-term followup of dynamic graciloplasty for fecal incontinence. Dis Colon Rectum 2003;46(6):716- 21.
46. Tillin T, Gannon K, Feldman RA, Williams NS. Third-party prospective evaluation of patient
outcomes after dynamic graciloplasty. Br J Surg 2006;93(11):1402-10.
47. Thornton MJ, Kennedy ML, Lubowski DZ, King DW. Long- term follow-up of dynamic
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48. Matzel KE, Stadelmaier U, Hohenfellner M, Hohenberger W. Chronic sacral spinal nerve
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49. Tjandra JJ, Chan MK, Yeh CH, Murray-Green C. Sacral nerve stimulation is more effective
than optimal medical therapy for severe fecal incontinence: a randomized, controlled study.
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50. Chan MK, Tjandra JJ. Sacral nerve stimulation for fecal incontinence: external anal sphincter
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51. OBrien PE, Dixon JB, Skinner S, Laurie C, Khera A, Fonda D. A prospective, randomized,
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52. Ortiz H, Armendariz P, DeMiguel M, Solana A, Alos R, Roig JV. Prospective study of
artificial anal sphincter and dynamic graciloplasty for severe anal incontinence. Int J
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53. Wong WD, Congliosi SM, Spencer MP, Corman ML, Tan P, Opelka FG, et al. The safety and
efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter
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54. Mundy L, Merlin TL, Maddern GJ, Hiller JE. Systematic review of safety and effectiveness of
an artificial bowel sphincter for faecal incontinence. Br J Surg 2004;91(6):665- 72.
55. Belyaev O, Muller C, Uhl W. Neosphincter surgery for fecal incontinence: a critical and
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56. Altomare DF, Binda GA, Dodi G, La Torre F, Romano G, Rinaldi M, Melega E. Disappointing
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57. Shafik A. Polytetrafluoroethylene injection for the treatment of partial fecal incontinence. Int
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59. Shafik A. Perianal injection of autologous fat for treatment of sphincteric incontinence. Dis
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60. Vaizey CJ, Kamm MA. Injectable bulking agents for treating faecal incontinence. Br J Surg
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61. Colquhoun P, Kaiser R, Jr., Efron J, Weiss EG, Nogueras JJ, Vernava AM, 3rd, Wexner SD. Is
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62. Norton C, Burch J, Kamm MA. Patientsviews of a colostomy for fecal incontinence. Dis
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72. Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, OBrien PM. Repair techniques for
URINARY RETENTION
Jennifer Marie B. Jose, MD
Background
Voiding dysfunction or lower urinary tract dysfunction is a term used to
describe various problems related to the bladders ability to store and empty urine.
Urinary retention is the inability to complete the voiding phase of the micturition
cycle and, often times, represent the end stage of voiding dysfunction.
Physiologically, a problem may be present with either the bladder, the outlet or both.
Voiding dysfunction is manifest clinically in lower urinary tract symptoms (LUTS)
which may be characterized as storage symptoms (frequency, urgency, nocturia and
urge incontinence) or emptying symptoms (decreased force of stream, incomplete
emptying, hesitancy straining to void and urinary retention). Symptoms do not always
correlate with the underlying pathology, and numerous conditions may exist that can
have similar presentations.
Distinguishing neurogenic from non-neurogenic voiding dysfunction is
important. The latter category is often caused by bladder outlet obstruction and this
may be functional, 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.1
The standardization of terminology of lower urinary tract dysfunction,
published by the International Continence Society (ICS), has recently defined LUTS
in relation to voiding difficulty and retention.2
Acute retention of urine is defined as a painful, palpable or percussable
bladder, when the patient is unable to pass any urine.
Chronic retention of urine is defined as a non-painful bladder, which remains
palpable or percussable after the patient has passed urine. Such patients may
be incontinent.
Recommendations
1. Acute retention should be managed with an indwelling catheter and
evaluation and management of possible precipitant and contributory
factors, followed by a voiding trial after about 1 week (perhaps longer for
retention volumes over 1 liter).3 If the voiding trial fails, then further
urodynamic
investigation
is
needed
(including
sphincter
electromyography [EMG]). If prolonged catheterization is necessary,
suprapubic catheterization should be considered because of its lower risk
of catheter associated infection and urethral trauma.4 (Level I, Grade A)
Summary of Evidence
Short term use of an indwelling catheter is commonly used to manage
acute urinary retention. In most cases, continous drainage by foley catheter is
necessary until bladder function normalizes, usually within 48 to 72 hours.5
Summary of Evidence
If voiding difficulty is due to urethral stenosis, urethral dilatation using
Hegar dilators or preferably the Otis urethrotome is an appropriate option.
The place of bladder neck incision in patients with outflow obstruction
should never be performed unless diagnosis is confirmed by pressure/ flow
videourodynamics.
Partial cystectomy has been performed for treating the myogenic
decompensated bladder and excessive residual urine. However, the results are
disappointing. Urinary diversion using appendix or fallopian tube,
colocystoplasty, latissimus dorsi myoplasty and vesical cap operation with
ileal seomuscular patch grafts have all been tried with variable success.9
III. BLADDER TRAINING
Bladder training should be guided by patients bladder capacity,
symptoms and fluid intake. 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). (Level III, Grade C)
Summary of Evidence
There are no randomized trials comparing CISC and clamping the foley
catheter intermittently for bladder training. One main advantage of CISC is that
the voiding trials can be done before self-catheterization. In addition, it can be
implemented as a one-time treatment repeatedly over a short period of time,
on an occasional basis, or may be life-long for persons with chronic bladder
emptying disturbances. It is often preferred to indwelling catheters, because it
can result in a better quality of life for the patient has less complications, such
as urinary tract infections (UTI), urethral stricture, compared to indwelling
catheters.
The evaluation, management and treatment of female patients with
voiding dysfunction and urinary retention is often complex and must take
multiple factors into consideration, including the degree to which the patients
symptoms is bothersome and whether the upper tracts are in jeopardy. A
patient specific diagnostic approach is recommended, depending on
symptoms, degree of bother and whether there is a history of suspicion of
neurologic disease. In certain cases, empirical treatment is appropriate.
However, when a formal diagnosis is indicated, specific therapy can be
directed based on urodynamics and other basic tests.8
Summary of Evidence
Behavioral and biofeedback treatments are safe, noninvasive, and
effective interventions that are useful in the management of idiopathic urinary
retention. Behavioral changes enlighten patients about their fluid intake and
voiding behavior. Biofeedback involves surface or internal (vaginal or rectal)
electrodes that transducer muscle potentials into auditory or visual signals.
This helps the patient learn to increase or decrease voluntary muscle activity.17
3. Diazepam was reported to be successful to be used in treatment. (Level II1, Grade B)
Summary of Evidence
Diazepam relaxes the pelvic floor striated musculature during bladder
contraction, or that such relaxation removes an inhibitory stimulus to reflex
bladder activity.1
4. Amitryptyline was reported to be successful. (Level III, Grade A)
5. Endoscopic and transperineal injection of botulinum toxin has been
performed in women with dysfunctional voiding. (Level III, Grade A)
6. Sacral neuromodulation is effective for restoring voiding in patients with
idiopathic retention (Fowlers syndrome).7 (Level III, Grade A)
Summary of Evidence
Dagupta and colleagues provided long term results of sacral nerve
stimulation in women with Fowlers syndrome. The retrospective study
included 26 women who were followed for more than 6 years. Seventy-seven
percent were voiding successfully more than 5 years post operatively: 54%
required revision surgery. The study supported effectiveness of sacral nerve
stimulation (SNS) for at least 5 years after implantation.18
Shaker and Hassouna treated 20 patients, with idiopathic, nonobstructing, chronic urinary retention dependent on CISC who had at least
50% improvement on percutaneous nerve evaluation screening. The patients
were followed for a mean of 15.2 months and had significant improvement in
voiding function, pelvic pain, and sensation of emptiness after voiding. 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.19
helping the woman to mobilize, and ensuring privacy during voiding and having a
warm bath. None of the pharmacologic drugs have been studied systematically in
postpartum women, as most women would be breastfeeding. If conservative
measures fail, it is advisable to insert a urethral catheter and remove it after the
bladder has been emptied. 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, a foley catheter should be inserted. A trial without catheter can be
attempted after 24-28 hours. The duration of catheterization is empirical, and no
standard has been agreed to. If trial without catheter fails, 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. If this is not feasible, send her home with an
indwelling catheter for 48 hours and repeat the voiding trial.
Overdistention bladder injury in the postpartum period can be avoided by
strict vigilance in ensuring that voiding occurs regularly. Women with potential
risk factors, e.g. regional anesthesia, instrumental delivery, obstetric anal sphincter
trauma or severe perineal tears should be catheterized during labor and delivery.
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.21- 24
References
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15. Carley ME, Carley JM, Vasdev G, Lesnick TG, Webb MJ, Ramin KD et al. Factors that are
associated with clinically overt postpartum urinary retention after vaginal delivery. Am J
Obstet Gynecol 2002;187(2);430-3.