TREATMENT OF VAGINAL WALL PROLAPSE & INCONTINENCE AT

DESERT WOMEN’S CARE

Desert Women's Care provides complete services addressing female pelvic relaxation and uncontrolled urinary loss.

Our Urodynamic lab combined with a thorough History & Physical and evaluation of a Voiding Diary allow us the greatest precision in determining the cause(s) of urinary loss.

Any uncontrolled loss of urine is defined as incontinence. Incontinence is not a normal part of aging and should not be viewed as such.  Desert Women’s Care has extensive experience in diagnosing and treating female incontinence.  Desert Women’s Care additionally has a full Urodynamics lab in its offices to assure we provide the most personalized and discrete care possible to women suffering from these symptoms.

Ten to fifty percent of women report incontinence at some time in their lives. Incidence varies from 10 -30% of premenopausal women to over 50 % of older women in nursing facilities.  Pregnancy and childbirth increase incidence as well as post-menopausal status.  Industry estimates indicate only 10 – 20% of women with incontinence initiate a discussion with their care givers regarding the problem. Moreover, studies show only about a third of Primary Care physicians ever ask about urinary incontinence during health screening or “annual” examinations. 

Urinary incontinence negatively impacts quality of life in so many ways. Patient’s physical, psychological, social, domestic, occupational, and sexual lives are touched by this problem:

In the U.S. alone, sale of adult diapers exceeded $ 1.8 billion in 2000.  The typical incontinence patient spend over $1,000 annually on absorbable products. An estimate by Wagner, et al, in the journal, Urology, estimated that $26.3 billion was spent in the U.S. on incontinence.  From any perspective, this is a huge problem.

There are many types of incontinence. The ones treated at Desert Women’s Care are principally Over Active Bladder (OAB) and Stress Urinary Incontinence (SUI).  There is also a combination disorder including both conditions termed “Mixed Incontinence.”   If you occasionally loose urine unexpectedly, you probably can be helped (take a moment to access and print the AUS Bladder Control Quiz).

OVER ACTIVE BLADDER

With OAB a woman experiences an overwhelming need to urinate and often leaks before getting to the bathroom.  Often these patients need to wake at night to empty their bladders and loose urine then.  Alternatively, women with SUI loose urine with cough, sneeze or straining.  Women with “Mixed” disorder have a combination of symptoms. 

Other women have Overflow Incontinence or simply loose urine continuously. 
The incidence of OAB and SUI vary based on a woman’s age:

OVERACTIVE BLADDER

The overactive bladder often results from neurological injury between the brain and the bladder. Some causes of OAB include frequent urinary tract infection, stroke, multiple sclerosis, spinal cord injury, or diabetes. Most cases of OAB can be diagnosed based on a patient’s history and physical examination. Typical questions include:
1.  Do you carefully limit fluid intake when you are away from home?
2.  Are you always aware of where washrooms are located?
3.  Do you urinate more than eight times per day?
4.  Do you often wake up at night two or more times per night?
5.  Do you have uncontrollable urges to urinate often ending in wetting accidents?
6.  Do use pads to protect your clothes?

Patient who answer affirmatively to many of these questions have a high probability of having OAB.

The next step in evaluation is for the patient to fill a voiding diary (click here to access and print the DWC Voiding Diary). This tracks timing and volume of fluids consumed, timing of and volume of voiding episodes, timing of leaking episodes and urgency episodes. Your DWC physician can provide you with a voiding diary.  
 Laboratory evaluation includes urinalysis and blood testing. Urinalysis includes dipstick and culture and looks for evidence of infection or diabetes. Blood testing is used to exclude diabetes and electrolyte abnormalities.
Treatment of OAB involves restriction and timing of fluid intake and measures to stabilize the bladder. Lifestyle changes and behavioral modification are used to limit fluid intake and to avoid triggers of OAB symptoms.

Food and beverages irritating to the bladder must be avoided to minimize symptoms. For many people these include coffee, tea and other caffeinated beverages.  Evening fluids must be controlled particularly in the hours before sleep.  Bladder training is another strategy that is of benefit.  Interval between voids can be increased with the intention to “stretch” the bladder and gradually increase capacity before symptoms of urgency arise.  Close adherence to fluid restriction and bladder training can ease the symptoms of OAB.  Kegel exercises to strengthen the pelvic floor have some utility as well. Behavioral modification is a central part of any strategy to ease symptoms of Over Active Bladder (click here to access and print Instructions from the American Urological Society on Behavioral Modification).

Drug therapy is beneficial for many OAB patients.  Anti-muscarinic therapy is the most efficacious treatment. These drugs inhibit involuntary bladder contractions and increase bladder capacity. Just as with any drug, a variety of other effects are observed throughout the body.

Anti-muscarinic drugs’ principal side effects include dry mouth, constipation and indigestion or heart burn.  Behavioral modification in terms of fluid restriction is often a challenge when patient’s have dry mouth and wish to drink to relieve it. 
Most common drugs used to treat OAB include:

1.     Detrol
2.     Ditropan
3.     Sanctura
4.     Vesicare
5.     Enablex
6.     Toviaz

For patients who have failed anti-muscarinic therapy a new drug named Myrbetiq is available. This drug is a B3 adrenergic agonist. It works by selectively stimulating B3 adrenergic receptors relaxing bladdr smooth muscle.

The FDA has also recently approved Botox (onabotulinumtoxinA) to treat women with OAB.  Botox is injected with cyctoscopy into the bladder muscle at twenty separate points (5 units each point).  At 12 week follow-up the initial study showed 1.6 – 1.9 fewer incontinence episodes per day and a decreased sensation of urgency.  Botox injections need to be repeated every twelve weeks to maintain the beneficial effects. 

Patients with OAB not responding to the above measures (behavioral modification, bladder training and drug therapy)  can sometimes benefit from use of the InterStim device or other similar electronic nerve stimulation devices. 

Patients who do not respond also need to be certain their diagnosis is correct.  OAB is sometimes confused with SUI or Mixed Incontinence.

STRESS URINARY INCONTINENCE

Stress Urinary Incontinence (SUI) results from damage to the pelvis secondary to pregnancy and childbirth.  Damage can also be caused by trauma, radiation therapy, prior surgery and muscle disease and hormonal changes. 

This slide from New England Journal of Medicine demonstrates the relationship of pregnancy and route of delivery to development of SUI.

Women who were pregnant and delivered by Cesarean Section were about 1.5 times more likely than a woman who was never pregnant of developing SUI.  A woman who is pregnant and delivers vaginally is about 3 times more likely than a woman who was never pregnant of developing SUI.  A woman who delivered vaginally was twice as likely than a woman having C – Section of developing SUI.  Therefore, the enlargement of the uterus that accompanies pregnancy damages the pelvis leading to SUI in many woman. The act of expelling the fetus vaginally further injures the pelvic musculature making development of SUI even more likely.

A 2011 study from American Journal of Obstetrics & Gynecology (AJOG 2011;204:70.e1-6) showed the hazard ratio for having surgery for pelvic organ prolapsed compared to women only having Cesarean Delivery was 2.1 after first vaginal delivery and 4.5 after three or more vaginal deliveries. Peak incidence of surgery was three decades after the deliveries.

SUI is associated with loss of urine from coughing, sneezing or straining—acts that increase the intra-abdominal pressure. Because there is a change in the angle between the bladder and the urethra any sudden increase in intra-abdominal pressure can cause leaking.  Pelvic relaxation can be associated with sensation of pelvic pressure particularly when there is decensus of the uterus.  Patients often perceive the pelvic pressure increases throughout the day, particularly on days with significant exertion. Patients can sometimes feel a bulging which is the prolapsed anterior vaginal mucosa or cervix.

The goal of treatment is to strengthen the pelvic muscles or to restore the normal pelvic anatomy which will contribute to enhanced bladder control. 

Non-surgical attempts to control SUI are often tried first.  Kegel exercises involve tensing the pelvic floor muscles in a repetitive manner on a regular basis (click here to access Kegel Exercise Instructions from the American Urological Society).  Just as with athletes trying to build muscle tone and bulk, Kegel exercises  must be done frequently, purposefully and, for many women, over more time than they are prepared to invest in order to realize any measurable benefit.  For this reason many women often abandon  Kegel’s and resign themselves to wearing pads or diapers.

Surgical treatment is another alternative for control of SUI. The goal of current therapy is to elevate the mid-urethra, restoring a normal angle between the urethra and bladder.  Normal and abnormal anatomy is diagrammed below: 

The second diagram shows how the bladder and urethra fall down into the cystocele and change the bladder neck angle.

Various surgical options are available for SUI.  Historically, open abdominal surgery was used to elevate the tissue around the urethra to restore normal anatomy.  Burch or Marshal – Marchetti – Kranz procedures were the most common abdominal surgeries for SUI.  Many women’s mothers have had these procedures. By the early 1990’s with the development of new laparoscopy equipment, abdominal procedures were converted to laparoscopic ones.  The laparoscopic Para-Vaginal Repair or Burch elevated the para-vaginal tissue and suspended it from Cooper’s ligament.   This procedure is demonstrated below:

The final image shows sutures on each side, through the para-vaginal tissue elevating up like a pulley to Cooper's ligament.

Five year “fix” rate with the laparoscopic Para-Vaginal repair was in the order of 85%.  In other words, 85% of women undergoing thee surgery were still continent five years afterwards. A five year interval is a common measurement convention in medicine (this is not to say the correction only lasts five years—this is the percentage of women still improved at that interval). 

Newer procedures have been developed over the last ten to fifteen years that do not even require laparoscopic access.  The first such procedure, Trans-Vaginal Tape (TVT) involves passing synthetic graft material from behind the pubis down under the urethra and back up again. Over a decade of experience with TVT is available.  TVT offers a minimally invasive approach, is highly efficacious and has a very low incidence of adverse events associated with its use. The most common untoward event associated with TVT is bladder perforation because trocars are passed in the retropubic space blindly.

A newer generation of procedures involves passing tape in a hammock-like manner through the obturator foramen to elevate the midurethra—the Transobturator Tape procedure (TOT). Based on the anatomy of its placement, TOT is far less likely to injure the bladder in its placement.

Data from Barber, et al (1), suggests similar efficacy in treatment of genuine SUI with TOT vs. TVT. An equivalence trial involving 170 patients is published. One year after surgery 79% of patients with TVT and 82% of patients with TOT were either “much better” or “very much better.” As expected bladder perforation was 7% in the TVT group and 0% in the TOT group.  Additional studies are under way which will likely substantiate the efficacy of the TOT in treatment of SUI.

The Trans-Obturator Tape procedure  is diagrammed below:

Two small punctiform incisions are created a few centimeters lateral to the clitoris.  A three centimeter defect is created in the anterior vaginal mucosa just posterior to the urethral meatus.  Introducers are used to withdraaw  polypropylene mesh through the two lateral defects, in effect, putting a “hammock” of mesh under the urethra and elevating it with gentle tension.  This procedure takes less than twenty minutes and iss done with either a general anesthetic or a regional block. Bladder control is immediate and patients are discharged within an hour or two from the surgical facility or hospital.

An even newer variant of this procedure has been developed wherein only a single defect is required in the anterior vaginal mucosa. Mesh is applied through this midline defect and affixed to the membrane covering the obturator foramen on both sides without piercing the skin.

Trans-Obturator Tape (TOT) procedures are our mainstay of treatment for women with SUI under our care. Long-term studies have demonstrated the equivalence between outcome of the TOT procedure and the Laparoscopic Para-Vaginal Repair. 

PERI-URETHRRAL BULKING AGENTS

Some patient continue to lose urine despite elevation of the mid-urethra secondary to a disorder termed “intrinsic sphincteric deficiency.”    Injection of a "bulking agent" lateral to the urethra can help these patients in achieving meaningful bladder control.  An operating cystoscope is to visualize the urethra.  The scope is introduced into the bladder then withdrawn into the urethra. A needle is passed through the operating channel and through the wall of the urethra. Macroplastique is injected at 2 o'clock, 6 o'clock and 10 o'clock extrinsically compressing the urethra.

Trans-urethral injection of a "bulking agent" often requires several treatments separated by three to five weeks. 

MAKING THE DIAGNOSIS

A detailed History and Physical Examination is used to begin the evaluation of Urinary Incontinence. Initial work-up includes Urinalysis, Urine Culture and Sensitivity and testing to rule-out diabetes. Ultrasound is performed to make certain there are no masses compressing the bladder and to assure the bladder empties appropriately (residual urine volume after a spontaneous void is assessed).  Patients are given a voiding diary which is discussed with the physician at the next appointment (click here to access and print the DWC Voiding Diary).

Urodynamic testing is next scheduled. Urodynamic testing assesses function of the urinary tract by measuring various aspects of urine storage and evacuation. Some specific types of urodynamic testing are:

• Cystometry  evaluates bladder function by measuring pressure and volume of fluid in the bladder during filling, storage, and voiding.
• Uroflowmetry measures the rate of urine flow.
• Urethral pressure profile tests urethral function.
• Leak point pressure determines the bladder or abdominal pressure when leakage occurs due to increased abdominal pressure (Valsalva or cough) to assess urethral resistance.

The purpose of urodynamic testing is to aid in understanding physiologic mechanisms of lower urinary tract dysfunction, thereby improving the accuracy of diagnosis and facilitating targeted treatment.

The American College of Obstetricians and Gynecologists (ACOG) states urodynamic testing is  recommended to confirm the diagnosis of Stress Urinary Incontinence when surgery is planned, unless the history and physical examination are uncomplicated and consistent with the diagnosis.The elements of urodynamic testing are explained--

CYSTOMETRY — Cystometry measures bladder pressure during bladder filling. It is used to assess detrusor activity and bladder sensation, capacity, and compliance. Cystometry can be done with one channel measuring bladder pressure alone or with an additional channel that simultaneously measures abdominal pressure through the rectum or vagina. The advantage of the multichannel test is that it can discriminate between changes in abdominal versus bladder pressure by electronically subtracting the abdominal component from intravesical pressure.

UROFLOWMETRY — Uroflowmetry measures urine volume voided over time. It can be done with or without a pressure-flow study, which measures detrusor pressure during voiding.

URETHRAL PRESSURE PROFILE — The pressure in the urethra should be equal to or greater than the bladder pressure during bladder filling. When the bladder and urethra are in their proper anatomic location, increases in intraabdominal pressure will also increase urethral pressure, thereby preventing leakage. Low urethral pressure can be associated with incontinence and is related to aging, hypoestrogenic state, multiparity, and previous significant urogynecological operations.

LEAK POINT PRESSURE — Leak point pressure refers to the amount of abdominal pressure required to overcome urethral resistance and produce urine leakage when the patient is not trying to void. The pressure can be produced by Valsalva or cough. Unlike the urethral pressure profile, the leak point pressure reflects urethral function in the dynamic situation that produces incontinence.  Leak point pressure is used to assess intrinsic sphincter function. It is more reliable than the urethral pressure profile for diagnosis of intrinsic sphincter deficiency. Confirmation of this diagnosis can be important in selecting the correct surgical approach. Intrinsic sphincter deficiency is treated with a sling procedure or periurethral injections, rather than retropubic suspension.

POSTVOID RESIDUAL VOLUME — This measurement is made either by straight catheterization or by bladder ultrasound. Small portable ultrasounds specifically for postvoid residual measurement are available. A normal patient should have the ability to void at least 80 percent of the total bladder volume and have residual urine less than 50 cc immediately after voiding. A high residual urine on repeated determinations indicates outlet obstruction or poor detrusor contractility.

CORRECTION OF PELVIC PROLAPSE

In patients requiring complex surgery for correction of pelvic relaxation, DWC has a superb track record in successfully concluding procedures using Minimally Invasive Surgery, with almost complete avoidance of laparotomy. Using Laparoscopy allows us to care for even the oldest or most medically complicated patients without extended hospital stays.

For women with uterine procidentia a sequeence is presented showing the before image, an intra-operative photo during the anterior compartment repair, and a post-operative image. In the video (below) you will see the same type 1 polypropylene "Y" shaped graft placed and affixed to the sacrum to support the vagina.

As the population ages the number of women who will require surgery for Stress Urinary Icontinence and Pelvic Organ Prolapse will most certainly increase.

Remember, the single most important factor in determining whether your patient will avoid laparotomy is the choice of Surgeon you make!

To view our video, "SELS: Improved Manipulator for Laparoscopic Vagino-Sacropexy," click on the icon below:

To view our video, "SELS: LSH and Vagino-Cervico-Sacropexy," click on the link below:

To view the abstract for Dr. Demir's oral presentation at the 2014 Annual Meeting of the Society of Laparoendoscopic Surgeon's (SLS), click on the icons below.

Contact Desert Women’s Care in Scottsdale and Chandler, AZ for more information on treatment of vaginal wall prolapse or our multi-disciplinary approach to pelvic pain.

Treatment of Vaginal Wall Prolapse Chandler at DWC (480) 559-4776

Desert Women's Care  

80 North McClintock Drive, Suite 104, Chandler, Arizona  85226

9377 East Bell Road, Suite 131, Scottsdale, Arizona 85260

Copyright 2015 - Desert Women's Care - All Rights Reserved