On behalf of SAUGA we would like to wish you all a prosperous 2019.
Good fortune to those who will be taking the sub-speciality exams early in 2019!

And a huge thank you to Dr Suran Ramphal and his colleagues for the interesting papers: we all have a lot to learn.

Warmest regards and Happy New Year!

Zeelha Abdool and Peter De Jong


Pain and Dyspareunia with POP Surgery: Some Thoughts - Suran Ramphal

Pelvic organ prolapse (POP) is a common condition with increasing prevalence worldwide. Fifty percent of parous women will develop prolapse at some stage of their life. Surgery remains the gold standard in the treatment of prolapse and there is no consensus on the most effective surgery. The lifetime risk of undergoing prolapse surgery by age 80 is one in 11 and 30% will undergo repeat prolapse surgery. The aim of surgery is to restore anatomy, alleviate symptoms, avoid complications, maintain sexual function, and prevent recurrences and the onset of new symptoms. The development of pain and dyspareunia following surgery is the fear of most pelvic surgeons and when it occurs, it becomes a challenge to manage.

It is prudent that prior to surgery, one should evaluate and exclude chronic pain syndrome and determine whether the patient is in a healthy and supportive sexual relationship. Failure to ascertain this information often leads to the patient blaming the surgery for her symptoms of pain or dyspareunia. If preoperative pain symptoms are not discussed, then patients may have a grievance with the surgeon if these symptoms were her major concern and were not addressed or corrected. Women with systemic or centralized pain processing problems such as migraine, interstitial cystitis, vulvodynia, IBS, endometriosis, and chronic pelvic pain are prone to have pain after surgery and surgical interventions must be carefully planned with counselling. The use of mesh in these patients should be avoided at all costs. Furthermore, it is important that the patient has a healthy vaginal epithelium and normal levator ani function before surgery. With pelvic reconstructive surgery, it is important that post surgery the introitus and vagina are pliable, the introitus permits at least 2 fingers, there are no contraction rings or bands, vaginal length is at least 8 cm, there are no fixation points that create pulling or fibrosis and there is a perpendicular plane between the posterior vaginal wall and the perineal body. Scarring of perineal laceration repairs and iatrogenic introital stenosis are unfortunate surgical complications that can contribute to dyspareunia. Patients having repeated vaginal reconstructive procedures must be made aware of the risk of scarring, shortening of the vagina and fibrosis that may contribute to dyspareunia.

To date, the aetiology of pain following surgery is often difficult to elucidate and the question often asked is “Why does pain develop following surgery?” The onset may be related to underlying pain problems in selected patients, surgical technique, choice of sutures, healing problems or prosthetic implants such as mesh. The usage of vaginal mesh with prolapse surgery is very controversial in 2018. In the study looking at the Austrian registry and evaluating vaginal prolapse surgery with transvaginal mesh, dyspareunia was reported by 7% and 10% of 265 and 181 sexually active patients at 3 and 12 months postoperatively respectively. Renaud de Tayrac reported a 7% de novo dyspareunia at a minimum of one year on 118 patients who underwent the Uphold procedure (utero-vaginal suspension using bilateral vaginal anterior sacrospinous fixation with mesh). However, anatomical success was 93% and patient satisfaction 95%. Sacrocolpopexy (SCP) with the usage of abdominal mesh is not without its problems. In a case series reported by Walters, 3 patients presented with apical vaginal pain in the absence of mesh erosion following SCP, and all 3 patients had symptomatic relief with abdominal excision of the mesh.

The unfortunate issue with mesh is that when it is removed, pain and dyspareunia may still persist. In a report by Morgan et al, removal of vaginal mesh resulted in only a 50% symptom resolution of pain and dyspareunia. Furthermore, little is known about the risk factors for persistent pain. Hence many patients are subjected to neuromodulating drug therapy such as pregabalin, trigger point injections and physical therapy.

In a systematic review and metanalysis of the impact of native tissue repair for pelvic organ prolapse on sexual function by Jha and Gray, sexual function was significantly improved and dyspareunia significantly reduced following surgery. In fact, there was a 2.5X increased chance of sexual function improvement. However, native tissue surgery also has its own problems. Excessive plication of the pubocervical fascia (anterior repair) or perirectal fascia (posterior repair) combined with aggressive epithelial trimming can result in constriction rings and dyspareunia. One has to respect site specific defects and correct the appropriate defect. Patient selection for sacrospinous fixation (SSF) for vaginal vault prolapse or uterovaginal prolapse must be carefully chosen. It is prudent that you have a vaginal length of at least 9 cm and the procedure best avoided in the sexually active young patient because of vaginal angulation. One of the vaginal surgical procedures that contribute to dyspareunia is lavator plication for posterior compartment prolapse repair. Peter Dwyer and his team addressing “the effect of vaginal pelvic organ prolapse surgery on sexual function” concluded that surgical interventions for POP improved the vaginal and sexual matters at 6 and 12 months postoperatively. However levator plication with posterior vaginal repair is associated with an increase in postoperative dyspareunia and decreased sexual function. Hence in sexually active women, levator plication is best avoided.

When patients present with pain following prolapse repair, one has to be sensitive. A detailed history is critical and the clinician must address quality of life issues and sexual function. Examination should involve Q tip testing of the vestibule and vaginal epithelium and if the patient is tolerable to this intervention, then only should one proceed to a detailed pelvic and speculum examination. This includes levator ani muscle assessment, excluding tight bands/fibrotic strings, points of tension and mesh exposure or erosions.

With mesh, one has to make the decision to remove the entire mesh or part removal/release of the mesh. If there is a point of friction, pulling or fixation and this is the only area of pain, then one should address this targeted site and best avoid entire mesh removal. With surgical excision of mesh, one should do a careful EUA to define the mesh and assess rectum and bladder, cut the mesh in the midline with sharp dissection around the mesh, and have adequate vaginal margins to re-appose after removal of the mesh. If the arms are under tension, then release as much tension as possible. One should not remove mesh arms that are asymptomatic as this can result in bleeding or damage to adjacent tissue.

Other modalities of treatment include vaginal oestrogen and vaginal dilatation in selected cases. With pelvic floor muscle tension, trigger point injections with local anaesthetic and steroids may have benefit. Physiotherapists are essential partners in the management of these patients and offer pelvic floor rehabilitation and support. A pain specialist is pivotal in guiding medication choices.

References on request
Can Vaginal Birth Related Perineal Trauma Be Prevented? - Thinagrin Naidoo

Perineal injury following vaginal birth is associated with an increase in the incidence of pelvic floor disorders (especially when the anal sphincters are involved), both in the immediate post-partum period and in the long term.1,2, 3 These include pelvic organ prolapse (POP), anal incontinence (AI), urinary incontinence (UI), perineal pain and dyspareunia, all of which may lead to impaired quality of life. The incidence of perineal injuries which may occur spontaneously or as a result of an episiotomy, has been reported to be as high as 53-79%4, and vary depending on differences in classification and reporting. The most common of these injuries are usually first or second-degree lacerations (perineal skin only, and perineal skin and muscles, respectively).4 Naidoo and Moodley3 in a local study found a 16.2% incidence of perineal injuries, with only 4.1% being either 3rd or 4th degree tears.

Primiparity, young maternal age, induction of labour, heavier birth weight, longer duration of labour, maternal obesity, instrumental deliveries, epidural analgesia and occipital posterior position have all been identified as risk factors.5,6 The evidence for episiotomy as a risk factor for perineal injury varies, with some studies showing associations5 and others protective effects.6 It has also been suggested that episiotomy may be directly related to problems such as POP, AI, UI and perineal pain in the long term.1,2 There may be a racial variation in terms of risk for obstetric perineal injuries, with genetic, demographic and socio-economic factors playing a role.3, 6

The question that arises is, “are perineal lacerations and the subsequent morbidity associated with these injuries preventable?” A wide range of techniques have been described for peripartum use to avoid episiotomy and perineal injury. These include manual perineal support (MPS), perineal massage, warm compresses7, maternal position in the second stage of labour5, delayed pushing8, immersion in water during labour9, pelvic floor exercises before and after birth10, perineal injection of hyaluronidase in the 2nd stage of labour and the antepartum use of the Epi- No birth trainer.11 The effectiveness of these techniques in reducing perineal trauma has been the subject of a considerable amount of research, and much debate.

Often referred to as the “hands on method” MPS at delivery is commonly practiced. Several different techniques are described, including the flexion technique and the Ritgen maneuver (or a modification of either). It is thought that by slowing down the birth of the foetal head, and by reducing its presenting diameter perineal trauma is less likely.12 MPS continues to be a point of debate however, with some advocating ‘hands on’ and others advocating ‘hands off/poised’ techniques. A recent Cochrane Review7 showed that while MPS may reduce the incidence of episiotomy, it had no effect on other perineal trauma. A meta-analysis by Bulchandani et al12 suggested that the current evidence was insufficient to recommend a specific practice. It is claimed that Perineal massage can prevent perineal lacerations, protect perineal integrity, and enable women to rapidly regain function after vaginal delivery by stimulating both the rehabilitation and the re-elasticization of tissue and muscle in the perineal area13. However studies have provided varying results regarding the effectiveness of this technique in preventing perineal trauma. While some studies indicate that prenatal Perineal massage and Perineal massage during the second stage of labour reduce the rate of perineal trauma13, 14, others have reported that Perineal massage provides neither an advantage nor a disadvantage in terms of the rate of perineal trauma.8, 15 The literature regarding the effects of Perineal massage on episiotomy rates is also conflicting, with some suggesting no significant difference14, while others suggested a lower rate.8, 15

Warm perineal compresses are pads soaked in warm sterile water (heated to between 45° and 59 °C) and applied either during contractions once the baby’s head distends the perineum (the pad is re-soaked between contractions to maintain warmth), or continually during and between contractions. Asheim et al7 in their Cochrane review in 2017 found that the application of warm perineal compresses during pushing reduced the incidence of third and fourth-degree perineal lacerations, however there was no effect on rates of episiotomy or first or second-degree perineal tears. Most women find warm compresses acceptable and hence it might be reasonable to offer them this option.

Maternal position during labour has also been looked at in terms of reducing perineal trauma. Gupta et al16 in their meta-analysis in 2012 found that upright or lateral birth positions compared with supine or lithotomy positions were associated with fewer episiotomies and operative deliveries, but higher rates of second-degree lacerations in women without epidural analgesia, while Kemp et al17 in their meta-analysis in 2013 did not show a clear benefit of any upright position compared with the supine position in women with epidural analgesia. A recent randomized trial, looking at women with epidural analgesia, found that women in the lateral position with delayed pushing were more likely to deliver with an intact perineum than those in lithotomy positions pushing at full dilatation18. Roberts et al8 in their review of randomized trials comparing delayed pushing (between 1 hour and 3 hours) to immediate or early pushing (within 1 hour of full dilation) found no differences in rates of perineal laceration or episiotomy between the groups. Immersion in water during labour has not been shown to reduce the rates of serious perineal tears or episiotomy.9 It has been suggested that Pelvic floor exercises to strengthen perineal muscles before and after birth helps protect against pelvic floor damage, dyspareunia, and urinary and anal incontinence.19,20 Leon-Larios et al.21 in their randomised control trial in 2017 found that women who underwent daily perineal massage and pelvic floor exercises from 32 weeks onward had significantly lower rates of episiotomy, severe perineal trauma and higher intact perineum, than those who did not; suggesting that this intervention was effective in reducing perineal trauma.

The Epi- No® birth trainer is a vaginal dilator consisting of an inflatable silicone balloon connected to a hand pump. It is designed to dilate the vagina hence enabling the vagina and perineum to adapt to the penetrating foetus. Women are able to train their pelvic floor muscles and mimic the sensation of pushing process labour. The antepartum use of the Epi- No birth trainer has been shown to increase the likelihood of having an intact perineum and reduce the rates of episiotomies11. Recent studies however reported that it had no influence on reducing perianal tears22, or intrapartum levator ani damage, or anal sphincter and perineal trauma.23

It is clear that training in identification and management of perineal injuries is necessary to prevent morbidity. Appropriate management requires that health care workers are able to accurately identify these injuries and have the necessary skills to manage them effectively thereby preventing negative outcomes. This is an area which has been demonstrated to be poorly understood by health care workers. Fernando et al24 examined the knowledge and opinions of obstetric consultants, obstetric trainees and colorectal surgeons regarding sphincter injuries. They found that 33% of consultants and 22% of trainees incorrectly classified the degree of injury. This is significant as the degree of injury determines the technique of repair. They also found a significant variation in the preferred technique for repair, with 64% of participants feeling that their training in management of obstetric anal sphincter injuries was unsatisfactory. In a study carried out in Australia only 77% of doctors and 13% of midwives reported that they were confident in diagnosing anal sphincter injuries despite all the doctors and 71% of the midwives reporting having been trained to make the diagnosis. Furthermore, despite all the doctors having been trained in perineal repair only 88% felt confident performing the procedure. Training does not always translate into confidence25.In a Palestinian study by Zimmo et al26 the knowledge of healthcare workers before and after expert training was examined. Prior to training it was found that only 11,4% of physicians and 9,8% of midwives had accurate knowledge of perineal anatomy. The study demonstrated significant improvement in knowledge after expert training, thus emphasising the value of quality training. The majority of these studies were performed in developed countries; it would be good to know what the perception of health care workers regarding their management of perineal trauma in our setting is.

Hence in answering the question are perineal lacerations and the subsequent morbidity associated with these injuries preventable?”; the evidence suggests that at the time of delivery, warm compresses and perineal massage, may reduce third- and fourth-degree tears, while the hands-off/ poised technique may reduce episiotomy; but the impact of these techniques on other perineal trauma is unclear or inconsistent. There is insufficient evidence to suggest whether other perineal techniques described result in improved outcomes with regard to perineal trauma. It is also clear that training in identification and management of perineal injuries is necessary to prevent /reduce the associated morbidity. Further research should be performed evaluating how the various techniques utilised to protect the perineum impact women and their babies; while at the same time exploring the women’s acceptance and perceptions of these various techniques. Much of the evidence emanates from high income settings; hence there is a need for future research to involve low to middle income settings like ours.


1. Handa VL, Blomquist JL, McDermott KC, Friedman S and Munoz A. Pelvic floor disorders after vaginal birth. Effect of episiotomy, perineal laceration and operative birth. Obstet Gynecol 2012; 119: 233–239.

2. Gyhagen M, Bullarbo M, Nielson TF and Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primipare after vaginal or caesarean delivery. BJOG 2013; 120: 152–160.

3. Naidoo TD, Moodley J. Obstetric perineal injury: risk factors and prevalence in a resource-constrained setting Tropical Doctor 2015, Vol. 45(4) 252–254

4. Vale de Castro Monteiro M, Pereira GM, Aguiar RA, Azevedo RL, Correia-Junior MD, Reis ZS. Risk factors for severe obstetric perineal lacerations. Int Urogynecol J 2016; 27:61–7.

5. Gupta N, Rajaram S and Mehta S. Obstetric anal sphincter injury: a clinical audit. BJOG 2012; 119: 1152.

6. Ampt AJ, Ford JB, Roberts CL and Morris JM. Trends in obstetric anal sphincter injuries and associated risk factors for vaginal singleton term births in New South Wales 2001–2009. Aust NZ J Obstet Gynaecol 2013; 53: 9–16.

7. Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017 Jun 13;6:CD006672. doi: 10.1002/14651858.CD006672.

8. Roberts CL, Torvaldsen S, Cameron CA, Olive E. Delayed versus early pushing in women with epidural analgesia: a systematic review and meta-analysis. BJOG 2004;111: 1333–40.

9. Cluett, E.R., Burns, E., 2012. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews. 2018, Issue 5. Art. No.: CD000111.DOI: 10.1002/14651858.CD000111.

10. Du, Y., Xu, L., Ding, L., Wang, Y., Wang, Z., 2015. The effect of antenatal pelvic floor muscle training on labor and delivery outcomes: a systematic review with metaanalysis. International Urogynecology Journal 6, 1415–1427., (Epub 2015 Feb 25).

11. Ruckhaberle, E., Jundt, K., Bauerle, M., et al., 2009. Prospective randomised multicentre trial with the birth trainer EPI-NO for the prevention of perineal trauma. Australian and New Zealand Journal of Obstetrics and Gynaecology 49, 478–483. http:// x.

12. Bulchandani S, Watts E, Sucharitha A, Yates D, Ismail KM. Manual perineal support at the time of childbirth: a systematic review and meta-analysis. BJOG 2015; 122:1157– 1165.

13. Johanson R. Perineal massage for prevention of perineal trauma in childbirth. Lancet 2000;355(9200):250–1

14. Geranmayeh M, Habibabadi RZ, Fallahkish B, Farahani MA, Khakbazan Z, Mehran A. Reducing perineal trauma through perineal massage with vaseline in second stage of labor. Arch Gynecol Obstet 2012;285(1):77–81.

15. Karaçam Z, Ekmen H, Calişir H. The use of perineal massage in the second stage of labor and follow-up of postpartum perineal outcomes. Health Care Women Int .2012;33(8):697–718.

16. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.

17. Kemp E, Kingswood CJ, Kibuka M, Thornton JG. Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD008070. DOI:10.1002/14651858.CD008070.

18. Walker C, Rodriguez T, Herranz A, Espinosa JA, Sanchez E, Espuna-Pons M. Alternative model of birth to reduce the risk of assisted vaginal delivery and perineal trauma. Int Urogynecol J 2012; 23:1249–56.

19. Hay-Smith J.C. Therapeutic ultrasound for postpartum perineal pain and dyspareunia (Cochrane Review). In: The Cochrane Library 2000. Update Software,Oxford, (CD000495).

20. Carroli, G., Mignini, L. Episiotomy for Vaginal Birth Cochrane Database Syst Rev 2009. 21 (1), CD000081.

21. Leon-Larios F., Corrales-Gutierrez I., Casado-Mejía R., Suarez-Serrano C. Influence of a pelvic floor training programme to prevent perineal trauma:A quasi-randomised controlled trial. Midwifery 50 (2017) 72–77

22. Oliveira Brito, L.G., Ferreira, C.H., Duarte, G., Nogueira, A.A., Marcolin, A.C. Antepartum use of Epi-No birth trainer for preventing perineal trauma: systematic review. International Urogynecology Journal .2015. 26, 1429–1436.

23. Kamisan Atan, I., Shek, K.L., Langer, S., et al. Does the Epi-No(®) birth trainer prevent vaginal birth-related pelvic floor trauma? A multicentre prospective
randomised controlled trial. BJOG. 2016. 123, 995–1003.

24. Fernando RJ, Sultan AH, Radley S, Jones PW, Johanson RB. Management of obstetric anal sphincter injury: a systematic review & national practice survey. BMC Health Services Research. 2002 May 13;2(1):9.

25. East CE, Lau R, Biro MA. Midwives׳ and doctors׳ perceptions of their preparation for and practice in managing the perineum in the second stage of labour: A cross-sectional survey. Midwifery. 2015;31(1):122-31.

26. Zimmo K, Laine K, Vikanes Å, Fosse E, Zimmo M, Ali H, Thakar R, Sultan AH, Hassan S. Diagnosis and repair of perineal injuries: knowledge before and after expert training—a multicentre observational study among Palestinian physicians and midwives. BMJ open. 2017 1;7(4): e014183.

The Refractory overactive bladder - Mzwethu Khumalo

Overactive bladder syndrome (OAB} has been defined by the ICS as a bladder storage problem consisting of urgency with or without urge incontinence, usually with frequency and nocturia. It is worth emphasising that this is not a disease but a syndrome, hence confounding pathology such as Urinary Tract Infection, Interstitial cystitis, metabolic disorders (eg. Diabetes, nephrotic syndrome), and intravesical organic pathology (eg. Bladder calculi) must be excluded. Refractory overactive bladder (ROAB) is a distressing condition for both the physician and the patient. Although there is no agreed definition of what constitutes ROAB, it is widely accepted that failure of first and second line treatment over a period of 8-12 weeks labels these patients. First and second line treatment includes:
  • Lifestyle modification (eg restriction of bladder irritants such as caffeine, limiting fluid intake to about 25ml/kg/day, cessation of smoking, loss of weight and dietary modifications.
  • Bladder drill/Retraining
  • Pelvic Floor Exercises
  • Drug therapy that includes anticholinergics and Beta sympathomimetics such as Mirabegron.
All the above interventions are undertaken to improve the Quality of life (QOL) for the OAB sufferer. Affectation of QOL can include psychological, social, occupational, physical and sexual impairment. Some patients will present with frequency and urgency, whilst others will present with urge incontinence and nocturia, affecting their QOL significantly. What is perceived as success in treatment may differ from one patient to another, and from a patient to a treating physician. The lack of standardisation as to the definition of success further confounds this topic. Failure of pharmacotherapy is difficult to define and encompasses factors such as lack of efficacy, adverse effects, contraindications and patient perception and expectation of treatment. However, most researchers and studies suggest a 50% reduction in symptoms as a desired outcome. Therefore, when first and second line is judged to have failed, then the starting point is reassessment of bladder diary and exclusion of confounding factors stated above. The treatment failure point in most studies suggest 12 weeks for first and second line treatment exposure.

Our topic therefore relates to an ideal patient, who has tried it all and has no significant improvement, or the initial improvement has worn off. At this juncture, one has to decide on what further treatment options do we offer and what guides our choice from the available options. In an ideal world, the answers would be scientifically evaluated. Unfortunately there is a paucity of data, a lack of Level 1 evidence, small study populations on the available data, costly treatment options and a lack of standardisation to treatment outcomes. However, since the early 90’s, the available literature suggests two treatment modalities as options, namely Intradetrusor botox bladder injections and neuromodulation.

Both therapeutic mechanisms of action have been presented by Prof Zeelha Abdool in the past SAUGA newsletter. It is worth noting that a new leadless titanium device in the neuromodulation group has been developed. This device is called eCoin and is the first implantable posterior tibial nerve stimulator. It is 23mm in diameter and 2.2mm thick. More studies are needed to evaluate its efficacy, durability and cost effectiveness against traditional options.

How do we choose between Botox and Neuromodulation?

Komesu et al (AJOG2018), did a double blind randomised controlled trial looking at the effect of age on ROAB. The age cut off was either 65years. The findings of this study found no difference in efficacy of either sacroneuromodulation (SNM) or Botox on either side of age cut off. There was a statistical reduction in urgency urinary incontinence scores in the younger group, irrespective of whether they received Botox or SNM. A higher incidence of UTI/Recurrent UTI occurred in the older group. Post void residuals were greater in the older group following Intradetrusal Injections. This study demonstrated that age is an independent risk factor and patients need to be counselled accordingly.

In another study by Amundsen et al (European Urology2018), Botox 200iu was compared to SNM and efficacy was compared at 24months. There was no statistical difference between both arms using symptom specific QOL questionnaires at the end of the study. A higher resolution of UUIE at 6 months was documented with higher Botox doses compared to the traditional 100iu dose. Reinjection interval was also greater with the higher dose.

Autiero et al, showed that SNM was more cost effective when compared to optimal medical therapy, PTNS or Botox injections. At the time of acquisition and treatment commencement, SNM was more expensive. However, beyond five years, the cost of the SNM becomes more favourable and this was attributed to the need for ongoing costs with the other interventions such as follow-ups, need for reinjections at 9 months and use of continuous medical therapy. The same study suggested that other factors besides cost-effectiveness may influences decision and choice. A cognitively impaired patient may not do well in self-assessment of symptoms and device adjustments. Having the device may preclude the patient needing to be investigated with MRI for other illnesses.

A recently published systematic review by Niu et al (Int j of surgery 2018) comparing Botox to SNM. Four aspects were evaluated:
  1. Change from baseline in UUIE per day,
  2. UUIE reduction post treatment,
  3. safety of Botox vs SNM for UUI,
  4. treatment satisfaction of Botox vs SNM for UUI.
Botox fared well at 6months for the first objective. However, there was no statistical significant difference at 1 or 2 years. With post treatment initiation, Botox was superior to SNS. Its effectiveness in reducing UUIE was more than two-fold of SNM, however by two years Botox had equated to SNM because of its decreasing efficacy. This was consistent with higher reinjection rates reported after 9 months of first injection. Immediate treatment satisfaction was higher with Botox within the first 6 months. In the long run, there was no statistically significant difference. Side effect profiles are different and lower with strict protocols of either injection or implant placement. Dysuria and UTI is common with Botox.

In conclusion there is no one option that has all the advantages or benefit. The heterogeneity of studies, lack of head to head data and inequality in resource distribution compounds the problem. It seems that choice depends on counselling, age, cognitive functioning and the resources available. The eCoin looks promising and one awaits future research with this device.

References on request