SAUGA NEWSLETTER DECEMBER 2017
Welcome

Message from the Editor:

As we approach the festive season, it is my pleasurable duty to wish everybody a cool yule from Cape Town. That’s for those that celebrate Yuletide. Otherwise, I wish you a happy festive season.

Cape Town is anything but cool - 40°C is now the usual norm, and we are approaching level 5 water restrictions! Fortunately the summer gives way to winter, but that’s an age away. This year has been difficult in many respects. We all know the “challenges” we face, and yet we must be grateful for the successes we enjoyed.

A great big thank you for those who have works so hard – the SAUGA committee has been indefatigable in their efforts to advance Urogynaegology in SA.

Many have enquired about the “grandfather / grandmother” clause for registration as a Urogynaecologist. Please logon to the HPCSA website and download form 21.2. Good Luck!!

I tried to “grandfather” and they advised the form 42: the “great grandfather” sub-speciality clause.

Wishing you all a wonderful 2018, and hope this new year brings peace, stability and prosperity!

The Editor
Peter de Jong

Message from the President:

At the recent ‘SASOG Vision 2030’ meeting, relevant subspecialties presented and proposed their 2030 vision. I would like to share that vision with you as you each play a significant role towards achieving goals in Urogynaecology.

Firstly, effort should be directed toward accreditation of academic units nationally while securing funding for fellowship training.

Secondly as SAUGA is affiliated to IUGA, accredited units will ultimately have the opportunity to apply as a ‘fellowship training site’ on the IUGA database.

Thirdly, SAUGA should develop an SOP for local fellow exchange/ observerships thus facilitating collaboration between the units. Extension of training into the private health sector and developments of a national database amongst other goals, are also key areas of potential discussion and growth. We would love to hear your thoughts!

I would like to take this opportunity to thank the members, SAUGA board, our editor ‘in Chief’, the web administrators (e2 solutions) and SASOG Council for your continuous support and drive.

To the newsletters contributors a huge thank you for making this quartely communication a reality.

Remember ‘People who are crazy enough to think they can change the world, are the ones who do’ – Steve Jobs

Dr Zeelha Abdool
SAUGA President


Spinal cord injury and the Bladder:

Spinal cord injury (SCI) commonly occurs as a result of trauma to the spine, but can also be the result of infection or ischaemia. It is estimated that up to 53 new individuals per million are affected by SCI per year in Western Countries, with more than 250 000 documented cases in the United States alone.

The sequalae of such a disability are numerous and manifold. Economically and psycho-socially, the individual and society as a whole carry the significant burden created by this disease.

One of the more pervasive complications faced by the affected individuals is dysfunction in the genitourinary and gastrointestinal function. The vital functions performed by these systems are often deeply affected by SCI’s, the fallout being dependant on the level and degree of injury.

Evidence has shown that proper management of genitourinary symptoms is linked to improved patient continence and the re-establishment of quality of life. It follows therefore that one of the most crucial steps following SCI is bladder and genitourinary management.

The form that this takes is dependent on patient factors such as: sex, socio-economic circumstances, hand dexterity, and health care provider access.

Immediately following SCI and lasting up to three months post event the patient will experience what is termed spinal shock. During this phase, a number of things occur:
  1. Dysfunction of autonomic input to the bladder
  2. Bladder atony with no sensation of filling
  3. Urinary retention caused by disruption of the axis below the pons, and inhibition of the micturition reflex.
During this phase, voiding dysfunction should be treated with clean intermittent self catheterisation or an indwelling catheter. Following this phase, bladder contraction may return in an involuntary and uncoordinated manner, resulting in reflex bladder function. Urodynamic studies should be performed after the initial spinal shock phase is complete.

Symptomatology subsequent to the spinal shock phase is dependant on the level of the spinal injury.

For the purposes of the bladder we can divide the lesion into supra-sacral and sacral lesions.

The table below details how each of the lesions will manifest.
 

Level of lesion

Sensation of bladder filling

Typical UDS findings

Associated symptoms and signs

Supra-sacral

  • May be present
  • Voluntary inhibition of micturition reflex absent
  • Detrusor instability
  • Detrusor sphincter dyssynergia (DSD)
  • High post void residuals
  • High voiding pressure
  • Urinary incontinence

Sacral

  • Absent
  • Acontractile bladder with functional but non contractile sphincter
  • Compliant bladders which do not contract
  • Competent non relaxing sphincters

The main complications of neurogenic bladder are urinary tract infections, renal stones, or impairment. These may occur as a result of the disease, or due to the use of urinary catheters.

There are countless medical and surgical approaches available for the management of bladder dysfunction secondary to SCI. A clinical team capable of the appropriate assessment and management of SCI is mandatory.

Dr Frances Paterson
Fellow in Urogynaecology, Steve Biko Academic Hospital

References upon request

  
Detrusor Underactivity

The inability to empty the bladder completely leads to a number of lower urinary tract symptoms (LUTS). This however can be caused by a number of different aetiologies. It can for instance be caused by bladder outflow obstruction such as one would see with urethral obstruction due to prolapse or with neurological conditions such as detrusor sphincter dyssynergia. The same symptom complex can however also be caused by poor bladder contractility that then cannot generate sufficient intravesical pressure to produce sufficient flow and empty the bladder.

The impaired bladder contraction then leads to a combination of voiding symptoms (reduced flow and a feeling of incomplete bladder emptying due to increased post void residual volume) and storage symptoms (frequency, urgency, nocturia and sometimes incontinence). This detrusor contractility problem is commonly referred to as detrusor underactivity (DUA).

The diagnosis can only be made with invasive urodynamic testing. The 2002 ICS definition states that it is a condition characterised by a “contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span”. Unfortunately other terms for the same condition are also used. These are terms like bladder areflexia, impaired detrusor contractility, UAB, hypotonic bladder and detrusor failure. This leads to uncertainty about a proper single definition.

Symptoms: The symptoms overlap with the symptoms of OAB and bladder outlet obstruction (BOO). In the voiding phase DUA might present with hesitancy, a weak stream, interrupted stream and straining and a feeling of incomplete emptying. The storage symptoms depend on whether the DUA is accompanied by over or undersensitivity. The diagnosis can thus only be made on urodynamic evaluation. Uroflow cannot distinguish between DUA and BOO. In older women it is estimated that the prevalence ranges between 12 – 45%.

Causes:
DUA becomes more common as women age. When there is no evidence of neuropathy, no BOO, be it functional or anatomical, low detrusor pressure and Qmax <10ml/s usually with post void residual (PVR) of 150ml the term of idiopathic DUA is used. DUA can also be caused by neurogenic factors, both afferent and efferent. These are diseases such as strokes, Parkinsons disease, diabetes and multiple sclerosis. There are also myogenic causes, mostly associated with ion storage/exchange pathology and this has been correlated with electron microscopy ultrastructural changes. BOO will initially lead to detrusor hypertrophy and eventually to detrusor decompensation and failure.

Diagnosis:
A detrusor contraction initiates both an increase in intravesical pressure and flow is initiated. Both these parameters will also be influenced by BOO. Two parameters are important for the diagnosis namely Qmax and PdetQmax. Pdet of lower than 10-15 cm water or PdetQmax of <30 cm water is suggestive of DUA.

The problem:
As the diagnosis can only be made with some certainty with UDS evaluation, the prevalence is unclear. It is thus crucial that patients with LUTS undergo UDS before any surgery for incontinence or prolapse is performed. If a patient has poor detrusor function she is likely to suffer prolonged urinary retention after prolapse surgery. Due to the poor detrusor function they frequently find it difficult to initiate voiding after surgery and would also have high PVR’s.

As the symptoms cannot clearly be differentiated from OAB, these patients will sometimes get prescriptions for anticholinergics. This will paralyse the detrusor even further and can increase the PVR. It is thus very important to always measure the PVR before initiating anticholinergics.

Also keep in mind the condition of detrusor hyperactivity with incomplete contractility (DHIC). These patients have detrusor contractions during filling but poor contractions during voiding.

Management:
Firstly try to avoid the situation by relieving obstructive flow, such as a too tight sling, before detrusor failure occurs. Once the condition is established, intermittent self-catheterization might improve the situation when chronic distension is prevented. There is no pharmacological cure and sacral nerve stimulation has been used successfully in these cases especially in DHIC.

Dr Paul Swart
References upon request

The value of Questionnaires in Urogynaecology:

While mortality and morbidity from pelvic floor dysfunction is rare, the impact on quality of life can often be significant and even life changing .We will agree that clinical care rendered should ultimately translate into improved symptoms and improved quality of life e.g. reduction in incontinence episodes and lack of the need to manually digitate. Evaluating objective outcomes which is often fact based (such as POP-Q stage or urodynamic parameters) ignore the impact of intervention on patients’ lives. Recently the use of patient-reported outcomes (PROs) in the form of specific questionnaires form an integral part is assessing the impact of treatment on various quality of life domains in women with pelvic floor dysfunction.

Currently there are numerous condition- specific, validated questionnaires in Urogynaecology which have been translated into various languages to encourage their use globally. Examples of these include:

Condition Type of assessment
Urinary incontinence King’s Health questionnaire Incontinence Impact QuestionnaireBristol Female Lower Urinary Tract Symptoms Questionnaire
Prolapse Prolapse Quality of lifeSheffield Prolapse Symptoms Questionnaire 
Fecal incontinence Wexner scoreFecal Incontinence Quality of life Scale 
Sexual function Female Sexual Function indexProlapse and Incontinence Sexual Function Questionnaire

Table 1: Examples of condition-specific questionnaires for assessing and measuring health-related quality of life in women. Reproduced from: Radley S, Quality of life measurement and electronic assessment in Urogynaecology, The Obstetrician & Gynaecologist, 2011.

The International Consultation on Incontinence Modular Questionnaire (ICIQ) (www.iciq.net) provides a variety of questionnaires to assess different pelvic floor issues such as ICIQ vaginal symptoms questionnaire (ICIQ-VS) and ICIQ female lower urinary tract symptoms (ICIQ-FLUTS) etc. and makes worthwhile reading into further understanding the development of questionnaires.

These questionnaires can be used in both everyday clinical practice and in clinical research. Although time constraints and lack of resources are frequently cited barriers a combined effort involving staff, patient and clinician and use of electronic platforms enable a more streamlined process. In conclusion PROs are an important tool in evaluating treatment outcomes and should form part of our clinical care. Neil W. Wagle (MD,MBA) elegantly summarizes this point by stating ‘ PROs are precisely the missing link in defining a good outcome. They capture quality of life issues that are the very reasons that most patients seek care: to address a bothersome symptom, limited function, or ailing mental health.’’

Dr Zeelha Abdool
References upon request


Picture Gallery
  

Thank you to Professor H Cronje for the stunning images

SAUGA NEWSLETTER December 2017