SAUGA NEWSLETTER First Quarter 2018
Welcome

Message from the Editor:

This edition of the Newsletter contains three interesting papers from Stellenbosch University.

Thanks to Kobus van Rensburg for his paper on the effect of urinary incontinence on female sexual dysfunction.

Lonese Jacobs gives tips on how to set up a “one stop” physiotherapy service for women with urinary incontinence, which should serve as a model for those contemplating a similar service. I found the paper by Lonese Jacobs to be fascinating and a revelation of facts surrounding the human biome.

We carry 2.5kg of faecal e.coli in our colon (some have more) and this is of huge importance to colonic health. Incidentally, try to you-tube “faecal transplantation”. This gives practical tips on the subject.

However, you may wish to destroy your kitchen blender after liquification of somebody else’s faeces in the machine.

Warm regards from a dry and dusty Cape Town!

The Editor
Peter de Jong

Message from the President:

The first quarter of 2018 began with a profound Urogynaecological theme. In February 2018 many national academic units participated in the Bulkamid road show (organized by Meducat) and hosted by Mr Ash Monga, Urogynaecologist from Southampton University Hospital Trust. The background of the global mesh debacle sets the scene for further and more robust research studies on bulking agents. Watch this space!

Secondly, congratulations to the Dr Suran Ramphal and his team for hosting yet another successful SASOG congress. State of the art Urogynae lectures and workshops hosted by international experts drew many to the scene and stimulated interesting debate and discussion.

But most importantly, a Big Thank you to the Minister of Health who has finally promulgated Urogynaecology. I would like to acknowledge SAUGA’s efforts and tenacity in this regard. Finally, please renew your 2018 membership and for those of you travelling to Vienna for the upcoming IUGA 2018 meeting, be safe and enjoy!

"Perhaps by means of the past one can begin to comprehend the present - or learn which way to run from the future”- P.J.O’Rourke

Dr Zeelha Abdool
SAUGA President


Microbiomes in the Female Urogenital Tract - Farzana Cassim (Tygerberg Hospital Urology)

With the establishment of the NIH Common Fund Human Microbiome Project (HMP) in 2008, it has become increasingly evident that there is an entire world of bacteria and commensals living on every surface of the human body. The International Consultation on Incontinence Research Society (ICI-RS) defined the microbiome as the “symbiotic microbial colonisation of healthy organs” (1). This describes the bacterial milieu, or habitat that exists in and on every organ. These microbiota are largely commensals as opposed to pathogenic organisms. The volume of microbes outnumbers the number of cells in the body in a ratio of 10:1 (2). These organisms, however, are not always detected with routine culture methods. The individual microbiota are identified using 16S ribosomal RNA (rRNA) sequencing. The microbiome consists of (1):
  • Bacteria
  • Eukaryotes (all have a nucleus and membrane-bound organelles)
  • Viruses
  • Archaea
    • Prokaryotes (cells without bound organelles)
    • Energy-consuming
Traditional culture methods are now coming into question for several reasons. One of these reasons is that perhaps we direct culture media and techniques towards finding organisms that we expect, thereby missing some organisms that are actually present in the specimen. The discrepancy between the findings with RNA sequencing when compared to routine cultures forms the basis for the myriad of uncertainties that now exist regarding culture techniques (1,2).

The largest body of evidence exists for the gut microbiome. This has ultimately led to faecal transplantation as part of the therapeutic armamentarium against Clostridium difficile (2). Faecal transplantation is now being investigated for uses in other instances, such as patients with Crohn’s disease, as well as malnutrition.

With regard to the urogenital tract, the microbiome may play a role in various areas, and with various disease processes. True causality that is directly attributed to the microbiome has yet to be proven. Preliminary studies are bringing to light the fact that the pathogenensis of certain disease processes is not as well understood as we once thought. Age-related differences in the vaginal microbiome exist, with a distinct difference between pre- and post-menopausal women. Pregnancy also alters the vaginal and urinary microbiome.

There is the possibility that such a thing as the “healthy microbiome” exists (3). This implies that certain commensals are protective against certain disease processes, and the lack of these, or overgrowth of certain other organisms, may predispose one to a particular disease process. However, it has been suggested that the reason why certain microbiota are protective in some people, but not so in others, is that the functional core is the determinant factor (1). This means that the functional core in terms of the metagenomes of the organism plays more of a role than the organism itself. The functional core must be optimally functional in order for the organism to work in harmony with its environment (1,3).

The roles of the urinary and vaginal microbiomes is being investigated in disease processes such as recurrent urinary tract infections (rUTIs), overactive bladder syndrome (OAB), bacterial vaginosis (BV), and urgency urinary incontinence (UUI) (2,4,5). Small case control studies looking at patients with these pathologies have provisionally shown some differences in the urinary and/or vaginal microbiome of cases vs. controls. The clinical significance of this finding is yet to be confirmed.

The proposed mechanisms associating microbiota and lower urinary tract symptoms (LUTS) involve increased colonisation of, as well as increased apoptosis of urothelial cells (5). Accelerated apoptosis leaves the underlying mucosal layer exposed to irritants, thereby enhancing the inflammatory reaction. Gardnerella vaginalis is thought to activate latent E. coli, thereby kick-starting the inflammatory process (5).

Not only is the microbiome implicated in disease pathogenesis, but it is also implicated in response to treatment (6). A study found that patients with and without UUI differed in terms of baseline characteristics of the microbiome. Patients with UUI had a larger volume and a more diverse microbiome than controls. Patients were then stratified in terms of response to solifenacin treatment. Those with a less diverse microbiome, and those with fewer microbiota responded better to treatment. Response was gauged using the Patient Global Symptom Control (PGSC) questionnaire (6). Although numbers were small in this study, it has has opened the doorway to further research surrounding the implications of the human microbiome.

Treatment options for certain pathologies may now target the microbiome, as opposed to symptomatic treatment alone. In patients with LUTS and rUTIs it may be beneficial to have the treatment aim as the establishment of a healthier microbiome, as opposed to purely using anticholinergics and antibiotics alone. Antibiotics alter the microbiome of not only the target organ, but of the whole body. The overall health implications of this phenomenon are well known, for example in the development of Clostridium difficile. Emerging antibiotic resistance is also becoming a greater problem due to the widespread and unchecked use of antibiotics. If it is possible to enhance the effect of drug treatment by re-establishing the healthy microbiome, or better yet, if it is possible to avoid drug treatment altogether, then the management of disease as we know it is going to be vastly different. With the increasing incidence of super-bugs, the possibility of avoiding or at least minimising the use of antibiotics is a very attractive option, and one that will surely be studied in great detail. Proposed mechanisms of re-establishing a healthy microbiome include the use of pre- and probiotics (1,3,7).

The usage of widespread probiotics in the community has led to more research into the development of this area of adjunctive therapies. Probiotics have now been developed that appear to be active (in-vitro) against certain strains of entero-hemorrhagic and uropathogenic E.coli (8,9). Further research into the development of non-antibiotic therapies that can actively combat infections will revolutionise the management of infectious diseases.

The human microbiome has opened up an entire molecular world that requires much investigation. The clinical implications in terms of disease pathogenesis, as well as for patient management still need to be clearly defined.

References available upon request
  
Sexuality, Urinary Incontinence and Pelvic Organ Prolapse - JA van Rensburg Dept O+G, TBH, University of Stellenbosch

Sexuality, urinary incontinence (UI) and pelvic organ prolapse (POP) is still regarded as a taboo even in this new millennium. These taboos affect quality of life which involves physical and mental health, social well-being and perceptions of their own body image. This can all have an influence on current and formation of future relationships with others. (1)

The World Health Organization in 2002 has defined female sexual dysfunction as the inability to derive satisfaction from their sexual act. Basson et al. in 1998 described four major categories of sexual dysfunction, which includes desire, arousal, orgasm and pain. (2) The American Foundation of Urological Disease included personal distress in the definition of all categories of sexual dysfunction. The DSM V classification combined hypo-sexual desire and female arousal disorder as a single classification (Table 1). To make a diagnosis of female sexual dysfunction (FSD) it must cause personal distress.

Prevalence of FSD:

The National Health and Social Life survey in 1999 reported female sexual dysfunction between the age group of 18-54 as high 43%.(3) The Global Study of Sexual Attitudes and Behaviours with a population of 13882 women aged between 40 and 80 years, reported a lack of interest in sex as the most common female sexual disorders across the world at 48%. The difficulty in reaching orgasms was reported between 18% and 41%.

Aetiology of FSD:

The aetiology involves 4 major categories where the physiology of the urogenital system as well as the psychological make-up of depression and anxiety is important for this script. The other 2 major categories involve interpersonal influences as well as social-cultural factors. (Figure 1) (4)

Urinary incontinence prevalence increases with age and peaks in some studies in the age group of 50-60 years of age. (5) Asoglu et al reported mixed urinary incontinence will more likely have associated anxiety disorders when compared to stress urinary incontinence (SUI) alone and SUI patients reported worse sexual lives than those with urgency and mixed UI. (6) It is accepted that UI has adverse impacts on sexual function and can affect all domains of sexual function. It was reported that women with UI are less sexually active compared to continent women. The main reasons for female sexual dysfunction with UI are due to wetness, odour, and fear of leakage of urine during intercourse and embarrassment. Should depression develop because of UI, it can contribute to female sexual dysfunction. (7)

Coital Incontinence

Coital Incontinence is defined as the complaint of involuntary leakage of urine during coitus. (8) This is associated with penetration and orgasm. The prevalence of coital incontinence is under reported and increase with direct questioning. The prevalence of coital UI is between 24-34%. (9)

Coital incontinence is a pathological sign, caused by a urethral disorder, over-active detrusor or a combination of both, and requires treatment. (8)

Coital incontinence associated with penetration indicates SUI and coital incontinence associated with orgasm indicates over-active detrusor. However, one should be careful to blame sexual dysfunction on purely coital incontinence and a holistic approach is necessary to look for a history of problems associated with FSD prior to coital incontinence.

Type of Urinary incontinence and FSD

At present time, it appears that it does not matter what type of incontinence will contribute to the biggest impact on sexual dysfunction. (10, 11)

In some epidemiological studies, sexual activity will decrease with increase in age. (12) The early menopause compared to the post-menopausal patient shows a two-fold increase in FSD for post-menopausal women. In 1995 Weber et al. showed age was the most important predictor of FSD.

Pelvic organ Prolapse

The impact of POP combined with UI with FSD showed conflicting reports. Ozel et al in a retrospective study showed POP and UI contributes more to FSD than UI alone. Barber et al (2002) showed prolapse contributed more than UI, and Handa et al (2003) showed UI contributes more than prolapse. (13)

Relationships

Hayder in 2012 reported detrimental effects of UI on new relationships and variable effects on existing partnerships. (14) Multiple participants wish that their partner could accept and understand the UI more fully and that they could discuss and master the problems it creates together. It is particularly important to feel supported and receive reassurance that the partnership is not in danger because of UI.

Measurement of the impact of urinary incontinence on FSD

To define the role of UI on FSD is difficult. This is partially due to the complex aetiology and the taboo nature of UI and sexual function. Hanzal mentioned in 2005 at the SAUGA/IUGA exchange meeting that there is no reliable instrument to diagnose and measure FSD. (15)

However, quality of life (QOL) assessment tools have been developed. These QOL questionnaires can be generic or condition or disease specific. The generic questionnaire is insensitive to a specific condition where the disease specific questionnaire has the advantage of evaluating the impact of a specific condition such as lower urinary tract symptoms on the QOL. The disadvantage is, however, that it does not evaluate the other health dimensions. For a questionnaire to be representative it needs to be validated.

The Kings Health questionnaire is an example to measure QOL specifically related to UI. (16)

The Simple Sexual Function questionnaire is an example of the measurement of QOL specifically to sexual function.

The PISQ-12 questionnaire measures sexual function specifically related to UI.

At Tygerberg Hospital in 2007, we developed a validated questionnaire to assess sexual function and UI. (17) We looked at 90 patients of which 16.7% had SUI and 14% urgency UI. The biggest group (56%) had mixed UI. Forty-two percent were unsatisfied with their sexual function, where 31% avoided intercourse and 33% were not sexually active.

Thirty-seven percent felt that UI had a large effect on sexual function. Urgeny UI was the most bothersome versus the other types in our study. Thirty-two percent had coital incontinence and was most commonly present with penetration. Coital incontinence with penetration was more commonly associated with SUI with 32%, versus urgency UI with 7.8%. Coital incontinence with orgasm was more common with urgency UI (15.4%) versus SUI (6.6%).

Eighty-two percent reported that they were not embarrassed to complete the questionnaire. The most common recommended complaint was that the patient had to empty the bladder before intercourse.

Treatment

The question arises if treatment of UI will restore female sexual function. Common sense would argue that the answer should be yes. However, the data is actually limited.

In the literature, treatment of UI is mostly assessed objectively and sexual function in most studies is only reported as a secondary outcome.

Barber et al in 2005 reported that conservative therapy has minimal long term negative effects and can improve overall sex life. Bo et al in 2000 reported in a placebo controlled trial of 59 patients with SUI that coital incontinence decreased by 50% but could not come to any conclusions due to this small sample size. This means that the pelvic floor muscle training is a unique first line treatment option. (18)

For surgical treatment, there is no randomized control surgical versus non-surgical trial available to evaluate the effect of surgery on sexual function. There are no interventional studies that aim specifically at FSD and UI. Some studies have assessed sexual function and SUI surgery.

Jha et al in 2012 reported in a systematic review and meta-analysis that overall, FSD showed no change in 50% of patients, with 31% with the small odds of improvements and 13% with deterioration. (19) They concluded that overall there is three times more likely chance to improve sexual function after surgery for SUI.

Complications of SUI with dyspareunia can be problematic with treatment. Recent guidelines reported the incision or release of the tape could improve pain with the result of recurrence of incontinence in 15%-50% of patients. (20) Kuhn et al reported an improvement of all the domains except orgasm after complete removal of the sling with recurrence rate of incontinence of 15% after surgery. (21) Erosion of the tape is associated with dyspareunia and treatment should involve only excision of the erosion. (20)

Conclusion

It is important that we should continue to address the taboo nature of UI and FSD. The evaluation and treatment of the women with FSD should be seen in the multi-factorial context. Conservative treatment for UI and FSD include advice to empty the bladder before intercourse and physio therapy as the first line of therapy.

Patients who require SUI surgery should also be properly counselled prior to intervention and sexuality should specifically be addressed. They should be informed that the surgical treatment of SUI is not detrimental to sexual function and can improve coital incontinence.

References available upon request

Tygerberg Hospital: Physiotherapy service in the Urogynecology Unit - Lonese Jacobs (Lonese.jacobs@gmail.com)

Tygerberg hospital is the largest hospital in the Western Cape and the second largest hospital in the country. It is a teaching hospital working with the University of Stellenbosch’s Health Science Facility. Patients are referred from the Urogynecology clinic as part of a holistic approach. There are instances when the patient has been diagnosed at an outside primary or secondary facility and is referred directly to physiotherapy. This allows the physiotherapist to commence with conservative management. Should the symptoms persist, the urogynecologist can commence further investigation and treatment.

The process followed for a patient presenting with urinary incontinence at the clinic is as follows:

Urogynecological assessment


Physiotherapy


Re-evaluation


Urodynamics
(Where indicated)


Surgery / Medication
(Where indicated)

There is no waiting list for physiotherapy. Patients are immediately provided with physiotherapy services and the clinic functions as a one-stop clinic.

Due to the proximity of the physiotherapists to the clinic, it offers the opportunity to discuss concerning symptoms or evaluations directly with the referring urogynecologist, shortening the time interval between management. This one stop clinic concept is something to consider when setting up an out-patient Urogynecology clinic.

The physiotherapy section of the clinic has been set up to include 2 physiotherapists who are both available at the out-patient urogynaecology clinic one afternoon a week for 4 hours. These specific sessions are made possible by the Western Cape Health services and supported by the Physiotherapy faculty at Health sciences of the University of Stellenbosch.

Physiotherapy is offered in groups and individual sessions. Group sessions consist of 4 sessions. The first session is compulsory for all who have been referred for physiotherapy, and 3 follow up sessions. The first session comprises of basic anatomy, physiology, hygiene for the genital area and pelvic floor exercises. The 3 follow up sessions cover other relevant topics for female health discussed and weekly feedback regarding the progress. Should there be a change in symptoms or lack of progress, this can be addressed immediately to allow for better adherence. Individual sessions are offered to all who are referred for physiotherapy, however, those referred with pain conditions are only seen on an individual basis.

The types of conditions treated by the physiotherapists at this clinic include:
  • Urinary incontinence
  • Urinary urgency/ frequency/ overactive bladder syndrome
  • Vulvodynia
  • Pelvic organ prolapse
  • Painful bladder syndrome
  • Faecal incontinence
  • Dyspareunia
  • Pelvic pain
As part of the holistic management of a patient, we would often refer to other physiotherapists for general physiotherapy of other musculoskeletal conditions. Other referrals include the social worker as some of the women might be dealing with a relative suffering a drug addiction or find themselves in abusive relationships.

The predominant reason reported for poor adherence has been financial (lack of money to travel to the hospital) and work commitments/restriction (unable to get the time-off to attend physiotherapy with a difficult employer or the impact of no work no pay). In these situations, we work with the patient to find dates that would increase their adherence.

It was an honour to host a site visit for the World Confederation of Physiotherapists Congress held in Cape Town 2017. Feedback from the attendees (physiotherapists) from around the world expressed their wish to implement similar multi-disciplinary focused Urogynecological clinics in their respective countries.

Should you need a qualified physiotherapist as part of your team, you can contact the Women’s Health Physiotherapy group of the South African Society of Physiotherapists (womenshealth@saphysio.co.za) for a contact list.

Should you be a physiotherapist who would like to visit the clinic or require more information about what we do or topics discussed with the patients, feel free to contact me Lonese.jacobs@gmail.com.


Tygerberg Hospital

Mrs Lonese Jacobs MSc Physiotherapy (Stellenbosch University) BSc Physiotherapy (UCT)
Private Physiotherapy Practice Table View, Cape Town
Sessional Physiotherapist at Tygerberg Hospital, Cape Town
SAUGA NEWSLETTER First Quarter 2018