SAUGA NEWSLETTER June 2019
Welcome
   
Message from the President:

Dear Colleagues

Thank you to the University of Pretoria, Urogynaecology unit for three topical issues that significantly affect our patients. While more than 50% of parous women may be affected by pelvic organ prolapse, the best overall outcome (whether anatomic or symptomatic) including type of procedure has yet to be decided. This is indeed a difficult topic due to the many confounding issues as highlighted in Dr Paul Swart’s article. Similarly, managing women with genital fistulas and painful bladder syndrome requires one to be familiar with a principles of management.

On behalf of the organizing committee, we extend a warm welcome to all of you for the upcoming SAUGA Congress (8-10 Aug 2019) hosted by University of Witwatersrand, Urogynaecology department, at Charlotte Maxeke Johannesburg Academic Hospital. To register please visit www.sauga2019.co.za 

“Logic will get you from A to B. Imagination will take you everywhere - Albert Einstein

Yours Truly
Prof Zeelha Abdool
SAUGA President

Message from the Editor:

From the desk of the Editor: Peter de Jong

I hope you enjoy the papers assembled in this edition of the newsletter. I found them particularly informative.

Dr Retief mentions in the article on fistula “the majority of obstetric fistula are preventable.” He is absolutely correct. The day the status of women in developing countries is respected, is when women will enjoy better obstetric care – and the occurrence of fistula will decrease.

Too many countries – many in Africa – have no access to caesarean sections.

When every women who needs a c/s gets one, is when obstetric fistula will disappear.

   
The varieties of surgery that we believe in:


Evidence based medicine is designed to tell us what the best approach would or should be in a problem that needs to be solved. It works well in most instances but has its shortcomings, for example when indicating what might well be the best approach if we look at outcomes in thousands of patients but does not predict the outcome in an individual patient. Even if we know the best approach to a clinical problem the outcome in an individual might well be disappointing and you might l end up wishing you chose another approach.

When we do surgery the problem is compounded by the preferences and the skills of the surgeon. As the pelvis is a complex system where there is interplay between physiology and anatomy, the surgeon has to make decisions where there are a significant number of variables that have to be taken into consideration. A typical example might be stress urinary incontinence in a patient with poor detrusor function.

In an ideal world, we would look at the current literature and do the same surgery for the same patients but this does not happen. One can only look at varying practices in different geographical areas to see this. I was fascinated by a recent study from Denmark where the procedures performed for apical prolapse over time in academic Urogynaecology units were analysed. Units were classified according to the degree of specialization as high level, medium level or no urogynecology specialization and the different procedures performed noted. They then also looked at the difference in preferences of highly specialized units. The results confirms my early statement that we just are not sure what is best. (Husby Int Urogynecology J 2019)



From this it would seem that uterine preservation should be the way to go for apical prolapse but look at the variations in the surgery performed at the highly specialised units.



There is no pattern. Manchester-Fothergill procedures vary between >80% to 10% of cases in these specialized units.

Then comes another publication that looks at failure rates after different techniques used for apical prolapse repair, also from Denmark by the same authors. ( Husby, Int Urogynecology J, 2019)



Here it is clearly shown that sacrohysteropexy procedures have a much lower success rate, particularly in the anterior compartment and is inferior to when the uterus was removed at the time of repair.
These variations in prefered technique in the same country does not surprise me in the least. I have no doubt that we have the same situation in our country. The lesson? Probably not to be too critical of people that hold different opinions to yourself!

Dr Paul Swart
Consultant OB-GYN
Steve Biko Academic Hospital
  
The principles of fistula management:

A fistula is defined as an abnormal epithelialized tract between two viscera or between the lumen of a viscus and the surface of the body. Fistulae can be considered gynaecological if the vagina is involved. These fistulae can either be enterovaginal, most commonly communicating with the rectum, or urovaginal, where the vagina can communicate with the urethra, bladder or ureters.

Fistulae are caused by compromise of normal tissue. The commonest causes for obstetric fistulae are due to prolonged and neglected obstructed labour that results in ischaemia and necrosis of the vaginal walls. Other causes include malignancy, radiation, infection, surgery, especially gynaecological, and trauma.

It is estimated that over two million women worldwide are affected by genital fistulae. The vast majority of these women are in developing countries and have obstetric fistulae due to a lack of access to resources and intrapartum care. These women often suffer difficulty with hygiene if the fistula leads to incontinence, and this may contribute to social isolation, withdrawal from employment, sexual dysfunction and relationship difficulty which further disrupts their support structures. In developed countries the leading causes of gynaecological fistulae are surgery, radiation and malignancy.

Most gynaecological fistulae can be readily visualized on examination. In the case of complex or high lesions, contrast imaging or cystoscopy may provide further information.

There are some well-recognised principles of fistula repair. Small vesicovaginal fistulae due to surgery may respond to prolonged bladder drainage by Foley’s catheter. If surgery is indicated, the first attempt at repair has a higher success rate than repeat repairs and therefore careful attention to preparation and surgical technique is essential. Surgical principles include patient preparation, adequate dissection and repair with appropriate materials, and careful post-operative care.

Prior to surgery the patient’s nutritional status should be assessed and optimized. This is of particular importance in developing communities where indigent patients may be ostracized because of their condition and lose access to resources and may be severely malnourished as a result. Co-morbidities should be addressed. HIV positive patients should be started on anti-retroviral therapy and adequate viral suppression ensured. Pre-operative vaginal oestrogen can be given women with poorly oestrogenised tissues. Attention should be paid to perineal care to help with hygiene and excoriation of skin due to soiling.

The aetiology of the fistula should be also be considered and addressed in planning a repair. If there is any suspicion of malignancy in otherwise unexplained fistulae biopsy is mandatory, and full workup and management of the malignancy will take precedence. The cause of the fistula will also determine the timing of repair. Early repair after surgery or trauma is feasible, but if the recognition of the fistula is delayed, delay of repair to allow infection, inflammation and induration to resolve may be preferable. Where temporary insults such as infection and radiation are responsible for tissue compromise full healing should be allowed before surgery to decrease the risk of breakdown of a repair.

The use of bowel preparation should be considered in the case of rectovaginal fistulae. Consideration should also be given to diversion ileostomy prior to repair of rectovaginal or enterovaginal fistulae, especially in the case of repeat procedures or large defects.

The size and position of the fistula are the key factors in deciding the route of surgery. While urethral and low vesicovaginal and rectovaginal fistulae can be approached vaginally, higher lesions and ureteric fistulae may need an abdominal approach to allow adequate dissection and interposition of tissue. Ureteric fistulae may need advanced reconstructive procedures such as ureteric re-anastomosis or reimplantation with bladder hitching. In the case of high enterocutaneous fistula bowel resection and primary reanastomosis of healthy bowel is most likely to be successful.

Dissection should be planned and carried out with care. The fistula must be exposed and surrounding structures such as the ureters identified and dissected to avoid injury. The tissues surrounding the fistula must be mobilised widely to allow for tension-free repair. The epithelialized fistula tract is usually excised or trimmed back if large, and the repair carried out in layers without tension. The repair must be watertight and should be checked if feasible.

In the event of inadequate tissue surrounding the fistula to effect a repair, special techniques may be necessary to interpose additional tissue. In an abdominal approach a J-flap of omentum can be readily mobilized and interposed. During vaginal procedures vascular pedicled flaps such the Martius, Singapore and Gracilis flaps can be applied to provide adequate vascularized tissue.

Post-operative care includes prolonged bladder drainage in the case of vesico-vaginal fistula. Attention should be given to maintaining regular bowel movements, and the use of stool softeners and bulk laxatives can be considered. For this reason the use of opioids for analgesia should be avoided.

The majority of gynaecological fistulae are potentially preventable – both the high volumes of obstetric fistula occurring in the developing world, as well as iatrogenic fistulae in developed countries. Primary prevention should be encouraged in training medical professionals. Until this unfortunate condition can be eradicated, these women should be provided advanced care for repair to improve quality of life.

References on request
Dr Francois Retief
Fellow in Urogynaecology
University of Pretoria

A Clinicians approach to Bladder Pain Syndrome/Interstitial Cystitis:

Introduction:

Bladder Pain syndrome is a diagnosis based on the symptoms of pain in the pelvic area, bladder, as well as lower urinary tract symptoms (LUTS) such as frequency and urgency. There is growing evidence of an association between BPS and other pain syndromes, such as Fibromyalgia, Migraine, and Chronic Fatigue Syndrome.

The European Society for the Study of Bladder Pain Syndrome (ESSIC) define BPS as chronic pelvic pain (more than 6 months duration), or discomfort related to the urinary bladder together with at least one other LUTS such as urgency or frequency.

The terminology of Bladder Pain Syndrome or Interstitial Cystitis has been plagued by discrepancies and disagreement as to the exact nature of the disease. The current nomenclature of BPS has been broadly accepted, although the term Interstitial Cystitis has not been abolished due to its established status in the health systems’ coding structure, which affects re-imbursement. We therefore may refer to the entity as Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC), and the two are often used interchangeably.

The aetiology of BPS is still under investigation, and several theories such as urothelial dysfunction, immune cell activations, autoimmune mechanisms, inhibition of urothelial cell proliferation, infection, and neurobiological dysfunction have all been postulated. This discussion is beyond the scope of this article, but the interested reader may find more detail in the 6th ICI review chapter on PBS aetiology.
We acknowledge that BPS is a complex disorder, most likely involving an interplay between genetic, immunologic, and infectious factors, further research into which is necessary to gain a deeper understanding of the disorder.

Diagnosis:
The first step in the diagnosis and management of BPS is the exclusion of other confounding LUT disease, such as urinary tract infection, OAB, endometriosis, and Vulvo/vestibulodynia.
Assessment should include a thorough history, physical examination, and investigations.
A baseline of voiding function and pain should be established to determine symptom severity and to measure therapeutic effect.

Treatment:
First line treatment:
  • General relaxation/stress management
  • Analgesia
  • Patient education/support groups
  • Self-care/behavioral modification
Second line treatment:
Physical therapy Oral therapies
  • Analgesia
  • Amitriptyline
  • Hydroxyzine
  • Cimetidine
  • Pentosan polysulfate (PPS)*
  • Cyclosporine A+ Intravesical therapies
  • Dimethyl sufloxide (DMSO)
  • Heparin
  • Lignocaine
Third line treatments
  • Cystoscopy under anesthesia with hydrodistention
  • Pain management
  • Fulguration of Hunner’s lesions if found
Fourth line treatments
  • Intra-detrusor botulinum toxin A
  • Neuromodulation
Fifth line treatments
  • Cyclosporine A
Sixth line treatments
  • Diverson with or without cystectomy
  • Substitution cystoplasty
Above is a stepwise approach which may be used when faced with a patient with the clinical picture of BPS. The level of therapy should be subject to symptom severity, clinical acumen, and patient preference. Various treatments can be considered in parallel if deemed necessary. Regular therapeutic efficacy evaluation is mandatory, and meticulous documentation of treatment efficacy is advised.
Given the complex nature of the disease, and the possible numerous failed attempts at treatment, it is imperative that the clinician address the patient in a multi-disciplinary and bio/psycho/social manner, with scrupulous counselling and management of patient expectations.

Dr Frances Paterson
Consultant OB-GYN
Steve Biko Academic Hospital


SAUGA NEWSLETTER June 2019