eNews - April 2021

In this eNews
President's Note Editor's Note Our OAB problem Sacral agenesis and the bladder The female urethra

Message from the President:

Dear Colleagues

As we navigate the second year of the COVID-19 pandemic, many Urogynaecological units have resumed outpatient clinical services and elective theatre lists, while a substantial part of teaching, learning opportunities and assessments continues digitally at a rapid momentum. This will certainly transform basic medical education in the young generation apart from impacting on continued service delivery to our patients.

I would like to draw your attention to a recent document published by the British Society of Urogynaecology and the Royal College of Obstetricians and Gynaecologists entitled: Joint RCOG/BSUG Guidance on Management of Urogynaecological Conditions and Vaginal Pessary Use During the COVID-19 Pandemic. The report highlights keys areas that require prioritization as well as modifications in Urogynaecological clinical services.

Please note that details of the biennial SAUGA meeting hosted by the University of Pretoria Urogynaecology faculty will be communicated soon.

Yours Sincerely,
Prof Zeelha Abdool
Chairman: SAUGA

“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.” — CHARLES DARWIN

From the Desk of the Editor:

This issue makes very interesting and enjoyable reading.

We have a case report of a person with sacral agenesis, with ideas on management. This rare case gives insight into unusual challenge.

Frans van Wijk gives some ideas on the female urethra in a piece dedicated to the late Ed Mc Guire.

And finally, Paul Swart provides new information on the topic of OAB, and highlights some important facts we need to consider in managing these patients.

Keep warm this winter, and ensure your thermal underwear is at hand. Please keep vigilant and don’t neglect our defences against the pandemic.

Stay safe – regards from a cold and blustery Cape Town.

Peter de Jong and Shirish Sheth: world
famous prolapse surgeon. Picture taken in
1992 at Sun City

Kind regards,
Peter

Our OAB problem

Dr. Paul Swart

Overactive bladder syndrome is common and has a major impact on quality of life. The algorithms for evaluation and management are reasonably well established with not too much debate on the sequences of how it should be done. There are however still many patients with sub-optimal results of treatment.

Once clinical evaluation has been performed, ideally just about all women should be referred for pelvic floor rehabilitation with biofeedback. We know that if this is done properly, with good patient compliance, symptoms improve. Compliance is the issue and therefore frequently disappointing results. Weight loss for OAB patients fall in the same category, successful if compliance is good but unfortunately it is not so easy to lose weight. Bladder retraining is even less likely to make my patients happy.

We frequently have to revert to pharmacological management. The side-effects of the anti-cholinergics have been known for decades. These lead to poor compliance and thus patients that would rather live with their OAB than take the prescribed drugs. Unfortunately the anti-cholinergics increase the risk of dementia.. We fortunately now have mirabegron as an alternative or adjunct to the anti-cholinergics.

I foresee that management of OAB is going to become more expensive in future as non-pharmacological management such as intra-vesical Botox and neuromodulation, both sacral and posterior tibial nerve, may be used earlier in the course of the disease.

A recent review article by Dmochowski et al (Neurology and Urodynamics 2020; 1-10) leaves little doubt about the negative impact anti-cholinergics have on cognition. A meta-analysis of 6 studies, 3 case control series and 3 cohort studies that represent 645 865 patients in 5 different countries was performed. The RR for dementia was 1.46 (95% CI: 1.17–1.81)

Sacral agenesis and the bladder

Dr. Frances Paterson

I recently encountered a patient in my practice who gave me pause for thought.
She is a 19-year-old university student with caudal regression syndrome. She has consulted various gynaecologists and urologists for most of her life, initially presenting with continuous urinary incontinence, which resolved after the use of intermittent self catheterisation (ISC). On recurrence, she was treated with Botox, and the symptoms subsequently worsened. The use of physiotherapy improved symptoms markedly..
Her current symptoms included

  • Continuous urinary leakage – possibly stress urinary incontinence, or overflow incontinence
  • Occasional urge urinary incontinence without leakage
  • High daytime frequency, >10 times per day, small to average volumes with no sensation of incomplete emptying and no use of voiding manoeuvres
  • Nocturnal enuresis, leaks throughout night without waking.
We attempted a uroflow study, which the patient was unable to perform. Her urodynamics study showed a non-compliant bladder with high residuals, which leaks at low pressures - at 49 cm water which implies the presence of intrinsic sphincter dysfunction. To make some sense of this case, and to assist other clinicians who may be faced with the same dilemma, I have presented a brief summary on available evidence surrounding this issue. In treating such a patient, the priority is preservation of renal function, with improvement in continence, and quality of life as secondary aims.

Sacral agenesis, otherwise known as caudal regression, is an uncommon condition describing a partial or complete absence of two or more lower sacral vertebrae. It commonly occurs as a part of the group of birth abnormalities affecting the bowel, limbs, genito-urinary tract, and caudal spine known collectively as caudal regression syndrome.

There is little data on the management of urologic complications in patients with sacral agenesis and associated disorders. However, knowing the nature of the lesion, one can possibly extrapolate some useful management strategies from the literature on sacral spinal cord injuries. Any sacral defect affecting one or more vertebrae can result in a neurogenic bladder. We know that injuries to the spinal cord at the sacral level result in parasympathetic decentralisation of the bladder and denervation of the urethral sphincter. Complete lesions cause decreased bladder sensation and awareness of bladder filling, resulting in compliant, flaccid bladders with urethral sphincters that preserve some measure of constant tone and are often unable to completely relax. Interestingly, altered sympathetic pathways may also lead to decreased bladder compliance. With regards to SA, There is poor correlation between the nature and severity of the bladder dysfunction and the type of skeletal defect. Having said this, there are characteristic features which have been found to be associated with this disorder. These are voiding dysfunction (in part at least due to loss of facilitatory input from higher centres), persistent day/night incontinence and recurrent urinary tract infections. There is also evidence that the symptoms associated with this disorder may evolve over time as a consequence of expansion, traction, or pressure on the sacral root or a tethered cord.

Conservative management strategies:

Evidence of behavioural treatments such as timed voiding and habit retraining is hindered by lack of standardisation but are valuable as they are inexpensive and non-invasive strategies, which may perhaps be used in the short term.
Voiding manoeuvres such as the Credé and Valsalva are not recommended as first line management of voiding dysfunction, as they may result in high intravesical pressures, hernias, or haemorrhoids.

Clean intermittent self-catheterisation (CISC) alone or in combination with other methods of voiding, applied every four to six hours is the most common stratagem to manage voiding dysfunction. The most common complication associated with CISC is urinary tract infection (UTI), with studies recording prevalence as high as 10% and 50% for asymptomatic and symptomatic UTI.
Any attempt other than ISC becomes complicated. Indwelling catheters remain an option but are generally reserved for patients who are unable to self catheterise, given the increased risk of renal dysfunction, bladder stone and cancer, urethral strictures and erosions. Studies have also shown that in poorly compliant bladders, compliance was preserved better with the use of spontaneous voiding and CISC.
Botox or Dysport have been shown to be very effective in patients with neurogenic detrusor overactivity, where studies show that it is effective in increasing compliance and bladder capacity and intravesical pressure. We do not have evidence on the use of Botox cases of SA, but as we have seen from the history above, it appears to have worsened our patients symptoms. One may surmise that the Botox may have worsened the incontinence by effectively paralysing an already impaired detrusor.

Options which reinforce or co-apt the urethra such as bulking agents are problematic in that the urodynamic study shows that the patient’s bladder empties poorly. The variation in sacral anatomy may possibly render attempts to insert the electrodes for Sacral neuromodulation impracticable. There is however a possibility that percutaneous neuromodulation may work.
In such a young patient one would prefer to avoid measures such as bladder augmentation or urinary diversion. The optimal solution seems to be one which would allow the patient to close the urethra when necessary while allowing her to void as required. The artificial urinary sphincter has proven effective in patients with neurological lower urinary tract dysfunction.
Despite these complexities, further treatment is crucial to prevent further deterioration of the (probably) fibrotic bladder wall. There is much room for further research in this area, and it is to be hoped that more case reports and studies will shed light on this obscure subject.

Edward J McGuire and the female urethra

Dr. Frans van Wijk

Edward J McGuire passed away on the 16th of February 2021. He was a world-renowned scholar, scientist and surgeon. As well as a passionate teacher and compassionate doctor. Dr McGuire was a founder member of neuro-urology and female pelvic reconstruction, a branch of Urology.

I dedicate this to the female urethra, a structure that Dr McGuire respected immensely.

The female urethra is about 4cm long and passes through the perineal membrane and is embedded in the adventitia of the anterior vaginal wall. The urethral epithelium has longitudinal folds, glands throughout its length and a lamina propria that supports it.

The urethral sphincter consists of 2 parts. The smooth muscle is continuous with the detrusor muscle and has a combination of longitudinal, circular and oblique muscles. The external urethral sphincter has 2 parts. The inner concentric fibers around the urethra and a outer part attached to the muscles of the pelvic diaphragm.

Continence also relies on the integrity, attachments and forces of the pelvic supportive structures as described by the integral theory.

This gives us an insight into how complicated and delicate the female urethra is, and that we as surgeons need to be when doing procedures around the urethra. Two procedures in close proximity to the urethra need to be highlighted.

  1. Midurethral tape placement. Regardless of the controversy around mesh or the differences in products, midurethral tape is the most often performed procedure with high a level of success for primary stress urinary incontinence. Industry through standardization and training helped to cement its use for general urologists and gynaecologists. There is a constant search for better material but the midurethral placement without tension is proven. Due to the dissection around the urethra and the importance of urethral integrity, emphasis on meticulous technique and placement is paramount. Injury to the urethra or too much tension might lead to devastating consequences.
  2. Bladder outlet obstruction due to a tight sling presents a difficult diagnostic and therapeutic dilemma. If a sling incision needs to be done, injury to the urethra is always a major concern. A recent small study from Moscow looked at 2 techniques. The traditional sub urethral incision versus transection on both the arms lateral to the urethra. Subjective relief of symptoms were the same in the 2 groups but recurrence of SUI was 3 times more in the group where sub urethral excision was made. (Urology Video Journal 4 (2019) 100016)

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