SAUGA NEWSLETTER 2nd Quarter 2018
Welcome
   
Message from the President:

I write this message along Europe’s second longest river, the Danube, after a very successful IUGA 2018 meeting in Vienna. Attended by a total of 1560 delegates, topics primarily focused on controversies in pelvic organ prolapse, both urinary and fecal incontinence and maternal birth trauma. The state of the Art lecture on Big data was indeed mind-blowing. For those who could not attend, select lectures will be available to members on the IUGA website shortly. Keep checking.

Locally, 2018 is indeed a turning point in the history of SAUGA as the first Urogynaecology subspecialty examination will take place during July and October. All the best to the candidates! Thank you to the UCT team for the three informative articles that follow.

‘A day without laughter is a day wasted’….…Charlie Chaplin

Prof Zeelha Abdool
SAUGA President

   

Kim Jong III

Message from the Editor:

As mentioned by our President, the 2018 IUGA Meeting in Vienna was a great success – and I hope to join as many of you as possible in Nashville, Tennessee, next year.

You will recall that this part of the world is famous for blue grass music, Jum Bream No 7, and Tabasco Sauce. Three good reasons to visit Nashville – and of course, the IUGA meeting.

Talking of meetings, make a note of two upcoming meetings with a urogynaecology slant – the Cape Town O&G Update in December www.ctog2018.co.za  and the Pretoria Update next year!!
See you there!

Warmest regards from an icy Cape Town

The Editor
Peter de Jong

Not all urgency is OAB - Lisa Kaestner and Alison Moore: Division of Urology, UCT

Overactive bladder (OAB) is a symptom complex defined as “urgency, with or without urge incontinence, usually with frequency and nocturia”, in the absence of a urinary tract infection or any other pathology.

A careful history, physical examination and urinalysis are the minimum required in the initial assessment. A bladder diary is often very useful. In patients without the typical symptom complex or with findings during the initial assessment suggesting an alternative diagnosis, further investigation is necessary.

Medical disorders

Polyuria may present with urinary urgency, frequency and nocturia. Associated medical disorders include: diabetes mellitus, diabetes insipidus, renal failure and hypercalcemia. Diuretics (especially bi-daily doses) may cause bothersome urinary frequency and urgency. Often the second diuretic dose is taken in the evening instead of the afternoon, causing nocturia. Glucosuria on urine dipstick may be helpful in diabetic patients, however HbA1c gives a much more accurate assessment of glucose control. Nocturia may be bothersome in many patients with renal dysfunction and diabetes as the ability to concentrate urine at night is impaired leading to a constant rate of urine production over a 24-hour period. Peripheral oedema associated with cardiac failure should be considered. The mobilisation of this fluid when the patient is supine may cause nocturnal polyuria.

Bladder calculi

Bladder calculi may cause urinary frequency and urgency, interruption of urinary stream and haematuria after activity. Recurrent urinary tract infections are often present. Bladder calculi usually form on foreign bodies or due to chronic bladder outlet obstruction. Urine dipstick often reveals leucocytes and blood. Many may be visible on plain abdominal X-ray, however cystoscopy confirms the diagnosis.

Distal Ureteric calculi

Distal ureteric calculi may present acutely after a pre-existing history of flank pain with urinary frequency, urgency and inguinal or labial pain. If the stone becomes lodged at the vesico-ureteric junction persistent irritative lower urinary tract symptoms may occur. If the ureter is unobstructed, pain may be absent or intermittent. Urinary dipstick may show leucocytes and blood. Most calculi are visible on X-Ray. Uncontrasted abdominal Computed Tomography scan confirms this diagnosis.

Urothelial Carcinoma of the Bladder

Patients with urothelial cancer may present with irritative lower urinary tract symptoms, however most newly diagnosed bladder tumours present as painless, macroscopic haematuria in patients with a smoking history. Papillary tumours seen on cystoscopy, confirms the diagnosis.

Urothelial carcinoma in situ

Patients with CIS may present with irritative voiding symptoms as their primary presenting complaint. They usually have a history of smoking. Macroscopic haematuria is seldom reported. Urine dipstick may reveal leucocytes and blood. It is a flat, high-grade tumour. On cystoscopy it may appear as a velvety, red mucosal lesion, or may occur in completely normal mucosa.

Radiation Cystitis

Irritative lower urinary tract symptoms are common after pelvic radiation therapy and are usually seen 6-12 months after radiation exposure.

Acute radiation cystitis occurs during or soon after radiation treatment, and is usually self-limiting. Late radiation cystitis can develop from 6 months to 20 years after radiation therapy and can be difficult to treat.

Haematuria is the most common presenting symptom, but patients can present with pain, urinary frequency and urgency, as well as incontinence. Features on cystoscopy include erythema, oedema, telangiectasia, bleeding ulcers, fistulas or fibrosis with reduced bladder capacity. If a bladder biopsy is performed, it must be done with care as there is to a higher potential risk for perforation/fistula formation.

Tuberculosis of the Bladder

Half of patients with urogenital TB will present with dysuria, and up to half will have storage symptoms. Chronic inflammation and mucosal scarring eventually result in fibrosis and bladder contracture. Late urogenital TB results in a tiny contracted bladder and renal dysfunction due to ureteric strictures or infundibular stenosis.

Urine microscopy will, in most patients, show sterile pyuria, with or without haematuria. Three early-morning urine samples should be sent for microscopy and culture for tuberculosis mycobacterium.

Cystoscopy findings may include: mucosal erosion, ulceration, granulomatous masses, gaping of the ureteral orifices and a small capacity.

This diagnosis can be missed as patients may not present with typical weight loss and night sweats. They are often treated for urinary tract infections due to leucocytes on dipstick, however cultures are persistently negative.

Schistosomiasis of the Bladder

Chronic infection with Schistosoma haematobium leads to chronic inflammation due to ova deposition in the bladder wall. This may lead to severe fibrosis, which results in a contracted bladder with a reduced functional capacity. Chronic suprapubic and pelvic pain with associated urinary urgency, frequency, and incontinence are common in schistosomal contracted bladder.

On urine dipstick, leucocytes or blood may be evident. Urine microscopy may reveal the presence of ova. On cystoscopy characteristic sandy patches may confirm chronic infection. Calcified, submucosal ova have a granular, yellow, glistening appearance and resemble grains of sand.

Urethral causes

Urethral diverticulae may present with urinary urgency and frequency but often have associated dysuria, post micturition dribbling, dyspareunia and discharge. They may also report a vaginal mass or recurrent urinary tract infections. Diagnosis may be obvious on examination if fluid can be expressed from an anterior vaginal cystic mass. Micturating cysto-urethrogram, MRI or trans-labial ultrasound may confirm the diagnosis.

Neurology

Subtle neurology may go unnoticed. Patients may have neurological fallout which only affects gait mildly or not at all.

14% of Multiple Sclerosis patients will present with urinary complaints and up to half will have urge urinary incontinence.

Patients with spina bifida often have a nevus or tuft of hair visible over the spine or may have asymmetry of the gluteal cleft. Most of these patients can be identified by careful examination and history. They may also have changing neurology during their adolescent growth spurt due to a tethered cord.

Patients with back pain, bladder and bowel dysfunction should be carefully examined for neurology. MRI is useful to exclude spinal compression or other spinal abnormalities.

Cognitive dysfunction

Patients with cognitive deterioration may lose the appreciation for or need for continence. These symptoms may be interpreted by carers as an inability to hold urine or as urgency. Neuropsychiatric assessment may help to identify these patients.

Mobility

In patients with impaired mobility, the perception of urgency may be altered. Improving access to toilet facilities and offering of 24-hour care-giver assistance may be of benefit.

Summary

In patients with a typical symptom complex, careful history, examination and urinalysis will exclude most alternative diagnoses. In those without the typical symptom complex or other abnormal findings, appropriate investigation is essential before accepting a diagnosis of overactive bladder.

*References on request
  
Urethra bulking agents (UBA) as a minimally invasive option for the treatment of stress urinary incontinence (SUI) - Kendall Brouard: Gynaecologist, Urogynecology Unit, GSH / UCT

The majority of surgical procedures used for SUI address the issue of urethral support. In contrast, urethral bulking addresses urethral function, specifically mucosal co-aptation. Most patients presenting with SUI probably have a deficiency in urethral support and function to varying extents.

The excellent success and safely of tension free vaginal tapes have been proven in the literature. On the other hand, UBAs have traditionally not been an attractive option for the management of SUI due to their lower success rates, the need for regular repeat treatment and the consequent cost. The advantages of UBAs are, however, that the technique is relatively simple and easy to learn. In addition, they can be injected under local anaesthesia, making it a potential minimally invasive option. Recent studies have now shown very promising outcomes using newer (nonbiodegradable) agents for urethral bulking.

In a study done by Robinson et al examining expectations around different treatment options, 60% of women expressed a preference for minor procedures with a low risk of complications and are prepared to accept a lower success rate. Bearing this in mind, together with the fact that many women are requesting non-mesh surgical procedures for the treatment of stress incontinence following the negative reports regarding vaginal mesh products in the media recently, perhaps we should start re-thinking the role of UBA in the treatment of patients with SUI.

The non-absorbable UBAs that are available in the South African market are Macroplastique ®, Bulkamid ® and Urolastic ®.

Macroplastique ® has been used since 1991. It consists of silicone polymers (polydimethylsiloxane PDMS) immersed in a polyvinylpyrolidone gel. These particles are large, thereby decreasing the likelihood of particle migration. There are over 50 publications reporting on its efficacy and safety. In 2015 a systematic review and meta-analysis of Macroplastique® for treating female stress urinary incontinence reported cure rates of 36% and improvement rates of 64% at 18 months. There was a 7% adverse event (AE) rate with no extrusion, migration, immune reaction, embolic phenomena, vascular occlusion or other serious AEs.

Bulkamid® has been used as a bulking agent for SUI for more than 10 years. It is a non-particulate homogenous hydrogel consisting of 2.5% cross-linked polyacrylamide with 97.5% non-pyrogenic water. The product has tissue-like viscosity and elasticity once injected. It is biocompatible with no chronic host inflammatory response. As a result, the bulking effect is due only to the volume of hydrogel injected, making the size of each bleb predictable, controllable and precise. The gel allows for cellular integration and is therefore resistant to degradation and migration, increasing durability.

Numerous studies have been published in the past 5 years looking at the safety and efficacy of Bulkamid® for the treatment of SUI or stress predominant MUI. The longest follow up period was 7 years. These studies all report success rates of >80% for women having a primary or repeat procedure. Bulkamid® has demonstrated a strong safety profile and has a low risk of procedure related AEs. There have been no reports of tissue scarring, foreign body reactions or gel migration. The most common AEs are that of acute urinary retention and urinary tract infections, with a rate of up to 5,7% and 3,6% respectively.

Urolastic® has been used for the treatment of SUI since 2009. It consists of vinyl dimethyl terminated polydimethylsiloxane (PDMS) which polymerizes in situ within seconds to form a uniform elastomer. This large, non-biodegradable homogeneous mass becomes encapsulated by the body following the host immune response. Encapsulation allows for decreased risk of migration and increased durability. There is no in-growth of tissue into the product, which together with the encapsulation allows for the product to be removed if required.

Over the past 2 years, there have been 3 studies published looking at clinical effectiveness and complications in patients treated with Urolastic® for stress urinary incontinence. In 2 studies the patients were treated for recurrent SUI, whereas in the 3rd study half of the participants were receiving primary treatment. In this study, subjective improvement was reported to be 70% in the primary procedure group and 67.5% in the recurrent group (mean follow up at 12 and 24 months respectively). In all 3 studies, complications were observed in approximately 25% of patients. Complications included bladder outlet obstruction, pain and dyspareunia, migration of bulking material into the bladder or vagina and bulking material extruding through injection site. The majority of these complications required out-patient re-intervention.

The differences seem in the outcomes between Urolastic ®and Bulkamid® could possibly be due to the nature of the bulking agent and the technique of injection. Bulkamid® is injected transurethral, whereas Urolastic® is injected paraurethral. In a number of the recent Urolastic ® studies it was being used after other previous failed treatment for SUI. This is a challenging group of patients which could be at risk of failure and of higher complication rates irrespective of treatment used. Needless to say, these two products can only be directly compared in a robust randomised controlled trial.

Given what has been reported regarding the outcomes of UBAs and a potential move away from mesh-based products in the future, what is the role of UBAs in the management of SUI? There is evidence to support UBA use as primary and repeat treatment. The reported erosion and pain rates with Urolastic ® is concerning and requires further evaluation. Bulkamid® has demonstrated a very favourable safety profile.

*references on request

Rectocoeles – when is surgery indicated? - Dr Claire Warden, Colorectal surgeon, Groote Schuur Hospital/University of Cape Town

Patient A: “I went to my gynaecologist for a routine check-up.
My gynaecologist said I had a rectocoele.
My gynaecologist said I should undergo surgery to have it fixed.
I was perfectly well…now I have a rectovaginal fistula and a stoma.”

A patient with a symptomatic rectocoele may benefit from surgical repair. Deciding which symptoms warrant proceeding to surgery and the appropriate surgical approach may be difficult. Rectocoeles are often associated with other pelvic floor conditions and it may be challenging to determine whether the symptoms are directly attributable to the rectocoele.

A thorough history and clinical examination are vital to guide rectocoele management. This management should always incorporate conservative measures. When conservative management is unsuccessful and obstructive defecation is well documented, then surgery may be beneficial in a well-informed patient.

Most rectocoeles are small, asymptomatic and considered to be a normal finding on clinical examination. Larger rectocoeles may present with pelvic pain/pressure and defecatory dysfunction. The typical history is that of the need to “splint” the posterior wall of the vagina in order to evacuate the rectum completely. This key symptom is often indicative of the patients who derive the most functional benefit of surgical repair. A new onset “change in bowel habit” that is not attributable to the above described defecatory dysfunction may well require further investigation with colonoscopy. Anal manometry testing can also be useful in patients with suspected poor anal sphincter function. It is worthwhile to be able to warn patients with poor anal sphincter tone about their risk of faecal incontinence post repair. Rectocoele repair decreases the rectal reservoir capacity and may predispose to faecal incontinence in patients with poor sphincter function.

Once it is clear that surgery is indicated, the surgical options for repair include transvaginal, transanal, transperineal and abdominal approaches. The key to the choice of surgical approach is that the operator should be well trained and experienced in their operation of choice. A systematic review published in GUT in 2015 did, however, indicate the superiority of transperineal over transanal repair. Other pelvic floor pathology may often appropriately influence the surgical choice. Traditionally tissue repairs are mostly used but some have attempted mesh repairs. Mesh repairs are highly controversial with much published internationally (academic journals, news outlets and internet blogs) on the serious complications. The national institute for health and care excellence (NICE) in the United Kingdom published their guidelines in December 2017 which identify serious safety issues with the use of transvaginal mesh. The current recommendation by this body is that transvaginal mesh (both anterior and posterior repair) is only used in the context of clinical research.

It should not be forgotten that restoring the anatomy is not the primary goal of rectocoele repair but rather the relief of the patient’s symptoms. Patients always benefit from an experienced surgical team and thus we are fortunate at Groote Schuur Hospital as in other academic centres in the country to have an experienced, well-established urogynaecology team. They have the necessary expertise to make these complex decisions and there is easy access to cross referral of patients depending on the colorectal, urological or urogynaecological expertise required.

References
  1. Zimmerman et al. Transperineal rectocoel repair: A systematic review. GUT 2015; 64(Suppl 1): A1-A584.
  2. www.nice.org.uk/guidance/ipg599/chapter/1-Recommendations
    
Pictures of Vienna City Centre.
     
SAUGA NEWSLETTER 2nd Quarter 2018