SAUGA NEWSLETTER September 2018
Welcome
   
Message from the President:

In this edition of the newsletter, the University of Free State’s effort reminds us of the complex anatomical relationship of the pelvic floor. In addition, in the October IUJ, two studies by Prof Hans Peter Dietz’s team on pelvic floor function are worth a read. The team reported a high prevalence of pelvic organ prolapse and significant uterine retroversion in Nepalese women, which adds to the limited evidence on epidemiology of POP in developing countries. The study on impact of subsequent pregnancies on pelvic floor anatomy in women delivered by caesarean section revealed that pelvic floor muscle function and organ descent is not affected when comparing women who had one, two, three or more C/Ss. An interesting finding!

Real time 4D pelvic floor ultrasound (PFUS) is an excellent tool that enables the Urogynaecologist to study the dynamic nature of the pelvic floor, and so I encourage all members to pursue the IUGA online imaging course on 4D PFUS (supported by Prof HP Dietz and the pelvic floor special interest group).

Remember, SAUGA appreciates constructive feedback from our members, and so please communicate your thoughts on content and education to info@sauga.org.za

‘Life isn't about finding yourself. Life is about creating yourself’
George Bernard Shaw (1856-1950; Irish playwright, critic and polemicist)


Yours Truly
Prof Zeelha Abdool
SAUGA President

   
Message from the Editor:

The latest issue of the newsletter is one of the most exciting in years.

Dr Makamba’s review highlights aspects of OAB management, and explains newer options for the condition. Many years ago I used the manage women who underwent augmentation cystoplasty. Thankfully this operation has been superseded by better options.

Prof Cronje’s paper is, as usual, thought provoking and has a clear message – abandon the levator plication operation for good!

Prof Henn’s paper on “The female prostate” is thought provoking and intriguing. Yet its existence has been described in 400 BC. Its still requires a fair amount of research – but who would have thought of the existence of a female prostate?

In my next life, I want to come back as a man.

The Editor
Peter de Jong

   
It is the time of new beginnings in nature this time of year and something that is warmly welcomed by most, and especially by us in the central South African region after another cold winter.

It is our pleasure to bring you this edition of the SAUGA newsletter form the University of the Free State with contributions from the North and East of our country.

We have included a hopefully interesting variety of topics in this newsletter. The female prostate article reflects on recent developments in the field of Urogynaecology and will provide some food for thought and stimulating discussions. The female perineum is an often misunderstood structure and its function and management still creates a disproportionately large amount of controversy for such a small anatomical area. The third article is a review of surgical treatment for the overactive bladder. This is an aspect few of us will fortunately encounter in clinical practice, but nonetheless something that we should not be ignorant about.

I trust that you will enjoy reading through these contributions while spending a moment appreciating a new season and the blossoming of new life at this time.

Professor Etienne W Henn
Head: Urogynaecology

BE AWARE OF THE FEMALE PROSTATE! - Professor EW Henn, Head Urogynaecology, UFS

The “female prostate” has been receiving some interest of late, both as a topic at the recent IUGA meeting in Vienna and via the International Society for Sexual Medicine (ISSM).



The “female prostate” as a functional sexual gland has been researched due to its anatomic location and proximity to the plane dissected during the placement of mid-urethral slings (MUS) for stress urinary incontinence (SUI).

In 1672 the anatomist Renier de Graaf described and illustrated a set of glands and ducts surrounding the female urethra that he called the “female prostate”. Subsequently, in 1880, Alexander Skene redirected attention to this structure, particularly to two paraurethral ducts (Skene's ducts) therein, and emphasized their importance in infection of the female genitalia. The female homologue of the male prostate is of clinical significance not only as a focus for acute and chronic infection, but also as the origin of other pathologic entities, including adenocarcinoma, which shows, as does its male counterpart, elevated PSA levels. PSA in the female can of course also be elevated due to breast diseases. Contemporary research has characterized this tissue consisting of glandular and secretory components, similar to that of the male prostate in 3D- modelling, wax casts and histological analysis. Immunohistochemistry studies with prostate specific antigen (PSA), androgen receptors and prostate specific acid phosphatase in female ejaculate showed female ejaculate to be similar to that from the male prostate. This female structure is embryologically and physiologically similar to that found in the male. A meta-analysis of 2350 women after MUS placement revealed a discrepancy between orgasm and global sexual function. Most women after SUI treatment exhibited an overall improvement in sexual function, but very few experienced increased orgasm satisfaction. The overall improvement is most likely due to the improvement in urinary continence. The hypothesis was formed that MUS might cause injury to neural pathways of the peri-urethral anterior vaginal wall tissue which might affect orgasmic quality in some women. The concern raised in the current discourse is that a MUS transverses the periurethral tissue in close proximity to these glands, blood vessels and nerves, and that disruption of the glandular and nervous function might result in negative effects on female sexual function. A recent review of this hypothesis included 60 publications. It reports that the existence of a sexually sensitive homologous “female prostate” in the anterior vaginal wall has been proposed since 400 BC.



There is thus convincing evidence that prostatic tissue exists in the female, and that the term “female prostate” is both fully justified and preferable to the terminology Skene's glands and ducts. There is concern that deep dissection during MUS placement might disrupt the function of this structure, but the relationship between the female prostate, MUS placement and sexual function still requires a fair bit of research.
  
APPRECIATING THE FEMALE PERINEUM - Prof HS Cronjé Cura Pelvic Unit, Mediclinic Midstream, Centurion

The perineum covers a fairly large part of the pelvic floor (Fig. 1). It consists of two triangles – the urogenital triangle anterior and the anal triangle posterior. In the middle between these two triangles is the perineal body.



From a practical point of view it is the perineal body that is really important. It is an assembly point for different muscles and therefore, it has an important role to play (Fig. 2).

Superficially, the transverse perineal muscles and the bulbocavernosus muscles meet in the perineal body. These are small muscles. Deep to them is the main constituent of the perineal body, the external anal sphincter (Fig. 3). It consists of two parts: a superficial component around the anus itself and a deep part around the anal canal. In total, it is about 4 – 5 cm long and 1 – 2 cm thick. Superiorly, it joins with the puborectalis (the most medial part of the levator ani muscle). The deep part is also joined by two small muscles, the transversus perinei profundus, one on each side. Laterally to the deep part of the anal sphincter is the ischiorectal fossa.



The perineal body also contains two membranes: a superficial and a deep fascial layer. The deep layer, also known as the perineal membrane, covers the external anal sphincter. It is triangular in shape and about 4 cm in depth. Around its borders, it interacts with the inferior rami of the pubis and ischium, the rectum and the central tendinous point of the perineum. Higher up, above the perineal body and puborectalis, there is no fascial layer over the lower rectum. The blood supply to the perineal body is derived mainly from the pudendal artery and peri-rectal vessels. Its nerve supply comes from the pudendal nerve as well as the dorsal nerve of the clitoris.

The perineal body has important functions:
  • It is largely responsible for anal continence.
  • It assists in the process of defecation.
  • Since it forms part of the musculature around the lower third of the vagina, it assists in sexual function.
  • A well-formed and functional perineal body is situated virtually in the vaginal entrance. There it functions as a “stop” for the development of pelvic organ prolapse. It will discourage stage 1 and 2 prolapse from becoming stage 3 and 4.
  • Together with the puborectalis, it presses on the urethra to prevent or minimize stress urinary incontinence. These structures also support the bladder base to discourage the development of an overactive bladder.
A deficient or defective perineal body will result in these functions becoming compromised and may have a significantly detrimental effect on a women’s quality of life.

Treatment of a deficient perineal body

Physiotherapy is the first line of treatment. It will strengthen the puborectalis and to some extent, the external anal sphincter. However, when the external anal sphincter is deficient, surgery is indicated.

Perineorrhaphy

The surgical correction of a deficient perineal body is known as perineorrhaphy. Traditionally, a perineorrhaphy consists of central plication of the relatively superficial tissue of the perineal body. This tissue involves mainly subcutaneous connective tissue. The deep part of the anal sphincter, which is the main deficient structure of a deficient perineal body, lies much deeper. Since the repair of this muscle is not part of a traditional perineorrhaphy, this procedure is ineffective in restoring adequate perineal body function.

Perineorrhaphy should involve repair of the deep part of the external anal sphincter. Damage to the puborectalis can’t be repaired surgically and the surgical repair of a damaged internal anal sphincter is usually ineffective because it is so thin. The superficial part of the external sphincter can be repaired if necessary.

The key to the repair of the external sphincter is the opening of the para-anal space between the external and internal anal sphincters. With a finger in the anal canal, fibrotic tissue is removed. Thereafter, with blunt dissection (with a scissors) on each side the para-anal space is easily opened. Medially to this space is the bowel (anal canal) and laterally the deep part of the external sphincter. With a flat instrument placed in this space (to protect the bowel, the deep part of the external sphincter is pierced laterally to the instrument with absorbable suturing material on each side and sutured together in the midline anteriorly to the anal canal. Three sutures are usually sufficient. Thereafter, the lower vagina is closed. The perineal skin is usually left intact. A levator ani plication does not assist in either the repair of a deficient perineal body or a rectocoele. It only carries the risk of creating a transverse ridge with dyspareunia. Therefore it should be abandoned.

Final remarks

Too many superficial perrineoraphies are done which are ineffective and complicate future proper repair of a deficient perineal body. The key to a perineal body repair is repair of the external anal sphincter.

THE USE OF AUGMENTATION CYSTOPLASTY IN REFRACTORY OVERACTIVE BLADDER IN CURRENT PRACTICE - Dr K Makamba, HOD Department of Urology, Livingstone Hospital

Introduction

Overactive bladder (OAB) is a common symptom complex which has a prevalence of about 12 to 17 % and has detrimental effects on the quality of life (QoL) in these patients. Treatment is usually conservative (behavioural and pharmacotherapy) and can be escalated to invasive treatment, the latter reserved for patients with refractory OAB which is the focus of this review.

OAB Treatment

The International Consultation on Incontinence (ICI) algorithms divide management into initial treatment (first and second-line treatment) and specialised therapy (third-line treatment). It is of importance to note that OAB symptoms are rarely cured but can be ameliorated to improve QoL. OAB does not affect survival, therefore taking this to account, the clinician should carefully weigh the potential benefit to the patient of a particular treatment against that treatment’s risk for adverse events (AE), the severity and the reversibility of AE
  1. Behavioural changes (First-line treatment)

    This includes lifestyle changes (reducing caffeine intake, weight loss), bladder retraining and pelvic floor exercises. Bladder training and pelvic floor exercises aim to extend the period of time between voids in an attempt to re-establish inhibitory influence.

  2. Pharmacotherapy (Second-line treatment)

    Anticholinergic drugs are typically the mainstay of pharmaceutical management of OAB. Acetylcholine is the main neuromuscular transmitter to the bladder, acting on muscarinic receptors on detrusor muscle. M3 receptors account for a third of detrusor muscarinic receptors; while less numerous than M2 receptors, they appear to have a greater relevance in the context of OAB. Antimuscarinic drugs are competitively inhibiting either all muscarinic receptors, or the M3 receptor selectively. The newest medication to manage OAB is mirabegron. This drug targets the sympathetic rather than the parasympathetic nervous system. It works by activating Beta 3 receptors located in the bladder wall, which increase the sympathetic nervous system activity and cause detrusor muscle relaxation.

  3. Surgical options (Third-line treatment)

    The American Urology Society (AUA) Guideline Statement 16 states that “Patients who are refractory to behavioural and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy.” (Expert Opinion). OAB symptoms remain refractory in 20% of women and it is recommended that patients who have failed first and second line therapy should be referred for further assessment and treatment at tertiary centres.

    Third-line treatment options include:
    1. Botulinum toxin injections
    2. Neuromodulation
      • Central neuromodulation: Sacral nerve stimulation (SNS)
      • Peripheral neuromodulation: Percutaneous tibial nerve stimulation (PTNS)
      • Cutaneous neuromodulation: Patient managed neuromodulation system (PMNS)
    3. Augmentation cystoplasty (AC)
The use of all third-line therapies requires careful patient selection and appropriate patient counselling.

Reconstructive surgery would previously have been the next mode of treatment after pharmacotherapy for patients with refractory symptoms (augmentation cystoplasty or urinary diversion), but these procedures are currently relegated to a last resort. Current evidence supports the use of less invasive treatment options.

AC involves the use of a gastrointestinal segment to enlarge the bladder. Ileocystoplasty is the most popular bladder augmentation procedure, but several other different types of bowel or stomach segments have been used successfully. The creation of a continent catheterisable channel at the time of augmentation can be considered when there is functional inability to catheterise the native urethra or for patients with severe urethral incompetence who will require concomitant bladder neck closure.

The newer and less morbid interventions seem to be reducing, but not eliminating the need for AC. In the UK, the overall number of bladder augmentation procedures have decreased over the last decade, falling from 192 operations in 2000 to 120 in 2010. Specifically, the number of ileocystoplasty procedures performed has decreased from 155 operations in 2000 to 91 in 2010. In comparison, the number of intravesical botox injection treatments has increased significantly from around 50 recorded episodes in 2000 to 4088 cases in 2010.

Intravesical botulinum toxin injection treatment can improve quality of life by reducing episodes of urgency incontinence and increasing bladder capacity. Many patients however may need to self-catheterize subsequently, and this group may not necessarily feel the voiding dysfunction is better than the storage symptoms. Patients should be informed that repeat injections are likely to be necessary to maintain symptom reduction.

The National Institute for Health and Clinical Excellence (NICE) guidelines recommend that reconstructive surgery is only undertaken when conservative measures and less invasive treatment modalities have failed or are not suitable. AC is invasive and irreversible. It is therefore currently not recommended for OAB patients except in extreme rare situations as there are short and long-term postoperative complications associated with the procedure. These complications include regular need for CISC, recurrent UTIs, metabolic and bowel disturbance, mucus accumulation, bladder stones formation, bladder perforation, impaired renal function and the risk of malignancy.

In order to avoid the morbidity associated with gastrointestinal anastomosis and the presence of gastrointestinal tissue in the urinary tract Cartwright et al. introduced the auto-augmentation in 1989. This operation involves making an incision in the detrusor muscle (detrusor myotomy), or resecting a portion of the detrusor (detrusor myomectomy), essentially creating a low pressure bladder diverticulum to increase capacity and compliance. It is not widely undertaken but does have reported benefits.

Conclusion

OAB is a common disorder which is more prevalent with ageing and has substantial negative effect on quality of life. Currently, cure is unlikely and treatments are therefore aimed at providing symptomatic benefit. Medical treatments are better tolerated and have enhanced patient compliance. Intravesical injection of botox is proving to be a popular, effective and safe minimally invasive treatment method. Reconstructive surgery (including AC) should be reserved for those women who have not responded to less invasive treatment modalities.

SAUGA NEWSLETTER September 2018