eNews - July 2020

In this eNews
President's NoteEditor's NoteBladder diaries and female incontinenceCauses of urinary retention in womenRole of periurethral bulking therapy

Message from the President:

Dear Colleagues

On the 27th March 2020, Minister Zweli L. Mkhize signed off his approval of the Regulations relating to the Certificate in Urogynaecology subspecialty, amongst others. On this note, SAUGA would like to acknowledge and thank all involved pioneers for their unwavering and steady support. This was indeed long overdue!

Remember to register for the Virtual 45th IUGA meeting commencing on 29th August 2020. Live broadcasts, workshops and expert sessions, including a virtual exhibition is planned to keep you busy in the comfort of your home/office. For those who have missed guidelines pertaining to Urogynaecology amidst COVID-19 pandemic, review at www.iuga/publications/COVID-19.

“Nature does not hurry, yet everything is accomplished.”
Lao Tzu

Best wishes,
Prof Zeelha Abdool
Chairman: SAUGA

Message from the Editor:

This season’s newsletter is published during a difficult time, and we are mindful of the staff caring for COVID patients.

Life goes on, and so must we. This issue has a variety of interesting papers, well worth reading and remembering.

Bulking agents are once again on the table, and polyacrylamide hydrogel has been recently launched in this country. Given the adverse publicity that mesh has encountered, bulking agents have enjoyed a resurgence of popularity.

Another paper considers the importance of bladder diaries in our practice.

There are especially cost-effective, and highly useful in the assessment of LUTS.

The article on urinary retention makes for interesting reading, and clearly sets out what we must consider should urinary retention occur.

All in all an excellent issue.

Keep safe and warm, and may these interesting times pass.

Bladder Diaries and Female Incontinence

Karen Swanepoel
Physiotherapist, Bloemfontein Life Rosepark Hospital

1. Background

A bladder diary is a simple, cheap and objective method of evaluation. It is widely used by pelvic health physiotherapists, continence nurses as well as doctors to assess Lower Urinary Tract Symptoms at different stages of treatment.

A lower urinary tract symptom (LUTS) is defined by the International Continence Society as a symptom originating from the bladder, urethra and/or adjacent pelvic floor or pelvic organs, or be referred from similarly innervated anatomy e.g. lower ureter.

A Bladder diary includes the recording of time of each micturition and the volume voided for at least 24 hours, fluid intake, pad usage, incontinence episodes and the degree of incontinence. The patient will record episodes of urgency and sensation, and document the activities performed during or immediately preceding the involuntary loss of urine. Additional information obtained from the bladder diary involves the severity of incontinence in terms of leakage episodes and pad usage.

Bladder diaries should be completed for a minimum of three days (NICE, 2013).

2. Interpretation of results

The results are compared to the normal values, including frequency, volume voided, fluid intake, incontinence, nocturia and maximum volume voided.

Frequency of voiding

Normal frequency is between five and eight voids in 24 hours. A high fluid intake may increase frequency.

When a patient voids less than 5 times per day, but leaks continuously, overflow incontinence should be considered. In patients with overactive bladder or urgency, an increased frequency could be present. A urodynamic study could provide more information in terms of Detrusor activity.

Total volume voided in 24 hours

The total volume of urine in a healthy adult is between 1500 and 2000 ml/24hours.

Many patients reduce fluid intake in an attempt to decrease leakage. They can increase their risk of developing a urinary tract infection and increase urgency due to irritation by the concentrated urine. These patients can be encouraged to increase intake to a more acceptable volume that should appropriately also increase voiding volume.

Total fluid intake and type of fluid ingested

Normal fluid intake is approximately 2000ml per day. Caffeine, carbonated drinks and artificial sweeteners act as bladder irritants. Fluid intake and urinary output should be closely monitored in patients with heart failure or patients on diuretics. Patients should be advised to reduce the intake of bladder irritants. If a patient is suffering from nocturia, limiting fluid intake for 90 minutes before bedtime and voiding just before retiring can improve outcome.

Nocturia

Waking once at night due to the desire to void is considered normal. When the largest proportion of urinary voiding volume occurs at night this is considered as nocturnal polyuria. Older women with nocturnal polyuria should be assessed to exclude medical causes.

Maximum volume per void

Normal functional bladder capacity in adults is approximately 300-400ml. The largest void is usually on rising.

A patient who does not empty the bladder completely, will also return to the toilet sooner to void. In an attempt to decrease frequency. Patients must be taught how to empty bladder completely. Measuring the volume voided can also determine whether voiding was driven by true volume or urgency.

Incontinence

Each episode of incontinence can be evaluated – was it brought on by urge, increased intra-abdominal pressure, Valsalva, or delayed voiding? Was the incontinence just after voiding, which would suggest post-micturition dribble or incomplete emptying. This will aid in correctly classifying the type of urinary incontinence the patient is presenting with, and will guide the pelvic floor physiotherapist to prescribe an individualized bladder rehabilitation plan.

3. Conclusion

Bladder diaries are a useful tool to assess LUTS, to aid diagnosis and to provide a baseline from which to plan treatment. It assists clinicians to plan individualized toileting programmes and to measure the progress during the treatment period.

References on request

Causes of Urinary Retention in Women

Dr Do-Jo Jordaan
Gynaecologist Bloemfontein

Urinary retention in women is uncommon, however if not diagnosed and treated in a timely fashion it can lead to permanent disability, with a severe impact on quality of life.

The voiding reflex is triggered in the pontine micturition centre and leads to relaxation of the urethral sphincter, via sympathetic innervation by the hypogastric nerve and pelvic floor muscle relaxation, via somatic innervation by the pudendal nerve. This is then followed by contraction of the detrusor muscle mediated by parasympathetic innervation from the pelvic plexus. Incomplete emptying can result from abnormal function anywhere along this pathway or when there is obstruction at the outlet level.

1. Obstructive causes of retention

Obstruction is caused by luminal compression either by bladder neck distortion or urethral compression.

It includes urethral stenosis that can occur due to atrophic changes associated with low vaginal oestrogen. Urethral stenosis may also occur after surgery, with chronic inflammation and fibrotic changes. Ironically urethral dilatation procedures that are sometimes performed to treat urethral stenosis is one of the main causes of urethral stenosis.

Masses can cause obstruction of the urethra. Intraluminal obstruction of the urethra can be caused by space occupying lesions like bladder stones, blood clots, urethral cancer, thrombosis in a urethral caruncle or stones in a urethral diverticulum. Extra luminal obstruction can be caused of the Skein’s gland, gynaecological tumours and fibroids.

Pelvic Organ Prolapse can cause kinking of the urethra with mechanical obstruction.

Surgery for urinary incontinence including Burch colposuspension and vaginal mesh procedures, especially urinary incontinence procedures with mesh, can cause retention. Urinary retention in the immediate postoperative period might be due to transient factors such as hematoma formation or prolonged analgesia. However, it can also be due to an over correction of the incontinence in which case loosening or removal of the stitches or tape would be necessary.

2. Neurological causes of retention

This can be due to cerebral, spinal or peripheral nerve damage.

Cauda Equina syndrome is caused by protrusion of a lumbar disc usually in the area of L4 to S1.

Extensive pelvic surgery, especially procedures done for cancer or endometriosis can cause peripheral nerve damage, with reduced sensation and difficult voiding. This can be transient and clean intermittent self-catheterization is of utmost importance to prevent permanent bladder damage.

Other neurological causes can include Multiple Sclerosis, Parkinson’s disease, Guillain Barre Syndrome, neoplastic, vascular and traumatic spinal cord injury and Diabetes mellitus with peripheral neuropathy.

3. Urinary retention due to decreased bladder contractility

Long term chronic obstruction can lead to bladder hypotonia. Other causes for bladder hypotonia include radiation cystitis and tuberculosis. It is sometimes also seen as part of ageing although it is important to exclude any modifiable causes before this diagnosis is made.

Decreased contractility can also be caused by “the infrequent voider” syndrome where voiding is postponed for prolonged periods usually due to work or social constraints.

4. Other causes of urinary retention

Detrusor hyperactivity can lead to impaired contractile function.

Medication that can cause urinary retention include opioid analgesics, anticholinergic drugs, calcium channel blockers, alpha adrenergic stimulants, psychotropic drugs and selective serotonin re-uptake inhibitors.

Other causes include constipation, Herpes simplex virus infection with severe dysuria, severe cystitis, post-partum urinary retention and post-operative urinary retention, Fowler’s disease (abnormal function of the urethral sphincter with painless urinary retention in young women) and psychogenic causes. Be wary of attributing retention to this cause and only do so after a full work-up including a neurological and psychiatric evaluation.

References: Available on request

The Role of Periurethral Bulking in the treatment of urinary stress incontinence in females

Schalk Wentzel
Urologist, Bloemfontein Medic-Clinic

1. Introduction

Stress incontinence is the leaking of urine through the urethra during an increase in intra-abdominal pressure for example during coughing, sneezing or exertion.1 This condition affects 4 to 35% of all women2 but is markedly under reported. It is suggested that 25-61% of symptomatic women never seek help at their general practitioner for this condition3. Since the introduction of mid-urethral slings, the incidence of anti-incontinence surgery has increased from 0,8/1000 women in 1979 to 1,0/1000 women in 20064 in the United States.

2. Risk factors for the development of urinary stress incontinence

  • Age: The incidence of stress incontinence in females rises with increasing age from about 3% in women under the age of 35 to 38% in women over 605.
  • Obesity: Obese women have a 3 times higher risk for the development of stress urinary incontinence than women with a normal body mass index6.
  • Parity: Multiparous women have a higher incidence of both stress incontinence and pelvic organ prolapse compared to nulliparous women7.
  • Mode of delivery: Women with a vaginal delivery has a higher chance to develop stress urinary incontinence than those who had a caesarean section, however women who had a caesarean section can also develop urinary incontinence8.
  • Family history: Genetic predisposition may play a small role in the occurrence of stress urinary incontinence but overactive bladder incontinence is a more common hereditary condition9.
  • Others: Other factors that play a role may include smoking, previous genito-urinary surgery, diabetes mellitus and depression.

3. Evaluation of female incontinence

  • History: A detailed history is extremely important in a patient with incontinence. The examiner needs to differentiate between the three most common forms of incontinence, namely pure stress incontinence, overactive bladder (urge) incontinence and overflow incontinence. It is important to realize that combinations of above three types do occur and should be recognized. The three incontinence questionnaire (3IQ) can help with this differentiation10. Comorbid conditions that include pelvic organ prolapse, diabetes mellitus, obesity and neurologic diseases should be identified and medication that can play a role in the development of incontinence must be recognized. Impact on quality of life can be validated using instruments like the Kings Health Questionnaire11.
  • Physical Examination: It should include a general and abdominal examination, pelvic examination and a limited neurologic examination. Pelvic examination should include a bladder stress test in order to prove stress incontinence.
  • Side room investigations: Urinalysis is done on all patients and urine culture is done if screening indicates infection or hematuria. An ultrasound is done after urination to evaluate post void residual (PVR) urine and the upper tracts is screened to rule out hydronephrosis.
  • Laboratory investigations: Urine culture if suspicion of infection or hematuria and renal function only if hydronephrosis is seen on upper tract ultrasound. Other laboratory test depends on your findings during history and physical examination.
  • Voiding Diary: A voiding diary cannot differentiate between the different forms of urinary incontinence but is helpful to determine bladder volume, frequency of urination (normal is 8 times per day and once at night) and volume of urine produced in 24 hours12.
  • Urodynamics: UDS is not routinely done in patients with symptoms consistent with pure stress, urge or mixed urinary incontinence. It is however important to perform in patients with neurological abnormalities on examination, overflow incontinence or previous anti-incontinence surgery.

4. Treatment of urinary stress incontinence in females

The treatment always start with the identification and modification of certain lifestyle factors that can contribute towards stress incontinence.

  • Weight loss: In a study of 338 women mean weight loss of 7.8 kg in 6 months lead to a bigger decrease in incontinence episodes if compared to a control group (47% versus 28%)13.
  • Dietary changes: Decrease in alcohol, caffeine and carbonated beverages can decrease incontinence episodes14. Small volumes of water regularly instead of big volumes at a time can also help.
  • Constipation: Can exacerbate incontinence episodes and treatment can decrease incontinence episodes.
  • Smoking: Smoking may be associated with urinary incontinence but cessation of smoking has not lead to less incontinence episodes in several studies15.

5. Non-Surgical treatment of female urinary incontinence

  • Pelvic floor muscle exercises: If done correctly and regularly over a prolonged period of time, it might lead to less urinary incontinence episodes16. However lack of motivation and incorrect technique of muscle contraction often causes failing of this therapy.
  • Biofeedback and bladder training: More effective in overactive bladder incontinence but can be tried in patients with pure stress incontinence
  • Topical vaginal estrogen: can be effective in peri- and postmenopausal women and a trial of vaginal estrogen should be tried. Systemic estrogen can worsen incontinence episodes17.
  • Pharmacotherapy: No drug has been approved by the FDA for the treatment of female incontinence18. Drugs like duloxetine and alpha adrenergic agonists have been tried with limited success.

6. Surgery for female stress incontinence

Surgery has been proven to be the most successful primary treatment for pure stress incontinence and has much better results than conservative therapy including pelvic floor muscle training, biofeedback, bladder training and drug therapy19. The only randomized controlled trial comparing mid-urethral sling (MUS) surgery versus physiotherapy reported subjective cure rate favoring surgery, 76,5% improvement versus 58,5% improvement in patients receiving physiotherapy19.

The introduction of mid-urethral sling surgery has revolutionized the treatment of stress urinary incontinence in females. The procedure can be done through either a retropubic or a trans-obturator approach (Grade 1B recommendation). Other procedures including autologous sling placement and colposuspension are done by some surgeons but the discussion thereof is outside the scope of this review.

7. Bulking therapy for female stress incontinence

Periurethral bulking therapy is seldom used as a primary therapy for pure stress incontinence. It can be used in patients that cannot tolerate or refuse surgery or want to defer surgery, after a course of conservative treatment has failed (Grade 2C recommendation). Some Uro-Gynecologists reserve bulking therapy for the frail or elderly, however studies have shown that the success and complication rates of MUS surgery are similar between younger and older patients with stress incontinence20. Periurethral bulking therapy is also indicated for females with persistent incontinence after previous MUS surgery, however even then the placement of a second sling is more effective than the use of periurethral bulking therapy21.

Periurethral injections can be done as an office procedure under local anaesthetic. Complications are mild and easily managed and include urine retention, urinary tract infection and pain at the injection site22. More serious complications like abscess formation, tissue necrosis and migration of injectable material are rare.

Materials available for periurethral injection therapy are the following:

  • Carbon-coated zirconium oxide beads suspended in a water-based gel (Durasphere EXP®)
  • Crosslinked polydimethylsiloxane (Macroplastique®) or polydimethylsiloxane (Urolastic)®
  • Calcium hydroxylapatite suspended in a water and glycerine gel (Coaptite®)
  • Polyacrylamide hydrogel (Bulkamid®): a homogeneous, stable hydrophilic polymer gel composed of 2.5 percent cross-linked dextranomer polyacrylamide and 97.5 percent water

For many years the bovine collagen (Contigen®) was used extensively. Allergic reactions and the need for re-injections were common so the use thereof was discontinued. Several trails have been done to evaluate the effectiveness of the products mentioned above, only a few will be named here to give an idea of the effectiveness of the different products.

  • Durasphere EXP®: Initial effectiveness was 80% but the continence rates decreased to 35%, 33% and 21% at 12, 24 and 36 months respectively. Re- injections were therefore necessary23.
  • Macroplastique® has shown a 37% cure rate and a 65% improvement of symptoms at 6-18 months follow-up24.
  • Urolastic®: In a small study of 20 women that received Urolastic® injections in the Netherlands the continence rate was 68% after 12 months and decreased to 45% after 24 months25.
  • Bulkamid®: In a study of patients that was randomized 2:1 to Bulkamid® or Contigen® periurethral injections, 47% of patients in the Bulkamid® group reported no stress incontinence in follow-up examination while 77% in total defined themselves as cured. (This was comparable to the Contigen® which is no longer available)26. Side effects were mild, however no long term follow-up data was reported (Only 12 months follow up).

Technique for the periurethral injections differs from product to product. The injections can either be given transurethral or periurethral. Some studies have indicated that transurethral injection is associated with less urine retention than a periurethral injection27.

8. Conclusion

Although periurethral bulking therapy is not a primary option for the treatment of stress urinary incontinence in females, it is a reasonable option for patients that decline or cannot tolerate MUS surgery. It is associated with minimal complications that can be treated easily. Patients should be aware of the fact that re-injection may be necessary in a high percentage of cases.

References: Available on request

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