eNews - October 2020

In this eNews
President's NoteEditor's NoteSave the DateHIV and Lower Urinary Tract DysfunctionManagement of female stress urinary incontinenceDescending Perineum Syndrome (DPS) & Defecatory difficulty

Message from the President:

Dear Colleagues

I would like to take this opportunity to congratulate the host, organizers and IUGA President for a successful, first ever virtual IUGA meeting which took place from 29th August to 4th September 2020. Surprisingly, there were more than 1100 registrants who even obtained a virtual meeting bag! For those who missed this meeting, it is now possible to access edited content including all plenary lectures. For more information visit www.iuga.org.

Please remember to diarize the upcoming biennial SAUGA meeting hosted by the University of Pretoria Urogynaecology faculty on 10-11th Sep 2021.The scientific programme, venue and registration details will be available early 2021.

Best wishes,
Prof Zeelha Abdool
Chairman: SAUGA

From the office of the Editor:

This monthís newsletter is particularly interesting, and has something for everyone.

Itís been some time since we presented information on the ODS and DPS Ė you will have to read the newsletter to learn what ODS and DPS represent.

The paper is written by Dr T Naidoo, and I found it to be an excellent outline of the subject. Well done to Dr Naidoo! The other two papers are equally informative, and well worth careful reading and review.

Well done to the doctors of Durban!!

In the meantime, stay safe and warm, remember your PPE, and a huge thanks to our colleagues who produced 3 papers in this newsletter.

Save the Date:
The Biennial South African Urogynaecology Association Congress

10 - 11 September 2021

Save the Date: The Biennial South African Urogynaecology Association Congress

HIV and Lower Urinary Tract Dysfunction. Is there an association?

Mzwethu Vusi Khumalo

Human Immune Deficiency Virus (HIV) has been with us for decades. Currently, South Africa has more than 8 million people living with this virus. During the 90s and early 2000s, HIV had a remarkably high mortality and morbidity and anti-retroviral therapy in that era came with its own morbidity. It was quite common to find a patient with a CD4 count below 50 and high viral counts. The advent of newer Anti-retroviral therapy (ART) has decreased HIV related mortality rate by more than 50 percent. The morbidity associated with the earlier Anti-retroviral therapies has also reduced significantly. The resultant effects of these newer therapies are the survival of people living with HIV far beyond the age of 50 years with high CD4 levels (above 300) and undetectable viral counts. These women as they age will present with urogynaecological conditions like the rest of the aging population, but is there a difference? This prospect raises two questions:

  1. Does HIV influence urogynaecological presentations, specifically lower urinary tract dysfunction?
  2. How do we deal with those links?

Lower urinary tract Dysfunction (LUTD) is a broad term referring to dysfunction of the bladder and urethra. It looks at deviation from the norm of either filling, storage, or voiding phases of micturition. Subclasses looked at are:

  1. Voiding Dysfunction
  2. Incontinence (Stress, Urge, Continuous)
  3. Overactive bladder
  4. Interstitial Cystitis

Voiding Dysfunction and HIV

Patients with voiding dysfunction usually present with difficulty in voiding, hesitancy, and poor stream. The majority are related to lower urinary tract infections and have dysuria. An estimated 17% of HIV positive individuals have urinary tract infections, where the commonest organisms isolated are E.Coli, Klebsiella and Pseudomonas. If the cultures are negative and the patient continues to be symptomatic, then atypical organisms such as Candida, Mycoplasma, etc., should be looked for.

Sexually transmitted infections such as Neisseria Gonorrhea and Chlamydia are also common in this population group. It is therefore not uncommon to find urethritis presenting as voiding dysfunction and dysuria. Hence it is prudent to do urethral swabs if a urethritis is suspected.

Incontinence and HIV

Although studies are not robust, it is suggested that there is a 25- 30% prevalence of Incontinence in individuals living with HIV, and stress urinary incontinence predominates in this group. Infections are still an important cause of incontinence and need to be excluded before evaluating these patients.

Another mechanism for incontinence is through the HIV entering the Central Nervous System early in the course of infection resulting in a sustained inflammatory reaction that persists even after virus replication is under control. Neurological complications of cerebral toxoplasmosis, HIV encephalitis, demyelination disorders or HIV related dementia can result in lower urinary tract dysfunction. The resultant effect can be an overactive bladder. If control of the disease is not achieved early and AIDS develop, 10% of these patients will develop vascular myelopathy, and together with the neurological manifestations such as spastic paralysis, poor bladder control and urinary incontinence occurs.

Urogenital fistulae secondary to malignancy and infections tend to be more common in women with HIV infection. It is not uncommon to find HIV co-existing with Human Papilloma virus (HPV) which has a strong association with cervical cancer. Where cervical cancer is present, a urogenital fistula may develop either from direct tumor invasion or following tissue necrosis secondary to radiotherapy. Similarly, the presence of continuous incontinence in the absence of cancer of the cervix should prompt a search for granulomatous infections e.g. Schistosomiasis and tuberculosis. It has been reported that Schistosomiasis increases sensitization to HIV infection. Managing these fistulae in the background of HIV is challenging and success rates are low with high recurrence rates.

Overactive Bladder and HIV

There is a paucity of data addressing overactive bladder (OAB) in women living with HIV. Patients with urinary tract infections tend to present with OAB symptoms and it is mandatory that these infections be excluded. Bladder Schistosomiasis and urinary stone formation especially with indinavir use, should be considered when there is no response to physiotherapy, behavioral modification, and drug therapy. Cystoscopy may be indicated to exclude yellow-white patches that are indicative of bladder bilharziasis and bladder calculi.

Interstitial Cystitis and HIV

Interstitial cystitis (IC), also known as Bladder Pain Syndrome, conventionally presents with a triad of symptoms namely, suprapubic pain, urgency/frequency, and hematuria. In addition, a typical weeping bladder phenomenon may be seen on cystoscopy, with or without Hunnerís ulcers. In HIV patients, the three symptoms of bladder pain, frequency and hematuria are common and although most are due to UTIís, interstitial cystitis must be suspected when there are no infections isolated. To our knowledge, there is no study addressing this debilitating condition in patients with HIV.

Conclusion

To date, there is limited evidence in the literature evaluating LUTD in women living with HIV. There is an urgent need for good quality studies to address the relationship between HIV and LUTD, and guidelines for management. With women living longer, they are more likely to present with LUTD where UTI will predominate. Atypical organisms must be looked for if infections are suspected and there is no growth on cultures. The presence of infections may also lead to atypical presentations or exacerbate the previously diagnosed urogynaecological conditions.

Management of female stress urinary incontinence after failed Midurethral Tapes

Suran Ramphal

Urinary incontinence (UI) may persist or recur following midurethral tape (MUT) surgery. The treatment of these patients constitute a challenge for the physician and it is a devastating problem for the patient. The aetiology of the UI may be multifactorial and the evaluation requires a thorough history, physical, clinical, radiological and urodynamic assessment.

When assessing these patients, every effort should be made to determine the preoperative decision making process and diagnosis of the patient prior to surgery. Preoperative anatomical, clinical, urodynamic investigations and surgical notes should be evaluated since it is unfortunate that in some patients, the indication for surgery may be incorrect, or the concomitant surgery (eg prolapse surgery) may have resulted in a poorer outcome of the correction of stress incontinence.

Common conditions for poor outcome are patients with intrinsic sphincter deficiency, immobile urethras, mixed urinary incontinence with predominantly urge or detrusor underactivity. A major drawback of todays practice is that few patients undergo urodynamic studies prior to primary surgery with MUS and the majority are labelled as Genuine or pure stress incontinence. This unfortunately, is contrary to the reported literature.

An important step when evaluating these patients is diagnosing the type of incontinence before embarking on treatment. This may be stress incontinence, urgency with urge incontinence, overflow incontinence or continuous incontinence secondary to a fistula. Each of these conditions merits specific treatment.

Symptomatic evaluation should include bladder diaries and validated questionnaires if available. History of the patient symptoms and expectations should be carefully evaluated. Physical examination should include assessment of pelvic organ prolapse, urethrovesical angle, urethral mobility, cough induced stress test, and detection of mesh complications. Measurement of flow rate and postvoid residual are mandatory. Hematuria and urinary tract infection should be excluded by urine analyses and culture. Trans-labial ultrasound is helpful in the localization of the tape (midurethra) and it is not uncommon to identify the mesh at the bladder neck in failed cases (presenting with voiding dysfunction, overflow incontinence, or urgency). Cystoscopy should be performed in patients with haematuria, repeated UTIís and pelvic or bladder pain to rule out mesh intrusion into the urethra or bladder.

The role of urodynamics (uroflowmetry, cystometrogram, pressure flow study and UPP) is prudent in the secondary surgical management of SUI in these patients, and may not be necessary prior to conservative management. This will help to detect ISD, detrusor overactivity, stress induced detrusor overactivity, detrusor underactivity and voiding dysfunction secondary to obstruction or hypotonic bladder.

Treatment options for SUI following failed MUT include conservative management and/or surgical intervention. Choices of surgery include repeat MUT, pubovaginal slings, retropubic suspensions (open or laparoscopic Burch Colposuspensions), periurethral bulking agents and artificial urethral sphincters (AUS).

Conservative treatment includer pelvic floor physiotherapy and rehabilitation, incontinence pessaries (ring pessary with support, incontinence pessary dish) commercially available devices (Uresta) or medical therapy. To date, there is a lack of evidence that performing PFMT in patients who have failed SUI surgery is effective. However, most clinical guidelines recommend PFMT as first option in the management of patients with recurrent SUI after failed MUT.

A recent review and metanalysis suggests that there is a lack of high quality evidence assessing the various surgical treatment for recurrent SUI and there are still no high quality data to recommend or refute any of the different management strategies for recurrent or persistent SUI after failed MUT.

Shortening of the existing tape is an option, but this must be done early, ideally before the 3rd month of the surgical procedure.

In patients with urethral hypermobility and no ISD, a second MUT (transobturator or retropubic tape) can be considered. However, of recent, many societies advocate the retropubic route because of the easier management of mesh complications in the retropubic space. Burch colposuspesion is also an option but is associated with a longer operative time, greater morbidity and risks of voiding dysfunction. In patients with the failed transobturator tapes, it will be logical to go through the retropubic route.

Patients with reduced urethral mobility with or without ISD are a challenging group of patients. Options include retropubic MUT, pubovaginal slings, Adjustable MUS (Remeex), periurethral bulking agents, and artificial urethral sphincters. The adjustable devices have mechanical properties that permit re-tensioning in the immediate post-operative period (24-72 hours). The lower efficacy with traditional MUT, morbidity with slings and complications associated with AUS, makes the adjustable MUS a favourable choice. With the present mesh debacle, pubovaginal slings is an ideal option and should be offered.

In patients with previous urethral surgery (diverticulum repair, fistula with mesh removal) and extensive urethrolysis, the pubovaginal sling should be the preferred option.

Periurethral or transurethral injection of bulking agents which is less invasive, should be the logical and feasible first choice when managing patients with failed MUT surgery. However worldwide, it is not so and there is a reluctance to use it and it is considered to many as the last choice. Its efficacy and duration of correction is limited, and there are more effective alternative surgical options. It is best reserved for patients who have mild SUI and do not wish major invasive therapy and are aware that efficacy and duration are inferior to traditional choices.

Recently, Bulkamid has become popularized and there are ongoing studies addressing its use with failed MUT. We await the results of these trials To conclude, persistent or recurrent SUI is not an uncommon entity that we face in our daily practices. There is a lack of robust data assessing the various treatment options and this is an area that needs high quality research. At present, there is no single best treatment option and choices will depend on the aetiology of the patients failure, patient comorbidities, patient preference and surgeons choice.

Descending Perineum Syndrome (DPS) & Defecatory difficulty: Evaluation and Management

Dr TD Naidoo

Introduction

Obstructed defecation syndrome (ODS) is a relatively common and challenging problem, which adversely affects quality of life. According to the National Institute for health and Clinical Excellence (NICE) ODS is characterized by the urge to defecate but an impaired ability to expel the fecal bolus. Described as a discrete clinical syndrome noted in patients with a history of constant straining during defecation, ODS can have multiple causes, (including pelvic dyssynergia, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse) and descending perineum syndrome (DPS).

Definition

Although DPS is clearly described by its name, the precise definition varies in the literature based either on physical examination or defecography. The term DPS is mainly descriptive since perineal descent upon straining is both the cause of the symptoms and the most obvious physical sign.

Perineal descent, according to Parkís definition, refers only to the superficial perineal plane, externally visible, but it is obvious that this external perineal descent is joined to the descent of the deep perineal plane, hence the anatomical muscular displacement is more complex and serious and involves the entire pelvic floor.

Radiologically, perineal descent is described as the craniocaudal movement of the anorectal junction during straining from a fixed point of reference, which may include the ischial tuberosities (bi-ischiatic line), the tip of the coccyx, or more commonly, a line drawn from the coccyx to the pubic symphysis (pubococcygeal line).

What constitutes normal versus abnormal perineal descent varies in the literature as there appears to be an overlap of normal and abnormal values. Early defecography studies of asymptomatic women have shown that 77 % had a measured perineal descent of fewer than 3 cm, with another study showing that 84 % of women had descent of fewer than 2 cm. A mean value of 2.6 cm has been seen in women without functional bowel symptoms, with descent up to 4.4 cm also being observed in asymtomatic women.

Resting perineal descent values ranging from 3 to 4 cm and straining values from 2.5 to 4 cm have all been described as abnormal and suggestive of DPS. The heterogeneity of study results underscores the challenge in the ability of imaging to detect anatomical abnormality due to the wide variation of normal values described in the literature.

Epidemiology

ODS is estimated to affect between 15% and 20% of the adult female population, and is common in middle-aged women, especially those with a history of treatment for pelvic floor conditions. Women who have undergone laparoscopic/vaginal hysterectomies or surgery for pelvic organ prolapse or urinary incontinence have nearly twice the risk of weekly obstructive defecation. DPS can be observed in 75% to 84% of patients with ODS.

Pathophysiology

Normal defecation is a complex process involving voluntary and involuntary processes in four distinct phases:

  • the basal phase,
  • the pre-defecatory phase, which generates the urge to defecate,
  • expulsive phase,
  • and the termination of defecation

In DPS a cycle of straining and constipation, leading to more straining and exacerbation of the anatomical abnormality and descent, ensues. The chronic straining results in perineal descent and ballooning of the rectum, with downward projection of the anterior rectal wall into the anal canal, and caudally outward into the perineum leading to a pronounced feeling of inadequate emptying. The resultant further straining potentially results in the rectal mucosa prolapsing, causing symptoms of mucoid discharge, bleeding, and peri-anal pruritus.

Risk Factors

Chronic repetitive straining in the background of a weakened pelvic floor can be attributable to a variety of causes, with pregnancy and parturition thought to be primary contributing factors. Risk factors for increased perineal descent appear to be related to female gender, age, vaginal parity, rectocele size, and rectal intussusception.

With excess perineal descent, pudendal neuropathy is a theoretical sequela. It is estimated that with persistent straining, pudendal nerve stretching of approximately 20% of its length can occur.The theory of pudendal strain leading to anal incontinence is conflicting as some studies indicate a linear relationship between increased pudendal nerve motor terminal latency (PNMTL) values and increased perineal descent, while others show no such relationship. The lack of a consistent association can be potentially attributed to the different and non-standardized methods used in the diagnosis of DPS.

Presentation

Abnormal perineal descent has been described in relation to a variety of anorectal disorders such as constipation, fecal incontinence and obstructed defecation. Patients often present with a history of chronic straining during defecation and the sensation of incomplete evacuation of the rectum followed by a sensation of obstruction. Complaints of mucoid discharge, bleeding; perineal irritation, chronic anal pain, and perineal pruritus are also not uncommon because of the prolapse of the anterior rectal wall. When prompted, patients may admit to the use of splinting and digitation to aid in evacuation. There may also be a history of a dependency on laxatives and enemas.

A systematic review of clinical studies, however, did not show an association of perineal descent with constipation and rectal or pelvic pain, and the existing data on the association of perineal descent with fecal incontinence and obstructed defecation are conflicting. Only a few papers have reported on the relation of perineal descent with symptoms of pelvic organ prolapse and stress urinary incontinence. In these studies, prolapse symptoms seemed to be associated with the degree of perineal descent, whereas an association with stress urinary incontinence symptoms was unlikely.

Anal incontinence is a potentially long-term sequela in these patients secondary to pudendal neuropathy as a consequence of increased stretching associated with persistent straining. However, this is not a consistent finding if sphincter pressures remain within normal ranges.

Clinical Examination

Physical examination can be helpful in observing perineal descent, but has significant limitations and must be coupled with symptom assessment to accurately diagnose the syndrome and assess for concurrent pathological conditions. It is important to be aware of other potential etiologies and coexisting pathological conditions in patients with obstructed defecation. Rectocele, sigmoidocele, enterocele, anismus, solitary rectal ulcer syndrome, intussusception, and malignancy are only a few of the many other causes that one must keep in mind during a workup for obstructed defecation.

Examination of the peri-anal region may show signs of posterior vaginal wall prolapse, rectal mucosa prolapse, and erythema/ irritation. Rectal examination often yields a feeling of bulging from the anterior rectal wall. Most significant is the caudal laxity of the perineum with digital examination traction and the rectal ampulla filling anteriorly and caudally with strain. Anal sphincter tone can also be normal or weakened.

Although the use of perineometers to measure perineal descent has been suggested, there is evidence that these devices significantly underestimate the amount of descent as they do not truly simulate defecation, measuring the anal verge rather than the anorectal angle, and being significantly affected by body fat over the ischial tuberosities, which alters the reference point.

According to Parks and colleaguesí criteria, DPS can be diagnosed on physical examination. The patient is asked to lie in a left lateral position and the anal canal is examined for rapid descent of more than 3 cm during a straining effort However, since this method is not physiologic (given the patient is on a lateral decubitus position), diagnosis of DPS depends on defecography and correlation with patient signs and symptoms.

Defecography

Defecography consists of placement of barium paste in the rectum and vagina with subsequent positioning of the patient either on a special commode or in the left lateral decubitus position. Placement of patients in the left lateral decubitus position does not appear to affect perineal descent on straining, but has been shown to minimize perineal descent measurements at rest. Defecography is a vital test in the diagnosis of DPS and one must take into account the normal range of perineal descent to appropriately diagnose DPS.

Contemporary Defecography

During the procedure several images are captured for evaluation and include:

  1. At rest with the anal bulb filled
  2. During maximum contraction of the anal sphincters and pelvic floor muscles
  3. During straining without evacuation
  4. During evacuation
  5. When evacuation is complete

The two most significant measurements consist of the anorectal angle and movement of the anorectal junction during straining. Variation exists regarding measurement of the anorectal angle as the point of reference used in measuring perineal descent such as the ischial tuberosities, the tip of the coccyx, and the pubococcygeal line varies in the literature. It is important for the ordering practitioner to be aware of how the procedure is performed at their institution to ensure consistent interpretation. In addition, it is important for the provider to properly counsel patients ahead of time on the nature of defecography to avoid potential anxiety as the examination should simulate physiological conditions as closely as possible to ensure that accurate results are obtained.

MR Defecography

Although contemporary defecography is considered the modality of choice in the evaluation of DPS, magnetic resonance (MR) defecography (also known as dynamic MRI) is a relatively newer imaging technique that shows promise. One major benefit of MR defecography is the lack of patient exposure to ionizing radiation. Prior research has shown that contemporary defecography exposes the ovaries and uterus to considerable amounts of ionizing radiation, while the absolute amount of radiation is not life-threatening, it does limit the ability to repeat the test if needed. MR defecography also allows for better delineation of the soft tissue structures of multiple compartments of the pelvis, allowing for a broader overview of other potential pelvic floor defects.

Limitations of MR defecography include the inability to use this modality in patients with certain metal implants. In addition, most MR configurations in the clinical setting comprise closed configuration systems that require the patient to be supine with knees flexed. Other pelvic floor disorders, such as rectal intussusception, which could potentially contribute to obstructed defecation symptoms, were more likely to be missed in the supine position.

Several studies have compared contemporary defecography with MR defecography, with evidence generally suggesting that contemporary defecography might be better able to measure perineal descent, although others have shown no significant differences. Both contemporary defecography and MRI defecography are essentially equivalent in the diagnosis of DPS and either test is a reasonable choice in the workup of a patient.

Management

Initial management of DPS generally consists of conservative measures in the form of laxatives, suppository use, enema use, and biofeedback. Some advocate the use of a high fiber diet, although there is concern that this may only exacerbate the problem at hand.

The utility of biofeedback in patients with DPS is varied in the literature, with success rates ranging from 30 to 50 % . It also appears that women with a smaller degree of perineal descent responded more favorably to biofeedback. Limitations of biofeedback for obstructed defecation, as with other pelvic floor conditions, are related to the short duration of effectiveness and the need for retraining, which can be cumbersome for patients.

It is controversial whether surgical management is even an option for patients with DPS. Cundiff et al. described a modification of the traditional abdominal sacrocolpopexy into a colpoperineopexy coupled with Halbanís culdoplasty, with promising short-term results in women with various stages of pelvic organ prolapse, though not specifically addressing women with DPS. The study was limited by a small sample size, inconsistent diagnosis of DPS, and short-term follow-up. This technique was further discussed using a laparoscopic approach in a case report, which again limits the application of the procedure to a larger population.

Retrospective data suggest a correlation between women with DPS who underwent an abdominal hysterectomy and the subsequent development of fecal incontinence. Similarly, there is evidence that women with increased perineal descent have higher rates of previous hysterectomy. Although no causation is shown, this further illustrates the challenges in addressing this syndrome with a surgical procedure.

A case series on a transperineal approach consisting of levator plate myorrhaphy was shown to improve symptoms and decrease perineal descent. Because of the small sample size of 9 patients, the lack of defecography for diagnosis and short-term follow-up, this technique has limited application. One of the only randomized control trials available looked at the efficacy of two transanal staple approaches and found a significant reduction in perineal descent radiographically and an improvement in constipation symptoms.

Others feel that surgical management plays no role other than to potentially offer a diverting stoma for patients in severe cases. At this point, there is certainly no consensus on a surgical procedure that can be recommended as being ideal for the treatment of DPS.

Conclusion

DPS is a phenomenon that is difficult to treat and can lead to significant quality of life disturbances for patients. The limited evidence and relatively sparse prospective research limits the conclusions that can be drawn.

Accurate recognition based on symptomology, physical examination, and imaging are crucial in making a correct diagnosis, followed by initiation of conservative therapy to alleviate symptoms and allow for patients to better manage their bowel function. In a few select cases, surgical therapy may offer some benefit, but until prospective trials are performed to evaluate long-term efficacy and appropriate patient selection, surgical management has limited application.

References available on request.

This electronic news service is powered by E2 on behalf of SAUGA.