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eNews - December 2019

In this eNews
Presidents note
Editors note
AUGS/IUGA scientific meeting Sept 24-28, 2019 Nashville USA
Voiding dysfunction – SAUGA Newsletter December 2019
What is new in the Management of Recurrent UTI?

Message from the President:

Once again, it is time to reflect and thank all team players on the milestones achieved in Urogynaecology 2019. To begin with, a big thank you to our customer support manager, Ms Amina Abrahams from E2 Solutions (Pty) Ltd for assisting with membership and timeous collation of the newsletters. The SAUGA Board also acknowledges all authors involved in the four SAUGA newsletter publications. We are grateful for your time and effort and will probably call on you again. The August SAUGA Urogynae Congress hosted by the Dept OBGYN at Charlotte Maxeke Johannesburg Academic Hospital imparted significant theoretical and surgical skills to the audience. Well done to Professor Andreas Chrysostomou and team. Finally with regards to subspecialty accreditation, SAUGA anxiously awaits promulgation of the Regulations by the Minster of Health.

Thank you for all your hard work and wishing you a fun-filled holiday season and a prosperous 2020!

“If you think in terms of a year, plant a seed; if in terms of ten years, plant trees; if in terms of 100 years, teach the people “- Confucius

Prof Zeelha Abdool
SAUGA Chairman

Message from the Editor:

Dear Colleagues

This newsletter highlights the importance of teamwork in our profession.

The 3 papers presented are important in highlighting this approach which is indispensable in the management of incontinence.

I hope you enjoy this issue – thanks to Hester van Aswegen for her efforts.

Peter de Jong

 


AUGS/IUGA scientific meeting Sept 24-28, 2019 Nashville USA

Feedback of some highlights

Reported by DR JA van Rensburg

The above conference included of a wide spectrum of pre-congress courses, workshops and in the conference itself state of the art lectures, key note lectures and podium abstract submissions. More than 800 research abstracts were submitted for this annual meeting.

In the opening presidential address by Ranee Thakar and Geoff Cundiff, innovation for our patients was addressed. This was appropriate with the background of the current dilemma in urogynaecology, namely the use of intravaginal mesh and subsequent complications and the recent pause on the use of intravaginal mesh in the UK since 2018.

Patient centered research was emphasised where innovation can benefit our patients. Products that are used should be effective, safe, of good quality, sustainable and affordable. Health systems and patients collaborate to improve how healthcare is delivered and provided to patients.

The threats to patient innovative research lie in different categories which include the industry, regulatory bodies, the physicians and academic institutions. Irresponsible regularities, industry led research, and the absence of the patient’s voice contributes to obstacles in patient’s centred innovative research. Inadequate safety data provided by the academics and unclear efficacy with its use by physicians can further contribute to threaten innovation for our patients.

Dr Thakar concluded that transparency, avoidance of conflict of interest, funding and the lectureship of innovation is key for the future of our patients.

An informative keynote lecture, reducing distractions in order to be more effective, by the neuro scientist, Paul Mohapel from Canada is worth mentioning.

Multitasking and digital devices significantly impact on distraction. He claims that multitasking increases brain function and creativity is false. He quoted Koechlin (2010) that our brain can’t really multitask where multitasking causes hyper excitability and suppression of the frontal lobes. Multitasking release stress chemicals and can be harmful to the prefrontal cortex responsible for regulation learning and attention, and the hippocampus, which is responsible for memory and learning. IQ drops as much as 10 points if a cell phone is present.

Closer to home he reported 42% of physicians reported burnout and a 20% rise in burnout was reported in the previous two years.(Medscape Physician lifestyle report 2014) The critical care physician reported the highest burn out at 48% and O+G at 46%. The lowest was reported by plastic surgeons at 23% (Medscape Physician lifestyle report 2019)

Electronic records increased burnout by 30%. For the physician 21% of working time involves multitasking, but physicians lack awareness how multitasking impacts on performance. The duration and frequency of e-mail checking increase stress, burnout and decreases productivity with a result in lower wellbeing and reduced engagement.

So what can be done to address these effects of multitasking and and electronic devices? He suggested two approaches, namely to set boundaries and limited the use of digital devices and to focus on “mono tasking”. For the older person (above 40y of age) optimal cognitive functioning for a 25h work week is as productive as a five day work week. (Melbourne institute of applied economics and social research).

The take home message was to avoid multitasking as it is not productive.

In a mini state of the art lecture Peter Rosenblatt did a presentation on the future of innovation in Pelvic reconstructive surgery. Innovation is usually triggered by frustrating existing treatment options and repetitive treatment failures. The current mesh controversy with more than 100 000 mesh related law suits contribute to difficulty to innovate. For us as gynaecologists we will need to think out of the box and involve the scientists and engineers…..and he made the point to go and look at other surgeons in the next operating room!

The innovator should consider the risk to the patient and the physician. Principles of innovative surgery include the encouragement of responsible innovation. Baby steps are required and successes and failures need to be shared. He ended with the quote of Henry Ford: If you always do what you have done you will always get what you have got.

There were different panel discussions and “The mid urethral –sling: Pursuing evidence –based Practise in the world of litigation and regulation” is worth mentioning. Perspectives from the UK, Australia and USA were offered.

Dr Duckett presented the UK perspective. A pause in the use of the synthetic mesh tape was introduced in July 2018 by the secretary of health and social care. This came at a time when intravaginal mesh kits were already abandoned. The NICE guidelines have been developed and registered centres for mesh removal have been developed. Criteria for the reversal of the pause include appropriate training of the surgeons, to report to a national base, to keep a registry of all procedures and to report complications.

Dr Bernadette Brown reported on the Australian perspective. Initial adverse events reported since 2006 led to a Senate enquiry in 2018. Their Senate recommended and made 13 recommendations which include mandatory report in adverse events, establish a registry, information sheets for patients who receive implants, fully informed consent and accreditation for medical practitioners who perform these procedures. In April 2019 the Australian government contributed financially to establish a pelvic floor procedure registry.

Dr Rardin reported on the perspective of the USA. In the USA the FDA did not ban or change the class of the MUS. He emphasised the required process for the introduction of newer technology to include pre-approval study with case studies, the comparative trials and RCTs, post approval studies with registries and patient reported outcomes. The FDA and AUGS are working to develop a coordinated network of registries and believe that innovation can and should continue.

After attending this conference I suggest it may be appropriate to relook at a registry format for intravaginal mesh procedures and adverse events in South Africa.

 

 

Voiding dysfunction – SAUGA Newsletter December 2019

By: Farzana Cassim

Voiding dysfunction in women is one of those entities that, like Painful Bladder Syndrome/Interstitial Cystitis, is challenging for both clinician and patient alike. It requires a significant amount of time spent meticulously teasing out a precise history from a frustrated patient that wants help instantaneously. This discussion does not include patients presenting with post-procedural voiding dysfunction (eg. Sling procedures), as this is a topic on its own.

In women, voiding dysfunction is unfortunately underdiagnosed and mismanaged with urethral dilatation. The true incidence and prevalence is therefore unknown. The incidence has been documented to be approximately 6% in women >40 years of age but another study showed an incidence of primary bladder neck obstruction to be as high as 47%.

The term voiding dysfunction is a generic one, referring to conditions causing poor coordination between the detrusor, the bladder neck and the external urethral sphincter. The International Continence Society defines voiding dysfunction in females as “abnormally slow and/or incomplete micturition (voiding) based on symptoms and urodynamic investigations”.

The causes for voiding dysfunction (or failure to empty) vary and are listed below. They are essentially separated into underactive/acontractile detrusor-related causes and bladder outlet obstruction (BOO):

 

Underactive detrusor:
  • Neurogenic
    • Cerebral
    • Spinal (sacral)
    • Peripheral
  • Myogenic (incl. ageing)
  • Mixed (DM)
  • Other risk factors:
    • Menopause
    • Immobility
    • Drugs
    • Psychogenic
BOO
  • Anatomical
    • Iatrogenic (sling procedures/urethral instrumentation)
    • POP
    • Inflammatory processes
    • Urethral strictures
    • Tumours
  • Functional
    • Dysfunctional voiding
    • DSD
    • Fowler’s syndrome

We present 2 cases. The first is a 54 year old female who presented with a 25 year history of voiding dysfunction after 2 traumatic catheterisation episodes. She subsequently sought help from various practitioners and was managed with serial urethral dilatations. By the time she presented to us for yet another opinion on her case, her urethra was almost completely occluded (unable to pass a feeding tube) and she had chronic outflow obstruction; she had bilateral hydroureteronephosis and a bladder palpable above her umbilicus. Her creatinine was elevated. On insertion of a suprapubic tube 2 litres of urine drained stat. The patient required admission for management of post-obstructive diuresis with IV fluids and repeat blood tests. Her creatinine settled to a normal level and the hydroureteronephrosis resolved. The patient does, however, have a trabeculated bladder and ongoing left-sided vesico-ureteral reflux secondary to the longstanding outflow obstruction. On further investigations she was found to have a completely occluded urethra secondary to chronic scarring, and a urinary diversion in the form of a mitrofanoff was performed.

The second patient presented with a similar history, but of a much shorter duration. She had had only 1 urethral dilatation, which partially improved her symptoms for 3 months only. On careful history, examination, and with a video-UDS + EMG, it was noted that the patient has primary bladder neck obstruction. This results in a poor stream and staccato voiding, with incomplete bladder emptying. Cystoscopy showed a patent urethra, excluding the need for urethral dilatation. The patient has improved with short-term alpha-blockade and longer term physio and urotherapy.

We therefore see 2 very different causes of voiding dysfunction with very similar presenting features. It is therefore vital to work these patients up fully, ideally with a good history (and bladder diary) and a careful clinical examination (including a neurological assessment). Urine dipsticks +/- urine cultures should be done. Video-UDS with EMG tracing is the ideal, but is not always available. In these complex patients, however, it does form a vital part of the work up. Cystoscopy is mandatory to exclude any obvious macroscopic pathology. Once the full assessment is complete, only then is one able to offer the patient the appropriate management plan. Urotherapy and the early involvement of a pelvic floor physiotherapist will go a long way in optimising patient care.

References
1. References on request

 

 

WHAT IS NEW IN THE MANAGEMENT OF RECURRENT UTI?

T van der Merwe; JA van Rensburg

Introduction

The American Urological Association (AUA) has released new guidelines this year on how to manage uncomplicated recurrent urinary tract infection. Simple cystitis is a common condition and it is estimated that 60% of women will experience an episode of bacterial cystitis in their lifetime. Recurrent UTI (rUTI) is not uncommon where 20-40% of women who experience an episode of cystitis will have a second episode. A new approach to rUTI has evolved due to better understanding of pathogenesis, emergence of antibiotic resistance, collateral damage and adverse effects of antibiotics and better information of outcomes of acute cystitis and rUTI.

Definitions

rUTI is defined as two episodes of culture-proven UTI and its associated symptoms in a space of 6 months, or 3 episodes in a space of one year. Most rUTI’s are due to reinfections, which is defined as a repeat UTI that occurs after 2 weeks since completed treatment by the same or different organism, but can also be relapse of infection, which is a UTI that occurs within 2 weeks of completed treatment with the same pathogen, usually due to incompletely treated infection or a resistant organism.(2)

Pathogenesis

The most common uropathogen is E. Coli, with the rest including K. Pneumonia, P Mirabilis, S. Saprophyticus. These are organisms usually colonizing the rectal flora. They occur in the vagina most commonly after sexual intercourse and menopause. The post-menopausal state creates a more favorable environment for these organisms due to the decreased level of estrogen. This leads to a decrease in lactobacilli with an increase in vaginal pH. They then colonize the peri-urethral tissue and ascend into the bladder to cause cystitis. Very virulent bacteria can overcome host defense mechanisms, but less virulent bacteria cause significant infection in abnormal urinary tracts and immune compromised individuals ).

Risk Factors

UTI is a common occurrence in the young, healthy patient. Proven risk factors for UTI and for recurrent UTI are sexual intercourse, use of spermicides (alters vaginal pH), new sexual partner, previous UTI, post-menopause status and a positive family history of UTI.

Table 1. Host factors that classify an UTI as complicated:

Complication Examples
Anatomic abnormality Cystocele, urethral diverticulum, fistula
Voiding dysfunction Vesicoureteral reflux, neurologic disease, pelvic floor dysfunction, high post void residual, incontinence
Urinary tract obstruction Bladder outlet obstruction, urethral stricture, ureteric pelvic junction obstruction
Iatrogenic Indwelling catheter, nosocomial infection, surgery (TVT)
Other Pregnancy, DM, stones

Management of rUTI

The guidelines for management released by the AUA in 2019 are summarized below. Guidelines are applicable specifically to uncomplicated recurrent UTI with no structural or functional cause.
  1. Evaluation
    • Take an accurate history and perform a full pelvic exam to exclude any functional and/or anatomical risk factors and causes.
    • Positive urine cultures associated with symptomatic episodes must be documented in order to make the diagnosis of rUTI.
    • Repeat a urine sample for culture and also consider taking a catheter specimen, if the initial sample is suspected to be contaminated.
    • Send urine for analysis with every symptomatic episode and await culture and sensitivity, prior to initiating treatment.
    • Individualize and offer prescriptions for treatment to women whilst awaiting culture results.
    • Do not routinely offer cystoscopy and upper urinary tract imaging in patients with rUTI, only if risk factors are present.
  2. Antibiotic treatment
    • The following drugs are considered first line therapy, but depend on the local antibiogram: Trimethoprim Sulphamethoxazole , Nitrofurantoin and Fosfomycin
    • Treat a symptomatic episode of UTI with a short as possible course, no longer than 7 days.
    • If an organism resistant to oral drugs is cultured, administer parenteral drugs according to sensitivity, as short as possible a course, no longer than 7 days.
  3. Non-antibiotic prophylaxis
    • Cranberry products can be offered to patients to use as prophylaxis, but the Cochrane suggest their efficacy has never been proven
  4. Antibiotic prophylaxis
    • Discuss the risks, benefits and alternatives with the woman, after which antibiotic prophylaxis for rUTI can be offered to women of all ages. Drugs used for prophylaxis are the same as above.

    Table 2. Recommended drugs by AUA:

    Trimethoprim Sulphamethoxazole 40/200mg once daily
    Nitrofurantoin 50-100mg once daily
    Fosfomycin 3g every 10 days

  5. Estrogen
    • Advise the use of vaginal estrogen cream in peri- and post-menopausal women with rUTI to reduce the risk of future UTI’s.
  6. Follow up and surveillance
    • Do not follow up with repeat cultures after treatment if women are asymptomatic
    • Do not treat asymptomatic bacteriuria
    • Repeat urine culture if symptoms persist after treatment episode, to guide further management
Comment on antibiotics

It is recommended that the reader will familiarize themselves with the drug sensitivity in their community and hospital. A study done in Gauteng showed the common organisms that cause UTI had susceptibility to Bactrim of only 44.3%, as opposed to Fosfomycin (Urizone) (95%) and Nitrofurantoin (Macrodantin) (91%). In other data from Tygerberg Hospital in the Western Cape from the Urology and Microbiology departments, which was reported in an article on UTI in the Elderly, the susceptibility of E. Coli for Bactrim was only 40%. The drug that we use as first line at Tygerberg for antibiotic prophylaxis is Nitrofurantoin, however, Fosfomycin is a drug with the best success rate to treat UTI and should become more freely available with the release of the new guidelines. The duration for the use of antibiotic prophylaxis is currently limited to 6-12 months, as there is no long term data yet on the safety of use for longer than this. When prescribing Nitrofurantoin, ensure that the creatinine clearance is more than 30ml/min to minimize risk of hepatic and pulmonary injury.

Conclusion

Uncomplicated rUTI is common in pre- and post-menopausal women. History and examination is key to identify any factors that will constitute a complicated UTI and should be managed accordingly. In the absence of any complicating factors, the AUA guidelines gives a very practical approach when managing these patients. Urine cultures are of utmost importance with all symptomatic episodes. It is not necessary to repeat cultures in asymptomatic patients, nor to treat asymptomatic UTI. It is important to keep in mind the local antibiotic resistance patterns, as for South Africa there is widespread resistance to Bactrim. Fosfomycin or Nitrofurantoin can be used as first line antibiotic prophylaxis for uncomplicated recurrent UTI. Vaginal Estrogen is advised for the peri- and post-menopausal women to reduce recurrence of UTI.

References:
  1. Dason S, Dason JT, Kapoor A. cua guideline Guidelines for the diagnosis and management of recurrent urinary tract infection in women. 2011;5(5):316–22.
  2. Anger J, Lee U, Ackerman AL, Chughtai B, Clemens JQ, Hickling D. American Urological Association ( AUA )/ Canadian Urological Association ( CUA )/ Society of Urodynamics , Female Pelvic Medicine & Urogenital Reconstruction ( SUFU ) Recurrent Uncomplicated Urinary Tract Infections in Women : AUA / CUA / SUFU Guideline Recurrent Uncomplicated Urinary Tract Infection. 2019;(April):1–36.
  3. Jeffery S, Jong P De. Textbook of Urogynaecology.
  4. Lewis DA, Uk F, Gumede LYE, Tech NDM, Hoven LA Van Der, Chb MB, et al. Antimicrobial susceptibility of organisms causing community-acquired urinary tract infections in Gauteng Province , South Africa. 2013;103(377):377–81.
  5. Van Rensburg K. UTI in the eldely woman. Menopause Focus. 2015;3(3):20.


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