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In this eNews
Presidents note
Editors note
Anal Incontinence for the Urogynaecologist
Sacral neuromodulation for the treatment of bladder dysfunction
Voiding dysfunction – SAUGA Newsletter December 2019


eNews - March 2020

Message from the President:

Dear Colleagues:

You will agree that to date there has been scant information on what constitutes normal bladder function measurements and in addition, the lack of population specific nomograms for females. The recent publication by Wyman et al. from the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium conducted a systematic review and meta-analysis of bladder function parameters, including those obtained by non-invasive tests obtained in healthy women. Pooled mean estimate results (24 studies; N= 3090 women, age range, 18-91 years) found the ffg:

  • Daytime voids: 6.6 (95%CI, 6.2-7)
  • Nighttime voids: 0.4 (95% CI,0.0-0.8)
  • 24 hour voided volume:1577mL(95% CI,1428-1725)
  • Post-void residual vol: 12mL(95% CI, 4-20)
  • Qmax: 28mL/sec(95% CI, 27-30)
I trust that these normative reference values will be of clinical value to you. Yes, this topic does require further research. Ref: Neurourol Urodyn 2020, 39(2): 507-522.

While the power of the Corona pandemic plays on, the SAUGA Board prays for minimal impact on vulnerable populations! Stay well and observe all healthcare precautions.

“It is the microbes who will have the last word.”-Louis Pasteur

Prof Zeelha Abdool
SAUGA Chairman

Message from the Editor:

This issue of the newsletter offers a variety of interesting papers.

We begin with an article on anal incontinence.

The topic is seldom discussed, and the author outlines the correct approach to management.

Anal incontinence is not something we should sweep under the carpet, but devote time and expertise to the patient.

Laparoscopic sacrocolpopexy is the gold standard in vault prolapse nowadays, and this paper give tips to the beginner starting out. Clearly the author does not intend a beginner to attempt this operation, but be mentored by an expert.

We end with an excellent piece on sacral neuromodulation – clear and concise, and well worth digesting.

Read, learn and enjoy these offerings!!

Peter de Jong

 


Anal Incontinence for the Urogynaecologist

Dr Kendall Brouard - Urogynaecology Unit, University of Cape Town

INTRODUCTION

Anal incontinence (AI), with an estimated prevalence of approximately 10% in older women, shares many risk factors with pelvic organ prolapse and urinary incontinence. As Urogynaecologists we are able to identify women suffering from this stigmatised condition.

MECHANISM OF AI

Continence requires intact higher mental function, intact sensory and motor nerve pathways, an adequate rectal reservoir and an intact internal and external anal sphincter complex. Stool consistency and the patient’s mobility are important.

CAUSES OF AI

Anal sphincter damage: e.g. obstetric trauma (by far the most common cause), pelvic tumour invading rectum or anus, post-surgical procedures

Neuropathic injury: e.g. diseases causing neurological degeneration (diabetes and multiple sclerosis) or pudendal nerve injury from obstetric trauma.

Nerve injury may cause decrease resting and/or squeeze pressure or an impaired perception of stool in the rectum, resulting in no urge to defaecate until too late.

Inflammatory conditions: e.g.rectal surgery, radiation, inflammatory bowel disease

Rectal scarring causes stiff, non-compliant rectal walls with loss of storage capacity.

Diarrhoea:

Diarrhoea for whatever reason can result in AI, especially if there is another contributing factor.

Constipation:

Prolonged stretching of the rectum and anal sphincter leads to muscle weakness.

Central nervous system disease: e.g. dementia, stroke, brain tumours, spinal cord lesions and multiple sclerosis.

EVALUATION OF A PATIENT WITH AI

HISTORY – important to establish:

  • Incontinent offlatus, liquid or solid stool (least, more, most severe)?
  • AI preceded by urgency, or passive (patient unaware)?
    EAS defects usually result in urge incontinence, while injury to EAS and IAS usually results in ‘passive soiling’.
  • Food and fluid history (meals and snacks), consider a diary.
  • Obstetric history: instrumental deliveries, episiotomies or perineal tears.
  • General medical conditions (diabetes, neurological and spinal diseases, etc.)
  • Mobility and access to toilets.
  • Bowel habits and stool consistency - note any recent change or symptoms suggesting colorectal neoplasia or inflammatory bowel disease.
EXAMINATION
  • General health status and mobility
  • Perineum and pelvis: scars, anal gapping, soiling, pelvic organ prolapse.
  • Perineal sensation and anocutaneous reflex - absence of anocutaneous reflex suggests pudendal neuropathy or a cauda equina lesion
  • Digital rectal examination: sphincter tone at rest and squeezing, exclude anorectal neoplasms and faecal loading
  • Full neurological or cognitive assessment when appropriate
INVESTIGATION

Colonoscopy

All women >50 years with new onset AI or change in bowel habits (exclude colorectal neoplasm or inflammatory bowel disease).

Anatomical assessment:
  • 2D Endoanal ultrasound (EAUS)
Gold standard. Identifies puborectalis muscle, IAS, EAS and transverse perinei muscle. Easy to perform, requires no patient preparation, minimal discomfort (rotating 360° endoprobe). Identifies patients with isolated sphincter injuries that may be suitable for surgical repair.
  • Other USS modalities
    • 3D EAUS – allows volume measurements, thereby better defining the defect and sphincter remnant.

    • Transperineal ultrasound (TPUS) 2D/3D – allows for simultaneous assessment of the dynamic interaction between the pelvic floor and pelvic viscera.

    • Vaginal endosonography using endorectal or endovaginal probe
  • Endoanal magnetic resonance imaging (MRI)
Can accurately define the sphincter anatomy, including the site/extent of sphincter tears and detect EAS atrophy (important when assessing a patient’s suitability for sphincter repair). Cost is a limiting factor.

Anal manometry

Measures maximum and mean resting and squeeze pressures of the anal sphincter, and the length of the anal canal. Low resting pressure indicates IAS dysfunction. Low voluntary squeeze pressure indicates EAS dysfunction.

Pudendal nerve terminal motor latency (PNTML) measurements

Measures the time for an electric stimulus to travel along the pudendal nerve between the ischial spine and the anal verge. Pudendal neuropathy will predominantly affect the ‘squeeze pressure’ of the EAS. Poor inter-observer reproducibility.

TREATMENT

First exclude or treat:
  • colorectal neoplasia
  • diarrhoea
  • rectal prolapse or third-degree haemorrhoids
  • acute disc prolapse/cauda equina syndrome.
  • faecal loading
CONSERVATIVE TREATMENT

Lifestyle modification

1)    LDiet

Should promote good stool consistency with predictable bowel emptying. Consult a dietician.

2)    LBowel habits

Encourage:
  • Bowel emptying after meals (gastrocolic response).
  • Private, comfortable and safe toilet facilities.
  • Sitting or squatting while emptying the bowel.
3)    LAccess to toilets

Important interventions:
  • Be aware of where the nearest toilet is
  • Equipment to help gain access to a toilet
  • Easily removable clothing
Refer to occupational therapists, physiotherapists for assessment of their home and/or mobility.

Medication
  • Consult GP/physician and consider alternatives to chronic medication that might be contributing to AI.
  • Offer antidiarrheal medication (loperamide hydrochloride) if AI is associated with loose stools (exclude other causes first). Patients can adjust the dose and/or frequency as required.
  • Codeine phosphate is another option if loperamide is not tolerated.Tricyclic antidepressants may have a role but needs to be balanced with the potential to reduce alertness.
Pelvic floor muscle training/biofeedback (PFMT)

Anal sphincter exercises and biofeedback have been used despite weak evidence and are recommended by The National Institute of Clinical Excellence (NICE) following failed conservative management. It should be based on patient-specific findings on digital assessment. Progress must be monitored by an appropriately trained healthcare professional.

SURGICAL TREATMENT

Secondary overlapping anal sphincter repair

Women with full-length EAS defect that is >90º on EAUS (+/- IAS defect) can be considered for sphincter repair, ideally performed by the most experienced surgeon. The most common complication is wound infection which increases the risk of failure. Short-term success rates are 47-90%, however, long-term success is poor.IAS defects, external sphincter atrophy, multiple defects, pudendal nerve neuropathy, irritable bowel syndrome, obesity and increased age decrease the success rate. Thorough preoperative counselling regarding realistic expectations is essential.

OTHER SURGICAL OPTIONS

Sacral nerve stimulation (SNS)

AI due to pudendal nerve dysfunction or surgically non- repairable anal sphincter injuries may improve following SNS. A Cochrane review concluded that despite limited evidence, SNS can improve continence in selected women withAI. It is recommended that potential patients undergo a trial stimulation period of 2 weeks, although this does not always identify those who will benefit from a permanent implant

Neosphincter construction - Following failed trial of SNS. Prosthetic sphincter or gracilis muscle transposition. Complex operation with significant complications.

Colostomy -Last surgical option for those who find a colostomy easier to managed than AI.

Antegrade colonic irrigation (via appendicostomy, neo-appendicostomy or continent colonic conduit) - In selected women with constipation and colonic motility disorders associated with AI.

OTHER OPTIONS TO IMPROVE QOL

Anal plugs -Inserted into anal canal, expand to create a watertight seal. Useful in patients with neurological disease and/or patients with impaired anorectal sensation.

Rectal washouts - when convenient, preventing soiling during the intervening time.

CONCLUSION:

Once life threatening conditions have been excluded in women reporting AI, conservative management can be started and referral made to a colleague with the experience to advise about further management. We should assist in preventing AI by ensuring high standards of obstetric care, early diagnosis and correct primary repair of anal sphincter injuries.

 

Sacral neuromodulation for the treatment of bladder dysfunction.

Dr Khumbo Jere
Urogynaecology Subspecialist trainee, University of Cape Town

Electrical stimulation therapies, such as sacral neuromodulation (SNM), can be offered to patients with refractory OABS following failed conservative measures. In patients suffering from urinary urgency, frequency and urgency incontinence, electrical stimulation of the sacral nerve significantly reduces urinary symptoms and improves quality of life. SNM is also used effectively for other forms of bladder dysfunction, such as underactive bladder and bladder pain syndrome (BPS).

The increased use of minimally invasive SNM has decreased the need for more open surgical procedures such as ileocystoplasty and urinary diversion.

Possible mechanism of action of SNM:

SNM uses an implanted electrode to the third or fourth sacral spinal nerve to deliver a painless electrical stimulus. The brain of the patient perceives this stimulus and effectively restores bladder function and alleviates the patients’ symptoms. Due to the system-oriented, and not organ-oriented, approach, SNM not only treats urinary disorders, but may also have a beneficial effect on bowel and sexual dysfunction as well as on pelvic pain.

The working mechanism of SNM is probably similar to that of other modes of urogenital neuromodulation, such as posterior tibial nerve stimulation (PTNS), transcutaneous electrical nerve stimulation (TENS), dorsal genital nerve stimulation and pudendal nerve stimulation. The main difference with those alternative therapies is that the SNM recruits 1000-times more axons by stimulating the sacral root and not a small nerve or some nerve fibres. Moreover, SNM provides continuous stimulation and as opposed to once per 1–2 weeks and offers more flexibility in stimulation parameters. Neuromodulation is also used for other diseases like epilepsy, depression and chronic pain. The working mechanism in these other diseases may have similarities to SNM for bladder dysfunction.

Current indications & outcomes for SNM:

Indications

  • OAB with or without urinary incontinence
The European Association of Urology and American Urological Association recommend SNM as a third-line treatment option when first-line (lifestyle intervention and pelvic floor exercises) and second-line (medication) have failed in patients with idiopathic OAB symptoms.
  • Underactive bladder (UAB)/detrusor underactivity (DU)
Defined as a nonpainful bladder with a chronic high post void residual (>100ml) which necessitates regular drainage of the bladder. An underactive bladder is also hyposensitive with a larger than normal maximum capacity of > 500 ml.

SNM was approved by FDA for treatment of non-obstructive urinary retention in 1999. It provides excellent outcomes for DU, but patient selection is important.

Outcomes

Table 1. Outcomes of Sacral neuromodulation at 5 years



Table 2: Complications and occurrences in first 5 years

Complications

Occurrence

(Siegel series)

Pain at the neurostimulation site

15.3%

New pain

9 %

Suspected lead migration

8.4 %

Infection

6.1%

Transient electric Shock

5.5%

Pain at lead site

5.4%

Adverse Change in bowel function

3%

Technical problems

1.7%

Suspected device problems

1.6%

Changes in menstrual cycle

1%

Adverse change in voiding

0.6%

Persistent skin irritation

0.5%

Suspected nerve Injury

0.5%

Device rejection

0.5%



SNM patient selection & implantation procedure:

The SNM implants are products of Medtronic and contain a lead with four electrodes and a neurostimulator, named Interstim II. The success of an implanted SNM depends to a large extent on a correct selection of the patient.

Theoretically, it should be possible that a test stimulation is not necessary and that selected OAB patients receive immediate implantation of the complete SNM with a chance of success of at least 90%. However, clinical practice teaches that all candidate patients receive a stimulation test trial. The test may be done in the outpatient clinic (peripheral or percutaneous nerve evaluation = PNE) or can be performed with a two staged implant in the operation room. The patient qualifies for a complete implantation of SNM when there is >50% improvement in one or more of the voiding parameters (frequency, voided volume or incontinence episodes}.

Comparing the baseline bladder diary filled out by the patient for 3–5 days before the test trial with a second bladder diary filled out during the test period constitutes the assessment

Figure 1. Placement of the device

 

Cost-effectiveness:

A study examining health care expenditure in the US for 1 year following neuromodulator placement found a 73% reduction in the average yearly office visit expenses from US$994 to US$265 per patient with a significant decrease in diagnostic and therapeutic procedures. Drug costs were also significantly decreased.

The cost of the Interstim device and its implantation in South Africa is considerable, this is set against the improvement in quality of life.

Conclusion:

Sacral neuromodulation is an effective treatment for refractory OABS with or without incontinence. An overview is given of the indications and operation procedure. Future developments could include expanded indications and the introduction of a rechargeable device.

*References on request

 

Laparoscopic Sacrocolpopexy for the Beginner

Dr Dakalo Muavha
Urogynaecologist, Pietersburg Hospital and the University of Limpopo

You have gone through basic training in laparoscopy. You are accustomed to the different techniques of safely establishing a pneumoperitoneum, inserting trocars and you have previously safely performed “many” other simple laparoscopic procedures. You now feel ready to do your first laparoscopic sacrocolpopexy (LSCP). What then?

This article will serve as a guide that you can use to navigate performing a safe Laparoscopic sacrocolpopexy. Usain Bolt, the current undisputed fastest man in the world says the real hard work is what he put in behind the scene during his PRACTICE and that is what makes him a champion. So, your first step in performing a safe successful first Laparoscopic sacrocolpopexy is:

Step 1: PRACTICE

Training in the dry lab will help you sharpen your 2D vision and master important techniques such as grasping, dissecting and suturing technique which are all crucial in performing LSCP safely and efficiently.

Another tip is to watch and learn from the masters of the craft performing the procedure. This can be through reading books, watching You Tube videos, attending a live conference, or if you are very lucky, to assist someone who has mastered the skill of LSCP.

Step 2: STRATEGISE YOUR NEXT MOVE (4Rs or R4s)

  1. Right patient (presumably LSCP is indicated) The other important parameters to consider for your first attempt is: BMI (preferably a thin patient), low risk for dense adhesions, vault prolapse where you do not need to start with laparoscopic hysterectomy.
  2. Right assistant – If you are lucky to get your mentor to assist you with your first case this is preferable, but if not, it must be an assistant you are familiar with and who is accustomed to your moves.
  3. Right Anaesthetist who is patient since your first LSCP is guaranteed to be very long (my first one was four hours).
  4. Right “tools” – these are the basic instruments and consumables that you will need:
at least two monitors

V lock suture (2/0)

lens (0 degree and 30-degree lens)

Gortex none absorbable suture

T lift

x3 Graspers

Y mesh

good needle holders

Manipulator

good suction device

Energy device (Harmonic, Bipolar or Monopolar scissors)

Arista powder

Tacker

third assistant

Step 3: POSITION AND PLACEMENT OF PORTS

You need to secure the patient with a none slip mattress, medical pneumatic mattress or strapping because you will need to put your patient in a very steep Trendelenburg as shown in the figure 1. Port placement figure 2


Figure 1


Figure 2
Step 4: SACRAL PROMONTORY DISSECTION.

This area should be carefully dissected by lifting the peritoneum to create a safe distance between the peritoneum and major vascular structure after palpating the sacral promontory (Figure 3). The opening at the sacral promontory must be wide enough for better visualization of the important landmarks within the interiliac triangle (Figure 4). To prevent presacral haematomas, middle sacral artery and veins are identified and ligated.


Figure 3

Figure 4
Step 5: LATERAL PELVIC WALL DISSECTION

The peritoneal opening progresses from the promontory towards the Pouch of Douglas, along the right side of the rectum, far from the right ureter. (Figure 5)


Figure 5


Step 6: DISSECTION AT THE POUCH OF DOUGLAS

The Pouch of Douglas (POD) is an avascular space which lies between the two uterosacral ligaments shown in figure 6. The peritoneum between the rectum and the vault is dissected to expose the pararectal fat ideally up to Levator ani muscle but extra vigilance is required to prevent rectal injury. If you are worried about the possibility of causing rectal injury by further dissecting down to the Levator ani muscle it is best to stay safe and only dissect to the lowest safest part of the posterior vault. Then do a posterior vaginal repair if deemed necessary after the LSCP.


Figure 6 Relation of the rectum, both uterosacral ligaments and the uterus

Step 7: ANTERIOR VAGINAL WALL DISSECTION

Dissect the vault to remove all the peritoneum in order to separate the bladder from the vault. Be very careful because the ureter is nearby (laterally and at the base of the bladder). Avoid overzealous dissection of the anterior vagina wall beyond the area where the catheter bulb is palpable.

Step 8: PLACEMENT OF A MESH

Insert the Y shaped mesh through the 10 mm trocar. For your first LSCP rather use a pre-cut mesh, easily available on the market. Fix the posterior arm of the mesh to the levator muscle or it can be attached to the posterior wall of the vault on both sides of the rectum. Then wrap the anterior part of the mesh around the vault. Fix with non absorbable Gortex suture. Trim the mesh arm and fix to the promontory with protack without tension.

Step 9: REPEROTINIZATION

Close the peritoneum with a V-lock suture.

Step 10: Do a cystoscopy to check bilateral efflux from the ureteric orifices.

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