Dr. Angelika Borozdina MBBS. PhD. FRANZCOG - PowerPoint Presentation

1. Dr. Angelika BorozdinaMBBS. PhD. FRANZCOGObstetrician and GynaecologistCVOGSABC of prolapse and incontinence A New Approach to Managing Atrophic Vaginitis

2. Urinary IncontinenceDefinition: Involuntary urine leakage during activity (effort/exertion).Occurs with loss of normal rise in urethral closure pressure in response to rising abdominal pressure. Anatomic and physiologic factors result in disordered pressure transmission. Distinguished from URGE Incontinence.

3. Three Common Types of Urinary IncontinenceUrgeStressMixed

4. Of the 1 in 3 adult women who have urinary incontinence7:Urge vs. Stress vs. Mixed IncontinenceUrge 11%Mixed 36%SUI 50%

5. SUI: 4 Types of Etiologic Risk FactorsInterveneBehavioralPharmacologicDevicesSurgical PredisposeFemale GenderRace, Culture and EnvironmentAnatomyNeurologic Incite Vaginal childbirthNerve DamageMuscle Damage Radiation PromoteConstipationPhysical workObesitySmokingMenopauseFluid IntakeToilet HabitsDecompensateAgingComorbid diseaseDementiaMedicationsEnvironment ContinentIncontinent

6. Components of SUI PathophysiologyLoss of anatomic urethral supportUrethral Hypermobility (UH) - weakness of pelvic structures that support urethral compression during increased abdominal pressureIntrinsic Sphincter Deficiency (ISD)Deficiency of urethral intrinsic closing mechanism

7. Incontinence EvaluationIncontinence on Physical Activity History and Physical examination: abdominal, pelvic, neurological Assess effect on quality of life Bladder diary MSU, if UTI treat Assess for pelvic organ mobility / prolapse Ultrasound of detrusor muscle, bladder neck and residual volume of urine post void UrodynamicsHISTORYCLINICAL ASSESSMENT

8. Pelvic ExaminationProlapse may mask incontinence Pelvic floor muscle tone Voluntary pelvic floor contractionPerineal skin conditionPalpation of anterior vaginal wall and urethraDetermine degree of estrogenizationMay observe leakage on coughingSUI Assessment .

9. Urinalysis1Tests of detrusor functionPostvoid residual (PVR) volume1Flow rate1Filling cystometrogram (CMG)1Tests of urethral sphincter functionValsalva leak point pressure (VLPP)2Maximum urethral closure pressure (MUCP)1 SUI Assessment (continued) 1. Abrams P, et al. he Standardisation of Terminology of Lower Urinary Tract Functioning: Report from the Standardisation Sub-committee of the Int’l Continence Society. Neurourol Urodyn. 2002;21:167-178.2. Blaivas JG, Groutz A. In: Retik AB, Vaughan ED Jr, Wein AJ, et al, eds. Urinary Incontinence: Pathophysiology, Evaluation, and Management Overview. Philadelphia, Pa: WB Saunders; 2002:1027–1052.

10. SUI ManagementIncontinence on physical activity History and urodynamic study confirm Stress incontinencePelvic floor muscle trainingOestrogen therapy of vaginaPessary managementSling operation or vaginal prolapse surgery Lifestyle interventions TREATMENTHISTORY/Clinicalexamination

11. SUI Surgical Treatmentsvs.ModernIntegral Theory’ of urinary incontinence*Control of urethra depends: pubourethral ligamentssuburethral vaginal hammockpubococcygeus muscleElevate bladder neck and proximal urethraSupport bladder neck and prevent funnellingIncrease outflow resistanceTraditional

12. Non surgical treatmentNeotonus MR ChairBased on Extracorporeal Technology produces highly focused pulsing magnetic fields

13. Mid-Urethral SlingsGoalsRestore and/or reinforce the pubourethral ligaments at the mid-urethraRestore and/or reinforce the suburethral vaginal hammock at the mid-urethraReinforce the paraurethral connective tissuepubourethralligamenturethropelvicligament

14. Advantages of Mid-Urethral SlingsEasily reproducibleLong-term successful clinical resultsMinimal complication riskMinimally invasiveMinimal tissue dissectionCan be performed under regional, or general anesthesia Most patients can be discharged the same day w/o catheter Shorter patient recovery than traditional open procedurePatient and Physician Benefits

15. Studies show that most patients are continent following the sling procedure and can resume normal, non-strenuous activities within a few days. Success Rate85-94%

16. Clinical data on AMS slings shows:19-22 *In a MiniArc study 90% of patients had negative cough stress test and 85% had a 1-hour pad weight test less than 1 gm at 1 year.*In a MiniArc study 94% of patients had significant improvement in pad use at 1 year.*In a Monarc study 90% of patients had a negative cough stress test and improvement in pad use at 1 year follow-up.*In a SPARC study 88% of patients had significantly reduced symptoms according to the Kings Health Questionnaire at 1 year.

17. Warnings and Precautions

18. Warnings and PrecautionsNOTE: Some of these adverse reactions are specific to procedures involving mesh repair (e.g. mesh extrusion).

19. Involuntary loss of urine associated with a sudden, strong desire to void.Urge Incontinence ( bladder muscle problem )Life style changes, bladder retrainingReduce caffeine , Vaginal Estrogen Magnetic chairAnticholinergic medication( SE)Neuromodulators Detrusor overactivity incontinence

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21.  50% of parous women (Swift 2000, DeLancey 1993, Beck 1991) 30 – 40% of women in general population (Slieker-tenHove 2004,Samuelsson 1999) Only 8.8% symptomatic (McLennan 2000) 11.1% lifetime risk of surgical repair 29 – 40% reoperation within 3 years (Clark 2003, Olson 1997)Basic Prolapse Stats

22. Pelvic organ prolapse (PLP) a common condition among female population ~ 60%Life time risk of surgery for POP 19% in WA (Smith FJ et al., 2010) higher than USA( 11%)Recurrence surgery 50%Prolapse surgery challenging - Multifunctionality of the vagina ProlapseHerniation of uro-genital tract

23. Pelvic organ prolapse (PLP) is a common condition among female population.Life time risk of surgery for POP was estimated to be 19% in the Western Australia (Smith FJ et al., 2010) which is higher than 11-12% reported from US.

24. Types of Pelvic Organ ProlapseCystoceleBladder prolapses or protrudes into the vaginaEnteroceleSmall bowel prolapses or protrudes into the vaginaRectoceleRectum prolapses or protrudes into the vaginaUterine ProlapseUterus prolapses or protrudes into the vaginaVaginal Vault ProlapseVaginal vault occurs when the upper portion of the vagina (the apex) descends into the vaginal canal

25. White 1910History

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27. So let’s POP-Q this (hymen = 0): Aa = -3Ba = -3C = -6D = -10Ap = -3Bp= -3Simply put, this vagina receives a POPQ of:-3, -3,-3, -3, -6, -10 (Aa, Ba, Ap, Bp, C, D)One line – loads of information

28. AaBaApBpDCSo, what is this?Here’s a hintHere’s the answer:+3, 0, -1, -3, -6, -9It’s a cystocele

29. Reconstructive surgical options include24Vaginal colporrhaphy and apical suspensions using native tissueSacrocolpopexyTransvaginal mesh (TVM) repair systemsSurgical Treatment Options

30. Elevate® is designed to:Offer a minimally invasive solutionMinimize tissue traumaRestore normal anatomy with a faster recovery than open abdominal approachesMinimize pain compared to more invasive proceduresElevate® Prolapse Repair System

31. Typically, procedures to correct prolapse take place on an in-patient basis and are performed under general anesthesia.In clinical studies, 91-96% of patients felt their prolapse symptoms were some or a lot improved following surgery with Elevate.28,29 Elevate Prolapse Repair System91-96%

32. Warnings and PrecautionsKnown risks of surgical procedures for the treatment of POP including the following:Mesh extrusion (presence of suture or mesh material within the vagina)Mesh migrationNerve damageObstruction of ureterPain/Discomfort/IrritationPerforation (or tearing) of vessels, nerves, bladder, ureter, colon, and other pelvic floor structures Urinary tract infectionVaginal contracture (tightening of the vagina)Voiding dysfunctionWound dehiscence (opening of the incision after surgery)

33. On October 20, 2008, the FDA issued a PHN regarding serious complications associated with transvaginal placement (meaning placement through the vagina) of transvaginal surgical mesh to treat POP and SUI.From Jan. 2008 to Dec. 2010 there were 2, 874 reports of complications associated with surgical mesh devicesFDA Notification: Transvaginal Mesh231,503 POP1,371 SUI

34. In July of 2011, the FDA issued an update to the PHN and provided physicians the following recommendations:Seek specialized training in transvaginal mesh proceduresAdvise their patients about the potential for serious complications associated with these procedures Be vigilant for potential complications from the mesh

35. In 2012, the TGA(Therapeutic Guidelines Australia) released a statement³² which in summary stated:Since 2006, the TGA has received 63 adverse event reports for all Uro-gynaecological surgical meshes.The Uro-gynaecological Society of Australia (UGSA) reinforced their view that the issues were about the use of these meshes rather than the meshes themselves. In light of this, the Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) and UGSA are advising that surgeons should have special training on performing these procedures and patient selection.TGA and Society Responses

36. The TGA urges any patients with mesh implants who are concerned to contact their surgeon.UGSA has released a statement supporting the use of mid-urethral slings for SUI.

37. Urodynamic study Quality of life assessment (POP-Q)Sexual function assessment(PISQ-12)Homework before the operation

38. Who needs urodynamic work-up ?Why do they get this work-up ?Can we obtain that information ?less costless effortless discomfortless site dependent

39. incontinence surgerysevere prolapsepre-operativelydetect occultincontinencedetect detrusoror voidingproblemsaimsdiffer

40. detect occultincontinencedetect detrusoror voidingproblemstheissueis

41. standardised historyexaminationquestionnaire24-hour-pad testpelvic ultrasoundurinary flow-metrybladder diaryCan these be detected in any other way ?

42. standardised historyexaminationquestionnaire24-hour-pad testpelvic ultrasoundurinary flow-metrybladder diaryall in a one steproom diagnosis!Can these be detected in another way?

43. Quality of life assessment (POP-Q)“Stage of complete physical, mental and social well-being and not merely the absence of infirmity and disease.”WHO Definition of Health

44. QoL is perception of:

45. Sexual responseexcitementplateauOrgasmresolutionMale and Female Sexual FunctionBy Master and Johnson

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47. Sexual responseexcitementplateauOrgasmresolutionThree times per week don’t feel like it, do it anyway – Working , washing A matter of health more than pleasure Heart protection - 30% less heart attack for men and women IS Sex A matter of health ??

48. Pessaries used for treatment since beginning of recorded history1800BC Kahun Papyrus Ebers Papyrus (1500 B.C.) which portrayed the uterus as an independent animal, usually a tortoise, newt or crocodile, capable of movement within its host.Hippocrates – halved pomegranite soaked in wine! Hippocrates perpetuated this animalistic concept stating that the uterus often went wild when deprived of male semen1625- Stromayr’s Practica Coposium – sponge and twineLatex products-1800’sSilicon now usedPelvic Organ Prolapse (POP) & Pessaries

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52. Pt preferenceMedical comorbiditiesDelayed surgeryRecurrenceVaginal ulcerationPOP in pregnancyDesiring future fertilityIndications

53. Vaginal/pelvic infectionMesh exposureNoncompliancecontraindications

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55. Follow up every 3 months erosion and infection

56. Vaginal repair +/_ hysterectomyNative tissue repair( midline, site specific)Biological mesh repairSynthetic mesh repair ( Elevate Mesh kit)Laproscopic pelvic floor repairMesh scaro-hysteropexySuture hysteropexy+/_ vaginal repair Prolapse repair

57. Abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and less dyspareunia than the vaginal sacrospinous colpopexyUse of mesh or graft inlays at the time of anterior vaginal wall repair reduces risk of objective recurrencePosterior repair better performed vaginallyNo evidence to suggest that the addition of any graft material at the posterior compartment repair results in improved outcomesValue of adding a continence procedure is uncertainTake home messages

58. ATROPHIC VAGINA

59. The upper 2/3 of Vagina is Mullerian originThe lower 1/3 is urogenital foldVaginal skin is estrogen and progesterone dependentEstrogen thickens the skin and progesterone thins the skinThe lower 1/3 is less estrogen sensitive Vaginal skin

60. Passage of blood flow during the periodsBirth canalSupports function and position of bladderSupports function and position of bowelConnects the abdominal cavity with outside via cervixVaginal lubricationSexual activityReproduction Vaginal Function

61. No vaginal glandsParacervical glands and Bart gland provide discharge at the time of orgasmVaginal epithelium stratified squamous epithelium and responsible for lubricationBalancing vaginal flora and pHAvoiding possible infection eg thrush Vaginal lubrication

62. Decrease in Oestrogen after menopauseUp to 40% of postmenopausal women suffer from Atrophic Vaginitis1Decreased quality of life and direct impact on women’s sex life- Vaginal dryness, painful sex, low libido, sluggish orgasm, urinary problems, vaginal infection Atrophic Vaginitis

63. Decrease in oestrogen levels Less Connective TissueLess capacity to retain waterIncreased risk of fissuring &ulceration3Decrease in glycogen in vagina tissueChange in vaginal floraChange in vagina pHIncreased risk of UTI& thrushAtrophic Vaginitis

64. Atrophic VaginitisNormal Pap SmearAbundant CytoplasmLow Nuclear Cytoplasmic RatioAtrophic Vaginitis Pap SmearEnlarged NucleiInflammatory ExudateAmorphous Basophillic Structurs (Blue Bulbs)Loss of Gylcogen in the Squamous Cells

65. Oestrogen Replacement4Systemic or LocalCan reverse or prevent symptoms Moisturizers and LubricantsCan be independently or with oestrogen replacement therapySexual Activity- 3 times per weekCurrent Best Practice

66. Oestrogen Replacement10-25% of women do not respond5 Physical limitation in older womenSmall increase risk of endometrial caOestrogen therapy in ER+ Breast cancer!Moisturizers and LubricantsShort term benefitSexual ActivityNo firm understanding of mechanismCurrent best practice Drawbacks

67. Platelet Rich Plasma Therapy - 27 gauge needle and vaginal gelV2 LR Laser Therapy - using a vaginal probe Non-Surgical, Non-Hormonal Options

68. High concentration of plateletsIncreased release of growth factors from plateletsPromotes regeneration of connective tissue Suggested applications in Dentistry, Maxillofacial Surgery, Plastic Surgery, and Orthopaedic Surgery.PlateletS Rich Plasma

69. LASER - Light Amplification by Stimulated Emission of RadiationAn intense beam of lightHighly directionalA single wavelength or colourWhat is a Laser?

70. Pump some energy into it – electrically or with lightThe material naturally emits light (of a characteristic colour)Feedback (between the mirrors) build the intensityLight ‘leaks’ out a partially reflecting mirrorHow does it work?Laser materialMirrorMirrorEnergy inexcitedLightLaser beam

71. 1. Greendale  GA, Judd  HL.  The menopause: health implications and clinical management.  J Am Geriatr Soc.  1993;41:426–362. Pandit  L, Ouslander  JG.  Postmenopausal vaginal atrophy and atrophic vaginitis.  Am J Med Sci.  1997;314:228–31.3. Rigg  LA.  Estrogen replacement therapy for atrophic vaginitis.  Int J Fertil.  1986;31:29–34.4. Handa  VL, Bachus  KE, Johnston  WW, Robboy  SJ, Hammond  CB.  Vaginal administration of low-dose conjugated estrogens: systemic absorption and effects on the endometrium.  Obstet Gynecol.  1994;84:215–8.5. Smith  RN, Studd  JW.  Recent advances in hormone replacement therapy.  Br J Hosp Med.  1993;49:799–808.6. Robert E Marx, DDS, a, Eric R Carlson, DMDb, Ralph M Eichstaedt, DDSc, Steven R Schimmele, DDSd, James E Strauss, DMDe, Karen R Georgefff (RN) Platelet-rich plasma: Growth factor enhancement for bone grafts, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology Vol 85, Issue 6, June 1998, 638-6467. Eppley, Barry L. M.D., D.M.D.; Pietrzak, William S. Ph.D.; Blanton, Matthew M.D., Platelet-Rich Plasma: A Review of Biology and Applications in Plastic Surgery, Plastic and Reconstructive Surgery. Nov 2006 Vol 118 Issue 6 147-1598. Timothy E. Foster, MD†*, Brian L. Puskas, MD†, Bert R. Mandelbaum, MD‡, Michael B. Gerhardt, MD‡ and Scott A. Rodeo, MD Platelet-Rich Plasma9From Basic Science to Clinical Applications, The American Journal of Sports Medicine Nov 2009 Vol 37 no 11 2259-2272References