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MRCOG PART 2 SBAs and EMQs

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ESSAY 228 - incontinence

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		Posted by Srivas P. Wed Feb 14, 2007 08:10 pm
a)Non surgical options of management of stress incontinence are conservative and medical options. Conservation option in the form of pelvic floor exercises should be offered first line as it has been found to be effective and devoid of side effects. It improves symptoms in 30-70% patients. But it needs motivation with high recurrence once it is stopped. Some women are unable to contract the pelvic muscles and maybe helped by a trainer. Occasionally biofeedback, weighted cones and electrical stimulation have been tried but results are not better than PFE alone. Mechanical devices which are bladder neck support devices may be offered if she is unwilling or is waiting for surgery or for a specific purpose like during physical exercise, social functions to avoid incontinence. These are intra urethral devices or intravaginal devices like tampons, rings, pessaries. They may cause UTI, haematuria, vaginal erosions and are not recommended over longer periods. Life style modifications like cessation of smoking, weight loss in obese patients, avoidance of constipation and fluid management add on to effects of PFE and medical therapies. She should be offered Duloxetine as second line treatment if she prefers medical option to surgical option. It is a combined Serotonin and nor-adrenaline receptor inhibitor and acts by improving the sphincter tone. 50% women show 65-100% improvement. But side effects like dry mouth, constipation, head ache, insomnia and sometimes somnolence can discourage continued use. Estrogen has no role for incontinence. Use of alpha adrenergic agents like phenylpropanolamine is now not favored due to possible cardiac effects. b) Options depend on presence of prolapse, previous surgical procedures if any and surgical expertise available. Mid urethral supports using Transvaginal tape (TVT) offers good results even in the presence of previous failed surgery, technically easy, can be done as day case, without GA, shorter hospital stay, reduced morbidity, and cost effective. Gives 85% Continence rate with low post op complication ?2% risks of Voiding dysfunction and 5% detrusor Overactivity and 4-9% risk of bladder perforation depending on surgical expertise. Burch coposuspension is equally effective as mid urethral TVT support and can correct coincident cystocele but unfortunately it may cause post op enterocele and prolapse in 14% case. Success rate is very high at 85% over one year and more than 70% after 5 years. Continence in secondary surgery is lower at 60%. Post op shows higher Voiding dysfunction 10% and 17% detrusor overactivity. Counselling should include these side effects. Aldridge autologous rectus fascial sling operation is comparable to previous two procedures with 80% success rate but having similar side effects- 10% voiding dysfunction and 14 % detrusor overactivity. Transobturator mid urethral supports seem encouraging but lacks long term data. Periurethral bulking agents like like silicone, collagen, Teflon injected into periurethral tissue around bladder neck have a role when other surgical prodedures have failed. It causes low post operative morbidity and has 76% continence rate but these declines over time to 48% and she may need repeat injection. Artificial urinary sphincters are last resort when all continence procedures have failed, due to high morbidity with the procedure which includes UTI, malfunctioning and erosion of device. Gives 92% continence rate but may need re-operation. Alternative retro pubic procedures like Marshall marchetti Krantz is not favoured because of risk of haemorrhage and osteitis pubis in 2.5% cases. Laproscopic colposuspension is not favored too due to lack of sufficient data, need for expertise in laproscopic surgery and lack of consensus on correct method, higher operation times and higher complication rates. Advantage compared to open colposuspension does include lower blood loss, shorter hospital stay and quicker recovery. Needle suspension procedures are not recommended due to high failure rate. Anterior repair is not recommended for operation for stress incontinence though there is no consensus yet on correct prodedure for stress incontinence with prolapse. Separate vaginal repairs with a TVT mid urethral support seem to be good option.
		Posted by GBENGA O. Wed Feb 14, 2007 10:46 pm
a) Modification of life style such as ceasation of alcohol and smoking will provide symtomatic relief.Avoiding provoking factors by treating chronic cough and chest infections will aslo bring some relief.Pelvic floor exercise if performed as recommended by the professional physiotherapist has been shown to be successful in about 40% of patient.Addition of biofeedback may increase the success rate.However,this has to be done for about 20weeks to bring the desired result.Urethral supports such as ring pessaries,vaginal-weighted cones have been tried with limited success.Duloxetine,a combined serotonin and nor-adrenaline re-uptake inhibitor increases the urethral pressure and thence continence.It also improves the quality of life.The dose is 20mg BD and it\'s recomended for 12 weeks for a desired result.Its side effects include nausea,vomitin and abdominal discomfort.Use of exogenous estrogen has been tried with very limited success. b) It is important to rule out co-existent detrusol instability before any surgical procedure is undertaken as this may be worsened post-op.Therefore urodynamic studies is performed if one has not been done.It is also pertinent to assess the woman for vaginal prolapse and urethral neck mobility,these would influence the type of procedure to offer the woman. Burch colposuspension which can be open or laparoscopic has a short-time continence rate of 85%.It is associated with voiding difficulty and urge incontinence.It cannot be performed as a 2nd procedure.Marshall-Machetti-Krantz is a similar procedure with lower success rate and associated with oestitis pubis.Sling procedure is another option.This essentially increases the mid-urethral pressure by using a mesh tape.Trans-vaginal free tape is a popular and tested example and has a continence rate of about 80-85%.It can be done as a day case with local anaesthesia.Some of its complications are voiding difficulty,bladder perforation,haemorrage.The other procedure in this category is trans obtutarator tape.Anterior repair is an option when there is a co-existent cystocoele>the continence rate is just about 60% with associated voiding difficulty,UTI,DVT and haemorrage.Other options include artificial urethral,urinary diversion,neo-urethral-but their outcome are not remarkable and quality of life are not greatly improved. It is important to take the woman\'s views and provide information leaflets to assist her in making a choice.
		Posted by Misbah W. Wed Feb 14, 2007 11:32 pm
A healthy 65 year old woman complaining of urinary leakage on straining is found to have genuine stress incontinence. (a) Critically evaluate the non-surgical treatment options [6 marks]. (b) Critically evaluate the surgical treatment options [14 . marks] a] Non-surgical treatment options are helpful in controlling symptoms ,High satisfaction rate and lack of morbidity when compare to surgical options .Behavioral modification like reduce fluid and tea intake will help to improve the symptoms. Treatment of constipation and weight reduction will also be helpful. Physical therapy modalities include pelvic floor exercise {with or without biofeedback] ,electrical stimulation and weight cones .These are superior to placebo in short term but requires to continue for long term success. Number of vaginal and urethral devices are available which have the advantage of being inserted and removed on patients discretion but not very helpful in severe cases .New drug duloxetine have shown improvement in symptoms and quality of life but is associated with side effects like headach and GI symptoms. Estrogen alone or with combination with alfha-agonist has been suggested but shown no proven value in clinical trails . Alfha- agonist and antidepressants have shown improvement but may aggravate hypertension ,hyperthyroidism and cardiac arrhythmas. B] Aim of surgical treatment of GSI is to correct the anatomical defects which are responsible for the loss of urine .Primarily, restoration of intra-abdominal position of bladder neck and increase resistant in uretra. Burch colposuspension is the most effective surgical procedure for GSI, with a continence rate of 85-90% at one year. There is slight fall in continence rate in long term but better than other methods like needle suspension. Complication associated are voiding difficulty[10%],De novo detrusor overactivity[17%], enterocele and ureteric damage. Marshall Marchitte-krantz is an equally effective suprapubic procedure but associated with more serious complications like pubis osteitis. Role of laparoscopic colposuspention and paravaginal repair is unclear. Sling procedures [TVT] produce a continence rate of 80%,which is maintained for long time when compare to suprapubic procedures. Complication like voiding difficulty and detrusor instibility are camparable to Burch colposuspension. Other complication are sling erosion, injury to bladder, bowel ,vessel or nerve. New transobturator tape[TOT ]have shown better results in respect of these complication but still under trails. Anterior repair is less successful for continence as compare to suprapubic procedure, but still has a role in treatment of prolapse without incontinence. Needle suspension procedures are no longer performed as failure rate is high when compare with suprapubic procedures.Bulking injectible agents have a short term success rate of 48% and a continued fall is seen with time .It is associated with low morbidity and can be offered in cases where other procedure have failed and in case intrinsic sphincter deficiency. Artificial sphincter can be successfully used after failed continence surgery or where surgery is refused. A cure rate of 80% is observed when used as primary procedure. Complication associated are cuff erosion and failure of device. Women should be provided with written information and leaflets. d
		Posted by sailaja devi K. Thu Feb 15, 2007 03:23 am
Stress incontinence is a distressing symptom that has major impact on women?s quality of life.Women experience discomfort,restriction of normal activities ,social isolation & misery. Conservative treatment was restricted as there were doubts about efficacy. Nonsurgical management is essential before embarking on surgical treatment .The conservative options were enhanced by pharmacotherapy . Lifestyle interventions like weight loss ,exercise ,cessation of smoking ,alteration of fluid management & relief of constipation reduce incontinence .There were no trials to study effectiveness of this treatment Physical therapy like pelvic floor muscle training is commonly recommended for stress incontinence .Adjuncts, like biofeed back or electrical stimulation are used with pelvic floor retraining.Intensive training is associated better outcome. Refer the women to physiotherapist trained in pelvic floor work as 50 % of women cannot perform exercises correctly .Exercise is associated with improvement in 40-60 % of women.There is no evidence to support the use of weighted vaginal cones. Devices to prevent urinary leakage are bladder neck support devices ,devices to block the external meatus& intraurethral devices.Bladder neck support showed improved results but required patient acceptance & manual dexterity.Intraurethral results demonstrated efficacy but associated with urinary tract infection & haematuria. The central nervous system control mechanisms were implicated in pathophysiology of stress incontinence.Neurotransmitters serotonin & adrenaline influence the contraction of urethral sphincter . Serotonine enhanced neurotransmission so have positive beneficial effect on continence.Duloxetine a noradrenaline & serotonin reuptake inhibitor showed improvement in 50 % of women experiencing a 60 -100 % reduction in episodes of incontinence. The most common adverse effect is nausea.Other adverse effects are dry mouth ,fatigue, insomnia,constipation headaches ,dizziness ,somnolence & diarrhea. Physiotherapy & duloxetine to be offered before surgery . Surgery is done for less than 5% of women with stress incontinence.Surgery is offered were conservative therapy failed .Surgery should be aimed to reduce incontinence & improve quality of life. Burch colposuspension has been treatment of choice ,with success rate of 85% at 5 yrs.,dropping to 70 % thereafter.Complications are voiding disorder in 10 %,de novo detrusor instability in 17% & genitourinary prolapse in 14 %.Bruch is most effective treatment than MMK procedure or paravaginal repair. Laproscopy has advantage of avoiding a large incision,resulting in short hospital stay & quick return to normal daily activities.Laproscopy requires long operative time.Laproscopy should be done by experienced surgeon .Laproscopy surgery should not be compromised by placing few sutures than would be the case with in an open surgery. In comprasion with TVT, laproscopy is less successful & cheaper . Classic open bladder neck surgery has success rate of 80% , higher success with synthetic material. There is 10 % risk of voiding dysfunction & 14 % risk of de novo detrusor overactivity .Synthetic material increases the risk of erosion & sinus formation. TVT is inserted vaginal at the level of midurethra .Place the tape under the urethra without tension.TVT can be done as day care surgery .TVT associated with 85% success rate, 2 % voiding disorder requiring release of tape & 5 % urgency.TVT is associated higher rate of bladder perforation.NICE recommended TVT & Bruch colposuspension in women in whom conservative treatment failed . The newer suburethral sling procedures are not equivalent to TVT in terms of evidence-base.Suburethal procedure uses transobturator approach rather than suprapubic . Periurethral bulking agents are injected into the urethral submucosa distal to the bladder neck to create to create artificial urethral coaptation & restore continence.Sucess rate is 50% at 2 yrs.Bulking agents has low morbidity .It has role when other procedures failed & when the women is unfit for surgery. Artificial urinary sphincter has role has role when conventiomal surgery has failed ,the patient is not willing to accept incontinence or catheter drainage or diversion procedure. The use of anterior repair & needle suspension are associated with poor long-term outcomes so do not have any role in treatment. TVT is the most cost effective primary procedure ,retaining the success rate & cure rate of open colposuspension but with decreased morbidity ,short hospital stay & quick return to work.
		Posted by neera B. Thu Feb 15, 2007 11:28 pm
a) GSI can significantly affect quality of life, hence treatment options should be discussed, leaflets given so that she can make informed choice. She should be advised to restrict fluid intake to 1-1.5 litres per day. Alcohol and caffeine should be cut down as excessive intake may worsen symptoms. Weight reduction in obese women is effective and cheap option of treatment . Incontinence pads should be provided and help from community incontinence advisor should be offered because old people sometimes maybe living alone. Barrier creams should be offered to those who have excoriations due to urinary leakage. The option of pelvic floor muscle training for 3 months is effective and cheap 1 st line option. It does not need hospitalization but patient has to be well motivated, lack of compliance reduces efficacy. Biofeedback and electric stimulation need time and trained personnel. They are not routinely recommended but may be useful if patient cannot contract pelvic floor muscles on her own. Duloxitine is a selective serotonin receptor inhibitor, is effective nonsurgical option but use is limited by side effects like dry mouth , headache, reduced libido and anorgasmia.Withdrawal effects are there . Moreover it is contraindicated in hepatic disease, with MAO inhibitors , warfarin, ciprofloxacin, tricyclic antidepressants and SSRIs. Though not a first or second line treatment option , it is useful if patient is unfit for or refuses surgery or is awaiting surgery or as an alternative to surgery. Hormone replacement therapy is not beneficial for GSI though intravaginal estrogen may help women with overactive bladder . Vaginal cones , contiguard, pessaries have not been found more effective than placebo. b) Rretropubic midurethral tape procedures using bottom up approach with polypropylene mesh (TVT) is an outpatient procedure which can be performed under local or regional anaesthesia. It is associated with earlier mobilization and lesser post operative morbidity than Burch colposuspension which involves abdominal incision , general or regional anaesthesia and usually 4-5 days of inpatient stay. Both are equally effective with 85-90% success rate at 1 year which is maintained over 3 yrs. Though initial cost of TVT may be more , but it is cost effective if the hospitalization cost with Burch colposuspension is considered. Voiding difficulty occurs in 2 % patients after TVT but 10 % with Burch. Need for self catheterization is thus lesser with TVT . De novo detrusor instability occurs in 5 % patients after TVT and in 17 % patients after colposuspension. Risk of mesh erosion and bladder perforation ( 2-9 %) exist with TVT . Post operative rectocele may occur with colposuspension. Autologus rectus fascial sling has similar success rate as the above 2 procedures with side- effects like colposuspension. Transobturator tape has similar advantages as TVT. Though early reports show lesser risk of bladder perforation than TVT , long term data are awaited . Laporoscopic colposuspension is associated with lesser blood loss , shorter hospital stay and quicker recovery but needs trained personnel . There is lack of long term data and lesser success rate than open Burch. Marchell Marchetti Krantz procedure is associated with osteitis pubis in 2 % cases and lack of sustained continence. Needle suspension procedures are not advocated due to lesser long term success rate and more side effects. Anterior vaginal repair is not effective for isolated GSI . Artificial sphincters are useful if previous incontinence surgeries have failed but device failure can occur , necessating replacement . Bulking agents like silicon and collagen injected aroung bladder neck are effective if previous continence surgery has failed but success rates are not maintained over the years. Options should be discussed with the woman, leaflets given to enable her to make an informed decision.
		Posted by Freha Z. Fri Feb 16, 2007 03:56 am
Conservative management are life style adjustments like reducing alcohol, caffeine intake, avoiding constipation, reducing weight and cessation of smoking. 50% of women may benefit from non surgical techniques. Pelvic floor exercises significantly improve stess incontinence than electrical stimulation and vaginal cones. Biofeedback doesnt improve outcome. It is associated with 30-67% improvement but recurrence can occur on discontinuation of exercises. Duloxetine a serotinin and noradrenaline reuptake inhibitor can result in increased sphincter activity. It results in significant improvement in incontinence episodes and reduction in social embarrasment. Side effects include anorgasmia , dry mouth & nausea vomiting. Oestrogen doesnt result in objective improvement in stress incontinence symptoms. Mechanical devices such as bladder neck support, continence guard and pads are associated with less acceptance and cystitis and vaginal bleeding. (b)Surgical treatment depends on primary or secondary surgery, associated prolapse, mobility of bladder neck, fitness of surgery expertise and objective cure rates. Retropubic procedures such as Burch colposuspension involves replacement of urethra in the abdomen so that increase in abdominal pressure can maintain continence. Continence rates are 85% at 1 year and 70% at 5 years compared to low rates in Marshall Marchetti Krantz procedure. Sucess is higher in primary surgery. Complications are de novo detruser instability, voiding dysfunction and enterocoele formation. Osteitis pubis can occur in Marshall Marchetti Krantz procedure. Sling procedures such as TVT can be performed under local anaesthesia with success rates 86% at 3 years. Long term data is not available and can be performed as a secondary procedure. It can lead to denovo detruser instabilty(15%), voiding dysfunction, bladder injury(9%) and errosion of mesh. Anterior colporraphy can be performed in association with surgery for prolapse but have low success rate for stress incontinence. It can unmask stess incontinence by unkinking the urethra in case of prolapse. Operation has low morbidity but reoperation rate is high. Needle suspension is associated with lower intraoperative complication rate but long term outcome is poor therefore procedure not recommended. Transobturator procedure uses same tape as TVT It is a relatively new procedure so long term data not available. Collagen injection can be used to butress urethra with 50% continence rate. Morbidity is low and can be used as secondary procedures. Other procedures with high morbidity and low succss rates are Artficial sphicter and urinary diversion. These procedure are limited to when all other treatments fail.
		Posted by Parveen Q. Fri Feb 16, 2007 08:16 am
(a) Life style modification, weight reduction, cessation of smoking can produce symptamatic improvement. Pelvic floor exercises, significantly reduces stress incontinence, are more effective than electrical stimulation or vaginal cones. It has to be done for long term for 15-20weeks . Addition of biofeed back doesnot improve outcome. It is the first line of treatment, for those reluctant for surgery. It has a cure rate of 27-67%.and should be offered a trial before contemplating surgery. Medical treatment -Duloxetine( combined serotonin, noradrenalin reuptake inhibitor )increases sphincter activity in the storage phase of the micturition cycle. When compared to plcebo, duloxetine reduces the incontinence episode per week, and reduces the social, and psycological impact of incontinence, and produces significant improvement in the quality of life. The other option is Oestrogen replacement , which helps in subjective improvement in symptoms, but it fails to produce any objective measures of incontinence. aAlpha adrenergic agonists, like phenylpropanolamine is not significantly different from pelvic floor exercises, 84% and 77%respetively. Mechanical devises like bladder neck support prosthesis, continence guard, urethral plugs produce 87% objective rates, but associated with complications like cystitis, vaginal abrasions. (b)Choice of operation depends on whether it is a primary or secondary procedure, presences of other pathology like prolapse, fitness for surgery, expertise and objective success rate, patient\'s choice. Difficulty to compare efficacy as there is no standarisation of technique, or length of followup. Burch colposuspension, is the most successful procedure. the aim is to replace the proximal urethra into the abdominal cavity, thus enabling the transmission of abdominal pressure to proximal urethra to maintain continence. Unlike other procedures, it has a long term cure rate of 85-90%at 1year, 70% at 5years. It has similar short term continence rate when compared to sling procedures. It corrects cystocole. The main problem is deno DI 17%, longterm voiding problems, and enterocole rectocoele after 5years. It can be performed laproscopically or open. MMK, is similar to bursch colposuspension, but involves suturing to the posterior pubic ramus. It doesnot correct cystocoele, and its complication is ostetitis pubis in 0.5 to 5%. Sling procedures, (pubourethral sling, TVT) aim to increase urethral pressure. It is suitable in case of intrinsic sphincter deficiency, and for those who had colposuspension previously. It can be done under local anaesthesia. Failure rate is high in those who had previous incontinece surgery. similar success rates to colposuspension- complete dryness 38%in TVT , 40%in colposuspension at 6months. Complications are bladder perforation , erosion of sling , intraoperative bleeding. Anterior colporrhaphy, aim to correct and repair defects in the pubovesical fascia. it has poor success rate , higher reoperation ratewhen compared to colposuspension, but associated with low morbidity, and minimum longterm voiding dysfunction. Needle suspensions has comparable outcome to colposuspension, but long term outcome is poor, only 18%dry at 5years ,are not recommended. Trans obturator foramen procedure , uses tape similar to TVT but uses different technique. Longterm data not available. Other procedures like periurethral collagen injections , has lower success rate,48%incontinence, but it declines over time. It is suitale for women with intrinsic sphincter difficiency. Other procedures like artificial urethra, urinary diversion is performed only in those with previous failed surgeries, but is associated with high morbidity, and reoperation rates.
		Posted by Parveen Q. Sun Feb 18, 2007 08:45 am
Dear Dr.Paul Thank you very much for correcting my essays. The Success rate -complete dryness is 38%for TVT and 40% for colposuspension at 6months, where as the success rate for colposuspension at 1year is 85-90%. sorry if i didn\'t make it clear. I am a relatively new user to the forum, and your markings stimulate me to read effectively. Thanks again. parveen.
		Posted by TAIWO NURENI Y. Sun Feb 18, 2007 09:42 am
a)Lifestyle interventions like modification of fluid intake do reduce symptoms and this could be aided by frequency - volume charts.Cessation of smoking and alcohol can also reduce symptoms.Physiotherapy in form of pelvic floor exercise carred out under professional supervision could give up to 27-60% cure rate.Patient however need to be motivated and the result gained could be lost on cessation of the exercise.Vagina weighted cones can be used as adjunct to pelvic floor exercise as well as electrical pudendal Nerve stimulation with electrode placed in the vagina.Their efficacy however has not being proven alone . Use of estrogen has not been confirmed to have any curative effect on incontinence.Mechanical device like intravagina continence guard coulbe used to elevate bladder and produce some result but for a short term use. Duloxetine a serotonin and nor epinephrine reuptake inhibitor is also effective when combined with other conservative measures but causes headache,nausea and abdominal discomfort.There is also need to continue the medication for long time or indefinitely. b)Surgical option depends on patient wish and expertise available.Burch colposuspension produce about 80% cure rate in the first year but this reduce to less than 70% in 5years.It is associated with morbidity like haemorrhage,bladder dysfunction and de novo detrussor instability in about 17% of patient.Enterocele is also a documented sequelea.The colposuspension could be done laparoscopically with reduced morbidity,shorter hospital stay but less effective than open surgery.Tension free vagina tape has comparable efficacy with colposuspension in the ist year but long term efficacy not yet available.It could be done under local anaesthesia hence shorter hospital stay but associated with urinary retention ,damage to bladder in about 8% and haemorrhage.There could also be mesh erosion in the long term.Marshall-marchetti krantz has a similar cure rate with colposuspesion but causes osteitis pubis which is very difficult to treat hence no longer in use.Stamey operation has lesser morbidity,shorter hospital stay and quicker recovery but less effective than colposuspension. Anterior colporrhaphy has about 60% 5year cure rate,less morbidity but need for repeat surgery is common .Neourethra or urinary diversion should be reserved for expert surgeons and intractable incontinence.
		Posted by Abi T. Mon Feb 19, 2007 03:42 am
a) The non surgical options include conservative and pharmacological treatments. Pelvic floor exercises (PFE) should be offered as first line treatment and as a trial to any woman contemplating surgery. It has shown a 27-67% improvement and this should be supervised by a physiotherapist to acheive the best results. However motivation may be a problem as it is recommended for at least 15-20 weeks and recurrence rates are high after cessation of PFE. Using biofeedback alone does not improve outcome and results from using vaginal cones are no better than PFE alone. Biofeedback and vaginal cones are invasive and may be unacceptable to some women. Intravaginal bladder neck supports such as Contiguards and tampons may be used temporarily whilst awaiting surgery or during social functions or holidays. However there are risks of infection (UTI) and vaginal erosions with long term use. Duloxetine is a new serotonin and noradrenalin reuptake inhibitor which increases sphincter contractility. Early studies have shown a significant reduction in incontinence episodes versus placebo. However side effects such as dry mouth, GI disturbances and blurred vision may cause discontinuance and long term data is unavailable to ascertain long term continence rates. Estrogen may improve subjective symptoms however RCTs have shown no improvement objectively. Phenypropanolamine is an alpha adrenergic which provides no better results than PFE alone. b)Choice of surgical options depend on presence of prolapse or any other voiding dysfunction,availabilty of surgical expertise and whether it is a primary or secondary procedure. The objective succes rates and inherent risks should be discussed with the patient. Anterior colporraphy is no longer used for GSI as retropubic and sling procedures have superceded this with better long term results. However it remains as a treatment for cystourethroceles. Colposuspension is a retropubic procedure and can be done as an open or laparoscopic procedure. The BIrch colposuspension offers an 85-90% continence rate at 1 year and 70% rate over 5 years. The short term results are similar results to sling procedures. It can also correct cystoceles. It does require a transabdominal approach and the risks are denovo detrusor instability and enterocele formation (7-17%) and is less succesful if done as a secondary procedure. The Marshall-Marcheti-Krantz is another open procedure but has fallen into disuse as it is likely to fail at 5 years and the risks are osteitis pubis and difficulty retaining sutures in the periosteum. Laparoscopic colposuspension procedures has the advantage of shorter hospital stay and less blood loss but higher objective failure rates than open procedures. However, experience of the surgeon and nature and number of sutures used can improve outcome. It is also more expensive and has longer operating time. Needle suspensions are no longer recommended as long term continence rates are poor and it has been replaced by sling procedures. Suburethral slings such as TVT have an 80% continence rate over 5 years. It can be done as a second procedure after failed colposuspension and has the advantage of being done under local or regional anaesthetic and requires shorter hospital stay. It does have a higher risk of bladder and urethral injuries.Voiding difficulties and denovo detrusor instability may arise in 3.7-66% of patients.Long term voiding difficulties are less common compared to colposuspension. Mesh erosion is a long term complication. TOT is another sling procedure which is relatively new and lacks long term data. Injection of periurethral bulking agents are suitable for women with intrinsic sphincter deficiencies and with previous failed multiple continence procedures. It has low morbidity and can be done under local anaesthetic. The long term success is poor and the procedure needs repeating. Artificial sphincters are useful in women who have had previous failed continence procedures or intrinsic sphincter defects, but the morbidity is high and may need further surgery.
		Posted by Fahima A. Mon Feb 19, 2007 07:20 pm
a) Non- surgical managements are usually tried before surgical management & some of them are very effective. Among them pelvic floor muscle exercises (PFME) significantly reduce the symptoms ( upto 60- 70%) & therefore all women are given a trial of 3 months physiotherapy before surgery. But only 50% of the women can perform it correctly & it needs to be well motivated, so supervised exercise is preferred. Electrical stimulation & weighted vaginal cones are tried with PFME in some cases but are not shown to be effective than PFME alone, hence not recommended. Life style modifications such as cessation of smoking, modification of fluid intake, relief of constipation, may produce symptomatic improvement. Bladder neck prosthesis, device to block external urethral meatus are tried but acceptability is not good as it may cause UTI, vaginal abrasion, discomfort. Medical therapy includes Duloxetine a combined serotonin & noradrenaline reuptake inhibitors show a significant reduction in incontinence. But the side effects include dry mouth, constipation, headache, dizziness, somnolence, & theoretical risk of suicidal ideation. It also has drug interactions with many drugs. Therefore it is only used as second line treatment when unfit for surgery or medical treatment is preferred. b) Tension free vaginal tape (TVT) a sling procedure, is widely accepted has a success rate 80-90%. It is a day case procedure, done without anaesthesia & therfore cost effective However there may risk of voiding dysfunction, bladder injury. Burch colposuspension: Open Burch colposuspension has long term data available, is also an acceptable procedure. It has a cure rate 85% in first year which decreases 70% after 5 years use. It has risk associated with anaesthesia , 18% risk of voiding dysfunction which decreases over time, denovo detrussor instability, rectocele and enterocele formation. Laporoscopic colposuspension is time consuming, needs skilled personal therefore data is not widely available. Transobturator tape (TOT) is a newer technique, may have lower risk of bladder perforation but needs more trial before making any comment. Autologus rectus fascial sling is an open procedure, has been largely replaced by TVT. Periurethral bulking agents are the periurethral injections( with silicone/ gluteraldehyde/cross linked collagen) can be given in failed procedure.It has low morbidity repeat injections can be given but efficacy is only 50%. MMK procedure has been abandoned because of lower success & higher morbidity ( ostities pubis 2%). Needle suspension procedure also has higher morbidity. Anterior colporraphy is an operation for cystocele not for GSI.