Urogynecology: Evidence-Based Clinical Practice

219 Pages·2013·4.395 MB·English

by  Kate H. Moore (auth.)

Urogynecology:
Evidence-Based
Clinical Practice

Kate H. Moore
Urogynecology:
Evidence-Based
Clinical Practice
Second Edition
Kate H. Moore, MBBS, FRCOG, FRANZCOG, MD, CU
Department Obstetrics & Gynaecology
St George Hospital
Kogarah
New South Wales
Australia
ISBN 978-1-4471-4290-4 ISBN 978-1-4471-4291-1 (eBook)
DOI 10.1007/978-1-4471-4291-1
Springer London Heidelberg New York Dordrecht
Library of Congress Control Number: 2012950313

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Contents
1 Taking the History . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
History Taking for Incontinent Women . . . . . . . . . . . . . 1
Incontinence Symptoms . . . . . . . . . . . . . . . . . . . . . . 1
Nonincontinent Symptoms of Storage Disorders:
Frequency, Urgency, and Nocturia . . . . . . . . . . . . . . 2
The Frequency–Volume Chart (FVC) . . . . . . . . . . . . . . . 3
Other Types of Leakage . . . . . . . . . . . . . . . . . . . . . . 5
How Bad Is the Problem? . . . . . . . . . . . . . . . . . . . . . . . . 5
History Taking for Voiding Difficulty . . . . . . . . . . . . . . . 6
History Taking for Prolapse . . . . . . . . . . . . . . . . . . . . . . 8
History Taking for Fecal Incontinence . . . . . . . . . . . . . . 8
Symptoms of Obstructive Defecation . . . . . . . . . . . . . . . 9
Assessing Previous Surgical History in Relation
to Urinary Incontinence . . . . . . . . . . . . . . . . . . . 10
History Taking for Dyspareunia . . . . . . . . . . . . . . . . . . . 11
History Taking for Recurrent Bacterial Cystitis . . . . . . . 12
History Taking for Painful Bladder
Syndrome/Interstitial Cystitis (IC) . . . . . . . . . . . 12
History of Drug Therapy That May Facilitate Urinary
Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
General Assessment of the Patient in Relation
to Urogynecology . . . . . . . . . . . . . . . . . . . . . . . . 14
2 Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Examine the Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Inspect the Vulva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Elicit a “Stress Leak” . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
vv
vi Contents
Speculum Examination . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Pass a Bivalve Speculum . . . . . . . . . . . . . . . . . . . . . 18
Pass a Sims Speculum . . . . . . . . . . . . . . . . . . . . . . . 18
POPQ Scoring System of Prolapse . . . . . . . . . . . . . . . . . 20
Perform a Bimanual Examination . . . . . . . . . . . . . . 21
Assess the Pelvic Floor Muscle Contraction
Strength: Oxford Score . . . . . . . . . . . . . . . . . . . 22
Do All Urogynecology Patients Need
a Rectal Examination? . . . . . . . . . . . . . . . . . . . . 23
Screening Neurological Examination . . . . . . . . . . . . . . . 23
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3 How to Manage the Patient After History
and Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
First, Treat Precipitating Factors . . . . . . . . . . . . . . . . . . . 25
Second, Obtain All Relevant Old Notes . . . . . . . . . . . . . 25
Third, Begin a Basic Management Program
for Urinary Incontinence . . . . . . . . . . . . . . . . . . 26
Fourth, if Anal Incontinence Is Present . . . . . . . . . . . . . 27
Fifth, if Prolapse Symptoms Are Present . . . . . . . . . . . . 27
If Associated Recurrent Bacterial Cystitis
(Urinary Tract Infection, UTI) Is Present . . . . . . 27
If Suprapubic Pain, with Severe Frequency,
Urgency, and Nocturia, Is Present . . . . . . . . . . . 27
A Few Words About Explaining the Situation
to the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . . . . 28
Anal Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4 How to Conduct Urodynamic Studies:
Essentials of a Good Urodynamic Report . . . . . . . . . . 31
Who Needs Urodynamic Testing? . . . . . . . . . . . . . . . . . 31
Different Forms of Urodynamic Studies . . . . . . . . . . . . . 32
Practical Advice About How to Perform
Urodynamic Studies . . . . . . . . . . . . . . . . . . . . . . 34
Calibration of the Equipment . . . . . . . . . . . . . . . . . . 35
Contents vii
General Clinical Guidelines . . . . . . . . . . . . . . . . . . . 35
Explaining the Test to the Patient . . . . . . . . . . . . . . . 36
Uroflowmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Performance of Cystometry . . . . . . . . . . . . . . . . . . . 39
Passing the Rectal Catheter . . . . . . . . . . . . . . . . . . . 40
Twin Channel Cystometry . . . . . . . . . . . . . . . . . . . . . . . 41
Urodynamic Diagnoses Available
from the Filling Phase . . . . . . . . . . . . . . . . . . . . 42
What Is Sensory Urgency, Now Termed Bladder
Oversensitivity? . . . . . . . . . . . . . . . . . . . . . . . . . 44
Features of the Atonic Bladder During
the Filling Phase . . . . . . . . . . . . . . . . . . . . . . . . . 46
Videourodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Videourodynamic Testing . . . . . . . . . . . . . . . . . . . . 47
Value of VCU in Cystocele . . . . . . . . . . . . . . . . . . . 49
“Occult” Stress Incontinence . . . . . . . . . . . . . . . . . . . . . 49
Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Voiding Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Diagnoses Made After Voiding Cystometry . . . . . . 54
Special Urodynamic Tests . . . . . . . . . . . . . . . . . . . . . . . . 57
Urethral Pressure Profilometry . . . . . . . . . . . . . . . . . 57
Abdominal or Valsalva Leak Point Pressure Test . . 57
Triple Lumen (Trantner) Catheter Test for
Urethral Diverticulum, Now Replaced by MRI . 59
Note Regarding Diagnostic Tests for Vesicovaginal
Fistulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Example of Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Case History, with Example of a Full Urodynamic
Report, Illustrating Contribution of Urodynamic
Studies to Management . . . . . . . . . . . . . . . . . . . 60
Urodynamic Result. . . . . . . . . . . . . . . . . . . . . . . . . . 61
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Diagnosis: Marked Detrusor Overactivity (DO)
with Mild Degree of Obstruction; Mild Stress
Incontinence Management . . . . . . . . . . . . . . . . . 63
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
viii Contents
5 Outcome Measures Used to Assess Response . . . . . . . 65
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Tests That Measure Patient’s Symptoms . . . . . . . . . 67
The Wexner Score for Fecal Incontinence . . . . . . . . 67
Tests That Quantify Patients’ Symptoms . . . . . . . . . . . . 67
Bladder Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
The Pad Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
The One-Hour Pad Test . . . . . . . . . . . . . . . . . . . . . . 71
The 24-Hour Pad Test . . . . . . . . . . . . . . . . . . . . . . . 71
Tests That Measure Anatomical and Functional
Observations by Doctors . . . . . . . . . . . . . . . . . . 72
Quality of Life for Incontinence . . . . . . . . . . . . . . . . . . . 72
Quality of Life Tests for Prolapse and Sexual
Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Why Do We Need QOL Tests for Prolapse? . . . . . . 73
Why Do We Need QOL Tests for Sexual
Function? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Socioeconomic Evaluation . . . . . . . . . . . . . . . . . . . . . . . 74
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6 Conservative Therapy of Urodynamic
Stress Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Managing Chronic Cough and Obesity . . . . . . . . . . . . . . 77
Treatment of Constipation . . . . . . . . . . . . . . . . . . . . . . . 78
Treatment of Postmenopausal Urogenital Atrophy . . . . 79
Practical Advice for Patients . . . . . . . . . . . . . . . . . . 80
Starting a Home-Based Pelvic Floor Muscle Training
Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
The Role of the Nurse Continence Advisor . . . . . . . . . . 82
Who Should Be Referred for Physiotherapy? . . . . . . . . . 84
What Does the Physiotherapist Do That Increases
Efficacy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
The Efficacy of Physiotherapy Techniques . . . . . . . . . . . 90
Extracorporeal Electromagnetic Chair
Stimulation Therapy . . . . . . . . . . . . . . . . . . . . . . 91
What to Do if Conservative Therapy Fails
but Patient Does Not Want Surgery . . . . . . . . . . 91
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Contents ix
7 Step-by-Step Guide to Treatment of Overactive
Bladder (OAB)/Detrusor Overactivity . . . . . . . . . . . . 97
Explain the Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Step-by-Step Guide to Bladder Training . . . . . . . . . . . . 100
How Do Anticholinergic Drugs Work? . . . . . . . . . . . . . . 101
Are Anticholinergic Drugs Effective? . . . . . . . . . . . . . . . 104
Role of Topical Estrogens . . . . . . . . . . . . . . . . . . . . . . . . 105
Alternative Therapies for Detrusor Overactivity . . . . . . 106
TENS (Transcutaneous Electrostimulation
Therapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
SANS Electro-Acupuncture (Stoller Afferent
Nerve Stimulator) . . . . . . . . . . . . . . . . . . . . . . . . 107
Hypnotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Electrostimulation . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Extracorporeal Electromagnetic Stimulation
Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Cystodistention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Botox Therapy (Botulinum Toxin A Injections) . . . 110
Intravesical Resiniferatoxin (RTX) Installation . . . . 111
Clam Cystoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Partial Detrusor Myomectomy . . . . . . . . . . . . . . . . . 112
Implantation of S3 Sacral Nerve
Root Stimulator . . . . . . . . . . . . . . . . . . . . . . . . . 112
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
8 Anal Incontinence and Disorders
of Obstructive Defecation . . . . . . . . . . . . . . . . . . . . . . . 117
Basic Physiology of Anal Continence and
Defecation for the Gynecologist . . . . . . . . . . . . 117
The Act of Defecation . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Overview of Anal Incontinence . . . . . . . . . . . . . . . . . . . 122
Treatment of Anal Incontinence . . . . . . . . . . . . . . . . . . . 124
Overview of the Disorders of Obstructive
Defecation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Assessing the Causes of Constipation . . . . . . . . . . . . . . . 127
Overview of Treatment of Disorders of Defecation . . . . 131
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132