Dr. Wagener explains what stress urinary incontinence and cytoceles are. He also looks at causes and treatment options.

1. Christopher W. Wagener MD Affinity Medical Group Obstetrics and Gynecology Stress Urinary Incontinence & Cytoceles

2. Overview Stress Incontinence What is it? What causes it? How is it treated? Cystocele What is it? What causes it? How is it treated? What’s new and what should you be aware of?

3. Incontinence International Continence Society (ICS) (2002) The complaint of any involuntary leakage of urine. It increases with age, but is not normal and treatment is available.

4. Incontinence Stress incontinence 50% Overactive bladder syndrome 25% Mixed incontinence 25% Overflow incontinence Fistulae Urethral diverticulum Functional Reversible causes

5. How the Urinary System Works Kidney Ureter Bladder Bladderneck Urinarysphincter Urethra

6. Stress Incontinence Involuntary leakage of urine on effort or exertion, or on sneezing or coughing Usually small amounts Pressure in the bladder exceeds the urethral pressure No bladder contraction

7. Stress Incontinence Causes Pregnancy/Childbirth Age Obesity BMI 25-30, 2x increase BMI >40, 66% Chronic cough ACE inhibitors Smoking Genetics Evaluation History Physical exam Cough stress test Urethral mobility Assess for prolapse Urine test Possibly urodynamic testing

8. Stress IncontinenceTreatment Weight loss, treatment of chronic cough Physiotherapy Pelvic floor muscle training Vaginal cones Biofeedback Pessary with incontinence knob Midurethral sling Periurethral bulking agents

9. Tension-Free Vaginal Tape Sling Indicated when conservative treatment fails Child bearing is complete Restores the urethral support 85 to 90 % success rate Minimally invasive 6 weeks of restrictions, recommend 2 weeks off work Risks Bleeding, infection, bladder or other organ injury Mesh erosion, urinary retention, overactive bladder symptoms

10. TVT Sling

11. Bulking Agents Minimally invasive Consider for patients with non-mobile urethra, prior unsuccessful incontinence procedures, significant health problems 40- 60 % success rate No restrictions after surgery May take more than one procedure No long term studies to show it is long lasting Risks: Urinary tract infection, retention, discomfort

12. Bulking Agents

13. Cystocele Protrusion of the bladder into the vagina (hernia) Also called a dropped bladder/prolapsed bladder May be associated with uterine prolapse, rectocele, or enterocele May notice a vaginal bulge or pressure Urinary symptoms including incomplete bladder emptying

14. Cystocele

15. Cystocele Causes Childbirth Age Genetics Occupation Medical conditions COPD, cough Obesity Constipation Evaluation History Symptoms Incontinence Pelvic exam Stage prolapse Strain or bear down Check uterus and ovaries +/- Cough stress test +/- Urine test

16. Natural History Prospective observational study 259 postmenopausal women, with a uterus Over 3 years Maximal descent increased by >2 cm in 11.0% Maximal descent decreased by >2 cm in 2.7% Obesity and grandmultiparity were risk factors for worsening prolapse Bradley, Obstet. and Gyn. 2007; 109:848

17. Cystocele Treatment: Pessary Appointment to fit Trial May not work for certain patients Side effects Discharge Pressure sores UTI

18. Surgery Cystocele repair Anterior repair Anterior colporrhaphy Without grafts Suture repair With grafts Biological grafts Synthetic grafts

19. Cystocele Treatment Symptom likely to resolve Questionable if symptom will resolve Bulge Pressure Urinary Gastrointestinal Sexual function Pelvic and back pain Consider pessary trial

20. Grafts Lower rate of failure Fewer hysterectomies with graft use Patient acceptance Possible risk factor for incontinence Minimize risks of intra-abdominal complications Complications

21. Graft supporting bladder and uterus 21

22. Risks of Synthetic Grafts Erosion 3-8 % Infection Rejection of mesh Dyspareunia (pain with sex) 10% Injury to adjacent structures

23. FDA Public Health Notification October 2008 Over 1000 reports of complications in a 3-year period Specific characteristics of the patients at risk have not been determined Complications of erosion through the vaginal epithelium, infection, pain and urinary problems

24. Recommendations for Physicians Obtain specialized training for each mesh placement technique, and be aware of its risks. Be vigilant for potential adverse events from the mesh, especially erosion and infection. Watch for complications associated with the tools used in transvaginal placement, especially bowel, bladder and blood vessel perforations. Inform patients that implantation of surgical mesh is permanent, and that some complications associated with the implanted mesh may require additional surgery that may or may not correct the complication. Inform patients about the potential for serious complications and their effect on quality of life, including pain during sexual intercourse, scarring, and narrowing of the vaginal wall (in POP repair). Provide patients with a written copy of the patient labeling from the surgical mesh manufacturer, if available.

25. Grafts Consider for patients with recurrences Paravaginal defects Severe prolapse or poor native tissue Weigh risks and benefits

26. The Future Robotically assisted prolapse surgery Minimally invasive Vaginal apex prolapse