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Clinical Practice Guidelines On Urogynecology: Philippine Obstetrical and Gynecological Society (POGS), Foundation, Inc
Clinical Practice Guidelines On Urogynecology: Philippine Obstetrical and Gynecological Society (POGS), Foundation, Inc
!
CLINICAL PRACTICE GUIDELINES
on
UROGYNECOLOGY
!
November 2010
!
FOREWORD!
REGTA L. PICHAY, MD
President
Philippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2010
REGTA L. PICHAY, MD
INTRODUCTION!
This publication represents the collective effort of the POGS in updating the
clinical practice of Obstetrics and Gynecology, specifically on Urogynecology, and
making it responsive to the most current and acceptable standard in this procedure.
A greater part of the inputs incorporated in this edition are the contributions
originating from the day-to-day academic interactions from the faculty of the different
Residency-Accredited Hospitals in Obstetrics and Gynecology in the country.
Profound gratitude is extended to all the members of the POGS, the Chairs
and Training Officers of the Residency-Training Accredited Institutions, the Regional
Directors, The Task Force Reviewers/Contributors, The CME Committee members,
and the 2010 POGS Board of Trustees.
OFFICERS
Regta L. Pichay, MD
President
Gil S. Gonzales, MD
Public Relations Officer
BOARD OF TRUSTEES
Efren J. Domingo, MD, PhD
Virgilio B. Castro, MD
Blanca C. de Guia, MD
Raul M. Quillamor, MD
Rey H. delos Reyes, MD
Ma. Cynthia Fernandez-Tan, MD
COMMITTEE ON CLINICAL PRACTICE GUIDELINES ON
UROGYNECOLOGY
MEMBERS
Ann Marie C. Trinidad, MD Ma. Victoria V. Torres, MD
Lisa T. Prodigalidad-Jabson, MD Christine D. Dizon, MD
Rommel Z. Duenas, MD
MANAGING EDITOR
Ana Victoria V. Dy Echo, MD
Lisa T. Prodigalidad-Jabson, MD
Chair
Members
Almira J. Amin-Ong, MD Lennette L. Chan, MD
Jennifer B. Jose, MD Maria Teresa C. Luna, MD
Manuel S. Ocampo, MD Judith M. Sison, MD
Regional Directors
Betha Fe M. Castillo, MD (Region 1) Noel C. de Leon, MD (Region 2)
Concepcion P. Argonza, MD (Region 3) Ernesto S. Naval, MD (Region 4)
Diosdado V. Mariano, MD (Region 4A NCR) Cecilia Valdes-Neptuno, MD (Region 5)
Evelyn R. Lacson, MD (Region 6) Belinda N. Pañares, MD (Region 7)
Fe G. Merin, MD (Region 8) Cynthia A. Dionio, MD (Region 9)
Jana Joy R. Tusalem, MD (Region 10) Amelia A. Vega, MD (Region 11)
DISCLAIMER, RELEASE AND WAIVER OF RESPONSIBILITY
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!
!
CPG ON UROGYNECOLOGY
TOPICS / CONTENTS / AUTHOR/S!
Introduction ……………………………………………………………… 1
Dr. Lisa T. Prodigalidad-Jabson
!
INTRODUCTION
Lisa T. Prodigalidad-Jabson, MD
References
1. Milsom I, Altman D, Lapitan MC, Nelson R, Sillen U, and Thom D. Epidemiology of urinary
(UI) and fecal incontinence (FI) and pelvic organ prolapse (POP). In Abrams P, Cardozo L,
Khoury S, and Wein A (Eds). Incontinence: WHO–ICUD International Consultation on
Incontinence, 4th edition, 2009.
2. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse
in the women’s health initiative: gravity and gravidity. Am J Obstet Gynecol
2002;186(6):1160-6.
3. Lapitan MC and Chye PLH on behalf of the Asia-Pacific Continence Advisory Board. The
epidemiology of overactive bladder among females in Asia: A questionnaire survey. Int
Urogyn J 2001;12(4):226-31.
4. Ramoso-Jalbuena J. Climacteric filipino women: a preliminary survey in the Philippines.
Maturitas 2004;19(3):183-190.
!
DEFINITION OF TERMS
Almira J. Amin-Ong, MD
Lower urinary tract symptoms are classified into three major categories
namely, storage, voiding and postmicturition symptoms. The following terms are
culled from the latest International Continence Society (ICS) Standardization of
Terminology for lower urinary tract symptoms published in 2009. The terminologies
serve to eliminate confusion and facilitate communication amongst clinicians.
A. STORAGE SYMPTOMS
B. VOIDING SYMPTOMS
C. POSTMICTURITION SYMPTOMS
1. Daytime frequency – number of voids during waking hour inclusive of the last
void before sleep and the first void upon waking in the morning
2. Nocturia – number of voids recorded during a night’s sleep, each void is
preceded and followed by sleep
3. Polyuria – urine production of more than 2.8 liters in 24 hours in adults
4. Nocturnal polyuria – is present when an increased proportion of the 24-hour
output occurs at night (> 20% in young adults to > 33% over 65 years)
5. Maximum voided volume – largest recorded volume of urine voided in a single
micturition as determined in the bladder diary or frequency/volume chart
6. SUI – observation of involuntary leakage from the urethra, synchronous with
exertion/effort, or sneezing or coughing
7. Overactive bladder – characterized by the storage symptoms of urgency with
or without urgency incontinence, usually with frequency and nocturia
8. Mixed UI – complaint of involuntary leakage associated with urgency and also
with effort, exertion, sneezing and coughing
9. Extraurethral incontinence – observation of urine leakage through channels
other than the urethra
10. Uncategorized incontinence – observation of involuntary leakage that cannot
be classified into one of the above categories on the basis of signs and
symptoms
11. Intravesical pressure – pressure within the bladder
12. Abdominal pressure – pressure surrounding the bladder which is estimated
from rectal, vaginal, or less commonly, from extraperitoneal pressure or bowel
stoma
13. Detrusor pressure – the component of vesical pressure that is created by
forces in the bladder wall, both active and passive. It is estimated by
subtracting the abdominal pressure from the intravesical pressure.
14. Filling cystometry – method by which the pressure/volume relationship of the
bladder is measured during bladder filling
15. Bladder diary – records the times of micturitions and voided volumes,
incontinence episodes, pad usage and other information such as fluid intake,
the degree of urgency and the degree of incontinence
16. Detrusor overactivity – a urodynamic investigation characterized by
involuntary detrusor contractions during the filling phase which may be
spontaneous or provoked
17. Terminal detrusor overactivity – defined as a single, involuntary detrusor
contraction, occurring at cystometric capacity, which cannot be suppressed
and results in incontinence usually resulting in bladder emptying
18. Detrusor overactivity incontinence – incontinence due to an involuntary
detrusor contraction
19. Neurogenic detrusor overactivity – involuntary detrusor contractions
occurring in patients with relevant neurological condition
20. Idiopathic detrusor overactivity – no defined cause for the involuntary
detrusor contractions
21. Bladder compliance – describes the relationship between change in bladder
volume and change in detrusor pressure
22. Cystometric capacity – the bladder volume at the end of the filling
cystometrogram when “permission to void” is given. It is the volume voided
together with any residual urine.
23. Maximum cystometric capacity – the volume at which a patient with normal
sensations feels she can no longer delay micturition (has a strong desire to
void).
24. Urodynamic stress incontinence – noted during filling cystometry and is
defined as the involuntary leakage of urine during increased intraabdominal
pressure, in the absence of a detrusor contraction. It replaces the term
”genuine stress incontinence”.
25. Abdominal leak point pressure – the intravesical pressure at which urine
leakage occurs due to increased abdominal pressure in the absence of a
detrusor contraction.
26. Detrusor leak point pressure – the lowest detrusor pressure at which urine
leakage occurs in the absence of either a detrusor contraction or increased
abdominal pressure
27. Detrusor underactivity – a contraction of reduced strength and/or duration,
resulting in a prolonged bladder emptying and/or failure to achieve complete
bladder emptying within a normal time span.
28. Acontractile detrusor – one that cannot be demonstrated to contract during
urodynamic studies.
29. Bladder outlet obstruction – a generic term for obstruction during voiding and
is characterized by increased detrusor pressure and reduced urine flow rate
30. Dysfunctional voiding – characterized by intermittent and/or fluctuating flow
rate due to involuntary intermittent contractions of the peri-urethral striated
muscle during voiding in neurologically normal individuals.
31. Detrusor sphincter dysynergia – a detrusor contraction concurrent with an
involuntary contraction of the urethral and/or peri-urethral striated muscle.
32. Non-relaxing urethral sphincter obstruction – occurs in individuals with a
neurological lesion and is characterized as non-relaxing, obstructing urethra
resulting in reduced urine flow.
33. Pelvic organ prolapse (POP) – defined as the descent of one or more of the
anterior vaginal wall, the posterior vaginal wall, and the apex of the vagina
(cervix/uterus) or vault (cuff) after hysterectomy.
34. Anterior vaginal wall prolapse – defined as the descent of the anterior vagina
so that the urethrovesical junction (a point 3 cm proximal to the external
urethral meatus) or any anterior point proximal to this is less than 3 cm above
the plane of the hymen
35. Posterior vaginal wall prolapse – defined as any descent of the posterior
vaginal wall so that a midline point on the posterior vaginal wall 3 cm above
the level of the hymen or any posterior point proximal to this is less than 3 cm
above the plane of the hymen
36. Prolapse of the apical segment of the vagina – defined as any descent of the
vaginal cuff scar (after hysterectomy) or cervix below a point which is 2 cm
less than the total vaginal length above the plane of the hymen
37. Rectal prolapse – defined as the circumferential full thickness rectal
protrusion beyond the anal margin
38. Anal incontinence – defined as any involuntary loss of fecal material and/or
flatus and maybe divided into:
a. Fecal incontinence (FI) – any involuntary loss of fecal material
b. Flatus incontinence – any involuntary loss of gas (flatus)
39. Acute retention of urine – defined as a painful, palpable or percussable
bladder, when the patient is unable to pass any urine.
40. Chronic retention of urine – defined as a non-painful bladder, which remains
palpable or percussable after the patient has passed urine. Such patients may
be incontinent.
III. TREATMENT
References
1. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, Shull BL, Amith
ARB. The standardization of terminology of female pelvic organ prolapse and pelvic floor
dysfunction. Am J Obstet Gynecol 1996;175:10-1.
2. Abrams P, Cardozo L, Khoury S, Wein A. Incontinence. 4th International Consultation on
Incontinence. 4th ed. 2009.
EVALUATION OF PELVIC FLOOR DYSFUNCTION AND THE
POP-Q SCORING SYSTEM
Judith M. Sison, MD, MPH
I. URINARY INCONTINENCE
Summary of Evidence
Post-void residual volume
A PVR < 50 ml is considered adequate bladder emptying and > 200 ml is
considered inadequate.4,5
Summary of Evidence
Summary of Evidence
4. The standard 1-hour pad test quantifies the volume of urine lost by
weighing a perineal pad before and after some type of leakage
provocation. A pad weight gain of > 1 g is considered positive for a 1-hour
test, and > 4 g for a 24-hour test.16,17 (Level II, Grade B)
Summary of Evidence
5. Dye test: The identification of the site of a fistula is best carried out by
instillation of methylene blue into the bladder. (Level III, Grade C)
Summary of Evidence
Summary of Evidence
The continence mechanisms imply that integrity of the levator ani and
the external urethral sphincter is necessary to maintain continence. It is
therefore important to test the contractility of these muscles.
A pelvic muscle contraction may be assessed by visual inspection,
palpation, electromyography or perineometry. When considering
methods/devices used to measure pelvic muscle strength, cost and availability
are important considerations.21
This can be qualitatively defined by the tone at rest and the strength of
a voluntary contraction as strong, weak, or absent by a validated grading
system, e.g. Oxford scale 1-5. Factors to be assessed include strength,
duration, displacement, and repeatability.22 The modified Oxford scale has
been shown to correlate well with surface electromyography and manometry
of pelvic floor muscles.23
Summary of Evidence
Summary of Evidence
Summary of Evidence
There was not enough evidence to show whether women with UI who
underwent urodynamics were less likely to be incontinent after treatment than
women who did not undergo urodynamic testing.30, 31
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
The POP-Q system was introduced for use in clinical practice and
research. Some have argued that the 9-points of the POP-Q system maybe
more detailed than necessary for clinical practice, and it is better suited for
clinical research purposes. It often is useful to include a measurement of the
extent of protrusion relative to the hymen to better assess change overtime.42
Summary of Evidence
The POP-Q is the current gold standard for measuring prolapse stage in
patients. It offers an objective evaluation that can be communicated between
physicians and used to compare pre- and post-surgical intervention examinations. It
was developed and adopted by the International Continence Society (ICS) and
endorsed by leading international organizations dealing with pelvic floor dysfunction.
Stages are based on the maximal extent of prolapse relative to the hymen, in one
or more compartments. The hymen is assigned the value of zero; points proximal to
the hymen are negative (inside the body) while points distal to the hymen are positive
(outside of the body). There are 6 vaginal sites as represented in the POP-Q grid, and
3 additional measurements which always have a positive value namely: a) genital
hiatus (Gh) b) perineal body (Pb), and c) total vaginal length (TVL). All
measurements, except for TVL, are made while patient is doing Valsalva maneuver.
All measurements are made to the nearest 0.5 cm. Both the patient’s position
(lithotomy, birthing chair, or standing) during the examination, and the state of her
bladder and rectum (full or empty) should be noted.
Summary of Evidence
Jackson, et. al. evaluated 247 women with either UI or POP. Thirty
one percent (31%) of women with UI and 7% with POP had concurrent anal
incontinence.45
References
Urinary incontinence (UI) affects women not only in the reproductive age but
more commonly in the postmenopause. It is often a neglected condition even if the
prevalence rate is quite high ranging from 17-55% in older and 12-42% in younger
women. Majority do not seek consult but opt to make provisions in their daily routine
to hide or live with the disorder thus affecting the overall quality of life.
The International Continence Society (ICS) describes three major categories
of incontinence – stress, urge and mixed. Differentiating among the three types would
help the primary care physician gear management towards that which will be
beneficial to the patient. There are several management schemes available for UI.
Conservative management alone entails numerous forms of intervention, which are
usually low cost and with low adverse effects. With the current crisis putting a strain
on the health care of most economies, conservative management is offered as an
option especially on the following circumstances: those awaiting or delaying surgery,
those in whom existing medical condition precludes any form of surgical intervention,
and those whose symptoms are not severe enough for surgical intervention.
I. LIFESTYLE INTERVENTION
There are very few randomized controlled trials (RCTs) on the field of
lifestyle intervention to control, prevent or improve UI. None of those available
specifically addresses the impact of age or any other variables on outcome.
Summary of Evidence
3. Smoking increases the risk of more severe UI. (Level III, Grade B)
Summary of Evidence
Summary of Evidence
Bryant, et. al. found that decreasing caffeine intake to 96.5 mg had
statistically significant reduction in urgency episodes (61% versus 12%) and
number of incontinence episodes (55% versus 26%) but this was not
statistically significant.8 In the Norwegian EPICONT Study, they found that
tea drinkers had higher odds of UI (OR 1.2, 95% CI 1.4-55) for up to 2 cups
per day and an OR of 1.3 (95% CI 1.5-19.0) for 3 or more cups compared to
none.5
4. Alcoholic beverages do not increase the incidence of UI. (Level II-2, Grade
B)
Summary of Evidence
6. Chronic straining may be a risk factor for development of UI. (Level III,
Grade C)
Summary of Evidence
7. Postural changes such as crossing the legs and bending forward might be
useful in reducing leakages during coughing or provocation. (Level III,
Grade C)
Summary of Evidence
There was a mean fluid loss of only 1.3 g (95% CI 0.5-2.1, p<0.001)
when legs are crossed to prevent leakages compared to the following postural
changes: 4.7 g when legs are crossed and body bent forward (95% CI 1.4-7.7,
p<0.01); 10.2 g (95% CI 6.5-13.0) when bending forward alone; and 12.3 g
(95% CI 8.5-16.1) when standing.12 Further studies on the effectiveness of
postural changes as treatment for UI still needed.
Addendum
Summary of Evidence
Summary of Evidence
Summary of Evidence
Vaginal cones are a set of weighted cylinders that are held in place by
contraction of the pelvic floor muscles. Therapy usually starts with the lightest
cone then graduated to the heavier ones. It is not readily available in our
country. Majority of the trials enrolled women with stress incontinence who
had subjective cure from UI.16 Compared with the control group who had
other forms of intervention, there were no differences in objective outcomes –
leakage episodes, pad test or pelvic floor muscle strength.16,17
Summary of Evidence
VII. PHARMACOLOGIC
Summary of Evidence
References
1. Danforth KN, Townsend MK, Lifford K, Curhan GC, Resnick NM, Grodstein F. Risk factors
for urinary incontinence among middle-aged women. Am J Obstet Gynecol 2006;194(2):339-
45.
2. Melville JL, Katon W, Delaney K, Newton K. Urinary incontinence in US women: a
population-based study. Arch Intern Med 2005;165(5):537-42.
3. Subak LL, Whitcomb E, Shen HUI, Saxton J, Vittinghoff E, Brwon JS. Weight loss: a novel
and effective treatment for urinary incontinence. J Urol 2005;174(1):190-5.
4. Subak LL, Wing R, Smith West D, et al, A behavioral weight loss program significantly
reduces urinary incontinence episodes in overweight and obese women [Oral presentation].
American Uroynecologic Society Annual Meeting 2007.
5. Hannestad YS, Rortveit G, Daltveit AK, Hunskaar S. Are smoking and other lifestyle factors
associated with female urinary incontinence? The Norwegian EPINCONT Study. BJOG
2003;110(3);247-54.
6. Nygaard I, Girts T, Fultz NH, Kinchen K, Pohl G, Sternfeld B. Is urinary incontinence a
barrier to exercise in women? Obstet Gynecol 2005;106(2);307-14.
7. Hisayama T, Shinkai M, Takayanagi I, Toyoda T. Mechanism of action of nicotine in isolated
urinary bladder of guinea-pig. Br J Pharmacol 1988;95(2):465-72.
8. Bryant CM, Dowell CJ, Fairbrother G. Caffeine reduction education to improve urinary
symptoms. Br J Nurs 2002;11(8):560-5.
9. Abrams P, Cardozo L, Kouri S, Wein A: Incontinence. Adult Conservative Management of
Urinary Incontinence. 4th International Consultation in Continence July 2009.
10. Swithinbank L, Hashim H, Abrams P. The effect of fluid intake on urinary symptoms in
women. J Urol 2005l;174(1):187-9.
11. Moller L, Lose G, Jorgensen T: Risk factors for lower urinary tract symptoms in women 40 to
60 years of age. Obstet Gynecol 2000;96(3):446-51.
12. Norton PA, Baker JE: Postural changes can reduce leakage in women with stress urinary
incontinence. Obstet Gynecol 1994;85(5):770-4.
13. Hay-Smith EJ, Bo K, Berghmans LC, et al. Pelvic floor muscle training for urinary
incontinence in women. Cochrane Database Syst Rev 2003, Issue 1.
14. But I, Faganelj M, Sostaric S: Functional magnetic stimulation for mixed urinary
incontinence. J Urol 2005;173(5):1644-46.
15. Morris AR, O’Sullivan R, Dunkley P, Moore KH. Extracorporeal magnetic stimulation is of
limited clinical benefit to women with idiopathic detrusor overactivity: A randomized sham
controlled trial. Eur Urol 2007;52:876-83.
16. Herbison P, Plevnik S, Mantle J. Weighted vaginal cones for urinary incontinence. Cochrane
Database Syst Rev 2003, Issue 1.
17. Williams KS, Assassa RP, Gilleis CL, Abrams KR, Turner DA, Shaw C, et al. A randomized
controlled trial of the effectiveness of pelvic floor therapies for urodynamic stress and mixed
incontinence. BJU Int 2006;98(5):1043-50.
18. Hay-Smith J, Herbison P, Ellis G, Moore K. Anticholinergic drugs versus placebo for
overactive bladder syndrome in adults. Cochrane Database Syst Rev 2003, Issue 1.
19. Holroyd-Leduc JM, Straus S. Management of urinary incontinence in women: scientific
review. JAMA 2004;291(8):986-95.
SURGICAL MANAGEMENT OF STRESS URINARY
INCONTINENCE
Lisa T. Prodigalidad–Jabson, MD
I. ANTERIOR COLPORRHAPHY
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
4. Bladder neck needle suspension procedures are not recommended for the
treatment of SUI. (Level I-II Grade A)
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
V. MID-URETHRAL SLINGS
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
References
I. VAGINAL PESSARY
Summary of Evidence
2. Clinicians should discuss the option of pessary use with all women who
have prolapse that warrants treatment based on symptoms. In particular,
pessary use should be considered before surgical intervention in women
with symptomatic prolapse. (Level III, Grade B)
Summary of Evidence
Patient factors that determine the type of pessary to be used are sexual
activity, site of POP and stage of POP. If the patient is fitted with the correct
pessary size, she is not aware of its presence when she wears it, she can void
readily, freely and completely and the pessary stays in place (while seated on a
toilet bowl and during ambulation). If the patient is fitted with the correct
pessary type, no site of defect protrudes when the pessary is in place.
Vaginal atrophy should be treated before and concomitant with pessary
initiation.
Serious complications such as erosions to adjacent organs are rare with
proper use and usually result only after a long time of neglect.
Pessary complications are rare occurrences in medically compliant
patients. The most common side effects of vaginal pessaries are vaginal
discharge and odor. Other complications include vaginal bleeding,
pelvic/vulvar/vaginal discomfort/pain, pessary expulsion, urinary incontinence
(UI), and rectal pain, depending on the type of pessary. Rarely, vaginal
pessaries can cause major urinary, rectal and genital complications including
fistula, fetal impaction, hydronephrosis and urosepsis.5
The vaginal pessary is removed nightly, washed with soap and water
and replaced the next morning. After initial pessary placement, the patient is
advised to come back for check-up after 1 week, during which time, the
vagina is inspected for erosions, abrasions, ulcerations, granulation tissue
formation and infection. Scheduling of subsequent visits is individualized.6
Vaginal estrogen is generally recommended to patients who, at the
time of their initial fitting or at subsequent follow up, are noted to have
vaginal atrophy or areas of ulceration or abrasions from pessary use. 7
Summary of Evidence
The muscles of the pelvic floor help support the abdominal and pelvic
contents from below, help control bowel and bladder function and play a role
in sexual response.
Pelvic floor muscle exercise helps in reducing the progression of POP.
The pelvic floor muscle exercise, also known as the Kegel exercise,
has been thought to offer a number of benefits to the patient. Firstly, the
patient learns to consciously contract before and during increases in
abdominal pressure. Secondly, the pelvic floor muscle exercise builds
permanent muscle volume and structure support.9
Summary of Evidence
References
1. Wu V, Farrel SA, Baskett TF, Flowerdew G. A simplified protocol for pessary management.
Obstet Gynecol 1997;90:990-994.
2. Sulak PJ, Kuehl TJ, Shull BL. Vaginal pessaries and their use in pelvic relaxation. J Reprod
Med 1993;38:919-923.
3. Clemons JL, et al. Patient satisfaction and changes in prolapse and urinary symptoms in
women who were fitted successfully with a pessary for pelvic organ prolapse. Am J Obstet
Gynecol 2004; 190(4): 1025–1029.
4. Rodriguez E, Trowbridge MD and Fenner DE. Conservative management of pelvic organ
prolapse. Clin Obstet Gynecol 2005;48(3):668-681.
5. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007;369:1027-1038.
6. Farrell SA. Practice advice for ring pessary fitting and management. J SOGC 1997;19:625.
7. Poma PA. Management of incarcerated vaginal pessaries. J Am Geriatr Soc 1981;29:325-327.
8. Hagen S, Stark D, et al. Conservative management of pelvic organ prolapse in women.
Cochrane Database Syst Rev 2006, Issue 4.
9. Bo K. Pelvic floor muscle training is effective in treatment of stress urinary incontinence, but
how does it work? Int Urogynecol J 2004;15:76.
10. Hagen S, Stark D, Maher C, et al. Conservative management of pelvic organ prolapse in
women. Cochrane Database Syst Rev 2:CD003882, 2004.
11. Rodriguez E, Trowbridge MD, Fenner DE. Conservative management of pelvic organ
prolapse. Clin Obstet Gynecol 2005;48(3):668-681.
SURGICAL MANAGEMENT OF PELVIC ORGAN PROLAPSE
Manuel S. Ocampo Jr., MD and Lisa T. Prodigalidad-Jabson, MD
Previous to the latter half of the twentieth century, the concept of prolapse
surgery was based on fascial weakness and defects and so procedures were done to
attenuate or strengthen ligaments or fascia supporting the pelvic organs. The work of
anatomists in the 1970’s resulted in discovering “breaks in the continuity of support
within the endopelvic fascia”. This thinking redirected how pelvic reconstructive
surgery is currently performed. This fulfilled the first goal of pelvic organ prolapse
(POP) repair that is to “restore normal anatomy”.1 In 2005, The Surgery for Pelvic
Organ Prolapse Committee of the World Health Organization (WHO)’s 3rd
International Consultation on Incontinence (ICI) made a comprehensive review of
POP surgery studies and published its recommendations based on the strength of
evidence using the Oxford System.2 Among the Level I conclusions are :
o Overall outcomes indicate that abdominal and vaginal surgeries are
equivalent.
o Abdominal surgery has higher short term morbidity.2
o The recommendation for the use of autologous and non-autologous materials
in pelvic floor reconstruction is guarded until more randomized controlled
trials (RCTs) are presented and sources of these meshes have “confirmed their
efficacy and safety”.3
Summary of Evidence
Summary of Evidence
Summary of Evidence
Because there are few RCTs comparing procedures and most are
uncontrolled retrospective studies, there is no gold standard to speak of. Because
of this, the choice of surgery would depend on the specific fascial defects.
Additionally the patient's age, co-morbidities, activity level, desire for future
fertility, history of prior prolapse surgery in other compartments, patient
preference, as well as the skill and comfort level of the surgeon with the particular
surgery are to be considered.10 Options for uterine preservation are the
Manchester procedure, sacrospinous hysteropexy, and the abdominal/laparoscopic
hysteropexy. The most common procedures for post-hysterectomy vaginal vault
prolapse include sacrospinous ligament fixation, McCall culdoplasty, uterosacral
ligament suspension, iliococcygeus fascia suspension, and colpocleisis. The route
of hysterectomy will depend on multiple factors to be considered. Options include
vaginal, abdominal, and laparoscopic hysterectomy. Laparoscopic hysterectomy
approaches are divided into laparoscopic assisted vaginal hysterectomy with or
without uterine artery release and total laparoscopic vaginal hysterectomy that
includes vault closure laparoscopically.
MANCHESTER PROCEDURE
Summary of Evidence
HYSTERECTOMY
Summary of Evidence
Summary of Evidence
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Summary of Evidence
McCALL CULDOPLASTY
Summary of Evidence
Summary of Evidence
Summary of Evidence
COLPOCLEISIS
Summary of Evidence
1. For posterior vaginal wall prolapse, the vaginal approach was associated
with a lower rate of recurrent rectocele and/or enterocele than the
transanal approach.15 (Level II-1, Grade B).
Summary of Evidence
References
1. Kovac SR, Zimmerman C. Advances in reconstructive surgery. Lippincott Williams &
Wilkins 2007;187-88.
2. Atiemo H, Griebling T, Daneshgari F. Advances in geriatric female pelvic surgery. BJU Int
2006;98(Suppl 1):92-93.
3. Cardozo L. Editorial comment: The use of synthetic mesh in female pelvic reconstructive
surgery. BJU Int 2006;98(Suppl 1):77.
4. Stanton S, Zimmern P. Female pelvic reconstructive surgery. Springer-Verlag London Ltd
2003.
5. Maher C, Baessler K, Glazener CM, Adams EJ, Hagen S. Surgical management of pelvic
organ prolapse in women. Cochrane Database Syst Rev 2007 Jul;18(3):CD004014.
6. Carey M, Higgs P, Goh J, Lim J, Leong A, Krausse H, Cornish A. Vaginal repair with mesh
versus colporrhaphy for prolapsed: a randomized controlled trial. BJOG 2009; 116(10):1380-
6.
7. Nguyen JN, Burchette RJ. Outcome after anterior vaginal prolapse repair: a randomized
controlled trial. Obstet Gynecol 2008 Apr;111(4):891-8.
8. Hiltunen R, Nieminen K, Takala T, Heiskanen E, Merikari M, Niemi K, Heinonen PK. Low-
weight polypropylene mesh for anterior vaginal wall prolapse: a randomized controlled trial.
Obstet Gynecol 2007;110(2 Pt 2):455-62.
9. Behnia-Willison F, Seman El, Cook JR, O’Shea Rt, Keirse MJ. Laparoscopic paravaginal
repair of anterior compartment prolapse. Minim Invasive Gynecol 2007;14(4):475-80.
10. Park AJ, Paraiso MF. Surgical management after uterine prolapsed. Minerva Ginecol 2008
Dec;60(6):493-507.
11. Ayhan A, Esin S,Guven S, Salman C, Ozyunco O. The Manchester operation for uterine
prolapsed. Int J Gynaecol Obstet 2006 Mar;92(3):228-33.
12. De Boer TA, Milani AL, Kluivers KB, Withagen MI, Vierhout ME. The effectiveness of
surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication
(modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication.
Int Urogynecol J Pelvic Floor Dysfunct 2009 Nov;20(11):1313-9.
13. Dietz V, de Jong J, Huisman M, Schraffordt Koops S, Heintz P, van der Vaart H. The
effectiveness of the sacrospinous hysteropexy for the primary treatment of uterovaginal
prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2007 Nov;18(11):1271-6.
14. Ridgeway B, Frick AC, Walter MD. Hysteropexy: A review. Minerva Ginecol 2008
Dec;60(6):509-28.
15. ACOG Practice Bulletin No. 85. Pelvic organ prolapse. American College of Obstetricians
and Gynecologists (ACOG). Washington (DC)
16. Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BW,
Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane
Database Syst Rev 2009 Jul 8;(3):CD003677.
17. Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy:
systematic review and meta-analysis of randomised controlled trials. BMJ 2005 Jun
25;330(7506):1478.
18. Lovatsis D, Drutz HP. Safety and efficacy of sacrospinous vault suspension. Int Urogynecol J
Pelvic Floor Dysfunct 2002;13(5):308-13.
19. Benedito de Castro E, Palma P, Riccetto C, Herrmann V, Bigozzi MA, Olivares JM. Impact of
sacrospinous vaginal vault suspension on the anterior compartment. Actas Urol Esp 2010
Jan;34(1):106-10
20. Shippey SH, Quiroz LH, Sanses TV, Knoepp LR, Cundiff GW, Handa VL. Anatomic
outcomes of abdominal sacrocolpopexy with or without paravaginal repair. Int Urogynecol J
Pelvic Floor Dysfunct 2010 Mar;21(3):279-83.
21. Ganatra AM, Rozet F, Sanchez-Salas R, Barret E, Galiano M, Cathelineau X, Vallancien G.
The current status of laparoscopic sacrocolpopexy: a review. Eur Urol 2009 May;55(5):1089-
103.
22. Chene G, Tardieu AS, Savary D, Krief M, Boda C, Anton-Bousquet MC, Mansoor A.
Anatomical and functional results of McCall culdoplasty in the prevention of enteroceles and
vaginal vault prolapse after vaginal hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct
2008 Jul;19(7):1007-11.
23. Cam C, Karateke A, Asoglu MR, Selcuk S, Namazov A, Aran T, Celik C, Tug N. Possible
cause of failure after McCall culdoplasty. Arch Gynecol Obstet 2010 Mar 16.
24. Silva WA, Pauls RN, Segal JL, Rooney CM, Kleeman SD, Karram MM. Uterosacral ligament
vault suspension: five-year outcomes. Obstet Gynecol 2006 Aug;108(2):255-63
25. Margulies RU, Rogers MA, Morgan DM. Outcomes of transvaginal uterosacral ligament
suspension: systematic review and metaanalysis. Am J Obstet Gynecol. 2010 Feb;202(2):124-
34.
26. Koyama M, Yoshida S, Koyama S, Ogita K, Kimura T, Shimoya K, Murata Y, Nagata I.
Surgical reinforcement of support for the vagina in pelvic organ prolapse: concurrent
iliococcygeus fascia colpopexy (Inmon technique). Int Urogynecol J Pelvic Floor Dysfunct.
2005 May-Jun;16(3):197-202.
27. FitzGerald MP, Richter HE, Siddique S, Thompson P, Zyczynski H. Colpocleisis: a review.
Int Urogynecol J Pelvic Floor Dysfunct. 2006 May;17(3):261-71.
28. Paraiso MF, Barber MD, Muir TW, Walters MD. Rectocele repair: a randomized trial of three
surgical techniques including graft augmentation. Am J Obstet Gynecol 2006
Dec;195(6):1762-71.
29. Gustilo-Ashby AM, Paraiso MF, Jelovsek JE, Walters MD, Barber MD. Bowel symptoms 1
year after surgery for prolapse: further analysis of a randomized trial of rectocele repair. Am J
Obstet Gynecol 2007 Jul;197(1):76.e1-5.
FECAL INCONTINENCE AND OBSTETRIC ANAL SPHINCTER
INJURIES
Lennette L. Chan, MD
I. NON-OPERATIVE TREATMENT
Summary of Evidence
Summary of Evidence
Summary of Evidence
6. Pelvic floor muscle exercises are recommended in patients who have not
responded to simple dietary modification or medication. (Level III, Grade
C)
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
6. For patients with sphincter defects of greater than 180 degrees or major
perineal tissue loss, individualized treatment is indicated. Initial pelvic
floor reconstruction can be performed. (Level III, Grade C)
Summary of Evidence
Summary of Evidence
9. Patients with sphincter defect who have failed SNS, sphincteroplasty can
be considered. Other alternatives include stimulated muscle transposition
and implantation of an artificial anal sphincter (AAS). (Level II, Grade B)
Summary of Evidence
10. Patients with passive FI to liquid or solid stool who had failed
conventional therapy, the use of injectable biomaterials report reasonable
short and midterm term success rate. (Level III, Grade C)
Summary of Evidence
11. Patients who fail surgical therapy for FI, or who do not wish to undergo
extensive pelvic reconstruction, should consider placement of an end
sigmoid colostomy. (Level III, Grade C)
Summary of Evidence
Summary of Evidence
Summary of Evidence
Cesarean delivery before the onset of the second stage of labor was
found to be protective64, however, in a systematic review, Nelson, et. al.65
found that pregnancy rather than delivery was a more important indicator of
post partum continence.
3. Avoid midline episiotomy. (Level I, Grade A)
Summary of Evidence
5. All women having a vaginal delivery with evidence of genital tract trauma
should be examined systematically to assess the severity of damage prior
to suturing. (Level I, Grade C)
Summary of Evidence
Summary of Evidence
References
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management of faecal incontinence in adults. In: Abrams P, Cardozo L, Khoury S, Wein A,
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2. Norton C, Thomas L, Hill J. Management of faecal incontinence in adults: summary of NICE
guidelines. BMJ 2007;334:1370-1.
3. Norton C, Chelvanayagam S. Bowel continence nursing. Beaconsfield: Beaconsfield
Publishers; 2004.
4. Whitehead WE, Wald A, Norton N. Treatment options for fecal incontinence: consensus
conference report. Dis Colon Rectum 2001;44:131-44.
5. Cheetham M, Brazzelli M, Norton C, Glazener CM. Drug treatment for faecal incontinence in
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6. Hanauer SB. The role of loperamide in gastrointestinal disorders. Rev Gastroenterol Disord
2008 Winter;8(1):15-20.
7. Bischoff A, Levitt MA, Bauer C, Jackson L, Holder M, Peña A. Treatment of fecal
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8. Bliss DZ, Jung H, Savik K, Lowry AC, LeMoine M, Jensen L, et al. Supplementation with
dietary fiber improves fecal incontinence. Nursing Research 2001;50(4):203-13.
9. Norton C, Chelvanayagam S. Conservative management of faecal incontinence in adults. In:
Norton C, Chelvanayagam S, editors. Bowel continence nursing. Beaconsfield: Beaconsfield
Publishers; 2004. p. 114-31.
10. Ardron ME, Main ANH. Management of constipation. BMJ 1990;300:1400.
11. Bode C, Bode JC. Effect of alcohol consumption on the gut. Best Pract Res Clin Gastroenterol
2003;17:575-92
12. Ryan D, Wilson A, Muir TS, Judge TG. The reduction of faecal incontinence by the use of
“Duphalac” in geriatric patients. Curr Med Res Opin 1974;2:329-33.
13. Byrne CM, Solomon MJ, Rex J, Young JM, Heggie D, Merlino C.Telephone vs. face-to-face
biofeedback for fecal incontinence: comparison of two techniques in 239 patients. Dis Colon
Rectum 2005 Dec;48(12):2281-8.
14. Boselli AS, Pinna F, Cecchini S, Costi R, Marchesi F, Violi V, Sarli L, Roncoroni L.
Biofeedback therapy plus anal electrostimulation for fecal incontinence: prognostic factors
and effects on anorectal physiology. World J Surg 2010 Apr;34(4):815-21.
15. Williams AB, Bartram CI, Halligan S, Spencer JA, Nicholls RJ, Kmiot WA. Anal sphincter
damage after vaginal delivery using three-dimensional endosonography. Obstet Gynecol
2001;97(5 Pt 1):770-5.
16. Mortele KJ, Fairhurst J. Dynamic MR defecography of the posterior compartment: Indications,
techniques and MRI features. Eur J Radiol 2007;61(3):462-72.
17. Gearhart S, Hull T, Floruta C, Schroeder T, Hammel J. Anal manometric parameters:
predictors of outcome following anal sphincter repair? J Gastrointest Surg 2005;9(1):115-20.
18. Maslekar S, Gardiner AB, Duthie GS. Anterior anal sphincter repair for fecal incontinence:
Good long term results are possible. J Am Coll Surg 2007;204(1):40-6.
19. Matzel KE, Stadelmaier U, Hohenfellner M, Gall FP. Electrical stimulation of sacral spinal
nerves for treatment of faecal incontinence. Lancet 1995;346(8983):1124-7.
20. Rosen HR, Urbarz C, Holzer B, Novi G, Schiessel R. Sacral nerve stimulation as a treatment
for fecal incontinence. Gastroenterology 2001;121(3):536-41.
21. Matzel KE, Schmidt RA, Tanagho EA. Neuroanatomy of the striated muscular anal continence
mechanism. Implications for the use of neurostimulation. Dis Colon Rectum 1990;33(8):666-
73.
22. Matzel KE, Stadelmaier U, Hohenberger W. Innovations in fecal incontinence: sacral nerve
stimulation. Dis Colon Rectum 2004;47(10):1720-8
23. Tjandra JJ, Lim JF, Matzel K. Sacral nerve stimulation: an emerging treatment for faecal
incontinence. ANZ J Surg 2004;74(12):1098-106.
24. Nygaard IE, Rao SS, Dawson JD. Anal incontinence after anal sphincter disruption: a 30-year
retrospective cohort study. Obstet Gynecol 1997;89(6):896-901.
25. Faltin DL, Otero M, Petignat P, Sangalli MR, Floris LA, Boulvain M, Irion O. Women’s
health 18 years after rupture of the anal sphincter during childbirth: I. Fecal incontinence. Am
J Obstet Gynecol 2006;194(5):1255-9.
26. Bollard RC, Gardiner A, Duthie GS, Lindow SW. Anal sphincter injury, fecal and urinary
incontinence: a 34-year follow-up after forceps delivery. Dis Colon Rectum 2003;46(8):1083-
8.
27. Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm MA. Long- term results of overlapping
anterior anal sphincter repair for obstetric trauma. Lancet 2000;355:260–5
28. Evans C, Davis K, Kumar D. Overlapping anal sphincter repair and anterior levatorplasty:
effect of patient’s age and duration of follow-up. Int J Colorectal Dis 2006;21(8):795-801.
29. Mous M, Muller SA, de Leeuw JW. Long-term effects of anal sphincter rupture during vaginal
delivery: faecal incontinence and sexual complaints. BJOG 2008;115(2):234-8.
30. Dudding TC, Vaizey CJ, Kamm MA. Obstetric anal sphincter injury: incidence, risk factors,
and management. Ann Surg 2008;247(2):224-37.
31. Madoff RD. Surgical treatment options for fecal incontinence. Gastroenterology 2004;126(1
Suppl 1):S48-54.
32. Bravo Gutierrez A, Madoff RD, Lowry AC, Parker SC, Buie WD, Baxter NN. Long-term
results of anterior sphincteroplasty. Dis Colon Rectum 2004;47(5):727-31; discussion 731-2.
33. Dudding TC, Pares D, Vaizey CJ, Kamm MA. Predictive factors for successful sacral nerve
stimulation in the treatment of faecal incontinence: a 10-year cohort analysis. Colorectal Dis
2008;10(3):249-56.
34. Conaghan P, Farouk R. Sacral nerve stimulation can be successful in patients with ultrasound
evidence of external anal sphincter disruption. Dis Colon Rectum 2005;48(8):1610-4.
35. Maslekar SK, Gardiner A, Duthie GS. Sacral nerve stimulation as primary treatment for faecal
incontinence secondary to obstetric anal sphincter damage: medium and long-term results
[abstract]. Dis Colon Rectum 2006;49(5):730. Abstract 38
36. Ratto C. Sacral nerve stimulation in fecal incontinence due to anal sphincter lesions. Paper
presented at: European Society of Coloproctology 2nd Annual Scientific Meeting; September
27, 2007; Malta
37. Jarrett ME, Dudding TC, Nicholls RJ, Vaizey CJ, Cohen CR, Kamm MA. Sacral nerve
stimulation for fecal incontinence related to obstetric anal sphincter damage. Dis Colon
Rectum 2008;51(5):531-7.
38. Melenhorst J, Koch SM, Uludag O, van Gemert WG, Baeten CG. Is a morphologically intact
anal sphincter necessary for success with sacral nerve modulation in patients with faecal
incontinence? Colorectal Dis 2008;10(3):257-62.
39. Pinedo G, Vaizey CJ, Nicholls RJ, Roach R, Halligan S, Kamm MA. Results of repeat anal
sphincter repair. Br J Surg 1999;86(1):66-9.
40. Nielsen MB, Dammegaard L, Pedersen JF. Endosonographic assessment of the anal sphincter
after surgical reconstruction. Dis Colon Rectum 1994;37(5):434-8.
41. Giordano P, Renzi A, Efron J, Gervaz P, Weiss EG, Nogueras JJ, Wexner SD. Previous
sphincter repair does not affect the outcome of repeat repair. Dis Colon Rectum
2002;45(5):635- 40.
42. Vaizey CJ, Norton C, Thornton MJ, Nicholls RJ, Kamm MA. Long-term results of repeat
anterior anal sphincter repair. Dis Colon Rectum 2004;47(6):858-63.
43. Deen KI, Oya M, Ortiz J, Keighley MR. Randomized trial comparing three forms of pelvic
floor repair for neuropathic faecal incontinence. Br J Surg 1993;80(6):794-8.
44. van Tets WF, Kuijpers JH. Pelvic floor procedures produce no consistent changes in anatomy
or physiology. Dis Colon Rectum 1998;41(3):365-9.
45. Rongen MJ, Uludag O, El Naggar K, Geerdes BP, Konsten J, Baeten CG. Long-term follow-
up of dynamic graciloplasty for fecal incontinence. Dis Colon Rectum 2003;46(6):716- 21.
46. Tillin T, Gannon K, Feldman RA, Williams NS. Third-party prospective evaluation of patient
outcomes after dynamic graciloplasty. Br J Surg 2006;93(11):1402-10.
47. Thornton MJ, Kennedy ML, Lubowski DZ, King DW. Long- term follow-up of dynamic
graciloplasty for faecal incontinence. Colorectal Dis 2004;6(6):470-6.
48. Matzel KE, Stadelmaier U, Hohenfellner M, Hohenberger W. Chronic sacral spinal nerve
stimulation for fecal incontinence: long term results with foramen and cuff electrodes. Dis
Colon Rectum 2001 Jan;44(1):59-66.
49. Tjandra JJ, Chan MK, Yeh CH, Murray-Green C. Sacral nerve stimulation is more effective
than optimal medical therapy for severe fecal incontinence: a randomized, controlled study.
Dis Colon Rectum 2008;51(5):494-502.
50. Chan MK, Tjandra JJ. Sacral nerve stimulation for fecal incontinence: external anal sphincter
defect vs. intact anal sphincter. Dis Colon Rectum 2008;51(7):1015-24; discussion 1024-5.
51. O’Brien PE, Dixon JB, Skinner S, Laurie C, Khera A, Fonda D. A prospective, randomized,
controlled clinical trial of placement of the artificial bowel sphincter (Acticon Neosphincter)
for the control of fecal incontinence. Dis Colon Rectum 2004;47(11):1852-60.
52. Ortiz H, Armendariz P, DeMiguel M, Solana A, Alos R, Roig JV. Prospective study of
artificial anal sphincter and dynamic graciloplasty for severe anal incontinence. Int J
Colorectal Dis 2003;18(4):349-54.
53. Wong WD, Congliosi SM, Spencer MP, Corman ML, Tan P, Opelka FG, et al. The safety and
efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter
cohort study. Dis Colon Rectum 2002;45(9):1139-53.
54. Mundy L, Merlin TL, Maddern GJ, Hiller JE. Systematic review of safety and effectiveness of
an artificial bowel sphincter for faecal incontinence. Br J Surg 2004;91(6):665- 72.
55. Belyaev O, Muller C, Uhl W. Neosphincter surgery for fecal incontinence: a critical and
unbiased review of the relevant literature. Surg Today 2006;36(4):295-303.
56. Altomare DF, Binda GA, Dodi G, La Torre F, Romano G, Rinaldi M, Melega E. Disappointing
long-term results of the artificial anal sphincter for faecal incontinence. Br J Surg
2004;91(10):1352-3.
57. Shafik A. Polytetrafluoroethylene injection for the treatment of partial fecal incontinence. Int
Surg 1993;78(2):159-61.
58. Maeda Y, Vaizey CJ, Kamm MA. Long-term results of perianal silicone injection for faecal
incontinence. Colorectal Dis 2007;9(4):357-61.
59. Shafik A. Perianal injection of autologous fat for treatment of sphincteric incontinence. Dis
Colon Rectum 1995;38(6):583-7.
60. Vaizey CJ, Kamm MA. Injectable bulking agents for treating faecal incontinence. Br J Surg
2005;92(5):521-7.
61. Colquhoun P, Kaiser R, Jr., Efron J, Weiss EG, Nogueras JJ, Vernava AM, 3rd, Wexner SD. Is
the quality of life better in patients with colostomy than patients with fecal incontience? World
J Surg 2006;30(10):1925-8.
62. Norton C, Burch J, Kamm MA. Patients’views of a colostomy for fecal incontinence. Dis
Colon Rectum 2005;48(5):1062- 9.
63. Catena F, Wilkinson K, Phillips RK. Untreatable faecal incontinence: colostomy or colostomy
and proctectomy? Colorectal Dis 2002;4(1):48-50.
64. Fynes M, Donnelly VS, O’Connell PR, O’Herlihy C. Caesarean delivery and anal sphincter
injury. Obstet Gynecol 1998;92(4 Pt 1):496-500.
65. Nelson RL, Westercamp M, Furner SE. A systematic review of the efficacy of caesarean
section in the preservation of anal continence. Dis Colon Rectum 2006;49(10):1587-95.
66. Fenner DE, Genberg B, Brahma P, Marek L, DeLancey JO. Fecal and urinary incontinence
after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States.
Am J Obstet Gynecol 2003 Dec;189(6):1543-9.
67. Eogan M, Daly L, O’Connell PR, O’Herlihy C. Does the angle of episiotomy affect the
incidence of anal sphincter injury? BJOG 2006;113(2):190-4.
68. Clemons JL, Towers GD, McClure GB, O’Boyle AL. Decreased anal sphincter lacerations
associated with restrictive episiotomy use. Am J Obstet Gynecol 2005;192(5):1620-5.
69. Groom KM, Paterson-Brown S. Can we improve on the diagnosis of third degree tears? Eur J
Obstet Gynecol Reprod Biol 2002;101:19–21.
70. Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injuries: myth or reality?
BJOG 2006;113:195–200.
71. Fitzpatrick M, Behan M, O’Connell PR, O’Herlihy C. A randomized clinical trial comparing
primary overlap with approximation repair of third-degree obstetric tears. Am J Obstet
Gynecol 2000;183(5):1220-4.
72. Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, O’Brien PM. Repair techniques for
obstetric anal sphincter injuries: a randomized controlled trial. Obstet Gynecol
2006;107(6):1261-8.
73. Williams A, Adams EJ, Tincello DG, Alfirevic Z, Walkinshaw SA, Richmond DH. How to
repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial.
BJOG 2006;113(2):201-7.
74. Garcia V, Rogers RG, Kim SS, Hall RJ, Kammerer-Doak DN. Primary repair of obstetric anal
sphincter laceration: a randomized trial of two surgical techniques. Am J Obstet Gynecol
2005;192(5):1697-701.
75. Fernando R, Sultan AH, Kettle C, Thakar R, Radley S. Methods of repair for obstetric anal
sphincter injury. Cochrane Database Syst Rev 2006;3:CD002866
76. Fernando RJ, Sultan AH, Radley S, Jones PW, Johanson RB. Management of obstetric anal
sphincter injury- A systematic review and national practice survey. BMC Health Serv Res
2002;2:9.
77. Thakar R, Sultan AH, Fernando R, Monga A, Stanton S. Can workshops on obstetric anal
sphincter rupture change practice? Int Urogynecol J 2001;12:S5.
78. Mahony R, Behan M, Daly L, Kirwan C, O’Herlihy C, O’Connell PR. Internal anal sphincter
defect influences continence outcome following obstetric anal sphincter injury. Am J Obstet
Gynecol 2007;196(3):217 e1-5.
79. Nyam DC, Pemberton JH. Long-term results of lateral internal sphincterotomy for chronic
anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum
1999 Oct;42(10):1306-10.
URINARY RETENTION
Jennifer Marie B. Jose, MD
Background
Recommendations
Summary of Evidence
Summary of Evidence
I. PHARMACOTHERAPY
Summary of Evidence
Summary of Evidence
Summary of Evidence
There are no randomized trials comparing CISC and clamping the foley
catheter intermittently for bladder training. One main advantage of CISC is that
the voiding trials can be done before self-catheterization. In addition, it can be
implemented as a one-time treatment repeatedly over a short period of time,
on an occasional basis, or may be life-long for persons with chronic bladder
emptying disturbances. It is often preferred to indwelling catheters, because it
can result in a better quality of life for the patient has less complications, such
as urinary tract infections (UTI), urethral stricture, compared to indwelling
catheters.
The evaluation, management and treatment of female patients with
voiding dysfunction and urinary retention is often complex and must take
multiple factors into consideration, including the degree to which the patients
symptoms is bothersome and whether the upper tracts are in jeopardy. A
patient specific diagnostic approach is recommended, depending on
symptoms, degree of bother and whether there is a history of suspicion of
neurologic disease. In certain cases, empirical treatment is appropriate.
However, when a formal diagnosis is indicated, specific therapy can be
directed based on urodynamics and other basic tests.8
III. NEUROGENIC VOIDING DYSFUNCTION
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
Summary of Evidence
Bladder neck surgery, tension free vaginal tape placement (TVT), and
collagen injection are recognized causes of compression and voiding difficulty.
Postoperative factors contributing to retention may include failure of
the sphincter to relax, edema surrounding the vesical neck and urethra, pelvic
floor spasm, and obstruction from bladder neck elevation.
Age, higher preoperative urethral resistance, straining during voiding,
and magnetic resonance imaging (MRI) evidence of greater bladder neck
elevation and urethral compression have been associated with the number of
days of voiding dysfunction after colposuspension.19
Summary of Evidence
5. The use of botolinum toxin injection into the urethral sphincter for
retention after anti-incontinence surgery is under investigation.11 (Level
III, Grade C)
Summary of Evidence
Phelan and colleagues were the first to report successful outcomes with
a botulinim A injections in women and in non neurogenic voiding dysfunction.
They studies 21 patients (13 women) with impaired bladder emptying who
were dependent on catheterization. All except one were able to void
spontaneously after the injection of 80-100 units of botulinum toxin.20
Kuo and associates repeated this study in 20 patients with urinary
retention and dysuria due to detrusor hypocontractility and non relaxing
urethral sphincter who who were refractory to conservative therapy. This
study clearly showed that botulinum toxin is effective in decreasing urethral
sphincter resistance and improving voiding dysfunction. Botulinum A toxin
injections do have therapeutic value in urethral spasticity, but larger, controlled
trials are necessary to establish value. 21
Summary of Evidence
Summary of Evidence
References
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15. Carley ME, Carley JM, Vasdev G, Lesnick TG, Webb MJ, Ramin KD et al. Factors that are
associated with clinically overt postpartum urinary retention after vaginal delivery. Am J
Obstet Gynecol 2002;187(2);430-3.