CONSERVATIVE MANAGEMENT OF STRESS URINARY INCONTINENCE

Conservative management of Stress Urinary Incontinence

1. An involuntary loss of urine during coughing, or physical exertion
2. Evident as leakage of urine on increased abdominal pressure without change in detrusor pressure (VLPP) during filling phase on UDS(SPECIALISED PRESSURE MANOMETRY)
It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners.

Usual cause of stress urinary incontinence
1. Vaginal delivery--multiple vaginal births(unattended deliveries common in ESPECIALLY in villages)
2. Aging
3. Estrogen deficiency(Some woman leak one week before menstrual period.The lowered estrogen levels that particular time may lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause, similarly because of lowered estrogen levels)
4. Neurological disease(especially diabetes)
5. In female high-level athletes, effort incontinence occurs in all sports involving abrupt repeated increases in intra-abdominal pressure that may exceed perineal floor resistance


As In India; multiple vaginal births are a common scenario and there is cultural taboo so incontinence is very high in prevalence but majority of household women suffer from it silently.Many of them avoid mingling in social occasions for fear of leakage preferring to remain aloof.The urine leakage is equally annoying to their sex partners which may severely affect sex life and adversely affect married life.There are certain myths in society about stress urinary leakage:
1. Urinary incontinence/prolapse is a natural part of aging
2. Nothing can be done about it
3. Surgery is the only solution(phobia for doctors;thinking that they will invariably suggest surgery for the disease)


Prevalence:
Reported prevalence rates range from 4.5% to 53%
Our Hopsital Statistics shows:
1. 50 Patients of stress/mixed incontinence / 6 months
2. 10 Undergo UDS/ 6months
3. 3-4 Undergo surgical intervention

Can we do something to remove doctor phobia especially in Indian society?
Can Nurse led continence service of any use?

A study was conducted by Matharu et al in 2004 where women aged ≥40 yrs with LUTS (n= 2421) were randomly allocated to a nurse-led continence service.Out of them , 450 underwent urodynamic study.The results showed women with OAB, 79.1% were correctly allocated anticholinergics & 64.8% were allocated pelvic floor training protocol(PFT).Of all women with urodynamic SUI, 88.8% were allocated PFT.This shows that nurse led continence service fairly treat women and this type of service can be initiated by Government of India to avoid urine leakage misery.

Management of tress urinary incontinence:
Continence and micturition involve a balance between urethral closure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence. Normal voiding is the result of changes in both of these pressure factors:urethral pressure falls and bladder pressure rises. SUI is due essentially to insufficient strength of the pelvic floor muscles. It is the loss of small amounts of urine associated with coughing, laughing, sneezing, exercising or other movements that increase intra-abdominal pressure and thus increase pressure on the bladder. The urethra is supported by fascia of the pelvic floor. If this support is insufficient, the urethra can move downward at times of increased abdominal pressure, allowing urine to pass.
So the basic aim of the treatment is Aim: To improve urethral resistance.These are the conservative measures:

1.Weight loss
A study published in The New England Journal of Medicine on January 29, 2009, demonstrated that weight loss in overweight women reduced stress incontinence. The study included women with a Body Mass Index (BMI) over 25 and at least 10 episodes of urinary incontinence per week. The results demonstrated that with exercise and restricted diet they had a 70% or greater reduction in overall incontinence episodes.So weigth loss should be the first thing a woman ahould follow for reduction in incontinence.
2. Absorbent products
Absorbent products include, undergarments, protective underwear, briefs, diapers and underpads.There are some assist devices used like vaginal pessaries,femsoft catheter as physical barrier for prevention of urinary leakage.
4. Exercises
One of the most common treatment recommendations includes exercising the muscles of the pelvis. Kegel exercises to strengthen or retrain pelvic floor muscles and sphincter muscles can reduce stress leakage.
Role of pelvic floor training:
The Cochrane Incontinence Group Specialized Trials Register included One arm comprised PFT, the other either no treatment, placebo, sham treatment. A total 13 trials involving 714 women were included.They concluded that PFT be included in first-line conservative management programs.Basically suffering woman should Identify the pubococcygeus muscle first with the help of urologist and then Exercise the muscle (10 s contraction followed by 10 s relaxation) 30 to 80 times /day.This Increases muscle support of the pelvic viscera &increased closing force on the urethra and the benefits may be seen in 2 to 6 weeks.
An alternative or adjunct to PME is exercises the pelvic muscles by holding small weights inside the vagina for up to 15 minutes bid.Successiely the weights can be increased I ncreasing the capacity of the pubococcygeus muscle contraction.Success rate up to 70% to 80%. A recent Cochrane Review shows no advantage to combining PFT with biofeedback over the use of well-done PFT alone.Atleast 3 months of pelvic floor exercises are necessary.
Biofeedback:
Biofeedback uses measuring devices to help the patient become aware of his or her body's functioning. By using electronic devices or diaries to track when the bladder and urethral muscles contract, the patient can gain control over these muscles. Biofeedback can be used with pelvic muscle exercises
RESULTS OF PELVIC FLOOR TRAINING:
There was a trial
1. 76 women underwent a 3-month exercise program & followed for 1 year.
2. 30% of subjects were cured &17% were improved.
3. Subjects with severe incontinence did not benefit from the therapy

Medications
Medications can reduce many types of leakage. Drugs with a-adrenergic activity to increase bladder outlet resistance.For Example ..phenylpropanolamine 25-75 mg bid &imipramine10-25 mg qd-tid.These medicines have been taken off from the U.S. market because of concerns about hemorrhagic strokes in young women.A new nedicine has been tried in SUI:duloxetene :called drug which kills three birds in one stone. It is Combined serotonin and nor-epinephrine re-uptake inhibitor.Its actions are :
o Increases tone of external urethral sphincter
o In an integrated analysis of 4 randomised controlled trials, it significantly decreased incontinence episode frequency by 51.5%
A study by Drutz et al revealed In a subgroup of women with severe SUI awaiting surgery, duloxetine was found to be effective.Incontinence decreased by 46% or their Incontinence Quality of Life (I-QOL) score improved by 6.3 points.

Vaginal oestrogens:
Vaginal oestrogens are used in SUI especially in aging population.The basis behind is
• Common embryonic origin of bladder urethra & vagina
• High concentration of estrogen receptors in pelvic tissues
• General collagen deficiency state (falconer et al., 1994)
• Urethral coaptation affected by loss of estrogen

The oestrogen cream can improve the mucosal integrity and suppleness of the urethra and the vagina thereby take care of the urethral coaptation.These medicines can produce harmful side effects if used for long periods. There is an increased risk of cancers of the breast and endometrium (lining of the uterus). A patient should talk to a doctor about the risks and benefits of long-term use of medications.
When should doctor send the patient for surgery?(Vague indicators)
1. Severe SUI(≥ 2 PADS /DAY)
2. Duration of symptoms> 5 years
3. VLPP≤80 cm H2O-Urdynamic parameters
Apart from that:
1. Pt with significant associated prolapse that may be corrected at the same time
2. High levels of physical stress owing to lifestyle or occupation-models,athletes,stage performers
Summary:
a) SUI needs to be treated with conservative measures initially: simple, inexpensive and without complications
b) No need of UDS prior to conservative measures
c) Duloxetine helpful in noncompliant pt.

Varicocele:Andrological point of view

Varicoceles:
Varicocele has been most controversial topic as to what is significant varicocele,how should it be diagnosed and how should it be operated.The dilemma still persists amongst health care professionals especially Gynecologists whether Varicocele surgery really helps in infertility.Below is a list of common questions cropped up in minds of health care professionals as well as common men and we are trying to give simple and scientific answers as follows..
1. What is varicocele?
2. What are the symptoms?
3. How to diagnose the condition?
4. Does it need surgery?
5. Basis of the treatment
6. What surgery is the best?
7. What should the patient expect post-operatively?
8. Any other modalities for the management?

What is varicocele?:
Varicoceles develop as a result of dilatation and tortuosity of veins of the pampiniform plexus secondary to retrograde flow into the internal spermatic vein (ISV).It may sometimes give feel of bag of worms in the hemiscrotum.
The incidence of varicocele in general population is as high as 15% so surgical selection of the case should be scrupulous.


What are the symptoms:
the common symptoms are dragging sensations in the hemiscrotum,contstant dull pain,testicular atrophy.




How to diagnose:
Clinical Examination in standing position and with Valsalva is all that is necessary although in obese patient sometimes Colour Doppler Ultrasound is needed to prove the diagnosis.


Colour Doppler should only be offered for obese or previously operated groins
Does it need surgery?
• Clinically detectable varicoceles associated with abnormal semen parameters normal female partner or female partner with potentially curable infertility problem. IVF with or without ICSI can be considered to be first-line treatment in the presence of an independent female infertility factor requiring the use of these techniques.
Certain factors predict good outcome like:
 Grade 3 varicocele
 Lack of testiculat atrophy
 Normal FSH
 Motility >60% and motile sperm count >5 ×106


• Palpable varicoceles in adolescent boys when accompanied by ipsilateral testicular atrophy. Adolescents with normal testicular size should be offered follow-up with annual measurement.



REDUCTION IN SIZE OF THE TESTES AS SEEN BY PRADERS ORCHIDOMETER
• Debilitating testicular pain. But unfortunately, 10-15% has either persistent or worsening symptoms.

Basis of the treatment:
• Infertile men with varicocele, were found to have an increased number of abnormal forms, decreased motility and lower mean sperm counts (‘stress pattern'. Varicocelectomy results in significantly improved semen parameters in 60% to 80% of men).
• A multi-center WHO study on the influence of varicocele on fertility parameters demonstrated that the mean Testosterone level of men older than 30 years of age with varicoceles was significantly lower than that of younger patients with varicoceles which was correctable after the surgery.
• Only two randomized, prospective, controlled studies have been performed to show cause and effect relationship between varicocelectomy and improvement in pregnancy rate. Nieschlag et al found that semen parameters improved significantly in the treatment groups but pregnancy rates were no different. Most of the varicoceles in that study were Grade I and a microsurgical; artery sparing technique was not applied. A second study by Madgar, et al. employed a cross over design. In that study, pregnancy rates were 6 times higher in the men undergoing immediate varicocelectomy compared to those in the observation group (60% vs. 10% respectively) over the first year.
• Varicocelectomy can be effective even in men with azoospermia. Matthews and Goldstein recently reported that 55% of azoospermic men had motile sperm observed in their ejaculate after repair.
What is the best modality of treatment:
Surgical repair may be accomplished by various surgical approaches like inguinal (Ivanissevich), subinguinal and retroperitoneal approaches (Palomo), Most experts perform inguinal or subinguinal surgical repair employing loupes or an operating microscope for optical magnification. Techniques using optical magnification help in reliable identification and preservation of the testicular artery or arteries, cremasteric artery and lymphatic channels and reliable identification of all internal spermatic veins and gubernacular veins reducing the risk of persistence or recurrence of varicocele. The introduction of microsurgical technique to varicocelectomy has resulted in a substantial reduction in the incidence of postoperative hydrocele formation and testicular atrophy. The use of magnification enhances the ability to identify and preserves the 0.5 - 1.5-mm testicular arteries, thus avoiding the complications of azoospermia.
Microsurgery only should be the choice for varicocele patient

Laparoscopy has been used for varicocele repair but this approach carries the risk of major intraperitoneal complications, such as injury to bowel, bladder and major blood vessels and also risk of leaving some tributaries especially above level of L4 vertebra.
In general; laparoscopy should not be assorted for varicocele treatment.
The Gold standard of varicocelectomy is Microsurgical Varicocele Ligation.
What should the patient expect post-operatively?

The semen count will take a while to improve so semen analysis should be repeated after an interval of 3 months. Adjuvant medicines such as L carnitine, CoQ 10,Selenium and zinc may facilitate further recovery of sperm count.

Any other modality of tretament:
Some treatments like applying cold water, Typical Yoga postures like Sarvangasan and sheershasan(relieving pressure off the veins) and avoiding sleeping prone are said to ease the varicocele but yet to be proved.

Vaginal Health:Problems with hypo-oestrogenism

A 56-year-old postmenopausal woman presented with a history of incontinence and weak micturition. The incontinence was continuous with intermittent normal voiding. The urine culture was sterile. General physical examination was within normal limits. Pelvic examination demonstrated extreme labial fusion with only a pinhole opening. Conservative management in the form of local estrogen cream application was instituted without improvement. The woman underwent labial separation under spinal anesthesia. There were also vaginal synechiae and urethral stenosis which were lysed and dilated with Hegar’s dilators. Postoperatively the patient was instructed to apply estrogen cream locally. She presented in the interim period twice with loose fibrinous adhesions for which gentle separation and Hegars dilatation under local anesthesia sufficed. She has till now not needed major procedure for treatment.
Adhesions of the labia are rare in the adult population.It presents with vulvodynia,pruritus ,dyspareunia etc.Labial fusion presentation with pseudoincontinence is still rarer. The etiology of labial adhesions probably relates to vaginal inflammation or irritation. Once the superficial epithelium of the labia is denuded subsequent healing leads to fibrous adhesions between the labia. Etiological factors for labial fusion in adult women are senile vaginitis, hypoestrogenism, lack of sexual activity, local trauma, vaginal laceration following childbirth, female genital cutting(practice prevalent in some communities) and recurrent urinary tract infections( and /or STDs). In the present case, pseudoincontinence was caused by collection of urine in the space behind the fused labia.
Treatment is most often conservative in the form of estrogen cream for hypoestrogenism and atrophic mucosa. Labial separation should be employed when this treatment fails; but as the labia are often tender the separation may need to be done under anesthesia. In addition, the presence of vaginal synechiae or urethral stenosis can make regional or general anesthesia essential. Postoperatively estrogen or steroid cream should help to prevent recurrence of the problem.
Labial fusion is a rare condition in adults, most often caused by hypoestrogenism. While conservative topical estrogen therapy is sufficient in most cases, labial fusion may persist and require surgical intervention.In our case; even after the surgical separation and local oestrogen therapy fusion recurred albeit the adhesion was filmsy and did not need anaesthesia.
In some refractory cases advancement flap surgery will be needed to cover the raw area.

Vaginismus-Cause of Infertility

A 34 year old gentleman presented to us with PRIMARY INFERTILITY.The Couple were trying for 5 years for conception.The investigation profile revealed moderate oligospermia.After having tried all medicines (both multivitamins,anti-ostrogens and alternative medicines) there was no fruitful outcome.The couple had almost given up.On presentation to us; we came across a very important finding which was failure of penetration of the male organ on account of vaginal pain (Vaginismus).The husband perse could never deposit semen in the vagina.
The presence of bordrline sperm count had almost driven the focus of attention from this important condition(vaginismus) to treatment of sperm count(? For years).
We were quite surprised as 5 years had elapsed since marriage and the marriage was uncosummated.
In our society majority of the couples entering into arranged marriage are virgins with little knowledge about sexual anatomy of themselves leave apart understanding the anatomy of the partner.No sexual experience and scanty sexual knowledge leads to vast majority of couples presenting to sexologist with inability to consummate.
Many couples are GUIDED by elderly members of the society that ‘things will work out’ especially after first childbirth as the vaginal canal will dilate.Ther poor couple was waiting for the first child to arrive without finishing the first essential formality of proper deposition of the sperms in the vaginal canal.
vaginismus, is a involuntary tightening of the vaginal muscle, which prevents penis-vagina intercourse. If a man pushes hard trying to enter, it can cause the woman intense pain. In other cases, vaginismus is due to a medical condition that causes pain in the vulvar area, inside the vagina, or elsewhere in the pelvic region. Tightening the pelvic muscles is an unconscious reflex effort to prevent further pain.
In some cases, vaginismus is caused by fear or aversion to sex. For women who experienced sexual abuse, rape or other trauma, this may be an effort to protect themselves from further violation or pain. Many women who are fearful or aversive to sex have no history of trauma, but may have heard scary stories about sex, learned negative sexual attitudes, or have frightening images relating to sex.
So basic sex counselling to correct misconceptions,allay the fears and teach the right technique of the intercourse.The lubricating non-spermicidal jellys can be used for decreasing the pain of penetration.All efforts should be focussed towards encouraging interpersonal relationship between husband and the wife.
Any underlying pelvic diseases should be treated with help of gynecologist.If still the problem persist then the women must be taught vaginal self dilatation.Gradually larger dilator can be accomodated and the fear of penetration will decrease.Vaginal self dilatation works in women with a tough hymen also without need of surgical hymenectomy.
One very useful adjust in such cases is pelvic relaxation exercise and Kegels exercise.This can wok wonders with self dilatation at least in 80% cases.










LUBRICATING JELLY AND SERIAL DILATORS FOR GENTLE PROGRESSIVE SELF DILATATION OF THE VAGINA

LASER prostatectomy in high risk old patient

A 90 year old gentleman presented to us with refractory retention and overflow incontinence. He had history of chronic subdural hematoma which was drained in the month of January 2010.On evaluation, he had grade 3 prostatomegaly.The Ultrasound examination revelaed 96 gm prostate and bilateral hydroureteronephrosis. Renal Function Tests revelaed mildly lelevated creatinine levels(1.8 mg%).
After initial stabilisation of creatinine with indwelling catheter(after subsidence of the bilateral hydro-ureteronephrosis) he was taken for LASER Prostatectomy.He was cleared by physician with moderate risk because of sub-optimal (45%)ejection fraction.

The Prostatectomy was done with Continuous wave Thulium Laser and took 40 minutes for the enucleation.The procedure was completed with morcellation.A 18-Fr Foleys catheter was kept in the bladder.The catheter was removed the very next day and the patient was discharged.The patient is voiding well with good amount void.
The Thulium LASER causes fast and clean cut without vibration because of continuous wave Technology.It causes rapid vaporization of both glandular and fibrous prostate.As the Laser is absorbed by cellular water –it is useful for both fibrous and glandular prostate.The depth of penetration of the Laser therefore is shallow and there is minimal chance of secondary hemorrhages as there is no necrotic tissue in the prostatic bed.This technology is very safe and effective in vessel sealing of both arteries and veins.

We used Richard Wolf 22.5 F Continuous Flow Scope so the rate of the urethral stricture is comparitively less than the other endoscopic methods.
This technology can be offered to old frail patients with cardiac risk and even on anticoagulants and platelet aggregate inhibitors.



Thulium LASER machine



Procedure being carried out