 Stephen T Jeffery University of Cape Town, South Africa Urogynaecology and laparoscopy clinic

Impact of Pelvic Floor Dysfunction  Very different from the experience in well resourced settings.  Heaviest burden is in the prevailing problem of obtsetric fistula.

Let’s kick off with a few typical cases

56 year old Complains of urgency, urgency incontinence daily episodes Also incontinence with coughing, laughing and sneezing On exam – obvious stress leak with cough Case 1

 Options?

Case 1: If she was living in Chicago / London / Paris For the urgency incontinence  Bladder retraining by specialist continence nurse  Pelvic floor exercises by women’s health physiotherapist  Trial of anticholinergic therapy including tolteridine, solifenacin, oxybutynin slow realease, mirabregnon  Possibly Intradetrusor Botox  Poterior tibial nerve stimulation  Sacral Nerve Stimulation

Case 1: If she was living in Chicago / London / Paris For the stress incontinence  Tension –free vaginal or transobturator tape

Case 1: If she was living in Accra / Kathmandu/ For the urgency incontinence  May have some advice about PFE / Bladder drill / Fluid advice  May get some Oxybutynin

For the stress incontinence  Depends on training  Possibly have a Burch / Pubovaginal sling  No option of a TVT or TOT Case 1: If she was living in Accra / Kathmandu/

AND would she even have sought help for this problem? Case 1: If she was living in Accra / Kathmandu/

Case 2  21 year old  Constant urinary leakage  Delivered a macerated, dead baby at home 6 months ago

Case 2

Case 3: Only likely to see in resource constrained setting

Case 4:

Prolapse Urinary Incontinence Fecal Incontinence

Other common referral problems Hematuria Recurrent UTIs Bladder pain syndrome Sexual dysfunction/dyspareunia Pelvic pain Defecatory difficulty Obstructed defecation

The most staggering statistics are the related to fistula

Pelvic Floor Health in Resource Constrained Settings  Under-reported  Under-diagnosed  Undertreated  Significant direct and indirect costs

First of all – get the basics right

Important symptoms: Urinary incontinence Stress Urgency / urgency incontinence Nocturia Leakage with sex How many pads Symptoms of voiding dysfunction Medications: Look for diuretics and Beta blockers Approach

Red flag symptoms – Voiding difficulties – Haematuria – Severe bladder pain Approach

Prolapse related queries Does the bulge protrude through the introitus? How big is it in relation to known objects such as a golf ball, egg, lemon, orange? How exactly is the problem BOTHERING her? What are her fears about the bulge? What are her expectations for treatment?

Faecal symptoms Faecal Urgency Faecal Incontinence Defaecatory difficulty Change in bowel habit Bleeding Straining and digitation Distinguishing between flatus and solid stool Rectal prolapse Approach

Sexual Dysfunction Approach

General Medical History – Multiple sclerosis – Parkinsons – Stroke – Risk factors for surgery Approach

Surgical History – Previous incontinence/ prolapse surgery? – Does she still have a uterus? – Previous gynaecological surgery? Approach

Neuro Exam  S2, S3, S4 nerves – peri-anal skin  Decreased ankle reflexes – SCI or Cauda Equina

Abdomen  Ileal disease – RLQ (Crohns)  Abdominal mass

Don’t only zoom in on the vagina

Fistula

Skin Irritation

Digital Rectal Exam  Squeeze  Some correlation with manometry

Case 45 year old with Stage III vaginal vault and rectal prolapse. She is sexually active. Total Vaginal Length is 8 cm What options would you present to this patient?

Pyuria UTI is an important cause of urgency Glycosuria DM – Peripheral autonomic neurop, UTI Haematuria Bladder Ca Urine dipstix

Bladder diary

Don’t forget the bladder diary

Check Urine Residual  Catheter Or  Ultrasound

Cheap “cystometry” (acknowledgements to Lauri Romanzi)

1 Position patient in lithotomy, with head raised if possible 2 Separate labia, STAND TO THE SIDE, as pt strains, then coughs – note presence/absence SUI, record data 3 Clean meatus with Betadine 4 Insert red rubber catheter use lubricant 5 Empty bladder, record volume Cheap “cystometry” (acknowledgements to Lauri Romanzi)

6 Evaluate urine for infection (dipstick, visual inspection) & record findings – defer filling if infected 7 Invert catheter & attach 60 ml catheter tip syringe 8 Fill bladder via gravity in 50 ml increments using normal saline 9 Note volume at which patient reports 1 st urge, moderate fullness, total fullness 10 Evaluate filling phase for presence/absence involuntary bladder contractions (detrusor instability) record findings Cheap “cystometry” (acknowledgements to Lauri Romanzi)

11 At capacity, remove catheter and have patient strain (Valsalva) & cough again – record presence/absence SUI 12 If patient does not demonstrate SUI supine, repeat strain & cough in standing position, record presence absence SUI 13 Have patient void into container – record audible characteristics of flow, volume voided, & calculate post-void residual (PVR) Cheap “cystometry” (acknowledgements to Lauri Romanzi)

Treatment options for stress and urge urinary incontinence, prolapse 55 Supporting pessaries, tampon incontinence pads Behavioral intervention reducing fluid intake prevent intoxications (coffee etc) bladder training cough technique reduction of weight prevent psychological and somatic stress situations Drug therapy Anti-cholinergics, α-sympaticomimetics Estrogen Pelvic floor physiotherapy Pelvic floor reeducation Kegel exercises Biofeedback Surgical therapy mid-urethral slings colposuspension bulking agents Prolapse surgery Fistula surgery No therapy ???

Inexpensive treatment options

Basic fluid advice

Group physio therapy sessions

Anticholinergics  Always worth trying Oxybutynin  If you can’t afford second line anticholinergic therapy, don’t worry – most of them don’t really work!

Persistence on Specific Medications for OAB Based on Prescription Data

Cheap posterior Tibial Nerve Stimulation

Pessaries

 Follow up 6 monthly  Clean and re-insert each time  No need to replace with new one

 Other essential tools of the trade

Identify keen doctors and support them  Don’t underestimate the power of energy and enthusiasm!

Training, training, training!

Identify your specific challenges  Lack of training  Lack of resources  No patients  Anaesthesia  Radiological investigations  Competing interests  Oncology  Obstetrics  Emergency gynae

Build your team  Urologist  Colo-rectal  Physio  Nurses

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