1.  Stephen T Jeffery University of Cape Town, South Africa Urogynaecology and laparoscopy clinic www.urogynaecology.co.za

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

7. Let’s kick off with a few typical cases

8. 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

9.  Options?

10. 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

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

12. 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

13. 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/

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

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

16. Case 2

17. Case 3: Only likely to see in resource constrained setting

18. Case 4:

19. Prolapse Urinary Incontinence Fecal Incontinence

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

21. The most staggering statistics are the related to fistula

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

24. First of all – get the basics right

25. 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

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

27. 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?

28. 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

29. Sexual Dysfunction Approach

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

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

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

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

38. Don’t only zoom in on the vagina

39. Fistula

40. Skin Irritation

42. Digital Rectal Exam  Squeeze  Some correlation with manometry

44. 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?

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

46. Bladder diary

47. Don’t forget the bladder diary

49. Check Urine Residual  Catheter Or  Ultrasound

50. Cheap “cystometry” (acknowledgements to Lauri Romanzi)

51. 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)

52. 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)

53. 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)

55. 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 ???

56. Inexpensive treatment options

57. Basic fluid advice

58. Group physio therapy sessions

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

60. Persistence on Specific Medications for OAB Based on Prescription Data

61. Cheap posterior Tibial Nerve Stimulation

63. Pessaries

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

68.  Other essential tools of the trade

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

70. Training, training, training!

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

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

75.  www.urogynaecology.co.za