CPG Urogynecology

8/9/2019 CPG Urogynecology

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Philippine Obstetrical and

Gynecological Society (POGS), Foundation, Inc.

November 2010

Task Force on Clinical Practice Guidelines

on Urogynecology

CLINIC L PR CTICE GUIDELINES

on

UROGYNECOLOGY

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REGTA L. PICHAY, MD

PresidentPhilippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2010

REGTA L. PICHAY, MD

FOREWORD


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EFREN J. DOMINGO, MD, PhD

Editor in Chief, Clinical Practice Guidelines, 2010

The Clinical Practice Guidelines on Urogynecology is the First Edition of this

Publication, 2010. The Philippine Obstetrical and Gynecological Society,

(Foundation), Inc. (POGS), through the Committee on Clinical Practice Guidelines

initiated and led to completion the publication of this manual in plenary consultation

with the Residency Accredited Training Hospitals’ Chairs and Training Officers, The

Regional Board of Directors, The Board of Trustees, The Task Force on

Urogynecology and the Committee on Continuing Medical Education (CME).

This publication represents the collective effort of the POGS in updating the

clinical practice of Obstetrics and Gynecology, specifically on Urogynecology, andmaking 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.

This Clinical Practice Guideline on Urogynecology is envisioned to become

the handy companion of the Obstetrician-Gynecologist in his/her day-to-day rendition

of quality care and decision making in managing the Gynecologic patient. This is also

envisioned to provide the academic institutions in the country and in Southeast Asia

updated information on Urogynecology as being practiced in the Philippines.

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.

EFREN J. DOMINGO, MD, PhD

INTRODUCTION


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BOARD OF TRUSTEES 2010

OFFICERS

Regta L. Pichay, MD

President

Sylvia delas Alas Carnero, MD

Vice President

Ditas Cristina D. Decena, MDSecretary

Jericho Thaddeus P. Luna, MD

Treasurer

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


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COMMITTEE ON CLINICAL PRACTICE GUIDELINES ON

UROGYNECOLOGY

Efren J. Domingo, MD, PhD

Editor in Chief

MEMBERSAnn 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

TECHNICAL STAFF ASSISTANTS

Ms. Emiliana C. Enriquez

Ms. Jhasmin G. De Guzman

TASK FORCE ON UROLOGYNECOLOGY

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

TASK FORCE REVIEWERS AND PLENARY REVIEWERS

Rainerio S. Abad, MD Ma. Flores Adiong, MD Imelda O. Andres, MDRuth Jinky Aposaga, MD Prudence V. Aquino, MD Nurlinda Arumpac, MD

Ricardo Braganza, MD Sybil Lizanne R. Bravo, MD Maria Nelvez Candilario, MD

Grace D. Caras, MD Abigail Elsie D. Castro, MD Ma. Theresa Cedullo, MD Ma.

Cherrie Climaco, MD Antonio Cortez, MD Lara David-Bustamante, MD

Macrina A. De Guzman, MD Grace D. delos Angeles, MD Lorina Q. Esteban, MD

Rodante P. Galiza, MD Gil S. Gonzales, MD Maribel Hidalgo-Co, MD

May N. Hipolito, MD Rosemarie R. Hudencial, MD Humildada Asumpta Igana, MD

Margarette Lavalle, MD Lourdes Ledesma, MD Jericho Thaddeus P. Luna, MD

Ma. Cecilia Maclang, MD Marilou Mangubat, MD Corazon B. Mata, MD

Jocelyn Z. Mariano, MD Rudie Frederick B. Mendiola, MD Marites Mendoza, MD

Suzette Miclat, MD Cristia S. Padolina, MD Mary Christine F. Palma, MD

Belen Pantangco-Rajagukguk, MD Gladys Pelicano, MD Regta L. Pichay, MD

Sarah Pingol, MD Kenet Prado, MD Ma. Carmen H. Quevedo, MD

Rico E. Reyes, MD Ricalynn Rivera, MD Bella G. Rodriguez, MD

Pura Rodriguez-Caisip, MD Alice Salvador, MD Jean Marie Salvador, MD

Esmarliza Tacud-Luzon, MD Patricia L. Tan, MD Ma. Theresa B. Tenorio, MD

Jean Anne B. Toral, MD Florentina A. Villanueva, MD Julieta Villanueva, MD

Faith Villaruiz, MD Marilou Viray, MD Regina P. Vitriolo, MD

Amaryllis Digna A. Yazon, 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)


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DISCLAIMER, RELEASE AND WAIVER OF RESPONSIBILITY

• This is the Clinical Practice Guidelines (CPG) on Urogynecology, First Edition,

November 2010.• This is the publication of the Philippine Obstetrical and Gynecological Society,

(Foundation), Inc. (POGS).

• This is the ownership of the POGS, its officers, and its entire membership.• The obstetrician gynecologist, the general practitioner, the patient, the student, the

allied medical practitioner, or for that matter, any capacity of the person orindividual who may read, quote, cite, refer to, or acknowledge, any, or part, or the

entirety of any topic, subject matter, diagnostic condition or idea/s willfullyrelease and waive all the liabilities and responsibilities of the POGS, its officers

and general membership, as well as the Committee on the Clinical PracticeGuidelines and its Editorial Staff in any or all clinical or other disputes,

disagreements, conference audits/controversies, case discussions/critiquing.• The reader is encouraged to deal with each clinical case as a distinct and unique

clinical condition, which will never fit into an exact location if reference is made

into any or all part/s of this CPG.

• The intention and objective of this CPG is to serve as a guide, to clarify, to makeclear the distinction. It is not the intention or objective of this CPG to serve as the

exact and precise answer, solution and treatment for clinical conditions and

situations. It is always encouraged to refer to the individual clinical case as the

one and only answer to the case in question, not this CPG.

• It is hoped that with the CPG at hand, the clinician will find a handy guide thatleads to the a clue, to a valuable pathway that leads to the discovery of clinical

tests leading to clinical treatments and eventually recovery.• In behalf of the POGS, its Board of Trustees, the Committee on The Clinical

Practice Guidelines, 2010, this CPG is meant to make each one of us a perfect

image of Christ, the Healer.


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Introduction ……………………………………………………………… 1

Dr. Lisa T. Prodigalidad-Jabson

Definition of Terms (Standardization of Terminology) …………………

Dr. Almira J. Amin-Ong

Evaluation of Pelvic Floor Dysfunction and POP-Q Scoring System …..

Dr. Judith M. Sison

Conservative Management of Stress Urinary Incontinence ………………

Dr. Almira J. Amin-Ong

Surgical Management of Stress Urinary Incontinence …………………….

Dr. Lisa T. Prodigalidad-Jabson

Conservative Management of Pelvic Organ Prolapse ……………………

Dr. Maria Teresa C. Luna

Surgical Management of Pelvic Organ Prolapse …………………………

Dr. Manuel S. Ocampo, Jr and Dr. Lisa T. Prodigalidad-Jabson

Fecal Incontinence and Obstetric Anal Sphincter Injuries (OASIS) ……..

Dr. Lennette L. Chan

Urinary Retention ………………………………………………………...

Dr. Jennifer B. Jose

Appendix: Level of Evidence and Grade of Recommendations ………….

CPG ON UROGYNECOLOGY

TOPICS / CONTENTS / AUTHOR/S


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INTRODUCTIONLisa T. Prodigalidad-Jabson, MD

Urogynecology and Reconstructive Pelvic Surgery has long been a recognized

specialty in the field of Obstetrics and Gynecology. However, here in the Philippines,Urogynecology is still at its infancy stage and only recently has there been a growing

interest in this field of pelvic reconstruction. Pelvic floor disorders such as pelvic

organ prolapse (POP), fecal incontinence (FI), and urinary incontinence (UI) are, at

present, aspects of women’s health that are frequently neglected or ignored.

POP is among the most common indications for benign gynecologic surgery.

A review by the National Center for Health Statistics in the United States lists genital

prolapse as one of the 3 most common reasons for hysterectomy in women. In the

University of the Philippines - Philippine General Hospital alone, over 100 cases of

vaginal hysterectomies are performed each year for prolapse. In a recent review by

the Women’s Health Initiative, POP was found to be a very common condition in

women during menopause and was consistently related to parity.2 This becomes of particular importance in a society such as ours where family planning, althoughstrongly advocated, is not widely practiced.

Likewise, female UI is a common problem that is often unrecognised, neglected,or ignored. It is a condition believed to be as natural as pregnancy, childbirth,

menopause, and aging. The prevalence of UI is reported to range from 2% to 57% andafflicts both the young and old. The wide range may reflect the difficulty in

estimating the incidence of UI, as most women experiencing such symptoms often do

not seek medical advice. In a 2001 study by the Asia-Pacific Continence Advisory

Board, the prevalence of overactive bladder as a cause of incontinence in Asians was

noted to be 51.4%. More specifically, Diokno states a 13% prevalence rate of UI

among Filipinos.3 This is in contrast to the incidence of 31% reported by Ramoso-

Jalbuena in 1994.4

With recent emphasis on women’s health and quality of life, caring for women

with various pelvic floor disorders would become an increasingly important aspect of

women’s health care. And, for a rapidly growing and aging population, the demand

for such care will inevitably escalate.

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 prolapsein 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. Theepidemiology 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.


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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 areculled from the latest International Continence Society (ICS) Standardization ofTerminology for lower urinary tract symptoms published in 2009. The terminologies

serve to eliminate confusion and facilitate communication amongst clinicians.

I. SYMPTOMS SUGGESTIVE OF LOWER URINARY TRACT

DYSFUNCTION

A. STORAGE SYMPTOMS

1. Urgency – the complaint of a sudden compelling desire to pass urine which isdifficult to defer

2. Increased daytime frequency – the complaint of the patient who considers thatshe voids too often by day; equivalent to pollakisuria used in many countries

3. Nocturia – the complaint that the individual has to wake up at night one ormore times to void

4. Stress urinary incontinence (SUI) – the complaint of involuntary leakage oneffort or exertion, or on sneezing or coughing

5. Urge UI – the complaint of involuntary leakage accompanied by orimmediately preceded by urgency

6. Mixed UI – the complaint of involuntary leakage associated with urgency andalso with exertion, effort, sneezing or coughing

7. Nocturnal enuresis – complaint of loss of urine occurring during sleep8. Continuous urinary leakage – the complaint of continuous leakage9. Normal bladder sensation – the individual is aware of bladder filling and

increasing sensation up to a strong desire to void

10. Increased bladder sensation – the individual feels an early and persistentdesire to void

11. Reduced bladder sensation – the individual is aware of bladder filling but doesnot feel a definite desire to void

12. Absent bladder sensation – the individual reports no sensation of bladder

filling or desire to void13. Non-specific bladder sensation – the individual reports no specific bladdersensation but may perceive bladder filling as abdominal fullness, vegetative

symptoms, or spasticity

B. VOIDING SYMPTOMS

1. Slow stream – perception of the individual of reduced urine flow, usuallycompared to previous performance or in comparison with others

2. Splitting or spraying – self-explanatory3. Intermittent stream (intermittency) – urine flow described as a stop and start

flow, on one or more occasions, during micturition4. Hesitancy – difficulty in initiating micturition resulting in a delay in the onset


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of voiding after the individual is ready to pass urine

5. Straining – describes the muscular effort used to either initiate, maintain orimprove the urinary stream

6. Terminal dribble – term used when an individual describes a prolonged final part of micturition, when the flow has slowed to a trickle/dribble

C. POSTMICTURITION SYMPTOMS

1. Feeling of incomplete emptying – self-explanatory term for a feelingexperienced by the individual after passing urine

2. Postmicturition dribble – involuntary loss of urine immediately after the patient has passed urine, or after rising from the toilet

D. GENITAL AND LOWER URINARY TRACT PAIN

1. Bladder pain – pain felt suprapubically or retropubically, and usually

increases with bladder filling, it may persist after voiding2. Urethral pain – felt in the urethra and the individual indicates the urethra as

the site3. Vaginal pain – felt internally, above the introitus4. Perineal pain – felt between the posterior fourchette and the anus5. Pelvic pain – less well defined than the bladder, urethral or perineal pain and

is less clearly related to the micturition cycle or to bowel function and is notlocalized to any single pelvic organ

E. GENITO-URINARY PAIN SYNDROMES

1. Painful bladder syndrome – complaint of suprapubic pain related to bladderfilling accompanied by other symptoms such as increased daytime or

nighttime frequency, in the absence of a proven urinary infection or other

obvious pathology

2. Urethral pain syndrome – occurrence of recurrent episodic urethral painusually on voiding, with daytime frequency and nocturia, in the absence of a

proven infection or other obvious pathology

3. Vulval pain syndrome / Vaginal pain syndrome / Perineal pain syndrome –occurrence of persistent or recurrent episodic vulval, vaginal or perineal pain

which is either related to the micturition cycle or associated with symptoms

suggestive of urinary tract or sexual dysfunction, with no proven infection orobvious pathology

4. Pelvic pain syndrome – occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual,

bowel or gynecological dysfunction, with no proven infection or obvious

pathology

II. SIGNS SUGGESTIVE OF LOWER URINARY TRACT DYSFUNCTION

1. Daytime frequency – number of voids during waking hour inclusive of the last

void before sleep and the first void upon waking in the morning2. Nocturia – number of voids recorded during a night’s sleep, each void is


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preceded and followed by sleep

3. Polyuria – urine production of more than 2.8 liters in 24 hours in adults4. 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 chart6. 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 withor without urgency incontinence, usually with frequency and nocturia

8. Mixed UI – complaint of involuntary leakage associated with urgency and alsowith effort, exertion, sneezing and coughing

9. Extraurethral incontinence – observation of urine leakage through channelsother 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

symptoms11. Intravesical pressure – pressure within the bladder12. Abdominal pressure – pressure surrounding the bladder which is estimated

from rectal, vaginal, or less commonly, from extraperitoneal pressure or bowel

stoma13. Detrusor pressure – the component of vesical pressure that is created by

forces in the bladder wall, both active and passive. It is estimated bysubtracting 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 byinvoluntary detrusor contractions during the filling phase which may be

spontaneous or provoked

17. Terminal detrusor overactivity – defined as a single, involuntary detrusorcontraction, occurring at cystometric capacity, which cannot be suppressed

and results in incontinence usually resulting in bladder emptying18. Detrusor overactivity incontinence – incontinence due to an involuntary

detrusor contraction

19. Neurogenic detrusor overactivity – involuntary detrusor contractionsoccurring in patients with relevant neurological condition20. Idiopathic detrusor overactivity – no defined cause for the involuntary

detrusor contractions

21. Bladder compliance – describes the relationship between change in bladdervolume and change in detrusor pressure

22. Cystometric capacity – the bladder volume at the end of the fillingcystometrogram 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 normalsensations feels she can no longer delay micturition (has a strong desire to

void).24. Urodynamic stress incontinence – noted during filling cystometry and is


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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 urineleakage 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 duringurodynamic studies.

29. Bladder outlet obstruction – a generic term for obstruction during voiding andis characterized by increased detrusor pressure and reduced urine flow rate

30. Dysfunctional voiding – characterized by intermittent and/or fluctuating flowrate 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 urethraresulting in reduced urine flow.

33. Pelvic organ prolapse (POP) – defined as the descent of one or more of theanterior 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 vaginaso 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 posteriorvaginal 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 hymen36. 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 hymen37. 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/orflatus 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.


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III. TREATMENT

1. Pelvic floor training – repetitive selective voluntary contraction and relaxation

of specific pelvic floor muscles

2. Biofeedback – technique by which information about a normally unconscious

physiological process is presented to the patient and/or therapist as a visual,auditory or tactile signal

3. Behavioral modification – the analysis and alteration of the relationship

between the patient’s symptoms and her environment for the treatment of

maladaptive voiding patterns

4. Electrical stimulation – the application of electrical current to stimulate the

pelvic viscera or their nerve supply

5. Catheterization – technique for bladder emptying employing a catheter to

drain the bladder or a urinary reservoir

6. Intermittent (in/out) catheterization – defined as drainage or aspiration of the

bladder or urinary reservoir with subsequent removal of the catheter

a. Intermittent self-catheterization – performed by the patient herself b. Intermittent catheterization – performed by an attendant (e.g., doctor,

nurse, or relative)c. Clean intermittent catheterization – use of a clean technique. This

implies ordinary washing techniques and use of disposable or cleansedreusable catheters

d. Aseptic intermittent catheterization – use of a sterile technique. Thisimplies genital disinfection and use of sterile catheters and

instruments/gloves

7. Indwelling catheterization – an indwelling catheter remains in the bladder,

urinary reservoir or urinary conduit for a period of time longer than one

emptying

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. 4 th International Consultation on

Incontinence. 4th ed. 2009.


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EVALUATION OF PELVIC FLOOR DYSFUNCTION AND THE

POP-Q SCORING SYSTEMJudith M. Sison, MD, MPH

I. URINARY INCONTINENCE

1. Patients with urinary incontinence (UI) should undergo a basic evaluation

that includes a history1, physical examination

2,3, measurement of post-

void residual volume (PVR), urinalysis, and 3-day bladder chart.

Standard chemical tests for renal function are recommended in patients

with UI and a high probability of renal damage. ( Level II-3, Grade A)

Summary of Evidence

Post-void residual volume

A PVR < 50 ml is considered adequate bladder emptying and > 200 ml isconsidered inadequate.4,5

Routine urinalysis with or without urine culture and sensitivity test

To assess for any lower urinary tract infection (UTI), a clean midstream orcatheterized urine sample should be obtained for dipstick urinalysis which

provides necessary information as a “multi-property” strip should be used.6 It

can also screen any urothelial lesion and stone disease.7

Three-day bladder diary (frequency/volume chart)

Urinary diaries are highly reproducible and correlated well with urodynamic

diagnosis.8

Consistent results have been shown between the first 3-day periodand the last 4-day period, suggesting that a 3-day chart may be adequate to

document symptoms, thus, improving compliance.9, 10

Standard blood chemistries for renal function

The routine use of a battery of common chemical tests in patients with UI

appears to be a prudent rule of good practice in the following conditions:

a. chronic retention with UI (overflow UI) b. neurogenic lower urinary tract dysfunctionc. when surgery is contemplatedd. when there is a clinical suspicion

2. Cough stress test strongly suggests a diagnosis of stress urinary

incontinence (SUI). Borderline or negative test results should be repeated

to maximize its diagnostic accuracy. (Level II-2, Grade B)

Summary of Evidence

Loss of small amounts of urine in spurts, simultaneous with coughingand in the absence of urge, strongly suggests a diagnosis of SUI.11 Prolonged

loss of urine, leaking 5-10 seconds after coughing, or no urine loss with

provocation indicates that other causes of incontinence, especially detrusor

overactivity, may be present. The inability to demonstrate the sign of SUI


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effectively carry out passive contraction therapy, an exercise program, or

any need for further evaluation. (Level III, Grade C)

Summary of Evidence

The continence mechanisms imply that integrity of the levator ani andthe 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 manometryof pelvic floor muscles.23

7. Urine cytology is recommended in patients with persistent microscopic

hematuria in the absence of UTI to exclude bladder neoplasm. (Level III,Grade C)

Summary of Evidence

Urine cytology should be requested in patients with microscopic

hematuria (RBC 2-5/hpf), ! 50 year-old with persistent hematuria or those

with acute onset of irritative voiding symptoms in the absence of UTI to

exclude bladder neoplasm.24 It is not recommended in the routine evaluation

of patients with incontinence.25

8. Cystometric testing is not required in the routine or basic evaluation of

UI.26

Whenever objective clinical findings do not correlate with or

reproduce the patient’s symptoms, simple cystometry is appropriate for

detecting abnormalities of detrusor compliance and contractibility.27

(Level II, Grade B)

Summary of Evidence

Office cystometry: Retrograde bladder filling provides an assessment

of bladder sensation and an estimate of bladder capacity. The definition of

normal bladder capacity lacks consensus, with values that range from 300-750

ml. In addition, large bladder capacities are not always pathologic.

Researchers showed that 33% of women with bladder capacities > 800 ml.

were urodynamically normal, and only 13% had true bladder atony.28 .

9. Minimum urodynamic investigation includes uroflowmetry, pressure-

flow study of voiding together with one or more of the following, as

indicated for the individual patient: abdominal leak point pressuremeasurement, urethral pressure measurement. (Level II, Grade B)


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Indications for urodynamics29:

a. Prior to invasive or irreversible treatment or retreatment of all types of

incontinence

b. Complex incontinence cases whenever there is doubt about the

underlying pathophysiology

c. Neurogenic bladders as an initial assessment or as part of a long-termsurveillance. If possible, videourodynamic testing should be employed.

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

10. Urethral pressure profilometry (UPP) and leak point pressure

measurements have not proved useful in the evaluation of UI. (Level III,

Grade C)

Summary of Evidence

Researchers found that UPP is not standardized, reproducible, or ableto contribute to the differential diagnosis in women with SUI symptoms.

Therefore it does not meet the criteria for a useful diagnostic test.32

Leak point pressure measures the amount of increase in intraabdominal pressure that

causes stress incontinence, although its usefulness also has not been proved.33

11. Cystoscopy should not be performed routinely in patients with

incontinence to exclude neoplasm. (Level II-2, Grade B)

Summary of Evidence

Indications for cystoscopy in patients with UI include those who have:

sterile hematuria or pyuria; irritative voiding symptoms, e.g. frequency,

urgency, urge incontinence in the absence of any reversible causes; bladder

pain; recurrent cystitis; suburethral mass; and when urodynamic testing fails toduplicate symptoms of UI.34 Bladder lesions are found in < 2% of patients

with incontinence35

; therefore, cystoscopy should not be performed routinely

in patients with incontinence to exclude neoplasm

36

.

12. Imaging: Ultrasound is not recommended in the primary evaluation of

patients with UI and/or POP. It is likewise an optional test in the

evaluation of patients with complex or recurrent UI and or POP.37, 29

MRI of the pelvic floor is rapidly gaining field in the evaluation of

enteroceles and in the morphological analysis of pelvic floor muscles

although the evidence of its clinical benefit is still unclear.29,38 (Level III,

Grade C)


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Summary of Evidence

Transabdominal, perineal or translabial, transrectal, and transvaginal

ultrasound is currently used due to its noninvasive nature, ready availability,

and absence of distortion. Although ultrasound is rapidly evolving and much

progress has been made, it remains optional as evidence of its clinical benefitis still weak.

29

MRI provides anatomical detail to the pelvic floor in a single non-

invasive study that does not expose the patient to ionizing radiation. Gousse,

et. al. reported a sensitivity of 83%, specificity of 100%, positive predictive

value of 100%, when comparing dynamic MRI to intraoperative findings.

These numbers were similar compared to physical examination alone.39

II. PELVIC ORGAN PROLAPSE AND PELVIC ORGAN PROLAPSE

QUANTIFICATION SYSTEM

1. The only symptom specific to prolapse is the awareness of vaginal bulge

or protrusion. For all other pelvic symptoms, resolution with prolapse

treatment can not be assumed.40

(Level II-3, Grade A)

Summary of Evidence

Almost half of parous women can be identified as having prolapse by

physical examination criteria, most are not clinically affected; the finding is

not well correlated with specific pelvic symptoms.41

2. The amount or severity of prolapse in each vaginal segment may be

measured and recorded using the pelvic organ prolapse quantification

system (POP-Q). (Level III, Grade C)

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 maybemore 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

2. Cystoscopy or cystourethroscopy should be performed intraoperatively to

assess for bladder or ureteral damage after all prolapse or incontinence

procedures during which the bladder or ureters may be at risk of

injury.43 (Level II-2, Grade B)

Summary of Evidence

A recent systematic review of urinary tract injuries during

urogynecologic surgical procedures and routine intraoperative

cystourethroscopy reported the overall ureteral injury rate was 8.8/1,000


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procedures (95% CI 2.3-12.6).43 The overall bladder injury rate after

urogynecologic surgical procedures was 16.3 (95% CI 4.3-26.6).44

PELVIC ORGAN PROLAPSE QUANTIFICATION SYSTEM (POP-Q)

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). Allmeasurements, 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.

Quantification Definitions and Ranges:POINT MEASUREMENT RANGE

Aa Anterior vaginal wall 3 cm proximal to hymen -3 to +3

Ba Leading-most point of anterior vaginal wall prolapse -3 to + TVL

C Most distal edge of cervix or vaginal cuff (if absent cervix) - /+ TVL

D Most distal portion of posterior fornix - /+ TVL

Ap Post vaginal wall 3 cm proximal to hymen -3 to +3

Bp Leading-most point of post vaginal wall prolapse -3 to + TVL

Gh Perpendicular distance from mid-urethral meatus to posterior hymen No limit

Pb Perpendicular distance from mid-anal opening to posterior hymen No limit

TVL Post vaginal fornix or vaginal cuff (if absent cervix) to the hymen No limit

The stages of POP are:

Stage 0 – No descent of any compartment

Stage 1 – Descent of the most prolapsed compartment between perfect support and

-1 cm

Stage 2 – Descent of the most prolapsed compartment between -1 cm and +1 cmStage 3 – Descent of the most prolapsed compartment between +1 cm and TVL -2

cmStage 4 – Descent of the most prolapsed compartment from TVL -2 cm to complete

prolapse


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Reproduced from: Bump RC, et al. The standardization of terminology of female pelvic organ prolapse

and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175: 10-7.42

III. FECAL INCONTINENCE

1. A simple assessment of possible anorectal dysfunction by history and

physical examination should be performed whenever lower urinary tract

function is evaluated. (Level III, Grade C)

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

2. The cheapness and speed of investigation makes endosonography the

ideal screening procedure to assess anal sphincter. Manometry may offer

little extra information where ultrasound is available. Preoperative

assessment in patients with possible atrophy is the main indication for

MRI.21 (Level III, Grade C)


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Summary of Evidence

Anorectal manometry is an optional test that may be used in difficult-

to-evaluate cases of fecal or anal incontinence. It should be considered if

therapy based on simpler assessments fails to yield the desired improvement.46

MRI is superior to ultrasound in diagnosis of perianal sepsis and inquantifying external anal sphincter muscle degeneration.

47

References

1. Scientific Committee of the First International Consultation on Incontinence. Assessment and

treatment of urinary incontinence. Lancet 2000;355:2153-8.

2. Ouslander JG, et al. Incontinence in the nursing home. Ann Intern Med 1995;122:438-49.

3. Blaivas JG, et al. The bulbocavernosus reflex in urology: a prospective study of 299 patients.

J Urol 1981;126:197-9.

4. Agency for Health Care Policy and Research. Urinary incontinence in adults: acute and

chronic management. Clinical Practice Guideline, No.2, 1996 Update. AHCPR Publication No. 96-0682. Rockville (MD): AHCPR; 1996.

5. Goode PS, et al. Measurement of postvoid residual urine with portable transabdominal bladder

ultrasound scanner and urethral catheterization. Int Urogynecol J Pelvic Floor Dysfunct

2000;11(5):296-300.

6. Semeniuk H, et al. Evaluation of the leukocyte esterase and nitrite urine dipstick screening

tests for detection of bacteriuria in women with suspected uncomplicated urinary tract

infections. J Clin Microbiol 1999; 37(9):3051-2.

7. European Urinalysis Guidelines. Summary. Scand J Clin Lab Invest 2000;60:1-96.

8. Wyman JF, et al. The urinary diary in evaluation of incontinent women: a test-retest analysis.

Obstet Gynecol 1988;71:812-7.

9. Nygaard I, et al. Reproducibility of a 7-day voiding diary in women with stress urinary

incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2000;11:15-7.

10. Addla S, et al. Assessment of reliability of 1-day, 3-day, and 7-day frequency volume charts. Eur Urol 2004;(Suppl 2):30.

11. Wall LL, et al. Simple bladder filling with a cough stress test compared with subtracted

cystometry for the diagnosis of urinary incontinence. Am J Obstet Gynecol 1994;171:1472-7;

discussion 1477-9.

12. Swift SE, Ostergard DR. Evaluation of current urodynamic testing methods in the diagnosis of

genuine stress incontinence. Obstet Gynecol 1995;86:85-91.

13. Karram MM, Bhatia NN. The Q-tip test: Standardization of the technique and its

interpretation in women with urinary incontinence. Obstet Gynecol 1988;71(61):807-11.

14. Walters MD, et al. Q-tip test: a study of continent and incontinent women. Obstet Gynecol

1987;70(2):208-11.

15. Bergman A. Invalidity of Marshall-Marchetti and Bonney stress tests. In: Ostergard D, Bent

A, eds. Urogynecology and urodynamics: Theory and practice (2e) Baltimore, MD: Williams

and Wilkins, 1991:179-84.

16. Kromann-Andersen B, et al. Pad-weighing tests; A literature survey on test accuracy and

reproducibility. Neurourol Urodyn 1989;8(3):237-42.

17. Jorgensen L, Lose G, et al. Diagnosis of mild stress incontinence in females: 24-hour pad

weighing test vs. the 1-hour test. Neurourol Urodyn 1987;6:165-6.

18. Kinn AC, Larsson B. Pad test with fixed bladder volume in urodynamic stress incontinence.

Acta Obstet Gynecol Scand 1987;66(4): 369-371.

19. Artibani W, et al. Imaging and other investigations. In: Abrams P, Cardozo L, Khoury S,Wein A (eds) Incontinence. Plymouth: Health Publication, 2002:425-77.

20. Raghavaiah N. Double-dye test to diagnose various types of vaginal fistulas. J Urol 1974;112: 811-2.

21. 4th International Consultation on Incontinence, Paris July 5-8, 2008. Incontinence edited byAbrams, Cardozo, et al. Health Publication Ltd. 4

th edition 2009

22. Laycock J, et al. Pelvic floor assessment: the PERFECT scheme. Physiotherapy 2001;87:631-42.


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23. Haslam J. Evaluation of pelvic floor muscle assessment: digital, manometric, and surfaceelectromyography in females. M Phil Thesis. University of Manchester, 1999.

24. Cohen RA, et al. Clinical Practice. Microscopic hematuria. N Eng J Med 2003;348:2330-8.

25. Chahal, et al. Is it necessary to perform urine cytology in screening patients with hematuria?

Eur Urol 2001;39:283-6.

26. ACOG 2007 Compendium Vol.11 Practice Bulletins pp1115-27.

27. Wall LL, et al. Simple bladder filling with a cough stress test compared with subtractedcystometry for the diagnosis of urinary incontinence. Am J Obstet Gynecol 1994;171:1472-7;

discussion 1477-9.

28. Weir J, et al. Large-capacity bladder. A urodynamic survey. Urology 1974;4:544-8.

29. Cardoso A, et. al. (ed). Incontinence. 4th

International Consultation on Incontinence Paris July

5-8, 2008. Health Publication Ltd. 4th

edition, 2009.

30. Ramsay IN, et al. A randomized controlled trial of urodynamic investigations prior to

conservative treatment of urinary incontinence in the female. Int Urogynecol J 1995;6:277

31. Khullar V, Cardozo L, et al. 30th

Annual meeting of ICS, Finland 2000.

32. Weber AM. Is urethral pressure profilometry a useful diagnostic test for stress urinary

incontinence? Obstet Gynecol Surv 2001;56:720-35.

33. Weber AM. Leak point pressure measurement and stress urinary incontinence. Curr Women’s

Health Rep 2001;1:45-52.

34. Association of Professors of Gynecology and Obstetrics. Clinical management of urinaryincontinence. Crofton (MD) APGO; 2004.

35. Awad SA, et al. Final diagnosis and therapeutic implications of mixed symptoms of urinary

incontinence in women. Urology 1992;39:352-7.

36. Agency for Health Care Policy and Research. Urinary incontinence in adults: acute and

chronic management. Clinical Practice Guideline, No.2, 1996 Update.AHCPR Publication

No. 96-0682. Rockville (MD): AHCPR; 1996.

37. Beer-Gabel M, et al. Dynamic transperineal ultrasound in the diagnosis of pelvic floor

disorders: pilot study. Dis Colon Rectum 2002;45:239-45.

38. Pannu HK, et al. Dynamic MR imaging of pelvic organ prolapse: spectrum of abnormalities.

Radiographics 2000;20:1567-82.

39. Gousse AE, et al. Dynamic half fourier acquisition single shot turbo spin-echo magnetic

resonance imaging for evaluating the female pelvis. J Urol 2000;164:1606-13.

40. ACOG Compendium of Selected Publications 2009. Clinical Management Guidelines forObstetrician-Gynecologists #85, September 2007: 417-29.

41. Samuelsson EC, et al. Signs of genital prolapse in a Swedish population of women 20-59

years of age and possible related factors. Am J Obstet Gynecol 1999;180:299-305.

42. Bump RC, et al. The standardization of terminology of female pelvic organ prolapse and

pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-7.

43. Gustilo-Ashby AM, et al. The incidence of ureteral obstruction and the value of intraoperative

cystoscopy during vaginal surgery for POP. Am J Obstet Gynecol 2006;194:1478-85.

44. Gilmour DT, et al. Rates of urinary tract injury from gynecologic surgery and the role ofintraoperative cystoscopy. Obstet Gynecol 2006;107:1366-72.

45. Jackson S, Walters M, et al. Fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 1997;89:423-7.

46. De Leeuw JW, et al. Relationship of anal endosonography and manometry to anorectal

complaints. Dis Colon Rectum 2002;45:1004-10.47. Rociu E, et al. Fecal Incontinence: endoanal ultrasound vs endoanal MR imaging. Radiology

1999; 212(2):453-8.

48. Cardozo L, Staskin D (Eds). Textbook of Female Urology and Urogynecology 2006; 2 nd edition Volume 1.

49. Chappe C, et. al. Multidisciplinary Management of Female Pelvic Floor Disorders 2006.


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CONSERVATIVE MANAGEMENT OF STRESS URINARY

INCONTINENCE Almira J. Amin-Ong, MD.

Urinary incontinence (UI) affects women not only in the reproductive age butmore 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 youngerwomen. 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 wouldhelp 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 anoption 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 availablespecifically addresses the impact of age or any other variables on outcome.

1. Women with a body mass index (BMI) of 30 or more should be

encouraged weight reduction as this significantly reduces prevalence of

UI. (Level II-1, Grade A)

Summary of Evidence

Obesity is an independent risk factor for UI even after controlling for

age and parity. In women with BMI of 30 or higher, the odds of severe urinary

incontinence were 3.1 times that of women with BMI between 22 and 241.

Another study found a 2.39 fold risk of UI compared with normal weightwomen.2 A 2005 RCT involving 48 participants showed that women who

were put on a liquid diet showed a 60% reduction of weekly incontinent

episodes and a weight loss of 15 kgs.3 Another RCT by the same author

involving 338 women (the Programme to Reduce Incontinence by Diet and

Surgery – [PRIDE]) who underwent a 6-month intensive weight loss program

showed a weekly incontinence episode reduction of 70% as compared to 22%

in the control group.4

2. Heavy lifting may predispose to development of UI. (Level III, Grade B)


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Summary of Evidence

There are no RCTs comparing heavy lifting with sedentary activities.

The association between heavy lifting and UI should be investigated further,

whether heavy exertion is a risk factor for incontinence or whether changing

exertions can improve existing incontinence. Present studies are conflictingwith one study of 27,936 women in 2003 reporting no difference in UI

between women engaged in high impact activities more than 2 hours per week

with those who engaged in less than 1 hour of activity per week.5 Nygard, et.

al., in a study of 3,364 women reported that UI with physical activity was

more common among highly active than less active women (15.9% versus

11.8%; p=0.01).6

3. Smoking increases the risk of more severe UI. (Level III, Grade B)

Summary of Evidence

There are currently no RCTs regarding the effect of smoking cessation

on resolution or promotion of the onset of UI. Current data are conflictingwith one in vitro study stating that nicotine produces phasic contraction of the

bladder musculature inducing the urge type of incontinence.7 A large study

involving 27,936 women found that smoking increases the odds of severe UI

(Odds Ratio [OR] 1.4, 95% CI 1.2-1.6). However, smokers were found tohave stronger urethral sphincters.5

4. Decreasing caffeine intake improves continence. (Level II-1, Grade B)

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 tonone.5

4. Alcoholic beverages do not increase the incidence of UI. (Level II-2, Grade B)

Summary of Evidence

Large epidemiologic trials using multivariate analyses assessed the

effect of alcohol consumption and UI but found no association between the

two even after adjusting for age and fluid intake.9

5. Limiting fluid intake to prevent UI should only be reserved to those with

abnormally high intake. (Level III, Grade C)


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Summary of Evidence

It is always the assumption that leakages can very well be controlled

by limiting the fluid intake. However, a state of negative fluid balance or poor

fluid intake may lead to urinary tract infections (UTIs), constipation or

dehydration – conditions that can readily be prevented by maintaining theaverage daily fluid intake. An RCT that used a small crossover design foundthat when fluid intake is decreased, women with stress urinary incontinence

(SUI) and women with detrusor overactivity had decreased incontinence

episodes10

.

6. Chronic straining may be a risk factor for development of UI. (Level III,

Grade C)

Summary of Evidence

There are no studies regarding the effect of resolving constipation orregulating bowel function on incontinence. One study reported that women

who strain during defecation are more likely to report SUI (OR 1.9, 95% CI1.3-2.6) and urgency (OR 1.7, 95% CI 1.2-2.4).11 Further research is needed

to evaluate the role of constipation or chronic straining in the pathogenesis ofUI.

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


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Summary of Evidence

Studies regarding PFMT are conflicting because of variations in the

technique used. However, the most recent Cochrane systematic review (2003)

which included studies of women with urge, stress or mixed type of

incontinence found that PFMT was more effective compared to placebointervention (drug, sham electrical stimulation, sham exercise).

13 Compared

with vaginal cones, there was a significant reduction in urinary leakage with

PFMT alone. There is also no benefit of combining PFMT with biofeedback.

PFMT supervised and continued for 3 months is a safe and effective treatment

for stress and mixed types of incontinence.

III. ELECTRICAL STIMULATION

Electrical stimulation for patients with stress or mixed type of

incontinence does not offer any benefit in reducing the frequency ofincontinent episodes. (Level I, Grade B)

Summary of Evidence

Electrical stimulation involves delivery of brief electrical impulses via

needle or surface electrodes to the sacral nerves to inhibit detrusor overactivityand to improve pelvic floor musculature. A randomized trial of 68 women

with urge type of incontinence did not reveal significant improvement at all.

For women with stress type of incontinence, a small trial of 26 women showed

no changes in urinary leakages per week based on an incontinence impact

questionnaire. Combined with PFMT, a recent trial of 200 women showed no

significant reduction in the frequency of incontinent episodes.9

IV. MAGNETIC STIMULATION

The benefit of magnetic stimulation for treatment of UI has not been

established. (Level II-3, Grade D)

Summary of Evidence

Extracorporeal magnetic stimulation is delivered to the pelvic floor

muscles and the sacral nerve roots by sitting on a magnetic chair. The patient’s

perineum is centered on the middle of the seat from where the pelvic floor

muscles are placed directly on the primary axis of the pulsating magnetic field

without any vaginal or anal probes. Usually, the treatment is given for 16

sessions for 6 weeks. There are still no trials regarding primary and secondary

prevention of UI. Regarding treatment, magnetic stimulation might be better

for both stress and urge type of incontinence.14,15 Further investigation is

warranted.


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V. VAGINAL CONES

Vaginal cones offer subjective cure but do not lead to significant

improvement on the number of leakage episodes, pad test or pelvic floor

muscle strength. (Level II-1, Grade B)

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

VI. BLADDER TRAINING

Bladder training combined with pelvic floor muscle training is more

effective than either alone. It should be offered as first line treatment for

urge or mixed type of incontinence. (Level I, Grade A)

Summary of Evidence

Bladder training is a technique to increase the time interval between

voids using progressive voiding schedules. It is usually advised on patients

who have intact cognitive and physical functions and can take months to

achieve a cure. There are not too many trials to support bladder training. There

were two small trials with 78 patients which showed few subjective cures in

patients who had bladder training alone versus those who did not receive any

at all (OR for failure, 0.07; 95% CI 0.03-0.19). However, when one combines

it with PFMT, it is more effective than a combination of bladder training with

drug therapy. There is good evidence though that bladder training is effective

for urge or mixed type of incontinence, with fewer adverse effects and lowerrelapse rates compared to drug treatment with antimuscarinics.13

VII. PHARMACOLOGIC

Anticholinergics are effective in the treatment of urge incontinence. (Level

1, Grade A)

Summary of Evidence

Anticholinergics are drugs prescribed to inhibit involuntary detrusor

contractions that could lead to urine leakages. A Cochrane systematic review

found that anticholinergics were better than placebo in subjective cure rate and

improvement rates (RR 1.41; 95% CI 1.29-1.54) and in improvement inleakages episodes in 24 hours (WMD, -0.56; 95% CI -0.73 to -0.39).18 When


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compared with other drugs used to treat urge incontinence, anticholinergics

still offer both subjective cure and improvement in leakage episodes.

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, P levnik 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.


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II. OPEN BURCH COLPOSUSPENSION

1. Open retropubic colposuspension can be recommended as an effective

treatment for primary SUI, which has longevity. (Level I, Grade A)

Summary of Evidence

Randomized trials comparing the open colposuspension with anterior

colporrhaphy, the MMK procedure, needle suspension procedures, abdominal

paravaginal repair, traditional sling procedures, the TVT, the transobturator

tape, and laparoscopic colposuspension include 4161 women with 1900

randomized to colposuspension. Analysis shows objective cure rates ranging

from 59% to 100% (median 80%) and subjective cure rates from 71% to 100%

(median 88%). The results from these studies show that the open

colposuspension has objective and subjective outcomes comparable to both

traditional sling procedures and to newer minimally-invasive mid-urethral

sling procedures. However, the colposuspension had better outcomescompared to the anterior colporrhaphy, the MMK, bladder neck needle

suspension, and paravaginal repair.

2. Although open colposuspension has to some extent been replaced by less

invasive mid-urethral slings, it should still be considered for those women

in whom an open abdominal procedure is required concurrently with

surgery for SUI. (Level I, Grade A)

Summary of Evidence

Abdominal retropubic urethropexy or colposuspension procedures,

particularly the Burch colposuspension, have become the gold standard for

treatment of primary or recurrent SUI. Main indications include primary and

secondary urethral sphincter incompetence, with or without a

cystourethrocele, but with adequate vaginal mobility and capacity. The

paravaginal tissues on either side of the bladder neck and bladder base are

sutured and attached to the ipsilateral iliopectineal ligament. The

colposuspension is most successful in patients with pure SUI withhypermobility of the urethrovesical junction. The colposuspension had better

outcomes compared to the anterior colporrhaphy, the MMK, bladder neck

needle suspension, and paravaginal repair.

3. The MMK procedure is not recommended for the treatment of SUI.

(Level I, Grade A)

Summary of Evidence





randomized to colposuspension. The studies showed that colposuspension had


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better outcomes compared to the anterior colporrhaphy, the MMK, bladder

neck needle suspension, and paravaginal repair.

4. Bladder neck needle suspension procedures are not recommended for the

treatment of SUI. (Level I-II Grade A)

Summary of Evidence








5. Paravaginal defect repair is not recommended for the treatment of SUIalone. (Level II-1, Grade A)

Summary of Evidence


colporrhaphy, the MMK procedure, needle suspension procedures, abdominal paravaginal repair, traditional sling procedures, the TVT, the transobturator





III. LAPAROSCOPIC BURCH COLPOSUSPENSION

1. Laparoscopic colposuspension is not recommended for the routine

surgical treatment of SUI in women. (Level I-II, Grade A)

Summary of Evidence

The laparoscopic approach has been compared to the standard openBurch colposuspension and the more recent mid-urethral slings, in particular

the TVT. Since 1997, there have been 10 randomized controlled trials (RCTs)

comparing laparoscopic colposuspension with the open colposuspension and 8

with the mid-urethral slings. Although studies included in the Cochrane

review had various lengths of follow-up (majority had follow-up of 6-18

months), subjective cure rates ranged from 58% to 96% in the open technique

and 62% to 100% in the laparoscopic approach, with a nonsignificant 5%

lower relative subjective cure rate for laparoscopic colposuspension (RR 0.95,

95% CI 0.90-1.00).

The objective cure rate, as determined by cough stress testing or pad

test within 18 months, was statistically lower following the laparoscopictechnique (RR 0.91, 95% CI 0.86-0.96). Following urodynamic testing,


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however, the open colposuspension had significantly higher success rates (RR

0.91, 95% CI 0.85- 0.99).

Studies comparing laparoscopic colposuspension with minimally

invasive mid-urethral slings (TVT) show no statistically significant difference

in subjective cure rates within 18 months (RR 0.91, 95% CI 0.80 to 1.02). The

overall objective cure rate, however, was higher for mid-urethral slings.A systematic review on laparoscopic colposuspension and TVT

showed evidence to favor the mid-urethral sling as the minimal-access

technique of choice for USI.

2. Laparoscopic colposuspension may be considered for the treatment of

SUI in women who also require concurrent laparoscopic surgery for

other reasons. (Level I-II, Grade B)

3. Laparoscopic colposuspension should only be carried out by surgeons

with specific training, expertise, and appropriate workload in

laparoscopic surgery and with expertise in the assessment andmanagement of UI in women. (Level I, Grade A)

IV. TRADITIONAL SLING PROCEDURE

1. Autologous fascial sling is recommended as an effective long-lasting

treatment for SUI. (Level I, Grade A)

Summary of Evidence

Trials on suburethral slings have compared this procedure with open

abdominal retropubic suspension (MMK and Burch colposuspension), needle

suspension, and even the TVT. Studies comparing different sling materials are

also numerous. In comparison with open colposuspension, the objective cure

rate from sling operations was not significantly different within the first year

(Relative Risk [RR] 0.19; 95% CI 0.02-1.53) or on longer follow-up (RR 0.49;

95% CI 0.17-1.42). In the largest RCT study done by Albo, et. al. comparing

colposuspension and fascial sling, the combined subjective and objectiveoutcome in terms of any incontinence (38% vs 47%, p=0.01) and SUI (49% vs

66%, p=


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may be synthetic or biological. The autologous sling may be harvested from

either the rectus fascia (as initially described by Aldridge in 1942) or fascia

lata. Recently, sling procedures have been done using allograft material

(cadaveric fascia or dura mater), xenograft (porcine dermis and small

intestinal mucosa or bovine fascia) or synthetic material (such as merselene or

prolene). The sling is placed at the level of the bladder neck and proximalurethra (in contrast to the minimally invasive mid-urethral slings) thru acombined vaginal and abdominal route. Complications include vaginal erosion

(0-16%), urethral erosion (0-15%), de novo detrussor instability (3.7-66%),

and voiding difficulties (10.8%).5

Studies comparing autologous rectus fascial sling with TVT involve a

total of 284 patients from 3 RCTs.11,13,14

Cure rates at 12 months range from

83% to 88% after TVT and 81% to 93% after fascial sling.

3. Further high quality research is required to clarify the place of

traditional sling procedures in relation to other procedures and to

establish the optimum sling materials.

V. MID-URETHRAL SLINGS

1. Retropubic mid-urethral slings (TVT) are recommended as an effective

treatment for SUI. (Level I-II, Grade B)

Summary of Evidence

Mid-urethral slings are performed via the retropubic approach (e.g.

TVT, IVS, and SPARC) or via the transobturator approach (e.g. transobturator

tape [TOT] and tension-free vaginal tape-obturator [TVT-O]). The TVT is a

modification of the traditional sling procedure that was introduced by

Ulmsten, et. al. in 1996.15 The procedure, initially described to be performed

in an ambulatory setting, has been compared to more traditional surgical

procedures (such as burch colposuspension and traditional sling procedure)

and is seemingly the new “standard” to which other mid-urethral slings are

compared.

2. TVT is equally effective as colposuspension and traditional sling

procedures. (Level I-II)

Summary of Evidence

Several randomized trials and cohort studies show that there is no

significant difference in the cure rates for the TVT procedure compared to the

Burch colposuspension and the fascial sling. Available literature suggests that

the TVT has short- and medium-term efficacy (cure rate of 63% to 97%)

similar to the open Burch colposuspension but is associated with shorter

operating time and hospital stay, less postoperative voiding dysfunction, and

quicker recovery. The TVT however appears to have significantly more

bladder perforations (6% versus 1%, RR 4.24, 95% CI 1.71-10.52) comparedto the open retropubic colposuspension. The TVT is also equally effective as


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techniques (periurethral or transurethral). However, the group felt that the

studies were small and of moderate quality such that meta-analysis was not

appropriate. Currently, greater subjective improvement was observed after

conventional surgery. Studies comparing bulking agents with non-surgical

therapy or minimal access surgery are lacking.

2. Women should be made aware of alternative minimally invasive

procedures.

References

1. Meschia M, Pifarotti P, Spennacchio M, Buonaguidi A, Gattei U, and Somigliana E. Arandomized comparison of tension-free vaginal tape and endopelvic fascia plication in women

with genital prolapse and occult stress urinary incontinence. Am J Obstet Gynecol

2004;190:609-613.

2. Glazener CMA and Cooper K. Anterior vaginal repair for urinary incontinence in women.Cochrane Database Syst Rev 2001, Issue 1.3. Burch J. Urethrovaginal fixation to Cooper’s ligament for stress incontinence, cystocele, and

prolapse. Am J Obstet Gynecol 1961;81:281-290.

4. Lapitan MC, Cody DJ, and Grant AM. Open retropubic colposuspension for urinaryincontinence in women. Cochrane Database Syst Rev 2005, Issue 3.

5. Bidmead J, Toozs-Hobson P, Cardozo L, Robinson D, Bailey J. Randomised comparison ofBurch colposuspension versus anterior colporrhaphy for patients with stress urinary

incontinence (letter). BJOG 2001;108:128-129"6. Colombo M, Vitobello D, Proietti F and Milani R. Randomised comparison of Burch

colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and

anterior vaginal wall prolapse. BJOG 2000; 107: 544-551.

7. Dean NM, Ellis G, Wilson PD, and Herbison GP. Laparoscopic colposuspension for urinary

incontinence in women. Cochrane Database Syst Rev 2006, Issue 3.8. Su TH, Wang KG, Hsu CY, Wei HJ, Hong BK. Prospective comparison of laparoscopic and

traditional colposuspensions in the treatment of genuine stress incontinence. Acta Obstet

Gynecol Scand 1997;76:576-582.

9. Dean NM, Herbison P, Ellis G, Wilson D. Laparoscopic colposuspension and tension-freevaginal tape: a systematic review. BJOG 2006;113:1345-1353.

10. Albo ME, et al and Urinary Incontinence Treatment Network. Burch colposuspension versusfascial sling to reduce urinary stress incontinence. NEJM 2007;356:2143-2155.

11. Bai SW, Jeon JD, Chung KA, Kim JY, Kim S, Park KH. The effectiveness of modified 6corner suspension in patients with paravaginal defect and stress urinary incontinence. Int

Urogyne J 2002;13:303-307.

12. Bezerra CA, Bruschini H, Cody DJ. Traditional suburethral sling operations for urinaryincontinence in women. Cochrane Database Syst Rev 2005, Issue 3.

13. Lucas M, Emery S, Alan W, Kathy W. Failure of porcine xenograft sling in a randomizedcontrol trial of three sling materials in surgery for stress incontinence. Joint meeting of

International Continence Society & International Urogynecological Association. Paris,

France, 2004.

14. Wadie BS, Edwan A, Nabeeh AM. Autologous fascial sling vs polypropylene tape at short-term follow up: a prospective randomized study. J Urol 2005;174: 990-993.

15. Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure underlocal anesthesia for the treatment of female urinary incontinence. Int Urogynecol J Pelvic

Floor Dysfunc 1996;7: 81-86.

16. Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment ofstress urinary incontinence in women. Prog Urol 2001;11:1306-13.

17. De Leval J. Novel surgical technique for the treatment of female stress urinary incontinence:transobturator vaginal tape inside-out. Eur Urol 2003;44:724-730.


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18. Latthe PM, Foon R, Toozs-Hobson P. Transobturator and retropubic tape procedures in stressurinary incontinence: a systematic review and meta-analysis of effectiveness and

complications. BJOG 2007;114: 522-31.

19. Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling operations forstress urinary incontinence in women. Cochrane Database Syst Rev 2009, Issue 4.

20. Keegan PE, Atiemo K, Cody JD, McClinton S, Pickard R. Periurethral injection therapy for

stress urinary incontinence in women. Cochrane Database Syst Rev 2007, Issue 3.21. NICE Guidance on Urinary Incontinence. National Collaborating Center for Women’s and

Children’s Health, 2006, National Institute for Health and Clinical Excellence, 2006b.

22. Smith ARB, Dmochowski R, Hilton P, Rovner E, Nilsson CG, Reid FM, Chang D. Surgeryfor urinary incontinence in women. In: Abrams P, Cardozo L, Khoury S, and Wein A (Eds)

Incontinence: WHO – ICUD International Consultation on Incontinence, 4th

edition, 2009.


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CONSERVATIVE MANAGEMENT OF PELVIC ORGAN

PROLAPSEMaria Teresa C. Luna, MD

I. VAGINAL PESSARY

A vaginal pessary is a removable device placed into the vagina. It is designed tosupport different sites of pelvic organ prolapse (POP). Available pessaries are

either made of silicone or latex rubber.

1. Pessaries can be fitted in most women with prolapse, regardless of

prolapse stage or site of predominant prolapse. (Level III, Grade A)

Summary of Evidence

Vaginal pessaries are the standard nonsurgical treatment for POP. A

vaginal pessary can be properly fitted in 78% of patients with approximately

50% of those properly fitted continuing to use a pessary a year later.1-3

Pessaries are most often used when the patient has a strong preference fornonsurgical management of POP or when the patient’s health status confers a

significant risk for surgical morbidity and mortality. 4

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 atoilet bowl and during ambulation). If the patient is fitted with the correctpessary 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 isadvised to come back for check-up after 1 week, during which time, the


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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

3. Currently there is no evidence from randomized controlled trials (RCT)

upon which to base treatment of women with POP through the use of

mechanical devices/pessaries.8 There is no consensus on the use of

different types of device, the indications, nor the pattern of replacement

and follow-up care. (Level III, Grade B)

II. PELVIC FLOOR MUSCLE EXERCISE

Despite of the lack of high quality scientific evidence supporting pelvic

floor muscle exercise for prevention and treatment of POP, it poses norisk and cost to the patient. It is offered to all patients who are

asymptomatic or mildly symptomatic and are interested in preventing the

progression of the condition and who decline other treatments. There is

some encouragement from a feasibility study that pelvic floor muscle

training (PFMT), delivered by a physiotherapist to symptomatic women

in an outpatient setting, may reduce severity of prolapse.10

(Level II-3,

Grade B)

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

III. PATIENT EDUCATION AND LIFESTYLE MODIFICATION

Patients with POP should be counseled on the importance of various

lifestyle modifications that may prevent or improve their symptoms of

prolapse. (Level III, Grade C)

Summary of Evidence

Maintaining an ideal body weight limits the pressure that the

abdominal content places on the pelvic floor. Any activity that engages the

pelvic floor such as walking or gardening can help strengthen the muscles.Patients should be instructed to contract their pelvic floor muscles when lifting


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or straining. Patient education should also include bowel movement retraining.

This will teach a passing motion without straining the pelvic floor muscles.

Advising women on correct posture will in aid in preventing strain on the

pelvic floor muscles.11

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 inwomen 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, buthow does it work? Int Urogynecol J 2004;15:76.

10. Hagen S, Stark D, Maher C, et al. Conservative management of pelvic organ prolapse inwomen. 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.


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SURGICAL MANAGEMENT OF PELVIC ORGAN PROLAPSEManuel 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 toattenuate 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 t

CPG Urogynecology

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