Download Female sexual dysfunction - International Urogynecological

Volume 7, Issue 1, 2012
IN THIS ISSUE:
• The Treatment of Female
Sexual Dysfunction by Dorothy
Kammerer-Doak, MD - page 1 - 3
• Letter from the SecretaryTreasurer - page 12
• The History of Sacral
Neuromodulation - page 9
• Controversial Corner: Are
Minislings Effective? Kocjancic v.
Nilsson - page 4-5
• Training of Trainers on the
Global Competency-based Fistula
Surgery Training manual - page
11.....and more
S
exual health is defined by the
World Health Organization
as the integration of somatic,
emotional, intellectual and social
aspects in ways that are positively
enriching and that will enhance
personality, communication and
love. Female sexual dysfunction
(FSD) is recognized as a widespread
problem, with prevalence ranging from 25-63%. Low libido is
the most common complaint, and
other sexual dysfunction categories include problems with arousal
and orgasm, and pain disorders.
The Official Newsletter
International Urog ynecological Association
THE TREATMENT
OF FEMALE
SEXUAL
DYSFUNCTION
By Dorothy Kammerer-Doak, MD
cular, endocrine and psychosocial
factors. Male sexual dysfunction
most commonly involves erectile
problems, and medications that
increase penile blood flow are effective treatments. FSD more commonly occurs in the arousal phase
involving difficulties with libido
and orgasm. Unfortunately, simply increasing clitoral and vaginal
blood flow with medications does
not usually result in improved desire, arousal, or orgasm. Treatment
of FSD usually involves an individualized approach using a combination of education, psychosoThe advent of new therapies to cial intervention, and mediations.
treat male sexual erectile dysfunction with “just a pill”, and the A first step for women with sexual
media attention this has received, problems is education. It is imhas led to widespread attention of portant that women know that
FSD. However, both female sexual there is no medical expected level
function and dysfunction are more of sexual activity or function, and
complex than the male, and FSD that lack of libido or ability to cliis more difficult to treat. Impor- max does not represent a sexual
tantly, the female sexual response dysfunction as long as the woman
is complex and involves neurovas-
experiences no personal distress.
Simple reassurance that media
portrayals of female sexual activities do not accurately represent
the average experience can be very
helpful. Specifically, average frequency of sexual activity is 6 times
per month, and 80% of women
report the inability to achieve orgasm with vaginal intercourse and
require direct clitoral stimulation.
Also, most women do not experience orgasm with every sexual
encounter. Only 30% of women
climax with almost every sexual
activity. An anatomy lesson regarding clitoral location as well as
techniques for stimulation such as
the vibrator may be helpful in giving the woman with psychosocial
barriers medical permission to treat
her sexual difficulties in this way.
The context in which women experience desire, arousal, and orgasm
incorporates physical, psycho-
Page 2
logical and emotional aspects. No
medical treatment will improve
a bad situation or relationship.
Psychosocial intervention may be
necessary based on the woman’s
relationship, current life stressors,
and sexual problems. As a strong
impetus for female sexuality is intimacy, the woman and her partner need to improve communication, reduce relationship strains
when present and simply make
protected time for sexual relations.
The only medication proven in
randomized placebo controlled
trials (RCT) to improve female
FIGURE 1-1:
sexual function is testosterone.
Male sexual response cycle de�ined by Masters and Johnson.
The best studies come from the
Masters WH and Johnson VE: Human Sexual Response, Boston, 1966, Little,
treatment of postmenopausal and
Brown & Co.
surgically castrated women. The
addition of testosterone, either
oral or transdermal to estrogen replacement therapy (ERT) resulted
in significant improvement in
sexual function, including desire,
arousal and orgasm, compared to
ERT alone. The use of androgens
in premenopausal women with
FSD has been poorly studied. One
small RCT reported improvement
in arousal with use of testosterone gel administered 4-8 hours
before planned sexual activity
compared to placebo. Unlike estrogen, androgen levels gradually
decrease with age starting at about
30 years, but there is no abrupt
drop at the time of menopause.
Therefore, premenopausal women
with serum free testosterone levFIGURE 1-2
els below the lowest quartile of
The interrelatedness of intimacy, sexual arousal, desire and satisfaction.
normal range and with FSD may
Female Sexual Response Cycle
be offered testosterone but need Copyright 2001 from “Complexities of Woman’s Sexual Function” by Basson R.
to be counseled on the absence
of efficacy data and safety. Blood
levels should be monitored to sistent in randomized controlled The ability of systemic HRT to
achieve physiological levels in the trials, including RCT. Since estro- enhance sexual arousal, desire
mid-upper level of normal range. gen improves vaginal and clitoral and ability to achieve orgasm is
blood flow, vaginal administra- not definitive, but recent RCT
The effects of systemic hormone tion best improves lubrication for have reported beneficial affects of
replacement therapy (HRT) on the treatment of pain disorders. ERT on sexual desire, enjoyment,
female sexual function are incon-
Volume 7, Issue 1, 2012
orgasmic frequency and vaginal
lubrication, but no difference in
coital frequency. Many experts do
initiate systemic HRT in the absence of contraindications in postmenopausal women with FSD.
Tibolone is a synthetic steroid
with estrogenic, progesterogenic
and androgenic properties with
possible positive effect on sexual
function utilized in Europe for
more than 20 years. In RCT, Tibolone demonstrates significant
improvement in clitoral circulation and sexual function scores as
compared to conventional HRT in
postmenopausal women with FSD.
Medications used to treat
male
erectile
dysfunction
such as sildenafil have also
been studied in women with
FSD. These medications increase
genital blood flow by inhibition
of phophodiesterase thereby facilitating nitric oxide mediated
relaxation of clitoral and vaginal
smooth muscle. In several large
trials of women with FSD, despite increased vaginal and clitoral
blood flow and increased lubrication and engorgement caused by
sildenafil, there is no consistent
improvement in sexual function.
Unlike the male, there is poor correlation between subjective and
objective arousal in the female,
and increased genital blood flow
does not translate into improved
subjective arousal. There does
not appear to be any clear benefit
to the use of sildenafil in FSD.
However, in women with isolated
arousal disorders who have low
vaginal engorgement as measured
by vaginal pulse amplitude with
photoplethysomography, a few
RCT have reported significantly
increased subjective arousal and
improvement in sexual function.
Women who benefit from this
class of drugs may be those who
Page 3
have an underlying medical cause
for deficient genital engorgement
and not those with deficient subjective arousal, such as type I diabetes or following genital radiation.
Other medications used to treat
FSD include topical and oral
medications which are available
over-the-counter. These preparations utilize a combination of
herbs and botanicals, and some
contain L-arginine, a precursor
for nitric oxide, which facilitates
genital smooth muscle relaxation.
Small RCT demonstrating improved sexual function have been
conducted using these medications. Prostaglandins topically
applied to the genitals have also
been studied for the treatment of
FSD. While topical prostaglandins increase genital vasocongestion and lubrication, this does not
translate to consistent improvement in female sexual function.
In summary, women with sexual
dysfunction commonly have problems which overlap the different
stages of FSD, arousal, desire, orgasm, and pain. Management involves assessment of the level of
dysfunction, education of average
sexual practices, ways to improve
intimacy, treatment of pain, evaluation for need for psychotherapy,
and medical management when
indicated. Hormone replacement
therapy, including testosterone,
is probably beneficial in the postmenopausal woman, but the role
of androgens in premenopausal
women with sexual dysfunction is still under investigation.
Call for IUGA Grant
Proposals for 2013
Coming Soon
In February, IUGA will be
announcing a Call for Proposals
for IUGA-sponsored grants that
have been developed to provide
hands-on training, promote
research and development, and
prompt exchange of knowledge
and ideas:
Research Grants: Designed to fund
development of the proposed research project including all materials and testing, statistical analyses,
and services required to complete
the research. 3 types of grants
in the amount of US$20,000
each will be awarded for 2013:
•Basic Science
•Clinical
•Least Developed Countries
Fellowship Grants (US$30,000):
Allow for increased dissemination
of urogynecological knowledge by
funding travel and living expenses
for a trainee to visit a renowned
Urogynecology Center and perform a Fellowship as well as formulate and complete a research study.
Observership: Offset costs of visiting an approved host site which
has proven expertise for a specific
specialty (selected by applicant).
Recipients will spend 2 to 4 weeks
at an approved site, with the agreement that a formal report of the observer’s experience will be submitted and published in the IUJ. Five
grants in the amount of US$4,000
each will be awarded for 2013.
For additional information about these
grants, including due dates, please visit
http://www.iuga.org/?page=education.
Page 4
Controversies in Urogynecology
By Ervin Kocjancic, Illinois
Minislings: A Molecular Cuisine
M
inislings can be viewed as the
molecular cuisine where the
essence of a certain food is taken, re-elaborated and served. The essence
of the stress urinary incontinence surgery
is mid urethra, the re elaboration is the
piece of tape placed only at that area and
voila’ a new dish is prepared. If we keep
in mind all the possible risks of incontinence surgery it does not seem a bad idea
to minimize the hazardous steps of the
procedure and preserve only the essential
portion, which is the piece of mesh under mid urethra. So, with this new technique there are no more blind passages
through the retropubic area with risks of
bladder perforation, major vascular injuries or even worse bowel penetration.
Additionally, the procedure can be done
with only one incision minimizing the
risk of infections due to skin incisions.
Minislings have another potential advantage, a lesser amount of mesh placed
in the patient’s body. The procedure is
quick and can be performed under local anesthetic and patients are usually
able to go home within a few hours after having the procedure. The recovery
time is also short; patients should have
little interference with daily activities.
It seems that we finally have an ideal procedure that can address all the
uncomplicated incontinence cases.
When I am talking of uncomplicated
urinary incontinence I have in mind
the one associated with excessive urethral mobility and a good quality urethral wall and sphincter muscles. I am
excluding Intrinsic Sphincter Deficiency
(ISD)! The type of patient I am referring
to is a relatively young patient, in the
prime of her life that is having some occasional urine leaks while golfing, dancing or exercising and uses few mini pads
a day to manage their problem. This is
a woman with uncomplicated urinary
incontinence who I believe is the ideal
candidate for a minisling procedure.
Unfortunately we are not there
yet! We have a good answer to address mid urethral hyper mobility, but our due diligence to reduce
the amount of mesh is still in progress.
Minislings are a pretty heterogeneous
category and the only common factor
among the various available minislings is
the fact that they all require a single incision for placement. We should call them
single incision slings and roughly divide
them in 3 categories based on anchoring
mechanism. Some of them are using a
Velcro effect (as the TVT secure), whereas the Needless, are using a pocket at the
end of the tape where the tissue is supposed to enter and fixate the mesh. This
particular tape can not really be called
minislings with its 12cm of length! The
majority of the other single incision slings
are using anchors for their attachment.
Another variability is also represented by the anatomical structure
where these slings should be attached.
The range goes from the periosteum
of the pubis, the obturator internal
muscle to the obturator membrane.
Keeping in mind the relatively high variability of the pelvic floor anatomy it is
easy to understand that not all these
products are feasible for all patients. For
instance, if we consider the variability of
the size and tonus of the muscles in different ages we cannot expect good, “juicy”
biceps in a 70 year old lady compared to
her nephew who is 25 years old and plays
tennis every day. Why would the obturator internal muscle be any different? In
my mind this is the main disadvantage
of the anchor-based minislings that are
relying only on the insertion of the anchor in this muscle. The other critical
point of these procedures is the fixed
length of the mesh that has to be used.
There are only two single incision slings
available worldwide, that are providing a
good anchoring mechanism, where the
anchors are inserted in a more reliable
structure than an atrophic muscle. I am
talking about two slings that should be
called as mini trans obturators (mini
TO’s) and these are Ajust and Altis. The
anchoring structure is represented by the
obturator membrane, the anchors are solid and built in such a fashion that in my
animal study we were not able to remove
them once implanted without breaking the mesh (this was not the case with
all the other minis that we tested). The
other peculiarity of these two products is
represented by the fact that they can be
easily and truly adjusted after they’re positioning. Yes, I know that we need some
science behind all this, and we need appropriate length prospective randomized
studies to confirm that these new products/procedures are as good in providing
cure rate and that they are really reducing
the incidence of complications. But, if
we are thinking of the anatomical facts,
the only difference between mini TO’s
and the old fashion trans obturator tapes
is represented by the skin and the fatty
tissue that covers the obturator foramen.
To my knowledge skin and fat does not
represent a valid anchoring mechanism.
In summary, I do like minislings, but the
ones that allows me a good and reliable anchoring and ones with an easy adjustability.
PRO
Volume 7, Issue 1, 2012Page 5
Controversies in Urogynecology
By Carl Gustaf Nilsson, Finland
Minislings: Advantages Few!
T
he first modern minimally
invasive surgical procedure
for treatment of female stress
urinary incontinence, the original
retropubic Tension-free Vaginal Tape
(TVT), was launched for clinical
use in 1998, at a time when several
prospective observational trials with
a follow-up of one to two years had
been published in peer reviewed journals. Now more than eleven years of
follow-up has confirmed the safety
and durability of the TVT operation. The efficacy of the TVT procedure has been shown to be superior
to more recent modifications of this
mid-urethra sling in randomized trials including under more demanding circumstances such as intrinsic
sphincter deficiency, recurrent incontinence and in patients with severe
stress urinary incontinence. Comprehensive registries from at least five
different countries revealed low rates
of complications, the most common
being bladder injury with a rate of
2.7-3.8% when the procedure was
performed under local anesthesia and
7.3% when performed under spinal
or general anesthesia. Major organ injury was found at a rate of 0-0.07%.
Due to these rare complications the
blind passage of the TVT trocars
retropubically has aroused concerns
and been substituted by a different
blind passage through the obturator
membrane and muscles including
the adductor muscles of the thighs.
These trans-obturator procedures
have different complications, some of
which are major in nature. Bladder
perforations have been reported with
all obturator procedures. Superiority of the transobturator procedures
over the TVT regarding efficacy,
safety and durability has not been
shown by randomized trials to date.
slings were developed to further decrease invasiveness by limiting the
amount of blind passage of the trocars. Theoretically they should maintain efficacy and reduce the risks of
complications. Similar to the original
TVT studies many reports on minislings stated that the operation can be
performed under local anesthesia. Yet
a great number of the single incision
slings have been performed under
spinal or general anesthesia according
to published literature. Invasiveness
of a procedure is not only accounted
by the procedure itself but also by the
mode of anesthesia. In addition, it is
a mistake to think that the single incision sling operations do not involve
blind passages of instruments or devices. The only difference compared
to the traditional mid-urethral slings
is the extent or length of the blind
passage, being shorter with the minislings. A recent meta-analysis along
with a few randomized trials indicated that the mini-slings are inferior
to the traditional mid-urethra slings
regarding efficacy. Interesting bladder injuries, heavy bleeding, hematomas, thigh pain, voiding difficulties
and de novo urgency symptoms have
been reported for the mini-slings at
a rate equivalent with the traditional
mid-urethral slings, perhaps with the
exception of bladder perforations.
fore had to be withdrawn from the
market. Withdrawal of devices is not
only an economical loss for the industry but, more importantly, it affects a
woman’s quality of life, confidence in
the medical profession and possibility of final cure as repeat procedures
have a poorer outcome than primary ones. Additionally it represents a
waste of limited health care resources.
Therefore “Why launch the mini
or single incision slings at a stage
when no evidence, what so ever, exists on the superiority of these over
well documented procedures regarding efficacy, safety and durability?”
Although nothing is perfect and one
should always seek improvements,
my suggestion is that innovations
should not be spread to general clinical use outside ethically approved
research projects until an improvement has been established by findings
from robust clinical research. As long
as no improvement has been shown
let’s stick to the procedures that we
know can easily be performed as a
day-case on the majority of women
who might benefit from surgery and
result in a safe and durable cure!
CON
The mini-slings or single incision
Most if not all the available minislings have been launched with hardly any documentation on efficacy beyond short follow-up of a few weeks
to a year. A lesson should have been
learned from the initial experience
with traditional mid-urethral slings
when it became evident that several
modifications of the TVT procedure
and the initial transobturator procedures, launched at an early state of
experience, did not fulfill expectations of efficacy and safety and there-
Page 6
felloWs Commitee UPdate
T
he Fellows Committee would like
to pay tribute to
the outgoing chair Sylvia Botros. Thanks to
her innovations, in the
last 12 months the Fellows Committee has undergone a complete reorganization, which has
had a remarkable effect
on the productivity of
the committee. During
the most recent annual
IUGA meeting in LisRufus Cartwright, MD
bon, the committee met
Incumbent Committee
to consolidate a new set of
Chair
bylaws, outlining a mission and aims, defining the membership specifications, and formalizing new subcommittees.
The new mission of the IUGA Fellows Committee is
to contribute to the academic development of fellows/
trainees in the field of Urogynecology/Female Pelvic Medicine and Reconstructive Surgery by fostering international collaboration and scholarship. All
IUGA membership holders in training or in a fellowship program are welcome as members of the Fellows
Committee. New members will be added yearly at
the annual IUGA meeting and are invited to stand
as Chair or co-Chair or join one of five subcommittees (Membership, Fellows Research Network,
Communication, Social Planning and Mentoring).
By Rufus Cartwright
The IUGA Fellows Mentoring Subcommittee was
created this spring, and is collaborating with the
Education Committee to create a resource document for those who are preparing for clinical clerkships or observerships to help with visa and licensure
issues. An assessment survey to better understand
the necessity and to prioritize the activities regarding the mentoring program was completed by the
IUGA members at the Lisbon meeting last summer. The most commonly cited priorities were:
1. To coordinate clinical training clerkships for
physicians-in-training at other institutions,
2. To coordinate research collaboration between
physicians
with
similar
interests and varying levels of expertise, and
3. To teach visiting physicians treatment methods
(surgical or non-surgical) that are unique to a
particular site. The Mentoring Subcommittee
plans to create a resource to connect interested
mentors and mentees based on these priorities.
The Fellows Social Planning Subcommittee coordinated a variety of events at the 2011 Lisbon meeting.
Fellows Day, held a day prior to the start of the meeting, was an absolute success. This program involved
fellow-directed lectures from world experts in the
field, a hands-on pelvic model session for mesh implants, and a fellow’s paper session where fellows had
the chance to receive feedback from well-published
authors on oral presentations and research design
for studies. At the end of the day, there was a special dinner for fellows to network and meet IUGA
Volume 7, Issue 1 2012Page 7
leaders. New this year was a Fellows Lounge with access to model
demonstrations, 3-D videos, computers with WiFi access, snacks,
and beverages. This lounge was a
great spot for fellows to network
and prepare their talks. Lastly,
an interactive Stump the Professor session was coordinated in the
General Session. IUGA past presidents were challenged with interesting cases presented by fellows.
This session was well attended
and sparked stimulating discussions. The Fellows Committee
hopes to continue providing similarly robust activities for fellows
in the upcoming annual meeting.
In previous years, the Fellows
Committee has had difficulty contacting first year trainees and fellows ahead of the annual meeting.
If you have new trainees starting
this fall who would like to get involved, please encourage them to
join the IUGA Fellows Group via
www.iuga.org. We look forward
to welcoming them to the Fellows Day activities in Brisbane,
and hope as many as possible
will put themselves forward as
members of either the Committee or the new Research Network.
Sylvia Botros, MD
Outgoing Committee Chair
IUGA Research Fellows Committee
Research Fellows Network (RFN)
Call for Proposals
In 2012, the IUGA Fellows Committee are forming a new
Fellows Research Network (FRN), intended to foster innovative
international studies across the breadth of Urogynecology.
Ahead of the next meeting in Brisbane 2012, the Fellows Committee
would like submissions for potential multi-centre studies, with the
intention of adopting one or two studies. In the first year of the
FRN, a total of US$20,000 is available. All proposals will be screened
by the FRN Steering Committee and Advisory Board prior to the
annual meeting. Selection of projects will be made by vote of the
IUGA-FRN members with input from the Advisory Board Members
present at the meeting.
If you have a study idea that you feel would benefit from this
international collaborative approach we would welcome a one
page structured summary, outlining the background, aims, target
population and likely outcomes.
Submissions can be made to [email protected] with a deadline of
May 16th, 2012.
For more information about the Fellows Research Network and to
download an application form and IUGA-FRN bylaws, please visit
http://www.iuga.org/?page=frncallproposals (IUGA login required).
Page 8
The highlight of this 3-day Symposium is the
Pre-Symposium Workshop on Ultrasound
Pelvic Floor Imaging conducted by Prof
Peter Dietz (Australia). He will be delivering 4
lectures: anterior and posterior compartment,
slings and pelvic trauma, and performing 2
live scanning sessions. After lunch Prof. Azmi
Md Nor (Malaysia) will conduct the Endoanal
Ultrasound Workshop for Beginners with a
lecture and live scanning demonstration.
The rest of the first day is dedicated to faecal
incontinence, obstetric anal sphincter tear
and irritable bowel syndrome.
The symposium proper over 2 days is equally
proportioned between pelvic organ prolapse
(POP) and urinary incontinence. Other
highlights of the symposium include:
•
•
•
•
Didactic lectures covering a wide
range of topics from basic and clinical
pelvic anatomy to investigations and
management.
Management of POP including conservative
treatment, uterine conservation, conventional
surgery, self-cut meshes and mesh kits,
laparoscopic surgery and female sexual
dysfunction.
Management of urinary incontinence
including conservative treatment, OAB,
recurrent UTI, painful bladder syndrome,
colposuspension (open & laparoscopic),
mid-urethral tapes, minislings, fistulae
and urinary tract injuries.
Q&A sessions
The regional IUGA Symposium for North
America will be held in Southern California and
is being hosted by University of California, Irvine.
This unique 2-day symposium is designed
for practicing urologists, gynecologists and
colorectal surgeons who are seeking solid
knowledge and basic skills in female pelvic
disorders. It is a multidisciplinary program presented by experienced international and U.S.
faculty in the fields of female urology, urogynecology, geriatrics, colorectal surgery and physiotherapy.
Highlights of the symposium include:
•
•
•
•
•
Focus on basics of female pelvic medicine
and reconstructive surgery.
All day Friday with didactic sessions and
Saturday for the hands-on laboratory cadaveric and inanimate surgical skills workshop taught by expert surgeons.
Basics and innovative hands-on training
sessions that participants will not have in
any other program
Six stations that provide cystoscopy training using bulking agents injections in a
model very close to the human bladder and
urethra.
Parallel to the endoscopy training, an anatomy session will be held proctored by the
expert faculty using several fresh frozen female cadaver pelves.
Course Director: Gamal Ghoniem, MD
To register to attend these symposiums, visit
www.iuga.org
Volume 7 Issue 1, 2012Page 9
The History of Sacral Neuromodulation
By Sohier Elneil
E
lectrical neuromodulation of
the lower urinary tract began over a
century ago, but it was
the pioneering work of
Tanagho and Schmidt
in the late 1980s that
demonstrated electrical activation of efferent fibres to the striated urethral sphincter inhibited detrusor contractions.
Stimulation of the third sacral root (S3) has been
shown to be effective in stimulating the urethral
sphincter. A large multicentre (Medtronic MDT103 - USA, Canada and Europe) prospective randomised clinical trial was set up to look at efficacy and safety of chronic neuromodulation to
the S3 nerve (sacral neuromodulation or SNM).
Results of this study led to approval by the Food
and Drugs Administration in October 1997. Over
25,000 neuromodulators (Interstim® and Interstim II®, Medtronic Inc, Minnesota, Minneapolis, USA) have so far been implanted for approved
urinary indications, paradoxically including both
overactive bladder syndrome and functional nonneurogenic urinary retention or chronic urinary
retention (CUR) and voiding dysfunction secondary to urethral sphincter overactivity (USO).
Indeed, SNM has been shown to be a most effective therapy in women with these conditions.
How SNM works remains to be clearly determined, but it is the work on women with CUR
and USO that has shed some light on the matter.
It is thought to restore normal micturition habits
in these women, by resetting brainstem function.
SNM was first described as a treatment for CUR
in the mid-1990s. The first stage of SNM was an
initial test procedure, known as a percutaneous
nerve evaluation test (PNE) which if found to be
positive and restore voiding ability, was followed
by the implantation of a permanent sacral electrode. Success rates for women with retention
for this method were reported at 40 – 50% for
the PNE, with approximately 60% voiding to
completion with formal implantation. At Queen
Square our experience has been comparable, with
two thirds of patients continuing to void without
need for catheterization at a follow up of 5 years.
However, we no longer use PNE as an evaluation
test, as our results with the staged procedure are
superior.
Various theories abound regarding its mode of action. Two components have been identified (i) activation of efferent fibres to the urethral sphincter
with negative feedback to the bladder (pro-continence reflex) and (ii) activation of sacral spinal
afferents resulting in inhibitory reflex efferent activity to the bladder. Reflex pathways at the spinal cord and supra spinal levels are thought to be
modulated to achieve these effects.
The prolonged beneficial effects of the stimulator,
after it is switched off, support this observation.
Further support for this hypothesis was provided
by a functional MRI study of the brain, where
brain responses to bladder filling in USO patients
were abnormal.
The overactive urethral sphincter was thought to
generate an abnormally strong inhibitory afferent signal, thus effectively blocking bladder afferent activity at the sacral level and deactivating
the higher centres. Hence, there would be a loss
of bladder sensation and voiding ability. SNM is
postulated to interfere with the inhibitory afferent activity arising from the urinary sphincter and
thus restoring the sensation of bladder filling and
the ability to void.
At a central level, decreases in regional cerebral
blood flow measured by PET scanning was demonstrated in the cingulate gyrus, the midbrain and
other adjacent structures in chronically implanted
patients with urge incontinence. SNM appears
to restore activity associated with brainstem auto
regulation and attenuation of cingulate activity,
critical to bladder function. Unsurprisingly, SNM
is now also used in chronic bowel and pelvic floor
dysfunction. With the advent of other peripheral
neuromodulation techniques, and an increasing
scope for the application of this technology, the
role of SNM in the urogynaecologist’s armamentarium is becoming increasingly important.
Page 10
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IT Director
Dear IUGA Members,
The International Urogynecology
Journal is introducing a new column entitled “Urogynecology Digest”, starting from the December
2012 issue onwards. The aim of
the new column is to inform readers about interesting and stimulating research in Urogynecology
topics published in other scientific
journals. In the last couple of pages of every IUJ issue, up to three
recent papers will be reviewed
accompanied by a short comment
highlighting the key features so
as to stimulate further reading.
IUJ is welcoming proposals for
studies published elsewhere
within the last year to be submitted to the column. Proposed
studies can be published either
by your own group or by other
researchers. Please submit your
proposed articles, with a brief review and a short comment (not
more than 400 words in total),
to [email protected], who
is currently coordinating this
new column. Final editing will be
performed by Paul Riss prior to
publication and of course your
name will be on the column page!
We are looking forward to your
contribution.
Volume 7 Issue 1, 2012
Page 11
FIGO and Partners Training of Trainers on Global
Competency-Based Fistula Surgery Training Manual
By Sohier Elneil
In the last three years,
there has been a worldwide initiative in developing a consensus document on standardized
training for surgeons in
the developing world on
urogenital fistulas, sustained as a consequence
Suzy Elneil, author/editor of the of
obstetric trauma.
Global Competency-Based FisWhilst FIGO initiated
tula Surgery Training Manual
the working group, the
document was drawn up
with input from members of different professional
bodies and non-government organizations. These included the International Society of Fistula Surgeons,
EngenderHealth, the Royal College of Obstetricians and Gynaecologists and the Pan-African Association of Urological Surgeons. It was funded and
supported by the United Nations Population Fund.
In July 2011, the final document was published
and made available freely on the FIGO website.
In August 2011, the first training of the trainers’
course took place in Dar-es-Salaam in Tanzania for
participants from Anglo-phone Africa. The meeting
was attended by members of the above organizations
and of IUGA. The training took place over two days,
where we held discussions about how to implement
a competency-based training system within different
teaching environments, how to appraise and achieve
accreditation in fistula surgery and how to deal with
the difficult trainee. All participants were already wellestablished fistula surgeons within their own right but
who nevertheless found the training sessions very helpful in understanding how the manual should be used.
The next training course is due in April 2012
for participants from Francophone Africa.
Further information about the manual can be found
by visiting
www.figo.org and selcting the Fistula link.
Pictured Below from left to right:
Back Row: Esam Gaffar (Sudan), Peter Melchert
(USA), Joseph Rumingo (EngenderHealth), Andrew
Browning(Tanzania),HamidRushwan(CEO,FIGO),
Abdelrahman Al-Fakih (Sudan), Lord Patel (Chair,
FIGOFistulaCommittee),GordonWilliams(Ethiopia),
Kevin Hayes (RCOG) and Tom Rassen (Kenya)
Front Row: Mulu Muleta (Ethiopia), Marietta
Mahendeka (Tanzania), Serigne Gueye (Senegal),
Suzy Elneil (Author/Editor), Ambaye Woldemichael
(Ethiopia) and Louise Knight (WAHA International)
Did you know that IUGA
members can view our
newsletter online? Just
visit www.iuga.org, log-in
and look for the “Access
the Newsletter” icon on our
home page.
Page 12
A Letter From the Secretar y -Treasurer
F
ive cities entered
bids to host the
2015 joint annual
meeting of IUGA and
ICS. A joint committee of IUGA and ICS
representatives reviewed
the bids and shortlisted
three for consideration
by the members of both
societies: Cape Town,
Lyon and Sydney. The
ballot closed just before
the holidays, and after
tallying the votes and
working with the ICS office on duplicate votes, the
winning city was Lyon, France. Co-chairs of the
winning bids are Brigtte Fatton (urogynecologist)
and Emmanuel Chartier-Kastler (urologist). Congratulations to the French colleagues! And thank
you to the other bidders who put in a lot of effort
in developing and presenting their bids to host.
Throughout this process our collaboration with the ICS
leadership has been excellent, and I would personally
like to thank Jacques Corcos and Sender Herschorn,
successive general secretaries of ICS, for the excellent
collaboration, which I’m sure will continue going forward in this joint endeavor. The next topic on the agenda will be our joint search for a professional congress
organizer to help us organize the meeting in 2015.
By Søren Brostrøm
The current office in Pompano Beach has moved to
a new larger, but temporary space in Ft. Lauderdale.
In the second half of 2012 we will relocate the office from South Florida to another US site which will
provide a better environment of networking and resources to meet our strategic goals. The Washington
DC area seems to be the best option.
We will work with an executive search consultancy
to hire an Executive Director with previous and extensive association and non-for-profit management
experience to oversee the transition and provide strategic leadership going forward .
All these measures will strain the 2012 budget, and
onwards the management of IUGA’s expenses will
be significantly larger than previously. The Executive
Board knew that these measures were vital to the future development and growth of IUGA, and a logical
consequence of the results of the strategic planning.
It is the intention to keep a South Florida office going
probably through most of 2012, as the search for an
Executive Director and setting up a new office in DC
will likely take some time. We will do our utmost
to ensure that these transitions are acceptable to everybody, and we will take good care of our current
staff, whilst striving to provide uninterrupted service
to the membership.
Kind Regards,
Mark your calendars for 30, June – 5, July 2015 for the Søren Brostrøm
joint meeting of IUGA/ICS.
Secretary-Treasurer
In the last newsletter I reported on the ongoing strategic planning and management assessment of IUGA
activities and organization that we initiated in Lisbon
last summer.
We’ve decided on some major changes in the future
management of IUGA:
We have expanded the current number of staff and
size of office space to accommodate the increasing
numbers of tasks and projects inside IUGA, and to
more properly service and retain the membership.
Our new office building
Volume 7 Issue 1, 2012Page 13
News from the IUGA Office
By Maureen Hodgson, CMM
T
he IUGA staff
has been very
busy these last
few months and we are
excited to share some
of our accomplishments with you:
Moved from our original location in Pompano Beach to the
downtown area of Fort
Lauderdale.
Expanded our staff by
hiring a new Membership Manager, Amy Cassini
and two part-time employees, Johanna Gomez who
is cleaning up the membership database and Alex
Marciello who is providing adminsitrative support.
Updated our phone system and file server to better
serve the needs of our members.
Assigned staff liaisons to each of the IUGA committees.
This is just a small sampling of the positive changes
happening within IUGA. Our number one priority
is to provide outstanding customer service to all of
our IUGA Members.
I am happy to report that we have compiled the
evaluation forms from our 36th Annual Meeting in
Lisbon. Overall the meeting was a huge success and
we received positive feedback in many areas:
Quality of A/V
Good
Services provided on site
Excellent
Organization of Scientific Program
Good
Ease of abstract submission
Good
Appropriate time for Q&A
Good
Congress website
Good
Ease of registration
Excellent
Overall organization
Excellent
Overall workshop programs
Good
Length of conference
Good
Social Program
Excellent
Facility conducive to learning
Good
As we plan our 37th Annual Meeting in Brisbane,
we will pay careful attention to these ratings and
strive to improve them. We will also do our best to
implement any suggestions or feedback our members
provided at the meeting.
Lastly, I would like to share with you that Elektra
McDermott has decided to pursue other career opportunities outside of IUGA. Elektra has been a valued team member for over 4 years and will be missed
greatly. Her last day with IUGA will be Wednesday, February 29th; after that, Elektra will work
for IUGA on a contract basis. In the meantime, the
IUGA office will be hiring her replacement to ensure
a seamless transition. Let us all wish Elektra much
success in her future endeavors.
Please make sure you update our new contact information:
790 East Broward Blvd, Suite 300
Fort Lauderdale, FL 33301
Office: +1954.763.1456
Fax: +1954.763.1236
Sunny Regards,
Maureen Hodgson, CMM
Administrative Director
Page 14
Membership
Ser vices
Dear Members,
I am so excited to be working at the IUGA office as the new Membership Manager. It’s wonderful to work for such a diverse association. With members from 40
different countries, you can imagine how challenging it can be to serve the indiviual needs of each member. Over the next year, I will be working diligently to
improve communication with our members and determine how we can best serve
them. Please know that your feedback and suggestions are always welcome and I
may be reaching out to some of you directly for assistance!
In the meantime, if you have any questions or concerns regarding your membership, please feel free to reach out to me via e-mail at [email protected] or by calling
954.763.1456 x.112.
I look forward to meeting some of you at the Annual Meeting in September!
Amy Cassini, Membership Manager
Affiliate Societies
Interested in becoming an Affiliate Society? National, international or regional organizations with a focus on Urogynecology may apply by letter or email for Affiliation with IUGA through the IUGA office. This application will be reviewed
by the Executive Committee and a response will be given within 30 days. A minimum of 30 paying members are
required. A Society representing a small nation/interest group may apply for exception to become an Affiliate Society.
For more information please contact Amy Cassini at [email protected]
or visit our web site affiliate’s page at http://www.iuga.org
AGES
AUB
BSUG
CAU
UGS
NVOG
URPSSI
IUS
AIUG
KUGS
SMUG
NBUG
PSURPS
SPCPR
PSUG
SSUG
SOGV
TUPRA
UPG
Australasian Gynaecological Endoscopy &
Surgery Society
Michele Bender
British Society of Urogynecology
Atia Khan
Austrian Urogynecology Working Group
Dr. Dieter Koelle
Colombian Association of Urogynecology
Dr. Carlos Diaz
Czech Urogynecological Society
Dutch Society for Urogynecology
Indian Society for Urogynecology
Israeli Urogynecology Society
Italian Society of Urogynecology
Korean Society of Urogynecology
Mexican Society of Urogynecology
Nucleus Brazilian Urogynecology Group
Phillipine Society for Urogynecology and
Reconstructive Pelvic Surgery
Dr. Mirek Masata
Dr. Wilbert Spaans
Dr. N. Rajamaheswari
Dr. Yuval Lavy
Maurizio Bologna
Dr. Yong Min Kim
Dr. Sergio Flores Rosas
Rodrigo Castro
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Dr. Lisa Prodigalidad
[email protected]
Portuguese Society for Pelvic Reconstructive Surgery
Dr. Helio Retto
[email protected]
Portuguese Society of Urogynecology
Slovene Society of Urogynecology
Dr. Liana Negrao
Society of Obstetrics and Gynecology of
Venezuela - Section of Urogynecology
Dr. Adolf Lukanovic
[email protected]
Dr. Dhelma Isabel Pellin
[email protected]
Dr. OnayYalcin
[email protected]
Turkish Society of Urogynecology
Urogynecology Peruvian Group
Dr. Rosa Reategui
[email protected]
[email protected]
Volume 7 Issue 1, 2012
Page 15
2012
Membership renewal
Membership starts on sign up date and is
valid for 1 year
$100 membership includes:
•
•
•
•
12 issues of the International Urogynecology Journal (IUJ)
Substantial discount on 2012 IUGA Annual Meeting registration
Members only content via www.iuga.org
IUGA newsletter
Complete this form
or
renew online at
www.iuga.org
To renew by FAX, please fill in the fields below and fax in to the IUGA office at +1-954-763-1236.
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advancing urogynecological knowledge around the world
IUGA Office
790 East Broward Boulevard, Suite 300
Fort Lauderdale, FL 33301 USA
Phone:+1-954.763.1456
Fax: +1-954.763.1236
E-mail: offi[email protected]
IUGA Office Staff
Maureen Hodgson
Administrative Director
[email protected]
x. 115
Kendra Busby
Finance Manager
[email protected]
x.113
Amy Cassini
Membership Manager
[email protected]
x. 112
Elektra McDermott
Director, Educational Programs
[email protected]
x. 116
IUGA Executive
Committee
IUGA International
Board
Harry Vervest
President
[email protected]
Peter DeJong
Africa
[email protected]
G. Willy Davila
Vice-President
[email protected]
Lisa T. Prodigalidad
Asia
[email protected]
Peter K. Sand
Past-President
[email protected]
Hans Peter Dietz
Australia
[email protected]
Søren Brostrøm
Secretary-Treasurer
[email protected]
Teresa Mascarenhas
Europe
[email protected]
Robert Shull
North America
[email protected]
Carlos Molina
IT Director
[email protected]
x. 114
Enrique Ubertazzi
Latin America
enrique.ubertazzi@
hospitalitaliano.org.ar
IUGA Committees
Education Committee
Jan Paul Roovers
Chairperson
Public Relations Committee
Lynsey Hayward
Chairperson
Scientific Committee
Michele Meschia
Chairperson
Fellows Committee
Rufus Cartwright
Chairperson
Research & Development
Committee
Dorothy Kammerer-Doak
Chairperson
Terminology & Standardization
Committee
Bernard Haylen
Chairperson
Publications Committee
Alex Digesu
Chairperson
The IUGA Newletter is published by the members of the Publications Committee
Editor: Alex Digesu
Associate Editors: Steven Swift & Suzy Elneil
Editorial Board: Eva De Cuyper, Alexandros Derpapas, Annette Kuhn, Pallavi Latthe, Mark Malak, Luis Miguel Monteiro, Menahem
Neuman, Paul Riss, Kamil Svabik, Bary Berghmans, Nathan Guerette, Kannan Kurinji, Deborah Karp, Aparecida Pacetta
If you are an IUGA member who is interested in joining a Committee, please e-mail [email protected]