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Sakineh Hajebrahimi
Associate Professor of urology Department
Program Director of Female Urology Fellowship
Tabriz University of Medical Sciences
Objectives
 the roles of pregnancy and delivery
in pelvic-floor dysfunction
 pelvic-organ prolapse
 urinary incontinence
 fecal incontinence
 Management
Conservative
Surgical
Case 1:
 A 46-Year-Old Woman with Pelvic-Floor Relaxation
after a Second Vaginal Delivery
 The patient had been well until 10 months earlier,
when she had experienced the rapid but otherwise
uncomplicated vaginal delivery of her second child. A
second degree laceration had occurred and had been
repaired.
 At her six-week, postpartum examination, she had
cystocele gIII and rectocele gII with gI-II utrine
prolapse
Next Four Months
During the next four months, the pelvic
discomfort worsened, and the
patient could see the cervix protruding
at the introitus. She reported urinary
frequency (12 or more times daily),
urgency, leaking, a slow urinary stream,
and a sense of incomplete
bladder emptying
Urodynamics Study
Differential Diagnosis
 Epidemiology: between the ages of 15 and 97
years revealed that 46 %of women and 11 percent
of men have pelvic-floor dysfunction
 A woman has an 11 % lifetime risk of undergoing
 surgery for incontinence, pelvic-organ prolapse, or
 both by 80 years of age.
Risk factors
Vaginal delivery
 Large baby
 Prolonged 2nd stage of labor
 Forceps
 Multiparous
Risk factors
Increased abdominal pressure
 Obesity
 Chronic constipation
 Chronic lung disease
Risk factors
Altered nerve function or tissue strength
 Diabetes
 Neurologic diseases
 Aging
 Collagen disorders
 Hypoestrogenism
 Pelvic surgery
Anatomic cosidrations
Anatomy
 Basic
 Levator ani muscles
 Pubococcygeuas
 Puborectalis
 Iliococcygeus
 Viscerofascial layer
 Endopelvic fascia - attaches uterus and vagina to pelvic wall
 Parametria - cardinal and uterosacral ligaments
 Fascial defects
 Neuromuscular pathophysiology
The roles of pregnancy and
delivery in pelvic-floor dysfunction
 How did this patient’s pregnancies contribute to
her problems?
 whether elective delivery by cesarean section
should be offered to minimize this risk?
Vaginal Delivery or C/S???
 Pelvic-organ prolapse
 Several observational study
 No differents for new prolaps and modle of
delivery (Level of Evidence C)
Vaginal Delivery or C/S???
 Urinary Incontinence
 According to two studies,an urgent need to
 urinate occurred in 22 % and 62 % of
pregnant women;
 8 percent and 18 percent of pregnant
women, respectively, had urge
incontinence or urodynamic evidence of
detrusor instability
Vaginal Delivery or C/S???
 In a study of 305 primiparous patients, urinary
incontinence appeared before, during, or after
pregnancy in 4 %, 32 %, and 7 %, respectively.
 In a survey of 1505 women at three months
post partum,the prevalence of incontinence was
higher in those who had given birth vaginally rather
than by cesarean section (24 percent vs. 5.2 percent
 This highly controversial proposal is supported by a
single trial of planned cesarean delivery versus
planned vaginal delivery in cases of breech
presentation, which showed a decrease in the rate of
stress incontinence in the cesarean delivery group at 3
months post partum (relative risk, 0.62; 95%
confidence interval, 0.41 to 0.93)
but no significant difference between the two
groups at 2 years post partum.
Vaginal Delivery or C/S???
 Insufficient Evidences in Favored of any delivery
model!!
Vaginal Delivery or C/S???
 Fecal incontinence
 Vaginal delivery appears to be responsible for fecal
incontinence, through a combination of compression
 and stretch injury to the pudendal nerve and
 disruption of the anal sphincter.
Management
 OUTCOME
Note:
 A clinician might well be prepared to
try a Antibiotics in a woman in whom
there was an 80% chance her
symptoms were due to cystitis, but the
urologist would want to be close of
100% Adenocacinoma before starting
Radical prostatectomy.
What are “tests” used for?
Log of reasons by several docs:
Diagnosis – most common
but also
Monitoring – has it changed?
Prognosis – risk/stage within
Dx
Treatment planning, e.g.,
location
Stalling for time!
Evaluation
Urinary Incontinence
Investigation
Simple
(Office tests)
Complex
(Urodynamics)
Urinalysis
Uroflowmetry
Urine culture
Cystometry
Urinary diary
Urethral function tests
Pad test
Ultrasound
Videocystometry
Ambulatory urodynamics
Stress Urinary Incontinence
Investigations - Uroflowmetry
Flowmeter
Normal flow trace
UDS
Urinary Incontinence
Treatment: Primary Prevention
Lifestyle interventions
 Weight loss
 Cessation of smoking
 Avoidance of heavy exercise / straining
 Effective management of constipation

Pregnancy and childbirth
 Antenatal pelvic floor exercises
 Active management of labour
 Role of elective caesarean section?
Urinary Incontinence - Management
HISTORY
Incontinence on physical activity
• General assessment
CLINICAL
ASSESSMENT
TREATMENT
• Physical examination: abdominal, pelvic, neurological
• ? Oestrogen status - if atrophic, treat as necessary
• Assess quality of life and desire for treatment
• Frequency volume chart
• Urinalysis ± urine culture – if infected, treat and reassess
• Assess post-void residual volume (by catheter or ultrasound)
• Assess for pelvic organ mobility / prolapse
• Consider imaging of the UT
• Urodynamics
• Lifestyle interventions ± Pelvic floor muscle training
If initial therapy fails, consider
• Stress incontinence surgery / correct prolapse surgically
Medications
 Duloxetine hydrochloride, a serotonin-reuptake
 Inhibitor
 A recent meta-analysis of randomized trials concluded
 that duloxetine significantly decreased the frequency
 of episodes of stress incontinence and
 improved the quality of life; adverse events, primarily
 nausea, were common but generally minor.
 Anti muscarinics for urge
Alpha agonists,
such as clonidine, have been used
empirically for the treatment of stress
incontinence, but this use is not
supported by rigorous studies, and
efficacy in clinical practice is limited.
 Postmenopausal estrogen treatment was previously
believed to decrease the symptoms of
stress incontinence. However, data from the Heart
and Estrogen/Progestin Replacement Study showed
a significantly higher risk of stress and urge incontinence
among women randomly assigned to
receive estrogen alone or estrogen and progesterone
than among those assigned to receive placebo.
Given these results, the initiation of hormone
therapy for treatment of stress incontinence is not
indicated.
Devices
Devices
 A randomized, controlled trial comparing the use of
super tampons and the use of pessaries to the use of no
device in women who were incontinent while
exercising found that the tampons and pessaries were
similarly effective in reducing the frequency of stress
Incontinence.
Surgery
A Burch
Colposuspension
C Tension-free Vaginal Tape
B Fascial
Sling
Suprapubic Approach
“Mini – Sling”
TVT SECUR System
Obturator Approach
Transobturator tape (TOT)
Pelvic organ prolapse
Prolapse Surgery
Never remove the
vaginal mucosa
Ethics
and
patient
safety
Areas of Uncertainty
 Definition of Cure
 Reported cure rates associated with surgical treatment
of stress incontinence by means of Burch
colposuspension, suburethral sling, tension-free
 vaginal tape, or transobturator tape range widely,
from 30% to 100%.
This wide variation relates in part to the use of
varying definitions of cure
Prevention
 Given the observational data indicating increased
rates of stress incontinence among women who
have undergone vaginal delivery as compared with
cesarean delivery, cesarean delivery has been
proposed as a strategy to prevent stress incontinence!!!!!!
New Surgical Procedures
 Many midurethral slings and related devices have
been approved for use by the Food and Drug
Administration
(FDA).
However, these approvals have involved the FDA’s
510(k), or premarket-notification,process that does not
require proof of safety and efficacy of the new device
but simply requires evidence that it is similar to one
that has already been approved
 The potential risks associated with this process are
evidenced by the experience with the ProteGen sling,
which was widely implanted in women before clinical
trials were conducted Until peer-reviewed comparative
data are available, caution is warranted in the adoption
of new devices, and patients should be informed that
the data available to guide the use of many new
techniques are limited
Conlusion
 I would with my patient discuss surgical treatment
as an alternative to behavioral or device therapies.
 I would explain that surgical treatment would
probably result in improved quality of life and
sexual function and would be expected to decrease
considerably, but not completely eliminate, all
symptoms of incontinence.
No
preventive
prolapse
surgery
Thank you