UPDATE IN UROGYNAECOLOGY

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UPDATE IN UROGYNAECOLOGY

• RHW/ AUST DOCTOR HORMONE WOMENS HEALTH DAY
  2006
• Bernard T. Haylen
• St. Vincents Clinic, Mater
  Randwick Urodynamic Centres, Sydney.
• www.bladder.com.au

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UROGYNAECOLOGY

• AREA OF GYNAECOLOGY AND FEMALE
• UROLOGY INVOLVING THE ASSESSMENT
• AND TREATMENT OF LOWER URINARY
• TRACT AND PELVIC FLOOR DYSFUNCTION
• INCLUDING UTERINE AND VAGINAL
• PROLAPSE

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INCIDENCE OF UROGYNAECOLOGICAL PROBLEMS

• OVERALL
• High
• INCONTINENCE
• 34 Australian women (11 severe)
• PROLAPSE
• 40 women (45-85) at routine gynaecological
  checkup will have significant (Grade1)
  uterine/vaginal prolapse.

4
FOUR SECTIONS
1 URINARY INCONTINENCE PROLAPSE MANAGEMENT
IN GENERAL PRACTICE.
2IS THE RETROVERTED UTERUS A PROBABLE RISK
FACTOR TO THE PELVIC FLOOR?
3 IS HRT BENEFICIAL TO THE BLADDER AND PELVIC
FLOOR?
4 CONCLUSIONS TAKE AWAY TIPS.
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FOUR SECTIONS
1 URINARY INCONTINENCE PROLAPSE MANAGEMENT
IN GENERAL PRACTICE.
2IS THE RETROVERTED UTERUS A PROBABLE RISK
FACTOR TO THE PELVIC FLOOR?
3 IS HRT BENEFICIAL TO THE BLADDER AND PELVIC
FLOOR?
4 CONCLUSIONS TAKE AWAY TIPS.
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SECTION 1
1 URINARY INCONTINENCE PROLAPSE MANAGEMENT
IN GENERAL PRACTICE.
2IS THE RETROVERTED UTERUS A PROBABLE RISK
FACTOR TO THE PELVIC FLOOR ?
3 IS HRT BENEFICIAL TO THE BLADDER AND PELVIC
FLOOR?
4 CONCLUSIONS TAKE AWAY TIPS.
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URODYNAMIC STRESS INCONTINENCE
(USI) (PREVIOUSLY GENUINE STRESS
INCONTINENCE) - 70 PATIENTS
OVERACTIVE BLADDER (OAB) (PREVIOUSLY
DETRUSOR INSTABILITY) - 25 PATIENTS
4 MAIN CONDITIONS IN UROGYNAECOLOGY
UTERINE AND/OR VAGINAL PROLAPSE - 65
PATIENTS
VOIDING DIFFICULTY - 39 PATIENTS
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URODYNAMIC STRESS INCONTINENCE (USI) The
condition of GSI is urinary incontinence due to
weakness or incompetence of the bladder neck
and/or urethral sphincter closure mechanisms
that normally maintain continence.
OVERACTIVE BLADDER (OAB) Abnormal contractions
of the intrinsic bladder (detrusor) musculature
4 MAIN CONDITIONS - DEFINITIONS
UTERINE/VAGINAL PROLAPSE Abnormal descent
into the vagina of uterus, bladder
(cystocoele), rectum (rectocoele), vaginal
vault (enterocoele).
VOIDING DIFFICULTY -Abnormally slow and/or
incomplete micturition -Abnormally slow urine
flow and/or high residual urine volume -
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1 HISTORY FULL HISTORY WITH OF
INCONTINENCE, BLADDER IRRITABILITY, PROLAPSE AND
VOIDING DIFFICULTY SOUGHT

• 2 CLINICAL EXAMINATION
• GENERAL
• CLINICAL STRESS LEAKAGE
• BIMANUAL PELVIC
• EXAMINATION
• UTERINE/VAGINAL PROLAPSE

INITIAL UROGYNAECOLOGICAL ASSESSMENT ALL
PRACTITIONERS CAN PERFORM
3 MID-STREAM URINE
4 BLADDER CHART (3-DAY)
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• INCONTINENCE
• STRESS
• URGE
• COITAL
• ENURESIS

IRRITATIVE FREQUENCY (gt 7) -URGENCY - NOCTURIA
(gt1)
COMMON SYMPTOMS IN UROGYNAECOLOGY - MOST WOMEN
PRESENT WITH MULTIPLE SYMPTOMS SUGGESTIVE OF gt 1
UROGYNAECOLOGICAL CONDITION

• PROLAPSE
• PELVIC PRESSURE
• VAGINAL LUMP
• SACRAL BACKACHE
• DYSPAREUNIA

• VOIDING
• -HESITANCY
• POOR STREAM
• INCOMPLETE EMPTYING
• NEED TO REVOID
• STRAIN TO VOID

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1 CLINICAL STRESS LEAKAGE Direct urine
loss with coughing, sneezing etc Bladder should
be FULL
2 BIMANUAL PELVIC EXAMINATION 8 Prevalence of
uterine and adnexal pathology esp.
fibroids Bladder best emptied
CLINICAL SIGNS MORE SPECIFIC THAN SYMPTOMS

• 3 EXAMINATION FOR UTERINE/ VAGINAL PROLAPSE
• Patient in left lateral (Sims) position
• Use of Sims Speculum
• Bladder volume should be EMPTY
• Identify the presence of and grade (0-4) each of
• uterine prolapse, cystocoele, rectocoele,
  enterocoele.

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FEMALE URINARY INCONTINENCE CLINICAL EXAMINATION

• GRADING OF PELVIC ORGAN PROLAPSE (POP) - ICS
• For each of uterine prolapse, cystocoele,
  rectocoele, enterocoele
•  
• GRADE 0 No prolapse
• GRADE 1 Descent towards vaginal introitus (gt1cm
  above hymen)
• GRADE 2 Descent to vaginal introitus (hymen /-
  1cm from hymen)
• GRADE 3 Descent through introitus (gt 1cm below
  hymen)
• GRADE 4 Prolapse totally outside introitus
• (uterine grade 4
  procidentia)

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UROGYNAECOLOGY ROLE OF MSU, BLADDER CHART

• MIDSTREAM URINE
• 33 of women with symptoms of pelvic floor
  dysfunction will have frequency and/or dysuria -
  ? UTI
• UTI might cause or exacerbate symptoms of pelvic
  floor dysfunction
• Recurrent UTIs might be a reflection of a
  chronic residual (above 30mls can lead to
  recurrent UTIs)

• BLADDER CHART 3 Day chart
• AMOUNT OF EACH VOID, FLUID INTAKE AND EPISODES OF
  INCONTINENCE
• Indicator of urinary frequency or nocturia (
  this can be altered by bladder training)
• Indicator of average voided volume (should be
  200-300mls)
• Indicator of severity of incontinence (number of
  leaks)
• Indicator of above average (gt2 litres) or below
  average (under 1 litre) fluid intake

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UROGYNAECOLOGY INITIAL GENERAL MEASURES

• WEIGHT LOSS often reduces symptom of stress
  incontinence
• REDUCED CAFFEINE reduced frequency, bladder
  irritability
• IMPROVE CHEST CONDITIONS or other exacerbating
  factors for stress incontinence
• VAGINAL OESTROGENS May improve frequency,
  nocturia, urgency and condition of the vaginal
  mucosa. Little proven benefit for incontinence
  over placebo
• MEDICATIONS Adverse effect of diuretics,
  Minipress
• PHYSIOTHERAPY Best if incontinence is mild to
  moderate and stress incontinence is the main
  symptom

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UROGYNAECOLOGY REFERRAL FOR URODYNAMICS
GENERALLY THE KEY TO ACCURATE DIAGNOSIS

• MIXED SYMPTOMS
• - DIAGNOSIS UNCERTAIN
• - SEVERE SYMPTOMS

- FAILURE OF INITIAL MEASURES - DEFINITIVE
TREATMENT ANTICIPATED . SURGERY FOR USI .
ANTICHOLINERGICS FOR URGE INCONTINENCE,
FREQUENCY etc
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URODYNAMIC STRESS INCONTINENCE (USI) CONFIRM
PRESENCE TESTS CLINICAL STRESS LEAKAGE,
ULTRASOUND IMAGING
OVERACTIVE BLADDER (OAB) IDENTIFY/ELIMINATE
DIAGNOSIS TEST CYSTOMETRY
ASSESS THE SEVERITY OF ALL DIAGNOSES
UTERINE AND/OR VAGINAL PROLAPSE CONFIRM
PRESENCE AND INTERACTION WITH OTHER BLADDER
DYSFUNCTION

• VOIDING DIFFICULTY
• IDENTIFY/ELIMINATE
• TESTS URINE FLOW RATE
• RESIDUAL URINE VOLUME
• VOIDING CYSTOMETRY

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1 URODYNAMIC STRESS INCONTINENCE
CLINICAL STRESS LEAKAGE (Examination, Pad
Test) BLADDER STABLE (or stable when leakage
occurs) IMAGING EVIDENCE Bladder neck
incompetent
2 OVERACTIVE BLADDER CYSTOMETRY PRESENCE
OF UNSTABLE BLADDER CONTRACTIONS ON FILLING OR
PROVOCATION ASSOCIATED WITH THE SYMPTOM OF
URGENCY
DIAGNOSES AFTER URODYNAMICS (Prolapse Dx
Clinical))
3 VOIDING DIFFICULTY SLOW URINE FLOW
(Under 10th Centile of Liverpool Nomogram) HIGH
RESIDUAL URINE Over 30mls is abnormal. 85 of
symptomatic women have no residual VOIDING
CYSTOMETRY - . No Contraction, poor or no
flow - Hypotonic or atonic . Strong
Contraction, slow flow - Bladder outflow
obstruction
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PHYSIOTHERAPY 50-65 improvement, 20-40
cure if properly supervised. 40 Contractions per
day for maximal compliance.
CONSERVATIVE TREATMENT OF USI MOST APPLICABLE
TO MILD/MODERATE SEVERITY
AIDS TO PHYSIOTHERAPY . Perineometer . Vaginal
Cones . Electrical Stimulation
MECHANICAL DEVICES . Tampons (e.g leakage with
exercise . Pessaries (more applicable to prolapse)
AIDS TO PHYSIO
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UROGYNAECOLOGY SURGICAL TREATMENT OF USI

• SURGERY FOR USI
• Minimally Invasive
• Tension-free vaginal tape
• 90 success, best data. Other
• suprapubic, obturator tapes
• available.
• Traditional
• Colposuspension

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MILD/MODERATE SEVERITY Behavioural Therapies
. Bladder Training . Maximal electrical
stimulation . ? Acupuncture/ Hypnosis
MODERATE/MARKED SEVERITY Medication .
Anticholinergics . Antidepressant .
Antidiuretics
TREATMENT OF THE OVERACTIVE BLADDER DOESNT SEEM
TO GET ANY EASIER 50 EFFICACY FROM MOST Rx vs
30 FOR PLACEBO
BLADDER TRAINING SUPRESS URGENCY INCREASED
VOIDED VOLUMES DECREASED FREQUENCY DECREASED
URGENCY
VERY SEVERE OAB TRANSVESICAL BOTOX INJECTIONS
(STILL IN RESEARCH STAGE RADICAL SURGERY (CLAM
CYSTOPLASTY)
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UROGYNAECOLOGY DRUG TREATMENT OF DETRUSOR
INSTABILITY

• PROBANTHINE (15-30mg tds) - anticholinergic
• . Best for Frequency
• OXYBUTYNIN (2.5-5mg tds) musculotrophic
• . Best for Urgency, Urge Incontinence
• TOLTERODINE (1-2mg BD) - new anticholinergic with
  reduced S/E
• TRYPTANOL (10-25mg) - Antidepressants for
  Nocturia
• TOFRANIL (25-75mg) nocte
• MINIRIN (1-2 Sprays nocte) - Antidiuretic for
  Enuresis

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UROGYNAECOLOGY TREATMENT OF UTEROVAGINAL
PROLAPSE

• ACONSERVATIVE Future child bearing desired
  younger (under 34) Medically compromised
• physiotherapy
• ring pessary

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UROGYNAECOLOGY TREATMENT OF UTEROVAGINAL
PROLAPSE

• B Future childbearing
• unlikely under 40 years
• conservative measures
• unsuitable
• Manchester repair sacrospinous hitch
  (St. Vincents Repair)

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UROGYNAECOLOGY TREATMENT OF UTEROVAGINAL
PROLAPSE

• C No future childbearing
• over 40 years
• vaginal hysterectomy repairs /- sacrospinous
  hitch

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UTERINE PROLAPSE FAMILY COMPLETE VAGINAL
HYSTERECTOMY (except v large uterus abdo
hyst) FAMILY NOT COMPLETE MANCHESTER REPAIR
CYSTOCOELE . PRIMARY ANTERIOR REPAIR
. RECURRENT CASES - Anterior (re-do) - Mesh
(Pro-lift, Perigee) - Paravaginal Repair
SURGICAL TREATMENT OF PROLAPSE
VAGINAL TECHNIQUES EFFECTIVE IN MOST CASES WITH
THE EXCEPTION OF MAJOR VAGINAL VAULT PROLAPSE
VAGINAL VAULT (ENTEROCOELE) SMALL POSTERIOR
VAGINAL REPAIR MEDIUM/LARGE SACRO- SPINOUS HITCH
(90 SUCCESS) LARGE/ V LARGE OPEN OR LAP
COLPOSACROPEXY
RECTOCOELE . PRIMARY POSTERIOR REPAIR
. RECURRENT CASES - Posterior (re-do) - Mesh
(Pro-lift, Apogee) - Posterior Intravaginal
slingplasty
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1 UTERINE/ VAGINAL PROLAPSE REPAIR PROLAPSE
OFTEN MAJOR DECREASE IN RESIDUAL URINE VOL.
2 IDIOPATHIC VOIDING DIFFICULTY
(Recurrent UTIs due to high RUVs) LONG-TERM
UTI PROPHYLAXIS
TREATMENT OF VOIDING DIFFICULTY SEE CAUSE
EFFECTIVE UTI PROPHYLAXIS IS AN IMPORTANT
PART OF Rx OF VOIDING DIFFICULTY (HIPREX 1Gm BD/
VIT C 500Mgm BD IS EFFECTIVE IN MAJORITY OF CASES)
3 POSTOPERATIVE/ POSTPARTUM CATHETERISATION If
prolonged Suprapubic catheter Intermittent
self-catheter (urethral 12FG/14FG plastic)
4 DISTAL URETHRAL STENOSIS URETHRAL
DILATATION ?VAGINAL OESTROGENS
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SECTION 2
1 URINARY INCONTINENCE PROLAPSE MANAGEMENT
IN GENERAL PRACTICE.
2IS THE RETROVERTED UTERUS A PROBABLE RISK
FACTOR TO THE PELVIC FLOOR ?
3 IS HRT BENEFICIAL TO THE BLADDER AND PELVIC
FLOOR?
4 CONCLUSIONS TAKE AWAY TIPS.
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IS UTERINE RETROVERSION A PROBABLE RISK FACTOR
FOR THE PELVIC FLOOR?

• WHAT IS
• THE
• RETROVERTED
• UTERUS?

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UTERINE VERSION
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UTERINE RETROVERSION

• Axis of the body of the uterus is directed to the
  hollow of the sacrum away from its normal
  (anteverted) position overlying the bladder
• Cervix of retroverted uterus is anteriorly placed
  in the vagina close to the bladder and urethra as
  opposed to the position of the cervix of an
  anteverted uterus in the posterior fornix

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UTERINE RETROVERSION

• Normally a developmental occurrence
• Familial tendency
• Acquired retroversion can occur with the effects
  of endometriosis, pelvic inflammatory disease and
  pelvic tumours

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UTERINE RETROVERSION
THERE IS NO EVIDENCE FOR THE FOLLOWING
THEORY ANTEVERSION RETROVERSION
PROLAPSE
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IS UTERINE RETROVERSION A RISK FACTOR FOR THE
PELVIC FLOOR?

• WHATS
• KNOWN
• ABOUT THE
• RETROVERTED
• UTERUS?

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UTERINE RETROVERSION

• ONLY
• 74
• CITATIONS
• IN THE
• LITERATURE

38
Dyspareunia Ventrosuspension 15 papers
CVS Difficulties 5 papers
SONOGRAPHY SURGICAL ISSUES 18 papers
71 CITATIONS
IVF Difficulties 10 papers
Difficulties with IUCD Insertion Abortion 6
papers
Endometrial Resection Difficulties 5 papers
Uterine Incarceration In Pregnancy 12 papers
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UTERINE RETROVERSION ONLY 3 CITATIONS IN THE
LITERATURE ABOUT ITS EFFECT ON THE BLADDER AND
PELVIC FLOOR

• 2 OTHER ARTICLES IN GENERAL GYNAECOLOGY
  LITERATURE

Lenck, L.C.,Albuisson, E Jacquetin
B Correction of uterine retrodeviation with a
Celioscope. Operative technique.
Complications. Effects on urinary
function. Revue Francaise de Gynecologie et
dObstetrique (1990)85 (11) 603-610
Weinberger, M.W. Julian, T.M. Voiding
dysfunction caused by uterine retroversion. A
case report. J. Reprod Med (1995)40387-390
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UTERINE RETROVERSION ONLY 1 ARTICLE IN THE
UROGYNAECOLOGY LITERATURE
HAYLEN, BT CERQUI, A POSTPARTUM UTERINE
RETROVERSION CAUSING BLADDER OUTFLOW OBSTRUCTION
CURE BY LAPAROSCOPIC VENTROSUSPENSION. INT
UROGYNECOL J, 1999, 10 353-355
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UTERINE RETROVERSION - PREVALENCE
15 CITATIONS FOR PREVALENCE FIGURES (All
Non-systematic Studies)
Range 10 to 36 Women
Mean 20 Women
THE TRUE PREVALENCE OF THE RETROVERTED UTERUS
REMAINS UNKNOWN
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UTERINE RETROVERSION FIRST SYSTEMATIC
PREVALENCE STUDY (Haylen B, McNally G., Birrell
W.)
METHODS 205 WOMEN ATTENDING FOR
SUBSPECIALIST GYNAECOLOGICAL ULTRASOUND
)
SCANNING
. ABDOMINAL (FULL BLADDER) .
TRANSVAGINAL (EMPTY BLADDER
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UTERINE RETROVERSION FIRST SYSTEMATIC
PREVALENCE STUDY (Haylen B, McNally G. et al.)
RESULTS PREVALENCE 19 (c.f. Repeat study Dr
Philippa Ramsay 15 Combined result 17 (1 in
6)
ACCURATE DIAGNOSIS REQUIRES . TRANSVAGINAL
ULTRASOUND . EMPTY BLADDER (Uterine axis may
change with bladder fullness, only from
anteverted to retroverted)
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WHAT IS THE SIGNIFICANCE OF THE RETROVERTED
UTERUS FOR THE BLADDER AND PELVIC FLOOR?
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UTERINE RETROVERSION SIGNIFICANCE FOR THE
BLADDER AND PELVIC FLOOR
PATIENTS 592 WOMEN FIRST UROGYNAECOLOGY/URODYNAMIC
S VISIT
CLINICAL ASSESSMENT COMPREHENSIVE HISTORY
CLINICAL EXAMINATION FULL URODYNAMIC ASSESSMENT
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UTERINE RETROVERSION SIGNIFICANCE FOR THE
BLADDER AND PELVIC FLOOR

• AIMS OF STUDY
• COMPARE RETROVERTED UTERUS WITH
• - ANTEVERTED UTERUS
• - ABSENT UTERUS (Prior hysterectomy)
• FOR (i) ASSOCIATION WITH ALL TYPES OF
• PROLAPSE
• (ii) ALL URODYNAMIC DIAGNOSES

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UTERINE RETROVERSION SIGNIFICANCE FOR THE
BLADDER AND PELVIC FLOOR

• URODYNAMIC DIAGNOSES
• - USI
• - OVERACTIVE BLADDER
• - UTERINE/VAGINAL PROLAPSE
• - VOIDING DIFFICULTY
• - RECURRENT URINARY TRACT INFECTIONS (UTI)
• (2 or more UTIs in the last 12 months)

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RESULTS (1) PREVALENCE IN UROGYNAECOLOGY
PATIENTS

• 
  
  592 in cohort
• Women with uterus present - 395 (66 of total)
• Women with uterus absent - 197 (34 of total)
  
• Women with uterus present - 34 retroverted
• -
  66 anteverted
• Retroverted uterus is 79 more prevalent in
  urogynaecology
• than in general gynaecology patients (19).
  N.B. 100 more
• prevalent if 17 mean prevalence (2 studies)
  is used.

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RESULTS (2) MEDIAN AGE AT PRESENTATION AS
UROGYNAECOLOGY PATIENTS

• - RETROVERTED UTERUS 52 years
• - ANTEVERTED UTERUS - 56 years
• - ABSENT UTERUS - 64 years

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RESULTS (3) PREVALENCE OF PROLAPSE IN
UROGYNAECOLOGY PATIENTS (ANTEVERTED/RETROVERTED
UTERI)

• RETROVERTED UTERUS Associated with
• 4.5 x Prevalence of Grade 2/4 uterine prolapse
  (plt0.001)
• 1.9 x Prevalence of Grade 2/4 cystocoele
  (p0.008)
• 4.7 x Prevalence of Grade 1/2/3/4 vaginal vault
  prolapse (plt0.001)
• COMPARED WITH THE ANTEVERTED UTERUS

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Degree of Uterine ProlapseICS 2-4
4.5x
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RESULTS (3) PREVALENCE OF PROLAPSE
69 ICS GRADE 2-4 UTERINE PROLAPSE INVOLVES THE
RETROVERTED UTERUS
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Incidence of all forms of prolapse Retroverted
vs Anteverted Uterus
1.9x Plt0.008
4.7x Plt0.001
4.5x Plt0.001
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RESULTS (4) ASSOCIATION OF RETROVERTED UTERUS
WITH OTHER URODYNAMIC DIAGNOSES

• No significant differences between anteverted
  uterus, retroverted uterus and no uterus for all
  major urodynamic diagnoses
• - URODYNAMIC STRESS INCONTINENCE
• - OVERACTIVE BLADDER
• - VOIDING DIFFICULTY
• - RECURRENT URINARY TRACT
• INFECTIONS

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UTERINE RETROVERSION CONCLUSIONS (1)

• Prevalence of retroverted uterus is 79 more
  in the urogynaecology than general gynaecology
  populations.

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UTERINE RETROVERSION CONCLUSIONS (2)

• Uterine Retroversions main association is with
  a significant increase in the prevalence of
  uterine prolapse and higher grade cystocoele over
  that with an anteverted uterus.

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UTERINE RETROVERSION CONCLUSIONS (3)

• Uterine Retroversion does not appear to be
  associated with an increase in other urodynamic
  diagnoses compared with that found with either an
  anteverted or absent uterus.

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UTERINE RETROVERSION LIKELY MECHANISM OF
INCREASED PROLAPSE PREVALENCE (NEW THEORY)

• - Axis of retroverted uterus is similar to
  vaginal axis. Pulsion forces in an axial vaginal
  direction causes the prolapse
• - Pulsion forces on the anteverted uterus
  directs it towards the rectum (less likely to
  prolapse)

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SECTION 3
1 URINARY INCONTINENCE PROLAPSE MANAGEMENT
IN GENERAL PRACTICE.
2 IS THE RETROVERTED UTERUS A POSSIBLE RISK
FACTOR TO THE PELVIC FLOOR ?
3 IS HRT BENEFICIAL TO THE BLADDER AND PELVIC
FLOOR?
4 CONCLUSIONS TAKE AWAY TIPS.
61
IS HORMONE REPLACEMENT THERAPY BENEFICIAL TO THE
BLADDER AND PELVIC FLOOR?

• Significant amount of research on the role of HRT
  on
• Breast cancer
• Osteoporosis
• Cardiovascular disease
• Cerebrovascular disease
• Relatively little research on the role of HRT on
  bladder function and the pelvic floor

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• SOME BENEFIT
• OF HRT FOR USI
• Elia Bergman, 1993
• Bergman, Karram Bhatia, 1990
• Fantl et al., 1988

NO IMPROVEMENT IN POSTMENOPAUSAL USI WITH
OESTRODIOL Jackson et al., 1999 (Large
placebo- controlled trial)
WHAT DO WE KNOW OF THE EFFECT OF HRT ON THE
BLADDER PELVIC FLOOR? CONFUSING!

• INCREASED RISK
• OF UI WITH HRT
• Grodstein et al., 2001
• - Samuellson et al., 2000
• (large population
• studies)

ESTROGEN/ PROGESTIN RECEPTORS IN THE UTEROSACRAL
LIGAMENTS -Krissi et al., 2001 (E,P) Phillips et
al., 2001 (E)
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COCHRANE DATABASE ANALYSIS (Moehrer, Hextall,
Jackson) 2001 - CONCLUSIONS

• 28 CITATIONS - 3000 WOMEN
• Assess the effects of HRT for treatment of
  urinary incontinence
• Varying combinations of HRT, dose, duration of
  treatment and follow up
• CONCLUSIONS
• HRT may improve or cure incontinence, however
  most likely with urge incontinence
• Few data to address reliably different HRT types

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EFFECTS OF ESTROGEN WITH/WITHOUT PROGESTIN ON
URINARY INCONTINENCE

• WOMENS HEALTH INITIATIVE (WHI)
• Multicentre, doubleblind, placebo-controlled
• randomized clinical trial of HRT
• 27,347 postmenopausal women
• CONCLUSIONS
• Estrogen and E/P increases the risk of urinary
  incontinence in continent women
• Worsen the characteristics of UI among
  symptomatic women after 1 year

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IS HORMONE REPLACEMENT THERAPY BENEFICIAL TO THE
BLADDER AND PELVIC FLOOR?

• AIMS OF STUDY
• EVALUATE THE INFLUENCE OF
• HORMONE REPLACEMENT THERAPY
• FOR (i) ASSOCIATION WITH ALL TYPES OF
• PROLAPSE
• (ii) ALL URODYNAMIC DIAGNOSES

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IS HORMONE REPLACEMENT THERAPY BENEFICIAL TO THE
BLADDER AND PELVIC FLOOR?

• URODYNAMIC DIAGNOSES
• - USI
• - OVERACTIVE BLADDER
• - UTERINE/VAGINAL PROLAPSE
• - VOIDING DIFFICULTY
• - RECURRENT URINARY TRACT INFECTIONS (UTI)
• (2 or more UTIs in the last 12 months)

69
IS HORMONE REPLACEMENT THERAPY BENEFICIAL TO THE
BLADDER AND PELVIC FLOOR?
PATIENTS 592 WOMEN PROSPECTIVE STUDY 2003/2004
(ANALYSIS 2005) FIRST UROGYNAECOLOGY/URODYNAMICS
VISIT
CLINICAL ASSESSMENT COMPREHENSIVE HISTORY
MENOPAUSE STATUS EXAMN CLINICAL STRESS,
PROLAPSE, BIMANUAL PELVIC FULL URODYNAMIC
ASSESSMENT
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IS HORMONE REPLACEMENT THERAPY BENEFICIAL TO THE
BLADDER AND PELVIC FLOOR?
MENOPAUSAL STATUS . PREMENOPAUSAL .
MENOPAUSAL - HRT
- NO HRT
TYPES OF HORMONE REPLACEMENT THERAPY . SYSTEMIC
OESTROGENS - (E) . COMBINED OSTROGEN/PROGESTERONE
- (E/P) . TIBOLONE (LIVIAL) (TIB) . VAGINAL
OESTROGENS (VAG E)
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IS HORMONE REPLACEMENT THERAPY BENEFICIAL TO THE
BLADDER AND PELVIC FLOOR?
RESULTS (1)
592 WOMEN MEDIAN AGE 57 . PREMENOPAUSAL 182
WOMEN (31) . MENOPAUSAL - 410 WOMEN
(69)

MENOPAUSAL WOMEN 410 PATIENTS . NO HRT 291
WOMEN . HRT 119 WOMEN E (61)
- E/P (35)
- TIB (13)
- VAG
E (10)
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IS HORMONE REPLACEMENT THERAPY BENEFICIAL TO THE
BLADDER AND PELVIC FLOOR?
RESULTS (2) UTERINE PROLAPSE
MENOPAUSAL WOMEN NOT TAKING HRT COMPARED TO
THOSE WOMEN TAKING HRT

1 (OVERALL) UTERINE PROLAPSE 1.4x PREVALENCE (p
0.063) 2 RETROVERTED UTERINE PROLAPSE 2.4x
PREVALENCE (p lt 0.001) 3 ANTEVERTED UTERINE
PROLAPSE NO INCREASED PREVALENCE (p 0.837)
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Prevalence of uterine prolapse in Retroverted and
Anteverted uterus in HRT vs Non HRT
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IS HORMONE REPLACEMENT THERAPY BENEFICIAL TO THE
BLADDER AND PELVIC FLOOR?
RESULTS (2) VAGINAL PROLAPSE
MENOPAUSAL WOMEN TAKING HRT COMPARED TO THOSE
WOMEN NOT TAKING HRT

1 (OVERALL) VAGINAL PROLAPSE 1.13 x PREVALENCE
(p 0.077) 2 VAGINAL PROLAPSE WOMEN ON E -
ONLY HRT(p lt 0.001) FIRST STUDY TO HIGHLIGHT
THIS ASSOCIATION
75
IS HORMONE REPLACEMENT THERAPY BENEFICIAL TO THE
BLADDER AND PELVIC FLOOR?
RESULTS (3) SUI/ OTHER LUTS
MENOPAUSAL WOMEN TAKING HRT COMPARED TO THOSE
WOMEN NOT TAKING HRT

1 STRESS URINARY INCONTINENCE (SYMPTOM) 1.33 x
PREVALENCE (p 0.005) AGREES WITH FINDINGS (JAMA
2005) 2 OTHER LOWER URINARY TRACT SYMPTOMS NO
SIGNIFICANT RELATIONSHIP BETWEEN THEIR PREVALENCE
AND HRT USAGE.
76
IS HORMONE REPLACEMENT THERAPY BENEFICIAL TO THE
BLADDER AND PELVIC FLOOR?
RESULTS (4) URODYNAMIC SI
MENOPAUSAL WOMEN TAKING HRT COMPARED TO THOSE
WOMEN NOT TAKING HRT

1 (OVERALL) URODYNAMIC SI (DIAGNOSIS) 1.11 x
PREVALENCE (p 0.112) NS 2 URODYNAMIC SI
WOMEN gt 62 YEARS 1.78 PREVALENCE (p 0.005)
FIRST STUDY TO HIGHLIGHT THIS ASSOCIATION E/P USE
MAIN ASSOCIATION OF THE FINDING
77
IS HORMONE REPLACEMENT THERAPY BENEFICIAL TO THE
BLADDER AND PELVIC FLOOR?
RESULTS (5)OTHER URODYNAMIC Dx
MENOPAUSAL WOMEN TAKING HRT COMPARED TO THOSE
WOMEN NOT TAKING HRT

NO SIGNIFICANT RELATIONSHIP BETWEEN HRT AND OTHER
URODYNAMIC DIAGNOSES . OVERACTIVE BLADDER .
VOIDING DIFFICULTY . RECURRENT UTI
78
IS HRT BENEFICIAL TO THE BLADDER AND PELVIC
FLOOR- CONCLUSIONS.

• 1 NO HRT-USE
• . Significantly increased prevalence of prolapse
  of retroverted uterus
• (No increased prevalence of prolapse of an
  anteverted uterus)
• 2 E-ONLY HRT-USE
• . Significantly increased prevalence of vaginal
  prolapse

79
IS HRT BENEFICIAL TO THE BLADDER AND PELVIC
FLOOR- CONCLUSIONS?

• 3 POSTMENOPAUSAL HRT-USE
• . Increased symptom of stress incontinence
• . Significantly increased prevalence of the
  diagnosis of
• USI in women aged over 62 years 1st study to
  show this
• 4 HRT EFFECT ON VOIDING DIFFICULTY, OAB,
• RECURRENT UTI Nil Significant

80
SECTION 4
1 URINARY INCONTINENCE PROLAPSE MANAGEMENT
IN GENERAL PRACTICE.
2 IS THE RETROVERTED UTERUS A POSSIBLE RISK
FACTOR TO THE PELVIC FLOOR ?
3 IS HRT BENEFICIAL TO THE BLADDER AND PELVIC
FLOOR?
4 CONCLUSIONS TAKE AWAY TIPS.
81
SECTION 1
1 URINARY INCONTINENCE PROLAPSE MANAGEMENT
IN GENERAL PRACTICE.
82
URINARY INCONTINENCE PROLAPSE MANAGEMENT IN
GENERAL PRACTICE - CONCLUSIONS

• 1 Four Main Conditions Urodynamic stress
• Incontinence, overactive bladder, uterovaginal
• Prolapse, voiding difficulty.
• 2 Initial Assessment History, examination, MSU
• Bladder chart.
• 3 Clinical signs more specific than symptoms
• 4 General measures try as appropriate
• 5 Urodynamics often needed for accurate
  diagnosis

83
URINARY INCONTINENCE PROLAPSE MANAGEMENT IN
GENERAL PRACTICE - CONCLUSIONS

• 6 Physio for USI Best for mild/moderate
  severity
• 7 Surgery for USI Tapes e.g TVT generally
  indicated
• 8 Behavioural Rx for OAB if mild/moderate
  severity
• 9 Drug Rx for OAB Side-effects limit compliance
• 10 Surgery for prolapse Vaginal approach still
  OK
• 11 Mesh for prolapse Increasing use with
  recurrences
• 12 Voiding Difficulty Antiseptics (UTI
  Prophylaxis) a good complement to any other
  specific Rx

84
SECTION 2
2IS THE RETROVERTED UTERUS A PROBABLE RISK
FACTOR TO THE PELVIC FLOOR ?
85
IS UTERINE RETROVERSION A RISK FACTOR FOR THE
PELVIC FLOOR- CONCLUSIONS?

• 1 Prevalence of retroverted uterus 79 greater
  in urogynaecological than general gynaecological
  patients
• 2Uterine retroversions main association is with
  a significant increase in the prevalence of
  uterine prolapse (4.5x) and higher grade
  cystocoele, all grades of enterocoele over that
  with an anteverted uterus.

86
IS UTERINE RETROVERSION A RISK FACTOR FOR THE
PELVIC FLOOR- CONCLUSIONS?

• 3Uterine Retroversion does not appear to be
  associated with an increase in other urodynamic
  diagnoses compared with that found with either an
  anteverted or absent uterus.
• 4 Likely mechanism- Axis of retroverted uterus
  is similar to vaginal axis. Pulsion forces in an
  axial vaginal direction causes the prolapse
• - Pulsion forces on the anteverted uterus
  directs it towards the rectum (less likely to
  prolapse)

87
SECTION 3
3 IS HRT BENEFICIAL TO THE BLADDER AND PELVIC
FLOOR?
88
IS HRT BENEFICIAL TO THE BLADDER AND PELVIC
FLOOR- CONCLUSIONS.

• 1 NO HRT-USE
• . Significantly increased prevalence of prolapse
  of retroverted uterus
• (No increased prevalence of prolapse of an
  anteverted uterus)
• 2 E-ONLY HRT-USE
• . Significantly increased prevalence of vaginal
  prolapse

89
IS HRT BENEFICIAL TO THE BLADDER AND PELVIC
FLOOR- CONCLUSIONS?

• 3 POSTMENOPAUSAL HRT-USE
• . Increased symptom of stress incontinence
• . Significantly increased prevalence of the
  diagnosis of
• USI in women aged over 62 years 1st study to
  show this
• 4 NO SIGNIFICANT EFFECT OF HRT ON VOIDING
  DIFFICULTY, OAB, RECURRENT UTI

90
UPDATE IN UROGYNAECOLOGY

• RHW/ AUST DOCTOR HORMONE WOMENS HEALTH DAY
  2006
• Bernard T. Haylen
• St. Vincents Clinic, Mater
  Randwick Urodynamic Centres, Sydney.
• www.bladder.com.au