UROGYNECOLOGY FOR THE FAMILY PRACTIONER UPDATES PELVIC FLOOR

UROGYNECOLOGY FOR THE FAMILY PRACTIONER: UPDATES PELVIC FLOOR DISORDERS Meadow M. Good, DO, FACOG Chief, Female Pelvic Medicine & Reconstructive Surgery University of Florida Health Jacksonville

DISCLOSURES § None

OBJECTIVES § Perform patient history, exam, & office evaluation for pelvic floor disorders § Understand treatment options of pelvic floor disorders § Describe strategies for prevention pelvic floor disorders § Refer to Urogynecologist, aka Female Pelvic Medicine & Reconstructive Surgery Specialist (FPMRS) when appropriate

DOES SHE HAVE A PELVIC FLOOR DISORDER (PFD)? § More than 50 percent of women ≧ 55 yo suffer one or more of the problems caused by pelvic floor disorders § One in three women (30 %) with overactive bladder or urinary incontinence also suffer from bowel control issues

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DOES YOUR PATIENT HAVE A PELVIC FLOOR DISORDER? 3 types: § Bladder Control/Urinary Incontinence (UI) § Overactive bladder § Urge urinary incontinence § Stress urinary incontinence § Pelvic Organ Prolapse (POP) § Bowel Control § Constipation § Accidental bowel leakage § Fecal Incontinence (FI) § Incontinence of Gas

OFFICE EVALUATION: HISTORY Bladder Control § Overactive Bladder § Urgency, Frequency of urination § Nocturia § ± Leaking urine § Urinary Incontinence § Leaking urine with the Urge § Leaking with Stress § Cough, sneeze, exercise § Mixed § Voiding Dysfunction § Push to void § Slow stream § Urinary Retention

OFFICE EVALUATION: HISTORY Pelvic Organ Prolapse 1 § Vaginal bulging 2 § Pelvic heaviness § Incomplete emptying bladder/bowel § Splinting § Discomfort during sex § § Urinary frequency Urinary urgency Urinary incontinence Obstructive voiding/ straining to void § Urinary retention § Recurrent UTI *Most patients – no symptoms until prolapse beyond hymen 3 1 Culligan PJ. Obstet Gynecol 2012 MD. Clin Obstet Gynecol 2005 3 Swift SE. Am J Obstet Gynecol 2003 2 Barber

OFFICE EVALUATION: HISTORY Bowel Control § Anal Incontinence § Flatus, Liquid stool, Solid stool § Rectal prolapse

OFFICE EVALUATION: HISTORY Other Urogynecologic Disorders § Recurrent Urinary Tract Infections § Hematuria § Gross § Microscopic (≥ 3 RBCs on formal UA) § Urethral masses/ Diverticulum § Genitourinary Fistulas

OFFICE EVALUATION: HISTORY Pelvic Organ Prolapse and Urinary/Fecal Incontinence § § § Degree of bother! Duration, frequency, provoking/relieving factors Impact on lifestyle & sexual function Severity of symptoms Previous treatments 1 Brown J. Urology 2003 PJ. Obstet Gynecol 2012 2 Culligan

OFFICE EVALUATION: GENERAL EXAM General Health Neurological Exam § Nutritional status § Obesity § Physical dexterity Mental Status § Masses § Bladder distension § Surgical scars § Cognitive ability Functional Status Abdominal Exam § Mobility Wieslander CK. Obstet Gynecol Clin N Am 2009

OFFICE EVALUATION: PELVIC EXAM-TAKE A LOOK Inspection Cough Stress Test § Vulvovaginal Atrophy § Suburethral mass n Standing, supine n Prolapse reduction

OFFICE EVALUATION – PELVIC EXAM Pelvic Organ Prolapse Quantification (POP-Q) § Genital Hiatus § Rest/Straining § Perineal Body § Total Vaginal Length Genital Hiatus (GH) Perineal Body (PB)

OFFICE EVALUATION: PELVIC EXAM Pelvic Organ Prolapse Quantification (POP-Q) § Isolate and evaluate each compartment § Bivalve speculum for apical compartment § Half speculum for anterior and posterior compartments § Hymen is an important landmark 1 Anterior (Aa, Ba) Apex (C, D) Posterior (Ap, Bp) 1 Swift SE. Am J Obstet Gynecol 2003

OFFICE EVALUATION: PELVIC EXAM POP-Q Staging STAGE DEFINITION 0 No prolapse 1 The most distal portion of the prolapse is >1 cm above the level of the hymen 2 The most distal portion of the prolapse is <1 cm proximal or distal to the hymen 3 The most distal portion of the prolapse is >1 cm below the hymen but protrudes no further than 2 cm less than the total vagina length 4 Complete eversion of the total length of the vagina. The distal portion protrudes at least the total vaginal length minus 2 cm beyond the hymen Adapted & Modified from: Jelovsek SE. Lancet 2007 0 1 2 3 4 1 Swift 3. 8%1 44. 9% 48. 4% 2. 9% <1% SE. Am J Obstet Gynecol 2003

OFFICE EVALUATION – PELVIC EXAM POP-Q Staging § Hymen is an important landmark 1 Stage 2 Stage 4 Stage 3 1 Swift SE. Am J Obstet Gynecol 2003

OFFICE EVALUATION – PELVIC EXAM Indications for Urgent Treatment/Referral 1 § Obstructed urination § Urethral or ureteral obstruction § Hydronephrosis, hydroureter § Obstructed defecation § Non-resolving vaginal erosions 1 Jelovsek SE. Lancet 2007

OFFICE EVALUATION: OTHER TESTS § Urinalysis § Urine culture § Post-Void Residual (PVR) § ≤ 100 – 200 m. L § Cystometrics/Urodynamics § Simple/Multichannel § Imaging Upper Urinary Tract § *Indicated when treatment of prolapse beyond the hymen is observation only 1 § Renal Sonogram/CT Urogram 1 Abrams P. Neurourol Urod 2010

TREATMENT: PFD § No treatment needed if patient not bothered and can empty bladder and bowels § Expectant Management / Reassurance § May stay the same, get better, or worse § Estrogen §Increases urogenital health but not a treatment §Vagina, Urethra, Bladder trigone with Estrogen receptors §Prevent/treat pessary erosions (local>systemic) and enhances success of initial fitting 4 1 Gilchrist 2 Bradley 3 Handa AS. Neurourol Urod 2013 CS. Obstet Gynecol 2007 VL. Am J Obstet Gynecol 2004 LA. Int Urogynecol J 2011 4 Hanson

TREATMENT: UI & POP Pelvic Floor Muscle Therapy § RCTs demonstrate anatomic and symptomatic improvement for mild to moderate prolapse (stages I-III)1 -3 § Anatomic prolapse stage improvement § 19% treatment vs 8% no treatment (p = 0. 035)3 § ATLAS RCT showed 50% much better after 3 months behavioral training (PFPT) = pessary = combined therapy § 75% reduction in UI episodes after 3 months § At 12 months, ~30% much better § ? Long term benefits § Poor compliance over time 4 1 Hagen S. Int Urogynecol J 2009 L. Int J Urogynecol 2011 3 Braekken IH. Am J Obstet Gynecol 2010 4 Bo K. Obstet Gynecol 2005 2 Stupp

PELVIC FLOOR EXERCISES: KEGELS Recommend KEGELS to ALL women

TREATMENT: POP & SUI Pessary– first line treatment Support § Needs introital support § Ring § Incontinence dish Space-filling § Self-retaining § Gellhorn § Cube § Improvement in SUI & bulge symptoms—also improve OAB sx if prolapse present § Improved sexual satisfaction and body image 1 § Success rates 63% - 86%2 § Ring/Gellhorn equally effective 3 1 Lamers BHC. Int Urogynecol J 2011 SA. Urol Nurs 2012 3 Cundiff GW. Am J Obstet Gynecol 2007 2 Atnip

TREATMENT: OAB OR UUI § Check for UTI before treatment! § Lifestyle & Behavior: § § § Diet! Bowel regulation Pelvic Floor Muscle Exercises/ PT Bladder Retraining & Urge Suppression Panti-liners, Pads, Briefs, and Diapers 1 Atnip SA. Urol Nurs 2012 MJ. Int Urogynecol J 2004 2 Donnelly

TREATMENT: OAB & UUI § Anticholinergics § All equally effective § 13% resolution in UUI in ABC trial § ~70% report adequate control of symptoms at 6 months § XL formulation with less side effects § Shown to eliminate 2 UUI episodes per day § Contraindicated in untreated narrow angle glaucoma § Risk increase in dementia § >3 years of use associated to 54% increase in memory loss/dementia 1 Atnip SA. Urol Nurs 2012 MJ. Int Urogynecol J 2004 2 Donnelly

UUI TREATMENT: MEDICATIONS § Anticholinergics § Oxybutinin (Ditropan) § M 1, M 2, M 3 antagonist, local analgesic, myotrophic relaxation § Tolteridine (Detrol) § M 2 & M 3 antagonist § Solifenacin (Vesicare) § M 3 antagonist § Darifenacin (Enablex) § Selective M 3 antagonist § Fesoterodine (Toviaz): § Converts to metabolite to decrease SE § Trospium (Sanctura) § M 1, M 2, M 3 antagonist § Quaternary Amine § Does not Cross BBB

ANTICHOLINERGIC MED POSSIBLE SIDE EFFECTS § Anticholinergics § Constipation § Dry Eyes § Dry Mouth § Urinary Retention § Stomach Pain § Cognitive Effects

UUI TREATMENT: MEDICATIONS § Other Meds § Mirabegron (Myrbetriq) § § Selective B 3 agonist Relaxes bladder muscle Side effect cardiac, increase in BP Contraindicated in uncontrolled HTN § Imipramine (Tofranil) § Tricyclic antidepressant with α-adreneric and anticholinergic properties § Central acting

UUI TREATMENT § Botox injection of Detrusor Muscle § 100 Units for OAB/UUI § 60 -90% of patients have clinical response § 27% are continent at 6 months § Duration is variable (3 -12 months) § SE: urinary retention (~5%) and 33% UTI

OAB/UUI TREATMENT: POSTERIOR TIBIAL NERVE STIMULATION Tried 2 or more OAB medications or cannot use medications § In office, 30 minute sessions § Weekly x 12 weeks § Then as needed § Improvement 60 -80% § Can be used with medications

UUI SURGIAL TREATMENT: SACRAL NEUROMODULATION Sacral Neuromodulation § Refractory urge incontinence § Fecal incontinence § Surgically implanted device § Leads in S 3 foramina § Improvement 60 -75% Cure 45%

TREATMENT: SUI First-line treatments § Pelvic floor muscle exercises (Kegels) § Pelvic floor physical therapy § Incontinence Pessary

TREATMENT: SUI Surgery – SUI § Midurethral Sling § TVT or TOT § >90% Effective at 10 years § Urethral Bulking § >60% success § Burch § 70% Success at 14 years § Pubovaginal Sling § >60% success

SUI: SURGICAL TREATMENT PERIURETHRAL BULKING § Can be done in clinic § SUI who do not want mesh or surgery in OR § SUI associated with ISD § Poor surgical candidates § A number of materials are available § 60 -70% improvement § May need more than 1 injection

TREATMENT: POP § Surgery § Vaginal § Transvaginal hysterectomy with vaginal vault suspension, native tissue repair (anterior/posterior repair) § 60 -80% overall success § Abdominal (laparoscopic or robotic) § Sacrocolpopexy with mesh graft augmentation § >95% success (no reoperation) at 10 years

TREATMENT: POP & SUI Pessary or Surgery? Pessary § First-line treatment § Older age § Pregnant § Planning pregnancy § Inability to comply with post-operative restrictions § Career/family priorities § Medical comorbidities increase operative risks § Do not desire surgery Surgery § Higher prolapse stage § Prior prolapse or incontinence surgery § More bothersome prolapse or SUI symptoms § Sexually active Culligan PJ. Obstet Gynecol 2012 Heit M. Obstet Gynecol 2003 Atnip SA. Urol Nurs 2012 Arias BE. Int Urogynecol J 2008 Kapoor DS. Int Urogynecol J 2009

WHAT IS GOING ON WITH THE MESH MESS? § Transvaginal mesh kits § Prolapse repair technique § Has been associated with increase in pain, erosion, infection in some women § Not recommended in primary prolapse repairs § Undergoing research in PFDN

WHAT ABOUT PATIENTS WITH MESH IN THE VAGINA? § Transvaginal mesh kits § Should have yearly vaginal exam § No need for referral to Urogyn for having mesh per say; most follow their patients yearly § Refer to Urogyn if has complaints of vaginal pain, vaginal bleeding, discharge or dyspareunia § Midurethral slings and Sacrocolpopexy with mesh § Gold standard procedures § Estrogen vaginal cream

PFD PREVENTION Risk Factor Modification §Limited Data §Lifestyle Changes/Reduce Modifiable Risk Factors § Weight Loss § Avoid repetitive strain § Treat constipation § Optimize asthma/smoking cessation § Avoid heavy lifting occupations § Pelvic floor muscle exercises (Kegels) 1 Jelovsek SE. Lancet 2007

WHO TO REFER § Pelvic organ or Vaginal Prolapse § Stress Incontinence § Urge Incontinence § After titrating up one medication and still bothered § Accidental Bowel Leakage § Recurrent UTI § Microscopic Hematuria on UA or Gross Hematuria

THANK YOU

REFERENCES § § § § Abrams P, Andersson KE, Birder L, et al. Fourth international consultation on incontinence recommendations of the international scientific committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urod 2010; 29: 213 -40. Arias BE, Ridgeway B, Barber MD. Complications of neglected vaginal pessaries: case presentation and literature reviews. Int Urogynecol J 2008; 19: 1173 -8. Atnip SA, O’Dell K. Vaginal support pessaries: indications for use and fitting strategies. Urol Nurs 2012; 32: 114 -24. Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA 2014; 311: 1023 -34. Barber MD. Symptoms and outcome measures of pelvic organ prolapse. Clin Obstet Gynecol 2005; 48: 648 -61. Bash KL. Review of vaginal pessaries. Obstet Gynecol Surv 2000; 55: 455– 60. Bo K, Kvarstein NI. Lower urinary tract symptoms and pelvic floor muscle exercises after 15 years. Obstet Gynecol 2005; 105: 999– 1005. Braekken IH, Majida M, Engh ME, et al. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? an assessor-blinded, randomized controlled trial. Am J Obstet Gynecol 2010; 203: 170. e 1– 7. Bradley CS, Zimmerman MB, Qi Y, et al. Natural history of pelvic organ prolapse in postmenopausal women. Obstet Gynecol 2007; 109: 848 -54. Brown J, Mc. Naughton, K, Wyman J, et al. Measurement characteristics of a voiding diary for use by men and women with overactive bladder. Urology 2003; 61: 802 -9. Bump RC, Mattiason A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175: 10– 17. Cogan SL, Weber AM, Hammel JP. Is Urethral Mobility Really Being Assessed by the Pelvic Organ Prolapse Quantification (POP-Q) System? Obstet Gynecol 2002; 99: 473– 6. Clemons JL, Aguilar VC, Sokol ER, et al. Patient characteristics that are associated with continued pessary use versus surgery after 1 year. Am J Obstet Gynecol 2004; 191: 159– 64. Clemons JL, Aguilar VC, Tillinghast TA, et al. Risk factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse. Am J Obstet Gynecol 2004; 190: 345– 50. Clemons JL, Aguilar VC, Tillinghast TA, et al. Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse. Am J Obstet Gynecol 2004; 190: 1025– 9.

REFERENCES § § § § Culligan PJ. Nonsurgical management of pelvic organ prolapse. Obstet Gynecol 2012; 119: 852 -60. Cundiff GW. Amundsen CL. Bent AE, et al. The PESSRI study: symptom relief outcomes of a randomized crossover trial of the ring and gellhorn pessaries. Am J Obstet Gynecol 2007; 196: 405. e 1– 8. Donnelly MJ, Powell-Morgan S, Olsen A, et al. Vaginal pessaries for the management of stress and mixed urinary incontinence in women. Int Urogynecol J 2004; 15: 302– 7. Fernando RJ, Thakar R, Sultan AH, et al. Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse. Obstet Gynecol 2006; 108: 93– 9. Friedman S, Sandhu S, Wang C, et al. Factors influencing long-term pessary use. Int Urogynecol J 2010; 21: 673– 8. Gilchrist AS, Campbell W, Steele H, et al. Outcomes of observation as therapy for pelvic organ prolapse: a study in the natural history of pelvic organ prolapse. Neurourol Urod 2013; 32: 383 -6. Ghroubi S, Kharrat O, Chaari M, et al. Effect of conservative treatment in the management of low-degree urogenital prolapse [in French]. Ann Readapt Med Phys 2008; 51: 96 – 102. Hagen S, Stark D, Glazener C, et al. A randomized controlled trial of pelvic floor muscle training for stages I and II pelvic organ prolapse. Int Urogynecol J 2009; 20: 45– 51. Handa VL, Garrett E, Hendrix S, et al. Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol 2004; 190: 27 -32. Hanson LA, Schulz JA, Flood CG, et al. Vaginal pessaries in managing women with pelvic organ prolapse and urinary incontinence: patient characteristics and factors contributing to success. Int Urogynecol J 2006; 17: 155– 159. Heit M, Rosenquist C, Culligan P, et al. Predicting treatment choice for patients with pelvic organ prolapse. Obstet Gynecol 2003; 101: 1279– 84. Hendrix SL, Clark A, Nygaard I, et al. Pelvic organ prolapse in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol 1996; 186: 1160 -6. Kapoor DS, Thakar R, Sultan AH, et al (2009) Conservative versus surgical management of prolapse: what dictates patient choice? Int Urogynecol J 2009; 10: 1157– 61

REFERENCES § § § § § Karp DR, Peterson TV, Jean-Michel M, et al. "Eyeball" POP-Q examination: shortcut or valid assessment tool? Int Urogynecol J 2010; 21: 1005 -9. Komesu YM, Rogers RG, Rode MA, et al. Pelvic floor symptom changes in pessary users. Am J Obstet Gynecol 2007; 197(620): e 1– 6. Lamers, BHC, Broekman, BMW, Milani, AL. Pessary treatment for pelvic organ prolapse and health-related quality of life: a review. Int Urogynecol J 2011; 22: 637 -44. Laycock J, Whelan M, Dumoulin C. Patient assessment. Chapter 7. In: Haslam J, Laycock J, editors. Therapeutic management of incontinence and pelvic pain, 2 nd edition. London: Springer-Verlag; 2008. p. 62. Lukasz ES, Lawrence JM, Contreras R, et al. Parity, mode of delivery, and pelvic floor disorders. Obstet Gynecol 2006; 107: 1253 -60. Maito JM, Quam ZA, Craig E, et al. Predictors of successful pessary fitting and continued use in a nurse-midwifery pessary clinic. J Midwifery Womens Health 2006; 51: 78– 84. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford family planning association study. BJOG 1997; 104: 579 -85. Moalli P, Jones I, Meyn LA, et al. Risk factors associated with pelvic floor disorders in women undergoing surgical repair. Obstet Gynecol 2003; 101: 869 -74. Mutone MF, Terry C, Hale DS, et al. Factors which influence the short-term success of pessary management of pelvic organ prolapse. Am J Obstet Gynecol 2005; 193: 89– 94. Pott-Grinstein E, Newcomber JR. Gynecologists’ pattern of prescribing pessaries. J Reprod Med 2001; 46: 205– 8. Sarma S, Ying T, Moore KH. Long-term vaginal ring pessary use: discontinuation rates and adverse events. BJOG 2009; 116: 1715– 21. Stupp L, Resende AP, Oliveira E, et al. Pelvic floor muscle training for treatment of pelvic organ prolapse: an assessor-blinded randomized controlled trial. Int J Urogynecol 2011; 22: 1233– 9. Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol 2003; 189: 372 -7. Ternent CA, Bastawrous AL, Morin NA, et al. Standards Practice Task Force of The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2007; 50: 2013 -22. Vierhout ME. The use of pessaries in vaginal prolapse. Eur J Obstet Gynecol Reprod Biol 2004; 117: 4– 9. Wieslander CK. Clinical approach and office evaluation of the patient with pelvic floor dysfunction. Obstet Gynecol Clin N Am 2009; 36: 445 -62. Wu V, Farrell SA, Baskett TF, et al. A simplified protocol for pessary management. Obstet Gynecol 1997; 90: 990– 4