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Retha van Rensburg February 2011

Retha van Rensburg February 2011. Periurethral injection of Autologous Adipose-Derived Stem Cells with Controlled- Release Nerve Growth Factor for the treatment of Stress Urinary Incontinence in the Male rat Urethra. (S)VNL. PRESENTING PROBLEM. 44y female

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Retha van Rensburg February 2011

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  1. Retha van RensburgFebruary 2011 Periurethral injection of Autologous Adipose-Derived Stem Cells with Controlled- Release Nerve Growth Factor for the treatment of Stress Urinary Incontinence in the Male rat Urethra.

  2. (S)VNL

  3. PRESENTING PROBLEM • 44y female • Mother of 3 (girl 14y; twins 9y) • C/O leaking urine while playing tennis and running • Trampolining with the twins is impossible

  4. History Medical Surgical 2 x caesarean sections Repair ITB left • Pituitary adenoma

  5. Examination Further questioning: Urine leaks on coughing, sneezing, running and jumping No urge incontinence or any signs of overactive bladder Examination: Pelvic exam: urine loss with cough no signs of prolapse BMI = 25.4 (overweight)

  6. Bio-psycho-social model

  7. “THE SILENT EPIDEMIC” Urinary incontinence (UI) in the female

  8. Myths: • Urinary incontinence / prolapse is a natural part of aging • Nothing can be done about it • Surgery is the only solution

  9. Urinary incontinence • Defined as involuntary urinary leakage • May occur as a result of: • functional abnormalities of the lower urinary tract • other illnesses • These tend to cause leakage in different situations

  10. Types of UI

  11. Prevalence in women Stress : 49% Urge : 22% Mixed : 29%

  12. Genuine Stress Incontinence: • Loss of urine with increases in abdominal pressure • Caused by pelvic floor damage/weakness or weak sphincter(s) • Symptoms include loss of urine with cough, laugh, sneeze, running, lifting, walking

  13. Urge Incontinence: • Loss of urine due to an involuntary bladder spasm (contraction) • Complaints of urgency, frequency, inability to reach the toilet in time, up a lot at night to use the toilet • Multiple triggers

  14. Mixed Incontinence: • Combination of stress and urge incontinence • Common presentation of mixed symptoms • Urodynamics necessary to confirm

  15. Fecal Incontinence: • Approximately 10% women with urinary incontinence have incontinence of flatus or stool

  16. Spot the risk factors

  17. Spot the risk factors Associations and possible risk factors include: • age • obstetric factors such as pregnancy and parity • menopause and hysterectomy • lower urinary tract symptoms • family history and genetics • smoking, diet and obesity • cognitive or functional impairment

  18. Increased Intra-abdominal Pressure:(main risk for SUI) • Pulmonary disease • Constipation/straining • Lifting • Exercise • Ascites/hepatomegaly • Obesity

  19. Patient Evaluation: • History • Physical examination • Urinalysis • Urodynamic studies

  20. Patient History: • Focus on medical, neurologic, genitourinary history • Review voiding patterns/fluid intake • Voiding diary • Review medications (rx and non-rx) • Explore symptoms (duration, most bothersome, frequency, precipitants) • Assess mental status and mobility

  21. Thüroff. 2006 European Association of Urology

  22. Patient Evaluation: • History • Physical examination • Urinalysis • Urodynamic studies

  23. Physical Examination: • General examination • Edema, neurologic abnormalities, mobility, cognition, dexterity • Abdominal examination • Pelvic and rectal exam • Examination of back and lower limbs • Observe urine loss with cough

  24. Patient Evaluation: • History • Physical examination • Urinalysis • Urodynamic studies

  25. Patient Evaluation: • History • Physical examination • Urinalysis • Urodynamic studies

  26. Urodynamic studies • Expensive • Invasive • PVR (Postvoid Residual Volume) - if indicated • Symptoms of incomplete emptying • Longstanding diabetes mellitus • History of urinary retention • Failure of pharmacologic therapy • Pelvic floor prolapse • Previous incontinence surgery

  27. Management

  28. Manage conservatively

  29. Training and drugs Pelvic floor muscle training (alone and in combination with adjunctive therapies is effective - rates of 'cure' and 'cure/improvement' up to 73% and 97% respectively) Physiotherapy • Pelvic floor exercises • Eight contractions, three times a day, 3 months minimum Vaginal cones Devices for reinforcement Pessaries • Support devices to correct the prolapse • Pessaries to hold up the bladder Kegelcones. Weighted vaginal cones used to strengthen the pelvic floor musculature. Neumann. BMC Women's Health 2006, 6:11 and NICE guidelines

  30. Training and drugs • Bladder training (OAB) • 6 weeks minimum • Regular voiding by the clock • Gradual increase in time between voids • Double voiding • Antimuscarinic drugs • Immediate-release oxybutynin as first choice Offer support and advice for side effects

  31. Treatment: Non-surgical Fluid management • Avoid caffeine and alcohol • Avoid drinking a lot of fluids in the evening Reduce caffeine, alcohol, and smoking

  32. Surgical management

  33. Surgical management If conservative treatments have failed for: • stress UI offer • - retropubic mid-urethral procedures • alternatively colposuspension or rectus fascial sling • overactive bladder with or without urge UI offer - sacral nerve stimulation

  34. Surgery: For stress incontinence Bladder neck elevation • Burch repair • Marshall-marchetti-krantz repair • Sling • Needle suspension • Injections • Tension free vaginal tape (TVT)

  35. Refer??

  36. Refer?? • Uncertain diagnosis / unclear treatment plan • Unsuccessful therapy / patient requests further therapy • Surgical intervention considered / previous surgery failed • Hematuria without infection

  37. Refer?? (cont) • Existence of other co-morbid conditions • Recurrent symptomatic UTI’s • Recurrent symptoms of difficult bladder emptying • Symptomatic pelvic prolapse • Suprapubic or pelvic pain • Neurologic conditions: MS; spinal cord lesions/ injury • Diabetes mellitus

  38. PrevalenceUI is common but hidden Estimated 4 million women over 40 years regularly incontinent in UK (NIICE guidelines)

  39. Prevalence • South Africa ? • USA : 17 million people Annual cost 55.8 Billion $ (2009) 14th On list - Beats AIDS and STD’s !!!

  40. UI in sport

  41. UI in sport Thyssen et al (2002) • 291 elite female athletes and dancers • 51.9% had experienced urine loss, • 43% while participating in their sport • and 42% during their daily life. • urine leakage was the highest in gymnastics (56%), ballet (43%) and aerobics (40%) respectively Vosloo. 2008

  42. UI in sport (cont) Nygaard et al (1994) • 144 nulliparous women (mean age of 19.9 years) • 28% experienced urine leakage while participating in sport. • Gymnastics, again, had the highest prevalence (67%), followed by basketball (66%), tennis (50%) and field hockey (42%). Golf was the safest option with no leakage reported. Vosloo. 2008

  43. UI in sport (cont) • Eliasson et al (2002) • stress urinary incontinence prevalence 35 elite Swedish trampolinists (12 –22 years of age) • a staggering 80% reported involuntary leakage during trampolining • Including all participants aged over 15 • duration of training and training frequency were significantly associated with incontinence • in most, leakage started after 1–4 years of training. Vosloo. 2008

  44. UI in recreational sport

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