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Nonsurgical Therapies for Women with Pelvic Floor Disorders Raymond T. Foster, Sr., M.D., M.S., M.H.Sc. Assistant Professor of Obstetrics and Gynecology.

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Presentation on theme: "Nonsurgical Therapies for Women with Pelvic Floor Disorders Raymond T. Foster, Sr., M.D., M.S., M.H.Sc. Assistant Professor of Obstetrics and Gynecology."— Presentation transcript:

1 Nonsurgical Therapies for Women with Pelvic Floor Disorders Raymond T. Foster, Sr., M.D., M.S., M.H.Sc. Assistant Professor of Obstetrics and Gynecology Director, Missouri Center for Female Continence and Advanced Pelvic Surgery University of Missouri School of Medicine Columbia, Missouri

2 Topics for Discussion  Why not surgery?  Obstructed defecation  Pelvic organ prolapse  Overactive bladder  Urge incontinence  Urgency/frequency  Nocturia  Stress incontinence  Levator spasm  Case Presentations

3 Why not surgery? Shull, BL et al., A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments, Am J Obstet Gynecol, 183: 1365-73, 2000 Bleeding Shull et al reported their experience with 302 patients undergoing transvaginal surgery, including USVS Mean EBL: 243mL 1% rate of blood transfusion

4 Why not surgery? Bleeding SSLF is generally associated with a higher rate of bleeding complications (compared with other vaginal procedures for apical support) In one study of elderly women (≥80), hemorrhage was noted in 28% of 25 subjects The largest problem with bleeding during SSLF is the associated risk to the rectum and pudendal nerve during attempts to control bleeding Optimal strategy for bleeding control includes packing and vascular clips from the vaginal approach, with or without interventional radiology techniques Nieminen, E., and Heinonen, P.K., Sacrospinous ligament fixation for massive genital prolapse in women aged over 80 years, BJOG, 108: 817-821, 2001 Barksdale, P.A., et al., An anatomic approach to pelvic hemorrhage during sacrospinous ligament fixation of the vaginal vault, Obstet Gynecol, 91: 715-718, 1998

5 Why not surgery? Bleeding Obesity has been studied as a risk factor for hemorrhage Isik-Akbay et al., compared surgical complications in 189 obese patients undergoing TAH versus 180 obese women having a TVH Both groups had a 13% transfusion rate The authors concluded that obesity is a risk factor for hemorrhage during pelvic surgery, regardless of approach Isik-Akbay, E.F., et al., Hysterectomy in obese women: a comparison of abdominal and vaginal routes, Obstet Gynecol, 104: 710-714, 2004

6 Why not surgery? Bleeding Most MIS case series report a 1-3% rate of excessive bleeding Abouassaley et al. reported their experience with 241 midurethral sling procedures 2.5% intraoperative hemorrhage (16 patients) 1.9% developed a clinically significant pelvic hematoma Abouassaly, R., et al., Complications of tension-free vaginal tape surgery: a multi-institutional review, BJU Int, 94: 110-113, 2004

7 TVT video

8 Why not surgery? Injury to the Lower Urinary Tract 224 consecutive patients undergoing transvaginal, pelvic reconstructive/urogynecologic surgery 4% rate of otherwise unrecognized injury to the lower urinary tract Among 144 patients undergoing vaginal hysterectomy, 11 (7.6%) had injury to the lower urinary tract detected by cystoscopy Concurrent prolapse surgery was an independent risk factor for urinary tract injury

9 bladder video

10 Why not surgery? Graft material problems Infection DVT Nerve injury

11 Obstructed Defecation MechanicalFunctional Rectocele Perineal Rectocele Enterocele Rectal prolapse Neurologic disorder Pelvic floor dysenergia Levator spasm

12 Obstructed Defecation Prolapse Animation


14 Pelvic Floor Rehabilitative Therapy One recently published meta-analysis showed that pelvic floor rehabilitative therapy was superior to various other treatments (laxatives, placebo, sham training, and botox) (OR: 3.657; 95% CI: 2.127–6.290, P < 0.001) Enck P, Van Der Voort IR, and Klosterhalfen S; Biofeedback therapy in fecal incontinence and Constipation, Neurogastroenterol Motil (2009) 21, 1133–1141 22 patients with constipation related to pelvic floor dysenergia were enrolled in a prospective case series to undergo pelvic floor rehabilitative therapy. Symptom severity decreased after physical therapy (2.1±0.7 vs. 1.3±0.9, P=0.007). Quality of life also improved significantly (2.6±0.8 vs. 1.5±1.0, P=0.007). Lewicky-Gaupp C, Morgan DM, Chey WD, Muellerleile P, and Fenner DE; Successful Physical Therapy for Constipation Related to Puborectalis Dyssynergia Improves Symptom Severity and Quality of Life, Dis Col Rect (2008) 51, 1686-1691

15 Pelvic Organ Prolapse

16 BLS Interviews

17 Bladder Control in Women V B R PVPV PuPu P u > P v Continence P u ↓↓ Intrinsic Extrinsic P v ↑↑ P u ↓↓ and P v ↑↑ Stress Urge Mixed Myogenic Neurogenic Idiopathic

18 Bladder Control in Women ↑P u

19 Bladder Control in Women ↓P v

20 Behavior Modification Timed voiding Squeeze before you sneeze Quick flicks Fluid moderation in the evening Avoid bladder irritants Alcohol Caffeine Chocolate Bladder Control Therapy

21 Levator Spasm

22 Ethel 90 y/o G4P3 OAB complaints for 2 years Worsened symptoms with recent sacroplasty

23 Ethel Stress incontinence OAB symptoms worse at night Wears a depends diaper AND a large poise pad (this ensemble changed 5/day)

24 Ethel 4 UTI’s in the past year Drinks 3 glasses of water, 2 glasses of juice, 1 cup of coffee and 1 soda on an average day Uses Miralax daily and strains to have 1 or 2 BM’s per day 24 hour pad weight: 803g Bladder diary: 16 voids/24 hrs Nocturia X4

25 Ethel PMH: HTN, anemia, hernia, sinusitis, GERD, hypothyroidism, Raynaud’s syndrome, IBS-C PSH: sacroplasty, cholecystectomy, appendectomy, hysterectomy, and BSO

26 Ethel Diagnoses Rectocele (stage II) Defecatory dysfunction Urogenital atrophy Urgency/frequency Nocturia Urge incontinence Stress incontinence UTI Recurrent UTI’s

27 Ethel Treatment Plan Bowel regimen Premarin cream Treat UTI (fosfomycin) Prophylactic Abx for recurrent UTI (trimethoprim) Pelvic floor rehabilitative therapy Imipramine QHS

28 Ethel Clinical Outcome Patient reported 100% improvement after 5 sessions of pelvic floor therapy. She voids 7-8/day and 2/night. Her daytime incontinence completely resolved and she leaks only drops during the night. She wears a panty liner for peace of mind. She remains on Trimethoprim at bedtime. She remains on Imipramine QHS She takes Oxybutynin only occasionally when going out

29 Ethel Clinical Outcome cont. She continues with Premarin vaginal cream 1 x week She continues to do pelvic floor exercises 4 x day She takes Metamucil daily and reports 1-2 bowel movements per day without straining She just returned from a vacation with her family in which they drove over 500 miles in the car

30 Anne 70 y/o G2 P2002 c/o stress incontinence, urgency/frequency, urge incontinence and nocturia Symptoms bothersome over last 6-8 months

31 Anne On an average day she drinks 5-6 glasses of water, 1 glass of juice, 1 glass of milk, 2 cups of coffee, 1 glass of tea and 1 soda Her bladder diary indicates she voids 7 x in 24 hours Her 24 hour output averages 3400cc

32 Anne Completely healthy with no PMH/PSH 2 term vaginal deliveries with maximum birth weight of 8 lbs., 15 oz.

33 Anne Diagnoses Stage II cystocele Stage II rectocele Nocturia Urodynamic stress incontinence Urge incontinence Urogenital atrophy Defecatory dysfunction

34 Anne Treatment Bowel regimen to treat defecatory dysfunction Premarin vaginal cream for urogenital atrophy Moderate fluids, especially in the evening Pelvic floor therapy for urge and stress incontinence

35 Anne Clinical Outcome Patient reports 85% improvement in her symptoms after 6 sessions of pelvic floor therapy Her urge incontinence has resolved and she continues with mild stress incontinence 2-3 x month She continues on Premarin vaginal cream 1 x week for urogenital atrophy She continues with pelvic floor exercises and urge suppression techniqes daily She continues to moderate her caffeine intake

36 Anne Clinical Outcome cont. Anne was pleased with her results but her best friend’s bladder was limiting her (Anne’s) lifestyle. Her friend completed a course of pelvic floor therapy They have just returned from two weeks in Italy and reported complete bladder control and no anxiety about being on a tour bus all day

37 Questions

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