2. SUMMARY & RECOMMENDATIONS for URINARY NCONTINENCE
Z . Ghanbari Professor- Urogynecologist Department of Female Pelvic Floor Medicine & Surgery Imam Khomeini Hospital

3. SUMMARY AND RECOMMENDATIONS
PRIOR TO INITIATING THERAPY
Determining the Classification of Urinary Incontinence type
Having a baseline assessment of symptoms (voiding diary, quality of life measures)
Addressing contributory factors such as medical conditions and medications
Indications for further evaluation or referral :
Sudden onset of incontinence
Associated abdominal/pelvic pain
Hematuria in the absence of infection
Suspected vesicovaginal fistula or urethral diverticulum
Advanced pelvic organ prolapse
Uncertainly in diagnosis
History of Pelvic Reconstructive Surgery or Pelvic Irradiation
Prsistently Elevated Postvoid Residual
Topical vaginal estrogen (Grade 2C)
In peri- or postmenopausal women with vaginal atrophy and either stress or urgency incontinence
داشتن یک سیستم ارزیابی

4. SUMMARY AND RECOMMENDATIONS
Initial treatment (stress, urgency, or mixed) :
Lifestyle modifications
Pelvic floor muscle exercises
Kegel (Grade 2A)
Bladder training
Most effective for women with urgency incontinence
Some women with stress incontinence only at higher bladder volumes (may also benefit)
Typically treat initially for six weeks before considering subsequent therapies

5. SUMMARY AND RECOMMENDATIONS (con.)
Urgency In.
Initial Treatment
Pharmacologic Therapy (urgency, urgency-predominant mixed urinary incontinence, or overactive bladder (OAB) with incontinence) :
Antimuscarinic is suggested (Grade 2B)
Mirabegron is considered as an option for women with an insufficient response to or who cannot tolerate antimuscarinic therapy
Women who fail initial and pharmacologic therapy require referral to a specialist to consider third-line options

6. SUMMARY AND RECOMMENDATIONS FOR Treatment (con.)
Overflow In.
specific to the etiology:
Bladder outlet obstruction (surgery)
Detrusor under activity (CIC)
Chronic urinary retention (CIC)
Mixed In.
Initial Treatment (lifestyle modification and pelvic floor muscle training)
Subsequent therapy should be focused first on alleviation of symptoms causing most degree of bother
Surgery should not be considered as a primary treatment for refractory urge incontinence
Special Populations 
Pregnant women
Cognitive impairment
Neurologic disease
درمان اولیه باید در تخفیف علایمی متمرکز گردد که باعث بیشترین آزار بیمار میشود
جراحی نباید به عنوان یک درمان اولیه برای ارج مقاوم به درمان دارد در نظر گرفته شود :mixed in.در

7. SUMMARY AND RECOMMENDATIONS FOR Treatment (con.)
SUI
If initial treatments described are not sufficient
Pessaries (Level B)
Pharmacologic therapy? (Not Recommended)
Surgery

8. SUMMARY and RECOMMENDATIONS Preoperative evaluation for a primary procedure
Basic office evaluation for a primary procedure ( Combination of History , Ph.exam and Urinary stress testing)
Assessment for Pelvic Organ Prolapse and/or Anal Incontinence (may alter surgical decision making)
Evaluation Medical and Voiding History
Urodynamics: not necessary for most women with Uncomplicated SUI (Level A)
Uncomplicated SUI:
Normal PVR (Level A)
Negative U/A (Level A)
Positive cough stress test (Level A)
Cough stress test (instantaneous leakage with cough →SUI, while delayed leakage → detrusor overactivity incontinence, especially if there is a large flow of leakage that is difficult for the patient to stop)
Stage 1&2 POP (No POP beyond the hymen)
Urodynamic testing is helpful (complicated SUI ) :
when the diagnosis of lower urinary tract dysfunction is unclear
when objective findings do not correlate with subjective symptoms
when a patient fails to improve with treatment, and when surgical treatment is planned

9. SUMMARY and RECOMMENDATIONS for surgical treatment of SUI
Surgical Treatment of SUI Is Best Avoided in Women who Plan Future Childbearing
Vaginal or Abdominal approach?
For most healthy women with SUI who desire surgical treatment and accept synthetic surgical materials, midurethral sling placement rather than Burch colposuspension or bladder neck sling is recommended(Grade 1B)
Procedures that are clearly less effective than midurethral slings are: anterior colporrhaphy (even with Kelly-Kennedy plication), transabdominal paravaginal repair, and transvaginal needle suspension

10. SUMMARY and RECOMMENDATIONS for surgical treatment of SUI (con)
For women with Recurrent/Persistent SUI who desire surgical treatment and are surgical candidates, procedure Midurethral Or Bladder Neck Sling rather than retropubic urethropexy (Burch colposuspension) is suggested (Grade 2C)
For women with SUI who are undergoing open Abdominal Sacrocolpopexy Retropubic Colposuspension rather than Midurethral Sling placement is suggested(Grade 2C)
For women undergoing retropubic colposuspension, Burch rather than Marshall-Marchetti-Krantz procedure is suggested (Grade 2B)
For women who decline or cannot tolerate surgery, but have failed conservative therapy ,Injection of Periurethral Bulking Agents is suggested (Grade 2C)

11. SUMMARY and RECOMMENDATIONS Midurethral Sling
Contraindications for TOT – TVT include current Pregnancy or Urinary Tract Infection. Plans for a future Pregnancy are a Relative Contraindication
Patients should be counseled about risks of adverse events for each type of sling
Antibiotic prophylaxis for surgical site infection for surgical procedures for treatment of pelvic organ prolapse or stress urinary incontinence that utilize surgical mesh is recommended (Grade 1A)
Use of local anesthesia with conscious sedation or regional anesthesia rather than general anesthesia for midurethral sling placement is suggested (Grade 2C) (General anesthesia may be used if it is strongly preferred by the patient or if it is required for a concomitant procedure)
For women planning midurethral sling surgery, A Full-length rather than Single Incision Sling (mini sling) is suggested (Grade 2B)

12. SUMMARY and RECOMMENDATIONS midurethral sling (con.)
TOT or TVT?
TOT & TVT appear to have comparable efficacy
Bladder perforation and Voiding dysfunction are more likely to occur in women who have undergone a TVT
Groin pain is associated almost exclusively with TOT slings
An increased risk of injury to retropubic structures in TVT (ie, due to prior surgery or a current hernia that may result in the presence of viscera or major vessels in the retropubic space)
Surgeons should be aware of the potential for serious complications, including bowel injury, vascular injury, and urinary tract fistula
Voiding dysfunction following sling placement may be treated initially with Bladder catheterization or urethral dilation *. Persistent symptoms may require sling release, which may result in recurrent SUI
Patient Request?
Surgeon Request?

13. SUMMARY and RECOMMENDATIONS Bladder Neck Slings
● Reserving Bladder Neck Slings for:
Contraindicated Midurethral Slings : urethral reconstruction (diverticulectomy or fistula repair)
Unsuccessful or Declined to have Synthetic Sling
Preoperative prophylactic antibiotics and thromboembolism prevention should be given to women undergoing bladder neck slings
Rectus fascia harvested from the patient (autologous graft) is the preferred non-mesh graft material
All women should undergo a standardized voiding trial after placement of a bladder neck sling
●Common complications of bladder neck slings:
Cystitis
urinary retention
voiding dysfunction

14. SUMMARY AND RECOMMENDATIONS for Urgency In.
Initial Treatment
Pharmacologic Therapy
third-line options
Pharmacologic Therapy
Antimuscarinic (Grade 2B)
Mirabegron

15. SUMMARY and RECOMMENDATIONS for surgical treatment of SUI
First Line: Midurethral –TOT or TVT (Grade 1B)
Recurrent/Persistent SUI: Midurethral Or Bladder Neck Sling
Sacrocolpopexy or Abdominal Surgery: Burch (Grade 2B)
Reserving Bladder Neck Slings for: urethral reconstruction - Unsuccessful or Declined to have Synthetic Sling
For women who decline or cannot tolerate surgery, but have failed conservative therapy : Injection of Periurethral Bulking Agents (Grade 2C)

16. Thanks for your attention

17. CASE 1
خانمی78 ساله با شکایت خروج توده از واژن مراجعه نموده ،همچنین اظهار می دارد برای تخلیه کامل ادراربایستی به جلو خم شود و گاهی توده را به داخل واژن ببرد اقدامات خود را به ترتیب بنویسید .

18. CASE 1 (con.) -1شرح حال دقیق شامل : شرح حال جنرال
شرح حال پلویک فلور(عملکرد ادراری ،روده ای ، سکس و عملکرد حمایت لگنی )
-2 معاینه جنرال وپلویک:
ارزیابی اورترا:
) منفی - با مثانه پر مثبت ESSTبا مثانه خالی ( تست سرفه با اصلاح پرولاپس
175 cc : PVR
معاینه پرولاپس :
رکتوسلStage 2آپیکال - Stage3
سیستوسل (سانترال ،عرضی و پاراواژینال با درگیری پاراواژینال راست ) - Stage4

19. CASE 1 (con.) -3 تستهای تشخیصی : نرمالU/C ,U/A
بررسی ارودینامیک با اصلاح پرولاپس

20. CASE 1 (con.) تشخیص : -4 5- درمان با توجه به داشتن همسر :
پرولاپس پیشرفته لگن
Urinary retention secondary to prolapse
Occult SUI
5- درمان
با توجه به داشتن همسر :
جراحی الف -
Midurethral Sling (TOT , TVT) و Uterosacral Ligament Suspension ، TVH-
Midurethral Sling (TOT , TVTلفورت و :Sex درصورت نداشتن همسر و عدم
ب – کنسرواتیو
پساری در صورت عدم تمایل بیمار به جراحی ویا داشتن مشکلات مدیکال مغایر بابیهوشی پیشنهاد میگردد

21. CASE 2
خانمی 75ساله با شکایت خروج توده از واژن، فریکونسی، بی اختیاری ادرار و ارجنسی مراجعه نموده است.
اقدامات شما پس از گرفتن شرح حال کامل ومعاینه جنرال به ترتیب چیست؟

22. CASE 2 (con.) معاینه پلویک: ارزیابی اورترا: معاینه پرولاپس :
تست سرفه با اصلاح پرولاپس: منفی
PVR :150 CC
معاینه پرولاپس :
رکتوسلstage2 آپیکال- stage3– سیستوسل (سانترال) stage3

23. CASE 2 (con.)
:FVC
در آن 14بار درروزکه 3 بار با بی اختیاری ادرار همراه بوده بار در شب.
: نرمالU/A
ارودینامیک:

24. CASE 2 (con.) تشخیص : 1- Detrusor over activity
2 - Urinary retention secondary to prolapse

25. CASE 2 (con.) :PLANE OAB Treatment
Bladder Training ,Antimuscarintherapy
به همراه پساری ، در صورت عدم تمایل به پساری
پس ازیک دوره درمان دارویی،جراحی پرولاپس

27. Thanks

29. SUMMARY and RECOMMENDATIONS for Postoperative urinary retention in women
Diagnosis of POUR is made by performing a retrograde voiding trial and obtaining an elevated postvoid residual volume (PVR) (more than 100 mL) via bladder catheterization or ultrasound
The retrograde voiding trial to the spontaneous voiding trial is preferred because the retrograde method is more predictive of need for continued catheterization in randomized trials
Causes of postoperative voiding dysfunction include :
bladder muscle dysfunction (eg, anesthesia, pain medications), urethral obstruction, and failure of pelvic floor relaxation. Urethral obstruction (such as with suburethral incontinence slings) or urethral perforation require surgical intervention. Dilation of the urethra following a synthetic sling placement has been associated with mesh erosions into the urethra and is not recommended
Symptoms associated with POUR include :
slow urine stream, straining to void, a feeling of incomplete bladder emptying, pelvic pressure or pain, need to immediately re-void, and position-dependent micturition. The clinician may palpate the bladder on exam
The diagnosis rarely requires urodynamic testing

30. SUMMARY and RECOMMENDATIONS for Postoperative urinary retention in women(con)
●Diagnostic evaluation includes examining the patient, treating reversible causes of dysfunction, and ruling out delayed complications. Patients may require bladder drainage with clean intermittent catheterization (CIC) or an indwelling catheter to prevent overdistention injury. Urodynamic testing is not typically used to evaluate patients in the immediate postoperative period but may be helpful in patients who present months from surgery
●Cystotomy, which can mimic voiding dysfunction, is differentiated from urinary retention by irrigating the bladder with 75 mL to 100 mL of sterile saline through a bladder catheter and then attempting to withdraw the same amount of fluid
●If the need for catheterization continues, CIC rather than an indwelling urethral or suprapubic catheter is suggested (Grade 2C
●Women who have undergone an incontinence procedure and have an “obstructed” urethra may still have a normal PVR. Urodynamic testing that includes pressure-flow studies and urethral pressure profiles is helpful in making the diagnosis. If voiding obstruction remains unrecognized, women can develop detrusor overactivity and new symptoms of urinary urgency, with or without incontinence
●Women with persistent postoperative voiding dysfunction undergo a repeat examination to assess for pelvic muscle spasm or pain, new prolapse, or urethral obstruction from a sling. Intervention depends on the cause. Women whose symptoms are inconsistent with their medical and surgical history undergo postoperative urodynamics
●Women who develop voiding symptoms months or years after surgery must be examined for pelvic organ prolapse, mesh erosion if applicable, and occult urethral obstruction
●Inadequate treatment of postoperative voiding dysfunction can result in acute overdistention injury, long-term bladder (detrusor) muscle hypertrophy, and overactive voiding symptoms