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Lower Urinary Tract & Sexual Function Following Pelvic Surgery. “The Vulnerable Pelvis”. Patricia A. Wallace M.D. Assistant Professor, UCIMC Female Pelvic Medicine & Reconstructive Surgery The Incontinence & Support Institute. Objectives. Definitions: Lower urinary tract symptoms (LUTS)

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lower urinary tract sexual function following pelvic surgery

Lower Urinary Tract & Sexual Function Following Pelvic Surgery

“The Vulnerable Pelvis”

Patricia A. Wallace M.D.Assistant Professor, UCIMC

Female Pelvic Medicine & Reconstructive Surgery

The Incontinence & Support Institute

objectives
Objectives
  • Definitions:
    • Lower urinary tract symptoms (LUTS)
    • Female sexual dysfunction
  • Prevalence of LUTS & sexual dysfunction in general population
  • Pelvic anatomy & vulnerable areas
objectives3
Objectives
  • Effects of pelvic surgery
    • General gyn surgery
    • Incontinence & prolapse surgery
    • Surgery for gyn malignancy
    • Surgery for colorectal disorders
  • Multidisciplinary approach to surgery & recovery
lower urinary tract symptoms luts
Lower Urinary Tract Symptoms(LUTS)
  • Symptom-subjective indicator of a change in condition as perceived by patient, caregiver, or partner and may lead to the person seeking health care
  • Storage symptoms
    • Urgency, frequency, nocturia, incontinence, abnormal bladder sensation
  • Voiding symptoms
    • Slow stream, hesitancy, split stream, intermittent stream
  • Post micturition symptoms
    • Postvoid fullness or dribbling
lower urinary tract symptoms luts5
Lower Urinary Tract Symptoms(LUTS)
  • Symptoms associated with prolapse
    • Vaginal bulge or pressure
  • Symptoms associated with intercourse
    • Dyspareunia, dryness, incontinence
  • Urinary tract & sexual pain symptoms
    • Pain in bladder, vulva, vagina, etc
lower urinary tract symptoms luts6
Lower Urinary Tract Symptoms(LUTS)
  • Frequency >8 voids/24 hrs
  • Urgency- strong desire to void
  • Nocturia > 1-2 /nt
  • Incontinence- (Symptom) Involuntary leakage of urine
    • Preceded by urgency-Urge
    • Associated w/increased abdominal pressure-Stress
  • DetrusorOveractivity- (Sign/Dx) involuntary detrusor contraction, spontaneous or provoked
    • Idiopathic detrusoroveractivity replaces detrusor instability
    • Neurogenicdetrusoroveractivity replaces detrusorhyperreflexia

The Standardization of Terminology of Lower Urinary Tract Function

International Continence Society; Neurourology and Urodynamics 2002

overactive bladder
Overactive Bladder
  • A collection of symptoms consisting of urgency, frequency, nocturia, with and without incontinence
  • No identifiable pathologic or metabolic condition to explain symptoms
overactive bladder urinary incontinence
Overactive Bladder & Urinary Incontinence
  • Approximately 15-17% of population have symptoms of OAB
  • Incidence increases with age
    • 38% of women > 65
    • 27% of women < 65
  • Incidence in institutionalized women > 80%
  • Associated with poor quality of life, depression
  • More common than osteoarthritis and diabetes
prevalence of luts
Prevalence of LUTS
  • 2863 postmenopausal women
  • HERS trial
  • Mean age 66.7 yrs
  • Baseline questionnaires
  • Prevalence
    • Stress incontinence sx- 13%
    • Urge incontinence sx-14%
    • Any incontinence sx- 28%
  • Urge incontinent women voided more frequently during day & night

Brown et al. Obstet Gynecol 1999

prevalence of luts10
Prevalence of LUTS
  • 4103 community dwelling women screened using validated questionnaires
  • Age 24-84 (mean 56.5)
  • Prevalence
    • Stress incontinence 15%
    • OAB 13%
    • POP 6%
    • Anal incontinence 25%
  • Co-occurrence of mixed sx 69-80%

Lawrence. Obstet Gynecol 2008

risk factor for luts
Risk Factor for LUTS
  • Pelvic floor disorders
    • Age
    • Race
    • Obesity
    • Smoking
    • Childbirth
  • Urge incontinence/OAB
    • Increased age
    • Menopausal status
    • Diabetes
    • Urinary tract infection
    • Prior pelvic surgery
  • Stress incontinence
    • Caucasian race
    • Increased BMI
    • Higher waist to hip ratio
    • Parity/mode of delivery
  • Prolapse
    • Parity
    • Mode of delivery
  • Brown. Obstet Gynecol 1999
  • Lawrence. Obstet Gynecol 2008
  • Lucacz. Obstet Gynecol 2006
  • Dooley Y et al. J Urol 2008
  • Fenner D et al. J Urol 2008
sexual function vs dysfunction
Sexual Function vs Dysfunction

Highly variable

Life cycle & age

Sexual response cycle in women

Personal distress caused by symptoms related to sexual response cycle

blended intimacy based sexual drive based cycles
BLENDED INTIMACY-BASED SEXUAL DRIVE-BASED CYCLES

Emotional Intimacy

Motivates the sexually neutral woman

Emotional & Physical Satisfaction

To find/ be responsive to

“Spontaneous

sexual drive

hunger”

Sexual Stimuli

Arousal & Sexual Desire

Psychological and biological factors govern “arousability”

Sexual Arousal

Basson R. Obstet Gynecol 2001; 98:350

prevalence of sexual dysfunction
Prevalence of Sexual Dysfunction

Affects 25%-43% of women 1

Multidimensional and multicausal combining biological, psychological, and interpersonal factors 1,2

Physically and emotionally distressing

Increases with age 1

1.Bancroft j. Arch Sex Behav. 2003; In Press

2. Laumann EO, et al. JAMA. 1999;281:537

risk factors for sexual dysfunction
Risk Factors for Sexual Dysfunction

Aging and menopause

Chronic medical conditions: DM, HTN, Depression, CAD

Pelvic surgery*

Neurological disorders: MS, epilepsy, paralysis

Endocrine disorders: Addisons disease, hypothyroidism

Medications: SSRIs, antihypertensives, steroids, statins, other psychotropics

Infection: STDs or condyloma

female sexual dysfunction
Female Sexual Dysfunction
  • Sexual desire disorders
    • Hypoactive sexual desire disorder
    • Sexual aversion disorder
  • Sexual arousal disorder
  • Orgasmic disorder
  • Sexual pain disorders
    • Dyspareunia
    • Vaginismus
    • Noncoital sexual pain disorder

*International Consensus Development Conference on Female Sexual Dysfunction.Basson R, et al. J Urol. 2000;163:888-93.

luts sexual dysfunction
LUTS & Sexual Dysfunction
  • 25-50% women with pelvic floor disorders
  • Most common
    • Decreased libido
    • Dyspareunia
    • Decreased orgasm
  • Urinary incontinence independently associated with worse sexual function

Handa. AJOG 2004

the vulnerable pelvis20
The Vulnerable Pelvis

Superior hypogastric plexus

Inferior hypogastric plexus

Pudendal nerve & sacral nerve roots

general gynecology
General Gynecology
  • El-Touky. J Obstet Gynecol 2004
  • Kluviers. J Minim Invasive Gynecol 2007
  • Gutl. J Psychosom Obstet Gynecol 2002
  • Kupperman et al. Obstet Gynecol 2005
  • Hysterectomy- any route
    • Mild improvement in LUTS 1,2
    • Improvement in sexual function 3
      • Postmenopausal status, severity of gynecologic complaints, & preop frequency predictors of sexual outcomes
      • Abdominal scar/pain short term impact
    • Supracervical & abdominal hysterectomy-similar outcomes 4
oophorectomy
Oophorectomy
  • Teplin. Obstet Gynecol 2007
  • Aziz. Maturitas 2005
  • Premenopausal woman
    • Worse body image
    • Poor sleep
    • Decreased overall quality of life SF-36
    • No difference in sexual scores, urinary complaints
    • At 2 years-Equivalent!
    • Improvement in gynecologic condition & postoperative well-being
incontinence surgery luts
Incontinence Surgery & LUTS
  • Burch
    • Postoperative retention
      • >30 days rare
      • Usual catheter 7-10 days
    • OAB 7-27% postop
    • Enterocele & rectocele 7-26%
  • Slings
    • Pubovaginal slings
      • Postop voiding disorders 12.8% (3-37%)
      • OAB/UI 7% (3-30%)
    • Retropubic
      • Voiding dysfunction/retention 1-3%
      • OAB/UI 2-50% (includes de novo & preexisting)
      • Erosion 3%-7%
    • Transobturator
      • Groin pain & abscess <1-3%
incontinence surgery sexual function
Incontinence Surgery & Sexual Function
  • Limited research
  • Short term1
    • Improvement in sexual function scores
    • Correlates with improvement in incontinence
    • No change in frequency, desire, arousal, orgasm & satisfaction
  • Retropubicvstransobturator sling
    • Improvement in sexual life2
    • ?increased risk of sexual pain 3-14%3
  • Rogers. AJOG 2006 3. Latthe. BJOG 2007
  • Pace. J Sex Med 2008
prolapse surgery
Prolapse Surgery
  • Postoperative voiding dysfunction variable
  • 10-30% risk of recurrence of prolapse
  • Sexual dysfunction
    • Rectocele repair (5-37% dyspareunia)
    • Abdominal apical repair1
      • More women sexually active
      • Decreased sx interfere w/sex & avoidance of sex
      • Less pain
    • Vaginal apical repair vs abdominal repair2
      • Dyspareunia at 1 yr 34% vs 7%, 3 yrs 32% vs 11%
  • Handa. AJOG 2007
  • Arya. SGS 2008
prolapse surgery with mesh
Prolapse Surgery with Mesh

Posterior Mesh Kit

Anterior Mesh Kit

prolapse repair with mesh
Prolapse Repair with Mesh

8 papers/presentations at AUGS Oct 2007

10 papers/ presentations at SGS April 2008

Erosion rates 2-13%

Reoperation rates for erosion, fistula, or pain 20%

Dyspareunia 38-41%

sgs guidelines for use of graft in prolapse surgery
SGS Guidelines for Use of Graft In Prolapse Surgery
  • Systematic review
  • Medline 1950-2007
  • Publications on comparative studies using vaginal grafts
  • Adverse events of non-comparative studies
how to grade the evidence
How to GRADE the evidence…
  • Quality of Evidence
    • High-more research unlikely to change confidence in effect
    • Moderate-more research likely to change confidence in effect & may change estimate of effect
    • Low-very likely to change confidence in effect & likely change estimate of effect
    • Very Low- any estimate of effect is uncertain
  • Recommendations
    • Strong- high quality evidence &/or other considerations support strong recommendation
    • Moderate-high or moderate evidence &/or other considerations support moderate recommendations
    • Weak-low or very low evidence support weak recommendation, based mostly on expert opinion
sgs recommendations
SGS Recommendations
  • Anterior Compartment
    • Biologic & Absorbable synthetic- Native tissue repairs are appropriate when compared to biologic graft (weak)
    • Synthetic-Non-absorbable mesh may improve anatomic outcomes, but trade-offs with risk of adverse events (weak)
  • Apical/Multiple Compartments
    • No comparative studies to guide any recommendation on the use of biologic, absorbable, & non-absorbable synthetic graft in multiple compartment repair when compared to native tissue repair (weak)
  • Posterior Compartment
    • Biologic & Absorbable synthetic- Native tissue repairs are appropriate when compared to biologic graft (weak)
    • Synthetic- No comparative studies to guideuse of non-absorbable mesh when compared to native tissue repair (weak)

SGS Proposed Clinical Guidelines on Vagina Graft Use 2008

surgery for gynecologic malignancy
Surgery for Gynecologic Malignancy
  • Recognized risk of injury to genitourinary tract
  • Radical nature of surgery
  • Pelvic radiation & chemotherapy
  • Limited literature
    • Mostly retrospective
    • Primarily cervical malignancy
    • Evaluated postoperative or therapy
effects of radical hysterectomy
Effects of Radical Hysterectomy
  • Hypertonicity-early & transient
  • Voiding dysfunction
    • Abdominal straining
    • Decreased compliance
  • Stress incontinence
  • Detrusoroveractivity
gynecologic malignancy luts
Gynecologic Malignancy & LUTS
  • Farquharson et al 1986
    • 15% baseline report urinary incontinence
    • Stress incontinence more common in surgery alone group-26% (10-52%)
    • Urgency, mixed incontinence >RT group
    • 63% incidence of incontinence following radical hysterectomy + radiation
    • No difference in bladder sensation
    • RH + RT less bladder compliance
gynecologic malignancy luts43
Gynecologic Malignancy & LUTS
  • Lin et al 2000
  • 210 women w/cervical CA plan RH
  • Preoperative urodynamics
  • Mean age 49
  • 42% menopausal w/o HRT
  • 17% had NORMAL preopurodynamics
  • 83% at least one type of LUTD
  • 73% storage dysfcn
  • 51% urinary incontinence (37% stress, DO 8%, mixed 6%)
  • No difference in age, parity, or stage
gynecologic malignancy sexual function
Gynecologic Malignancy & Sexual Function
  • Retrospective & limited to postoperative evaluation
  • Interruption in sexual activity common leading up to diagnosis
  • Surgery impacts frequency of intercourse & dyspareunia
  • Radiation more effect locally
  • Most common effects:
    • Loss of desire, sensation, & increased pain
  • Different cancers pose different problems
gynecologic malignancy sexual function46
Gynecologic Malignancy & Sexual Function
  • 148 women w/gyn malignancies
  • S/p surgery, RT +/-chemo
  • Validated questionnaires
  • Sexually active
    • 19/41(46%)endometrial
    • 19/35(51%) cervical
    • 20/30(66%) ovarian
  • 74% lack of desire
  • 40% dyspareunia
  • 51 cervical ca survivors
  • Validated questionnaires
  • No difference
    • Interest
    • Sexual pleasure
  • Survivors
    • Increased pain, dryness
    • More likely to use HRT
    • Trend towards dec arousal & orgasm

Wenzel. Gyn Onc 2005

Thranov. Gyn Onc 1993

colorectal surgery
Colorectal Surgery

Sigmoid & rectal cancer patients most vulnerable

Similar risk to adjacent organs & nerves

Most studies retrospective or descriptive, done postoperatively

Men studied more than women

Combined LUTS & sexual function

Improvement in outcomes with evolution of nerve sparing techniques

prevalence of male female sexual dysfunction is high following surgery for rectal cancer
Prevalence of Male & Female Sexual Dysfunction is High Following Surgery for Rectal Cancer
  • 223 pts s/p curative colorectal cancer surgery
    • 81 women, 99 men
  • Validated questionnaires
    • FSFI
    • IIEF
    • EORTC QLQ-C30 & QLQ-CR38
  • 25/81 (31%) sexually active
    • 20 yrs younger than non-active grp
    • 20 yrs younger at time of surgery
  • 19/81 (23%) reported surgery made sex life worse
    • 73% Desire problems (28% A vs 54% NA)
    • 68% Arousal problems (20% A vs 37% NA)
    • 75% Orgasm problems (24% A vs 44% NA)
    • 100% Dyspareunia (36% A vs 56%NA)

Hendren et al Ann Surg 2005

goals of surgery
Goals of Surgery

Remove pathology

Restore anatomy

Improve function

Extend survival

….DO NO HARM!

what we know
What we know…
  • Lower urinary tract symptoms are common
  • Sexual function is complex
    • Sexual dysfunction is difficult to measure
    • Common in our patients
    • Coincides with LUTS often
  • Pelvic surgery impacts the genitourinary tract, often adversely
  • Radical pelvic surgery & radiation have unique risks
moving forward
Moving Forward….

Establish prevalence of these symptoms in specific populations

Evaluate patients for LUTS & sexual dysfunction before pelvic surgery

Give better informed consent & counseling of postoperative expectations/functional changes

Offer treatment or concomitant surgery, when appropriate

evaluation for sexual pain following surgery
Evaluation for Sexual Pain Following Surgery
  • Careful History
    • Attention to any grafts, complications, pre-existing pain issues (Fibromyalgia, IBS, Endometriosis, IC, Vulvodynia)
  • Careful exam
    • Abdominal trigger points, psoas, iliacus
    • Musculoskeletal restrictions
    • Pelvic exam
      • Vaginal length, caliber, scarring, ridges, palpable grafts/sutures
      • Atrophy
      • Levator tenderness
tests
Tests

Cystoscopy

Colonoscopy

Urinalysis, urine & vaginal cultures

+/- uroflow or urodynamics

treatment
Treatment
  • Aimed at physical & emotional findings
  • Establish short & long term goals
  • Multidisciplinary
    • Physician, PT, Psych, Pain Management, Sexual Therapy
treatment58
Treatment
  • Physician
    • Surgical revision, removal of mesh, etc
    • Dilators
    • Trigger point/pudendal injections
      • Kenalog 10mg/ml, 0.25% marcaine, sodium bicarbonate
    • RX: compounded medications for vagina/vulva
      • Baclofen, ketamine/lidocaine/gabapentin, amitriptyline/baclofen/gabapentin, cyclobenzaprine, estradiol, testosterone, etc.
    • Botox injections 20-40 units levators
    • InterStim
current research
Current Research

Prevalence of Lower Urinary Tract Symptoms in Women with Gynecologic Malignancy planning to Undergo Surgery

Lower Urinary Tract and Sexual Function in Women following Surgery for Colorectal Disorders

Trigger Point Injections with Manual Physical Therapy for Treatment of Pelvic Muscle Tension Myalgia