urogynecology in eds - the ehlers danlos society · 2018. 9. 28. · interstitial cystitis/painful...
TRANSCRIPT
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Urogynecology in EDS
Joan L. Blomquist, MDGreater Baltimore Medical Center
August 2018
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“One in three like me”
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Voiding IssuesFrequency/UrgencyUrinary Incontinence
“neurogenic bladder”
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Neurologic supply of the bladder
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Evaluation of Bladder Issues
• History• Urinary Diary• Physical examination• Post void residual test– Ultrasound or catheter
• Urodynamics
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Voiding Issues• Symptoms
– Urinary hesitancy– Slow stream– Urinary frequency– Bladder infections– Kidney problems
• Causes– Inadequate detrusor
contraction– Inadequate urethral
relaxation– High tone pelvic floor– Pelvic organ prolapse
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• Inadequate urethral sphincter relaxation– Pelvic floor physical
therapy– Medications
• Cardura• tamsolosin
– Self catheterization
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• High tone pelvic floor– Pelvic floor physical
therapy– Relaxation techniques– Muscle relaxants
• Vaginal suppositories
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Urinary Frequency and Urgency
• Voiding dysfunction• Overactive bladder• Interstitial cystitis
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Overactive Bladder
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OAB – treatment options
Behavioral modifications-weight loss-avoidance of bladder irritants-fluid management
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OAB - treatment
• Pelvic floor muscle exercises
• Physical therapy
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OAB - treatment
• Medicationsanticholinergics
oxybutynintolterodinedarifenicinesolifenicinetrospium
Beta agonistmirabegron
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Percutaneous Tibial Nerve Stimulation
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Sacral Nerve Stimulation
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Botox
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Interstitial cystitis/Painful bladder syndrome
• AUA (2011)– unpleasant sensation (pain, pressure, discomfort)
perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes.
• ICS (2002)– the complaint of suprapubic pain related to bladder
filling, accompanied by other symptoms such as increased daytime and night-time frequency, in the absence of proven urinary infection or other obvious pathology
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Pathophysiology
• No recognized comprehensive pathophysiologic explanation
• Theories include• Autoimmune• Systemic disease• Neurogenic inflammation• Allergic/Mast cell activation• Defective GAG layer (‘leaky epithelium’)
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PathophysiologyMultifactorial Model
Initiating event
Change in urothelial function
‘Leaky’ Urothelium
Sensitization of peripheral nerves
Release of substance P and inflammatory mediators
Mast cell activation
Vascular congestion and protein extravesation
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Diagnosis
Typical appearance of glomerulations after bladder distention in a patient with nonulcerative IC
Typical appearance of Hunner’s ulcer in an IC patient before bladder distention
Walsh: Campbell's Urology, 8th ed., Copyright © 2002 Elsevier
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First Line Treatments
• General relaxation/stress management• Pain management– Calcium Glycerophosphate, phenazopyridine, aloe
vera• Pt education• Behavioral modification– Adequate water, dietary modifications
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Second Line Treatments
• Appropriate manual physical therapy techniques
• Oral: amitriptyline, cimetidine, hydroxyzine, Pentosan polysulfate
• Intravesical: DMSO, heparin, lidocaine• Pain managment
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Physical Therapy for IC/PBS
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Third Line therapies
• Cystoscopy under anesthesia with hydrodistention
• Neuromodulation• Intravesical botox
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Types of Urinary Incontinence
Stress IncontinenceUrge IncontinenceMixed IncontinenceFunctional IncontinenceOverflow IncontinenceFistula
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Stress Incontinence
• Leakage of urine during physical movement or activity– Coughing, Laughing, Sneezing, Running,
Exercising, Lifting, Straining
• Increases in abdominal pressure are transmitted to the bladder
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Stress Incontinence
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Treatment for Stress Incontinence
• Pelvic Floor Exercises• Pessary/Impressa• Surgery• Urethral injections
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Pelvic Floor Exercises
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Pelvic Floor Muscle Therapy
• Kegel, 1948– Successful therapy of 64
patients with SUI
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Electrical Stimulation
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Pessary
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Impressa
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Transvaginal Sling
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• Unique aspects – Involvement of pelvic
floor muscles– Tethered cord– Mast cell activation– POTS– Multiple medications
• Recommendations– Knowledgeable provider– Conservative treatments– Pelvic physical therapist