Treating complexity in the older adult - the role of the geriatric giants

As people age, they accumulate medical conditions. Geriatric giants comprise a group of conditions that lead to significant mortality and morbidity and contribute to the complexity in treating geriatric patients. They are common and rarely occur in isolation. The 5 Is of geriatric giants are: iatrogenesis, immobility, instability, incontinence and impaired cognition. Consequences for the patient and their caregivers include loss of functional independence, institutionalisation and caregiver burnout. Primary care practitioners are often the first port of call for geriatric patients in South Africa and by asking a few key questions and performing a thorough examination; these conditions can be recognised early. Whilst there are often limitations to cure, the main aim is to maintain the older adult's functional independence as much as possible, and by following an organised management approach to each of these conditions, the quality of life of patients can be improved

A Clinical Audit of Female Urinary Incontinence at a Urogynaecology Clinic of a Tertiary Hospital in Durban; South Africa

Background. Urinary incontinence (UI) is a common condition with an increasing prevalence worldwide. Although it is not a life-threatening condition; it can be very disabling.Objective. To describe the clinical profiles; risk factors; diagnosis; treatment and clinical outcomes of women with different subtypes of UI who attended a tertiary hospital in Durban; South Africa.Methods. A retrospective chart review was performed. A structured data form was used to obtain the relevant information.Results. Seven hundred and fifty-eight of 945 charts with a diagnosis of UI were analysed. Stress urinary incontinence (SUI) was the most common subtype of UI (30). The mean (standard deviation (SD)) age was 50.9 (15.2) years; mean (SD) parity 2.8 (1.4) and mean (SD) body mass index 29.2 (5.3) kg/m2. Indians (n=366; 48.3) were the predominant racial group; black Africans constituted 32.7 (n=248). Mid-urethral tape was the preferred surgical treatment for SUI (n=134; 62.0). Urge UI was treated mainly with pharmaceutical agents (n=138; 74.2) with physiotherapy as adjunctive therapy. Urogenital fistulas were repaired via laparotomy (n=42; 53.9) and vaginally (n=25; 32). Mid-urethral tapes and Burch colposuspension had success rates of 97 and 83.3; respectively. Both laparotomy and vaginal fistula repairs had success rates of 95.Conclusions. Stress UI was the most common subtype of UI observed in this study. Patients were predominantly Indians and overweight or obese. The majority of patients with urogenital fistulas were black Africans. Surgical outcomes at our centre were in keeping with those in international reports

Rolled Vaginal Wall Flap for the Treatment of Stress Urinary Incontinence

Objectives: Anterior vaginal wall slings (AVWS) have been used for decades in the treatment of female stress urinary incontinence (SUI). The main drawback of using the vaginal wall as a sling is its tendency to weaken and stretch over the course of years. The use of synthetic tapes for the treatment of SUI is effective but costly. For patients who cannot afford synthetic tapes; we describe the preliminary results of a modified AVWS technique for the treatment of SUI types II and III. Patients and Methods: In this series; a modification of the AVWS was applied in 35 female patients with SUI. A fortified and rolled flap is used to provide compression and support of the urethra. The vaginal mucosal surface of the flap is cauterized and two diagonal sutures are placed across it. The flap is then rolled on itself with a running 2/0 vicryl suture. Two sutures attached to both ends are passed retropubically to the anterior abdominal wall and tied over the rectus sheath. Results: All 35 female patients had type II/III SUI. After a median follow up of 43 months; 91of the patients were dry or used 0-1 pad per day. Only one patient suffered from transient retention for one week post-operatively. Conclusion: This is a simple method to reinforce vaginal wall flaps. It could offer a durable and effective option for the treatment of SUI in patients who can not afford synthetic tapes. Long-term follow up is required to evaluate the durability of the procedure

Rectus Fascia Sling for the Treatment of Total Urethral Incontinence in Males

Objectives: Urinary incontinence in patients with neurological disease is a major health problem. A modified rectus fascial sling has been assessed in incontinent male patients. Patients and Methods: Fourteen adult male patients with total incontinence due to neurogenic or post-traumatic and etiology were included in this study. A rectangular rectus sheath flap was harvested and defatted.The flap was placed around the bulbar urethra and sutures were passed both in front of and behindthe pubic bone. Both sutures on each side were tied to each other over the pubic bone. Results: Of the 14 patients; 9 (64.3) were completely dry; 3 (21.4) reported improved continence; while 2 (14.3) were a failure. In total; 71.4of the patients showed significant improvement using the Incontinence Quality of Life (IQoL) questionnaire. A significant decrease in the number of pads used per day of 61.3(p

Evaluation of vaginal pessary use by South African gynaecologists

Introduction:The use of vaginal pessaries for conservative management of pelvic organ prolapse (POP) is well established. However; there is limited data on current clinical practice among gynaecologists; and thus the aim of this survey was to evaluate vaginal pessary use among South African gynaecologists. Methods: An anonymous self administered one page questionnaire was designed by the author and administered to South African gynaecologists at an Obstetrics and Gynaecology Update meeting in 2009. Results: The response rate was 32(133 out of 420). 24(29 out of 123) offered vaginal pessaries as first line treatment for pelvic organ prolapse in their clinical practice. The ring pessary was the commonest pessary for all compartmental defects. The two most favored reasons for pessary use was surgical or anaesthetic risk (64) (85 out of 133) and patient declining surgery (50) (66 out of 133). Recurrent involuntary expulsion (52) (69 out of 133); discomfort (41) (55 out of 133); opting for surgery (39) (52 out of 133) were the three top reasons for pessary discontinuation. 88(92 out of 105) responded that they would have reviewed patients within 6 weeks after initial pessary insertion; and thereafter 46(44 out of 96) reviewed patients on 3-6 monthly interval. Conclusion: When compared to other surveys fewer South African gynaecologists offer vaginal pessaries as first line treatment to patients with symptomatic pelvic organ prolapse. Similar practice trends included the choice of pessary; follow up interval and reasons for pessary discontinuation

Tension-Free Vaginal Tape Versus Transobturator Tape for Treatment of Female Stress Urinary Incontinence

The transobturator tape (TOT) is based on a similar principle as the tension-free vaginal tape (TVT); but introduced through the obturator foramen. The aim of this study was to compare these slings as surgical procedures for the treatment of stress urinary incontinence (SUI) in women. Patients and Methods This is a retrospective case-control study including female patients with SUI; either due to urethral hypermobility or intrinsic sphincter deficiency. Thirty patients were treated with TVT (group 1) and 30 were treated with TOT (group 2). The parameters studied were: pre-operative clinical data; operative data and surgical outcome. Results The post-operative complications in group 1 consisted of bladder perforation in one patient (3.3); urinary retention in 3 (10) and de novo urgency in 3 (10). The post-operative complications in group 2 consisted of vaginal xposure in 2 patients (6.7); de novo urgency in 2 (6.7) and transient urinary retention in one (3.3). In the TVT group; objective cure was achieved in 27/30 patients (90); while 3 patients (10) reported subjective cure; failure was not encountered. In the TOT group; objective cure was achieved in 24/30 patients (80) and subjective cure in 4 patients (13.3); and it failed in 2 patients (6.7). Conclusion TVT and TOT are effective procedures for the treatment of female SUI; with comparable results regarding operative time; hospital stay and the risk of complications

Review of Obstetrics Genito-urinary Fistulae in the University of Calabar Teaching Hospital Calabar; Nigeria

Obstetric fistulae with Urinary incontinence are one of the most distressing maternal morbidities. It is associated with physical and social deprivation such as wife abandonment and violent reactions against the victims particularly in the developing countries of the world. To study the demographic and reproductive profiles as well as management of patientswith obstetric fistulae inUCTH;Calabar;Nigeria. Afiver-year retrospective study of case records of 37 patients managed inMaternity Annex of University of Calabar Teaching Hospital; Calabar Nigeria for obstetric genito-urinary fistulae was carried out. One in every 122 parturients during the period had fistula. Eleven (29.7) were teenagers. Many patients weremarried (54.1); nulliparous (59.4); come from low socioeconomic class (72.9) and did not utilize modern obstetric facilities properly. Many cases resulted from prolonged obstructed labour (51.4) and 70.2presented with total incontinence of urine. Eighteen (48.7)were diagnosed within 6 month of delivery. Themain types encountered includedwere vesico-vaginal (34.4) or complex (10.8) fistulaewho were manage conservatively (21.6) or with bladder repairs. Majority (29.7) were referred for further treatment. Parturient in Calabar still suffer from this age long obstetric morbidity mainly due to poor utilization of modern obstetric care facilities. Results of treatment are largely unsatisfactory; therefore resources should be channeled towards prevention

Traitement de l'incontinence urinaire post-operatoire de l'homme par bandelette sous uretrale: a propos de 16 cas

Objectif: Evaluer les resultats preliminaires de la mise en place d'une bandelette sous uretrale pour le traitement d'incontinence urinaire suite a une chirurgie prostatique chez l'homme selon la technique de Comiter modifiee (sans vissage osseux). Patients et methodes: Entre janvier 2005 et decembre 2006; 16 patients ont ete pris en charge pour incontinence urinaire qui apparut apres chirurgie prostatique. Une bandelette de polypropylene fixee sur le perioste des branches ischio-pubiennes par des fils de nylon et comprimant l'uretre bulbaire a ete mise en place. L'evaluation pre et post-operatoire a ete basee sur l'examen clinique et le nombre de protections utilisees par jour. Les patients ont ete revus a un mois post-operatoire; puis tous les trois mois. Resultats: Avec un recul moyen de 18 mois; 11 patients sont continents ne necessitant pas de protection et 3 patients sont nettement ameliores. Un echec a ete note chez un patient qui avait presente initialement une incontinence severe. Un autre patient a developpe une infection de la bandelette necessitant son retrait et a ete exclus de la serie pour l'evaluation fonctionnelle. Nous n'avons pas constate de douleurs perineales persistantes ni d'erosion uretrale ni d'osteite. Conclusion: Notre modification de la technique selon Comiter semble avoir des resultats satisfaisants comparables avec la technique originale. Elle presente un avantage economique certain par rapport a d'autres kits du marche

Combined Abdominal Sacrocolpopexy and Burch Colposuspension for the Treatment of Stage 3 and 4 Anterior Compartment Prolapse

Objective. To review our experience with sacrocolpopexy and Burch colposuspension for stage 3 and 4 anterior compartment prolapse. Methods. Review of 154 patient records drawn from a urogynaecological database; with stage 3 and 4 anterior compartment prolapse treated by sacrocolpopexy and Burch colposuspension. Results. The median age of the patients was 60 years and a third of them had had previous prolapse surgery. Patients presented with bladder (41) and bowel (55) symptoms; and most complained of prolapse protruding through the vaginal introitus (86). Recurrent prolapse; stage 2 - 4; occurred in 24 patients (15.6); 9.7were anterior compartment prolapses. Where mesh was omitted from the anterior vaginal wall but placed on the posterior vaginal wall; significantly more recurrent anterior compartment prolapses occurred (95confidence interval (CI) 0.2; 34.8) compared with cases where mesh was placed both anteriorly and posteriorly to the vagina. Perioperative complications occurred in 13of patients. A tension-free vaginal tape (TVT) procedure for urinary stress incontinence was done at a later stage in 8of the patients. Conclusion. Sacrocolpopexy effectively treated anterior compartment prolapse where mesh was attached to the anterior vaginal wall as well. A Burch colposuspension probably did not make a difference

The Sexual Function and Influence of Urinary Incontinence Questionnaire (SF-IUIQ) - Assessing Sexual Function of Urinary Incontinent Women in South Africa

Objective. To develop and psychometrically validate a questionnaire that assesses sexual function of urinary incontinent women in South Africa and the influence of inconti- nence on their sexual function. Design. A prospective descriptive study. Setting. Urogynaecology and gynaecology outpatient clinics at Tygerberg Hospital; Stellenbosch University; South Africa. Subjects. All patients attending the urogynaecology or gynaecology outpatient clinic at Tygerberg Hospital; who were older than 18 years; not pregnant and could communicate in either Afrikaans or eng. Outcome measures. The content validity; reliability (internal consistency) and construct validity (convergent and discrimi- nant validity) of the Sexual Function and Influence of Urinary Incontinence Questionnaire (SF-IUIQ). Results. Of the subjects 33were not sexually active. Sexual quality of life was significantly influenced by urinary incontinence in 37.7of individuals. Leakage during sexual activity occurred in 32.Conclusions. The SF-IUIQ is a reliable and valid measure of sexual function in urinary incontinent women; and ofthe influence of urinary incontinence on sexual function

Incontinence urinaire de la femme en milieu urbain au Burkina Faso : enquete epidemiologique aupres de 759 femmes a Bobo Dioulasso

Objective: To evaluate the prevalence of urinary incontinence; identify its risk factors and describe its effects on the life of women affected by it in an urban area in Burkina Faso. Patients and Methods: This prospective study was carried out between January and April 2003 and was based on interviews with 759 female patients presenting to the Department of Urology; Sanou Souro Teaching Hospital; and five other medical centers in the city of Bobo-Dioulasso. By means of a questionnaire we collected information on socio-demographic patient characteristics; history of previous surgical or gynecological interventions; type of urine loss and the effects of urinary incontinence on the patients' physical; psychological and economical condition. Results: The mean age of the patients was 29;8 years. The majority (63.6) were housewives; 65.5of them married. The overall prevalence of urinary incontinence was 21;3with a predominance (54;6) of stress urinary incontinence. Multivariate analysis of the risk factors (using the logistic regression model) showed that the following risk factors were significantly associated with urinary incontinence: dystocia; repeated urinary tract infections; chronic constipation; episiotomy and obesity. The physical and psycho-social effect of urinary incontinence on the patients is described. Conclusion: Urinary incontinence is frequently encountered in our environment although only few cases are seen in our gynecology and urology departments. A population-based investigation on a national scale will allow for a better judgment of the actual extent of the problem and will help to establish a strategy on how to better control it

Transobturator Tape (TOT) for treatment of female stress incontinence : early experience

Objective Evaluation of the transobturator tape (TOT); the newest tension-free technique for the treatment of female stress urinary incontinence (SUI) and its early results with 6 months follow up. Patients and Methods This study was conducted at King Saud Hospital; Saudi Arabia; between September 2002 and March 2004. Fourteen cases with pure SUI were treated with Uratape; a low- elasticity polypropylene tape; according to the technique described by Delorme1;2. Preoperative assessment included full history; urogynecological examination; cough stress test; Q-tip test; cystogram and urodynamic studies. Perioperative cystoscopy was also done. Results No intraoperative complications were recorded. Postoperative complications included transient incisional pain in 2 (14.3); transient voiding difficulty in 5 (35.7) and urgency and frequency withmild pyuria in 3 cases (21.4). Mild groin ecchymosis was seen in 5 cases (35.7). Vaginal wound infection and wound dehiscence with subsequent tape removal occurred in one case only (7.1) Twelve cases (85.7) achieved full continence and one patient (7.1) had minimal leak with extreme stress but was fully satisfied. Conclusion From the promising results of our early experience we conclude that the TOT procedure is a simple; safe; fast and minimally invasive technique for the treatment of SUI in women with few minor complications and a high success rate. Further studies on a larger number of patients will however be needed to confirm these results

Le sphincter artificiel urinaire chez l'homme à propos de 23 cas

Objectif Evaluer notre experience dans la mise en place des sphincters artificiels urinaires (SAU). Discuter; apres une revue de la litterature; les indications; les examens complementaires et le pronostic. Patients et methodes Il s'agit d'une etude retrospective; a partir de 23 cas de sphincters artificiels type AMS 800; poses a des patients de sexe masculin; dans le service d'urologie au Centre Hospitalo-Universitaire Dupuytren de Limoges; et colliges sur une periode de 10 ans; entre avril 1996 et avril 2005. L'age moyen de nos patients etait de 70.3 ans; avec des extremes de 47 et 77 ans. Huit de nos malades ont recu un traitement par radiotherapie pelvienne d'un cancer de la prostate. Les causes d'insuf-fisance sphincterienne etaient: une prostatectomie radicale dans 10 cas; une resection endoscopique d'un adenome de la prostate dans 5 cas; une adenomectomie transvesicale dans 4 cas; une sphincterotomie endoscopique avec un agrandissement vesical dans 2 cas; une radiotherapie externe curative pour adenocarcinome localise de la prostate stade T2a dans un cas; et une cysto-prostatectomie avec enterocystoplastie type Camey II dans un cas. Les examens complementaires demandes etaient une analyse des urines; un bilan biologique inflammatoire et infectieux; une uretro-cystoscopie et un bilan urodynamique. Une reeducation perineale a ete pratiquee dans tous les cas; tandisqu'une injection du materiel macroplastique n'a ete faite que dans 15 cas. Enfin un sphincter artificiel a ete mis en position periuretrale dans tous les cas. Resultats L'appreciation du resultat fonctionnel du sphincter artificiel est basee sur la clinique et la satisfaction du patient. On a evalue ces resultats 6 mois apres l'activa-tion du sphincter. Sur nos 23 patients; 18 se disent entierement satisfaits et les 5 autres signalent des fuites qui sont minimes et positionnelles ou liees a des efforts; dont un avec une diminution du jet. Les complications sont apparues plus tard; en effet sur nos 23 SAU; 9 ont ete greves de complications dont 3 cas ont ete facilement corriges. Il s'agit: d'une complication d'ordre technique avec une hyperpression dans le ballon; une fistule vesico-parietale a minima et une migration de la pompe ayant necessite de la repositionner. Dans les autres 6 cas; la complication etait une erosion de l'uretre par la manchette; survenue en moyenne dans un delai de 5 ans apres la mise en place. Conclusion L'efficacite du sphincter artificiel AMS 800 pour la prise en charge de l'incontinence urinaire par insuffisance sphincterienne chez l'homme est indiscutable comme en temoigne le taux de satisfaction des patients qui en sont porteurs. Neanmoins; il persiste encore un taux d'echec non negligeable ayant souvent des consequences graves puisqu'il se solde en general par l'ablation du materiel surtout s'il s'agissait d'une erosion uretrale. Pour ceci; un respect des indications; une selection stricte des candidats; et un bon suivi des patients est necessaire dans l'espoir de diminuer l'emergence de complications

Incontinence urinaire post cure de fistules uro-genitales a propos de 38 cas

Nous avons rapporte les resultats d'une etude prospective de 38 cas d'incontinence urinaire post cure de fistules uro-genitales dans le service d'urologie de l'hopital du Point G sur une periode de 14 mois. L'objectif principal est de faire une recherche operationnelle sur l'incontinence urinaire apres la cure de la FVV. L'etiologie obstetricale a ete retrouvee dans 37 cas (97;4); on note egalement 1 cas de FVV lie a une hysterectomie. Ainsi les FVV etaient toutes de la cloison vesico-vaginale; soit 68;4de trigonales et 31;6de retro trigonales. Les incontinences post fistule ont represente 33 ;6de FVV fermees. Cette incontinence a ete dominee par l'IUE et les fuites par imperiosite mictionnelle; soit 36;8chacune; les fuites nocturnes 15;8; les fuites permanentes 10;5.Malgre l'absence d'examen uro-dynamique pour permettre un diagnostic etiologique 14 de nos patientes ont beneficie d'un traitement medical de leur incontinence. Notre chirurgie de l'incontinence basee sur les techniques classiques a ete pratiquee chez 24 patientes; soit 7 cas de BURCH (29;3); 8 cas de MARRION KELLY (33;3); 3 cas de plastie vaginale (12;5); 6 cas de suspension uretrale (25). Nous avons obtenue 65;8de succes; 23;7d'amelioration; 10;5d'echec

Diagnosis of unilateral single system ectopic ureter in girls in the era of magnetic resonance urography (MRU)

Objective: The ectopic ureter frequently drains an ectopic dysplastic or hypoplastic kidney. The present study aims at defining the role of MRU in establishing the diagnosis of this anomaly. Patients and Methods: Between February 1996 and March 2000; 11 girls presented or were referred to our department for management of urinary incontinence. Their age at presentation ranged from 4-9 years (mean 6.5 years). Radiological work up included abdominal ultrasound (US); excretory urogram (IVU); voiding cystourethrography (VCUG); 99 m technetium-dimercaptosuccinic acid (99m Tc-DMSA) renal scan; enhanced spiral computed tomography (CT) and magnetic resonance urography (MRU). Results: Ultrasound showed evidence of a solitary kidney with failure to visualize a contralateral kidney in 7/11 patients. In the remaining 4 patients (36.4); US revealed a pelvic kidney in two and a pelvic cystic mass in another two patients. IVU revealed only one functioning renal unit in all cases. None of the patients showed vesicoureteral reflux on VCUG. On 99m Tc-DMSA ; a single kidney was seen in 9/11 patients and ectopic pelvic kidneys with normal contralateral kidneys in 2/11 patients. The 7 patients; in whom US and 99m Tc-DMSA scan had failed to localize the kidney; underwent CT scanning which visualized a pelvic hypoplastic kidney with a normal contralateral kidney in 2/7 patients. The remaining 5 patients underwent MRU that disclosed a normal kidney with a contralateral lumbar hypoplastic kidney in one and a pelvic ectopic kidney in four. The patients were managed by nephrectomy (n=9) and ureteroneocystostomy (n=2). Conclusions: A single system ectopic ureter should be suspected in all girls with continuous urinary dribbling after the age of successful toilet training. With the inclusion of MRU into radiological workup; dysplastic or hypoplastic kidneys can be accurately localized. MRU is indicated for the diagnosis and for therapeutic planning in such cases