Prevention of OASIS

Predicting OASIS and tears in individual women is inaccurate and midwifery practices can do little to prevent them. 

§  Clinicians need to be aware of the risk factors for obstetric anal sphincter injuries (OASIS) (Grade D)

§  Elective / low thresh-hold for LSCS in patients with the following risk factor/s:

•         Nulliparity 

•         Macrosomia  of more than 4kg

•         Gestational diabetes mellitus (GDM)

•         Prolonged 1st stage of labour (7-to-10 interval >3hours)

•         Prolonged active 2nd stage of labour >60 mins)

•         No/poor descent during instrumental delivery

•         High head (not visible on parting vagina, PA & VE)

§  Encourage epidural analgesia

§  Perineal protection at crowning can be protective, control delivery of the head may prevent burst injuries.  (Grade C) PINCHING TECHNIQUE

§  Left hand slowing down the delivery of the head, the head is flexed and the right hand protecting the perineum (Pinching Technique as in Finish Intervention Trial).

§  Clinicians should explain to women that the evidence for the protective effect of episiotomy is conflicting. ( Grade C)

§ If an episiotomy is warranted than, a medio-lateral episiotomy (60 degree angulation) has been shown to reduce OASIS.

§   Early extension of episiotomy should be performed to avoid further damage

§   Forcible delivery should be avoided,  it should be replaced with vacuum delivery by use the Kiwi cup for OT & OP positions

§ Delivery the head should be in between contraction. The mother should not push vigorously when head is crowning (communicate).

§ Do take care during the delivery of the shoulder, continue to protect the perineum (midwife/assistant) during delivery of the head & shoulders

The above is video demonstrating how to perform a 60 degrees episiotomy & how to do the perineal protection using PINCHING TECHNIQUE

Consent Has been Taken from Patient to publish this video ( For Teaching Purpose)

Reference : RCOG Greentop guidelines No 29. June 2015

                   Justine RL , Episiotomy & repair. Medscape April 2021

Spontaneous and complete uterine scar rupture occurred 26 days after caesarean section: A case report

 Kartina Ariffin, Jumaida Abu Bakar, Aruku Naidu

 Department of obstetrics & Gynaecology, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

Abstract:

Caesarean section rates have increased worldwide. Following this, the rate of uterine scar dehiscence or rupture is also increased in pregnancy. Rupture of lower uterine segment incision at post-partum is extremely rare clinical condition. We present a 25 year old patient at day 26 post caesarean section, presented with lower abdominal pain with copious vaginal discharge. The examination was unremarkable. On Pelvic ultrasound and Computerized Tomography, an anterior hyperechoic mass with fat attenuation with the mass was visible, measuring 3.3x 7.2x 7.7cm , an anterior uterine wall defect was also noted.  The patient underwent an exploratory laparotomy. There was a spontaneous and complete rupture of the lower uterine segment with omentum enclosing the defect. The debris, clot & fluids were evacuated, followed by repair of the defects in 2 layers with polyglactin suture material size 1. The patient’s post-operative recovery was uneventful. In conclusion, the diagnosis of post-partum caesarean scar dehiscence or rupture is difficult clinically, but radiological modality is essential to establish the diagnosis. As this patient is young, primiparous and with future reproduction function in mind, an exploratory laparotomy was performed as it is both diagnostic & therapeutic in this rare case.

Key words: post- partum, caesarean scar, rupture uterus

Introduction

The post-partum lower abdominal pain and per vaginal discharge is common presentation in patients after caesarean section or childbirth. The common cause is urinary tract infection, endomyometritis and retained placenta. Spontaneous caesarean scar dehiscence or rupture at post-partum is unusual and difficult to diagnose clinically. Radiological modality is a usual tool to help in the diagnosis. Scar dehiscence or rupture not only can be missed but can be potentially life-threatening in her subsequent pregnancy if not address properly. Preoperative diagnosis is usually difficult, thus exploratory laparotomy is both diagnostic and therapeutic for this rare condition. We report a case of spontaneous and complete rupture of a caesarean scar at day 26 post-partum.

Case Report:

The patient was a 25-year-old primiparous woman who underwent emergency caesarean section for deep transverse arrest. The course of her pregnancy had been normal and uneventful. She had no significant medical or surgical history. The labour was spontaneous and progress smoothly until she reach the second stage. The second was prolonged for 1 and half hours with OS fully. Caesarean section was decided as there was large caput & it was not suitable for instrumental delivery. Her caesarean section operation was complicated with bilateral extended uterine tear, the tears was extended and involved the broad ligaments. These tears were repaired in two layers using polyglactin suture size 1. The uterine incision was also sutured in two layers using the same material by a specialist. There were no active bleeding. The abdomen was closed in layers.

She was clinically stable, with normal vital signs throughout her hospital stay and was discharged well on day 2 post-operative day. She was perfectly well during her post-delivery visits. On the Day 26 postpartum, she presented with lower abdominal pain and foul smelling lochia/discharge. She had no fever, any evidence of sepsis or any excessive per vaginal bleeding.

On examination, she was afebrile, her blood pressure was 104/62mmHg, pulse rate was 100bpm and abdomen was soft, but mild tender on palpation. Uterus was contracted well at 16 weeks. Vaginal examination revealed copious amount of yellowish vaginal discharge, and draining from the OS. A pelvic ultrasound showed irregular and hyperechoic mass above the uterine incision. The mass appeared like haematoma measuring 4.1x 6.7x7.0cm. Computerized Tomography was carried out, which also reported the same finding and a possibility of caesarean scar rupture with blood or abscess collection. An anterior hyperechoic mass with fat attenuation with the mass was visible, measuring 3.3x 7.2x 7.7cm. The bladder wall was separate and well defined. The hemoglobin concentration was 10.9 g/L, the total white blood cell was 9.0x 10⁹ /L. The high vaginal swab was no growth detected.  Histology report suggest acute on chronic inflammation with granulation tissue formation.

As the patient was young and primiparous, a decision was made to perform an exploratory laparotomy and repair of the ruptured uterine defect.  The patient & her husband was adequately counseled prior to the operation. At laparotomy, there was minimal pus in peritoneum. The omentum was adhered to anterior uterine wall. The omentum was released from the scar. There was a complete scar rupture of the lower segment uterine incision. The margins of the incision were unhealthy, with some collection of blood and pus. The scar was debrided until a fresh layer of uterine wall. The uterine cavity was normal. The bladder wall was intact.

Uterine defect margins were refashioned and approximated in 2 layers with continuous closure and interrupted suture respectively using polyglactin suture material size 1. Thorough abdominal lavage done and abdominal drain was inserted. The integrity of the bladder and ureters was confirmed prior abdominal closure. Her blood pressure remained stable throughout the surgery.

The patient’s postoperative course was uneventful and she received broad spectrum antibiotics for 14 days. She was discharged well on the 3rd day postoperative day and remained well thereafter. She was reviewed 6 weeks after the laparotomy. The abdominal wound has healed well. A repeat pelvic Ultrasound reveal well define uterine margins.

Ultrasound picture:

Intraoperative picture

Discussion

Abdominal pain and per vaginal discharge after post caesarean delivery is a common complaint. The common causes for such symptoms are urinary tract infection, endomyometritis and retained placenta However, pain secondary to uterine dehiscence or rupture are a rare clinical condition. The incidence of post-partum uterine scar dehiscence or rupture is between 0.6% - 3.8%¹. Delayed presentation of caesarean scar rupture up until 6 weeks postpartum period has been reported in literature². Postpartum scar dehiscence or rupture can present as secondary post-partum hemorrhage, localized or generalized pain and peritonitis, sepsis or even shock. In our case, the presenting complaint was only tenderness at the lower abdomen associated with copious vaginal discharge, which may suggested a possibility of endomyometritis. This case report shows that it is important to have high index of suspicion to exclude uterine dehiscence or rupture in patients who present with localized tenderness or even pelvic haematoma or abscess. Risk factors for lower segment uterine incision rupture during the post-partum period are advance age, multiparity, diabetes, immune compromised, wound infection and hematoma. In our case, we postulated that the extended tear may have led to haematoma and subsequently developed infection that caused tissue necrosis and scar dehiscence. This was evident by presence of copious vaginal discharge vaginally. Among other factor that is associated with poor wound healing is malnutrition. The body mass index of the patient during booking was 16. Whether this has a direct relationship with uterine dehiscence, is unknown.

Ultrasound is the commonly used imaging modality to help with the diagnosis. On ultrasonography, the uterine incision site may show full thickness defect, some hypoechoiec area along the uterine incision line or in some cases some blood or abscess collection anterior to the incision site. Other imaging modality that we can use to aid in our diagnosis is computed tomography (CT) an magnetic resonance imaging ( MRI). An MRI with a heavily T2 weighted image may show a bright fluid filled tract³. However, the clinical usefulness using this modality in acute setting needs to be defined.

Management of these patient’s will depend on the clinical situation taking into account the haemodynamic stability, the severity of infection and patient future reproductive potentials. The management includes conservative or surgical management. In conservative management, broad spectrum antibiotics should be considered and long term follow is need. Patient uterine integrity is difficult to test if this patients plan for further pregnancies and deliveries. In those patients who are unstable, exploratory laparotomy is recommended. Option between refashioning of the edges of the uterine incision or hysterectomy should depend on the intraoperative findings and patient future needs. In our case, the scar margins was intact, hence re-suturing of the incision site was carried out. If the edges are necrotic and irregular, hysterectomy may be considered.

The consequence of this complication for a future pregnancy remains unknown. Mode of delivery in next pregnancy is preferably a repeat caesarean section. For our patient, we have recommended for an elective caesarean delivery at around 37 weeks. 

Disclosure

None of the authors has anything to disclose

Consent Taken from Patient to use the pictures & publish this article

References:

1. El-Agwany AS et al. Conservative management of infected post partum uterine dehiscence after   c   cesarean section. J Med Ultrasound. 2018;26(1):59. doi:10.4103/jmu.jmu_5_18.

2. Wagner MS, Bédard MJ. Postpartum Uterine Wound Dehiscence: A Case Report. J Obstet Gynaecol Canada. 2006;28(8):713–5.doi:10.1016/s1701-2163(16)32236-8

3. Jastrow N, Chaillet N, Roberge S, Morency AM, Lacasse Y, Bujold E. Sonographic lower uterine segment thickness and risk of uterine scar defect: a systemic review. J Obstet Gynaecol Can 2010;32:321-7

4.  Sengupta Dhar R, Misra R. Postpartum uterine wound dehiscence leading to secondary PPH: Unusual sequelae. Case Rep Obstet Gynecol 2012;2012:154685.

 

Algorithm for Management Of Urinary Incontinence In Women

   

 

 

 

 

 

 

 

 

 

 

 

Management of Urinary Incontinence in Women ( GP GUIDE)

A. Definition and Epidemiology

          B. Classification of Urinary Incontinence

C. Making the diagnosis (History/ Physical & pelvic Assessment/Investigation)

D. Red flags and Referral

E. Treatment option for Primary Care Givers

A. Definition and Epidemiology

Urinary incontinence (UI) has been defined the by International Continence Society (ICS) as involuntary loss of urine which is objectively demonstrable and is a social and hygienic problem1. Urinary incontinence is the most common chronic medical disorder in women, accounting for about 35% of all chronic medical conditions, much more common than hypertension (25%), depression (20%) and diabetes (8%) (2). The most common causes for urinary incontinence in women are urinary stress incontinence, urge incontinence, mixed urinary incontinence & overflow incontinence. Urine loss through other than the urethra is extra-urethral incontinence, e.g. congenital, fistula (3).

Prevalence data varies considerably with the definition of urinary incontinence and population base or studies. European and American epidemiological studies reported the prevalence to be between 10-40%. An Australian based study showed that every 1 in 4 women suffers from urinary incontinence(4). In a study in Malaysia, among young nulliparous women, the prevalence of Lower Urinary Tract Symptoms (LUTS) was 52.7% (5). 

Urinary incontinence has a significant impact on the quality of life. A wide range of women (8-58%) who suffer urinary incontinence reported some degree of interference with their physical, psychological, and social lives. The impact of urinary incontinence on the quality of life includes social isolation, and depression. Many of them suffer in silence and do not seek help (6,7).

B. Classification of Urinary Incontinence 

For simplicity the UI in women are divided in four categories.

SUI: (25-45 %) of UI usually seen in younger women can be due to childbirth trauma (urethral hypermobility), congenital weakness, previous surgery, radiation (intrinsic sphincter deficiency, ISD). Usually it is easy to diagnose this condition; patients usually have urine leakage on valsalva/ exersion/ cough/sneezing /physical activity7. The urine leakage can be demonstrable on lying down, at the time of pelvic examination. We can also ask patients to stand on covered sheet and ask them to bend forward and do some valsalva/cough vigorously few times. Presence of urine leakage on the cover sheet indicates a positive stress test. Patients must not empty the bladder before this test (there must be at least 150mls in bladder before doing this test) (1,2,7).

Urge Incontinence: (9-31 %) Idiopathic in most cases, nervous system disorders like multiple sclerosis, diabetes, genital syndrome of menopause (GSM)/ atrophic vaginitis, constipation/ impaction stool, urinary stones, cancer or cystitis are some of the common causes for UI. In patients with Urge incontinence, most patients will have Frequency (F), Urgency (U) with or without incontinence and Nocturia (N):  “FUN” symptoms (1,2,7)

Mixed UI: (20-30%) In cases of mixed incontinence, the patients normally have mixed symptoms of stress incontinence and urge incontinence. In managing such patients the GP’s need to find out which is the predominant symptom and treat the most troubling symptom first (3,7). 

Overflow Incontinence: Occurs in 5-7% of cases. This is usually due to chronic retention which can be the result of local factors like urethral stricture/ stenosis, vaginal or peri-urethral mass or obstruction and in some case any pelvic organ prolapse may also cause obstruction or kinking effect on the urethra. The systemic factors are like brain (CNS) mass or lesions, cognitive disorders/impairments, spinal trauma, spinal disc problems, medications, CNS surgery and tumours (1,2,7).

C. Making the diagnosis (History/ Physical & pelvic Assessment/Investigation)

A thorough assessment is required to make an accurate diagnosis. This includes history-taking, physical examination and some relevant investigations. 

1. History taking 

The assessment of urinary incontinence (UI) involves taking a detailed history regarding the duration and nature of UI. Understanding the symptoms allows appropriate questions to be asked, and this is crucial to differentiate the types of urinary incontinence.

-  Stress urinary incontinence: Urine leak on exertion, like coughing, sneezing, laughing or doing certain physical activity that causes increase intra-abdominal pressure.

- Urge urinary incontinence: Urine leak associated with urgency (women may have urgency and wet themselves before reaching the toilet)

- Urgency: A strong desire to pass urine, in which the patient finds it hard to differ urination.

          - Frequency: Urinating more than 8 times /day during the day time.

- Nocturia: Urinating more than once after going to bed. 

- Overflow incontinence: Patient may present with difficulty to initiate micturition, some may need to strain to void, poor or disruptive flow of urine & incomplete voiding.

- Mixed urinary incontinence:  The presence of both  stress & Urge urinary incontinence.

In addition:

- Fluid intake history

- Symptoms suggestive of utero-vaginal prolapse, bowel symptoms & sexual history

- Past obstetric history including the number deliveries, the weight of the babies and       any episiotomy or instrumental vaginal deliveries. 

- Past surgical history, e.g. incontinence surgery, caesarean section, pelvic organ prolapse repair and hysterectomy

- Patient general health or medical problems like COAD, asthma, mental status/cognitive disorders and any neurological condition

- Drug history, as some medications may contribute to UI, such as diuretics, some anti-depression, anti-psychotic, alpha & beta-adrenergic blockers & agonist.

2. Physical examination: 

- In patients with UI, it’s essential to perform an abdominal and pelvic examination/assessment (7,8). Neurological assessment may need to be done in certain indicated cases.

- Abdominal examination: look for old surgical scars which may indicate prior hysterectomy or incontinence surgery; also feel for any pelvic masses or distended bladder

- Pelvic assessment: look at the external genitalia, any prolapse, vaginal discharge and signs of  atrophy of the vulvo-vaginal. Speculum and bimanual examination will provide some information on the stage of prolapse if any, the size of uterus and any pelvic masses.

- Cough/stress test: This simple test can be done on lying or standing. The patient must not pass urine before the test. Ask patients to cough or perform valsalva manoeuvre a few times. Any urine leakage may indicate the patient has stress urinary incontinence (SUI).

- In some cases, a gentle stroke on the urethral or bladder base may induce spontaneous urinary leakage. This may suggest overactive bladder/ urge incontinence.

- Neurological examination: Look for any upper motor or lower motor lesions or disorders. Pay more attention to the nerve distribution of S2-4. These nerves can be assessed by assessing the lower limb motor function & reflex responses, testing the perineal and perianal sensation/ tone.

3. Investigations

- Bladder diary: This basic investigation tool is also known as Frequency Volume Chart (F/Q Chart). It is simple and patients can easily complete it. Patients are required to list down all the type and volume of fluid intake and output. They also need to record any events like urgency, urinary leakage and condition associated with the urine leak. By looking at the pattern of fluid intake and urine output, the GP’s can assess if the patients are consuming too much or too little fluids. They can also detect the presence of urinary frequency and nocturia. The presence of urgency and urge incontinence may indicate urge incontinence.

- Urine analysis and culture: This may rule out any evidence of urinary tract infection (UTI) as the cause for the UI. If there is a presence of significant hematuria, the patient may require further evaluation.

- Pelvic/Bladder Ultrasound: A pelvic ultrasound can exclude any pelvic masses, can assess the bladder volume and post-void residual urine (PVR). Overflow urinary incontinence can easily be diagnosed if a woman has urinary incontinence and ultrasound showed a distended bladder high PVR, more than 100mls after micturition (7,8).

D. Assessment to rule out RED flag cases and referrals

- Presence of RED flag markers may indicate some serious pathology & these patients need further evaluation. The Red flag markers including recurrent UTI, painful bladder syndrome, distended bladder,  presence of hematuria, passing out urinary stones, presence of a visible vaginal prolapse, neurological deficits and etc. It is advisable to refer such patients to the respective specialty. 

- If no improvement in 6-8 weeks, a referral can be made to the community continence service/ urogynaecologist or urologist for further assessment, conservative or supportive treatment, and in some cases surgery may be indicated

E. Treatment option for Primary Care Givers

Management of urinary incontinence encompasses detail history taking, doing proper general & pelvic assessment and doing appropriate investigation. In most cases the diagnosis can be established if we follow the sequence of investigation as mention above. Once the diagnosis is establish than we can focus on managing them based on the diagnosis (7,8). 

1. The initial treatment in any of the urinary incontinence is behavioral modification or life style intervention. 

- Patient should be advised to consume about 2-litres (6-8 cups) a day. The change in fluid intake is adjusted based on the bladder dairy (9).

- In older/geriatric patients, there is a strong correlation between evening fluid intake and nocturia. In such cases, patients are advised to avoid any fluid intake 2 hours before going to bed. 

- Avoid ‘just in case’ voiding patterns or habits

- They should be taught on proper toiletry hygiene 

- Proper technique to pass urine (lean forward technique), passing urine with feet flat on the floor and elbows resting on knees (10,11). 

- Patients are also advice to avoid bladder irritants like caffeinated drinks & alcohol. Patients are encouraged to consume cranberry/ spirulina juice or tablets as some studies consider them as bladder friendly.(12)

- Other interventions include reducing weight, reduction in excessive physical activity, avoidance of constipation/straining and cessation of smoking (13). 

- Patients who are post-menopausal and have symptoms of GSM are advised to apply topical estrogen.  

2.  Pelvic floor exercise (PFE): The pelvic floor exercises are aimed at strengthening the pelvic floor muscles. The PFE can be taught to patients at the time of pelvic assessment or referred to the physiotherapist to help with the exercises. The exercises should be done with three to four sets of about 8-10 slow pelvic contractions, sustained for 8-10 seconds and repeated 3-4 times per week. The PFE is performed for 6 weeks to 3 months. The short term improvement & cure rate are quoted from 65-75%. PFE is effective for stress as well as mixed urinary incontinence (14). 

3. Bladder Retraining: Is a behavioral modification technique which can be taught to patients at GP setting. The aim of bladder retraining is to increase the capacity of the bladder until it can hold the normal amount of urine (300 – 500 mls). By stretching the bladder, patients can reduce visits to the toilet to 5-7 times during the day and 0-1 time at night. Patients can be taught about proper bladder care, technique to increase the void internal in cases of urgency, urge incontinence and overactive bladder. Patients are advised to delay the void interval from 15-30min initially and gradually  increase the intervals to 3-4 hours. They are also taught how to defer the void sensation with various distractive techniques. The distractive techniques include in-curving of the 1st toes, squeezing the pelvic muscle, mental distraction at the time of urge and others (15).

4. Estrogen Therapy: Application of topical estrogen has been shown be effective in reducing vaginal & bladder irrigative symptoms. Meta-analysis by Fantl & Sultana in 1994 has shown that it is more effective for urge incontinence, recurrent urinary tract infection than stress incontinence (16,17). 

5. Pharmacological therapy: 

- There is no effective medical treatment for stress incontinence.  Alpha- adrenergic agonists & duloxetine are some of the drugs used for SUI. These drugs did not get US FDA approval for usage in SUI.

- For urge incontinence/ overactive bladder symptoms: 

The commonly used drugs are anticholinergic or antimuscarinic drugs. These drugs are contraindicated in patients with narrow-angle glaucoma and cardiac arrhythmia. Patients also need to be counseled about the common side effects which include dry mouth, constipation, tachycardia and transient blurring of vision. Antimuscarinic drugs that are commonly used are oxybutynin, tolterodine, solifenacin, derifenacin and others. Mirabegron is a beta –adrenergic agonist that acts on beta-3 receptors in the detrusor muscles and increase the bladder capacity (18,19,20). Use of medical therapy is ONLY recommended after the first line / initial treatment fails.

- When using medical therapy, there must be a clear indication. Patient must be adequately counselled with regards to the indication, side effects, contraindications, duration of treatment and the benefits of this treatment

- Initial medical treatment is started with low dose & long acting drugs, patient must be review 6-8 weeks to assess the side effects & effectiveness of this treatment. Doses can be adjusted depending on patients’ response. Bladder dairy can be of use to assess the symptoms & effectiveness of the treatment  (20).

F. Devices & other no pharmacological therapy

- In patient with genuine stress incontinence (SUI), one can try incontinence pessaries/occlusive devices. Some form of training is required before GP’s can try these pessaries or occlusive devices.( 21)

- Electrical stimulation (percutaneous tibial nerve stimulation) can be tried for urge UI. A weekly stimulation for 3 months followed by monthly stimulation has shown similar effect as antimuscarinics medication (21).

- For patients with obstructive bladder symptoms secondary to prolapse, one can insert a vaginal pessary to release the pressure / kinking effect. Application of pessary or devices needs practice & some training.

-  If there is an over-distended bladder without any obstructive pathology, one can insert an indwelling catheter to empty the bladder before sending to specialist hospitals.

References

1.  Hayden BT, de Ridder D, Freeman RM at el. An International  Urogyanecological Association/International Continence Society report on the terminology for female pelvic floor dysfunction. Neurouro urodyn. 2010;29(1):4–20. 
2. Kreder KJ . managing Incontinence: One size fits all. Contemp Urol 2002;14(Supp 9):S5 
3. Abrams P, Cardozo L, Fall M et al. The standardization of terminology of lowerurinary tract function: Report from standardization sub-committee of International Continence Society. Am J Obs Gynaecol. 2002;187:116–28. 
4. Moore K. The cost of urinary incontinence. Med J Aust. 2001;174:436–7.
5. Zalina N, Aruku N. Prevalence of lower urinary tract symptoms (LUTS) among young age medical population.  IMJM 2011; 10:1:7-15
6. Khandelwal C, Kistler C. Diagnosis of Urinary Incontinence. Am Fam Physician. 2013;87(8):533–50.
7. Hu SJ, Elyse FP. Urinary Incontinence in Women: Evaluation and Management. Am Fam Physician. 2019;100(6):339–48.
8. Chiarelli P, Brown W. et al. Leaking urine: prevalence and associated factors in Australian women. Neurourol Urodyn. 1999;18(6):576–7.
9. Swithinbank L, Hashim H, Abrams P. The effects of fluids intake on urinary symptoms in women. J Urol. 2005;174:187–9.
10. Devreese AM, Nuyens G. Do posture and straining influence urinary-flow parameters in normal women? Neurourol Urodyn. 2000;19(1):3–8.
11. Rane A, Corstiaans A. Does leaning forward improve micturation? J Obs Gynaecol. 2000;20(6):628–9.
12. Jepson RG, Craig JC. A systematic review of the evidence for cranberries and blueberries in UTI prevention. Mol Nutr Food Res. 2007;51(6):738–45.
13. Subak LL, Whitcomb E, Sheh H et al. Weight loss: a novel and effective treatment for urinary incontinence. J Urol. 2005;174:190–5.
14. Hay-Smith EJ, Bo K, Berhmans LC. Pelvic floor exercise training for urinary incontinence in women. Cochrane Database Syst Rev. 2003;(1):CD001407.
15. Wallace, Roe B, Williams K, Palmer M. Bladder training for urinary incontinence in adults. Cochrane Database Syst Rev. 2004;2004(1):CD001308.
16. Fantl JA, Cardozo L, Mcclish DK. Estrogen therapy in the management of urinary incontinence in postmenopusalwomen: a meta-analysis. Obs gynaecol. 1994;83:12–8.
17. Sultana CJ, Walters MD. Estorgen and urinary incontinence in women. Maturitas. 1994;20:129–38.
18. Sum Lam, Olga Hilas. Pharnacological management of Overactive Bladder. Clin Inter Aging. 2007 Sept;2(3)337-345
19. Herbison P, Hay-Smith J, Moore K. Effectiveness of anticholinergic drugs compared with placebo in the treatment of overactive bladder: systematic review. BMJ. 2003;326:841.
20. Nabi H, Cody JD, Ellis G, Hay-Smith J. Anticholinergic drugs versus placebo for overactive bladder syndrome in adults. Cochrane Database Syst Rev. 2006;Oct 18(4):CD003781.
21. Balk E, Gaelen PA, Kimmel H, Rofeberg V et al. Nonsurgical Treatments for Urinary Incontinence in Women: A Systematic Review Update. Comp Eff Rev. 2018;212:1–108.

 

Three cases of paraurethral angiofibroblastoma

Three case reports of angiofibroblastoma.

Case 1

A 32 year old lady presented with an asymptomatic, but gradually enlarging vaginal lump over 3 months. On examination, there was a small 3x2 cm rubbery tissue mass arising from the left paraurethral region. An examination under anesthesia and excisional biopsy was thus organized. However she defaulted on her surgery due to anxiety, and failed to attend her follow up appointment. Six months later she returned complaining od pain and bleeding on voinding. On examination, the solitary paraurethral lump had noe enlarged to a size 8x8x4 cm, amd had become ulcerated and infected ( figure 1). There was no associated inguinal lymphaadenopathy. Due to the pain and voiding difficulties, an examination under anesthesia, cystoscopy and excision of the mass was promptly carried out. Intraoperatively, the tumour was found to be localized to the paraurethral regionand had not invaded into the urethra or bladder. It was found that the tumour was well circumscribed and was able to be ‘shelled out’ relatively easily. The patient did not require any indwelling catheter post operatively and subsequently made an uneventful recovery ( figure 2). Histopathology confirmed the mass to be a benign angiofibroblastoma.

Case 2.

A 42 year old Para 2+1,  This patient initially presented on 9.10.2008 because she noticed a mass per vaginal which had been present for 2 years, it was reducible but protruded back out immediately. The mass was firm, nodular and mobile, measuring 4x3 cm. The mass progressive got bigger and causing voiding dysfunction.  An examination under anesthesia was carried out on 226.2009. An indwelling catheter was inserted to assist in the surgery. The mass was very close to the urethra and has distorted the anatomy of the urethra. The mass was easily enucleated.  The estimated blood loss was 100mls. There were no intraoperative complications. The catheter was kept for three days. The histology was consistent with suburethral angiofibroblastoma (4x3cm).

Case 3.

This a 65 year old lady Para 6, presented with elongated and firm mass near the urethral meatus. The mass was initially small but over six year its size has increased and causing pain and difficulty in walking. She also has difficulty in micturation. She has to move the elongated mass to one side. On examination there was a 7x4x4 cm elongated mass with the tip of the distal part of the mass appeared fungating and necrosing. The proximal part of the mass had a 4cm stock/ base. She underwent examination under anaesthesia and excision of the mass. The surgery was straight forward. Check cystoscopy was normal. The histology was consistent with    Angiomyofibroblasroma.

Discussion

Angiomyofibroblastoma is a rare mesenchymal tumour of the female genital tract that was only first described in 1992(1). This tumour is predominately found in the vulval region, bu can also arise from the vagina, clitoris, labia majora and perineum. Unusual cases involving the male scrotal and inguinal regions have been reported 9(1). They have been reported in women from the age of 23-86 (mean 45.8) years. They usually appears as a painless lump that may have been present for a few weeks or up to 13 years. Clincally, this tumour can be mistaken for a bartholin gland cyst, skene’s gland cyst, urethral diverticulum or Gardner duct cyst.

Angiomyofibroblastoma is a slow growing tumour that is usually well circumscribed, and has a soft rubbery consistency with a bulging, pink, section surface. Histologically, this tumour is composed of two components: the blood vessels and stromal cells. It shows alternating hypercellular and hypicellular oedematous ares, in which numerous thin walled, small to medium sized vessels are irregularly distributed throughout. The tumour cells show immune reaction for vimentin and desmin and , more recently, it was noted to be muscle specificactin-positive or Alfa-smooth muscle actin-positive (2,3,4). It is typically benign in nature. Only one case of a malignant transformation of an angiomyofibroblastoma ( ‘angiomyofibrosarcoma’) has been reported(3).

Angiomyofibroblasroma may have been reported as an aggressive angiomyxoma. Unlike Angiomyofibroblasroma, aggressive angiomyxoma affects deeper tissues with infiltrative margins, and tends to recur (4). The pathogenesis of Angiomyofibroblasromais still unclear, although it has been proposed that it may originated from an immature mesenchymal cell in the sub epithetial myxoid zone of the lower female genital tract, or in perivascular areas. The outcome in these patients were good, and is always favorable with simple excision of the tumour mass.

References

1.      Fetchers CDM, Tsang WY, Fisher C, lee KC & Chan JK. Angiomyofibroblasromaof the vulva. A benign neoplasm distinct from aggressive angiomyxoma. Am J Surg Patho 1992; 16;373-82.

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