Why is it done?

• To alter the neurotransmission from the nerve to muscle receptor.
• Refractory overactive bladders with urge incontinence.
• Chronic pelvic pain?
• Causative factors:
  • Undetermined
  • Neurogenic causes such as Multiple Sclerosis.
  • Non-neurogenic.
• NOT INDICATED FOR A PATIENT WITH A HIGH POST VOID RESDUAL URINE VOLUME

How is BOTOX administered

• A sedation/local anesthetic is administered.
• You will be placed supine with legs in comfortable frog position
• A flexible cystoscopy procedure is done.
• 20 sites of 1 ml blebs are created in a grid fashion with sub-mucosal injections of BOTOX.

• Usually, 100-200 IU with non-neurogenic bladders and 300 IU with neurogenic causes.
• Dose may be individualized with subsequent treatments.
• WARNING: You may not be able to pass urine for up to 2 weeks on your own and may require intermittent self-catheterization. Therefore, if you are not willing to self-catheterize, this is not for you

After the procedure?

• You will be assessed to see whether you empty your bladder completely.
• ISC may be instituted if you cannot void or residuals are more than 300cc.

What to expect after the procedure

• Some local discomfort may be experienced.
• Your voiding nature will change within the next week to 10 days with a slow stream which may require ISC in < 2% of patients.
• Systemic effects of BOTOX would cause muscle weakness with higher doses.
• If you require ISC, this may be required for 2-4 weeks, it will improve thereafter.
• Neurogenic bladder patients will still continue with ISC as before.
• NB! Each person is unique and for this reason symptoms may vary!

What next?

• A date will be set for a review by myself on regular intervals.
• Please don’t hesitate to direct all further queries to Dr Schoeman’s rooms.

 

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Wes Intravesical BOTOX

For those guys who suffer persistent low-intermediate grade of stress urinary incontinence after their radical prostatectomy for prostate cancer. Usually 2 level 2 pads per day.

Why is it done?

• Male Stress incontinence
• Usually after a TURP/TUVP, Radical Prostatectomy in 2% of cases.

 

How is it done?

• This procedure is done under a spinal / general anesthetic, as decided by the anesthetist.
• The legs will be elevated into the lithotomy position.
• A 5-7cm incision is made on the perineum (space between scrotum and anus).
• The sling is placed around the bulb of the penis.
• The arms of the sling are brought to the skin at the inner thigh, with a small incision.
• The sling is placed with descent tension, pulling the bulb inwards by at least 2 cm.
• The bladder will be inspected with a cystoscopy to exclude any injuries to the bladder wall and urethra.
• The wounds are closed with dissolvable sutures.
• A local anesthetic is given for pain relief.
• A urinary catheter is placed for 24hrs.
• The catheter will be removed early the next morning.
• The patient’s post void residual volume will be measured. (Patients will be required to do this up to 3 times.)
• If the residual amount of urine is more 250-300 cc the patient may have to self-catheterize, until the residual volume is acceptable.
• You may require an indwelling catheter for 7 days.
• Prophylactic antibiotics will be given to prevent infection.

 

What to expect after the procedure?

• Any anesthetic has its risks, and the anesthetist will explain all such risks.
• Complications: hemorrhaging, requiring blood transfusion <1%.
• Patients will wake up with a catheter in the urethra and bladder. This will remain in the bladder for 24 hrs.
• Inner thigh discomfort/pain will persist for a few days but this will subside / settle.
• If you cannot urinate after 2-3 attempts, the catheter may be replaced for a further 7 days
• You may be required to self catheterize for a week or two.
• If there is no improvement the sling may be cut, to allow spontaneous urination
• This may only be 50% effective in irradiated patients
• NB! Each person is unique and for this reason symptoms may vary!

 

 

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Wes Male Advance Sling

Why is it done?

• Stress urinary incontinence.
• A combination of stress incontinence and lesser degree of detrusor overactivity – mixed incontinence.
• Involuntary urine leakage with any exertion, coughing or sneezing.
• Risk factors:
  • More than 2 pregnancies, big babies.
  • Complicated deliveries, episiotomy.
  • Smokers.
  • Being overweight.
  • Diabetes
• Where Intrinsic Sphincter Deficiency has been proved due to a failed previous sling.

How is it done?

• This procedure is done under a spinal / general anesthetic, as decided by the anesthetist.

• The legs will be elevated into the lithotomy position.
• A small incision is made in the vagina. The sling is placed behind the pubic bone and brought to the skin above the pubic bone, with a small incision.
• A synthetic mesh is used after in detail consultation with yourself
• This will be used as a last resort
• You will be made aware of the TGA mesh withdrawal in Australia and Europe – especially involving mesh used for vaginal prolapse surgery
• The sling is placed tension free.
• If you have a suspected Intrinsic Sphincter Deficiency (ISD), the sling may be placed tighter.
• The bladder will be inspected with a Cystoscopy to exclude any injuries to the bladder wall.
• The wounds are closed with dissolvable sutures and/or skin glue.
• A local anesthetic is given for pain relief.
• A urinary catheter is placed for 24hrs.
• A vaginal plug will also be placed.
• The catheter and plug will be removed early the next morning.
• The patient’s urine output will be measured each time they urinate, and the residual will be measured. (Patients will be required to do this up to 3 times).
• If the residual amount of urine is more than 250-300 cc, the patient may have to self-catheterize, until the residual volume is acceptable.
• Prophylactic antibiotics will be given to prevent infection.

What to expect after the procedure?

• Any anesthetic has its risks, and the anesthetist will explain all such risks.
• Complications:
  • hemorrhaging, requiring blood transfusion <1%.
  • bladder perforation, requiring an open repair <1%.
• Patients will wake up with a catheter in the urethra and bladder. This will remain in the bladder for 24 hrs.
• Above pubic bone area discomfort/pain will persist for a few days, but this will subside or settle.
• If you cannot urinate after 2-3 attempts, the sling may be readjusted.
• You may be required to self catheterize for a week or two.
• If there is no improvement the sling may be cut, to allow spontaneous urination.
• NB! Each person is unique and for this reason symptoms may vary!

 

What next?

• Patients will have a trial of void without catheter the next day.
• Patients will be discharged as soon as they can completely empty the bladder.
• Patients may be required to self-catheterize for a week or two.
• Patients may initially suffer from urge incontinence and frequency, but this will improve within the next 6 weeks.
• Your flow will be slower.
• Allow 6 weeks for symptoms to stabilize.
• There may be some blood in the urine. This can be remedied by drinking plenty of fluids until it clears.
• On discharge a prescription may be issued for patients to collect.
• Patients are to schedule a follow-up appointment in 6 weeks.
• Please direct all queries to Dr Schoeman’s rooms.
• PLEASE CONTACT THE HOPSITAL DIRECT WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

Remember to discuss mesh and its complications with Jo. This is used as a last resort, and you should be aware of the risks!

 

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Wes Mid-urethral Retropubic sling

• Urodynamics is a collective name for a number of tests of bladder functions.
• The main test is called Cystometry, which measures your bladder’s ability to store and pass urine.
• Flow Rate measures the top speed and average speed of your urine flow
• A Voiding Cystogram will be done while you are emptying your bladder to exclude a neurological cause and Vesico-Ureteric Reflux

 

Why is it done?

Urinary problems, especially incontinence, may affect women of any age. Commonly more in over-65s.

Problems such as these usually increase with age and is associated with a history of spinal injury, the onset of Diabetes, Parkinsons and history of Cerebro-Vascular Incidents. Longstanding bladder outlet obstruction is a common cause.

Your symptoms may include:

• Loss of urine while coughing, sneezing, laughing or exercising
• Sudden and/or frequent urge to pass urine, occasional urge incontinence.
• Getting up at night frequently to pass urine
• Difficulty in emptying your bladder
• Recurrent bladder infections

Results from urodynamic tests may demonstrate the reason why you have the symptoms you have, and allows an opportunity to offer you the best treatment for your problems.

How is it done?

• You may first be asked to pass urine into a special toilet – Flowmeter- to measure how quickly your bladder is able to empty.
• You may have a bladder scan immediately after you have passed urine to assess how well your bladder has emptied.
• Following this, a small plastic tube called a catheter will be inserted into your bladder so it can be filled with fluid.
• It also has a fine sensor on the end which records the pressures in your bladder.
• A second catheter is placed in the vagina. These lines will record pressures measured in your abdomen.
• You will be asked to do a series of exercises (cough, laugh, strain) with a full bladder to see how bad your leakage is. This is called a leak test.
• If no leaking has been observed, these tests may be repeated in the standing position
• Don’t worry, you will not be expected to do anything which you are not normally able to do easily.
• Where a neurogenic bladder is suspected, the fluid placed in your bladder will contain radiological contrast medium, to exclude vesicoureteric reflux and to anatomically define the bladder anatomy and posterior urethra.
• The information contained in this brochure is intended to be used to aid in obtaining a diagnosis and/or evaluate the effects of treatment
• During the procedure, you will be asked questions about the sensations in your bladder.
• You will also be asked to do some of the things which might trigger the problem you have (e.g. cough, strain, jog, stand up, or listen to the sound of running water).
• Let the person doing the test know when your bladder feels full.
• Finally, you will be asked to empty your bladder again, with the two fine sensors still in place. This will be done with X-ray imaging. The sensors are then removed.
• Post voided residual volumes are checked either with ultrasound measurement or by aspirating urine through the bladder catheter.
• This is followed by a Flexible Cystoscopy (see Flexible Cystoscopy)
• The procedure is now complete, and you can get dressed
• Jo will discuss the findings with you and formulate management options specific to your problem

 

Flexible Cystoscopy

• Once the procedure is done, the area is cleaned again.
• Local anaesthetic placed again in the urethra
• A Flexible camera (cystoscope) is passed with water opening the urethra as is progresses.
• The urethra, prostatic urethra and bladder are inspected.
• You could experience light bleeding and burning with initial urination afterwards

 

Complications

• No matter how carefully the test is performed urine infections can sometimes occur after it.
• You should drink more water than usual for a day or two to flush out any bacteria.
• You may be advised to take antibiotics for a short period of time after the test

 

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Wes Urodynamic Studies-Women

Copyright 2019 Dr Jo Schoeman