Ambulatory Urology and Urogynaecology, 2021

Ambulatory Urology and
Urogynaecology
Ambulatory Urology and Urogynaecology
Edited by
Abhay Rane, OBE, MS, FRCS, FRCS(Urol)
Surrey and Sussex Healthcare NHS Trust
Redhill, Surrey, UK
Ajay Rane, OAM, MD, FRCOG, FRCS, FRANZCOG, CU, PhD,

FICOG (Hon), FRCPI (Hon), GAICD, FACOG (Hon)
Department of Obstetrics and Gynaecology
James Cook University
Queensland, Australia
With co-editors
Jordan Durrant, MBBS, FRCS (Urol)
Department of Urology, East Surrey Hospital
Surrey, UK
Arjunan Tamilselvi, MBBS, DGO, FRCOG

Institute of Reproductive Medicine & Women’s Health
Department of Urogynaecology, Madras Medical Mission Hospital
Chennai, India
Sandhya Gupta, MBBS, DGO, FRCOG, Dip Endoscopy

Department of Obstetrics and Gynaecology
The Townsville Hospital, Townsville, Australia
This edition first published 2021
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Library of Congress Cataloging-in-Publication Data

Names: Rane, Abhay, editor. | Rane, Ajay, editor. |
Durrant, Jordan, editor. | Tamilselvi, Arjunan, editor. | Gupta, Sandhya, editor.
Title: Ambulatory urology and urogynaecology / edited by Abhay Rane,
Ajay Rane ; with co-editors, Jordan Durrant,
Arjunan Tamilselvi, Sandhya Gupta.
Description: Hoboken, NJ : Wiley-Blackwell, [2021] | Includes
bibliographical references and index.
Identifiers: LCCN 2020025492 (print) | LCCN 2020025493 (ebook) |
ISBN 9781119052296 (hardback) | ISBN 9781119052272 (adobe pdf) | ISBN 9781119052265 (epub)
Subjects: MESH: Urologic Diseases–surgery | Urologic Surgical Procedures |
Ambulatory Surgical Procedures
Classification: LCC RD571 (print) | LCC RD571 (ebook) | NLM WJ 168 |
DDC 617.4/610597–dc23
LC record available at https://lccn.loc.gov/2020025492
LC ebook record available at https://lccn.loc.gov/2020025493
Cover Design: Wiley

Cover Images: © SEBASTIAN KAULITZKI /SCIENCE PHOTO LIBRARY/ Getty Images,
© SCIEPRO/Getty Images
Set in 9.5/12.5pt STIXTwoText by SPi Global, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
This book is dedicated to our parents, Murali and Snehalata, who
gave us everything.
vii
Contents
List of Contributors xi
Section I Basic Principles of an Ambulatory Service 1
1 Principles of an Ambulatory Surgery Service 3

Mark Salmon and Benjamin Patel
Section II Ambulatory Urogynaecology 17
2 Introduction and Epidemiology of Pelvic Floor Dysfunction 19

Jay Iyer and Ajay Rane
3 Ambulatory Evaluation of Pelvic Organ Prolapse and Urinary

Incontinence 33
Tanvir Singh, Sandhya Gupta, and Ajay Rane
4 Role of Cystoscopy 53
Arjunan Tamilselvi
5 Role of Nurse Practitioners in Ambulatory Urogynaecological Care 63

Angie Rantell
6 Non-Surgical Management of Pelvic Floor Disorders 69

Arjunan Tamilselvi
7 Ambulatory Surgical Procedures in Stress Urinary Incontinence 81

Dudley Robinson
viii Contents
8 Pelvic Organ Prolapse Surgery as an Ambulatory Procedure 99

Marcella Zanzarini Sanson and G. Willy Davila
9 Common Urethral and Vaginal Lesions in Ambulatory Urogynaecology 109

Mugdha Kulkarni and Anna Rosamilia
10 Ambulatory Management of Childbirth Pelvic Floor Trauma 123

Khaled M.K. Ismail, Rasha Kamel, and Vladimir Kalis
11 Teaching and Training in Urogynaecology 137

Ajay Rane
Section III Ambulatory Urology 149
Foreword 151
Jordan Durrant
12 Ambulatory Penile and Inguino-Scrotal Surgery 153

Ben Pullar
13 Ambulatory Management of Renal Stone Disease 159

Aakash Pai
14 The Management of Recurrent Urinary Tract Infections 167

Jordan Durrant
15 An Ambulatory Approach to Benign Prostatic Obstruction 175

Tharani Mahesan
16 Urethral Catheters and Ambulatory Management

of Urinary Retention 185
Ashiv Patel
17 Paediatric Urology 193

Tharani Nitkunan and Sylvia Yan
18 Urothelial Bladder Cancer: Diagnosis and Management

in the Outpatient Clinic 201
Jordan Durrant
Contents ix
19 Prostate Cancer: Diagnosis and Management

in the Outpatient Clinic 207
David Thurtle
20 Renal Cancer: Diagnosis and Management in the Outpatient Clinic 217

Karan Wadhwa
21 Penile Cancer: Diagnosis and Management in the Outpatient Clinic 223

Karen Randhawa and Hussain Alnajjar
22 Testis Cancer: Diagnosis and Management in the Outpatient Clinic 233

Benjamin Patel
23 Plain X-Ray, Computed Tomography Scanning, and Nuclear Imaging

in Urology 239
Tharani Mahesan
24 Magnetic Resonance Imaging in Urology 247

Benjamin Patel
Index 251
xi
List of Contributors
Editors Jordan Durrant, MBBS, FRCS (Urol)

Abhay Rane OBE, MS, FRCS, FRCS(Urol) Department of Urology
Professor of Urology East Surrey Hospital
Surrey and Sussex Healthcare NHS Trust Surrey; Sussex Healthcare
Redhill, Surrey, UK NHS Trust
United Kingdom
Ajay Rane, OAM, MD, FRCOG, FRCS,
FRANZCOG, CU, PhD, FICOG (Hon), Sandhya Gupta, MBBS, DGO, FRCOG, Dip
FRCPI (Hon), GAICD, FACOG (Hon) Endoscopy
Consultant Urogynaecologist Specialist, Department of Obstetrics
Department of Obstetrics and and Gynaecology
Gynaecology The Townsville Hospital
James Cook University Townsville, Australia
Queensland, Australia
Khaled M.K. Ismail, MBBCh,
Contributors MSc, MD, PhD
Hussain Alnajjar, MBBS ChM (Urol), Professor
FEBU FRCS (Urol) Department of Gynecology and
Department of Urology and Andrology Obstetrics
University College London Hospitals Faculty of Medicine in Pilsen
NHS Trust University Hospital Pilsen
United Kingdom Charles University
Czech Republic
G. Willy Davila, MD, FACOG (FPMRS)
Director of Women and Children’s Services Jay Iyer, MBBS, MD, DNB, FRCOG,
Holy Cross Medical Group FRANZCOG
Dorothy Mangurian Comprehensive Specialist, Department of Obstetrics
Women’s Center and Gynaecology
Fort Lauderdale The Townsville Hospital
FL, USA Townsville, Australia
xii List of Contributors
Vladimir Kalis, MD, PhD Ashiv Patel, MBBS

Associate Professor Department of Urology
Department of Gynecology and East Surrey Hospital
Obstetrics Surrey and Sussex Healthcare NHS Trust
Faculty of Medicine in Pilsen United Kingdom
University Hospital Pilsen
Charles University Benjamin Patel, BA, BM BCh
Czech Republic Department of Urology
East Surrey Hospital
Rasha Kamel, MBBCh, MSc, MD Surrey and Sussex Healthcare NHS Trust
Professor United Kingdom
Maternal-Fetal Medicine Unit
Department of Obstetrics and Ben Pullar, MBBS, BSc, FRCS (Urol)
Gynecology Department of Urology
Cairo University The Lister Hospital
Egypt Stevenage, United Kingdom
Mugdha Kulkarni, MBBS, FRANZCOG

Karen Randhawa, MBChB, MFST(Ed),
Urogynaecology Fellow
FRCS (Urol)
Monash Health
Department of Urology and Andrology
Melbourne, Australia
University College London
Hospitals NHS Trust
Tharani Mahesan, MBBS, BSc, MRCS United Kingdom
Department of Urology
East Surrey Hospital Angie Rantell, PhD, RCN, ALNP
Surrey and Sussex Healthcare Lead Nurse, Urogynaecology/Nurse
NHS Trust Cystoscopist
United Kingdom King’s College Hospital
London, United Kingdom
Tharani Nitkunan, BSc Hons, MBBS, PhD,
FRCS (Urol) Dudley Robinson, MD, FRCOG
Department of Urology Department of Urogynaecology
Epsom and St Helier University King’s College Hospital
Hospitals NHS Trust London, United Kingdom
United Kingdom
Anna Rosamilia, MBBS,
Aakash Pai, BSc, MBBS, FRCS (Urol) FRANZCOG, CU, PhD
Department of Urology Urogynaecologist and Head of Pelvic
Northampton General Hospital Floor Unit
NHS Trust Monash Health
United Kingdom Melbourne, Australia
List of Contributors xiii
Mark Salmon, MBBS, FRCA, DipIMC David Thurtle, BMBS, BMedSci, MRCS
Department of Anaesthesia Department of Urology
East Surrey Hospital University of Cambridge and North
Surrey and Sussex Healthcare West Anglia NHS Foundation Trust
NHS Trust United Kingdom
United Kingdom
Karan Wadhwa, PhD (Cantab),
Marcella Zanzarini Sanson FRCS (Urol)
Department of Obstetrics and Department of Urology
Gynecology Mid and South Essex NHS Trust
Medical School of Ribeirão Preto United Kingdom
University of São Paulo
Brazil Sylvia Yan, MBChB, MRCS
Department of Urology
Tanvir Singh, MB, BS, MS – OBGyn, Epsom and St Helier University
Bachelor Endoscopy – MIS Hospitals NHS Trust
Consultant United Kingdom
Department of Obstetrics and
Gynaecology
Tanvir Hospital
Hyderabad, India
Arjunan Tamilselvi, MBBS, DGO, FRCOG

Consultant Urogynaecologist and
Pelvic Surgeon
Department of Urogynaecology
Institute of Reproductive Medicine &
Women’s Health
Madras Medical Mission Hospital
Chennai, India
1
Section I
Basic Principles of an Ambulatory Service

3
Principles of an Ambulatory Surgery Service

Mark Salmon and Benjamin Patel
According to the International Association for Ambulatory Surgery (IAAS),

ambulatory surgery should be defined as ‘an operation/procedure, excluding an
office or outpatient operation/procedure, where the patient is discharged on the
same working day.’ The origins of ambulatory surgery can be traced back to the
pioneering work of James Nicholl at the Glasgow Royal Hospital who reported
8988 paediatric day- case procedures between 1899 and 1908. Despite initial
scepticism from the surgical profession, there has been a rapid expansion in the
complexity and amount of ambulatory surgery in recent years: between 1989 and
2003 the percentage of elective surgery undertaken as day case in the UK
increased from 15 to 70%. Many health services have set targets for the percent-
age of elective surgeries to be done as day-case procedures, and in the UK this
target is set at 75%.
The rise of ambulatory surgery has been driven by technological advances that
reduce the need for overnight hospital stays, enhanced recovery programmes that
advocate early mobilisation, and the need for economic efficiency. With growing
interest in ambulatory surgery, multiple associations have been formed promot-
ing education, quality standards, and research in the field.
Infrastructure
Ambulatory care is delivered in various environments, including
●● Free-standing self-contained units
●● Integrated self-contained units
●● Integrated non-self-contained units
Ambulatory Urology and Urogynaecology, First Edition. Edited by Abhay Rane and Ajay Rane.
© 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.
4 Ambulatory Urology and Urogynaecology
Free-standing units, separate to inpatient units, are common in the United

States, increasing in number from 67 in 1976 to over 4000 in 2004 (IAAS: day sur-
gery). They may be multidisciplinary, serving a larger market, or uni-disciplinary.
Potential benefits include cost-effectiveness and efficiency because it is easier to
generate a streamlined care pathway and to encourage teamwork amongst health-
care professionals. Furthermore, they may have lower rates of hospital-acquired
infection. The disadvantage is that they are remote from a comprehensive medical
facility with a full range of specialties including intensive care, meaning that there
will occasionally be a need for outsourcing and transfer of patients. The need for
low-risk patients ultimately encourages stricter patient selection, self-limiting the
service. Most unplanned overnight admissions after ambulatory surgery are due
to bleeding and longer-than-expected procedure length, with urological and
gynaecological surgery accounting for a particularly high proportion of bleeding
patients (Vaghadia 1998).
Integrated self-contained ambulatory units are located on a hospital site with
their own dedicated theatres and personnel. They are generally seen as the ideal
model for ambulatory surgery, benefiting from the comprehensive range of medi-
cal services provided by that hospital, whilst also specialising in providing a
streamlined ambulatory service with one dedicated team well trained in ambula-
tory surgical care.
Integrated non-self-contained ambulatory units vary significantly in set-up:
some may not have dedicated theatres or personnel. This makes the system
inefficient, because there is a chance that low-risk day-case procedures may be
cancelled, a streamlined patient pathway is often lacking, and unintended
overnight stays arise due to difficulties ensuring safe discharge. However, if
there is a dedicated ambulatory ward and theatres, this environment does have
some benefits; it is easily expandable, meaning that as new procedures are
transferred to day surgery, the same infrastructure can be used with appropri-
ate retraining of staff.
Pre-operative Assessment
Once the decision to operate has been established and the intended procedure is
planned as a day case, a dedicated pre-assessment team, generally made up of
trained nurses, should comprehensively assess the patient. This assessment
should ideally take place in the same unit in which the procedure will take place
but can be undertaken remotely via telephone or computer. It should happen far
enough in advance so that patients’ co-morbidities, medications, and social factors
can be optimised preoperatively.
The pre-operative assessment begins with gathering information about health,

medications, and social circumstance. The health assessment is generally history-
based and most commonly involves a questionnaire with basic screening ques-
tions and more detailed history where appropriate. Pre-operative examination
and investigations including blood tests, ECG, and X-rays are less useful in most
patients. A decision is then made regarding whether the patient is suitable for day
surgery. Modern ambulatory units have moved away from a specific set of con-
traindications and instead assess patient suitability individually according to the
combination of physiological status, social circumstance and intended procedure.
Social Selection Criteria
Several social factors must be considered before ambulatory surgery. Patients or

carers must be able to understand the nature of the procedure, and be willing to
adhere to the peri-operative instructions. Patients must have appropriate support
at home; in general, they need to be discharged into the care of a responsible adult
for 24 hours after the operation, although this is probably excessive for some
minor operations. Additionally, a generally accepted rule is that they must live
within one hour’s travel time to the surgical unit. In those living remote from
ambulatory unit, the option of an overnight local lodging can be discussed, instead
of overnight hospital admission.
Physical Selection Criteria
There are multiple factors that reduce the suitability of patients for day surgery
and must be assessed in detail prior to surgery (Fong 2014). Identifying high-risk
patients can help facilitate a multidisciplinary strategy to optimise their pre-
operative condition, anticipate intraoperative challenges, and plan postoperative
disposition (Walsh 2018). Although a comprehensive review of these is beyond
the scope of this chapter, we will mention a few notable parameters.
Age should not independently decide whether a patient is suitable. In one study,
elderly patients did not have worse outcomes than younger patients (Chung
1999), although in another, advanced age was associated with greater rates of
readmission (Whippey 2013). Ambulatory surgery may actually confer some
benefits to the elderly population, having been shown to reduce rates of post-
operative cognitive dysfunction (Rasmussen 2015).
The American Society of Anaesthesiologists grading system (ASA grade) is used
to evaluate a patient’s physical state before surgery and classifies patients into
6 categories. Grade 1 being a normal healthy patient and grade 5 being moribund
patient. The ASA grade is not a particularly useful measure of suitability for day
surgery. An ASA 3 patient does not experience greater complication rates when
compared to an ASA 1 or 2 in the medium to late post-operative period (Ansell
2004). Some ASA 4 patients may also be suitable for procedures undertaken using
local or regional anaesthesia.
Suitability of obese patients is a controversial area, a body mass index (BMI) of
up to 40 being acceptable for the majority of procedures and many anaesthetists
would accept higher BMIs (Atkins 2002). Complication rates do appear to be
higher in the extremely obese group (BMI > 50 kg/m2), although readmission
rates are not significantly greater (Joshi 2013).
With regards to chronic medical conditions, a general rule is that stable patients
are fit for ambulatory surgery. Chronic obstructive pulmonary disease (COPD) is
not a contraindication for ambulatory surgery. Asymptomatic patients have a low
risk of post-operative complications, but those who have been symptomatic
within a month of the proposed surgery may need to have their procedure
postponed (Warner 1996). Smokers should be encouraged to stop smoking, as
even short-term cessation pre-operatively has been demonstrated to reduce
complications (Myles 2002). Patients with obstructive sleep apnoea should have
good control of symptoms and be established on nasal continuous positive airway
pressure pre-operatively and during the post-operative period.
Cardiovascular status should also be assessed pre-operatively. Patients with hyper-
tension should have their blood pressure reasonably controlled. The majority of
those with ischaemic heart disease will be suitable, except for those with unstable or
severe angina and those who have experienced recent myocardial infarction.
Additionally, ambulatory surgery is generally not undertaken within a year of drug-
eluting stent placement (Wijeysundera 2012). Diabetes mellitus does not itself pre-
clude a patient from day surgery; in fact, day surgery reduces disruption to normal
routine. However, patients should ideally be screened for other co-morbidities
including cardiovascular and renal dysfunction. Patients with end-stage renal failure
may be appropriate for minor ambulatory procedures undertaken under local or
regional anaesthesia but, given their poor physiological state and the practical issues
with regards to dialysis, major ambulatory operations are generally contraindicated.
Preparation for Surgery
Once the patient has been adequately assessed and deemed suitable for ambula-
tory surgery, the clinical team will start to prepare. This will involve completion of
any further anaesthetic investigations and surgical diagnostics. Consent should be
obtained with explanation and post-operative plan discussed.
The patient must be given appropriate information regarding the perioperative

period. This will include an overview of fasting requirements, medications that
need to be taken, and information pertaining to personal hygiene. In addition,
simple information about location and timings should be provided. Finally, the
patient and carer/responsible adult should be given information on whom to con-
tact for queries or help with post-operative complications.
Anaesthesia
Pre-operatively, a full anaesthetic assessment should be performed, including pre-
vious anaesthetic history, post-operative nausea and vomiting (PONV) risk, and
an airway assessment. PONV a common complication of anaesthesia, occurs most
often in females, those with a similar past history, those with motion sickness,
nonsmokers, and those requiring post-operative opioids (Apfel 1999). Pre-
operative assessment should aim to identify risk factors for difficult pain control
allowing for individualised perioperative analgesia planning.
Most current anaesthetic agents convey predictable and rapid recovery.
Desflurane-based anaesthetic has been reported to have the most predictable
emergence from anaesthesia (Dexter 2011; Watchel 2011), although desflurane
and sevoflurane-based anaesthesia appear to provide equal numbers of patients
eligible for fast-tracking (White 2009). Propofol is frequently used for induction
and maintenance of ambulatory anaesthesia, due to rapid metabolism and emer-
gence, few side-effects, and low rates of PONV.
Depth of anaesthesia monitors, such as Bi-spectral Index (BIS), facilitate drug
titration and have been shown to reduce drug consumption, reduce PONV (Liu
2004), and reduce rates of post-operative cognitive dysfunction in elderly patients
(Chan 2013).
Post-operative pain will vary according to patient factors as well as the specifics
of the surgical procedure and anaesthesia used. Utilising minimally invasive sur-
gical techniques and regional anaesthesia are obvious ways to reduce pain.
Regional anaesthetic techniques such as peripheral nerve blockade or neuraxial
blockade, can mitigate the side effects of general anaesthesia such as PONV and
aspiration pneumonia and may accelerate recovery by facilitating early analgesia
(Moore 2013) and reducing opioid requirement. For neuraxial blocks, drug selec-
tion and dosing must be carefully considered so that prolonged effects do not
delay discharge.
A number of antiemetics have been investigated and compared for efficacy. The
5HT3 antagonists such as ondansetron have good efficacy, especially when used
in combination with dexamethasone. These should be started before the end of
anaesthesia (Tang 1998) and continued in the community if necessary. Side effects
should be evaluated when choosing an agent. Dexamethasone should be avoided
in patients with lymphoma because of risk of tumour lysis syndrome. Ondansetron

should be avoided in patients with, or at risk of long QT.
Early Recovery: Emergence from Anaesthesia

Early recovery commences from the discontinuation of anaesthetic agents, allow-
ing the patient to emerge from anaesthesia, recover airway reflexes and resume
motor activity. Classically, this occurs in the post-anaesthesia care unit (PACU),
before stepping down to the day-surgery unit (DSU). The modified Aldrete scor-
ing system can be used for determining when patients are fit for discharge from
PACU (Aldrete 1995).
There is a growing trend towards ‘fast-track’ of patients directly from the operat-
ing theatre to the DSU, bypassing PACU. This is (i) safe as many patients achieve
step-down criteria from PACU as soon as they arrive, and (ii) economically effi-
cient as PACU is more labour intensive. Complication rates in PACU are low, with
one group demonstrating rates of 8%, of which only 0.7% were respiratory or cir-
culatory (Duncan 1992).
One group achieved fast-track rates of over 80% in simple orthopaedic proce-
dures, with patients being successfully discharged home earlier (Duncan 2001).
Fast-track is more achievable with desflurane and sevoflurane-based anaesthesia
(Song 1998) and with BIS, ensuring minimum necessary anaesthesia and quicker
recovery (Song 1997).
The modified Aldrete scoring system is limited in deciding whether patients are
fit for fast-track as it does not consider pain, nausea, or vomiting which are gener-
ally addressed in PACU. White’s criteria (White 1999), or the WAKE score (2011)
are more appropriate. Ultimately, patient safety should always be maintained and
a clinical judgement should be made as to whether fast-track is appropriate.
Achieving adequate pain relief is an important factor for patient satisfaction
and should be managed with objective methods of pain evaluation and evidence-
based protocols for pain control. Utilisation of ibuprofen and celecoxib have been
demonstrated to improve recovery (White 2011), probably because they are asso-
ciated with lower opioid requirements and reduction of oedema. Units have
developed protocols with routine use of multimodal analgesia, including non-
steroidal anti-inflammatory drugs (NSAID), local anaesthetic techniques, and
opioids as necessary. These protocols and methods have demonstrated improved
post-operative pain control and patient satisfaction (Elvir-Lazo 2010).
Intermediate Recovery: Discharge Criteria

There is an increasing pressure for rapid discharge of patients. However, this must
be balanced with the risks associated with premature discharge, including read-
mission, complications, and legal consequences. Several scoring systems exist,
guiding clinicians about safe discharge. The Post Anaesthesia Discharge Scoring
System (PADS) (Chung 1995) is one utilised example and includes observations,
patient orientation, bleeding, and post-operative symptoms including pain and
nausea. Post-operative voiding and tolerance of oral intake are also included in
this scoring system.
The type of anaesthesia and surgery can be a determinant of post-operative
voiding function. Specific to pelvic-floor procedures is the effect of anaesthesia on
bladder function. The insertion of the mid-urethral sling has been performed
under both regional and local anaesthetic, with regional anaesthesia having been
found to increase the rates of post-operative urinary retention (Adjusted OR = 4.4,
95% CI 1.9, 10.2) (Wohlrab 2009), a factor that could influence length of stay.
A systematic review looking at the effect of anaesthesia on bladder function,
found the dose of intrathecal local anaesthetic used with regional anaesthetic, as
well as the potency of the anaesthetic used, to correlate with the duration of blad-
der dysfunction (Choi 2012). Encouragingly, a retrospective review of 119 patients
who were discharged the same day as undergoing outpatient tension-free vaginal
tape (TVT) surgeries found no significant difference in the need for catheteriza-
tion among patients who received spinal anaesthesia compared to those who
received general or local anaesthetic with sedation (Barron 2006).
Voiding before discharge has been a core concept in ambulatory surgery,
because of the concern that patients may develop urinary retention, bladder atony,
and subsequently renal complications. However, there is good evidence (Pavlin
1999) that patients at low risk of urinary retention can be discharged without
needing to void, but with clear instructions to seek medical attention if unable to
void within eight hours of discharge. On the other hand, the literature and opin-
ions are mixed regarding patients at high risk of retention. Guidelines support
that those who have not voided within three hours post-operatively should receive
bladder scanning; if >600mls is present, then they will need catheterisation with
trial without catheter (TWOC) in the community (Pavlin 1999).
Tolerance of oral fluids was also previously mandated before discharge.
However, several studies have proven that this does not improve outcomes and
may even worsen rates of nausea and vomiting (Jin 1998, Kearney 1998), making
this a historic requirement.
Once discharge criteria have been met, patients should be supplied with ade-
quate analgesia and clear instructions to take it regularly to prevent breakthrough
pain. Prepackaged medication is convenient, prevents delays, and eliminates the
need for a patient or carer to visit the pharmacy. Patients should be given clear
verbal and written instructions on what they should and should not do, alongside
contact details in case of emergency or concerns about symptoms or complica-
tions. Patients should be discharged with a responsible adult to accompany them,
and those who have had a general anaesthetic should be advised to avoid alcohol
and driving for 24 hours.
Late Recovery: Care After Discharge

Patients are discharged from ambulatory surgery once their baseline physiological
states have returned. Although major complications and morbidity are rare
(Warner 1993), residual symptoms and side effects are not uncommon. Patients
need to be followed up in the community. This can happen through telephone
consultations (Kamming 2004), GP/nursing follow-up, outpatient clinics or
‘mhealth apps,’ on smartphones (Hwa 2013, Armstrong 2014). A dedicated con-
tact phone number or routine follow-up call the next day, may help avoid unsched-
uled emergency or general practitioner visits after discharge. Telephone follow up
has reported high satisfaction rates (>90%) with all women preferring it to an
office visit (Schimpf 2016). Ambulatory centres should consider this as a routine
part of their postprocedure care. Follow-up should consider pain, nausea, bleed-
ing, oral intake, voiding, bowel function, fever, sore throat, disorientation, and
psychological status.
Setting Up an Ambulatory Centre
Planning a new ambulatory unit is a major undertaking. A board team, consisting

of at least a surgeon, anaesthetist, nurse, and project manager should be set up.
Market research must be performed, considering demand and financial viability.
Local health authorities and regulatory bodies must be involved. The location
must be identified taking into account transport links, and infrastructure must be
decided upon.
Staff must be recruited and appropriately trained. Nurses must be educated in
pre-operative triage/assessment and be trained in assessing patients post-
operatively for discharge using standardised protocols. They should be able to
engage the patient and family in the process of ambulatory surgery to ensure
compliance and success. Anaesthetic teams must be trained in appropriate
techniques for day surgery. Surgical teams must stay up to date with guidelines,
such as the British Association of Day Surgery (BADS) directory, which makes
recommendations on which procedures are appropriate in the ambulatory setting.
All groups should demonstrate competency in dealing with emergency scenarios.
An ambulatory surgical checklist should be developed and tailored to different
specialities. Staff should be trained in communication skills. The ‘Situation-
Background-Assessment-Recommendation (SBAR)’ tool is a useful framework.
Formal training in teamwork should ideally be given, generating a patient-centred
culture of safety. Systems should be established to deal with unprofessional behav-
iour, mistakes, and complaints. An audit and quality improvement team must be
set up. Staff must be trained in hand hygiene and infection control.
The design of the unit is central to its success. The capacity must be determined,
including theatre number and bed number. From this, an estimate of size can be
extrapolated. The board team and architect must decide on build type, storage,
and sterilisation facilities. They then must consider which ‘model’ to follow. The
‘racetrack’ model has a uni-directional flow path, meaning that pre- and
post-operative patients are not mixed and there is no congestion of flow. The dis-
advantage of this model is that more space is required to house pre- and post-
operative patients in separate areas and at certain times of the day, there will be
unused space. The ‘non-racetrack’ model conversely does mix patients, economis-
ing on space, but possibly at the detriment of quality.
Following this, members of the board team need to consider space for recep-
tion, patient’s changing rooms, toilets, consulting rooms, staff common rooms
and catering facilities. Medical gas supply must be incorporated into the design.
Hardware such as trolleys, operating tables, beds, blood fridges, and emergency
trolleys must be thought out. Operating theatres must be designed and anaes-
thetic equipment taken into account.
Following the design, a business plan should be constructed, including the capi-
tal costs, income, and expenditure over the next five years. This will need to be
presented to investors or local funding panels
Economics of Ambulatory Surgery

The economic benefits of ambulatory surgery are a major drive for uptake.
A number of studies have demonstrated the cost-effectiveness of various proce-
dures when performed in the outpatient versus inpatient setting (Hollingsworth
2012). In 1990, the UK’s Audit Commission suggested that if all health authorities
in England and Wales performed day surgery consistently for 20 common proce-
dures, an additional 186 000 patients could be treated each year without increased
costs. This led to the England’s Department of Health recommendation that 75%
of all elective surgery be undertaken as day-case procedures (Alan Milburn NHS
plan 2002). The UK Department of Health’s reference costs for 2013–2014 calcu-
lated that the average day-case cost was £698 compared to £3375 for elective inpa-
tient cases (reference costs 2013–2014).
These economic benefits stem from shorter hospital stays, with reduced wait-
ing lists and higher patient turnover; fixed scheduling with reduced cancella-
tions; staff reductions with lower overnight capacity; reduced operating times
and lower costs associated with post-operative care (Aboutarabi 2014).
Furthermore, patients benefit from reduced disruption from normal routine and
quicker recovery back to work.
Various strategies have been proposed to economise even further within ambu-
latory surgery. Nerve blocks for reduction of pain, fast-tracking, and modifying
the type and amount of anaesthesia have all been investigated in detail. Future
innovations in terms of surgical technology and technique, anaesthesia and post-
operative monitoring including the use of telemedicine will likely further the
scope and economic efficiency of ambulatory surgery.
Complication Rates
Transfer to an acute care facility or hospitalisation after discharge is often used as
a marker of the complication rate for day-care surgery. Outpatient gynaecological
and urogynaecology procedures have been successfully performed with very few
patients (1.6%) requiring inpatient treatment within 72 hours (Kannan 2008).
Similar results have been replicated in numerous studies of urology patients.
A multicentre quality improvement project performed in the USA found that
12% of patients undergoing other ambulatory surgery required hospital transfer
and 10% required hospitalisation or an emergency room attendance within
48 hours of discharge from the day-care unit (Davis 2019).
Conclusion
Redistributing surgical procedures from the inpatient setting to ambulatory cen-

tres can be done without impacting quality. Ambulatory surgery confers substan-
tial advantage and will continue to increase in popularity, in line with economic
pressures. Re-evaluation and improvement are central to its success and units
should routinely audit their cases and outcomes, along with the incorporation of
novel techniques and innovations.
Further Reading
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minimization analysis of day-care versus in-patient surgery for five most common
general surgical procedures. Journal of Health Policy and Sustainable Health.
1 (2): 33–36.
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7 (1): 89–91.
Ansell, G.L. and Montgomery, J.E. (2004 Jan). Outcome of ASA III patients
undergoing day case surgery. Br J Anaesth. 92 (1): 71–74.
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predicting postoperative nausea and vomiting: conclusions from cross-validations
between two centers. Anesthesiology. 91 (3): 693–700.
Armstrong, K.A., Semple, J.L., and Coyte, P.C. (2014 Sep 22). Replacing ambulatory
surgical follow-up visits with mobile app home monitoring: modeling cost-
effective scenarios. J Med Internet Res. 16 (9): e213.
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system for home readiness after ambulatory surgery. J Clin Anesth. 7 (6): 500–506.
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surgery. A comparison between elderly and younger patients. Can J Anaesth.
46 (4): 309.
Davis, K.K., Mahishi, V., Singal, R. et al. (2019). Quality Improvement in Ambulatory
Surgery Centers: A Major National Effort Aimed at Reducing Infections and Other
Surgical Complications. J Clin Med Res. 11 (1): 7–14.
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average and variability of time to extubation for meta-analysis comparing
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centre study of anaesthetic outcomes: III. Are anaesthetic complications
predictable in day surgical practice? Can J Anaesth. 39 (5): 440.
Duncan, P.G., Shandro, J., Bachand, R., and Ainsworth, L. (2001 Aug). A pilot study
of recovery room bypass (“fast-track protocol”) in a community hospital. Can J
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ambulatory surgery: role of multimodal analgesia. Anesthesiol Clin. 28 (2): 217–224.
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undergoing ambulatory surgery. Curr Anesthesiol Rep. 4 (4): 303–315.
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Medicare beneficiaries undergoing outpatient urological surgery. J Urol. 188 (4):
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ambulatory surgery. J Perianesthesia Nurs Off J Am Soc PeriAnesthesia Nurses.
19 (3): 174–182.
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17
Section II
Ambulatory Urogynaecology
19
Introduction and Epidemiology of Pelvic Floor

Dysfunction
Jay Iyer and Ajay Rane
Introduction
The pelvic floor consists of the muscles, ligaments, and connective tissue that
constitute the pelvic organ supports. The pelvic organs include the bladder,
uterus and cervix, vagina, rectum and bowel. The supporting pelvic floor not
only prevents the descent of these organs, but also maintains their anatomical
position and helps in their normal function. Pelvic floor dysfunction (PFD) is
a group of disorders that affects these various structures and can therefore
lead to bladder and/or bowel dysfunction.The condition cannot only affect
daily activities, sexual function, and exercise, but it can also impact negatively
on one’s emotional and psychological state. The presence of pelvic floor
dysfunction can have a detrimental impact on body image and sexuality.
Diagnosis is often delayed because most women are embarrassed to discuss
their condition.
Types of Pelvic Floor Dysfunction
Pelvic Organ Prolapse (POP)

The International Continence Society (ICS) defines prolapse as the descent of one
or more of the anterior vaginal wall, the posterior vaginal wall, and the apex or the
vault of the vagina. Symptoms generally include difficulty in emptying the blad-
der or rectum, urinary or faecal incontinence, pelvic pressure, vaginal bulge and/
or sexual dysfunction.
Urinary Incontinence
ICS defines urinary incontinence (UI) as the involuntary loss of urine. The most
common recognised subtypes of UI are stress urinary incontinence (SUI), urge
urinary incontinence (UUI), and mixed urinary incontinence (MUI). Overactive
bladder (OAB) syndrome presents most commonly as urinary urgency, and can be
accompanied by frequency and nocturia, with or without urge incontinence, in
the absence of urinary tract infection (UTI) or other obvious pathology.
Anal Incontinence
Includes the involuntary passage of gas, mucus, liquid, or solid stool. The most
common type of incontinence is watery/liquid stool (>20%), followed by hard and
normal stool (approximately 9% for both). The prevalence as suggested by interna-
tional population-based studies of faecal incontinence is between 0.4 and 18%.
Paradoxical Puborectalis Contraction

The puborectalis muscle, part of the levator ani muscle, wraps like a sling around
the lower rectum, acts to control the anorectal angle and consequently facilitates
evacuation of bowel content. During a bowel movement, the puborectalis muscle
relaxes to allow the bowel contents to pass. If the muscle does not relax and/or
contracts paradoxically, it can lead to straining and functional constipation, which
is challenging to treat.
Levator Syndrome
Levator syndrome refers to abnormal muscle spasms of the pelvic floor. Spasms may
occur after a bowel movement or may be idiopathic. Patients often have long periods
of vague, dull, or achy pressure high in the rectum. These symptoms may worsen
when sitting or lying down. Levator spasm is more common in women than men.
Coccygodynia
Coccygodynia is pain of the coccyx, usually worsened with movement and after
defecation. It is usually caused by trauma to the coccyx, although in a third of
patients no cause may be found.
Proctalgia Fugax
This functional disorder is caused by spasms of the rectum and/or the muscles of
the pelvic floor, leading to sudden abnormal anal pain that often awakens patients
from sleep. This pain may last from a few seconds to several minutes and goes
away between episodes.
Pudendal Neuralgia
The pudendal nerves are mixed nerves, with predominant sensory supply to the
pelvic floor, external genitalia and perineum. Pudendal neuralgia is chronic pelvic
floor pain involving the pudendal nerves. This pain may first occur after child-
birth, but often waxes and wanes without reason.
Epidemiology
The prevalence of PFD increases steadily with age. With improved life expectancy,
the prevalence and burden of the disorder is bound to increase. The burden of the
disease is perceived not just at an individual level but healthcare providers also are
affected and the impact on healthcare is likely to increase.
Pelvic Organ Prolapse
About 316 million women suffer from genital prolapse worldwide. Based solely
on patient symptoms, the prevalence of pelvic organ prolapse (POP) is 3–6%; how-
ever, it rises up to 50% if based on clinical examination because most of the mild
cases are asymptomatic. According to the Women’s Health Initiative (WHI) in the
United States, 40% of women have some degree of POP with 14% having uterine
prolapse. The incidence of POP surgery varies from 1.5–1.8 per 1000-woman years
with peak age at 60–69. The probability of having a surgical correction for POP by
age 80 is estimated to be one in five.
Based on the WHI data, incidence of stage 1–3 prolapse is estimated to be 9.3
per 100 woman-years for cystocele, 5.7 per 100 woman-years for rectocele, and 1.5
per100 woman-years for uterine prolapse. Prolapse progression ranged from 1.9%
for uterine prolapse, to 9.5% for cystocele, and 14% for rectocele. Older, parous
women are more likely to develop new or progressive prolapse.
In the United States, POP is thought to be the leading cause of more than
300 000 surgical procedures per year with 25% undergoing reoperations at a total
cost of more than one billion dollars annually. The estimated direct annual cost of
ambulatory care utilisation for pelvic floor disorders during a nine-year period
(1996–2005) increased by 40% and, if extrapolated to POP surgery, the total annual
cost would be over 1.4 billion.
UI is more common in women than men and studies from numerous countries have
reported the prevalence of UI in women to range from approximately 5–70%, with
most studies reporting a prevalence of any UI in the range of 25–45%. In nonpreg-
nant women aged 20 years and above, the prevalence has been reported at 10–17%.
These figures increase with increasing age, and in women 65 years and older, more
than 50% of the population is affected. The estimated cost of UUI with OAB in the
United States during 2007 was $65.9 billion, with projected costs of $76.2 billion in
2015 and $82.6 billion in 2020. With the addition of SUI, this figure may be higher.
Anal Incontinence
The prevalence and epidemiology of anal incontinence is poorly documented and

under-reported by patients primarily due to embarrassment and concerns regard-
ing treatment options. The prevalence of faecal incontinence in American women
is estimated to impact 2.2–24% depending on the definition used. Severe faecal
incontinence, defined as incontinence greater than or equal to one episode
monthly, is reported to be present in 6.3% of women.
Furthermore, obstetric anal sphincter injuries in vaginal births are serious com-
plications that share a well-known association with anal incontinence. Injury to
the anal sphincter during childbirth approximately doubles the risk of developing
anal incontinence within six months after a first delivery.
Predisposing Factors
●● Genetic predisposition: Women with prolapse were more likely to have posi-
tive family history and an increased prevalence of congenital weakness of con-
nective tissue. A systematic review of genetic studies found that collagen type 3
alpha 1 was associated with POP (OR 4.79).
●● Age: According to The National Institute of Health study, the prevalence of
PFD varies from 10% at ages 20–39 years, 27% at 40–59 years, 37% at 60–79 years
to nearly 50% affected at 80 years of age and older. The US National Health and
Nutrition Examination Survey 2005–2010 stated that the prevalence of faecal
incontinence increased from 2.91% among the 20–29 years old to 16.16% among
participants 70 years and older.
●● Race: Although the evidence is scarce, Latin and Caucasian women were found
to have a higher risk of symptomatic POP as compared to African American
women. Similarly, the age-adjusted prevalence of weekly UI varied based on
ethnicity. Hispanic women had the highest rates, followed by white, black, and
Asian American women (36, 30, 25, and 19% respectively, p > 0.001). It may be
important to note the bias due to the impact of culture-based differences in
perception of symptoms.
●● Obesity: Increased body mass index (BMI) is an independent risk factor for
pelvic floor disorders and progression of POP. Weight loss has not been associ-
ated with prolapse resolution, but studies have shown that weight loss through
lifestyle changes and/or bariatric surgery in overweight or obese women
improves both urinary and faecal incontinence.
●● Parity: Though vaginal birth has been considered the most important inciting
factor for pelvic floor disorders, pregnancy itself has been shown to be a risk
factor. Studies have shown a direct correlation between the incidence of pelvic
floor disorders and parity: 12.8, 18.4, 24.6, and 32.4 for 0, 1, 2, and 3 or more
deliveries, respectively (P < 0.001). Operative vaginal deliveries and perineal
lacerations increase the risk further. Spontaneous vaginal birth as compared to
caesarean birth without labour has been associated with higher rates of pro-
lapse or stress incontinence.
●● Smoking: The Pelvic Organ Support Study (POSST) 2005, revealed that smok-
ing was an independent risk factor for pelvic disorders including POP and
UI. The prevalence of prolapse increased significantly amongst nulliparous
smokers as compared to nulliparous non-smokers (28vs 12%, adjusted OR 1.95).
●● Medical disorders: Studies have shown an association between pelvic floor
disorders and various medical conditions including diabetes mellitus, connec-
tive tissue disorders, chronic obstructive pulmonary disease (COPD), and cer-
tain neurological diseases.
●● Coexisting pelvic floor disorders: Pelvic floor disorders often coexist. Patients
with POP often complain of SUI due to obvious reasons. It is often difficult to
find patients with any one form of incontinence as most patients have concur-
rent stress and urge incontinence. Therefore, it is important to analyse these
patients thoroughly before formulating a treatment plan.
●● Others: Traumatic injury to the pelvic region including injuries due to pelvic
surgery or pelvic irradiation and heavy lifting are associated with PFD.
Pelvic Organ Support
Pelvic Floor
The pelvic floor consists of muscular and fascial structures. It encloses the pelvic
cavity, the external vaginal opening (for intercourse and parturition), and the
urethra and rectum (for elimination). The pelvic muscles provide the primary
support and with the connective tissue (endopelvic fascia) keep pelvic organs in
proper alignment. Together they stabilise, support, and also help in appropriate
functioning of the pelvic organs. A sound understanding of the clinical relevance
of the bony, muscular, and fascial supports is vital to optimise the surgical tech-
niques in pelvic surgery.
Muscular Support
The levator ani muscle and associated connective tissue attachments constitutes
the pelvic diaphragm. It has two main components that function as a unit: the
diaphragmatic part (iliococcygeus and coccygeus muscles) and the pubovisceral
part (puborectalis and pubococcygeus). The pelvic diaphragm is stretched like a
hammock from pubis to coccyx and is attached along the lateral pelvic walls to a
thickened band in the obturator fascia, the arcus tendineus levator ani (ATLA).
The iliococcygeus spans from the ATLA between pubis and ischial spine (IS) to
insert in the midline onto the anococcygeal raphe and the coccyx. The anococcy-
geal raphe between the anus and coccyx is referred to as the levator plate and
provides support to the uterus, upper vagina, and rectum. The coccygeus muscle
originates from the IS and inserts on the lateral lower sacrum and coccyx and
overlies the sacrospinous ligament. It often blends with the sacrospinous ligament
making it difficult to distinguish the two as they both share a common origin and
insertion.
The puborectalis arises from the posterior inferior pubic rami and passes poste-
riorly forming a U-shaped sling around the vagina, rectum, and perineal body to
form the anorectal angle. Some of the fibres of the muscle intermingle with the
anal sphincter muscle and contribute to faecal continence. The pubococcygeus
has a similar origin, but it inserts in the midline onto the anococcygeal raphe and
the anterolateral borders of the coccyx. The openings between the levatorani mus-
cles through which the urethra, vagina, and rectum pass are known as the uro-
genital hiatus (Figure 2.1).
The pelvic floor muscle fibres maintain resting tone (type I or slow-twitch
fibres) to support the pelvic viscera, and voluntarily contract (type II or fast-twitch
fibres) when required. It is the skeletal component that contracts to help maintain
continence in acute stress states such as cough, laugh, or sneeze. Contraction of
the levator ani can be assessed and felt as a U-shaped sling on rectovaginal
examination.
The levator ani muscle may get thinner and attenuated with ageing and
POP. Neuromuscular injury to the levator, as occurs during childbirth, can lead to
widening of the urogenital hiatus, which leads to vertical inclination of the leva-
tor plate with resulting pelvic organ dysfunction or POP. Levator avulsion, a docu-
mented injury of childbirth, involves the detachment of the puborectalis portion
from the pelvic sidewalls. It occurs in about 36% of women after vaginal delivery
UROGENITAL DIAPHRAGM
Urethral opening
Vaginal opening
Rectal opening
Obturator internus
Puborectalis
Pubococcygeus
Illiococcygeus
Figure 2.1 Levator ani muscle –pubococcygeus, puborectalis, and iliococcygeus.
and about 50–60% after forceps delivery. Avulsion can be diagnosed digitally by
palpating the inferior pubic ramus and feeling for the insertion of the puborectalis
portion. In the presence of levator avulsion, 2–3 cm lateral to the urethra, the bony
surface of the pubic ramus can be palpated devoid of the muscle.
The perineal body is an important structure that supports the distal vagina and
maintains normal rectal function. Lying between the distal vagina and anus, it
provides insertion of bulbospongiosus, superficial, and deep transverse perineal
muscles, external anal sphincter, perineal membrane, distal part of rectovaginal
fascia (RVF), pubococcygeus and puborectalis portions of the levator ani. Surgical
reconstruction of perineum (perineorrhaphy) requires proper approximation of
these muscles in order to restore the normal function of perineal body (Figure 2.2).
The perineal membrane (formerly known as the urogenital diaphragm) is a
thick fibromuscular sheet that stretches across the anterior urogenital triangle. It
attaches laterally to the ischiopubic rami and has a free posterior margin with
anchorage at the perineal body. The urethra and vagina pass through the hiatus in
the perineal membrane. The perineal membrane therefore fixes the distal urethra,
distal vagina, and the perineal body to the bony pelvis at the ischiopubic rami. The
Bulbospongiosus
lschiocavernosus
Perineal body
Superficial
transverse
perinei
Puborectalis
Pubococcygeus
Iliococcygeus
Gluteus maximus
Figure 2.2 Perineal body with its muscular attachments.
superficial perineal space lies external to the perineal membrane and contains the
superficial perineal muscles, ischiocavernosus muscle, bulbospongiosus muscle,
and superficial transverse perineal muscles.
The deep perineal pouch lies between the perineal membrane and levator ani
and contains the external urethral sphincter, the compressor urethra, urethrovagi-
nalis, and the deep transverse perineal muscles (Figure 2.3).
Fascial Support
The parietal and visceral (endopelvic) fascia constitute the fascial components.
Parietal fascia covers the pelvic skeletal muscles and provides attachment of mus-
cles to the bony pelvis extending from the lateral pelvic wall to the superior sur-
face of pelvic diaphragm, and it is characterised histologically by regular
arrangements of collagen. The obturator fascia covering the obturator muscle has
two parts: ATLA and arcus tendineus fascia pelvis (ATFP), extending from IS to
posterior pubis. Visceral endopelvic fascia is less discrete and not a true fascia but
Deep perineal pouch

Perineal membrane
Deep
Vaginal opening transversus
perineal
Urethral opening muscles
Compression
urethrae
Sphincter urethrovaginalis
External urethral sphincter
Figure 2.3 Muscles of the deep perineal pouch.
is endopelvic connective tissue. It contains a meshwork of loosely arranged col-

lagen, elastin, and adipose tissue through which the blood vessels, lymphatics,
and nerves travel to reach the pelvic organs. By surgical convention, condensa-
tions of this fascia have been described as discrete ‘ligaments’, such as the cardi-
nal, uterosacral, pubovisceral, and pubourethral ligaments. The endopelvic tissue
is a continuous layer extending from the uterosacral ligaments proximally to the
pelvic portion of levator ani muscle distally, up to the level of urethra. The fascia
also extends from the lateral wall of the cervix and vagina to the pelvic sidewall
along the ATFP. This attachment stretches the vagina horizontally between the
bladder and rectum thereby dividing the pelvis into an anterior and posterior
compartment. The bladder and urethra occupy the anterior compartment; the
rectum and anal canal, the posterior compartment; and the uterus and cervix, the
middle or apical compartment.
DeLancey (1994) described the three integrated levels of pelvic support defined
by the endopelvic connective tissue attachments to explain POP (see Table 2.1).
All are connected through a continuation of the endopelvic fascia (Figure 2.4).
Table 2.1 Level of supports, with diagnosis and co-relation to symptoms.
Level of pelvic
organ support Organ affected Type of Prolapse Symptoms
Level Uterus and cervix/ Uterocervical/ Vaginal pressure, sacral

I – uterosacral vaginal vault vault prolapse/ backache, ‘something
ligaments/ enterocele coming down’,
Cardinal ligaments dyspareunia, vaginal
discharge
Level II – arcus Anterior - Urinary Cystocele ‘Something coming down’,
tendineus fascia bladder double voiding, occult
pelvis (ATFP) stress incontinence,
recurrent urinary tract
infections

Posterior – Rectum Rectocele ‘Something coming down’,
difficult defecation,
manual digitation
Level III – anterior Urethra Urethrocele ‘Something coming down’,
(pubourethral stress incontinence
ligaments)
Level Lower third of the Enlarged Vaginal laxity, sexual
III – posterior vagina/ vaginal genital hiatus dysfunction, vaginal flatus,
(perineal body) introitus/anal canal needing to apply pressure
to the perineum to
evacuate faeces
Rectum
LEVEL I
Uterosacral/cardinal
Cervix ligament complex
External anal
sphincter
LEVEL II
Arcus tendineus
fascia pelvis Arcus tendineus
Arcus tendineus levator ani
fascia rectovaginalis
Perineal membrane
(posterior) Perineal body
LEVEL III Vagina
(anterior) Pubouretheral ligaments
Urethra
Figure 2.4 The endopelvic fascia in a post-hysterectomy patient divided into DeLancey’s
biomechanical levels: level I, proximal suspension; level II, lateral attachment; level III,
distal fusion.
Level I Support
The cervix and upper vagina are suspended by the endopelvic fascia (parametria)
and condensations of the connective tissue, the uterosacral and cardinal liga-
ments. The uterosacral ligaments pass from the posterior aspect of the cervix and
upper vagina, form the lateral boundaries of the pouch of Douglas, and attach to
the anterior surface of the sacrum at the level of the sacrococcygeal joint up to the
level of S3. The uterosacral ligaments are each 12–14 cm long and subdivided into
distal (2–3 cm), intermediate (5 cm), and proximal (5–6 cm). The distal portion is
commonly used to anchor the vaginal apex in McCall’s culdoplasty. The proximal
portion is diffuse in attachment and generally thinner. The intermediate portion
is thick, well defined, and at least 2.5 cm away from the ureter and hence suitable
for suspension procedures. The cardinal ligaments (transverse cervical) attach to
the posterolateral pelvic walls from the cervix and lateral vaginal fornix. These
attachments are referred to as the level I or suspensory support. Together, they
support the lower uterus, cervix, and upper vagina. They also maintain vaginal
length and a nearly horizontal vaginal axis supported by the levator plate. Failure
of the level I support leads to uterine or vaginal vault prolapse (apical prolapse).
Level II Support
The fascial attachment in the mid-vagina extends from the lateral vaginal walls to
the ATFP anteriorly and arcus tendineus rectovaginalis posteriorly. It maintains
the midline position of the vagina directly over the rectum and prevents the
descent of the anterior and posterior vaginal walls with increased intra-abdomi-
nal pressure. The ATFP shares the same origin as ATLA at the ischial spine.
However, it traverses infero-medially to the ATLA before it inserts on the inferior
aspect of the superior pubic rami over the origin of the puborectalis muscle. This
explains the normal axis of the upper vagina, as the axis of both ATLA and ATFP
are nearly horizontal in a standing woman (Figure 2.5). The endopelvic fascia
blends with the vaginal muscularis anteriorly, the rectal muscularis posteriorly,
and the perineal body inferiorly. The arcus tendineus rectovaginalis is approxi-
mately 4 cm in length and changes the axis of the distal vagina towards the vertical.
The endopelvic connective tissue also extends as pubourethral ligaments, from
the urethra to the posterior surface of the pubic bone, providing urethral support
and maintenance of bladder neck closure during Valsalva manoeuvres. The blad-
der neck through its relation to the anterior vaginal wall is also indirectly sup-
ported by its attachment axis. Hence, failure of level II support leads not only to
anterior and posterior vaginal wall prolapse but may also lead to SUI.
The differentiation between a ‘central cystocele’ and a ‘paravaginal defect’ in
anterior compartment prolapse is based on the type of endopelvic fascia defi-
ciency. In central cystocele (distension cystocele), there is weakening of the
Ischial spine
Arcus tendineus
fascia pelvis
Pubocervical fascia
Arcus tendineus fascia

rectovaginalis
Figure 2.5 The lateral attachments of the pubocervical fascia (PCF) and the
rectovaginal fascia (RVF) to the pelvic sidewall. Also shown are the arcus tendineus fascia
pelvis (ATFP), arcus tendineus fascia rectovaginalis (ATFRV) and ischial spine (IS).
connective tissue in the midline, resulting in the loss of midline rugosity of the
vaginal wall. A lateral cystocele or paravaginal defect results from lateral detach-
ment of the fascia from the ATFP, and the central rugosity is preserved in these.
Prior to surgical intervention, it is important to identify the type of anterior wall
prolapse as either a lateral detachment or central defect in order to plan the opti-
mal surgical technique.
Level III Support

The lower one-third of the vagina is fused with the surrounding structures through
the endopelvic fascia anteriorly to the distal urethra, posteriorly to the perineal
body, and laterally to the pubovaginalis muscle and perineal membrane. Together
they support and maintain the normal position of the distal one-third of the
vagina and introitus. The perineal body is critical for support of the lower part of
the vagina and proper function of the anal canal.
Perineal descent can occur due to separation of the anchored perineal mem-
brane from the perineal body and can contribute to defecatory dysfunction.
Therefore, level III disruption anteriorly can result in SUI from urethral hypermo-
bility, and posterior disruption can result in distal rectocele or perineal descent.
The endopelvic fascia becomes the primary mechanism of support in circum-
stances when neuropathic injury or mechanical damage leads to pelvic floor mus-
cle weakness. This may lead to loss of normal anatomic position if the ongoing
stress overcomes the strength of the endopelvic fascial attachments. The resultant
altered vector forces may lead to POP and/or visceral dysfunction. The goal of
reconstructive pelvic surgery should be to recreate these supportive connections
and restore the anatomical position of the pelvic organs while maintaining ade-
quate vaginal length to maintain the vaginal apex in a natural position.
Conclusion
A thorough understanding of pelvic anatomy is necessary prior to planning any

urogynaecological procedure. The types of pelvic floor disorders and being aware
of the risk factors help the surgeon in planning the appropriate surgery.
Further Reading
Abrams, P., Cardozo, L., Fall, M. et al. (2002). The standardisation of terminology of
lower urinary tract function: report from the Standardisation Subcommittee of the
International Continence Society. Neurourol and Urodyn. 21 (2): 167–178.
DeLancey, J.O. (1994 Aug). The anatomy of the pelvic floor. Current Opinion in
Obstetrics & Gynecology 6 (4): 313–316.
DeLancey, J.O.L. (2003). Functional anatomy of the pelvic floor. In: Imaging Pelvic
Floor Disorders (eds. C.I. Bartram and J.O.L. DeLancey), 27–38. Berlin, Heidelberg:
Springer.
Iglesia, C.B. and Smithling, K.R. (2017). Pelvic organ prolapse. Am. Fam. Physician 96
(3): 179–185.
MichiganUo (2018). Urinary Incontinence: an inevitable part of aging? National Poll
on Health Aging. http://www.healthyagingpoll.org/sites/default/files/2018-11/
NPHA_Incontinence-Report_
Whitcomb, E.L., Rortveit, G., Brown, J.S. et al. (2009). Racial differences in pelvic
organ prolapse. Obstet. Gynecol. 114 (6): 1271–1277.
33
Ambulatory Evaluation of Pelvic Organ Prolapse

and Urinary Incontinence
Tanvir Singh, Sandhya Gupta, and Ajay Rane
This chapter deals with the role of different ambulatory practices in the evalua-
tion of pelvic organ prolapse (POP) and urinary incontinence (UI). A good history
combined with a proper clinical examination is simple, inexpensive, and a time
saving tool, in the diagnosis of pelvic floor disorders. This leaves very few women
requiring sophisticated tests for evaluation and management.
History
Presenting Symptoms
The aim of eliciting a complete description of the nature of the patient’s
symptoms is to put together a working diagnosis and gauge the impact of the
symptoms on the patient’s quality of life. While taking a history, it is important
to define the most troublesome symptom and the patient’s expectations from the
treatment.
Urinary Incontinence (UI) is the complaint of any involuntary leakage of
urine. It is a storage symptom and should be described by specifying relevant fac-
tors such as type, onset, frequency, severity, progression/regression, precipitating
factors, social impact, effect on hygiene and quality of life, response or non-response
to treatment, the measures used to contain the leakage (wearing of protection)
and whether the individual seeks or desires help because of UI. Urinary leakage
may need to be distinguished from other causes of wetness such as sweating or
vaginal discharge.
Stress Urinary Incontinence (SUI) is the complaint of involuntary leakage on

effort or exertion—for example, lifting heavy weights, jumping, or on sneezing or
coughing.
Urge Urinary Incontinence (UUI) is the complaint of involuntary leakage
accompanied by or immediately preceded by urgency. Information on triggering
events such as cold, running water and ‘latch key’ incontinence should be noted.
Mixed Urinary Incontinence (MUI) is the complaint of involuntary leakage
associated with urgency and also with exertion, sneezing, or coughing.
Nocturnal Enuresis is the complaint of loss of urine occurring during sleep.
History of previous childhood nocturnal enuresis and delayed bladder control in
childhood is associated with detrusor overactivity (DO) or overflow incontinence
in adulthood.
Continuous Urinary Incontinence is the complaint of continuous urinary
leakage, usually suggestive of urinary fistula.
Urological History
There is usually an overlap of symptoms with stress, urge, and mixed inconti-
nence. A careful history should be obtained regarding frequency, urgency, dysu-
ria, and nocturia. UI symptoms of recent onset, combined with irritative bladder
symptoms, should prompt investigation for an infective cause. To evaluate a
patient with incontinence, objective tools to use include the incontinence specific
quality-of-life scales or validated questionnaires. These allow evaluation of the
severity and the relative contribution of UUI and SUI symptoms and the response
to their therapies. The following questionnaires have good test–retest reliability:
The International Consultation on Incontinence Questionnaire (ICIQ), Bristol
Female Lower Urinary Tract Symptoms (BFLUTS), Incontinence Quality Of Life
(I-QOL), Stress and Urge Incontinence Quality of life Questionnaire (SUIQQ),
Urinary Incontinence Severity Score (UISS), The Stress related leak, Emptying
ability, Anatomy, Protection, Inhibition, Quality of life, Mobility and Mental sta-
tus (SEAPI-QMM), and The King’s Health Questionnaire (KHQ).
Pelvic Organ Prolapse (POP)

The preferred system to describe and document the POP is the Pelvic Organ
Prolapse Quantification (POPQ) system. Over the years, many clinicians have
familiarised themselves with the POPQ and use it in their daily practice. The symp-
tomatology of POP, apart from pelvic mass, can be related to bladder or bowel
disturbance symptoms. The presenting feature can therefore be a combination of
any of the following symptoms, and it is important to elicit the history accordingly.
3 Ambulatory Evaluation of Pelvic Organ Prolapse and Urinary Incontinence 35
Bulge Symptoms
Bulge/mass at the vaginal introitus
Pelvic or vaginal pressure
Bearing down sensation
Feeling of something falling out
Urinary Symptoms
UI/frequency/urgency
Dysuria
Pain on bladder filling
Weak or prolonged urinary stream
Hesitancy
Bowel Symptoms
Rectal tenesmus or constipation
Digital splinting to defecate
Pain
Lower back discomfort or vulval discomfort
Pain in the vagina, bladder, or rectum
Sexual Symptoms
Difficult intercourse due to the mass
Vaginal looseness
Dyspareunia
Decreased lubrication/Vaginal dryness
Decreased arousal or orgasm
Vaginal flatus
Bowel Habits
Bowel dysfunction frequently affects urinary function. Constipation is the second
most important predisposing factor for UI after vaginal birth. UI may coexist with
faecal incontinence, and most women are hesitant to talk about this symptom.
One study evaluated 247 women with either UI or POP and found that 31% of
women with UI and 7% with POP had concurrent anal incontinences. For these
reasons, women should be specifically asked about anal incontinence including

the type of loss, such as flatus, liquid stool or solid stool and the frequency.
General Medical History

The initial history includes a review of medical problems, current medications,
and history of pelvic surgeries. Medical conditions can influence bladder function
and symptoms. Some drugs can worsen incontinence (Table 3.1). Neurological
conditions such as multiple sclerosis may cause overflow incontinence and urinary
retention. Visual impairment and immobility such as severe arthritis makes it dif-
ficult for the patient to reach the toilet in time. In addition, obesity, smoking, con-
stipation, and work involving heavy lifting can chronically increase intra-abdominal
Table 3.1 Effects of common medications on bladder functions.
Medication Mechanism Bladder dysfunction
Cough and cold preparations Increase urethral closure Urinary retention

Pseudoephedrine, ephedrine, pressure
phenylpropanolamine
Antihypertensive agents Alpha adrenergic Worsen stress urinary
Prazosin, terazosin, methyldopa, antagonists decrease incontinence
reserpine, guanethidine urethral pressure
Diuretics Increase urinary output Worsen urinary
Thiazides, loop diuretics, alcohol frequency/urge
incontinence
Anticholinergic agents Detrusor relaxation Urinary retention
Antihistamines, tricyclic
antidepressants
Antiparkinson agents Detrusor relaxation Urinary retention
Benztropine, trihexyphenidyl
Beta-blockers Detrusor relaxation Urinary retention
Pindolol, disospyramide
Antipsychotic agents Alpha adrenergic Urinary retention
Haloperidol, thioridazine antagonists decrease
urethral pressure
Calcium channel blockers Detrusor relaxation Urinary retention
Verapamil
Iron, narcotics, sedatives Constipation
ACE inhibitors Indirect cough effects
Enalapril
pressure, which can worsen urinary symptoms. Obesity in women is associates

with a threefold increased risk of UI compared to non-obese women. Caffeine
intake, diabetes, stroke, depression, faecal incontinence, genitourinary syndrome
of menopause, vaginal atrophy, hormone replacement therapy, radiation, pelvic
surgeries including hysterectomy are some of the other risk factors.
It is important to consider conditions outside the urinary tract that may influence
continence. Treating these conditions often restores continence. Functional causes
of incontinence as been summarised using the acronym ‘DIAPPERS’ (Resnick):
D = Delirium
I = Infection
A = Atrophic urethritis or vaginitis
P = Pharmacologic agents
P = Psychiatric disorders
E = Excess urinary output (e.g. congestive heart failure, hyperglycaemia)
R = Restricted mobility or dexterity
S = Stool impaction
Obstetric History
UI in pregnancy is reported by 7–60% of women and in most, will resolve after
delivery. Parity, mode of delivery including instrumental deliveries, and birth
weight, are some identifiable risk factors in both UI and POP.
Vaginal delivery is identified as an independent risk factor for prolapse. This
risk increases with forceps delivery, with increasing parity and in women having
their first child at a later age. Caesarean delivery however does not appear to be
protective.
Gynaecological History
Presence of a pelvic mass, such as fibroids or ovarian cysts, and the menopausal
status is also relevant. In several studies, the prevalence of pelvic floor disorders
has been shown to increase with menopause. The prevalence of any one pelvic
floor disorder with menopause was estimated to be 37%, which included SUI 15%,
OAB 13%, POP 6% and anal incontinence 25%.
Family History
The existence of inherited risk factors for pelvic floor disorders has long been
recognised and there is a clear familial aggregation for these conditions. Having
an affected first-degree relative with incontinence or prolapse is associated with
an approximately two- to threefold increased risk of developing either condition.

A study looking at twins, attributed a 35–55% genetic contribution to urge incon-
tinence/overactive bladder but only 1.5% for stress incontinence.
Quality of Life
A more objective tool to assess the quality of life would be to use the incontinence
specific scales or validated patient questionnaires. The Modified Bristol Female
Lower Urinary Tract Symptoms Questionnaire can be used to evaluate the severity of
UUI and SUI symptoms and the response to their therapies. The Pelvic Floor Distress
Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ) can assess the
urinary, colorectal, and prolapse symptoms in detail. The International Consultation
on Incontinence Questionnaire and the Kings Health questionnaire are available for
evaluating impact of incontinence on quality of life. The Patient Global Impression
of Improvement (PGII) and Patient Global Impression of Severity (PGIS) are also
acceptable measures to assess improvement and satisfaction, respectively.
Sexual Dysfunction
Coital incontinence may occur during arousal, on penetration, throughout inter-
course, or specifically on orgasm. Urodynamic stress incontinence (USI) is the
most common urodynamic finding; however, DO is found more often when leak-
age is restricted to orgasm. It is therefore helpful to define when urine leakage
occurs during these acts. Up to 68% of women report that their sex life is ruined
due to urinary symptoms.
Physical Examination
General Examination
A general physical examination includes assessment of a women’s body mass
index (BMI), identification of mobility restriction or visual impairment, and the
odour of urine, smoke, or alcohol. The information gained from these observa-
tions needs to be addressed and modified for the success of any treatment.
Neurological Examination
All patients should have a neurological evaluation and it begins with the assess-
ment of mental status. Bladder dysfunction is common in patients with dementia,
stroke, parkinsonism, multiple sclerosis, and hence, facial symmetry, gait,
dexterity and speech pattern should be noted. In cognitively impaired patients, a

family member or friend should be present during examination to improve the
compliance.
The neurological control of bladder storage and voiding function necessitates
assessment of the thoraco-lumbar and sacral segments of the spinal cord. Motor
strength, deep tendon reflexes, lower limb sensation and the sacral reflexes – bulbo
cavernous and anal reflex – can identify neurological problems.
Abdominal Examination
This examination is particularly important to identify abdominal masses such as
fibroids or ovarian cysts, which can compress on the bladder causing frequency,
urgency, UI, or obstruction. Suprapubic tenderness may indicate infective aetiology or
a urinary tract stone. Along with the evaluation of masses, scars, and organomegaly,
the integrity of the abdominal wall should be assessed. Abdominal wall defects such
as diastasis recti can influence the symptoms of stress incontinence and prolapse.
External Gynaecological Examination

Inspection of the vulva and perineum is often the neglected part of the gynaeco-
logical examination. It is important to look for excoriation and erythema due to
incontinence and the use of pads. Clinician should also look for signs of hypoes-
trogenism (Figure 3.1) such as atrophy of the vulvar skin, agglutination of the
labia minora (Figure 3.2) or urethral caruncle.
The clinical sign of UI is defined as urine leakage seen during examination,
which may be urethral or extra-urethral. Extra-urethral incontinence is defined as
urine leakage from a site other than urethra, such as ectopic ureter (congenital) or
urogenital fistula.
External examination also involves identifying level III support defects such as
measurement of the genital hiatus (normal 4–6 cm in length) and of the perineal
body (normal 2–4 cm in length). In POP, assessment of level I and level II defects
is required and is further described in the following section.
The perineal body is attached anteriorly to the perineal membrane and cranially
to the posterior vaginal wall. This cranial attachment causes the perineum to be
concave and limits its downward mobility to about 1 cm. Perineal descent is char-
acterised by bulging and widening of the perineum during Valsalva, with the per-
ineal body movement being greater than 2 cm below the level of ischial tuberosities.
On POPQ examination this is identified by widening of genital hiatus and short-
ening of perineal body. With complete disruption of the perineal muscles, a per-
ineal rectocele develops. When this occurs, the perineal body elongates and
demonstrates ballooning on Valsalva.
Figure 3.1 Signs of hypoestrogenism, scarcity of pubic hair, loss of elasticity of skin,
dryness of labia, introital stenosis, vulvar erythema. Source: With permission from
Dr Meeta and patient.
Figure 3.2 Labial fusion due to genito urinary syndrome of menopause (GSM).
Source: With permission from Dr Meeta and patient.
Internal Gynaecological Examination

A speculum examination of the vagina is needed to evaluate for atrophy and
POP. The woman is examined at rest and at maximum Valsalva, while in the
supine position with the legs comfortably flexed. DeLancey has defined three lev-
els of support of pelvic organs – Level I, Level II, and Level III, which is accepted
worldwide. On speculum examination, prolapse of each level and each compart-
ment is evaluated as follows:
●● Apical prolapse or Level I (prolapse of the cervix or vaginal vault) – A bivalve
speculum is inserted into the vagina and then slowly withdrawn, any descent of
the apex (cervix, vault) is noted.
●● Anterior vaginal wall or Level II – A Sims retractor or the posterior blade of a
bivalve speculum is inserted into the vagina with gentle pressure on the poste-
rior vaginal wall to isolate and visualise the anterior vaginal wall.
●● Posterior vaginal wall or Level II – A Sims retractor or the posterior blade of a
bivalve speculum inserted into the vagina with gentle pressure on the anterior
vaginal wall to isolate and visualise the posterior vaginal wall.
●● Perineum or Level III – Evaluation involves measurement of the genital hiatus
and perineal body and identification of stress urinary incontinence.
Staging of the extent of prolapse is done using a Simplified POPQ validated

against original staging system of POPQ:
Stage 1: Prolapse where the given point remains at least 1 cm above the hymenal
remnants (see Figure 3.3).
Stage 2: Prolapse where the given point descends to the introitus, defined as an
area extending from 1 cm above to 1 cm below the hymenal remnants (see
Figure 3.4).
Stage 3: Prolapse where the given point descends greater than 1 cm past the hyme-
nal remnants, but does not represent complete vaginal vault eversion or com-
plete uterine procidentia. This implies that at least some portion of the vaginal
mucosa is not everted (Figure 3.5).
Stage 4: Complete vaginal vault eversion or complete uterine procidentia. This
implies that the vagina and/or uterus are maximally prolapsed with essentially
the entire extent of the vaginal mucosa everted.
At the end of the speculum assessment, bimanual examination is performed
to evaluate the uterus and adnexa for enlargement and any masses. Finally, a
rectal examination to evaluate the tone and integrity of the anal sphincter may
be needed.
Figure 3.3 Evaluation of
posterior vaginal wall prolapse
in Valsalva demonstrating
Stage 1 Posterior wall POP.

anterior vaginal wall prolapse in
Valsalva demonstrating Stage 2
Anterior wall POP.

anterior vaginal wall prolapse in
Valsalva demonstrating Stage 3
Anterior wall POP.
Assessment of Pelvic Muscle Function

Digital assessment of the bony architecture, muscle mass, connective tissue sup-
port, pelvic floor muscle contraction and grading using the modified Oxford grad-
ing scale (Table 3.2) can be helpful in discussing management options such as
pelvic floor exercises.
Table 3.2 Modified Oxford grading scale

for pelvic floor muscle strength.
Grade Definition
0 No contraction
1 Flicker of contraction
2 Weak muscle activity
3 Moderate muscle contraction
4 Good muscle contraction
5 Strong muscle contraction
Investigations
The diagnosis of pelvic floor disorders is often clinical, based on history and exam-
ination. This is particularly true in the case of POP. Diagnostic tests and investiga-
tions are aimed mainly to assess the severity or rule out co-existing problems.
Urinary Diary
A urinary diary is an inexpensive tool that is easy to keep and interpret. It may
suggest a diagnosis and allows conservative treatment to be started. The patient
records the type and amount of fluid intake, episodes of incontinence, times
voided, and volume of urine voided. Though frequency and volume are neither
specific nor sensitive in determining the cause of incontinence, it guides behav-
ioural modification. Ideally a three-day voiding diary to assess outcomes of treat-
ment is suggested in most clinical studies, but compliance is better with a 24-hour
diary. Normal voiding frequency is less than eight times a day and once at night,
with total volumes of less than 1800 ml per 24 hours.
Urine Analysis
Urinalysis is a fundamental and frequently performed test that determines any
evidence of hematuria, pyuria, glycosuria, or proteinuria. Urinary tract infections
(UTI) can be identified using urinalysis and treated before initiating further inves-
tigations or therapeutic interventions for UI. If the urinalysis tests positive for
both leucocytes and nitrites, a midstream urine specimen is sent for microscopy,
culture and analysis of antibiotic sensitivity. If symptomatic, these women can be
prescribed an appropriate course of antibiotic pending culture results. If women
do not have symptoms of a UTI, but their urine tests positive for both leucocytes
and nitrites, do not offer antibiotics without the results of midstream urine cul-
ture. It is worth noting that 60% of women with a stable bladder will develop DO
at the time of a UTI. A urine specimen is sent for cytology if there is haematuria
or irritative voiding symptoms to rule out a malignancy. Haematuria consisting of
more than 5–10 red cells per high-power field warrants further investigations by
imaging and cystoscopy.
Cough Stress Test

A cough stress test (CST) is used in the evaluation of women with SUI. It is an
objective test to diagnose and assess the outcome of treatment of SUI syndrome
(SUI–S).
The ICS-Uniform Cough Stress Test (ICS-UCST) has standardised the tech-
nique of the CST. It recommends that the patient be in a supine/lithotomy
position with 200–400 ml of fluid in the bladder. She coughs forcefully one to four
times and the examiner directly visualises the urethral meatus for the presence of
leakage. Leakage of fluid from the urethral meatus coincident with/ simultaneous
to the cough(s) is considered a positive test. Upright CST: If the supine/lithotomy
position ICS-UCST is negative, the patient undergoes a repeat test in upright or
standing position. It is reported as a positive upright CST.
Supine empty stress test (SEST): A positive CST performed in the supine posi-
tion with an ‘empty’ bladder (volume < 100 ml) has been suggested to indicate the
presence of intrinsic sphincter deficiency (ISD). In a prospective series it was
noted that a positive SEST was associated with a lower maximum urethral closure
pressure (MUCP) (mean, 20 vs. 36 cm H2O). SEST had sensitivity of 65–70% and
specificity of 67–76% for predicting ISD. The IUGA suggests that a SEST could be
used as a simple test to be reasonably assured that ISD is not present (without
resorting to multichannel urodynamics). In a patient with SUI, a negative ICS-
UCST can be reassessed with an ICS standard pad test and/or urodynamic testing
to completely evaluate the lower urinary tract function, as per current practice
guidelines.
Urethro-Vesical Mobility
Support to the bladder neck is assessed by evaluating the mobility of the urethro-
vesical junction. Urethral hypermobility is defined as a 30° or greater displace-
ment of the urethra from the horizontal (measured with a cotton tip swab in the
urethra). The test, referred to as the ‘Q-tip test’, is performed in the supine lithot-
omy position and at maximum Valsalva effort. The angle is measured using a
goniometer.
Other methods of evaluating urethral mobility include measurement of point
Aa of the POPQ system, visualisation (inaccurate method), ultrasonography, and
lateral cystourethrogram. Women with stress incontinence who have demon-
strated urethral hypermobility have a lower risk of failure after a mid-urethral
sling procedure. In women with SUI without urethral hypermobility, where leak
can be due to ISD, bulking agents were considered to be a more appropriate surgi-
cal option. This notion is however being increasingly questioned with use of mid-
urethral slings, where cure rate of 77% is quoted with tension-free vaginal tape
(TVT) in patients with ISD.
Pad Test
The pad test is a non-invasive diagnostic test, which is low cost, simple to per-
form, and gives both qualitative (presence or absence of UI) and quantitative
assessment (determination of degree of UI). The ICS has standardised the pad
test both for one-hour and 24-hour testing. In the one-hour pad test, the bladder
is filled to a set starting volume of about 150–300 ml of fluid through instillation.
A pre-weighed pad is put on by the patient, without voiding. The patient drinks
500 ml of sodium-free liquid in <15 minutes and then sits or rests. Then, the
patient walks for 30 minutes, including climbing one flight of stairs (up and
down) before performing the following activities: standing up from sitting
(10 times), coughing vigorously (10 times), running on the spot for one minute,
bending to pick up an object from the floor (five times), and washing their hands
in running water for one minute. The total amount of urine leaked is determined
by weighing the pad and a weight gain of >1.4 g (equal to 1.4 ml) is significant. If
a moderately full bladder cannot be maintained through the hour (if the patient
must void), the test has to be started again.
The 24-hour pad test should be started with an empty bladder. The normal daily
activities should be followed and recorded in a voiding diary so that the same
schedule will be observed during follow-up re-testing. To avoid urine loss through
leakage or evaporation, the pads should be worn inside waterproof underpants
and changed every four to six hours during daytime. The pads should be weighed
immediately, and if weighing is to be performed at the clinic, the pads must be
stored in an airtight bag. A weight gain of >4.4 g (equal to 4.4 ml) is considered
significant, in a 24-hour test. An increase of 4–20 g/24 hour is classified as repre-
senting mild incontinence, 21–74 g/24-hour represents moderate incontinence
and >75 g/24-hour represents severe incontinence. The 24-hour pad test, is more
reproducible than a one-hour test, but it is highly dependent on patient compli-
ance and therefore not suitable for all patients.
Urogynaecological Ultrasound
The diagnostic utility of ultrasound in imaging pelvic floor disorders is limited to
certain specific pathologies but can nonetheless prove to be invaluable. Ultrasound
of the abdomen and pelvis, combined with assessment of post-void residual urine
volume, can help in ruling out pelvic masses, identifying upper urinary tract dila-
tation and any voiding problem.
Three- and four-dimensional trans-labial/trans-perineal ultrasonography is a
relatively new imaging modality with high accuracy in the evaluation of pelvic
floor disorders such as UI, POP, and levator avulsion. A two-dimensional ultra-
sound can also be used to confirm which compartment a prolapse may be of.
Evaluation of mesh implants is another important indication for this modality.
A trans labial ultrasound is used in the assessment of bladder wall thickness,
bladder neck and mid-urethral mobility, and funnelling of bladder neck, in
women with UI. A two-dimensional mid-sagittal image at rest helps in assessing
the post-void residual urine volume.
During Valsalva, the hiatal dimension is measured and a value of less than 25 mm2
at Valsalva is unlikely to be associated with POP. The extent of ballooning, defined
as excessive distention of the hiatus, is categorised as mild (25.0–29.9 cm2), moder-
ate (30.0–34.9 cm2, marked (35.0–39.9 cm2), or severe ( 40 cm2). POP can be evalu-
ated and quantified with trans-labial scans in all three pelvic compartments.
The endoanal scan performed with a high-resolution probe is considered the
reference standard for sphincter evaluation. However, the use of transvaginal
probes placed exo-anally in the coronal plane has been accepted for anal sphincter
evaluation at rest and during contraction. The normal mucosa is visualised as a
hyperechoic area surrounded by a hypoechoic ring that represents the internal
anal sphincter. The more external hyperechoic tissue represents the external anal
sphincter. Anal sphincter injuries appear as discontinuity of the rings of the inter-
nal and external anal sphincter and the clock face is used to report the locations of
these injuries (Figure 3.6).
Uroflowmetry
Uroflowmetry is a non-invasive measurement of the rate of urine flow over time.
It measures the maximum flow rate, average flow rate, voided volume and gives
the flow pattern. It also gives us post-void residual volume, but cannot be used
EAS
IAS
Figure 3.6 Endoanal Scan (IAS – Internal Anal Sphincter, EAS – External Anal Sphincter).
alone to diagnose the cause of an abnormality. The patient is asked to void into a
specially designed commode that measures voided volume, maximal, and average
urinary flow rates. Uroflowmetry is usually used to determine obstructive voiding.
The International Continence Society (ICS) has not defined normal voiding
ranges according to maximum flow rate (Qmax) in healthy women (Figure 3.7).
Urodynamic Testing (UDS)

Urodynamics and cystoscopy are not essential in the initial assessment of patients
presenting with uncomplicated UI. The role of urodynamics before prolapse sur-
gery is contentious and there is no universal consensus in women with concomi-
tant SUI. UDS could facilitate counselling of patients; however, there is no
evidence that the testing alters the outcome of surgery.
The term urodynamics encompasses a number of varied physiological tests of
bladder and urethral function, which aim to demonstrate an underlying abnor-
mality of storage or voiding. Urodynamics should be used selectively in women
with UI to answer specific functional questions. It is important to rule out urinary
infection prior to this invasive testing. After undertaking a detailed clinical history
and examination, multichannel filling and voiding cystometry are indicated in
women who have
●● Symptoms suggestive of voiding dysfunction
●● OAB symptoms refractory to pharmacotherapy
●● Symptoms of OAB with uncertain aetiology or a clinical suspicion of neuro-
genic DO prior to surgical intervention in women with SUI
●● Urinary symptoms following anti-incontinence procedure
Cystometry is a useful method for assessing detrusor muscle function and of
bladder symptoms in relation to storage and voiding. Following a uroflowmetry
and measurement of the post-void residual urine volume, cystometry is com-
menced. Cystometry, can be either a single channel cystometry or, more com-
monly, multichannel cystometry.
In multi-channel cystometry, bladder and rectal/vaginal lines are inserted and
residual urine if any, is noted. The bladder is filled at a rate of 50 ml/min and the
filling medium is usually normal saline or sterile water at room temperature. The
aim is to replicate the woman’s symptoms by filling the bladder and observing
the pressure changes. The pressure from the bladder is termed Pves or vesical
pressure and the Pabd or abdominal pressure is recorded from the rectal/vaginal
line. The detrusor pressure Pdet is calculated by subtracting the abdominal from
vesical pressure. (Pdet = Pves – Pabd).
Bladder storage functions obtained with filling cystometry include bladder sen-
sation, cystometric bladder capacity, compliance, and presence of involuntary
ml 1000 1 Uroflow Results
Permission to void
VOID 34 / 260 / -
Qmax 34.5 ml/s
Vmic Time to Qmax 10 s
Voided volume 258 ml
Flow time 18 s
Voiding time 23 s
0
ml/s 50 Hesitancy 10 s
Average flow rate 13.9 ml/s
Corrected Qmax 16 sqrt
Miction index --
Qura
0
Time 00:20 00:40 01:00 01:
Liverpool nomogram
Qur 80 Average flow rate Qmax
(ml/s)
95th
60
40 50th
95th
20 5th
50th
5th
0 100 200 300 400 500 600 100 200 300 400 500 600
Volume (ml)
Voided volume: 258 ml Average flow rate: 14 ml/s Qmax: 34 ml/s
Figure 3.7 Uroflowmetry in a healthy woman with stress urinary incontinence. A normal ‘bell shaped’ curve.
detrusor contractions. Urinary leak demonstrable with cough or Valsalva during

filling cystometry is referred to as USI. Presence of involuntary detrusor contrac-
tions during filling, associated with urgency and/or leak is referred to as DO. The
first desire to void occurs when intravesical pressure is usually about 150 ml and a
strong desire at 400 ml in the normal bladder. The average bladder has a capacity
of 250–550 ml.
In voiding cystometry, the patient is asked to void once maximum bladder
capacity is reached or if patient requests permission to void. Voiding takes place
with the lines in situ for pressure recording. The important aspects in voiding
cystometry include maximum flow rate, the detrusor pressure, the voided volume,
and presence of abdominal straining. An underactive (hypotonic) detrusor is
diagnosed when voiding occurs with a slow urine flow rate and low detrusor pres-
sure. In women, obstruction is defined as a peak flow rate of less than 15 ml/s with
a maximum voiding detrusor pressure greater than 60 cm of H2O.
Video-urodynamics involves synchronous radiographic screening of the blad-
der with multi-channel cystometry using radio-opaque dye as filling medium.
Anatomical abnormalities such as diverticulae and reflux can be visualised, and
that visualisation is useful in identifying an open bladder neck and proximal ure-
thra. Ambulatory urodynamics involves multi-channel cystometry carried out
with physiological bladder filling rates and using portable recording devices,
which enable the woman to remain ambulant during the test.
A systematic review of 99 studies including over 80 000 women found insuffi-
cient evidence to support the ability of urodynamic testing to predict the outcomes
of nonsurgical treatment for stress incontinence. In addition, no improvement in
surgical outcomes was demonstrated in a randomised multi-centre trial of preop-
erative urodynamic testing for uncomplicated stress incontinence. Urodynamics
is an invasive test and has to be used judiciously to provide reliable information
and to be cost-effective.
Urethral Pressure Profile

There are numerous tests for urethral function, including urethral pressure pro-
filometry and leak point pressure measurement. Intravesical pressure and the
intraluminal urethral pressure are measured simultaneously using pressure trans-
ducers that are about 5 cm apart. The pressures are measured during filling and
during Valsalva. These are used to derive values that reflect the ability of the ure-
thra to resist urine flow, expressed most commonly as maximum urethral closure
pressure (MUCP) or as abdominal, cough, or Valsalva leak point pressures (ALPP,
CLPP, VLPP, respectively). A MUCP less than 20 cm H2O denotes ISD and a high
MUCP may denote urethral obstruction or diverticulae. ALPP measures the
bladder pressure at leak generated by Valsalva and is dynamic in nature. This is

used as an indirect measure of the urethral sphincter function. Leakage at an
ALPP of less than 60 cm of H2O is diagnostic of ISD.
Cystoscopy
Cystoscopy is the direct visualisation of the bladder and urethral lumen using
either a rigid or flexible cystoscope. A flexible cystoscope is preferable to the rigid
for diagnostic purpose, because it can obviate the need for anaesthesia. Cystoscopy
may be of value in women with pain or recurrent UTIs, following previous pelvic
surgery or where fistula is suspected. Its role in recurrent SUI without these addi-
tional features is less clear. Cystoscopic examination is used to identify areas of
inflammation (interstitial cystitis), tumours, stones, foreign body, and diverticula,
all of which are findings that will require management within a different clinical
pathway. Cystoscopy is contraindicated in the presence of an acute cystitis and in
patients with severe coagulopathy.
Conclusion
In the evaluation of UI and with the bladder being an ‘unreliable witness’, several
tests have been postulated either to assess the severity or delineate the problem.
However, prior to any testing, an appropriate questionnaire, a directed history,
and thorough examination must be done. Choosing the appropriate test forms the
core of the initial clinical assessment. In POP, diagnosis is mainly clinical, with
investigations required only to evaluate any co-existing bladder or bowel prob-
lems. In long standing stage IV POP, anatomical and functional assessment of the
renal tract with ultrasound imaging and renal function tests may be needed. Anal
dysfunction diagnosis, relies on imaging to assess any structural problems in the
anal sphincter and anal manometry to assess its function.
Further Reading
Abrams, P., Cardozo, L., Fall, M. et al. (2002). Standardisation of terminology of

lower urinary tract function: report from the standardisation sub-committee of the
international continence society. Neurourology and Urodynamics 21: 167–178.
Avery, K., Donovan, J., Peters, T.J. et al. (2004). ICIQ: a brief and robust measure for
evaluating the symptoms and impact of urinary incontinence. Neurourology and
Urodynamics 23: 322.
Tamilselvi, A. and Rane, A. (eds.) (2015). Principles and Practice of Urogynaecology.

India: Springer https://doi.org/10.1007/978-81-322-1692-6-5.
Weber, A.M., Abrams, P., Brubaker, L. et al. (2001). The standardization of
terminology for researchers in female pelvic floor disorders. International
Urogynecology Journal 12 (3): 178–186.
53
Role of Cystoscopy
Arjunan Tamilselvi
Cystoscopy is an important armamentarium in the hands of the urologists,

urogynaecologists, and gynaecologists. Origins of the cystoscope, follows the
endoscopy path, where instruments were designed to peer into the human inter-
nal organs. Philip Bozzini, a young obstetrician, is credited with the honour of
being the forerunner in designing endoscopy. In 1806, he designed an instrument
to be passed through orifices, to inspect the internal organs using candle as light
source. Bozzini’s Lichtleiter did not break ground with the medical community at
that time. This was followed by attempts of several people to rework on the Bozzini
design principle to create an endoscope. The next major breakthrough in cystos-
copy was achieved by the combined work of a German urologist, Maximilian
Nitze, and an instrument maker from Vienna, Joseph Leiter.
The Nitze–Leiter Cystoscope was a success and with the invention of light
bulbs in 1880, the cystoscope was well on its way to become part of the surgical
practice. Modifications to the Nitze model continued with use of different
optics, incorporating catheterization units, operating units, diathermy units,
and several others as deemed necessary for the operator. The use of fibre optics
revolutionised cystoscopy, providing good visualisation and clear photographs
of the bladder.
Cystoscopic examination currently uses either a rigid or flexible cystoscope and
is employed either for diagnostic or therapeutic procedures. Cystoscopy is one of
the procedures ideally suited to be done in an ambulatory set-up.
Instrument
A rigid cystoscope consists of a metal sheath, obturator, bridge, and telescope to

which the light source is attached (Figure 4.1).The sheath has channels for irriga-
tion fluid, and the bridge can have one or two working channels for insertion of
B
C
Figure 4.1 Rigid Cystoscope. (A) Sheath with irrigation channels and obturator.
(B) Bridge. (C) Sheath cover. (D) Telescope.
instruments. Cystoscope sizes are given in French scale and refer to the outside
diameter of the sheath in millimetres. (1 Fr = 0.3 mm, 15 Fr = 5 mm). The diam-
eter of the sheath that is used commonly in adults is 17–24 French. In selected
cases, a paediatric cystoscope may be needed (8 French).
Irrigation fluid in a cystoscope is usually sterile water or normal saline. If any
electro-coagulation is planned, electrolyte containing solutions must be avoided.
Fluid distension in cystoscopy is gravity based with the fluid bag, placed mini-
mum 80 cm above the patient position.
Different types of lenses are used in cystoscope and the operator chooses them
according to the area to be visualised. A 0° or 12° lens is usually used for inspec-
tion of urethra, but are not particularly useful for visualisation of entire bladder.
A 30° lens is useful in the visualisation of the posterior wall and base of the blad-
der and helpful in ureteric catheterization or stent insertion. A 70° or 120° lens
helps in good visualisation of antero-lateral aspect, dome of the bladder and in
over elevated urethro-vesical junction. Retrograde lenses with an angle of view of
more than 90° can visualise the urethra and anterior bladder neck clearly.
Flexible cystoscopes have fibre optic bundles, telescope and irrigating channel
combined into a single unit. The greatest advantage is the ability to visualise any
aspect of the bladder and urethra, as the camera can be deflected from zero degree
to 220°. The tip deflection can be on the same side as the lever deflection or on the
opposite side from the lever deflection. The diameter of the flexible cystoscope is
usually between 15 and 18 French (Figure 4.2).
Figure 4.2 Flexible cystoscope.
Comparing the rigid and flexible cystoscopes, the rigid cystoscope has the advan-
tage of better optics, larger lumen for irrigation, in turn giving better visualisation,
larger working channels for instruments, and ease of manipulation and orienta-
tion. Rigid cystoscopy can be done under local anaesthesia, in the office set-up
when it is primarily diagnostic. With the larger diameter rigid scopes, the proce-
dure can be done under general anaesthesia or IV sedation to reduce discomfort.
The flexible cystoscope on the other hand, in view of its size, is more comfortable
to patients and they are able to tolerate it with just local anaesthetic gel instillation.
Flexible cystoscopes are more suitable to be done as an office procedure. In a flex-
ible scope, with the deflection of the tip of the instrument, it is possible to visualise
at any angle, the bladder neck, bladder wall, and urethra. Flexible cystoscopy, how-
ever, has a longer training curve compared to rigid cystoscopy.
Pre-procedure
Urine analysis with microscopy or a urine culture done about five to seven days
before the procedure helps in ruling out a urinary tract infection. An informed
consent is obtained prior to the procedure. Antimicrobial prophylaxis is not rec-
ommended in routine diagnostic cystoscopy in the absence of risk factors.
However, in the presence of risk factors such as, elderly patients, immunodefi-
ciency, long-term steroid use, abnormalities of urinary tract, or in a poorly con-
trolled diabetic, a single dose of aminoglycoside or third generation cephalosporins
should suffice for prophylaxis. Prophylaxis lasting less than 24 hours with either a
fluoroquinolone or trimethoprim-sulfamethoxazole is recommended for thera-
peutic procedures.
Indications
Cystoscopy is used mostly as a diagnostic tool in urogynaecological practice. The

common diagnostic indications are:
●● Haematuria – macroscopic and microscopic
●● Bladder pain syndrome (BPS) (chronic pelvic pain, interstitial cystitis)
●● Recurrent UTI
●● Bladder abnormality on imaging studies
●● Abnormal urine cytology
●● Voiding abnormalities
●● Overactive bladder symptoms, not responding to anticholinergics
●● Intra-operative – to check, bladder, urethra, and ureteral integrity, during anti-
incontinence procedures and other pelvic surgeries
●● In evaluation of anterior vaginal wall cysts
●● Evaluation of urinary fistula
●● Identification of diverticular opening
●● Assessment in cervical cancer, to check bladder involvement
●● Bladder mucosal biopsy
Use of cystoscopy as treatment modality is indicated in:
●● Insertion and removal of ureteric stents
●● Removal of foreign body, calculi, polyp, or tumour in bladder
●● Intra-detrusor Botulinum toxin (Botox) injection
●● Injection of urethral bulking agents
●● Hydrodistension
Contraindication to cystoscopy is active urinary infection. In the presence of

pain intolerance, the procedure should not be done as an office procedure and
should be done under anaesthesia.
Technique
Patient is placed in the dorsal lithotomy position, with the legs supported and but-
tocks at the edge of the table. Perineum including the peri-urethral and vagina are
prepared. External genitalia and urethral opening visualised prior to cystoscope
insertion. Presence of a urethrocele, urethral mucosal prolapse or urethral diver-
ticula is noted. If done under local anaesthesia, 1% lidocaine gel is instilled in the
urethra, which acts both as a topical anaesthetic and a lubricant.
A cystoscope is introduced into the urethra under direct vision. A rigid cysto-
scope is introduced either with or without an obturator and it is usually
recommended to introduce it with an obturator in females to minimise urethral

trauma. The cystoscope should be directed anteriorly as it enters the urethra in
females. At times even with the smallest telescope it might be difficult to negotiate
into the urethra and gentle dilatation may be helpful. It is important to avoid
forceful dilatation of the urethra.
Cystoscopic examination of urethra and bladder should be systematic. The
female urethra is only 2.5–4 cm long. Urethral mucosa should be examined for
strictures, diverticular opening, or polyps, and the bladder neck is visualised as
scope enters and exits the bladder. Base and trigone of the bladder are initially
inspected. Trigone lies proximal to the bladder neck; it is the triangular area
bounded by the inter-ureteric ridge and the bladder neck at the base of the blad-
der. One of the most common features of the trigone is squamous metaplasia,
present in up to 50% of the women. It is a benign feature with no malignant
potential.
In staging for cervical cancer, when imaging suggests stage 3 or 4 disease, cys-
toscopy is indicated. The bladder base and trigone appearance such as bullous
edema, inflammatory changes, or infiltration has to be documented, and in case
of infiltration, biopsy should be part of the evaluation.
Ureteric orifices are slit-like openings easily identifiable by the presence of
efflux on either side of the inter-ureteric ridge (Figure 4.3). The ureteral orifices
location, number, nature of ureteric efflux (clear, blood stained), and any ana-
tomical distortion is noted. In a woman with anterior vaginal wall prolapse or an
underlying cervical mass, identification of trigone or ureteric orifices may be dif-
ficult. In such cases, placing a finger inside the vagina and elevating the bladder
base with a finger will be helpful.
Blood stained ureteric efflux denotes upper tract pathology and further assess-
ment of the ureter and kidneys is indicated, either by ultrasound or a CT scan of
the kidneys, ureters, and bladder (CT KUB). In intra-operative or post-operative
Figure 4.3 Ureteric orifice (right and left sides).

ureteral integrity assessment, presence of just ureteric peristalsis does not rule
out ureteral injury. Checking for ureteric efflux after administration of methylth-
ionium chloride or indigo carmine (5 ml) IV is effective in confirming ureteral
patency.
Bladder dome is usually identified by the presence of a small air bubble. The
surgeon can visualise the lateral walls by rotating the cystoscope and keeping
the camera orientation fixed. The dome and posterolateral walls of the bladder
are inspected using a 70 or 90° lens on a rigid scope or by retroflection on a
flexible scope, right, left, anterior, and posterior. Examination should be thor-
ough, using a reference point like 12 o’clock position and moving the scope
either clockwise or anticlockwise from dome towards the bladder neck. The
bladder mucosa should be inspected for bladder stones, trabeculations, sac-
culation, diverticula, mucosal abnormalities, haemorrhagic spots, erythema-
tous patches, papillary/sessile bladder lesions, bladder stones or any foreign
body. If a suspicious lesion is identified, it should be biopsied using cysto-
scopic instruments. Usually, following such biopsies there is no bleeding and
there is no need for cauterization.
Bladder diverticulae are herniations of the bladder mucosa between the fibres
of the detrusor muscle, which can be congenital or acquired. The acquired vari-
ety are secondary to bladder obstruction, associated with trabeculations and
commonly present with recurrent urinary tract infection secondary to the stasis
in diverticulae. The neck of the diverticular opening can be identified fairly
easily on cystoscopy with adequate distension of the bladder. In contrast, ure-
thral diverticular opening identification requires a high index of suspicion and
experience.
Identification of fistulous opening in a vesicovaginal fistulae and planning the
surgical route and technique, is an essential pre-requisite prior to the fistula repair.
Bladder Pain Syndrome (BPS)

In evaluation of patients with BPS, cystoscopy should be done only under regional
or general anaesthesia, because the pain can preclude the assessment of the entire
bladder when done under local anaesthetic instillation. The aim of cystoscopy in
BPS is to identify classical features of Interstitial cystitis (Figure 4.4). This includes
presence of glomerulations, petechial haemorrhages and/or Hunner’s Ulcers.
However, these typical features are absent in at least 32–42% of patients. The cys-
toscopy technique in BPS varies in that, at the initial distension the bladder
mucosa may not show any abnormality. On double-fill (i.e., refilling after empty-
ing) with hydro-distension, the typical features of interstitial cystitis may become
apparent.
Figure 4.4 Petechial haemorrhagic spots.
Intra-operative Cystoscopy
Identification of intra-operative bladder injury is one of the major indications of
cystoscopy. It is an intra-operative step during an incontinence procedure such as
mid-urethral slings, pubovaginal slings, Burch colposuspension, and Stamey’ pro-
cedure. For procedures in which instruments and trocar are introduced via the
retropubic space and cystoscopy is done to rule out bladder perforation, certain
principles have to be adhered to. The bladder needs to be filled beyond 400 ml and
a 70° telescope should be used, as the perforation is likely to be closer to the dome
of the bladder and likely to be missed otherwise.
Other pelvic floor surgeries where the risk of bladder or ureteric injury is
increased such as in high uterosacral ligament suspension (HUSL) and in
other major vaginal and urogynaecological surgeries, the American
Urogynaecological Society (AUGS) and the American Urological Society
(AUS) recommend cystoscopy. When the risk of ureteric injury is high, admin-
istering 5 ml of indigo carmine intravenously, slowly over 5–10 minutes, helps
in checking ureteral patency.
In a large series involving 526 patients, routine intraoperative cystoscopy
detected 2.9% lower urinary tract injuries in procedures which were not done for
incontinence. Anterior colporraphy was the most common cause of unrecog-
nised and unsuspected urinary tract injury, occurring in 2% of anterior vaginal
wall repair.
Cystoscopy as Surgical Tool
Hydro-distension using a cystoscope is a simple treatment option in patients with

interstitial cystitis. Cystoscopy can be of value in simple procedures such as
suprapubic catheterization as an ancillary tool. Insertion and removal of ureteric
stents is an ambulatory procedure and can be done with or without imaging
guidance.
Cysto-lithotripsy performed by the urologists, in the treatment of bladder cal-
culi is essentially a cystoscopic surgery. Using either a lithotripter or a helium
laser, the vesical calculi is broken into smaller fragments and extracted. The pro-
cedure can be done as day care but an indwelling catheter may be needed for a
couple of days, until the urine clears. Post-operative use of antispasmodic agents
helps in the immediate post-operative period.
Use of urethral bulking is one of the treatment options in patients with stress
urinary incontinence. Bulking agents such as collagen, macroplastique are
injected around the bladder neck under cystoscope guidance. This improves the
co-optation of the urethral mucosa and increases the urethral resistance thereby
promoting continence.
Intra-detrusor injection of Botulinum toxin is used in the treatment of refractory
and neurogenic detrusor overactivity 100 or 200 IU of diluted Onobotulinum toxin
A is injected via cystoscope guidance at 20 sites in the detrusor muscle, of 1 ml injec-
tions. This is essentially an ambulatory procedure with complications such as uri-
nary tract infection and high post-void residual resolving soon. Though the effect
lasts for less than a year, repeat procedures can be done without loss of efficacy.
Side Effects and Complications
Cystoscopy is well tolerated by most patients with the most common side effects
being mild burning sensation, urgency, and haematuria. These usually resolve in
24–48 hours. The two most immediate complications of the procedure include
bleeding and urinary obstruction, and this should be assessed before the patient
leaves the day care centre. Serious complications of cystoscopy such as injury to
the urethra or bladder are not common.
Conclusion
Cystoscopy is one of the most important diagnostic tools used by the urologists
and urogynaecologists. It is relatively simple and can be performed as an office
procedure in most cases. It provides a means of diagnosis for numerous
conditions and invaluable intra-operatively in assessing ureteral and bladder

integrity. For this reason, it is important for gynaecologists and not just urologists
to be trained in this simple procedure.
Further Reading
Foon, R., Elbiss, H., and Moran, P.A. (2006). Cystoscopy for gynaecologists. Obstet.
Gynaecol. 8: 78–85.
Hanno, P.M., Landis, J.R., Mathews-Cook, Y. et al. (1999). The diagnosis of interstitial
cystitis revisited: lessons learned from the National Institutes of Health Interstitial
Cystitis Database Study. J. Urol. 161: 553–557.
Kwon, C.H., Goldberg, R.P., Koduri, S. et al. (2002). The use of intraoperative
cystoscopy in major vaginal and urogynecologic surgeries. Am. J. Obstet. Gynecol.
187 (6): 1466–1472.
Ramai, D., Zakhia, K., Etienne, D., and Reddy, M. (2018). Philipp Bozzini
(1773–1809): the earliest description of endoscopy. J. Med. Biogr 26 (2): 137–141.
Weinberger, M.W. (1998). Cystourethroscopy for the practicing gynaecologist. Clin.
Obstet. Gynecol. 41: 764–766.
63
Role of Nurse Practitioners in Ambulatory

Urogynaecological Care
Angie Rantell
Introduction
Ambulatory care is defined as ‘a personal healthcare consultation including

diagnosis, observation, treatment, intervention, and rehabilitation services using
advanced medical technology or procedures delivered on an outpatient basis (i.e.
where the patient’s stay at the hospital or clinic, from the time of registration to
discharge, occurs on a single calendar day).’ Many different specialties across
healthcare settings provide ambulatory care services, and they represent the most
significant contributors to increasing hospital expenditures to set‐up services
whilst improving the performance of the healthcare system in most countries,
including most developing countries. Ambulatory gynaecology services were first
reported in the literature in 2005, and many healthcare organisations around the
world are actively moving towards an ambulatory model of care because it has
been found to be associated with reduced morbidity and cost savings.
In some health systems, urinary incontinence has traditionally been seen solely
as a nursing problem. The evolution of the nursing role and the provision of
ambulatory care has significantly improved care and available treatment options.
The role of the nurse practitioner (NP) was first developed in the United Kingdom
(UK) in the 1980s and they now play a fundamental clinical role in many special-
ties, especially continence.
This chapter aims to describe the role of the NP within an ambulatory urogy-
naecology setting. It will discuss the different facets of the NP role prior to sug-
gesting examples of diagnostics and treatments that can be provided by an NP as
well as reviewing the additional risk and governance structures that need to be in
place for safe working.
Who is a Nurse Practitioner (NP)?
The traditional nursing role is similar throughout the world and generally involves
patient observations, toileting, personal hygiene assistance, medication adminis-
tration, wound care, post‐operative care, and specific tasks assigned to them by
the doctors in charge of the patient’s care. In many countries, however, this role
has evolved not only as a result of reduced working hours for doctors and increas-
ing demands for health services, but also due to enhanced education for nurses.
NPs not only provide advanced clinical care but are also involved in research,
audit, education‐and‐policy development, and they have an organisational role, as
part of management teams; they may also be responsible for budgets, purchasing,
and finding suppliers.
From a clinical perspective NPs work autonomously, providing general and
specialist health assessment, diagnostic investigations and treatment planning,
as well as performing certain treatments. Many will be independent nurse pre-
scribers. Ultimately, NPs in specialist practice are exercising higher levels of
judgement, discretion, and decision‐making in clinical care. A significant part
of the role is also in the education and counselling of patients regarding their
condition, prognosis, and available treatments, in addition to being a patient
advocate.
One of the expanding roles of all NPs has been in the performance of minor
surgery. It was reported by Dunlop in 2010 that in several specialties, nurses
have started to undertake minor surgical procedures to ease waiting‐list pres-
sures and to increase capacity to enable training of more junior doctors in com-
plex cases. This has included performing procedures such as flexible cystoscopy
hysteroscopy, insertion of supra‐pubic catheters and intra‐detrusor injections of
botulinum toxin A under local anaesthetic or mild sedation. With the advent of
more surgical devices for incontinence that can be inserted under local anaes-
thetic this role may soon expand further. NPs have been shown to be as effective
as junior doctors at many of these procedures. A Cochrane Review also explored
the substitution of doctors with NPs and found similar patient health outcomes,
at least in the short‐term, over the range of care investigated. Within a conti-
nence/urogynaecology setting, the role of the NP has been reported as essential
for service development, to ensure integrated care and optimal continence care
packages.
To perform this role, NPs must have an advanced level of understanding of
anatomy and physiology, be experienced and proficient clinical decision makers.
A formal assessment pathway to ensure competency must be performed by an
appropriate medical professional to ensure safe practice in line with regulatory
bodies and individual trust/hospital protocols.
Table 5.1 Potential diagnostics and treatments.
Urogynaecology
Diagnostics: Treatment/Procedures:
Uroflowmetry Pelvic floor muscle training
Filling & voiding cystometry Bladder retraining
Video cysto‐urethrography Bladder instillations
Ambulatory urodynamics monitoring Posterior tibial nerve stimulation
Abdominal/pelvic ultrasound Vaginal pessaries for prolapse and incontinence
Pelvic floor ultrasound Trial without catheter/ trial of void
Flexible/rigid cystoscopy Supra‐pubic catheter changes
Ureteric stent removal
Botulinum toxin A injection
Injection of bulking agents
Mini‐slings
Laser therapy
Perineal wound care
Telephone follow‐up for post‐op women
What Can a Urogynaecology Nurse Practitioner Do?
Within the ambulatory setting, a vast array of assessments and procedures can
be performed by a specialist urogynaecology NP. These may be related to more
traditional nursing care roles or advanced diagnostics/treatments within urog-
ynaecology, general gynaecology, or early pregnancy care. Table 5.1 lists
some of the assessments and procedures that NPs perform in relation to
urogynaecology.
Educational/Training Requirements
There is considerable international variation with the level of education required

for NPs. Generally, most have a minimum of a bachelor’s degree, but other posts
require a minimum of a master’s degree or even a PhD. All NPs will have to dem-
onstrate a minimum number of years of clinical experience within their field and
evidence of post‐graduate education. There are currently no educational courses
dedicated to urogynaecology, however, educational courses on continence and
also in gynaecology are available for nurses in the UK, the United States, Europe,
and Australia. More courses are beginning to appear in Asia, notably Hong Kong
and Singapore.
For many ambulatory procedures there are national training requirements. For
example, in the UK, the British Association of Urology (BAUS) and the British
Association of Urology Nurses (BAUN) have a training guideline for nurse cys-
toscopists, including stent removal, Botox injections and biopsies/diathermy.
These should be used where available to encourage safe working practice. In
many countries, it is necessary to provide proof of training and perform re‐valida-
tion for professional indemnity.
The main challenge for NPs and for the medics training them is in the time
taken and number of procedures that need to be performed to ensure compe-
tency. This is generally far more extensive than the training requirements for
junior doctors but is essential to fulfil the increased requirements for govern-
ance and safety.
Documentation
Accurate documentation is a fundamental part of healthcare and needs to be

adapted for use by NPs in specialist services to ensure that it meets the govern-
ance requirements. If the ambulatory service is predominantly led by NPs, an
operational policy should be developed to incorporate all clinical and potential
emergency scenarios. Appropriate plans should be in place for discussing
patients with a multidisciplinary team (MDT) and for onward referral if appro-
priate. The policy should act as a guide for all staff working within the service
and for those referring patients to the service. Treatment protocols should also
be available to guide all clinical staff performing or assisting in procedures, to
ensure exactly what their responsibilities are and that appropriate training is
provided.
Table 5.2 shows criteria to be included in an operational policy and treatment
protocol.
For many services, it is a requirement that NPs use pre‐approved procedure‐
specific consent forms and patient information leaflets. These should be approved
by the local governance committee to ensure that they are accurate, at a reading
age appropriate for the local population, and clearly outline whether the proce-
dure will be performed by an NP or a doctor. Depending on the healthcare service,
it may be necessary to have these available in a range of languages.
In line with the recommendations of the World Health Organisation, a safer
surgical checklist should also be completed before all procedures and, if indicated,
a decontamination audit trail should also be recorded regardless of the profes-
sional performing the procedure.
Table 5.2 Criteria for operational policy and treatment protocol.
Operational Policy Treatment Protocol
Overview of service Indications/contra‐indications

Location for procedure
Hours of operations Potential complications
Medical/nursing establishment Consent and accountability
Internal/External referral pathways Key points
Admission/Discharge criteria Patient preparation
Transfer to inpatient care Equipment
Follow‐up Performing the procedure
Supplies and procurement Post‐procedure
Cleaning and maintenance Follow‐up
Performance, monitoring, management and audit Documentation
Managing Risks and Governance Requirements
For many services, the delay or concern of moving towards NP‐led ambulatory
services has been around legislative issues, lack of understanding about how the
nursing role can be advanced, lack of supervision, and administrative restrictions.
Although NPs work in an autonomous role, they must have access to an MDT to
discuss complex cases and findings. The ability to capture still pictures or live
videos can prevent diagnostics having to be repeated, in addition to aiding discus-
sion and further treatment planning with the wider team.
A further concern is the management of emergency situations or complications
associated with certain treatments. NPs should, as a minimum, be trained in basic
life support to ensure that any intra‐procedure emergencies can be managed
appropriately. The level of experience, training, and supervision will dictate how
they manage complications, and this should be included as part of NPs’ educa-
tion. Regular audits of practice, safety, and outcomes should be performed to
ensure that they are in line with expectations.
Conclusions
NPs have a lot to offer towards ambulatory service models of care. Although there
is a lack of data specifically regarding urogynaecology, the NP role has been shown
to improve patient care, reduce medical workload, improve waiting times, and,
following an initial training period, be cost‐effective in the long‐term. With a
receptive medical team that is willing to provide training and indirect supervision,
the role can continue to expand and evolve along with clinical practice.
Further Reading
Berman P. Organization of ambulatory care provision: a critical determinant of
health system performance in developing countries. Bulletin of the World Health
Organization 2000; 78 (6):791.
Dunlop, N., 2010. Advancing the role of minor surgery for nurses. British Journal of
Nursing, 19 (11), pp. 685–691.
Geurts‐Laurent MG, Reeves D, Hermens RP, Braspenning JC, Grol RP, Sibbald
BS. Substitution of doctors by nurses in primary care. Cochrane Database of
Systematic Reviews 2004; 4: CD001271, doi: https://doi.org/10.1002/14651858.
CD001271.pub2.
Ghoshal, S. and Smith, AR., 2005. Ambulatory surgery in urogynaecology. Best
Practice & Research. Clinical Obstetrics & Gynaecology, 19 (5), pp. 769–777
Hudson, L. (2005). Best practice in care planning and documentation. In: Nurse Led
Continence Clinics (ed. R. Addison). Coloplast, UK: Peterborough.
Winston, W.J. (1985). Marketing Ambulatory Care Services, 9–11. UK: Routledge:
Abingdon‐on‐Thames.
69
Non-Surgical Management of Pelvic Floor Disorders

Arjunan Tamilselvi
Pelvic floor disorders of urinary incontinence, pelvic organ prolapse (POP) and
anal dysfunction have the potential to significantly affect the quality of life (QoL).
All these conditions are amenable to non-surgical management and their efficacy
has been studied in detail. Conservative measures of lifestyle changes, pelvic floor
exercises (PFE), use of pessaries, and pharmacological interventions play a major
role, either as a short-term intervention or as a definitive treatment in pelvic floor
disorders.
General Life-Style Interventions
Elements of general life-style interventions of exercise, weight loss, smoking ces-

sation, and avoiding constipation are all commonly applied in the management of
pelvic floor disorders. The advantage of these interventions is that, they can be
started solely based on the clinical history, without any exhaustive diagnostic
work-up.
Weight loss in women who are overweight or obese has been shown to
improve the symptoms of urinary and faecal incontinence. One study has
shown in obese women, who lost 3–5% of their baseline weight, there was a
47% reduction in stress incontinence episodes. With weight loss surgeries,
improvement in urinary and faecal incontinence symptoms has been
demonstrated.
In patients with POP, studies have shown that risk of prolapse progression
increases in overweight and obese women compared to women with healthy body
mass index and this progression was demonstrated consistently in all three com-
partments, anterior, apical, and posterior. However, weight loss has not been
shown to improve prolapse symptoms and not associated with reduction in the
grading of prolapse. The progression with increased BMI and the lack of regres-
sion with weight loss, suggests that damage to pelvic floor with obesity, might
become irreversible over time.
Smoking is associated with chronic cough and bronchitis, which can increase
intra-abdominal pressure and thereby weaken the pelvic floor muscle and con-
nective tissue. Epidemiological studies have shown a strong association between
urinary and anal incontinence and smoking. There are no studies to demonstrate
that smoking cessation reduces the progression of urinary incontinence, overac-
tive bladder symptom (OAB) and anal incontinence. The association between
smoking and POP appears to be variable.
Pelvic Floor Exercises
Pelvic floor exercises (PFE) or pelvic floor muscle training (PFMT) have shown to
be an important component in the treatment of pelvic floor disorders. Commonly
referred to as Kegel’s exercise, it has been in practice since 1948. In PFMT, the
pelvic floor muscles are assessed and regular contraction of the pelvic floor mus-
cles is taught to improve the strength and endurance of muscles and thereby facil-
itate better support of the pelvic organs. Assessment of pelvic floor muscle involves
vaginal palpation of the muscle to assess its strength and tone. The Modified
Oxford grading system is widely used to quantify muscle strength (Table 6.1).
PFMT, when done correctly, is likely to increase the pelvic muscle strength and
thereby the levator plate.
In both urinary and faecal incontinence, PFMT is used as first-line intervention
with or without behavioural approaches. In urinary incontinence, PFMT is more
commonly employed in patients with stress urinary incontinence (SUI) and less
commonly in those with urge or mixed incontinence. In a Cochrane review (2018),
Table 6.1 Modified Oxford scale.
Modified Oxford Grading for Pelvic Floor Muscles
0 No contraction/muscle activity
1 Minor muscle flicker
2 Weak muscle activity with no circular contraction
3 Moderate muscle contraction
4 Good muscle contraction
5 Strong muscle contraction
the cure rate for SUI with PFMT was 56% compared to 6% in the control group.
The review also showed reduction in the number of leakage episodes and improve-
ment in urinary incontinence specific to QoL, all reiterating the beneficial effect
of PFMT in SUI.
PFMT and biofeedback have been shown to alleviate the symptoms of faecal
incontinence. Compared to urinary incontinence, however, the data on PFMT in
faecal incontinence management is limited. Biofeedback, is a way of notifying the
patient when certain physiological events are occurring. Using an anorectal
manometry or surface electromyography (EMG), biofeedback therapy focuses on
rectal sensitivity training, strength training using visual or auditory signals for
proper muscle isolation and coordination training focusing on rectal distension
and anal sphincter contraction. The success rate for PFMT combined with bio-
feedback in faecal incontinence varies from 38 to 100%.
The efficacy of PFE in the treatment of POP was evaluated in the multicentre
randomised controlled POPPY trial (pelvic organ prolapse physiotherapy trial).
The study evaluated whether one-to-one PFMT would reduce the symptoms of
prolapse and the need for further treatment in women with stage I–III prolapse.
There was a good improvement of prolapse symptoms and reduction in its sever-
ity, in women doing PFMT compared to the controls, but there was no statistically
significant difference in the objective improvement of POP assessed by pelvic
organ prolapse quantification staging (POP-Q). Nevertheless, since treatment for
POP is used to alleviate the POP symptoms, PFE remains the first mode of inter-
vention in patients with POP.
Supervised PFMT and Biofeedback
PFMT though being a simple exercise, about a third doing Kegel’s exercise do not
contract the pelvic muscles and instead contract the lower abdominal, thigh or but-
tock muscles. Learning the correct technique is an important aspect in the success of
PFMT. The first step is to identify the pelvic floor muscle and several techniques are
taught, such as pretending to trying to avoid passing gas or trying to stop urine flow
in mid-stream. Once the correct muscles are identified, the PFE is initially practised
in the lying position and thereafter can be done in sitting or standing position. The
minimum number of contractions recommended is 30 per day, spread out through-
out the day. Women receiving regular and frequent supervised PFMT with a health
professional, are more likely to show improvement of their symptoms than women
doing training with little or no supervision. The most intensive programmes in terms
of supervision, weekly over three months, are shown to be the most successful.
In an attempt to improve the efficacy of PFMT, it has been evaluated using other
modalities as adjunct, such as vaginal cones, electrical stimulation, and use of
magnetic chairs. Vaginal cones of increasing weight, in equal shape and volume
are used. Starting with the lightest weight, gradually increasing the cone weight
successively, women are taught to place the cone into the vagina while standing
and hold it in place with voluntary contraction of the pelvic floor. The heaviest
weight that can be retained by the women is called the active cone and women are
advised to exercise the pelvic floor muscle using this. This effectively acts like a
biofeedback helping in the PFMT.
Electrical stimulation is a more sophisticated form of biofeedback therapy in
PFMT. Electrodes are inserted into the middle third of the vagina and using an
on–off pulse cycle, over a range of 0–100 mA, the maximum current intensity
comfortably tolerated by the patient is delivered. A study comparing PFE, use of
vaginal cones, and electrical stimulation identified all three interventions as
equally effective in women with urinary incontinence. Use of cones and electrical
stimulation did not significantly increase the strength of pelvic floor muscle as
compared to PFMT alone.
Use of magnetic chair was introduced as an additional tool in the conservative
management of urinary incontinence. The patient sits in a specially designed
chair and within the seat is a magnetic field generator, that delivers rapidly chang-
ing magnetic impulse. The principle is that magnetic impulse delivered to the
pelvic floor can increase its muscle strength. The studies have not shown any sig-
nificant improvement of symptoms of both urinary and faecal incontinence with
extracorporeal magnetic stimulation.
PFMT has been shown to be an effective strategy in patients with SUI, faecal
incontinence, and in a group of patients with stage I–III POP. Hence, it would be
the first line of conservative management, and vaginal cones, electrical stimula-
tion, and extracorporeal magnetic stimulation can be offered to women who find
it difficult to identify and contract their pelvic floor.
Bladder Re-training
In patients with urge incontinence, behavioural interventions such as bladder

training with patient education on type and amount of fluid intake – based on the
bladder diary – scheduled voiding, and urge-suppression strategies constitute
the first line of intervention. This is often reinforced with PFMT and biofeedback.
The PFE can increase the bladder outlet resistance and is also thought to inhibit
spontaneous bladder contractions, resulting in reduced leakage. In patients with
OAB, bladder training is an important strategy in reducing the urge episodes. The
aim is to increase the time interval between voids to three hours. Patients are
asked to start with shorter intervals and gradually increase the time interval using
urge-suppression strategies such as crossing legs or contracting pelvic floor
muscles, until the three-hour interval is achieved. Restricting alcohol, caffeine,

and aerated drinks and ensuring last fluid intake is at least one to two hours before
bedtime are other measures helpful in OAB.
Pessaries
Pessaries are commonly employed as non-surgical treatment option in women
with prolapse. A pessary is a vaginal support device made of inert material such as
silicone or plastic and can be used to treat symptoms of POP and SUI. A variety of
pessaries are available, broadly classified into support pessaries, space-filling pes-
saries, and incontinence pessaries (Figures 6.1–6.7). The most common types of
Figure 6.1 Ring pessary without knob and with knob.
Figure 6.2 Dish pessary with knob.

Figure 6.3 Doughnut pessary.
Figure 6.4 Gellhorn pessary.
Figure 6.5 Shelf pessary.

Figure 6.6 Cube pessary.
Figure 6.7 Inflatoball pessary.
pessaries in clinical use are the ring pessary and the Gellhorn pessary. The incon-
tinence pessaries have the addition of a knob that can fit against the bladder neck,
thereby preventing a urine leak.
The commonest group in which a pessary is used for POP are, the elderly frail
patients, with or without co-morbid problems which preclude surgery. In young
women, pessaries are used for POP and SUI in those who prefer conservative
management rather than surgery.
Choice of the pessary depends on the presenting problem, stage of prolapse,
and the desire for sexual activity. In patients presenting with POP and SUI, the
incontinence pessaries can provide support to pelvic organs and to the bladder
neck. The selection between space-occupying and support pessary is largely
dependent on the sexual history of the women. Space-filling pessaries cannot be
used in patients who are sexually active, unless they can be trained on self-inser-
tion and removal technique. Most clinicians will avoid inserting pessaries that
pose difficulty with insertion and removal, particularly in the elderly.
Prior to fitting the pessary, a pelvic examination should assess the width and
length of vagina, stage and compartment of prolapse, presence of infection, ulcer-
ation, or atrophic changes. Topical oestrogen cream can be prescribed over two to
four-week period prior to insertion in those with significant atrophic changes.
Pessary treatment should aim to relieve the prolapse symptom. Appropriate size
and type of pessary should be selected, to avoid pain and ulceration of vaginal
mucosa. Pessary fitting is an art rather than science.
Pessaries are sometimes used to see what would be the effect of surgery for POP
on urinary symptoms, especially in advanced stages of POP. This is called a ‘pes-
sary trial’. If any occult SUI is revealed with pessary prior to surgery, procedure to
correct SUI can be combined along with prolapse surgery.
The overall success rate for prolapse symptoms with pessaries is quoted around
71%. The PESsary Symptom Relief Impact (PESSRI) study, looked at the symptom
relief outcomes using standardized questionnaires, with randomised crossover
trial of the ring with support and Gellhorn pessary. The study showed there were
statistically and clinically significant improvements in the majority of pelvic floor
distress inventory (PFDI) and pelvic floor impact questionnaire (PFIQ) scoring
with both pessaries and no clinically significant differences between the two. Both
effectively relieved the symptoms of protrusion and voiding problem. In patients
with SUI, ring pessaries with and without support were found to be effective in
relieving symptoms in 78% and 63%, respectively, in a study. The success rates
with pessaries have been quoted from 41 to 74% in different studies, irrespective
of the compartment of prolapse. A long or wide vagina is not a contraindication
for vaginal pessary. If pessary fitting is successful at the end of four weeks, most
women would continue to use it over five years. The usual recommendation for
pessary change is every three to four months, and at each change the vaginal wall
should be examined to rule out ulceration.
There are very few complications associated with pessaries and they include
discharge, pain, discomfort, ulceration, bleeding, constipation, and rarely
disimpaction. When using in the elderly age group, the social situation should be
addressed to check if patient has support system in place for regular pessary change.
Pessaries are contraindicated in the presence of cervical or vaginal ulcerations,

undiagnosed vaginal bleeding, active pelvic infection, and patients allergic to sili-
cone or latex.
Pharmacotherapy
In women with urinary incontinence, the role of pharmacotherapy in patients

with OAB is well defined compared to those with SUI. In the broadest definition,
SUI is the result of urethral sphincter incompetence and pathologically results
from urethral or bladder neck hypermobility or reduced mucosal co-optation in
intrinsic sphincter deficiency.
Alpha-adrenoceptor (α-AR) agonists, estrogens, and tricyclic antidepressants
(TCAs) have been used in the pharmacological treatment of SUI. There is little or
no evidence of the effectiveness of these drugs, and some of them have been
shown to have significant adverse effects. Alpha agonists can cause a rise in blood
pressure, and imipramine can cause orthostatic hypotension and constipation.
Oestrogen deficiency is identified as a causative factor for SUI, but oestrogen ther-
apy is more effective in patients with urge incontinence and its role in SUI is
controversial. Duloxetine, a serotonin nor-adrenaline re-uptake inhibitor (SNRI)
has been used in the treatment of SUI. This drug has shown moderate efficacy in
the treatment of mild to moderate SUI with adverse events of nausea, constipa-
tion, dry mouth, and fatigue limiting its use.
In patients with OAB symptoms, with or without urge urinary incontinence
(UUI), the primary modality of intervention along with life style intervention is
pharmacotherapy. Urgency, frequency, nocturia, and urge incontinence result
from detrusor contractions during the storage phase of the micturition cycle. The
contraction is predominantly mediated by the muscarinic receptors on the detru-
sor muscle, so anticholinergic (antimuscarinic) drugs are the medications of
choice in OAB. The new entrant in the pharmacotherapy for OAB is the
β3-adrenoceptor agonist, Mirabegron. The mode of action is by stimulation of
the β3-adrenoceptors on the detrusor muscle, promoting bladder relaxation dur-
ing the storage phase.
The different anticholinergic drugs, oxybutynin, tolterodine, trospium chloride,
solifenacin, darifenacin, fesoterodine are all associated with systemic anticholin-
ergic effects of dry mouth and constipation with varying incidence. Oxybutynin
the non-selective anticholinergic, also exerts muscle relaxant and local anaes-
thetic effects. Tolterodine, trospium, solifenacin, darifenacin, and fesoterodine are
selective antimuscarinic agents, acting on the M2 and M3 receptors. The very low
penetration of darifenacin, across the blood brain barrier is beneficial in the
elderly, as it is less likely to cause confusion.
The Cochrane systematic review in 2012, compared the anticholinergic drugs

against each other. In terms of efficacy, all these anticholinergic drugs have been
shown to be effective, with reduction in urgency and incontinence episodes. The
systematic review comparing the oral immediate release (IR) oxybutynin and
tolterodine, concluded the latter might be preferred with a reduced risk of dry
mouth. The extended-release preparations are preferred to the IR because of
lesser-side-effect profile. Solifenacin, and fesoterodine when compared to IR
tolterodine, the former two have lesser incidence of dry mouth and constipation.
Because the efficacy is similar for the antimuscarinics, it is the side-effect profile,
that determines the continuation of treatment.
Mirabegron, a β3-adrenoceptor agonist with its different receptor target, should
not have the anticholinergic side-effect profile. The efficacy of mirabegron in the
treatment of OAB has been demonstrated in randomised, placebo-controlled tri-
als. The drug has been efficacious in reducing the mean number of micturition
and incontinence episodes per 24 hours, as well as in improving other secondary
outcomes such as OAB symptoms and QoL measures.
Common adverse drug events seen with mirabegron include hypertension,
nasopharyngitis, urinary tract infections, and headache. Given the efficacy and
safety data currently available, mirabegron represents a reasonable alternative to
antimuscarinics for patients with OAB.
ercutaneous Posterior Tibial Nerve

P
Stimulation (PTNS)
Percutaneous posterior tibial nerve stimulation (PTNS) is a neuromodulation

technique, where the sacral nerve plexus is indirectly stimulated and the detrusor
and rectal function/activity is modified. The mechanism of neuromodulation is
not completely understood, and alteration of the afferent and efferent pathways
between the brain, brain stem, and pelvic organs are thought to modulate the
voiding reflex and facilitate storage. PTNS is a treatment option in women with
refractory OAB, who do not respond to pharmacotherapy and in those with urge
faecal incontinence.
The sympathetic and parasympathetic innervation of the pelvic organs is
mediated via nerves originating from L2 to S4 segments of the spinal cord. The
sciatic nerve is composed of fibres from L4 to S3 and one of its branches is the
posterior tibial nerve. Stimulation of this peripheral nerve is believed to cause
cross-signalling between the sympathetic and parasympathetic postganglionic
nerve terminals and synapses, and is postulated to modulate neural transmission
altering bladder and rectal function.
Figure 6.8 PTNS connection.
PTNS involves insertion of a 34-gauge needle approximately three fingers

breadth cephalad to the medial malleolus, between the posterior margin of the
tibia and soleus muscle. The tip of the needle should be close to the posterior tibial
nerve without actually touching it. The needle is inserted to a depth of about
2–4 cm at an angulation of 60–90° and the adhesive electrode is fixed near the arch
of the foot (Figure 6.8). The needle and the electrode are connected to a low volt-
age (9 V) stimulator with an adjustable pulse intensity of 0–10 mA, a fixed pulse
width of 200 microseconds and a frequency of 20 Hz.
During the initial test stimulation, the amplitude is slowly increased until the
large toe starts to curl or the toes start to fan. Once optimal position is assured,
stimulation is applied at an intensity level well tolerated by the patient and can
be increased or decreased during the treatment. During PTNS, the patient’s
leg is comfortably elevated and supported. Most treatment schedules consist
of 12 outpatient consecutive treatment sessions lasting 30 minutes each, given
1–2 times/week.
The overall subjective success, defined as improved QoL or willingness to con-
tinue treatment, was found in 56–63% of OAB patients. Overall objective success
with 50% decrease in urge or UUI and 25% reduction in daytime and/or night
time frequency was found in 33–71%. In those with faecal incontinence, PTNS has
shown statistically significant improvement in patients with urge and mixed fae-
cal incontinence, with improvement in the Cleveland Clinic Florida (CCF)-FI
score, with an associated improvement in the QoL score. Studies have also shown
significant improvements in the median deferment time and median number of
weekly faecal incontinence episodes.
PTNS is a low risk non-surgical treatment option with limited contraindica-
tions. It should not be used in those under the age of 18, patients with pacemakers
or implantable defibrillators, coagulopathy, neuropathy, those who are currently
pregnant or with the intention to become pregnant, and in those with local skin
pathology. Apart from the other conservative measures employed in pelvic floor
disorders, PTNS is the other intervention most suitable to be done in the ambula-
tory setting.
Conclusion
In POP and SUI, surgical management though an effective intervention – it

might not be the treatment of choice in some women. PFMT and pessaries are a
good first line option in those women, and in those with OAB, PFE, bladder
retraining combined with pharmacotherapy are the treatment of choice for the
majority.
Further Reading
Cundiff, G.W., Amundsen, C.L., Bent, A.E. et al. (2007). The PESSRI study: symptom
relief outcomes of a randomized crossover trial of the ring and Gellhorn pessaries.
American Journal of Obstetrics and Gynecology 196 (4): 405.e1–405.e8.
Dumoulin, C., Cacciari, L.P., and Hay-Smith, E.J.C. (2018). Pelvic floor muscle
training versus no treatment, or inactive control treatments, for urinary
incontinence in women. Cochrane Database of Systematic Reviews (10): CD005654.
https://doi.org/10.1002/14651858.CD005654.pub4.
Hagen, S., Stark, D., Glazener, C. et al. (2013). Individualised pelvic floor muscle
training in women with pelvic organ prolapse (POPPY): a multicentre randomised
controlled trial. Lancet 383: 796–806.
Madhuvrata, P., Cody, J.D., Ellis, G. et al. (2012). Which anticholinergic drug for
overactive bladder symptoms in adults. Cochrane Database of Systematic Reviews
(1): CD005429. https://doi.org/10.1002/14651858.CD005429.pub2.
81
Ambulatory Surgical Procedures in Stress Urinary

Incontinence
Dudley Robinson
Introduction
The term stress urinary incontinence (SUI) may be used to describe the symptom
or sign of urinary leakage on coughing or exertion but should not be regarded as
a diagnosis. A diagnosis of urodynamic stress incontinence (USI) can only be
made after urodynamic investigation, and this is defined as the involuntary leak-
age of urine during increased abdominal pressure in the absence of a detrusor
contraction.
All women who complain of the symptom of SUI will initially benefit from
lifestyle advice and pelvic floor muscle training (PFMT). Those who fail to improve
with conservative measures may benefit from Duloxetine or may ultimately
require continence surgery. This chapter will focus on those surgical options that
may be performed as ambulatory or outpatient procedures.
Epidemiology
Stress incontinence is the most commonly reported type of urinary incontinence

in women. In a large epidemiological study of 27 936 women from Norway, 25% of
women reported urinary incontinence of whom 7% considered it to be significant.
The prevalence of incontinence increased with age. When considering the type of
incontinence, 50% of women complained of stress, 11% of urge, and 36% of mixed
incontinence. The prevalence of urinary incontinence among nulliparous women
ranged from 8 to 32% and increased with age. In general, parity was associated
with incontinence and the first delivery was the most significant factor. In the age
group 20–34 years, the relative risk of stress incontinence was 2.7 (95% CI: 2.0–3.5)
for primiparous women and 4.0 (95% CI: 2.5–6.4) for multiparous women.
There was a similar association for mixed incontinence, although, not for urge
incontinence.
Pathophysiology
There are various underlying causes that result in weakness of one or more of the
components of the urethral sphincter mechanism (Table 7.1).
The bladder neck and proximal urethra are normally situated in an intra-
abdominal position above the pelvic floor and are supported by the pubo-urethral
ligaments. Damage to either the pelvic floor musculature (levator ani) or pubo-
urethral ligaments may result in descent of the proximal urethra such that it is no
Table 7.1 Causes of stress urinary incontinence.
Urethral hypermobility
Urogenital prolapse
Pelvic floor damage or denervation
Parturition
Pelvic surgery
Menopause
Urethral scarring
Vaginal (urethral) surgery
Incontinence surgery
Urethral dilatation or urethrotomy
Recurrent urinary tract infections
Radiotherapy
Raised intra-abdominal pressure
Pregnancy
Chronic cough (bronchitis)
Abdominal/pelvic mass
Faecal impaction
Ascites
(Obesity)
longer an intra-abdominal organ and this results in leakage of urine per urethra
during stress.
This theory has given rise to the concept of the ‘hammock hypothesis,’ which
suggests that the posterior position of the vagina provides a backboard against
which increasing intra-abdominal forces compress the urethra. This is supported
by the fact that continent women experience an increase in intra-urethral closure
pressure during coughing. This pressure rise is lost in women with stress inconti-
nence, although, may be restored following successful continence surgery.
In addition to pelvic floor damage, there is also evidence to suggest that stress
incontinence may be caused by primary urethral sphincter weakness or intrinsic
sphincter deficiency (ISD). In order to distinguish this type of stress incontinence
from that caused by descent and rotation of the bladder neck during straining, the
Blaivis Classification has been described based on video-cystourethrography
observations. This proposes that Type I and Type II stress incontinence are caused
principally by urethral hypermobility, whereas Type III, or ISD, is caused by a
primary weakness in the urethral sphincter. Factors associated with ISD are
pudendal denervation injuries, loss of integrity of the striated urethral sphincter
and urethral smooth muscle, as well as the loss of urethral mucosa and submu-
cosal urethral cushions.
The ‘mid-urethral theory’ or ‘integral theory’ described by Petros and Ulmsten
is based on earlier studies suggesting that the distal and mid-urethra play an
important role in the continence mechanism and that the maximal urethral clo-
sure pressure is at the mid urethral point. This theory proposes that damage to the
pubourethral ligaments supporting the urethra, impaired support of the anterior
vaginal wall to the mid urethra and weakened function of part of the pubococ-
cygeal muscles, which insert adjacent to the urethra, are responsible for causing
stress incontinence.
mbulatory Procedures for Stress

A
The acceptance of the ‘Integral Theory’ of incontinence and the success of mid-
urethral sling surgery has transformed the approach to continence surgery.
There has been a shift from more traditional procedures such as colposuspen-
sion and autologous fascial slings, which required an in-patient stay, to day-case
procedures. Minimally invasive surgery is associated with less morbidity and
considerable cost savings. This had led to a move towards minimally invasive
procedures performed as a day-care procedure in an ambulatory setting
(Table 7.2).
Table 7.2 Ambulatory procedures for stress

urinary incontinence.
Urethral Bulking Agents

Single Incision Mini-Slings
Laser Therapy
Radiofrequency Ablation
Urethral Bulking Agents
Urethral bulking agents may be performed in the ambulatory clinic under local
anaesthetic. They are particularly useful in younger women who haven’t yet com-
pleted their families, in the elderly with co-morbidities, and in those women, who
have undergone previous operations and have demonstrated ISD.
Although the actual substance that is injected may differ, the principle is the
same. It is injected either periurethrally or transurethrally on either side of the
bladder neck or mid-urethra under cystoscopic control. It is intended to increase
urethral coaptation without causing out-flow obstruction.
There are now a number of different products available (Table 7.3). The use of
minimally invasive implantation systems has also allowed some of these proce-
dures to be performed in the ambulatory setting without the need for concomitant
cystoscopy.
Table 7.3 Urethral bulking agents.
Urethral Bulking Agent Application Technique
Polydimethylsiloxane Cystoscopic
(Macroplastique) Implantation System
Pyrolytic carbon coated zirconium oxide beads Cystoscopic
(Durasphere)
Calcium Hydroxylapatite in carboxymethylcellulose gel Cystoscopic
(Coaptite)
Polyacrylamide hydrogel Cystoscopic
(Bulkamid)
Vinyl Dimethyl Polydimethylsiloxane (PDMS) Polymer Implantation System
(Urolastic)
Polycaprolactone (PCL) Cystoscopic
(Urolon)
Macroplastique
Macroplastique (Cogentix) (Figure 7.1) is a particulate bulking agent composed of

polydimethylsiloxane particles suspended in a bio-excretable carrier gel that is
removed un-metabolised by renal excretion within one week. The carrier gel is
then, over time, replaced by host collagen. Macroplastique may be injected using
a cystoscopic approach, a periurethral approach, or by using the Macroplastique
implantation system (MIS).
As with most bulking agents Macroplastique was compared to the Contigen
Collagen Implant (Bard) in a large North American study of 248 women with
USI. The outcome was assessed objectively using pad tests and subjectively at
12 months. Overall, the objective cure and improvement rates favoured
Macroplastique over Contigen (74 vs 65%; p = 0.13). Although this difference was
not statistically significant, subjective cure rates were higher in the Macroplastique
group (41 vs 29%; p = 0.07).
Macroplastique is one of the few bulking agents to have long-term efficacy data
with dry rates of 67% reported at one year and 41% at two years, as well as 85%
improvement rates at two years. These results are supported by a systematic
review and meta-analysis of 958 patients from 23 studies, which demonstrated
75% (95%CI: 69–81) in the short term, 73% (95%CI: 62–83) in the mid-term and
Figure 7.1 Macroplastique.

64% (95%CI: 57–71) in the longer term. Dry rates were 43% (95%CI: 33–54), 37%
(95%CI: 28–46) and 36% (95%CI: 69–81), respectively. Importantly, there were no
serious adverse events reported.
Bulkamid
Bulkamid (Contura) (Figure 7.2) is a homogenous biocompatible bulking agent

composed of non-degradable cross-linked polyacrylamide hydrogel and is 97.5%
water and 2.5% dry matter. It is injected using a urethroscope under direct vision.
The safety and efficacy of Bulkamid has now been reported in both European
and North American trials. A two-year European study of 135 women has reported
a subjective responder rate of 64%, which was compatible with the 67% responder
rate at 12 months, and this was supported by a significant decrease in inconti-
nence episodes, frequency, and urinary leakage. The overall reinjection rate was
35% and there were no long-term safety concerns.
These results are supported by a large prospective single-blind, randomised con-
trolled study comparing Bulkamid to collagen in 229 North American women at 33
centres. At 12-month follow up, responder rates, defined as a greater than 50%
reduction in leakage and incontinence episodes, were 53.2% in the Bulkamid arm
and 55.4% in the collagen arm. Dry rates at 12 months were 47.5 and 50%, respectively.
Figure 7.2 Bulkamid.

Coaptite
Coaptite (Boston Scientific) (Figure 7.3) is a particulate bulking agent composed of

calcium hydroxylapatite particles and is injected using a cystoscopic technique.
Coaptite has been compared to collagen in a 12-month prospective randomised
comparative study of 231 women. At 12 months, 63.4% of the Coaptite group showed
improvement of one Stamey grade or more compared to 57% in the Collagen group.
In addition, re-injection rates were 62% in the Coaptite arm as compared to 73.9% in
the collagen arm, and there were no long-term safety concerns.
Durasphere
Durasphere (Coloplast) (Figure 7.4) is a particulate bulking agent composed of

pyrolytic carbon coated beads, which is injected using a trans-urethral or peri-
urethral technique. Durasphere has been compared to collagen in a multicentre,
Figure 7.3 Coaptite.

Figure 7.4 Durasphere.
randomised, double-blind controlled trial of 355 women with ISD. At 12 months,

80.3% of the Durasphere group reported improvement in Stamey grade or more
compared to 69.1% in the collagen group. Although adverse effects were similar
between groups, there were more cases of urgency and urinary retention reported
in the Durasphere arm. Subsequently, 56 women from one centre were followed
up over 36 months. Treatment was initially effective in 63% of women and this fell
to 33% at 24 months and 21% at 36 months compared to 19% and 9% for collagen,
respectively.
Urolastic
Urolastic (Urogyn) (Figure 7.5) is a homogeneous bulking agent composed of

vinyl dimethyl terminated polydimethylsiloxane polymer, tetrapropoxysilane
cross-linking agent, platinum vinyl tetramethyl siloxane complex catalyst and
titanium dioxide radiopacifying agent and is injected peri-urethrally using an
application device. In a small proof of concept study of 20 women, a dry rate of
68% was reported at 12 months with corresponding improvements in health-
related quality of life (HRQoL) and pad weights. There was, however, a complica-
tion rate of 30% including pain and dyspareunia, and dry rates fell to 45% at
Figure 7.5 Urolastic.
24 months. A larger study of 105 women has also reported objective success rates
of 59.3% and improvement rates of 71.4% at 12 months, although, here again suc-
cess rates fell to 32.7% at 24 months with a complication rate of 25.8%.
More recently, a systematic review and meta-analysis of five papers has been
performed, which reported an objective success rate of 32.7–67% with a mean of
57% and a subjective improvement in 80% of patients.
Urolon
Urolon (Aqlane Medical) (Figure 7.6) is a polycaprolactone based bio-resorbable

urethral bulking agent that is thought to stimulate collagen production and is
injected cystoscopically. The efficacy and safety of Urolon has been reported in a
small multi-centre trial of 50 patients followed up over 12 months. Improvement
using the Stamey Grading Score was recorded in 57.9% of patients at 12 months
with a cure rate of 39.5%. There was a corresponding improvement in patient-
related outcome and HRQoL with no reported significant adverse events.
Single Incision Mini-Slings (SIMS)
The description of the Integral Theory and subsequent introduction of retropubic

and trans obturator mid-urethral slings has revolutionised continence surgery.
More recently there has been a move to a minimally invasive approach in the
Figure 7.6 Urolon.
Figure 7.7 Solyx.
ambulatory setting using single incision mini-slings (SIMS), which are associated
with a lower incidence of bladder perforation and may be performed under local
anaesthesia. Although several SIMS were developed, many have now been with-
drawn from the market. Solyx (Boston Scientific) (Figure 7.7), Ajust (Bard)
(Figure 7.8) and Ophira (Promedon) (Figure 7.9) are still available in some countries.
A systematic review and meta-analysis comparing SIMS with standard mid-
urethral slings reviewed 26 randomised controlled trials including 3308 women.
Figure 7.8 Ajust.
After excluding TVT Secur (now withdrawn), there was no significant difference
in patient-reported cure (RR: 0.94; 95% CI: 0.88–1.00) and objective cure (RR: 0.98;
95% CI: 0.94–1.01) at a mean follow up of 18.6 months between the two proce-
dures. Although SIMS were associated with less post-operative pain and an earlier
return to normal activities, there was a trend to higher rates of repeat continence
surgery (RR: 2.00; 95%CI: 0.93–4.31).
More recently, a further systematic review and meta-analysis has been reported
by the Cochrane group and assessed 31 trials involving 3290 women including those
trials assessing TVT Secur. Overall, women were more likely to remain incontinent
after SIMS when compared to retropubic TVT slings (RR: 2.08; 95% CI: 1.04–4.14)
Figure 7.9 Ophira.
and trans obturator slings (RR: 2.55; 95% CI: 1.93–3.36). In addition, there was a
higher risk of vaginal mesh exposure (RR: 3.75; 95% CI: 1.42–9.86) and bladder/
urethral erosion (RR: 17.79; 95% CI: 1.06–298.88). The authors concluded that
TVT Secur was inferior to standard mid-urethral slings and that there were insuf-
ficient data to allow reliable comparisons between the other SIMS and stand-
ard slings.
Synthetic Mid-urethral Slings

The use of synthetic slings, either as a retropubic approach (using TVT) or a trans-
obturator approach (using TVT-O), had largely replaced the traditional inconti-
nence procedures in the last two decades. The efficacy of it has been proven in
many studies. Following the reports in the media on mesh-related complications
in prolapse surgeries and the subsequent FDA warning, the general public has
become fearful of the mid-urethral sling. In the UK, this has led to a temporary
ban on the use of tension-free synthetic slings until more data becomes available.
If, on further information, synthetic mid-urethral slings become the procedure of
choice, its greatest advantage would be the possibility of doing an effective proce-
dure in an ambulatory setting.
Thermomodulation
There is currently increasing interest in the use of thermo-modulation devices

as ambulatory procedures for managing women with SUI. The evidence sup-
porting the use of laser therapy and radiofrequency is, however, currently
limited.
Laser
There are currently two different types of laser that are being used clinically
within urogynaecology; Micro ablative fractional CO2 laser (MonaLisa Touch,
Deka) (Figure 7.10) and non-ablative photothermal Erbium: YAG laser (Er: YAG-
laser) (Fotona Smooth, Fotona) (Figure 7.11). Both types of laser cause thermo-
modulation by heating and, in the case of the CO2 laser, ablating columns of
tissue. This leads to a controlled temperature rise, which results in vasodilatation,
collagen remodelling, collagen synthesis, neo-vascularisation and elastin forma-
tion. This improves vaginal elasticity and restoration of vaginal flora to premeno-
pausal status.
Although there is increasing evidence to support the use of laser therapy in the
management of women with genitourinary syndrome of menopause (GSM),
there is a paucity of evidence supporting usage in patients with SUI. A small pro-
spective randomised controlled trial comparing Er: YAG laser to sham therapy has
recently been reported in 114 premenopausal women. At three-month follow-up
there was a significant improvement in subjective outcome in the laser arm with
dry rates of 21% as compared to 4% in the sham arm. A further small nonran-
domised study has compared Er: YAG laser to TVT or TOT in 100 patients. Overall,
there were comparable improvements in the 1-hour pad test and HRQoL, although
the dry rates were significantly lower in the laser arm when compared to the TVT
and TOT arm (50%, 69%, and 68%, respectively).
Consequently, whilst laser therapy may be considered as an ambulatory treat-
ment for women with SUI, women need to be counselled regarding the lack of
robust evidence and the need for ongoing long-term clinical trials.
Figure 7.10 Monalisa Touch Laser, Deka.

Figure 7.11 Fotona Smooth, Fotona.
Radiofrequency
Radiofrequency devices emit focused electromagnetic waves that generate heat

upon meeting tissue impedance. At tissue temperatures between 40–45 °C, radiof-
requency can induce fibroblasts to produce collagen through activation of heat
shock proteins and initiation of the inflammatory cascade. Ex-vivo and in-vivo
studies have demonstrated that radiofrequency treatment produces thickening

and rearrangement of collagen and elastin fibres with no reported adverse events
in the epidermis, nerves, or blood vessels.
The safety and efficacy of radio frequency collagen denaturation has been
assessed in a number of small retrospectives series. A three-year follow-up of
21 patients reported that 56% of patients achieved a 50% or greater reduction in
incontinence episode frequency with no long-term adverse effects. These results
are supported by a larger prospective study in 139 women which reported a sub-
jective improvement in HRQoL, although, it did not evaluate outcome with any
objective measures.
The Cochrane group has recently published a systematic review and meta-anal-
ysis of transurethral radiofrequency collagen denaturation in the management of
women with SUI. Overall, only one sham controlled randomised trial of 173
women was suitable for analysis and, given the limitations of this study, the
authors concluded that the role of radiofrequency collagen denaturation in the
treatment of women with SUI remains unclear.
Conclusion
Minimally invasive therapies have revolutionised the surgical management of

SUI and many may now be performed as ambulatory procedures under local
anaesthesia. Ambulatory care minimises cost within the healthcare system,
reduces morbidity, and improves the patient experience. This results in an earlier
return to normal activities and hence an economic benefit to society beyond the
healthcare system.
Although the role of urethral bulking agents is well established, the precise role
of SIMS remains to be determined, and many devices have now been withdrawn
from the market.
Newer therapies continue to be developed, and there may be a role for laser
therapy and radiofrequency in the management of SUI. However, at present there
is a paucity of evidence for these new modalities and there remains a need for
robust clinical trials.
Further Reading
Blaivis, J.G. and Olsson, C.A. (1988). Stress incontinence: classification and surgical
approach. J. Urol. 139: 727–731.
DeLancey, J.O. (1994). Structural support of the urethra as it relates to stress
incontinence: the hammock hypothysis. Am. J. Obstet. Gynaecol. 170: 1713–1720.
Hannestad, Y.S., Rortveit, G., Sandvik, H., and Hunskar, S. (2000). A community-
based epidemiological survey of female urinary incontinence: The Norwegian
EPINCONT Study. J. Clin. Epidemiol. 53: 1150–1157.
Haylen, B.T., de Ridder, D., Freeman, R.M. et al. (2010). An International
Urogynaecological Association (IUGA)/International Continence Society (ICS)
joint report on the terminology for female pelvic floor dysfunction.
Int. Urogynecol. J. 21: 5–26.
99
Pelvic Organ Prolapse Surgery as an Ambulatory

Procedure
Marcella Zanzarini Sanson and G. Willy Davila
Urogynaecological procedures are particularly well served as ambulatory procedures

because most can be done via the vaginal approach, the anaesthetic time and sur-
gical duration are rather brief, and post-operative pain does not often limit dis-
charge. In the United States, the Centers for Medicare and Medicaid Services
(CMS – the national insurance plan for retirees) has classified most urogyneco-
logical procedures including vaginal hysterectomy and mid-urethral slings as day-
surgery procedures. Most private insurance companies have followed suit and as
a consequence, the standard of care in the United States is that most pelvic recon-
structive procedures performed vaginally are performed as day-care procedures.
We have reported on our experience with a model of all vaginal procedures
being performed as ambulatory same-day surgeries. Overall, clinical outcomes are
not negatively impacted, although, patient acceptance and satisfaction are greatly
dependent on pre-operative education.
Outside of the United States, institutions have followed this pattern of shifting
pelvic floor surgeries to the outpatient setting. Similar positive results in terms of
clinical outcomes and patient satisfaction have been reported.
This chapter will review the many steps pelvic reconstructive surgeons have
taken, to safely and efficiently perform pelvic reconstructive surgeries as ambula-
tory day-surgery cases.
General Requirements
In ambulatory surgical procedures, general peri-operative considerations have to

be followed. These include avoidance of medications with anti-coagulant proper-
ties, avoidance of pre-operative constipation, and the implementation of enhanced
recovery after surgery protocols (ERAS). Addressing specific aspects in the
urogynaecological procedures and adopting ERAS protocols can make prolapse

surgeries amenable to ambulatory care. The patient and her family should be
involved in the decision to perform a procedure in the ambulatory setting.
Enhanced Recovery Protocols
ERAS protocols utilise multidisciplinary teams to optimise patient outcomes with

improved patient satisfaction and decreased hospital costs. ERAS protocols have
been applied to urogynecologic surgery as well, with a positive impact being
noted. Overall, when compared to traditional management, no significant differ-
ences were noted, except that ERAS patients were more likely to be discharged
with a urinary catheter and had a slightly higher readmission rate but patient
satisfaction was high.
The essentials of ERAS protocols are based on four stages, all aiming to reduce
surgical stress, maintain normal physiological function perioperatively, and expe-
dite post-operative recovery (see Table 8.1).
The First Stage for ERAS is Pre-admission

The pre-operative phase is an opportunity to educate patients, set expectations of
what will occur before, during, and after the surgery. This includes a discussion
regarding postoperative pain and a management strategy (see Table 8.2).
At the time, the patient is advised to reduce alcohol consumption and quit
smoking. Smoking cessation four weeks before surgery has been associated with
fewer peri- and post-operative complications.
All medications, medical conditions, and nutritional status should be optimised
before surgery.
Precise ambulatory surgery protocols largely rely on the participation of the
patient, her family, and the entire clinical team in order to achieve a successful
and complication-free ambulatory procedure. Preoperative discharge planning is
key to a successful ambulatory vaginal surgery programme. Supportive family or
friends will make recovery much more pleasant for the patient and this should be
explored in the pre-admission discussion. Frequently, family members include
elderly spouses who may not be comfortable caring for a patient during the first
few days after surgery. Education regarding pain-medication dosing, assistance
with ambulation, presence of vaginal bleeding, among other details specific to the
procedure should be discussed during the informed-consent process prior to
surgery.
A significant proportion of patients following a urogynaecological surgery may
go home with a urinary catheter, and the possibility of post-operative
Table 8.1 Enhanced recovery after surgery (ERAS) protocol stages.
Stage of ERAS Area of Focus Intervention/Meds
Pre-admission Patient education

Medical optimization
Reduce alcohol consumption
and stop smoking
Nutritional and physical
condition
Explore home support
Pre-operative Reduce fasting time ●● 8 oz (250 ml) carbohydrate beverage
Avoid mechanical bowel 2–4 h before surgery.
preparation ●● No solids after midnight. Clear
Analgesia liquids diet 2–4 h before surgery.
●● Acetaminophen (paracetamol),
NSAID, Gabapentin
Intra- Minimally invasive surgery ●● Local infiltration
operative Non-opioid analgesia ●● Acetaminophen (paracetamol)
Euvolemia ●● Ketamine
Normothermia ●● Scopolamine transdermal Patch/
PONV prophylaxis Dexamethasone
Post-operative Mobilisation ●● Acetaminophen (paracetamol)
Euvolemia ●● NSAIDs
Early dispositive removal ●● Oral opioids as needed
Early oral intake
Multimodal analgesia
catheterization should be discussed. Up to 60% of patients undergoing pelvic floor

surgery will need catheter drainage beyond the first day, so all should be made
aware of the possibility of going home with a catheter. A frank discussion pre-
operatively regarding this is the key to managing expectations and to avoid a dis-
appointed or unhappy patient.
The Second Stage of ERAS is Pre-operative

Preoperative fasting increases catabolism that may affect peri-operative outcomes.
Reducing fasting to six hours for solid food and two hours for clear liquids
improves surgical outcomes with no increased risk of aspiration. Pre-operative
bowel preparation should be avoided for patients undergoing benign gynecologic
procedures. Even though patients can experience a high level of anxiety before
surgery, long-acting anxiolytics should be avoided. To minimise opioid exposure
Table 8.2 Peri-operative pain-management options.
Stage of ERAS Medication options
Pre-operative treatment Celecoxib 400 mg PO

Gabapentin 600 mg PO
PONV prophylaxis Dexamethasone 4–8 mg IV at incision
Ondansetron 4 mg before incision closure
Intra-operative analgesia Per anaesthesia routine
IV acetaminophen (paracetamol)
IV Toradol
Local lidocaine
Local bupivacaine liposome
Immediate post-operative IV acetaminophen (paracetamol) 1 g every 6 h
pain Celecoxib 200 mg PO every 12 h
Gabapentin 300 mg PO every 8 h
Toradol 15–30 mg iv every 6 h prn
Hydromorphone 0.5–1.5 mg IV every 3 h prn
POD 1 After discontinuation of IV medication
●● Celecoxib 200 mg PO every 12 h
●● Gabapentin 300 mg PO every 8 h
●● Acetaminophen (paracetamol) 1 g PO every 6 h

scheduled x 3 days (total)
●● Oxycodone 5–15 mg PO every 3 prn
Discharge ●● Acetaminophen (paracetamol) 1 g PO every 6 h

scheduled x 3 days (total)
●● Ibuprofen 600 mg PO every 6 h scheduled × 3 days
as needed.
●● Oxycodone 5–15 mg PO every 4–6 h prn
●● Tramadol or Tapentadol 50 mg every 6 h
and control pain, multimodal non-opioid analgesia can be administered immedi-

ately before entering the operating room: Acetaminophen (paracetamol, 1000 mg
PO), Gabapentin (600–1200 mg PO) or Pregabalin (100–300 mg PO) and Celecoxib
(200–400 mg PO) are examples of pre-emptive pain therapy.
The Third Stage of ERAS is Intra-operative

The anaesthetic protocol should allow for rapid recovery, including the use of
short-acting anaesthetic agents or using regional anaesthesia where possible.
Most vaginal procedures do not require paralysis or intubation. If performed in
an ambulatory surgical centre, where prompt room turnover and patient traffic
is a requirement, intravenous sedation with a laryngeal mask airway (LMA)
may be appropriate, along with local anaesthetic infiltration of the surgical
field. In POP surgeries, a spinal block containing bupivacaine plus hydromor-
phone (50–100 μg) or a light general anaesthetic with intravenous sedation will
normally suffice. Regional anaesthesia (spinal/epidural) is suitable for most pel-
vic procedures, but the time it takes for the block to wear off may negatively
impact on patient flow and can increase the likelihood of discharge with a uri-
nary catheter.
In vaginal surgery, the intra-operative use of Allen-type supportive stirrups
reduces the likelihood of neurologic complications and optimises the surgeon’s
access to the pelvis.
Preventing intra-operative hypothermia helps keep blood pressure stable dur-
ing surgery. Normothermia prevents a delay in wound healing and decreases the
risk of surgical infection, blood loss, and cardiac morbidity. ERAS protocols
emphasise the concept of euvolemia, as fluid overload contributes to peripheral
and visceral edema and electrolyte abnormalities. Hypovolemia, affecting cardiac
output and tissue oxygenation, should be avoided.
Intra-operative analgesia is important for appropriate post-operative pain
management. A small dose of Ketamine (0.5 mg/kg bolus at induction and clo-
sure, and an infusion of 10 μg/kg/min) was shown to reduce pain score and
opioid use in the post-operative phase. Local anaesthetics (i.e., 1% lidocaine
with epinephrine) used at the incision site can reduce acute post-operative pain,
however, the short duration of actions may limit the benefits. An intravenous
dose of Ketorolac (Toradol) prior to transfer to the recovery room reduces the
need for opioids.
Intravenous dexamethasone (4–8 mg) should be considered as prophylaxis
for post-operative nausea and vomiting (PONV). Managing nausea and vomit-
ing enhances the early recovery by improving subjective mood. Anecdotal
reports that dexamethasone is safe and useful peri-operatively has been tested
via randomised trials, and many ERAS protocols now implement this
medication.
Urinary retention is one of the barriers to performing urogynaecological proce-
dures as day-care surgery. Apart from pre-operative counselling, alternatives to
transurethral catheter drainage can be considered. This can include pre-operative
education on intermittent self-catheterization or the intra-operative placement of
a suprapubic catheter. Currently, there are no clear pre-operative predictors for
identifying which patient may require prolonged post-operative catheter drain-
age. Recognised risk factors include pre-operative urinary retention, abnormal
pressure voiding studies and uroflowmetry, performance of posterior colpor-
rhaphy, and tensioned pubo-vaginal sling.
The Fourth Stage of ERAS is Post-operative

Post-operative interventions aim to reduce patient discomfort and expedite recov-
ery. Early mobilisation is a key component of all post-operative-care protocols. It
improves pulmonary and bowel function, and decreases muscle wasting. The
removal of movement-limiting devices such as catheters, drains, and IV tubing as
soon as possible is directly related to facilitating mobility and pain control. A pro-
gressive increase in oral intake reduces the requirement for intravenous hydration
and decreases the risk of post-operative ileus.
Pain management is essential in ERAS and day-care procedures. Most post-
operative pain can be at least partially managed with non-opioid medications.
Acetaminophen and NSAIDs can reduce opioid consumption without compromis-
ing pain control. These medications in conjunction with pre-operative corticoster-
oids should be considered. Once needed, oral opioid administration is preferred to
parenteral. Even though opioids are potent pain relievers that can be used for post-
operative pain, narcotics commonly have predictable side effects including nausea,
vomiting, and constipation. They can also induce dependency and addiction.
PONV causes patient discomfort and a prolonged hospital stay. For this reason,
ERAS protocols should include not only nausea and vomiting prophylaxis but also
a clear treatment plan for when it occurs post-operatively. The application of a
trans-dermal scopolamine patch, alone or in combination with other medica-
tions, is effective for PONV control.
Some ambulatory care centres are equipped with a post-recovery room. A post-
recovery room (phase II) is an observation area where patients can be transferred
for a period of additional monitoring or care before deciding if same day discharge
is appropriate. This additional period of monitoring allows the effects of a spinal
anaesthetic to wear off, time to ensure a patient is safely mobilising, treatment of
ongoing nausea or vomiting, and provision of additional pain relief. It is also a
suitable setting to ensure a patient is adequately voiding, and replace a catheter or
teach intermittent self-catheterisation if necessary. Any barriers to home dis-
charge can be identified and addressed in phase II. If a longer period of care is
required, the patient can be either admitted or transferred to another care facility
depending on the capabilities of the particular surgical practice.
Urogynaecological Procedures
Most urogynaecological procedures that are approached vaginally can be per-

formed as day surgery procedures. However, individual variables such as chronic
pulmonary disease, impaired mobility, cognitive dysfunction, and significant car-
diac disease may not be appropriate for ambulatory care.
Vaginal Hysterectomy
Vaginal hysterectomy is commonly performed as surgical management of pelvic

organ prolapse. Until recently, it was not considered a day-surgery procedure;
however, with the need to reduce surgical wait times, the thinking and practice
has changed. Although a major surgical procedure, the need for prolonged hospi-
talisation has been challenged with the advent of evidence-based protocols ensur-
ing patient safety when performed in the outpatient setting. After a vaginal
hysterectomy, the indwelling catheter is often left in place. The post-operative use
of an indwelling catheter after vaginal hysterectomy is a routine practice citing
close proximity of the operative field to bladder. This routine practice has been
challenged by studies showing that indwelling catheterization after vaginal hys-
terectomy is not necessary.
Adopting the vaginal hysterectomy as a day-care procedure has not shown an
increased complication rate, even when the adnexa is removed vaginally. Ensuring
haemostasis of all pedicles and appropriate closure of the vaginal cuff forms the
mainstay of intra-operative safety. The use of electrosurgical bipolar vessel sealing
in vaginal hysterectomy has shown to reduce the operative time, intra-operative
blood loss, and post-operative pain which also facilitates day-care surgery.
Utilising laparoscopy to assist in vaginal hysterectomy (Vaginal Natural Orifice
TransEndoscopic Surgery – vNOTES) can further increase the success in perform-
ing it as an ambulatory procedure. Protocols have been published in the hope of
optimising outcomes for outpatient hysterectomy.
Anterior and Posterior Vaginal Repair (Colporrhaphy)

Performing vaginal repairs as day-case procedures was proposed as early as 1995
by J.R. Miklos. Native tissue repairs with dissection and plication of the pubo-
cervical and recto-vaginal fascia in anterior and posterior colporraphy, respec-
tively, are the most amenable to ambulatory repair. To start with, both these
procedures can be performed using local anaesthesia. Hydro-dissection using
Bupivacaine 0.25% with 1 : 200 000 adrenaline, helps assist fascial dissection and
effective haemostasis. In an anterior repair, the simple plication of fascia ensures
that post-operative pain is easily managed with simple non-opioid analgesics.
Posterior colporrhaphy or posterior repair entails not only restoration of
anterior rectal support but also normalisation of the vaginal introitus calibre. It
is this part of the procedure that can pose a challenge when performed in an
ambulatory setting. In order to normalise vaginal calibre, the laterally displaced
endopelvic fascia, perineal muscle, and occasionally pelvic floor musculature
must be plicated in the midline. This plication can lead to posterior vaginal and
perineal pain secondary to levator spasm and hyper tonus. Pain control can be
obtained in the short term with intra-operative injection of a long-lasting local
anaesthetic such as bupivacaine, although, not all studies have demonstrated a
significant benefit. Frequently, spasms of the levator musculature require opi-
oid analgesia and additional smooth/striated muscle relaxants such as
cyclobenzaprine.
The risk of major complications after vaginal repair is reported to be very low.
A study of the efficacy of repairs done under local anaesthesia has shown that
there is 63–80% improvement on POP-Q scores.
Vault Suspension Procedures
Vault suspension procedures can be performed via the abdominal or vaginal

route, with the abdominal route posing more challenges in the ambulatory set-
ting. Sacrospinous ligament fixation (SSLF) is a safe and effective technique for
vaginal support. Pre-operative bowel preparation, adequate dissection of the
para-rectal space, exposure of the sacrospinous ligament and proper suture
positioning are essential components in SSLF. The procedure can be associated
with temporary buttock pain and consideration can be given to injection of
local anaesthetic into the ligaments. Intraperitoneal uterosacral ligament sus-
pension requires entrance into the peritoneal cavity and packing of the bowel
contents. As such, this may require deeper anaesthesia during the procedure to
manage greater discomfort from peritoneal irritation. Nevertheless, patient sat-
isfaction is high with this method of vault suspension as an ambulatory
procedure.
Abdominal sacro-colpopexy, the gold standard for vaginal vault suspension,
requires prolonged general anaesthesia, abdominal incisions, bowel preparations
and packing, and mesh anchorage, all of which may not be suitable for the ambu-
latory setting. Recently, the feasibility of laparoscopic or robotic sacro-colpopexy
as day-care surgery has been analysed and protocols have been developed and
validated. The required general anaesthesia, deep Trendelenburg positioning and
prolonged surgical time may, however, impact the practicality and safety of these
procedures when performed as ambulatory procedures.
There are circumstances under which an open abdominal procedure can be
accomplished as a day-surgery procedure. Appropriate patient selection, pre-
operative counselling, an ERAS protocol, pre-incision local anaesthetic infiltra-
tion, and wound infiltration with bupivacaine liposome or usage of an ON-Q
pump (elastomeric local anaesthetic pump) allows for sufficient pain control for
same-day discharge. In general, most will use a 23-hour stay option to keep these
patients overnight.
Obliterative Colpocleisis
Prolapse in the advanced elderly with medical co-morbidities pose surgical chal-
lenges. A LeFort-type colpocleisis performed under spinal or light general anaesthesia
has been shown to be extremely safe and effective in this patient population. This
procedure can have marked benefits on a patient’s quality of life through improve-
ment in urinary retention, vaginal ulceration, and recurrent urinary tract infections.
A case series of women undergoing a colpocleisis, with the majority being done as
day-surgery procedures, showed minimal morbidity and extremely high success rates.
Fistulae
Most vesical-vaginal and recto-vaginal fistulae in developed countries are small
and amenable to ambulatory management. When counselled appropriately, the
need for post-operative catheterisation is not a barrier. Complex fistulae and those
in regions where access to medical care is limited, or when social barriers to care
are present it should not be undertaken in the ambulatory care setting.
ractical Considerations to Grow an Ambulatory

P
Urogynaecological Surgery Practice
Most vaginal and laparoscopic urogynaecological procedures are amenable to

ambulatory surgical management. Protocols need to be adopted and followed by
the entire care-provider team in order to be safe and effective. Patients need to be
educated and counselled pre-operatively regarding the implications of ambula-
tory surgery, focusing on the importance of home-care providers, pain control,
and possible need for discharge home with a urinary catheter in place. There
needs to be appropriate follow-up care for all patients and in particular those that
need to be discharged with a catheter in-situ.
For day-case vaginal repair surgery to be successful, it should be safe, acceptable,
and preferable to patients. There must be adequate protocols in place for bladder
care, out-of-hours access for advice, and admission to the gynaecology ward in case
of any problems requiring overnight stay. Once same-day discharge programmes
are implemented for urogynecologic procedures, outcomes and safety measures
have to be audited regularly including patient acceptance and satisfaction.
Further Reading
(2018). ACOG Committee Opinion No. 750 summary: perioperative pathways:

enhanced recovery after surgery. Obstet. Gynecol. 132 (3): 801–802.
Alas, A., Espaillat-Rijo, L.M., Plowright, L. et al. (2016). Same-day surgery for pelvic
organ prolapse and urinary incontinence: assessing patient satisfaction and
morbidity. Perioper. Care Oper. Room Manag. 5: 20–26.
Alas, A., Hidalgo, R., Espaillat, L. et al. (2019). Does spinal anesthesia lead to
postoperative urinary retention in same-day urogynecologic surgery?
A retrospective review. Int Urogynecol J 30: 1283–1289.
Carey, E.T. and Moulder, J.K. (2018). Perioperative management and implementation
of enhanced recovery programs in gynecologic surgery for benign indications.
Obstet. Gynecol. 132: 137–146.
Ghoshal, S. and Smith, A.R. (2005). Ambulatory surgery in urogynecology. Best Pract.
Res. Clin. Obstet. Gynecol. 19: 769–777.
Miklos, J.R., Sze, E.H.M., and Karram, M.M. (1995). Vaginal correction of pelvic
organ relaxation using local anesthesia. Obstet Gynecol 86 (6): 922–924.
Papa Petros, P.E. (1998). Development of generic models for ambulatory vaginal
surgery – a preliminary report. Int. Urogynecol. J. Pelvic Floor Dysfunct. 9: 19–27.
Rodriguez Trowbridge, E., Evans, S.L., Sarosiek, B.M. et al. (2019). Enhanced
recovery program for minimally invasive and vaginal urogynecologic surgery.
Int. Urogynecol. J. 30: 313–321.
Zebede, S., Smith, A.L., Plowright, L. et al. (2013). Obliterative LeFort Colpocleisis in
a large group of elderly women. (incl. video). Obstet Gynecol 121: 279–284.
109
Common Urethral and Vaginal Lesions

in Ambulatory Urogynaecology
Mugdha Kulkarni and Anna Rosamilia
Introduction
Benign urethral and vaginal lesions are commonly encountered in the urogynae
cology clinic setting. With the advent of ambulatory urogynaecology many of
these conditions can be managed as day care procedures. This chapter will cover
some of the common benign urethral and vaginal lesions: urethral caruncle, ure
thral prolapse, urethral diverticulum, urethral fistula, Skene’s duct cyst, Bartholin’s
cyst, Gartner’s duct cyst, and periurethral lesions. It is beyond the scope of this
chapter to cover any malignant lesions.
A review of the embryology and anatomy of the urethra and vagina helps to
understand the pathology and management of urethral and vaginal lesions.
Embryology and Anatomy of Urethra
The caudal portion of the vesicourethral canal forms the female urethra. It is
3–5 cm long and about 5–7 mm in diameter. The urethra is embedded in the
adventitia of the anterior vaginal wall, perforates the perineal membrane and
ends with the external orifice in the vestibule above the vaginal opening. The
urethra has intrinsic and extrinsic sphincter mechanisms which aid in main
taining continence. Urethral smooth muscles, along with the detrusor from the
bladder base form the intrinsic sphincter. The extrinsic sphincter is composed
of two portions: the inner portion of striated muscles within and adjacent to
the urethral wall and the outer portion of skeletal muscle fibres of the pelvic
diaphragm.
The urethra is surrounded by multiple periurethral ducts and glands. Skene’s

glands are adjacent to the distal urethra and are the largest. The urethra lies in
close proximity to the vagina. Vaginal epithelium is lined by loose connective
tissue called lamina propria and does not contain any glands. Vaginal lubrica
tion occurs as a transudate from vessels, cervix, and the Bartholin’s and
Skene’s glands.
Benign Urethral Lesions
Urethral Caruncle
A urethral caruncle is the most common female urethral lesion and is usually
seen in post‐menopausal women. It is a benign condition resulting from the
eversion of the distal portion of the posterior urethral meatus. A caruncle is
usually small, soft, smooth or friable, and bright pink to dark. Usually single,
it can be pedunculated and grow up to 1–2 cm long. Histologically, a caruncle
contains blood vessels, loose connective tissue and is covered by urothelium
and squamous epithelium. The pathogenesis of a urethral caruncle is not
clearly understood. It is thought to result from oestrogen deficiency in the
postmenopausal woman leading to atrophy of urothelium and retraction of
the vagina.
Most women are asymptomatic and caruncles are usually an incidental finding
on genital examination. Though most often seen in postmenopausal women, it
can also occur in premenopausal and prepubertal girls. Symptoms described have
been that of a lump, bleeding, dysuria, and pain.
A study looked at the effects of asymptomatic caruncles on micturition and found
that 6%of women who presented with urinary incontinence were noted to have carun
cles, but there was no effect on micturition when caruncles measured<1 cm. However,
some sources have reported voiding dysfunction in association with a caruncle.
Diagnosis is clinical and based on the characteristic appearance of a pink, soft,
sessile or pedunculated mass protruding from the urethral meatus, usually on the
posterior aspect. Biopsy is not necessary unless diagnosis is uncertain or if there is
a suspicion of malignancy.
There are no large studies or randomised controlled trials (RCTs) evaluating
various treatment strategies. Asymptomatic women do not require treatment.
A conservative approach with regular clinical observation or self‐observation is
suggested. In women who are symptomatic, initial management is topical oestro
gen cream for two to three months. In cases of large, persistent lesions, speciality
referral to a urogynaecologist or urologist should be considered. If initial therapy
of topical oestrogen fails, surgical treatment can be offered. Surgical treatment

involves initial cystourethroscopy to assess the urethra and bladder, followed by
catheterisation. Removal of a caruncle is either by excision and ligation or dia
thermy of the base under local or general anaesthesia. Following the procedure,
the patient can be discharged home with an indwelling catheter for planned
removal in the next 24–48 hours. Risks associated with the procedure include
bleeding or rarely external urethral meatal stenosis.
Urethral Prolapse
Urethral prolapse is uncommon and defined as eversion of the urethral mucosa
circumferentially through the distal urethra. It is usually seen in prepubertal and
postmenopausal women. One theory suggests that prolapse occurs as a result of
separation of the two muscular layers of the urethra, which can be congenital or
acquired. Other theories are similar to the one proposed for urethral caruncle,
based on a lack of oestrogen leading to urothelium atrophy and retraction of the
vaginal epithelium. This also fits with the bimodal age distribution. Urethral pro
lapse can also occur as a consequence of obstetric trauma.
Prepubertal girls are usually asymptomatic and this is an incidental finding on
examination. The most common symptom is vaginal bleeding along with a ure
thral mass. In contrast, postmenopausal women are often symptomatic with vagi
nal bleeding and voiding symptoms being a common presentation.
Diagnosis is by clinical examination. The urethral prolapse appears as a circum
ferential, small doughnut shaped mass protruding from the anterior vaginal wall
with the external urethral meatus in the middle (Figure 9.1). It can be erythema
tous, congested, infected, or even ulcerated.
Postmenopausal women are usually treated initially with topical oestrogen
therapy, but if unresponsive or large, surgical excision should be considered.
Excisional biopsy should be considered and is mandatory if malignancy is sus
pected. Surgical excision is indicated for young symptomatic patients and for
recurrent urethral prolapse.
An indwelling Foley catheter at the beginning of the procedure is helpful,
though it may be difficult to place it when tissue is oedematous. The prolapsed
mucosal tissue is excised using scissors or cautery in a circumferential manner.
Using stay sutures around the mucosa at 12, 3, and 9 o’clock position during the
excision helps in traction and prevents the mucosal edge from retracting. The ure
thral mucosa and the vaginal tissue edges are approximated with interrupted
sutures as the excision proceeds from anterior to posterior with 4–0 vicryl. The
catheter is left in place for 24 hours but patients can be discharged home the same
day, with adequate analgesia.
Figure 9.1 Urethral prolapse.
Urethral Diverticulum
A urethral diverticulum is the localised outpouching of the urethral mucosa
into the surrounding non‐urothelial tissues (Figure 9.2). This is a relatively
uncommon condition and it is difficult to estimate its true prevalence due
to the difficulty in diagnosis. Prevalence reported on basis of a urethrography
series is 1–5%.
Urethral diverticula can be congenital or acquired. The congenital diver
ticulae are thought to be remnants of the Gartner’s duct, but most are likely
to be acquired rather than congenital. The proposed theory is that the diver
ticulum develops as a result of chronic infection of periurethral glands. This
subsequently leads to obstruction and enlargement of glands and abscess for
mation. Once this abscess ruptures into the urethral lumen, it leads to a com
munication between the two forming a diverticulum. Various studies have
supported this theory, finding chronic inflammation on histology that results
Figure 9.2 Urethral diverticulum on cystoscopy.
in fibrosis within and surrounding the diverticulum. Other theories proposed

are trauma or injury during childbirth or vaginal and urethral surgery.
A diverticular opening into the urethra from a small diverticulum is usually
via a single ostium but it is not unusual to find multiple ostia and loculated
diverticulae.
The symptoms are highly variable. The most common symptoms are lower uri
nary tract complaints of frequency and urgency, in addition to recurrent urinary
tract infections and dysuria. The classic triad of dyspareunia, post‐micturition
dribble, and dysuria are seen in approximately 35% of patients. Haematuria, uri
nary incontinence, vaginal mass, vaginal pain, discharge, and urinary retention
can be other symptoms of an urethral diverticulum.
Diagnosis requires a high index of suspicion. Apart from history, a thorough
physical examination is essential because, in most cases, there will be a palpable
mass in the sub‐urethral region in the anterior vaginal wall. Diverticulae are usu
ally present in the distal or middle portion of the posterior aspect of the urethra,
about 2–3 cm proximal to the urethral opening. The pathognomonic finding of
urethral discharge expressed by pressure on the suburethral mass is present in
only 25% of cases. The mass is usually soft but can be firm to hard in the presence
of a calculus or malignant change.
Investigations are helpful in differentiating a urethral diverticulum from other
lesions such as vaginal wall cysts, cystocele, Skene’s gland abnormalities, ectopic
ureterocoele, vaginal leiomyomas and endometriosis. Urethroscopy with a 0‐ or
15° telescope and the urethrotome (Sachse) sheath can be valuable in identifying
the ostia, but it is important to understand that in the presence of inflammatory
changes, ostia may not be clearly visualised (Figure 9.3).
Figure 9.3 Diverticulum on cystogram.
Imaging in the form of a positive pressure urethrogram using a double balloon

catheter forcing contrast into the diverticulae was the diagnostic technique of
choice. Magnetic resonance imaging (MRI) currently seems to have the best diag
nostic performance and helps to exclude other periurethral lesions. In the pres
ence of resource implications, a transvaginal ultrasound (TV USG) has been found
to be helpful. It is important to remember not to compress the urethra with the
transvaginal probe. Translabial ultrasound is also a cost‐effective imaging modal
ity for identification of urethral diverticulum.
Management
Conservative treatment can be considered for women without bothersome symp
toms. These include digital compression with application of pressure on the sub‐
urethral mass after voiding or periodic needle aspiration. In patients with
recurrent UTIs, antibiotic prophylaxis is recommended. These might offer symp
tomatic relief; however, the anatomical defect will persist. Long‐term outcomes
for conservative treatment are not known.
Surgical treatment should be offered to women with persistent symptoms and
in the presence of diverticulum complications such as calculi. Surgical options
include urethral diverticulectomy, marsupialisation of the diverticular sac and
transurethral widening of the ostia.
The potential complication of urethrovaginal fistula in these procedures decrees
that adherence to good surgical principles, accurate reconstruction, and the oper
ation being performed only by surgeons trained in these procedures can reduce
the risk. A detailed pre‐operative evaluation is essential and includes ruling out
urinary tract infection and diverticular abscess at the time of the surgery. Accurate
assessment regarding the size and number of diverticula, number of ostia and
position of the ostia in relation to the urethra and bladder neck are important.
Complex diverticulae such as multiple, large, loculated or saddle‐shaped require
extensive dissection and possibly the need in some units, to be combined with a
fascial sling procedure. These may not be suitable for an ambulatory setting, but
in experienced hands, a straight forward diverticulum with a single ostium is
appropriate for a transvaginal diverticulectomy as a day care procedure. The need
for bladder drainage is still relevant regardless of diverticulum size.
Transvaginal Diverticulectomy
Urethroscopy to identify the ostia in the urethra is followed by placement of a
urethral catheter. A vertical or inverted U‐shaped incision is made in the anterior
vaginal wall over the diverticular swelling. The vaginal epithelium is mobilised
and the underlying periurethral fascia is identified. The fascia is then incised sep
arately and mobilised to create flaps on either side. The diverticular sac is then
excised and a probe is passed to identify the ostia at the base of the diverticulum.
The urethral defect is closed either transversely or vertically ensuring extra
mucosal closure. This is followed by closure of the periurethral fascia in layers
(‘vest‐over‐pants’ closure) with absorbable sutures.
The layered closure avoids overlying suture lines, thereby, reducing the tension
in the repair. Occasionally a vascularised Martius or labial fat pad graft is placed
over the fascial closure to augment the repair. Finally, the vaginal wall incision is
approximated with absorbable suture. The patient can be sent home with either a
suprapubic or transurethral catheter for 10–14 days. In women with pre‐operative
stress urinary incontinence evaluated with urodynamics, a fascial sling can be
placed although some studies suggest a staged approach since in many cases,
symptoms are resolved with diverticulum repair (Stav 2008). Synthetic slings are
contraindicated due to the risk of erosion and fistula formation. Following a
diverticulectomy, a success rate of up to 70% is quoted. The complications include
recurrence, stress incontinence, urethral stricture, and urethrovaginal fistula.
Marsupialisation of Diverticulum
Marsupialisation of the urethral diverticular sac, also referred to as the Spence
procedure, is recommended only in distal urethral diverticulum. The procedure
involves the creation of a permanent opening of the diverticular sac into the
vagina. An incision is made through the posterior wall of the urethra down to
the diverticulum and through the anterior vaginal wall. This incision thus
extends from the urethral orifice to the proximal extent of the diverticulum. The
urethra and diverticulum are opened and a 4‐0 absorbable suture is used to mar
supialise the vaginal wall with urethral mucosa. The diverticulum sac is sutured
onto the anterior vaginal wall. The cavity created can be packed to promote
fibrosis. It is a simple procedure and technically a generous meatotomy amena
ble to an ambulatory setting. Complications include splayed stream and ure
throvaginal fistula.
Transurethral Saucerisation of Diverticulum

This procedure is again confined to only distal single diverticulum. It involves
endoscopic transurethral incision of the ostia at the floor of the urethra, convert
ing the small neck into a wide opening. This allows the diverticulum to drain
freely. Performing this procedure in mid or proximal urethra can compromise the
continence mechanism. In women presenting with any sub‐urethral swelling, it is
important to rule out urethral diverticulum, a condition with both diagnostic and
management challenges.
Urethral Fistula
Urogenital fistula is an abnormal communication between the female genital
tract and the bladder, urethra, or ureters. Obstetric trauma is the leading cause of
urogenital fistula in the developing world, whereas gynaecologic surgery (such as
hysterectomy, carcinoma, or pelvic radiation) is responsible for most vesicovagi
nal or ureterovaginal fistulas in developed countries. Types of fistula depend on
the anatomic location, with vesicovaginal fistula being three times more common
than other types.
In this chapter, we will only focus on the urethral fistula, also referred to as the ure
throvaginal fistula –an abnormal communication between the vagina and urethra.
Pathogenesis
In the developed world, urethrovaginal fistulas are encountered after attempted

repair of urethral diverticulum, following anterior colporrhaphy or mid‐
urethral sling procedures, and after obstetric trauma following the use of rota
tional forceps. Less commonly, they can be congenital or caused by prolonged
indwelling transurethral catheterisation. Although an acute urethrovaginal
fistula can be caused by direct injury during trauma or secondary to dissection,
clamp, or crush injury, delayed fistula formation can result from suture
impingement, radiation, or a malignant process. The blood supply is compro
mised leading to necrosis and eventually tissue breakdown. This process may
Figure 9.4 Urethrovaginal fistula.
progress over days to months before presentation. Very rarely, mid‐urethral

surgery may result in urethral erosion. Either the erosion itself or corrective
surgery can lead to fistula formation.
Clinical features: Most women will present with painless urinary leakage. It
can be intermittent but more often presents with continuous leakage with spray
ing of urine during voiding in some cases. The diagnosis is clinical and involves
visualising urine leakage from the distal anterior 3–4 cm of the vagina. MRI may
be considered for diagnosis of a complex urethral fistula. Cystourethroscopy, as a
day procedure, helps in locating the fistulous opening and surgical planning
(Figure 9.4).
Classification of Fistula
Summary of classification as standardised by Judith Goh and Kees Waaldijk:

Goh’s classification is based on three variables –the length of the urethra (types
1–4), the size of the fistula (a–c) and the degree of scarring (I–III).
Urethral Length
Type 1 Distal edge of fistula >3.5 cm from the external urethral orifice (i.e., the
urethra is not involved)
Type 2 Distal edge 2.5–3.5 cm from the external urethral orifice
Type 3 Distal edge 1.5–<2.5 cm from the external urethral orifice
Type 4 Distal edge <1.5 cm from the external urethral orifice
Fistula Size
(a) <1.5 cm
(b) 1.5–3 cm
(c) >3 cm
Scarring
Scarring I No or mild fibrosis around fistula/vagina, and/or vagina length>6 cm or
normal capacity
Scarring II Moderate or severe fibrosis around fistula and/or vagina, and/or reduced
vaginal length and/or capacity
Scarring III Special considerations, e.g., circumferential fistula, previous repair
Treatment: Referral to a specialist with experience in fistula management is

necessary. A small fistula diagnosed early can be managed conservatively with
continuous bladder drainage that may assist in closure of the fistula. In most
cases, however, surgical closure is indicated, and it is not usually amenable to an
ambulatory procedure.
The surgical principles of urethrovaginal fistula closure are a tension‐free
closure repaired in layers. In a simple urethrovaginal fistula, after placing the
transurethral catheter, a vaginal incision is made lateral to the fistulous opening,
and the vaginal epithelium is mobilised. Using a 3‐0 polyglactin suture, the
urethral opening is approximated transversely with interrupted sutures in an
extra mucosal fashion. Periurethral and then pubo‐cervical fascia are then
approximated, over the defect closure, to provide support, and finally the vaginal
epithelium is closed. A Martius or labial fat pad or other graft may be considered
if the fistula is large, recurrent, or complex. Post‐operatively prolonged catheter
drainage is needed.
Vaginal Lesions
Bartholin’s Cyst
Bartholin’s glands originate from the urogenital sinus. Obstruction of a Bartholin’s
duct is a prerequisite for cyst or abscess formation. This can occur as a conse
quence of infection or blockage from mucus. The cyst can be asymptomatic or
present as a vaginal lump. In the presence of an infection, there is pain or
dyspareunia.
The diagnosis is usually clinical. Bartholin’s cysts are usually unilateral, 1–4 cm
in diameter and located lateral to the introitus at 5 or 7 o’clock position medial to
the labia minora. These lesions are easily visible on ultrasound, CT scan, or MRI;
however, this is not necessary for diagnosis (Figure 9.5).
Management
Asymptomatic cysts can be offered conservative management. Symptomatic
cysts or abscesses require surgical management under antibiotic cover.
Marsupialization under anaesthesia is the preferred treatment to prevent refor
mation and maintain function. A vertical elliptical incision is made in the ves
tibular area close to the hymen allowing an oval edge of the vulval skin and cyst
wall to be removed. The contents are drained and the cyst wall is sutured to the
adjacent vulval skin using 3‐0 absorbable sutures. The recurrence rate is
around 10%.
An alternative technique is fistulisation using a Word catheter. A Word catheter
is a 5.5 cm long, 15 Fr silicone catheter with a 3 cc balloon. The catheter is placed
in the cyst or abscess through a 5 mm incision under local anaesthesia to aid
drainage and epithelialization of the tract. The catheter is left in place for two to
four weeks to allow drainage.
Figure 9.5 Bartholin’s cyst.

The major complication of Bartholin’s cyst is the risk of recurrence. In cases of

repeated abscess or persistent cysts, removal of the Bartholin’s gland can be
recommended.
Gartner’s and Müllerian Duct Cysts

The internal urogenital tract is derived from the Wolffian ducts (mesonephric)
and the Müllerian ducts (paramesonephric). In women, during the eighth week of
embryologic development, the paired Müllerian (paramesonephric) ducts fuse
distally and develop into the uterus, cervix, and upper vagina. In addition, the
Wolffian ducts regress. If the ducts persist in a vestigial form, they can form
Gartner’s cysts.
Gartner’s duct cysts account for 11% of all vaginal cysts. These cysts are mainly
located in the right anterolateral wall of the proximal third of the vagina. The
Wolffian duct abnormality can also result in urinary tract abnormalities, such as
ectopic ureter, unilateral renal dysgenesis, and renal hypoplasia.
Symptoms: Most are asymptomatic and are an incidental finding on examina
tion, but they can enlarge in size and present as a vaginal lump and can be mis
taken for pelvic organ prolapse. Other symptoms described are: dyspareunia,
pain, vaginal discharge, or urinary symptoms due to extrinsic compression.
Diagnosis is by clinical history and physical examination.
Histologically, a Gartner’s cyst is lined by cuboidal low columnar, non‐ciliated
and non‐mucinous cells. These histological findings help differentiate it from
other vaginal cysts.
Müllerian cysts are another embryological remnant and typically found on the
anterolateral vaginal wall. They are lined by secretory epithelium resembling a
fallopian tube. They can occur anywhere in the vagina and usually contain mucus.
They can only be differentiated from Gartner’s duct cyst on histology.
Treatment: Complete surgical excision is the treatment of choice as marsupi
alisation has a higher rate of recurrence. Other treatments include surgical aspira
tion and injection of tetracycline solution, but are typically reserved for only
small cysts.
Skene’s Duct Cyst

Skene’s glands are bilateral paraurethral glands derived from the urogenital sinus.
They open into the external urethral meatus. Obstruction of a Skene’s duct sec
ondary to infection leads to cyst or abscess formation. This is often due to infec
tion by Neisseria gonorrhoeae or Chlamydia.
These cysts can often be asymptomatic. Cysts larger than 2 cm can present with
dysuria, recurrent urinary infection or voiding dysfunction. Abscesses are usually
swollen and tender. Due to its location, it is essential to distinguish a Skene’s duct
cyst from a urethral diverticulum. Compression of a Skene’s duct cyst won’t lead
to fluid extravasation, unlike a urethral diverticulum. MRI or translabial ultra
sound and urethroscopy can be used to distinguish the two.
Women with small cysts can be offered conservative management with observa
tion. Symptomatic larger cysts warrant complete surgical excision or marsupiali
sation, under antibiotic cover if infected.
Other Vaginal and Periurethral Lesions
Epithelial Inclusion Cysts

Epithelial inclusion cysts result from the mucosa becoming trapped in the submu
cosal area secondary to procedures such as episiotomy, vaginal wall repairs, and
trauma including childbirth. These cysts are lined with squamous epithelium and
contain keratin and sebaceous fluid. Large cysts can cause pain, and treatment is
excision of the cyst.
Leiomyomas
Although rare, leiomyomas can present as an anterior vaginal wall mass. They
originate from the smooth muscle of the urethra or the smooth muscle of the vagi
nal wall. Most are asymptomatic unless large, in which case symptoms are usually
urinary. Surgical excision is the treatment of choice, and urethral reconstruction
is likely to be needed with urethral leiomyomas. Malignant transformation is rare.
Urothelial Cyst
Urothelial cysts are uncommon and present as small cysts around the distal ure
thra. Lined by urothelium, the cause is thought to be surgical trauma. They are
often asymptomatic. If symptomatic, surgical excision is indicated.
Conclusion
Vaginal, urethral and paraurethral benign cysts commonly present as swelling

and the clinician should be able to ascertain the origin and nature of the cystic
swelling. Imaging may be needed in some cases to establish the true nature of the
lesion. Most of these cystic swellings can be managed in the ambulatory setting,
even if they require catheterisation for short‐ term. Referral to a specialist should
be considered in complex cases and if the diagnosis is in doubt.
Further Reading
Archer, R., Blackman, J., Stott, M., and Barrington, J. (2015). Urethral diverticulum.
Obstet. Gynaecol. 17: 125–129.
Dolan, M.S., Hill, C., and Valea, F.A. (2017). Benign gynecologic lesions. In:
Comprehensive Gynecology (eds. R.A.,.G. Lobo, G.M. Lentz and F.A. Valea), 371.
Philadelphia: Elsevier.
Goh, J.T. (2004). A new classification for female genital tract fistula. Aust.
N. Z. J. Obstet. Gynaecol. 44 (6): 502–504.
Stav K, Dwyer PL, Rosamilia A, Chao F, Urinary symptoms before and after female
urethral diverticulectomy: Can we predict De Novo stress urinary incontinence?
J Urol Sep 2008,17; PMD: 18804229.
Tsivian, M., Tsivian, A., Shreiber, L. et al. (2009). Female urethral diverticulum: a
pathological insight. Int. Urogynecol. J. Pelvic Floor Dysfunct. 20 (8): 957–960.
123
10
Ambulatory Management of Childbirth Pelvic

Floor Trauma
Khaled M.K. Ismail, Rasha Kamel, and Vladimir Kalis
Introduction
Annually, millions of women worldwide sustain trauma to the pelvic floor at the
time of childbirth. A significant number of these women suffer short-term and
sometimes long-term consequences, which can have a negative impact on both
physical and emotional health, and also affect their quality of life. The burden of
these complications is even greater when the age of the woman and the effect on
her family is taken into account. In recent years, there has been a lot of focus on
the prevention, assessment, and repair of childbirth-related pelvic floor trauma.
There has been a plethora of evidence-based guidelines, quality improvement ini-
tiatives, and innovations and multidisciplinary training programmes devised to
address these issues. Nevertheless, the focus has mainly been on intrapartum care
with relatively less attention to the antenatal and postnatal periods.
There is wide global variation in maternity service provision and funding.
Moreover, there are cultural differences that have an impact on several aspects of
maternity care including shared norms, beliefs, and expectations. These factors
will undoubtedly affect what services are being offered, how they are utilised, and
what is being prioritised. Irrespective of the type or location of healthcare, postna-
tal services do not receive the same level of attention or funding as antenatal and
intrapartum services. Furthermore, childbirth-related pelvic-floor trauma and its
consequences do not receive the required level of attention because of the ten-
dency to focus on pregnancy progress and foetal development. This, at least some-
times, translates to a significant number of women missing out on crucial
information relating to current or previous childbirth pelvic floor trauma and how
to mitigate the risk of complications in the short and long term. Although intra-
partum management of pelvic-floor trauma is considered a core skill of any birth
attendant, the management of its consequences requires specialised training.
Women’s pelvic floor pathology encompasses a wide spectrum of functional,

anatomical and neurological problems, which may be associated with symptoms
of bowel, urinary, and/or sexual dysfunction. Care for women with pelvic-floor
trauma is, therefore, best delivered via a multidisciplinary approach.
Childbirth pelvic trauma and its complications can be addressed in the
ambulatory care setting. This can include consultation, investigations, treat-
ment, interventions, and sometimes rehabilitation services. We believe that
this model of care should be utilised in the context of specialised postnatal
clinics because it will ensure that women receive fast, effective, consistent,
and evidence-based management without added pressure on other maternity
services. We see the ambulatory care setting as an interface between primary
and secondary care, receiving referrals from family physicians, community
midwives, as well as hospital referrals. If the healthcare system allows, we
believe women should be able to self-refer when plagued by a particular query
or concern. In this chapter, we will cover the services and procedures that can
be undertaken within an ambulatory service in relation to childbirth
pelvic-floor trauma.
Perineal Wound Complications
In women undergoing vaginal delivery about 85% are known to sustain some
form of perineal injury. The short-term sequelae of perineal injury include bleed-
ing and pain, but may include wound complications such as infection, dehiscence
and granulation tissue. Persistent pain after eight weeks postpartum occurs in
about 22% of women and with about 20% experiencing dyspareunia.
Anal dysfunction such as faecal or flatus incontinence can occur with obstetric
anal sphincter injuries (OASIs). In the long term, perineal trauma such as levator
muscle avulsion has been postulated as risk factors for pelvic floor disorders such
as pelvic organ prolapse and urinary incontinence.
Perineal Wound Infection

A two-iteration Delphi study of women who had previously sustained perineal
trauma was undertaken to determine patient-reported outcomes for perineal
trauma. The quality-improvement study demonstrated that the highest ranked
outcome was fear of perineal wound infection and delay in wound healing.
There is growing evidence that the number of women reporting perineal wound
dehiscence and infection in the community is increasing. A significant number of
these wound breakdowns occur within the first two weeks of delivery. However,
there are several issues that should be taken into account when discussing
childbirth-related perineal wound infections. These include:
●● In many healthcare settings there are no systems to track wound infection and
dehiscence in the community and this has led to the wide disparity of preva-
lence from 0.59 to 13.5%.
●● There is lack of perineal-wound validated screening tools that can be used in
the community or primary care for early identification of infection.
●● Disparity exists between clinically suspected and microbiologically confirmed
perineal wound infection.
●● Wide variation in the management of wound infection and dehiscence.
Perineal wound infection and dehiscence can have serious consequences on a
woman’s general health and quality of life. These problems include persistent pain
and discomfort at the perineal wound site, urinary and bowel problems, and dys-
pareunia, as well as psychological and psychosexual issues from perceived or altered
body image. The most serious complication that can arise is systemic sepsis. It is
imperative, therefore, that women with suspected perineal infection are reviewed
urgently. Women who have problems with their wound in the form of increasing
pain, excessive or offensive discharge, pyrexia, feeling generally unwell, swelling of
the wound, or evidence of wound dehiscence should have an urgent assessment.
There is a paucity of validated tools for the objective assessment of perineal
wounds for the early detection and follow-up of wound infection. Until a more
specific tool is available, we recommend the use of the REEDA score (Table 10.1)
for perineal wound assessment. The REEDA tool assesses Redness (R), Edema
(E), Ecchymosis (bruising) (E), Discharge (D) and approximation of the perineal
wound edges (A). Its scientific merit relies upon taking precise measurements and
providing objective descriptive data to assess the condition of the wound over a
period of time.
If a wound infection is suspected, microbiological swabs should be taken from
the perineal wound area and the woman should be prescribed appropriate broad-
spectrum antibiotics. We recommend that the antibiotic regimen discussed and
agreed upon with the local microbiology team is in line with unit policy. The pre-
scribed antibiotics should be reviewed once the swab results are available. Further
follow-up appointments will depend on the severity of infection, presence of
wound breakdown, and general maternal condition. In general, it will be appro-
priate for the woman to be seen in the clinic weekly for the first two to three
weeks. With each visit, an objective assessment of the wound condition using
REEDA score should be performed and documented. Once the infection is cleared
and the wound has healed, it would be prudent to arrange a follow-up visit after
8–12 weeks or even later, to check for any long-term complications such as
perineal pain or dyspareunia.
Table 10.1 The REEDA score.
Score Redness Edema Ecchymosis Discharge Approximation
0 None None None None Closed

1 Mild Mild Mild Serum Skin separation 3 mm or less
Less than 0.5 cm Less than Less than 1 cm from
from each side of the 1 cm from each side each side of the
wound edges of the wound edges wound edges
2 Moderate Moderate Moderate Serosanguinous Skin and subcutaneous fat
0.5 cm to 1 cm from 1 to 2 cm from each 1 to 2 cm from each separation
each side of the side of side of the wound
wound edges the wound edges edges
3 Severe Severe Severe Purulent Skin and subcutaneous fat
More than 1 cm from More than 2 cm from More than 2 cm from and fascial layer separation
each side of the each side of the each side of the
wound edges wound edges wound edges

Total
Overall score = +
Dehiscence
Wound dehiscence is frequently preceded by or occurs in association with wound
infection. This breakdown can involve the whole wound or only part of it. There
is a wide variation in how a wound dehiscence is managed. Some favour expect-
ant management; however, it can take up to 12–16 weeks for the wound to heal by
secondary intention. The evidence for the management of such a complication is
currently weak; nevertheless, it favours wound re-suturing 24–48 hours after
appropriate antibiotic cover. The latter policy seems to be associated with a reduc-
tion in the time required for wound healing and improved satisfaction with the
outcome after the wound has healed. In view of the negative impact of expectant
management, we strongly recommend that women are counselled and given a
choice about both management options so that they can make an informed choice.
Re-suturing a dehisced wound will require anaesthesia for wound debridement
and can be done as a day-care procedure under antibiotic cover in the absence of
sepsis. An ambulatory clinic can identify complications, initiate treatment,
provide counselling about management options, and follow up women after
re-suturing and those opting for expectant management.
Granulation Tissue
When a wound heals by secondary intention, granulation tissue may form to
bridge the gap between the wound edges. Less commonly, it can also form after
wound healing by primary intention. Women tend to be referred with what is
thought to be a skin tag, an area that is friable or bleeds easily when touched, or a
persistent and excessive discharge. In almost all cases, the excessive granulation
tissue can be chemically cauterised in the outpatient setting using silver nitrate.
Sometimes more than one treatment is required.
Superficial Dyspareunia Following Childbirth
It is reported that 17–23% of women continue to experience superficial dyspareu-

nia at three months after delivery and 10–14% at 12 months. In some studies, rates
of 62 and 31% were reported for three and six months postnatal respectively. In
view of the risk of such a problem triggering more complex psychosexual disor-
ders, it is important that they are dealt with promptly, sensitively, and efficiently.
The ambulatory set-up provides a suitable environment for this because women
would be seen away from both obstetrics and gynaecology outpatient environ-
ments where they can be given more time and also have their problem assessed by
a specialist.
The cause of superficial dyspareunia following childbirth can be physical and/

or psychological. One of the physical causes of superficial dyspareunia following
perineal trauma or episiotomy is scar tissue at the introitus, particularly over the
area of the fourchette (posterior commissure). This can result from excessive scar
tissue formation or poor anatomical repair of the perineal tear. Typically, a thin
band of scar tissue or a web of skin at the introitus can be seen on examination by
parting the labia and slightly stretching the area of the fourchette. This web of
skin or scar tissue will be very tender to touch on digital examination and during
intercourse. Some women complain that it splits and bleeds during penetration. It
is not uncommon for this problem to be missed on general inspection of the labia.
Conservative approaches, including the use of vaginal dilators, vibrators, and per-
ineal massage have been reported to provide relief of symptoms in a minority of
patients. The majority of women, however, will require a procedure to release or
remove this area of scarring. A modified Fenton’s procedure can be performed as an
outpatient procedure under local anaesthesia. One of the main benefits of under-
taking the procedure under local anaesthesia is the conscious pain mapping prior to
surgery. The procedure follows the same concept as Fenton’s, which involves a verti-
cal incision, dissection of underlying scar tissue, followed by closure of the incision
horizontally (Table 10.2). It is important to avoid overzealous dissection and the
recommendation is to use fine fast absorbing polyglactin suture and a continuous
technique for closure in two layers, to reduce the tension on the skin stitches.
Obstetric Anal Sphincter Injuries
Third- and fourth-degree perineal tears are collectively known as OASIs. This sec-
tion will not cover the prevention, identification, or primary repair of OASIs but
rather the management of women who have had this type of injury, in an ambula-
tory centre.
OASI Primary Repair and Follow-Up

It is good clinical practice that women who sustain OASIs have a follow-up
appointment in a dedicated clinic at 12 weeks postnatally. During that visit we
recommend the following:
●● Take a detailed bowel history exploring the timing of the symptoms in relation
to the OASIs. Using a bowel control, symptom-specific questionnaire can be of
value in assessing the degree of anal dysfunction.
●● Use the faecal incontinence severity index (FISI) and Faecal Incontinence
Quality of Life assessment tools to improve the objective assessment (see
Table 10.3).
Table 10.2 Steps of a modified Fenton procedure.
Band of scar tissue at the introitus part on parting the labia

and very tender to touch
Vertical incision
Dissection of underlying scar tissue
Repaired across in two layers using continuous 3/0

polyglactin suture
Source: Modified from Chandru et al. (2010).

Table 10.3 Faecal incontinence severity index.
Never Rarely Sometimes Usually Always
a) Solid 0 1 2 3 4
b) Liquid 0 1 2 3 4
c) Gas 0 1 2 3 4
d) Wears pad 0 1 2 3 4
e) Lifestyle alteration 0 1 2 3 4
●● Perform a clinical examination including checking the neurological function of

sacral segments, such as the anal wink reflex.
●● Assess the women’s ability to perform correct and effective pelvic floor muscle
training and discuss physiotherapy referral if required.
●● Give the woman the opportunity to ask questions about her birth and trauma.
●● Perform an endoanal ultrasound of the anal sphincter complex ± manometry.
●● Discuss the short and long-term implications of the trauma and counsel her
about mode of delivery for future births However, this will have to be reviewed
with any future pregnancy if there is any change in her bowel symptoms.
Further investigations, follow-up, and multidisciplinary involvement will need
to be tailored to the woman’s needs.
Ultrasonography
Assessment of the internal and external anal sphincter by means of ultrasonogra-
phy can be performed using an endoanal ultrasound (EAUS) or exo-anally using
trans perineal ultrasound scanning (TPUS). Colorectal surgeons traditionally use
endoanal ultrasonography, however, the availability of high-resolution volume
sonography and tomographic ultrasound has made the diagnostic accuracy of
trans perineal scanning in identifying anal sphincter pathology very comparable
to that of endoanal ultrasound. TPUS also has the added advantages of cost sav-
ing, patient acceptability, and the avoidance of internal stretch of the anal canal
and sphincters. With volume sonography, a volume is acquired with subsequent
multiplanar and tomographic ultrasound imaging (TUI) sub-analysis. For TUI, an
anal sphincter defect is defined as a defect of 30° or greater in the circumference
of the external anal sphincter in at least two of three slices for EAUS or four of six
slices for TPUS. Comparative studies of EAUS and 3D TPUS suggest good agree-
ment. A step-by-step practical guide on how to perform and interpret a TPUS for
the assessment of the anal sphincters is listed in Box 10.1.
Box 10.1 Technique of TPUS for the Assessment of the Anal Sphincters
1) Patient in lithotomy position.
2) Place vaginal probe vertically at the introitus on the posterior fourchette.
3) Start scanning in the sagittal plane till the anal canal is identified.
4) Without tilting, rotate by 90° to scan in the coronal plane. Alternatively, the
probe is horizontally placed on the perineum and gradually inclined until
the best view of the sphincters is achieved.
5) Care should be taken not to exert any pressure on the perineum, which
may distort the anatomy.
6) The hypo-echogenic ring, representing the internal anal sphincter (IAS)
encircling the echogenic irregularity of the anal mucosa and the complete-
ness of the outer hyper-echogenic ring reflecting the external anal sphinc-
ter is obtained.
7) In 3D TPUS examinations, describe defects of the external anal sphincter
by a clock-face notation or degrees as in measurements of angles in the
coronal plane. On applying TUI volume sub analysis, an anal sphincter
defect is defined as a defect of 30° or greater in the circumference of the
external anal sphincter in at least four of six slices (two of three slices for
EAUS) (Figure 10.5).
8) If IAS is torn, it retracts posteriorly creating the ‘half-moon’ sign.
Anorectal Manometry
Anorectal manometry is used for the functional assessment of the anal canal and
rectum. The anal sphincter pressures, rectal sensation, and anorectal reflexes are
measured using a number of pressure sensors mounted on a narrow balloon-
tipped catheter inserted into the rectum. The parameters measured include:
●● Anal canal resting pressure, which is generated by the resting tone of the IAS
(normal range 61–163 cm H2O).
●● Voluntary anal squeeze pressure generated by the external anal sphincter con-
traction (normal range 50–181 cm H2O).
●● Involuntary anal squeeze pressure generated by asking the woman to cough to
assess the external anal sphincter reflex (normal range 50–100 cm H2O).
Mode of Birth in Pregnancies Subsequent to OASIs
Following OASIs, women should be counselled about the mode of birth in subse-
quent pregnancies. Current guidelines recommend that women who have neither
bowel symptoms subsequent to their OASIs nor significant abnormality on
ultrasonographic evaluation of the sphincters or anorectal manometry be offered

a vaginal birth. There are fairly good levels of evidence to support this recommen-
dation. In contrast, women who do not fulfil the aforementioned criteria should
be offered an elective caesarean section in subsequent births, but the evidence in
support of the latter recommendation is not robust.
In women who attend for follow up after OASIs and undergo anatomical and
functional assessment of the anorectal complex, there is no reason that this dis-
cussion cannot be initiated at that time. This approach will give women the
opportunity to plan future pregnancies based on clinical information specific to
them. Although ultrasound findings should not change overtime, the woman’s
symptoms or anorectal manometry might. We, therefore, recommend that a
detailed assessment of the woman’s bowel function should be undertaken again
during the antenatal period of any future pregnancy and the mode of birth re-
discussed before a final recommendation is made. Women who did not have
investigations performed during the follow-up of their OASIs will need to have
these performed during the antenatal period of their subsequent pregnancy.
An ambulatory set-up provides a one-stop setting where investigations, results,
and counselling can take place with the aim to improve efficiency and reduce a
woman’s anxiety.
Levator Ani Muscle Avulsion
Pelvic floor disorders, urinary incontinence, and pelvic organ prolapse have been
identified as important long-term complications of perineal trauma. Apart from
the neurological damage and stretching of pelvic floor muscles in vaginal deliver-
ies, the avulsion injury sustained to pelvic floor muscles is attributed as an impor-
tant causative factor in pelvic floor disorders.
Levator avulsion (LA) is the detachment of the pubovisceral muscle (PVM)
component of the levator ani muscle from its insertion into the pubic bone. There
is wide variation in the reported incidence of avulsion injury, which ranges from
13 to 36% after the first birth. The risk is significantly higher following operative
vaginal birth especially with forceps. The difference in incidence is also contrib-
uted to by the variation in the method and timing of diagnosis. LA can be com-
plete or partial and either unilateral or bilateral. Although partial avulsions are
more likely to improve over time, they are still associated with subjective and
objective pelvic floor dysfunction. Palpation of the site of insertion of the PVM is
sometimes recommended as a method of screening for LA, however, the diagnos-
tic accuracy of this method relies on the skill of the examiner and the presence of
an intact side to act as a reference. Nonetheless, natural variation in PVM
insertions is a real limitation to this technique. Therefore, accurate diagnosis

relies on imaging techniques, mainly in the form of 3D ultrasonography or mag-
netic-resonance imaging (MRI). For this reason, the diagnosis tends to be made a
long time after birth. Good agreement between MRI and 3D TPUS has been
reported with the ultrasound assessment being more reproducible, more conveni-
ent and more cost-effective. The TPUS assessment for LA should be undertaken
upon pelvic muscle contraction for better tissue enhancement and with a vol-
ume acquisition angle of at least 70°. On TUI sub-analysis, LA is diagnosed
when abnormal insertion is detected in three central slices or with a levator-
urethral-gap (LUG) of >2.5 cm (Figures 10.1–10.4).
Although LA is known to increase a woman’s long-term risk of prolapse, there
is currently no policy or recommendation for routine screening even in high-risk
women (e.g., after forceps deliveries or births complicated by OASIs). If there is a
clinical need to confirm or refute the possibility of an LA, the presence of clinical
expertise and an imaging facility within the ambulatory clinic is beneficial.
At present, there are no effective surgical interventions for the repair of LA. There
does, however, seem to be potential benefits in structured antenatal pelvic floor
muscle exercises and alteration of avoidable risk factors such as obesity and con-
stipation to reduce the individual woman’s likelihood of developing significant
pelvic floor disorders in the future.
Figure 10.1 TUI sub-analysis of a 3D volume TPUS of a normally attached levator ani
upon muscle contraction.
Figure 10.2 3D Axial view of a unilateral right sided levator avulsion.
Figure 10.3 TUI sub-analysis of a 3D volume TPUS of a unilateral right sided levator
avulsion with a LUG of 27.9 mm.
Figure 10.4 TUI sub-analysis of a 3D volume TPUS showing bilateral Levator avulsion.
Figure 10.5 TUI sub-analysis of a 3D volume TPUS showing an EAS defect.

Conclusion
Perineal trauma after childbirth can pose significant physical and psychological
morbidity. A dedicated centre in the ambulatory set-up, which provides consulta-
tion alongside imaging modalities and the ability to perform day-care surgical
procedures, will be the way forward in caring for these women.
Further Reading
Chandru, S., Nafee, T., Ismail, K. et al. (2010). Evaluation of Modified Fenton
procedure for persistent superficial dyspareunia following childbirth. Gynecol Surg
7: 245–248. https://doi.org/10.1007/s10397-009-0501-7.
Dietz, H.P. (2018). Exoanal imaging of the anal sphincters. J. Ultrasound Med.
37: 263–280. https://doi.org/10.1002/jum.14246.
Dudley, L.M., Kettle, C., and Ismail, K.M. (2013). Secondary suturing compared to
non-suturing for broken down perineal wounds following childbirth. Cochrane
Database Syst. Rev.: 9. https://doi.org/10.1002/14651858.CD008977.pub2.
Hiller, L., Radley, S., Mann, C.H. et al. (2002). Development and validation of a
questionnaire for the assessment of bowel and lower urinary tract symptoms in
women. BJOG An Int. J. Obstet. Gynaecol. 109: 413–423. https://doi.
org/10.1111/j.1471-0528.2002.01147.x.
Ismail, K.M.K., Kettle, C., Macdonald, S.E. et al. (2013). Perineal assessment and
repair longitudinal study (PEARLS): a matched-pair cluster randomized trial.
BMC Med 11 https://doi.org/10.1186/1741-7015-11-209.
Laine, K., Rotvold, W., and Staff AC (2013). Are obstetric anal sphincter ruptures
preventable?- large and consistent rupture rate variations between the Nordic
countries and between delivery units in Norway. Acta Obstet. Gynecol. Scand.
92: 94–100. https://doi.org/10.1111/aogs.12024.
Royal College of Obstetricians & Gynaecologists (2015). The Management of
Third- and Fouth-Degree Perineal Tears: green-top Guideline No. 29. R. Coll.
Obstet. Gynaecol. 29: 1–11.
137
11
Teaching and Training in Urogynaecology

Ajay Rane
Urogynaecologists specialise in the female pelvic organs and their supporting

structures. This involves treating pelvic floor disorders including pelvic organ
prolapse, bladder and bowel dysfunction, incontinence, pelvic or bladder pain,
and fistulas. These specialists are surgically trained and many will also be skilled
in performing ultrasound. Urogynaecologists divide their time across outpatient
clinics, the operating theatre, outpatient procedures such as cystoscopy or
urodynamics, and ultrasound scanning. This work can be performed in the public
or private sector.
The practice of urogynaecology allows for a mix of clinical medicine, imaging,
and surgery. Many women are either too embarrassed to address their issues or
see them as a normal function of childbirth and ageing. The practice of
urogynaecology allows women to successfully manage what are often chronic
issues and regain their quality of life. By focusing on a particular area of gynaecol-
ogy, subspecialists are able to offer patients a higher level of expertise and training
in the management of pelvic floor dysfunction.
ole of the Generalist Gynaecologist

R
in Urogynaecology
The general gynaecologist is trained in the management of pelvic floor dysfunc-
tion and can manage many of the common urogynaecological presentations. The
general gynaecologist is often the first point of contact after the general practi-
tioner. When management has failed or is beyond the expertise of the generalist,
referral to a subspecialist is recommended. Complex cases, such as women who
have had previous surgeries or mesh complications, are best managed by a sub-
specialist whose training and experience in the area may translate to better patient
outcomes. The following is a summary of the role and qualifications of a generalist

gynaecologist in various countries:
Australia
The general gynaecologist in Australia will have been signed off for basic
vaginal surgery (anterior and posterior repair), intermediate vaginal surgery
(vaginal hysterectomy), and minor perineal surgery. The expectation prior to
sign-off is that the candidate will have completed 20 basic surgeries and
20 intermediate surgeries, which are guides and not mandatory numbers.
While there is no sign-off assessment for continence procedures, the logbook
recommendation is the performance of five continence surgeries during
training. It is also expected that trainees will have spent at least 100 hours in
gynaecology outpatient clinics.
The Royal Australian and New Zealand College of Obstetrics and Gynaecology
(RANZCOG) introduced Advanced Training Modules in 2019. There are two com-
pulsory and four optional modules. One of the optional modules pertains to urog-
ynaecology – the pelvic floor disorders module. This can be undertaken over a
12–24 month period during advanced training and should include a minimum of
45 urogynaecology theatre sessions and 45 urogynaecology outpatient clinic ses-
sions per 12 months. Requirements for this module include a logbook, presenta-
tion at morbidity and mortality meetings, and presentation of an audit of pelvic
floor treatment outcomes. The suggested numbers for logbook procedures include:
urinary stress incontinence procedures (10), vaginal hysterectomy (10), anterior
and/or posterior vaginal repair (20), post-hysterectomy vaginal vault suspension
procedures (5), urodynamic studies (10) and cystoscopy (20).
United Kingdom (UK)

The Royal College of Obstetricians and Gynaecologists (RCOG) offer advanced
training skills modules (ATSM) in the final two years of obstetrics and gynae-
cology. This training allows trainees to develop the skills required to practice in
various subspecialty areas as part of a generalist job with a particular focus or
interest. The relevant module is Urogynaecology and Vaginal Surgery (UGVS).
An optional laparoscopic urogynaecology module is also available, but can only
be undertaken after completion of the UGVS ATSM or concurrently with it
(i.e., it cannot be undertaken as a stand-alone module). On completion of the
ATSM, it would be expected that a trainee would be competent in: anterior
repair, diagnostic cystourethroscopy ± biopsy, mid-urethral tape (retropubic or
trans-obturator approach), posterior repair ± perineorrhaphy and vaginal
hysterectomy.
United States of America (USA)

In the USA, there are 241 obstetrics and gynaecology residency programmes
(1288 spots available). These programmes are all individualised and some have
more exposure to urogynaecology than others. On completion of residency,
a generalist obstetrician and gynaecologist (OBGYN) would be able to perform a
vaginal hysterectomy, uterine and vaginal vault suspension procedures, and
prolapse repairs.
Formal Urogynaecological Training by Country
Australia
Training in Australia is managed by RANZCOG. The training is three years in
duration at a minimum of two prospectively approved training sites. RANZCOG
trainees can undertake up to one year of subspecialty training as part of their
advanced training for their fellowship of the College. The first year of training
must be undertaken on a full-time basis. Selection is via a process of online
application including covering letter, personal statement, curriculum vitae, and
three references. Suitable applicants will then be invited to attend a panel
interview.
Requirements for training include maintenance of a logbook, written examina-
tion, research project, formative review (at 3 and 9 months each year) and sum-
mative appraisals (at 6 and 12 months each year). Multisource feedback is also
sought in the first year of training.
Minimum numbers are set for anti-incontinence procedures and reconstructive
procedures (100 of each). Attendance at urogynaecology lectures, tutorials, dem-
onstrations, and conferences is also expected.
The examination is of 3.25 hours duration and consists of 10 short answer
questions.
Some procedures are considered compulsory and need to be formally assessed
and signed off by a supervisor. There are two categories – generic procedural, of
which there are 8, and surgical procedural, of which there are 11.
Some time spent during training in an overseas unit is considered desirable.
The following objectives are from the handbook for the certification in
urogynaecology:
It is expected that the subspecialist in urogynaecology will:
●● Demonstrate a detailed knowledge of:
–– The embryology and anatomy of the pelvis, the pelvic musculature, and the
pelvic viscera
–– The physiology of urinary and faecal control

–– The pathology of abnormal urinary and faecal control
–– Neurotransmission and the pharmacology of drugs acting directly and
indirectly on the lower urinary tract
●● Have a basic knowledge of:
–– Imaging of upper and lower urinary tracts
–– The design and statistical analysis of clinical trials
–– The function of urodynamic equipment
●● Have an extensive personal experience in the assessment of patients with lower
urinary tract disorders by:
–– Clinical assessment
–– Urodynamic assessment
–– Cystourethroscopy
–– Organ imaging
●● Have a clinical competence in the following:
–– The medical and surgical management of pelvic floor dysfunction including
genital tract prolapse
–– The surgical and medical management of lower urinary tract dysfunction
–– The long-term care of patients with intractable incontinence
–– Organisation of community care of the incontinent community assessment
procedures liaison with nursing and general practitioner services
United Kingdom
In Britain, candidates for urogynaecology training complete subspecialty training
as the final two years of a seven-year general obstetrics and gynaecology (O&G)
training programme.
Eligibility
To enter subspecialty training, there is a need to fulfil one of the following criteria:
1) Hold a UK national training number or equivalent, including successful com-
pletion of clinical training to ST5 or ST6 level, confirmed by outcome 1 in most
recent Annual Review of Competency Progression (ARCP) or equivalent, and
have passed the Part 3 MRCOG.
2) Or hold a UK Certificate of Completion of Training (CCT) or Certificate of
Eligibility for Specialist Registration (CESR) and be on the UK specialist regis-
ter in obstetrics and gynaecology (O&G).
3) Be a European Economic Area or non-UK applicant who is listed on the UK
specialist register in O&G.
Training Requirements
The programme consisting of eight modules and two courses: the ATSM course
(same as for general urogynaecology) and a leadership and management course.
Competency is required in the following objective structured assessment of tech-
nical skills (OSATs) for subspecialty trainees: colposuspension, cystoscopy, mid-
urethral sling, posterior repair, sacro-colpopexy, sacrospinous fixation,
urodynamics, vaginal hysterectomy, anterior repair, laparoscopic sacro-colpopexy
(optional module only), and laparoscopic sacro-hysteropexy (optional mod-
ule only).
There are also eight mini clinical evaluation exercises (Mini-CEXs), eight case-
based discussions (CbDs), and team observation forms at least twice a year.
Competency in clinical governance include patient safety, audit, risk manage-
ment, and quality improvement. Trainees must maintain a logbook.
United States of America

In the United States, training in urogynaecology is called the Female Pelvic
Medicine and Reconstructive Surgery (FPMRS) Fellowship. The subspecialty cer-
tification has been available since 2011.
Eligibility
The fellowship involves a three-year commitment after completion of Obstetrics
and Gynaecology residency or a two-year commitment after completing a urology
residency. Some residency programmes provide more FPMRS exposure and train-
ing than others. The fellowship application process occurs during the third year of
residency and hence it can be difficult for some residents to have the requisite
exposure to this field prior to the application deadlines. All accredited FPMRS fel-
lowship programmes require candidates to undertake research to develop and
defend a thesis.
Application is through a standardised process via the Electronic Residency
Application Service (ERAS). Applicants must ensure they meet all programme pre-
requisites and institutional policies regarding eligibility for appointment prior to
ranking a programme through the National Resident Matching Program. Candidates
are then selected for interview. Candidates who have done research and attended
the American Urogynaecologic Society (AUGS) annual meetings will be considered
highly. It is also recommended to seek mentorship and a letter of recommendation
from a well-connected faculty member. Candidates also need to apply to participat-
ing programmes and apply to the institutions they are interested in. The interview
process is expensive and it is typically recommended that candidates interview at
approximately 10 programmes. Although the cost is variable, candidates should

roughly budget US$4500 to US$9500. The vast majority of this money is spent on
travel because most applicants will travel to 10 or more interviews.
Training Requirements
The curriculum varies from hospital to hospital and needs to be approved by the
Accreditation Council for Graduate Medical Education (ACGME). The ACGME
reviews each programme and accredit each if they can demonstrate that trainees
have adequate training time to develop the following skills: (i) demonstration of
competence in patient care, medical knowledge, practice-based learning and
improvement, interpersonal and communication skills, professionalism, and sys-
tems-based practice competency requirements; and, (ii) completion of a scholarly
paper or quality improvement project. The Review Committee will annually review
major components of the programme curriculum to monitor compliance with these
requirements. Further information on the milestones required during training can
be found at: www.acgme.org/Portals/0/PDFs/Milestones/FemalePelvicMedicinean
dReconstructiveSurgeryMilestones.pdf?ver=2016-04-04-143644-683.
An example of a possible curriculum follows:
Fellows will learn how to evaluate, manage, and treat patients with primary
pelvic organ prolapse and bladder control problems, as well as complex pelvic
floor disorders, including urethral diverticulum, vesicovaginal or rectovaginal
fistula, and pelvic floor myofascial pain.
Fellows will be trained to perform the full scope of surgical procedures, including:
●● Laparoscopic Sacro colpopexy
●● Robotic Sacro colpopexy
●● Vaginal hysterectomy
●● Vaginal apical suspension procedures
●● Slings
●● Bulking injection procedures
●● Sacral neuromodulation
●● Peripheral nerve stimulation
●● Vaginal electrical stimulation
Low-Resource Countries – FIGO Recommendations
The International Federation of Gynaecology and Obstetrics (FIGO) recognises that

not every country will be able to provide trainees with the resources or facilities in
which to achieve all of the goals of training that are set out for achievement in highly
resourced countries. The FIGO Task Force has therefore created guidelines for resi-
dent/general physician training to suggest minimum standards for urogynaecology
services for women in low–moderate resource countries. The requirements follow:
Knowledge (both specifically and broadly) should include at least the following
topics by the end of training:
●● Trauma and congenital anomalies that result in incontinence
●● Voiding dysfunction and urinary retention
●● Urinary incontinence types and assessment
●● Overactive bladder
●● Painful bladder syndrome/interstitial cystitis
●● Urinary tract infection
●● Lower urinary and intestinal tract fistulae
●● Pelvic pain syndrome
●● Pelvic organ prolapse
●● Childbirth – related pelvic floor trauma
●● Urethral lesions, i.e. diverticula
●● Effects of surgery and irradiation on the lower urinary and intestinal tracts and
pelvic floor function
●● Urinary disorders in pregnancy (including infections and incontinence)
●● Evaluation and care of the elderly with pelvic floor disorders
●● Lesions of the central nervous system affecting urinary and faecal control and
pelvic floor function
●● Disorders of the lower intestinal tract including difficult defecation, faecal
incontinence, and rectal prolapse
●● Obstetric anal sphincter injury
●● Emotional and behavioural disorders affecting the pelvic floor and lower uri-
nary and intestinal tract function
●● Urinary disorders of childhood
●● Pelvic floor disorders in the physically and mentally challenged individual
●● Sexually transmitted diseases
●● Effect of hormone deficiency states on the pelvic floor
●● Urinary problems secondary to medical conditions and drugs
●● Sexual dysfunction and coital incontinence
●● Vulvar disorders
●● Principles of evidence-based medicine, epidemiology, and critical appraisal of
urogynaecologic research
●● Electronic and non-electronic urodynamics studies.
Emerging Nations/Low-Resource Settings

Many low-resource settings are unable to provide training that meets the FIGO
requirements. It can be quite difficult for doctors in low-income countries to not
only access appropriate training in their own countries but also abroad. It can
actually be quite difficult for residents in first-world countries to get into
subspecialty training in their own countries. The obstacles for foreigners are often
substantially higher. An example of a surgeon who is actively working to train
surgeons in low-resource settings is Dr Stephen Jeffrey.
Dr Stephen Jeffrey – South Africa

Dr Stephen Jeffery is a urogynaecologist in South Africa. He received his accredi-
tation at the Royal College in London. He was the first gynaecologist in South
Africa to have received specialised training and accreditation in pelvic surgery
and reconstruction. He was awarded his subspecialty degree with distinction. He
is also president of the South African Urogynaecology Association. In this role, Dr
Jeffery has been instrumental in formalising the accreditation of urogynaecology
as a subspecialty in South Africa. He has trained surgeons from the USA, UK,
Ghana, Pakistan, India, United Arab Emirates, Kenya, Philippines, Germany,
Nepal, Mozambique, and Mauritius both in Cape Town and in their own countries.
Use of Technology and Simulation in Training
Laparoscopic surgery lends itself to simulation. From the basic box trainer to
multi-million-dollar computer simulation software, similar to flight simulators,
trainees can practice their laparoscopic surgical skills. Some of the more advanced
simulators also have haptics, which give feedback to the hands when an object is
‘touched’ on the screen.
Vaginal surgeries can be difficult for the trainee to grasp due to the confined
operating space and sometimes ‘blind’ operation (e.g., sacrospinous fixation). The
operating surgeon has command of the operation while the trainee initially holds
retractors. It can be difficult to transition from the assistant to the primary opera-
tor. Technology has not left vaginal surgeons behind however. The VITOM® – Video
Telescopic Operating Telescope developed by Karl Storz, allows for video record-
ing of operations for teaching purposes. The trainee can follow on a screen what
the operator is doing. This technology can also be used to ‘live-stream’ operations
to another room in the hospital (with patient consent) so that multiple doctors can
observe without compromising sterility. With the addition of video recording
technology in the theatre, the operating surgeon can also speak to the observ-
ing team.
There are also multiple resources available on the Internet with surgical videos
and training modules. Often fee-based membership of these sites is required.
Some of these websites have a particular gynaecology or urogynaecological focus.
For example, the International Academy of Pelvic Surgery has modules on sling
procedures, reconstructive procedures of the lower urinary tract, ureteral surgery,
surgical correction of pelvic organ prolapse, surgery for posterior pelvic floor
abnormalities, surgical management of mesh complications after sling proce-
dures, and mesh prolapse repairs, challenging cases in urogynaecology. Their
website is https://academyofpelvicsurgery.com/video-library.
Research
The highest goal of medicine is to practice an evidenced-based model of care.

Urogynaecology, being a relatively new field, data is often lacking but research
opportunities are many in this area. The gold standard for treatment for many
common conditions, such as interstitial cystitis, are still being investigated and
developed. Many training programmes have a research component and there is
scope for more research. Fellows should be encouraged to perform research in
areas of particular interests to them, and doctors with an interest in research
would be welcomed into the speciality.
The Mesh Saga
Currently, all vaginal mesh products have been removed from the market – as of
May 2019. Vaginal mesh for urogynaecological procedures was first approved in
the United States in 1996. Twelve years later (2008), the Therapeutic Goods
Administration (TGA) in Australia received the first adverse-events reports.Two
years later (2010), the US Food and Drug Administration (FDA) issued a safety
communication, recommending that surgeons consider further specialised train-
ing before inserting mesh while the TGA was investigating the reported adverse
events and consulting with an expert panel. The United States, Australia, and
New Zealand committees were all emphasising the need for informed consent
prior to insertion of mesh, so that patients understood that mesh was permanent,
not without complications, and that these complications could not always be
resolved with or without further surgery.
Over the following few years, further reports emerged on the complications asso-
ciated with vaginal mesh and more investigations began. The literature reported
conflicting information on success rates of mesh. By 2011, the FDA had updated
their communication to advise that the evidence did not support the use of posterior
compartment mesh. The communication also advised that, although anterior com-
partment mesh efficacy had some weight of evidence to support it, adverse events
were not rare and, therefore, patients should be counselled appropriately prior to
mesh insertion in addition to being advised that long-term data to support mesh was
limited. Post-market surveillance was stepped up. In 2014, urogynaecological
meshes were being withdrawn from the market amid increasing concerns about the
potential for serious and life-altering complications. In 2015, reviews from multiple
countries including Scotland, UK, the European Commission, Australia, and New
Zealand were published. These resulted in the reclassification of vaginal mesh by
the FDA in 2016 to Class III – a high risk device. Other countries followed suit in
2017. In the meantime, the PROSPECT study, a Scottish multi-centre trial showed
no benefit of vaginal mesh over native tissue repair. This ultimately led to the with-
drawal of all mesh by mid-2019. Class actions have been undertaken against manu-
facturer’s and the outcome of these is awaited.
Initial success with the adoption of transvaginal insertion of slings for urinary
stress incontinence soon led to their widespread acceptance as the gold standard
treatment. There were also initial reports that mesh showed promise for the repair
of pelvic organ prolapse. Many soon adopted it as the primary treatment for pelvic
organ prolapse. Could the complications have been predicted? Manufacturers
have been blamed for promoting the technology before results were available from
randomised controlled trials. Was it the case that surgeons without appropriate
training were adopting an industry-driven new technology as a primary prolapse
surgery with the promise of a ‘permanent solution’ to prolapse? Should the proce-
dure have been left to pelvic floor specialists, such as urogynaecologists? From
current data, it is hard to know whether there is a subset of patients that would
benefit from mesh – for example, recurrent anterior compartment prolapse in a
non-smoker with a normal BMI. Could better case selection have prevented the
current situation? Again, from current data, it is difficult to know. The fallout will
continue and the answers to these questions may become evident with hindsight.
Training Status
The UK (RCOG) removed mesh procedures from their advanced training modules
and subspecialty training modules in October 2018. Urethrotomy and ‘stapled
trans-anal resection procedure’ were also removed. Sacrospinous fixation was
added to the module at the same time.
When the Australian advanced training module was introduced in 2019, no
vaginal mesh procedures were expected. The vaginal mesh saga has also led to
investigation into mesh for sub-urethral slings. As of December 2017, RANZCOG
have removed sub-urethral slings from the general training requirements for gen-
eral obstetrics and gynaecology trainees in light of the difficulties in obtaining
exposure and training for these procedures. Prior to this time, surgical compe-
tency in transvaginal tape was required. This followed a decision in December
2016 to reduce the requirement from 20 continence procedures to 5 and a change
to the assessment of the procedure. The procedure could be signed off with some
input or ‘minimal input’ from the assessor (i.e., the trainee no longer had to be
competent to perform the procedure independently). The Australian advanced

training module specifies that 10 surgical procedures for urinary stress
incontinence are expected, but does not specify the mode of operation. A trainee
completing the pelvic floor disorders advanced training module could continue to
perform incontinence surgery after graduating provided they perform more than
20 such procedures each year to maintain competency. It is expected that auditing
of this will follow. Mesh removal has become the province of the urogynaecologist
and training courses now include procedures for mesh removal.
What can be learned from this?
Early adoption of technology without appropriate trials of efficacy can lead to
long-term debilitating consequences for patients that may lead to poor quality of
life. It behoves us all to question the rigour of research and trials before adopting
new techniques and technologies.
Appropriate training is also important and those learning, should be taught by
experienced operators.
In summary, urogynaecology is an expanding specialty that is progressing our
knowledge of the female pelvic floor and exploring ways to face its challenges and
conundrums.
Further Reading
Accreditation Council for Graduate Medical Education website (n.d.). www.

acgme.org
Drutz, H.P. (2010). IUGA guidelines for training in female pelvic medicine and
reconstructive pelvic surgery – updated guidelines 2010. Int. Urogynecol. J.
21: 1445–1453.
RANZCOG (2019). Certification in Urogynaecology. RANZCOG Training Program
Handbook. Melbourne Australia. https://ranzcog.edu.au/Training/Subspecialist-
Training/Current-Trainees-(4)/Training-Program-Handbooks.
RCOG (n.d.). ATSM urogynaecology and vaginal surgery. www.rcog.org.uk/en/
careers-training/specialty-training-curriculum/atsms/atsms-pre-august-2019/
atsm-urogynaecology-and-vaginal-surgery.
RCOG Urogynaecology Curriculum (2018). October. www.rcog.org.uk/en/careers-
training/specialty-training-curriculum/subspecialty-training/
urogynaecology-subspecialty-training.
Senate Community Affairs Committee Secretariat (2018). Number of women in Australia
who have had transvaginal mesh implants and related matters. Parliamentary Report
(28 March 2018). Senate Printing Unit, Parliament House, Canberra.
Stenchever, M.A., Rizk, D.E., Falconi, G., and Ortiz, O.C. (2009). FIGO guidelines for
training residents and fellow in Urogynaecology female urology and female pelvic
medicine and reconstructive surgery. Int. J. Gyne. Obs. 107 (3): 187–190.
149
Section III
Ambulatory Urology
151
Foreword
The concept of ‘ambulatory care’ is an evolving one, but as new systems and
techniques are developed, urology is one of the surgical specialties that remains
poised to best take advantage of these. Ambulatory urology encompasses not only
surgical procedures with same-day discharge, but also outpatient attendances
encompassing multiple tests and investigations in one visit.
In the drive for healthcare to be efficient, cost-effective, and timely for patients,
urology units are now increasingly looking for new ways to deliver an ‘ambulatory
service.’ So-called ‘one-stop’ clinics for the investigation of haematuria are now com-
monplace and increasingly similar models are being employed for assessment of
possible prostate cancer and benign conditions such as lower urinary tract symptoms.
With advances in surgical technology, a very high proportion of urological oper-
ations are now completed as ‘day-cases.’ Just a few decades ago, ureteric stones
were managed with open ureter lithotomy and an inpatient stay of several nights,
today ureteric stones are treated with ureteroscopy and laser stone fragmentation
and patients are normally discharged home within a few hours of leaving the
operating theatre. The vast majority of penile and scrotal surgery is now consid-
ered ambulatory and new techniques such as Rezūm prostate surgery mean that a
high proportion of urological pathologies have an ambulatory option for manage-
ment. In the coming years we are likely to see increased usage of robot assisted
laparoscopy as more surgeons are exposed to it during their training and more
manufacturers enter the marketplace. Day-surgery robot-assisted prostatectomy
is already a reality in some units, and this opens the door to ambulatory robot-
assisted surgery one day becoming the rule, rather than the exception.
Jordan Durrant
153
12
Ambulatory Penile and Inguino-Scrotal Surgery

Ben Pullar
Background
Day-case or ambulatory surgery is now the standard-of-care for the majority of

penile and inguino-scrotal procedures in modern urology. However, same-day
discharge cannot be reliably achieved unless consideration is given to achieving
this from the outset. In general, the patient should be aware of the nature of the
procedure and the intention that they will be discharged home the same day. This
starts at the initial clinic consultation and will continue through effective pre-
assessment to the day of the procedure itself. Recovery and ward nursing staff are
essential in delivering effective day case surgery with nurse-led discharge now
becoming routine, following a clear post-operative plan from the operating
surgeon.
Specific to surgical procedures, particular attention should be made to adequate
post-operative analgesia, catheter management (if applicable), and meticulous
haemostasis to avoid unnecessary re-admissions due to these preventable issues.
Individual Conditions and Procedures
Hydrocele
A hydrocele is an accumulation of fluid between the two layers (parietal and
visceral) of the tunica vaginalis surrounding the testes. The diagnosis is made on
clinical examination and it is important to differentiate a hydrocele from other
causes of scrotal swelling. Examination will reveal a smooth, unilateral scrotal
swelling with a palpable superior margin which trans illuminates. It is often
difficult to palpate the underlying testes.
The differential diagnosis of a unilateral scrotal swelling includes varicocele,

hernia, epididymal cyst, infection (orchiditis), or tumour.
Diagnosis is supported by ultrasound, which will both confirm the diagnosis
and confirm that the underlying testes are normal.
Surgical management of a hydrocele is indicated if symptomatic. Small hydro-
coeles or larger, asymptomatic hydroceles can be safely managed conservatively.
Hydrocele repair performed as a day case is well established. However, in older
patients or men with a large hydrocele in which a drain is placed post operatively,
an overnight admission may be warranted. Paediatric hydroceles are managed
differently with a groin incision and ligation of a patent processes vaginalis. They
are almost always performed as a day-case procedure. There are three options for
surgical management of an adult hydrocele. Definitive surgical repair is with
either a Jaboulay or Lord’s technique. The Lord’s procedure is suitable for small
and medium sized hydroceles. It involves plication of the hydrocele sac. Larger
hydrocoeles may be managed with the Jaboulay procedure in which the hydrocele
sac is excised. Both procedures can be complicated by recurrence or haematoma
formation. A drain insertion may be used for larger hydroceles to prevent haema-
toma accumulation.
Hydrocele aspiration (with or without sclerotherapy) may be reserved for a
patient deemed unfit to undergo any general anaesthesia (GA) procedure, but
accepting the high recurrence rates associated with it and the risk of haematoma.
Varicocele
Varicocele is defined as a dilatation of the pampiniform plexus of veins in the
spermatic cord. It is common and estimated to affect 15% of the general male
population. It is seen much more commonly in men being investigated for both
primary and secondary infertility.
Varicoceles develop from incompetent valves in the spermatic veins resulting in
retrograde blood flow and engorgement of and subsequent dilatation of the veins
in the pampiniform plexus. It is more common on the left side due the higher
pressures within the left testicular vein owing to the acute angle at which it enters
the left renal vein. (This is in contrast to the oblique angle at which the right-side
testicular vein enters the inferior vena cava (IVC), resulting in lower pressure on
the right side).Most varicoceles are asymptomatic but if large may cause scrotal
discomfort. They are commonly identified as part of the investigation of male sub-
fertility. The link between varicoceles and infertility is thought to result from a
loss of the countercurrent heat exchange mechanism that exists such that scrotal
temperatures are lower than the rest of the body. The resulting rise in scrotal
temperatures results in impaired spermatogenesis.
Diagnosis is on clinical examination and graded according to size. It is classi-

cally described as ‘a bag of worms’. Diagnosis is confirmed with scrotal ultrasound.
Treatment of a varicocele should be considered in sympomatic cases. The treat-
ment of varicocele for the treatment of subfertility is controversial. Whilst it may
result in improved semen parameters, this may not necessarily be reflected in
improved pregnancy rates. The European Association of Urology (EAU) guide-
lines currently recommend the treatment of men with a clinical varicocele,
oligozoospermia, and otherwise unexplained infertility in the couple, although it
accepts that the evidence for this is weak.
The mainstay of treatment is varicocele embolization. Success rates are around
85%. Surgical treatments involve ligation of the testicular veins via a sub inguinal
(Marmar), inguinal (Ivanissevich), or laparoscopic approach. Success rates of 95%
have been quoted. Whichever treatment modality is used, discharging the patient
on the day of the procedure is feasible.
Testicular Cancer + Radical Inguinal Orchidectomy
Testicular cancer accounts for 5% of all urological cancers and is the commonest
solid cancer in men between the ages of 20–45 years. The incidence is increasing
with a peak in the third and fourth decades. Owing to its sensitivity to platinum-
based chemotherapy regimens, in general, the prognosis is excellent.
Most patients will present to the general urology clinic having detected a lump
in the testes. This is usually otherwise asymptomatic although pain can be present
in approximately 5% of cases. It is essential that these patients are seen urgently
with a diagnosis confirmed on ultrasound and tumour markers sent (alpha feto-
protein, beta-human chorionic gonadotropin (βhCG), and lactate dehydrogenase
(LDH)). Prior to surgery, patients should also be offered semen preservation.
Computerized tomography (CT) for staging (abdomen, pelvis ± chest) is also
arranged.
Radical inguinal orchidectomy is the primary treatment option in almost all
patients (except those who present with high volume metastatic disease). This
may be performed in conjunction with insertion of a testicular prosthesis and
contralateral testicular biopsy.
The procedure is performed through a groin incision approximately 2 cm above
and parallel to the inguinal ligament. The external oblique aponeurosis is identi-
fied (along with the ilio-inguinal nerve just below it) and incised to expose the
cord. Early clamping of the cord adjacent to the internal ring is performed. The
testicle is then delivered and the gubernaculum divided. The cord is cut between
two clamps and ligated with heavy sutures. A non-absorbable suture may be used
to aid identification during any future lymph node dissection. Haemostasis and
vascular pedicle control are essential because a bleeding, retracted cord can be
difficult to control. A prosthesis, if requested, is then inserted and closure per-
formed with generous local anaesthetic infiltration of the wound. The majority of
patients (who are usually young and with few co-morbidities) will be discharged
with dressings the same day.
Phimosis and Circumcision
Tightness of the foreskin, which cannot be retracted behind the glans penis,
affects both adults and children. Physiological phimosis present at birth usually
resolves such that less than 1% of 17-year-old males have a persistent phimosis.
The indications for circumcision in the paediatric population is, therefore,
reserved for pathological phimosis resulting in recurrent balanitis, recurrent uri-
nary tract infections (UTIs) or the presence of balanitis xerotica obliterans (BXO).
In the adult male, recurrent balanitis or BXO can result in pathological phimo-
sis. Mild phimosis may be asymptomatic. Depending on the age of the patient and
severity of the phimosis, the patient may develop symptoms of bleeding, splitting,
difficulty with sexual intercourse and voiding problems. A tight phimosis may
also result in a paraphimosis in which the foreskin becomes stuck behind the
glans and cannot be replaced. This requires urgent attention to prevent glans
necrosis developing.
Phimosis may respond to topical steroids but these have often been tried in the
primary care setting before the patient is referred to the urology clinic.
Preputioplasty is an alternative to a full circumcision in cases of a mild phimosis.
There are multiple ways to perform a circumcision. Whichever technique is
used, it is imperative the (often young) patient has a full understanding of the
procedure and its associated complications, especially decreased glans sensitivity
and poor cosmesis. General principles for circumcision are the use of a penile
block, bipolar diathermy, and meticulous haemostasis (particularly with regard to
the frenular artery). The patient can be safely discharged on the day of surgery
with dressings and wound care advice.
Peyronie’s Disease and Penile Straightening Surgery
Peyronie’s disease affects up to 7% of men. It is characterised by penile deviation

due to fibrous plaque formation on the tunica albuginea. Penile deviation is a
consequence of the inability of corpora cavernosum underlying the plaque to
lengthen on erection in relation to the rest of the penis. The exact aetiology of the
condition is unknown although it is thought to be an inflammatory connective
tissue disorder related to repeated micro-trauma. It is characterised by an acute
(active) and a chronic (stable) phase. It is important that any surgical correction is
deferred until the chronic phase of the disease, once stabilisation of the plaque
has occurred.
Most patients will present with penile deviation, a palpable lump (plaque)
and/or pain on erection. It is essential to obtain a history regarding any co-existing
or new erectile dysfunction. It is useful to ask patients to bring a photo with them
to the clinic to assess the degree of deviation and progress over time.
Patients can be managed conservatively, medically, or surgically. There is lim-
ited evidence of the efficacy of medical treatments such as Vitamin E, tamoxifen,
or POTABA.
The two most commonly used surgical procedures to treat Peyronie’s disease
are Nesbitt’s and Lue’s procedures. Nesbitt’s procedure aims to correct the deform-
ity by incising an ellipse of tunica albuginea on the unaffected side. It is generally
indicated when the degree of deviation is <60%. In Lue’s procedure, an incision
on the plaque on the affected side is performed with insertion of a graft. Patients
must be informed of the risks of post-operative erectile dysfunction and loss of
erect penile length. In patients who present with Peyronie’s disease and moderate
to severe erectile dysfunction, insertion of a penile prosthesis may be offered.
Whilst these procedures are increasingly being performed in specialist centres,
all may be feasibly carried out as a day-case.
Vasectomy
Vasectomies are performed as a form of male contraception. In the UK currently,

many vasectomies are being carried out in the primary care setting. Often, patients
requesting vasectomies are seen in the urology clinic only if it is thought not to be
straightforward e.g. in the context of previous scrotal surgery or a patient’s request
for general anaesthesia. Even so, a vasectomy performed in hospital is still ideally
suited to be performed as a day case.
The procedure can be performed under either local or general anaesthetic.
Various techniques are described and either a single or two incisions used. General
principles of technique are to isolate the vas deferens between thumb and forefin-
gers, incise the skin over the vas, then lift the vas away from the scrotum by incis-
ing the sheath surrounding it. A 1–2 cm segment of vas is then excised and the
ends are occluded. This can be achieved by diathermy, clips, and suture ligation
with or without a fascial interposition.
It is essential that men requesting a vasectomy have a full understanding of the

procedure, risks, and alternatives. The consent process must highlight that the
procedure should be considered irreversible, the risks of primary and secondary
failure, bleeding, infection, chronic pain, and the need for contraception until
either a semen analysis shows no sperm after at least 12 weeks and 20 ejaculations
or special clearance has been given by a doctor.
Further Reading
BMJ Best Practice - Hydrocele (2020). https://bestpractice.bmj.com/topics/

en-gb/1104.
Hancock, P., Woodward, B.J., Muneer, A. et al. (2016). 2016 laboratory guidelines for
post vasectomy semen analysis. J. Clin. Path. 69: 655–660.
Laguna MP, Albers P, Algaba F et al. (2019). EAU Guidelines on testicular cancer.
http://uroweb.org/guideline/testicular-cancer.
Riddick, A. (1998). Testicular lumps in general practice. Practitioner 242 (1590):
627–630.
159
13
Ambulatory Management of Renal Stone Disease

Aakash Pai
Epidemiology
Urinary stones are the third most common affliction of the urinary tract, super-
seded only by infection and prostatic pathologies. The incidence of calculi is
increasing, with prevalence rates in countries such as the United States, Sweden,
and the UK more than 9%. Men have an increased risk of urolithiasis compared to
women; however, this difference in incidence is reducing. Stones can occur in all
ages; however, the peak age is approximately 45. The risk of stone formation has
shown correlation with body mass index and with certain diseases including
diabetes mellitus and cardiovascular disease.
Aetiology
Urinary stones have been affecting humans, and dogs, for civilisations. Despite
this, much of the aetiology of urolithiasis is unknown. Stone formation comprises
a complex cascade. Urine becomes supersaturated with stone forming salts, with
a resultant precipitation out of solution, forming crystals or nuclei. These crystals
can be retained within the kidney at anchoring sites that promote growth and
aggression and resultant stone formation.
Stone formation is related to supersaturation of urine. The solubility product is
the concentration product a solution reaches where no further added salt crystals
will dissolve. Below the solubility product, urine is undersaturated and crystals do
not form. Above the solubility product, crystals should form, but don’t because of
inhibitors in urine. Above a certain concentration, inhibitors become ineffective,
urine is supersaturated, and the concentration of solute at which this is reached
(crystallisation starts) is the formation product. Urine is metastable between the

solubility product and formation product.
Supersaturation explains the formation of crystals in static solutions, but it can-
not explain crystal formation in urine as it traverses through the nephron. Crystals
form (nucleation) and if they aggregate together, they may retain in the lumen
and grow (free particle theory). Alternatively, they may attach to damaged tubular
surfaces (fixed particle theory).
Types of Stones
Non-infection stones
Calcium oxalate
Calcium phosphate
Uric acid
Infection stones
Magnesium ammonium phosphate
Carbonate apatite
Ammonium urate
Genetic causes
Cystine
Xanthine
2,8-Dihydroxyadenine
Drug stones
Risk Factors
Diseases associated with stone formation

Hyperparathyroidism
Metabolic syndrome
Nephrocalcinosis
Polycystic kidney disease
Gastrointestinal diseases and bariatric surgery
Sarcoidosis
Spinal cord injury
Genetically determined stone formation
Cystinuria
Primary hyperoxaluria
Renal tubular acidosis type I
Drug-induced stone formation, e.g., antiretroviral stones (Indinavir)

Anatomical abnormalities associated with stone formation
Medullary sponge kidney (tubular ectasia)
Pelviureteric obstruction
Calyceal diverticulae
Environmental factors
High temperature
Symptoms
Ureteric stones commonly present with sudden onset severe flank pain. The pain
is commonly colicky (waves of increasing severity followed by reduced severity
pain) and may radiate from the loin to the groin.
Signs
Fifty percent of loin pain is non-urological in nature and therefore careful inspec-
tion of the patient is necessary. Patients with ureteric colic usually twist and roll,
trying to find a comfortable position. Conversely, patients suffering from condi-
tions that cause peritonitis classically lie completely still. It is important to ensure
that the patient is afebrile.
Investigation
It is imperative to perform a pregnancy test in any premenopausal female. Many

patients with ureteric colic have non-visible haematuria, however 10–30% have no
blood in their urine. Computed tomography of kidneys, ureters, and bladder (CT
KUB) is the gold standard diagnostic test for presumed ureteric colic with a sensi-
tivity of 99%. Blood tests including renal function should be taken.
mergency Management of the Infected

E
Obstructed System
The septic patient with an obstructed system is a urological emergency.

Immediate intravenous fluid resuscitation, urine and blood cultures, intrave-
nous antibiotics, and emergency decompression should be organised. Definitive
stone management should be delayed until after the sepsis has resolved. The oft
quoted randomised controlled trial by Pearle et al. (1998), showed that both
stent and nephrostomy were equally effective in decompression of 42 patients
with an infected obstructed system. The method of decompression is therefore
at the discretion of the urologist, depending upon patient, stone, and logistical
considerations.
Treatment
Conservative
Obstructing ureteric stones with manageable levels of pain, no signs of infection
and the absence of marked renal failure can be considered for conservative man-
agement and discharge home. The success of the conservative management of
ureteric colic is dependant primarily on stone size and location. Expectant man-
agement is usually reserved for stones less than 10 mm, with distal ureteric stones
less than 5 mm the most likely to pass. Consideration should be given to the fact
that the pelvic brim and vesico-ureteric junction are smaller in calibre than the
upper ureter and stones found to be lodged in the upper ureter on imaging are
therefore less likely to pass spontaneously.
Medical expulsive therapy (MET) with an alpha-blocker medication is conten-
tious; whilst it is a theoretically sound treatment, large scale randomised con-
trolled trials have not reliably confirmed efficacy and many surgeons are now
abandoning this treatment.
Patients should be discharged home with adequate analgesia (a non-steroidal
anti-inflammatory and an opioid) and given clear instructions to return to hospi-
tal in the event of worsened pain or onset of any kind of fever or malaise.
Ideally, patients should be followed up in an outpatient clinic after two weeks
for repeat imaging on the day with either ultrasound or plain x-ray to confirm
stone progress or passage. This allows adequate time to arrange alternative ambu-
latory therapy for cases in which successful stone passage appears unlikely, before
irreversible renal damage begins to occur.
Extracorporeal Shock Wave Lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) is a valuable modality for the
ambulatory treatment of renal and lower ureteric stones. Relatively compact
‘mobile’ ESWL machines can be quickly set up in any clinical of adequate size
with a suitable power source. Consideration may need to be given to adequate
shielding if x-rays are to be used for stone visualisation, and contingency

plans must be drawn up for emergency care in the exceptionally rare events
of a reaction to medication, bleeding, or cardiac arrythmia developing due to
shock waves. Most units performing ESWL will use NSAID medication as
analgesia, but small doses of midazolam or pethidine are also commonly in
use to ensure a comfortable treatment that is compatible with an ambulatory
approach.
As with all stone management, the suitability for, and success of, ESWL is
dependent on stone factors (size, location, Hounsfield units), patient factors (pref-
erence, obesity, anticoagulation, and severe hypertension) and anatomical factors
(calyceal anatomy). Lower ureteric stones can be considered for ESWL treatment;
however, generally ESWL is used more often for stones within the collecting sys-
tem. ESWL is not preferred for stones >10 mm, lower pole location, stones within
calyceal diverticulae, patients with pelviureteric juncture (PUJ) obstruction and
hard calcium monohydrate calculi.
Uretero-renoscopy
Small-calibre deflecting ureteroscopes coupled with the development of stone
baskets and high-power Holmium: YAG (yttrium aluminium garnet) lasers mean
that the popularity and indications for uretero renoscopy have increased. The
advent of single-use flexible ureteroscopes (such as the Pusen U-Scope) has intro-
duced reliable, high-fidelity visuals for every case and, in some cases, superior
manoeuvrability and deflection as compared ‘re-usable’ flexible cystoscopes. In
the majority of cases, the entire collecting system can be accessed by these mod-
ern scopes, thus maximising chances of successfully rendering a patient ‘stone
free’ with a single ambulatory visit.
Holmium laser is highly absorbed by water and has a very small penetration
depth of approximately 0.4 mm, making it a safe option for stone fragmen
tation during ureteroscopy. Success rates are generally higher than for
ESWL. Ureteroscopy is performed under general anaesthesia in most units, but
several authors have reported excellent experiences performing the procedure
under local anaesthesia. Even with general anaesthesia and even if neuro-
muscular blockage is required to minimise respiratory movement for collecting
system stones, same-day discharge is still easily achieved as long as the patient
recovers from surgery with sufficient analgesia. As with other treatment
modalities, NSAIDS and opioids are mainstays of pain control.
Traditionally stones >2 cm are treated with percutaneous nephrolithotomy
(PCNL), however larger stones are now being tackled via the ureteroscope,
although evidence of the efficacy of this approach is still evolving.
PCNL
Stones greater than 2 cm, inaccessible stones and those that have failed other
modalities are usually treated with percutaneous nephrolithonomy (PCNL).
PCNL has the highest stone free rates out of all modalities for renal calculi.
Direct collecting system puncture and stone fragmentation is technically a more
invasive procedure than ureteroscopy; however, the concept of a ‘tubeless’
PCNL (where no nephrostomy is left in place after the procedure) allowed the
first possibility of the procedure being compatible with same-day discharge. The
last decade has also seen the use of smaller tract sizes for PCNL; mini-PCNL
employs tract sizes at 14–20 Fr, ultra-mini is 11–13 Fr and micro-PCNL is 4.85 Fr.
This ‘miniaturisation’ has allowed an ever-increasing proportion or larger stones
to be managed as ambulatory surgery. Whilst smaller tracts are associated with
improved length of stay and reduced morbidity, but there is a potential for
reduced stone clearance.
ESWL’s lack of anaesthesia, the popularity of miniaturised PCNL tracts, and the
increased capability of ureteroscopes mean that there is an increasing overlap
between the indications for the respective modalities. The decision for the inter-
vention of choice is hence individualised; based upon patient and clinician
preference.
Long-Term Management and Prevention
Serum calcium should be checked in all stone patients. Stones should be sent for
analysis of their composition. 24-hour urine analysis should be considered for
those patients who are at high risk (e.g., young adult and paediatric patients,
recurrent high-volume stone formers).
Long-term prevention of renal calculi centres around ensuring a high fluid
intake (at least 2.5 l water a day). In addition, carbonated drinks should be avoided,
and the addition of fresh lemon juice to drinking water can be protective. Adults
should limit their salt intake (no more than 6 g a day). Calcium intake should not
be restricted. A reduced intake of meat and maintaining a healthy body mass
index (BMI) are also advisable.
Urinary alkalinisation with potassium citrate should be considered for patients
with recurrent stones that are predominantly composed of calcium oxalate.
Thiazide diuretics are an option in patients with recurrent calcium oxalate stones
and hypercalciuria.
Further Reading
Lingeman, J.E., Siegel, Y.I., Steele, B. et al. (1994). Management of lower pole
nephrolithiasis: a critical analysis. J. Urol. 151: 663–667.
Pearle, M.S., Lingeman, J.E., Leveillee, R. et al. (2015). Prospective, randomized trial
comparing shock wave lithotripsy and ureteroscopy for lower pole calculi 1 cm or
less. J. Urol. 173 (6): 2005–2009.
Pearle, M.S., Pierce, H.L., Miller, G.L. et al. (1998 Oct). Optimal method of urgent
decompression of the collecting system for obstruction and infection due to
ureteral calculi. J Urol. 160 (4): 1260–1264.
Turk, C., Petrik, A., Sarica, K. et al. (2016). EAU guidelines on diagnosis and
conservative management of urolithiasis. Eur. Urol. 69 (3): 468–474.
167
14
The Management of Recurrent Urinary

Tract Infections
Jordan Durrant
Urinary tract infections are a common issue in the urology outpatient clinic and
effective management is key in preventing future hospitalisation and inpatient
emergency admission. Unfortunately, it is not uncommon for the information
received in a referral for a patient with recurrent urinary tract infections (rUTI) to
be less than is required to make a full assessment of the patient. Therefore, history
taking is paramount in determining the exact cause of the patient’s complaints
and formulating a treatment strategy.
The majority of patients will be referred to your clinic with complaints of cystitis –
inflammation of the urothelium and bladder, presumed to be due to infection and
invasion of bacteria. It is this scenario that is discussed in this chapter.
History
In addition to a more generalised past medical history that makes note of condi-
tions that may contribute to rUTI (diabetes, menopause, immunosuppression,
etc.), it is important to take a full history of the patient’s complaints regarding
their cystitis symptoms. A note should be made of symptoms and signs that sup-
port the diagnosis of rUTI:
●● Recurrent episodes of frequency and urgency/irritative voiding symptoms
●● Associated supra-pubic discomfort/pain
●● Associated dysuria
●● Offensive and/or purulent urine
●● General malaise, fever, and associated systemic symptoms
●● A predictable and recognised trigger for an episode (intercourse, dehydra-
tion, etc.)
●● Positive/confirmatory mid-stream urine (MSU) culture results

●● Response to antibiotic therapy
In the absence of supporting evidence from the patient history, consideration

should be given to other possible diagnoses. For example, irritative voiding symp-
toms with recurrent bouts of visible haematuria and bacterial growth on MSU
may be a presentation of a bladder tumour (around half of bladder tumours are
colonised by bacteria). Alternatively, in the absence of positive microbiology,
bouts of irritative voiding symptoms with supra-pubic pain relieved by voiding is
indicative of Bladder Pain Syndrome.
Lastly, a brief history of any lower urinary tract symptoms (LUTS) at other
times should be sought.
If a true diagnosis of rUTI is suspected, potential risk factors should be identi-
fied as part of history taking (see below).
Definitions
Recurrent urinary tract infection is generally accepted to mean more than two
infections in a six-month period, or more than three episodes in a year.
Significant bacteriuria was originally defined by Kass as >105 cfu/ml. Most hos-
pital laboratories still adhere to this ‘cut-off.’ However, it is important to be aware
that in many patients with frequent proven infections some apparently ‘negative’
MSU samples (which indicate pyuria), may have growth of <105 cfu/ml and, in
fact, there may be meaningful bacteriuria. Indeed, the European Urology
Association now recognises >103 cfu/ml as significant.
Re-Infection is the development of a further infection several months after a
previous episode, whereas bacterial persistence can result in more frequent epi-
sodes of infection and is likely frequently underestimated as a cause for many
presentations of rUTI.
Risk Factors and Patient Discussion
A great deal of ‘common sense’ knowledge regarding potential risk factors for
development of rUTI is backed by good evidence. Certainly, no urologist would
argue that a male with a chronic urinary retention of 1 litre is at risk of infection,
but on a lesser scale there is no evidence to support the idea that a female with a
post-void residual of 150 ml is at any greater risk of developing infection than
a female with a 25 ml residual.
Personal Hygiene
Common advice to females regarding avoidance of bubble-baths and vaginal
douching and ensuring passage of urine after coitus have also not been proven to
lower the risk of UTI, even if the advice is logical.
Genetics
Some risk factors are not modifiable, but may be of interest to patients with
rUTI. There is compelling evidence of a genetic predisposition to rUTI in some
patients. A large case control study has shown that in women, having a mother
with rUTI was a risk factor for developing the condition. The P1 blood group phe-
notype also confers risk.
Fluid Intake
Inadequate fluid intake is associated with rUTI risk. It has been shown that peo-
ple who restrict their fluid intake during working hours for convenience have a
more than twofold increase in UTI risk as compared to controls.
Intercourse
The relationship between coitus and episodes of UTI is controversial. No reliable
link between intercourse and UTI is demonstrated in the literature. Some litera-
ture demonstrates a direct correlation, whereas other researchers have found no
association between intercourse frequency and positive urine cultures.
Anecdotally, this appears to be born out in the outpatient clinic, where some
women report no association, whilst others report a predictable association (dis-
cussed further later). There is compelling evidence, however, that intercourse
with condom or spermicide usage raises the risk of infection. No evidence exists
though to support the common advice for women to pass urine post-coitus, to
prevent UTI.
Menopause
Loss of oestrogens during menopause results in a rise in vaginal pH. Low pH
(below 4.5) virtually inhibits vaginal colonisation. Post-menopausal females with
rUTI can benefit from topical oestrogens because it lowers pH and bacterial colo-
nisation. Indeed, at lower pH levels, there is increased growth of lactobacillus,
which itself also serves to inhibit unwanted colonisation.
Biofilms and QIRs
In animal studies it has been demonstrated that uropathogenic Escherichia coli
forms intra-cellular niches within urothelial facet cells. These ‘quiescent intracel-
lular reservoirs’ (QIRs) persist following resolution of an infection and are highly
likely to play in role in relapsing infections. It should be born in mind that the
urothelium has a long ‘turnover time’ of approximately 200 days. This potentially
means that a facet cell containing bacteria may persist for six months.
In recent years, our understanding of the role of biofilms in rUTI has increased.
Biofilms are sessile bacterial communities attached to a substrate and each other,
embedded within extracellular polymeric substances that they have produced.
These organisms exhibit altered phenotypes and growth patterns that confer
increased resistance to their elimination.
Further Advice to the Patient

As discussed earlier, improving fluid intake appears to be a useful measure in
lowering the risk of rUTI episodes. Much is made of the advice to void after inter-
course, avoid bubble-baths and avoid certain underwear types, however, this
advice is not backed by evidence.
Cranberry juice and cranberry extract are often touted as a natural remedy for
rUTI. The usefulness of this intervention has been examined twice in Cochrane
reviews, and it was reported that cranberry usage has no statistically significant
effect of UTI frequency.
Another ‘natural’ remedy that appeals to patients is the use of probiotics. As
discussed earlier, lactobacilli cell walls have an inhibitory effect on coliform colo-
nisation. The use of both oral ingestion of lactobacilli preparations and vaginal
use of probiotics and lactobacilli was examined in a Cochrane review, there was
no strong evidence to support recommending it to patients.
Investigation
In the outpatient clinic, urine dipstick testing is an essential tool for routine inves-
tigation. If available, uroflowmetry and post-micturition residual volume meas-
urement may be indicated in patients who give a history suggestive of
associated LUTS.
Generally, further investigation will have a low diagnostic yield. However, renal
tract ultrasound may reveal anatomical abnormalities in a small proportion of
females with recurrent and difficult to treat infections.
A pattern of haematuria or persistent haematuria should raise concerns of
underlying bladder malignancy and be urgently investigated by cystoscopy.
The presence of proteus or repeated culture of other urea-splitting organisms

should prompt suspicion of nephrolithiasis.
Management Strategies
Recurrent urinary tract infection has the potential to be a distressing problem
for the patient and one that is difficult to manage for the clinician. A number of
evidence-based approaches to the issue exist.
Continuous Antimicrobials
Unsurprisingly, antibiotic usage is a highly effective way of managing the issue.
There is evidence across multiple studies that continuous low-dose prophylaxis
reduces the risk of a confirmed UTI by 80%. Multiple studies have shown this risk
reduction effect persisting for a period after discontinuation of antibiotics, giving
credence to the theory of biofilms in intracellular reservoirs.
From a practical viewpoint, a period of low-dose prophylaxis is likely to be one
of the first measures recommended for patients with difficult to treat rUTI. Choice
of antibiotic agent should be informed by evidence from MSU cultures and local
microbiology policies. Nitrofurantoin is likely the most evidenced antimicrobial,
but is not suitable for indefinite usage.
There is no strong evidence to make recommendations on length of low-dose
prophylaxis treatment. Many trials have been of 6-months duration, there is lim-
ited evidence that 12-month courses are associated with a longer period of risk-
reduction following discontinuation. The decision ultimately is at the clinician’s
discretion. However, modern understanding of QIRs and biofilms has seen a
trend towards longer, rather than shorter, periods of low-dose prophylaxis.
Self-Directed Prophylaxis
Numerous researchers have examined the effectiveness and ability of patients to
direct their own antibiotic usage. This is potentially a treatment strategy for less
severe of recurrent infections or suitable for management of infections following
cessation of continuous prophylaxis. Although contentious (see above), women
who report an association between intercourse and UTI experience a significant
reduction in UTI episodes when using self-directed antibiotics post-coitally.
Furthermore, it has been demonstrated that women reliably identify their own
bacteriuria based on symptoms alone, allowing self-directed treatment to be
appropriately instigated after the onset of symptoms.
D-Mannose
D-Mannose is widely available in health shops and may be of use in patients with
recurrent coliform cystitis. Ingested D-Mannose is excreted in urine and binds to
Type I Pili on uropathogenic E. coli, preventing subsequent adhesion to manno-
sylated residues on the bladder surface. In a small randomised controlled trial,
D-Mannose was found to significantly reduce risk of UTI episode and was compa-
rable to nitrofurantoin. In daily practice, most clinicians who advise D-Mannose
find it to be useful for some patients but not for others.
Methenamine Hippurate
This oral preparation has long been known to produce excretion of formaldehyde
in the urine, which can serve to sterilise the urine. Multiple small studies have
demonstrated its ability to reduce the incidence of infection, albeit less effectively
than nitrofurantoin. It is a key option for on-going prophylaxis for patients who
continue to suffer infections after initial treatment. A small proportion of patients
will experience gastrointestinal upset as a side effect.
Vaccines
A number of different vaccine preparations are commercially available for the
management of rUTI. These vaccines frequently come in the form of vaginal sup-
positories containing a mixture of heat-killed bacterial strains. Whilst their exact
mechanism of action remains unproven, it has been demonstrated that adminis-
tration of such vaccines increases levels of IgA and IgG at the introitus.
An oral preparation containing 18 heat-killed serotypes has been demonstrated
to reduce relative risk of UTI recurrence by almost 40%.
GAG Layer Treatments

The glycosaminoglycan (GAG) layer forms a mucous barrier over the superficial
facet cells in the bladder. Theoretically, deficiency or poor differentiation of this
layer allows bacteria to adhere more easily and penetrate facet cells and form
biofilms.
Existing treatments for replenishing and reinforcing the GAG layer have
been proposed as a management for rUTI. Multiple studies have shown that
sodium hyaluronate containing bladder instillations, when given in an induc-
tion and monthly maintenance schedule, reduce UTI rate by approximately
70–80%, Unfortunately, this is an expensive and time-consuming treatment
modality. However, the advent of preparations designed for self-administration
increase the scope for use of these treatments in the future.
Further Reading
Albert, X., Huertas, I., Inmaculado, P. et al. (2004). Antibiotics for preventing
recurrent urinary tract infection in non-pregnant women. Cochrane Database of
Systematic Reviews 3: CD001209.
Lee, B.S., Bhuta, T., Simpson, J.M. et al. (2012). Methenamine hippurate for
preventing urinary tract infections. Cochrane Database of Systematic Reviews
10: CD003265.
Mysorekar, I.U. and Hultgren, S.J. (2006). Mechanisms of uropathogenic Escherichia
Coli persistence and eradication from the urinary tract. Proceedings of the National
Academy of Sciences of the United States of America 103 (38): 14170–14175.
175
15
An Ambulatory Approach to Benign Prostatic

Obstruction
Tharani Mahesan
Perhaps the most common presentation to a urology clinic is the male patient
with lower urinary tract symptoms (LUTS). Patients may present to a general urol-
ogy clinic, via a ‘raised prostate specific antigen (PSA) clinic’ or as a result of a
failed trial without catheter (TWOC). Many urology units are now striving to offer
a merged ‘one‐stop’ clinic for all such conditions, and LUTS is a condition that
lends itself well to the ethos of ambulatory care. In a well‐organised service, it
should be possible to offer all necessary investigations and assessments in order to
reach a diagnosis and plan treatment for the male LUTS patient.
Lower urinary tract symptoms may be divided into storage and voiding symp-
toms. This differentiation is made on patient history and dictates appropriate
investigation. In patients with solely storage symptoms (urgency of urination, fre-
quency, and nocturia), diagnoses such as infection, overactive bladder (OAB) syn-
drome, or detrusor overactivity (DO) should be considered. Patients with voiding
symptoms (hesitancy, poor flow, intermittency, double voiding) and those with
mixed voiding and storage symptoms are more likely to have bladder outflow
obstruction as the underlying cause.
Bladder outflow obstruction must be considered in men presenting with uri-
nary tract infection, orchitis, acute urinary retention, bladder stones, and also
those with high post‐void residual volumes in the bladder and indications of
chronic urinary retention.
Bladder outflow obstruction is, to a degree, considered synonymous with benign
prostatic obstruction (BPO) and benign prostatic hyperplasia (BPH). Indeed, 50%
of men have BPH by the age of 60. However, other causes of obstruction are not
infrequent and should be excluded. Other diagnoses to consider should include
urethral stricture disease, bladder neck stenosis, detrusor failure, and obstruction
due to prostate cancer or urothelial cancer.
Table 15.1 Distinguishing between differential diagnoses.
Alternative diagnosis to
BPO as a cause of LUTS Investigations
Bladder neck stenosis Should be considered in men who have undergone

previous transurethral resection of the prostate
(TURP) or radical prostatectomy.
Can be diagnosed on flexible cystoscopy.
Urethral stricture Very poor Qmax
Classic appearance of flat flow rate on uroflowmetry
Should be considered in men with previous history
of stricture, radiotherapy or trauma but can be
present without.
Can be diagnosed on flexible cystoscopy.
Prostate cancer Should be considered as a potential diagnosis in all
men >50 years of age.
Digital rectal exam (DRE) may demonstrate nodules,
asymmetry or a firm prostate.
Raised PSA (>3.5 ng/ml).
Check for family history.
Investigate further with magnetic resonance imaging
(MRI) and consideration of biopsy.
‘Bladder failure’ aka Should be considered in men re‐presenting after
detrusor underactivity prior bladder outlet obstruction (BOO) surgery.
(DU) Urodynamic testing will demonstrate low voiding
pressure, intermittent flow and incomplete bladder
emptying. A calculated Bladder Contractility Index
<100 is considered diagnostic.
Several tools can be utilised in distinguishing between these aetiologies, and the
findings of such investigations are summarised in Table 15.1.
Further Assessment and Investigations
History
Crucial in any urology clinic is the history from the patient. It is important to
establish the nature, duration, and bother of his LUTS. One should attempt to
elicit which aspect of his LUTS he finds most bothersome, although other tools
will also help to elucidate that.
Table 15.2 Urine dipstick testing interpretation.
Outcome of urine
dipstick analysis Action
Blood Microscopic haematuria can indicate the presence of a

urothelial cancer.
Patients with this require investigation with a flexible
cystoscopy and upper tract imaging. Urine cytology can also be
offered.
Glucose This may indicate a diagnosis of diabetes mellitus and
predispose to symptoms such as frequency and nocturia. The
patient’s regular doctor may need to investigate this further
prior to urological intervention.
Leucocytes If this finding is associated with symptoms of dysuria and
+/− nitrite irritative LUTS may be associated urinary tract infection. In
such instances a mid‐stream urine sample should be sent for
culture and antibiotics commenced.
The patient’s regular doctor may have commenced medications and it is

important to establish what those are. Enquire about past medical history as well
as associated medications because several widely used medications are known to
have urological consequences despite being prescribed for non‐urological
problems (e.g., alpha‐blocker medication maybe prescribed for blood pressure
control and amitriptyline is associated with urinary retention).
It must be established whether any previous urological surgery has been under-
taken and consideration should be given to prostate cancer if there is a significant
family history. It is important to identify any ‘red‐flag’ symptoms such as visible
haematuria, weight loss, or anorexia.
Basic investigations should include urine dipstick testing (see Table 15.2),
serum PSA, and urea and electrolytes testing to assess renal function.
Perhaps most important is to elicit the patient’s expectations around the
referral. Many are concerned about the risk of prostate cancer and steps
should be taken to prove the absence of such disease in order to offer
reassurance.
Urine Dipstick Testing

A urine dip is a non‐invasive, easily available bedside test that can be used to iden-
tify other causes of LUTS.
Prostate Examination and PSA

An irregular prostate on digital rectal exam (DRE) may be an indication of pros-
tate cancer and requires prompt investigation with a PSA and MRI in order to
exclude a diagnosis of prostate cancer. A prostate exam also provides clinicians
with an idea of prostate size. This can be useful later in determining choice of
surgical intervention.
Clinicians should remember that PSA can be artificially elevated in chronic
retention and urinary tract infection. Invasive investigations such as flexible cys-
toscopy can produce appreciable but transient PSA elevations for up to six weeks
afterwards.
Uroflowmetry
Uroflowmetry allows the clinician a non‐invasive assessment or urinary flow
dynamics. Key data include voided volume, maximum flow speed (Qmax), and
voiding time. An ultrasound is routinely performed after a flow test to establish
the volume of urine remaining in the bladder, also known as a post‐void resid-
ual (PVR).
Modern urology units most commonly employ pressure transducers (electronic
weight scales) to measure the volume of urine voided by the patient and to calcu-
late the speed at which that weight change has occurred. This rate of change is
represented on a ‘flow chart’ diagram. Flow speed (ml/s) is plotted on the x‐axis,
with voiding time on the y‐axis. A normal flow pattern will appear as bell‐curve,
skewed slightly along the y‐axis. The maximum peak (Q‐Max) of the curve should
reach around 25 ml/s.
Results should be interpreted with caution as flow rates do not necessarily dif-
ferentiate between causes of obstructions and the risk of artefact secondary to a
wandering flow is high. (See Table 15.3.) Uroflowmetry where the voided flow is
less than 150 ml is not considered diagnostically useful.
Urodynamic Studies
Urodynamic studies are employed in the assessment of suspected BPO to confirm
or refute the presence of obstruction. It should be considered in men with equivo-
cal flow rates, those who are young and wishing to avoid inappropriate surgical
intervention or very elderly patients for whom surgery poses increased risk.
Patients with a potential neurogenic component to their symptoms (e.g., CVA or
Parkinson’s disease) and patient’s representing with refractory symptoms follow-
ing surgery should also be strongly considered for investigation.
Modern Urodynamics equipment offers automated calculation of the likelihood
of obstructed flow using the Abrams Griffiths nomogram or an equivalent. Close
Table 15.3 Interpretation of uroflowmetry results.
Flow rate finding Suggested Diagnosis
Flat flow rate with long voiding time and poor Qmax Stricture
Flow rate rises quickly to Qmax and is then maintained Normal
Poor flow rate, with slow rise to peak, failure to Obstructed
maintain and intermittency
Qmax <10 ml/s Likelihood of
obstruction is 90%
Qmax 10–14 ml/s Likelihood of
obstruction is 67%
Qmax >15 ml/s Likelihood of
obstruction is 30%
scrutiny of results (i.e. the Pdet Qmax) is still required to ensure that the computer
software has correctly identified the voiding phase of the study and has based the
calculation on detrusor pressures during this period.
Flexible Cystoscopy
Discussed further in Chapter 18, Urothelial Bladder Cancer, a flexible cystoscopy
can provide further evaluation of the lower urinary tract. It can be used to quickly
confirm the presence of urethral stricture disease and to assess prostate shape and
anatomy (which may impact choice of surgical intervention). It can also identify
features of high filling pressure within the bladder, such as diverticulae and tra-
beculation. Cystoscopy cannot identify obstruction, but the finding of a large or
occlusive prostate may lead one to suspect it.
Ultrasound and Post Void Residual Volume Measurement

In an ambulatory urology service, an ultrasound scanner (with a moderate degree
of training) can be used to add vital detail to the assessment of a patient with
benign prostate obstruction (BPO).
Ultrasound allows the clinician to make rapid assessments of urine volume
within the bladder and prostate volume and size (more accurately if a trans‐rectal
probe is used) and with training; hydronephrosis and upper urinary tract dilata-
tion may be identified in patients with high pressure chronic retention – indicat-
ing a potential need for inpatient admission following catheterisation.
Post‐void residual volume measurements of up to 300 ml are generally consid-
ered acceptable, if high. Residual volumes in the range of 150–300 mls may imply
an element of BPO. Post‐void residuals over 300 ml are indicative of chronic

urinary retention. More than 1000 ml within the bladder is considered a potential
indicator of high‐pressure retention (whether an ‘acute on chronic’ retention or
simply chronic). These patients are at risk of developing a post‐obstructive diure-
sis following catheterisation and should be considered for inpatient admission
and observation, especially when renal function is deranged.
International Prostate Symptom Score

The International Prostate Symptom Score (IPSS) is a short, validated patient
questionnaire that allows rapid assessment of patient symptoms, using a seven‐
question scoring system. Scores range between 0 and 35. An eighth, separate ques-
tion relates to the impact of these symptoms on the patient’s quality of life. Scores
of 0–7 correlate with mild symptoms and scores of 20–35 indicate severe
symptoms.
An IPSS is useful in guiding treatment decisions (lifestyle advice alone is
unlikely to prove useful with an IPSS of 25), establishing the extent of bother, and
assisting with the process of differentiating between storage and voiding
symptoms.
Medical Management
All discussions of management should begin with appropriate lifestyle modifica-

tion advice. Common guidance includes avoiding fluids before bedtime for those
with nocturia, and avoiding caffeine for those with irritative storage symptoms.
First line medication for patients with bladder outflow obstruction secondary to
benign prostatic hyperplasia (BPH) should be an α‐blocker medication, such as
Tamsulosin. This selective α1‐receptor antagonist relaxes smooth muscle in the
bladder neck and prostate to reduce bladder outflow resistance. Patients should be
cautioned on the risk of postural hypotension as well as the likelihood of retro-
grade ejaculation and floppy iris syndrome. Tamsulosin can take up to 3 days to
take effect and 14 days for maximum effect.
In severely symptomatic cases of BPO or cases refractory to α‐blocker treat-
ment, a 5 α‐reductase inhibitor such Finasteride or Dutasteride can be offered in
combination with Tamsulosin. These medications limit the bio‐active testoster-
one that drives prostatic hypertrophy. Trials such as medical therapy of prostatic
symptoms (MTOPS) and combination of Avodart (dutasteride) and Tamsulosin
(combAT) have consistently demonstrated the superior benefit of dual‐agent ther-
apy over single therapy, either in terms of reduction in progression of symptoms
or reduction of symptoms.
Patients who cannot tolerate Tamsulosin can be prescribed Finasteride alone.

Finasteride can take up to six months for significant improvements to become
apparent and is associated with side effects including sexual dysfunction such as
impotence, loss of libido, and erectile dysfunction in around 5% of patients.
Surgical Management
For men in whom medical management is inadequate, unsuccessful, or in those

who find medication to be undesirable or intolerable, surgical management may
be appropriate.
With appropriate patient selection, ambulatory surgery can be achieved for sev-
eral surgical techniques. Patients identified as appropriate for day‐case surgery
must have good functional status confirmed at pre‐operative assessment and an
appropriate home situation upon discharge.
For procedures requiring a post‐operative catheter (e.g., Rezūm, TURP, or hol-
mium laser enucleation of prostate [HoLEP]), careful planning of catheter man-
agement is required. Patients require adequate training in catheter care and
require access to medical support in case of difficulties and arrangements for
removal.
Choice of anaesthetic plays an important role in the ability of a surgeon to offer
a day case operation. With so many of our patients being elderly, the use of local
or spinal anaesthesia reduces the risk of cognitive impairment, which can be
problematic for this population after a general anaesthetic.
Transurethral Resection of Prostate (TURP)

Perhaps the most widely known prostate operation and historically the gold
standard, a transurethral resection of prostate (TURP) involves the removal of
benign adenoma in order to create a good urethral channel. A TURP may be per-
formed either using a monopolar loop with glycine containing solution as the
irrigant, or using a bipolar loop with saline as the irrigant (also known as transure-
thral resection on saline [TURIS]). A three‐way catheter is placed post‐operatively
for irrigation and control of haematuria.
Traditionally, surgeons were concerned about the risk of TURP syndrome,
a triad of hyponatremia, hypervolemia, and hyperammonaemia. This occurred as
a consequence of the absorption of glycine resulting in diluted serum sodium lev-
els, increased serum fluid levels, and the metabolism of glycine into ammonia
causing encephalopathy. The advent of TURIS has almost eliminated this risk, and
now, with careful post‐operative irrigation and good out‐of hospital access to post‐
operative advice, many centres successfully offer an ambulatory TURIS service.
Risks that should be highlighted to the patient are the risk of infection (1%), risk
of blood transfusion (1%), incontinence (1%), retrograde ejaculation (60–70%),
erectile dysfunction (10%). In selected patients it should be highlighted that if
there is underlying detrusor failure, the procedure may not be ‘successful’ and, in
general, for those with storage symptoms, one‐third of patients will continue to
experience some element of storage symptoms despite a ‘successful’ operation.
Urolift
For patients in whom sexual function is important, this minimally invasive proce-
dure offers an improvement in voiding LUTS, with preservation of sexual function.
Initially offered only to men with occlusive lateral lobes but no median lobe, an
increasing number of studies have now shown good efficacy even in those with sig-
nificant median lobes. Surgeons place implants to lift the enlarged prostatic tissue
away from the urethra. Implants are placed in pairs, one on each lobe. The numbers
of implants used directly correlated to the size and occlusive nature of the prostate.
There is persuasive 5‐ and 10‐year data demonstrating sustained benefits, although
it is widely acknowledged that many patients will require re‐do surgery and that
benefits seen are not as significant as with the more traditional surgeries such as
TURP. Urolift is not always suitable for men with very large (>100 cc) prostates.
Rezūm
Rezūm uses radio‐frequency energy to heat water, producing water vapour/steam.
This water vapour is delivered into the tissue using a needle. Upon contact with
the tissue the steam cools and condenses, and in doing so releases energy that
damages the cell membranes, initiating cell necrosis.
The Rezūm convective water vapour treatment is also considered ‘minimally
invasive’ and, although it is a newer technology, it is now starting to be performed
under local anaesthesia.
Outcomes in terms of flow improvement and symptom improvement are com-
parable with trans‐urethral resection, whilst impact on sexual function is highly
unlikely; retrograde ejaculation risk is in the order of 2% and the risk of erectile
dysfunction is less than 1%.
The procedure has the advantage of actually eliminating unwanted tissue and
not requiring implantation of a foreign body. One downside is that the majority of
patients require a two‐way catheter for around four days post‐operatively, but this
is normally well tolerated with proper education.
Rezūm is already safely used in prostate volumes of up to 120 cc in some centres
and is likely to become the treatment of choice for mild and moderate BPH in the
future due to its ambulatory nature.
Laser Procedures: Holmium Laser Enucleation of Prostate (HoLEP)

Holmium Laser Enucleation of the Prostate is now considered the gold‐standard
surgical management for very large prostate glands (>120 cc). An anatomical
enucleation of the tissues of the transitional zone is achieved with a combination
of blunt dissection using the resectoscope and laser energy to encourage tissue
separation and cauterise vessels. Risks are comparable with TURP, albeit with
slightly lower rates of erectile dysfunction (likely owing to the lack of conducted
electricity).
During HoLEP the enucleated prostatic adenoma is pushed into the bladder
where it is morcellated using a nephroscope via the outer resectoscope sheath for
vision. Morcellation should be performed carefully so as to not injure the bladder.
Photo vaporisation of the prostate (PVP), also known as potassium titanyl
phosphate (KTP) laser vaporisation, uses a YAG laser shone through a potas-
sium titanyl phosphate crystal to produce green light. This is preferentially
taken up by haemoglobin and used to vaporise prostatic tissue. Surgeons per-
forming high numbers of these procedures typically achieve excellent results,
but the procedure has seen a decline in popularity amongst some surgeons
in the last decade. PVP has been shown to be safe in patients taking anti‐
coagulation and anti‐platelet medications, offering a clear superiority over
some other techniques.
Both procedures can be performed under either general or spinal anaesthetic.
Providing men are happy to be discharged with a catheter, this operation is ame-
nable to a day case or a ‘23‐hour’ stay.
Other
The preceding list is by no means exhaustive. Open trans‐vesical prostate enuclea-
tion is now largely regarded as a historic procedure, but newer technologies such
as aquablation are garnering interest and could find a place in BPO surgical rep-
ertoire in the future. For the urologist looking to maximise the proportion of care
delivered as ambulatory, the ‘minimally invasive’ techniques detailed earlier are
the best means to achieve this.
Choice of Surgery
The choice of surgery will undoubtedly be dependent on the availability in your
hospital. Patients should be encouraged to pursue day‐case options where suita-
ble. Factors influencing decision‐making will include whether the patient is cath-
eterised, indication for surgery (patients with refractory haematuria will require
TURP or HoLEP), size of prostate, IPSS score, and patient choice.
Further Reading
Barry, M.J., Fowkler, F.J., O’Leary, M.P. et al. (1992). The American urological
association symptom index for benign prostatic hyperplasia. J. Urol. 148:
1549–1557.
Cynk, M. (2014). Holmium laser enucleation of the prostate: a review of the clinical
trial evidence. Ther. Adv. Urol. 6 (2): 62–73.
McVary, K.T. and Roehrborn, C.G. (2018). Three‐year outcomes of the prospective
randomized control Rezūm system study. Urology 111: 1–9.
Roehrborn, C.G., Siami, P., Barkin, J. et al. (2010). The effects of combination therapy
with dutasteride and tamsulosin on clinical outcomes in men with symptomatic
benign prostatic hyperplasia: 4‐year results from the CombAT study. Eur. Urol.
51 (1): 123–131.
185
16
Urethral Catheters and Ambulatory Management

of Urinary Retention
Ashiv Patel
The management of urinary retention is one of importance, particularly as most

patients presenting with urinary retention can be managed using an ‘ambula-
tory’ model.
Urinary retention occurs most frequently in men over the age of 60, with this
risk increasing with age. Males are 13 times more likely to be affected by acute
urinary retention (AUR) than women. Over a five-year period, 10% of men over 70
will develop AUR whilst 30% of men over 80 will be affected.
An ambulatory approach will result in a reduced financial burden, better utili-
sation of inpatient beds and an improvement in patient-based outcomes through
a reduction in admissions.
Risk Factors
Aside from advancing age, the presence of lower urinary tract symptoms (LUTS),
larger prostate volume and previous spontaneous retention are all considered risk
factors for urinary retention in men.
Definition of Acute Urinary Retention

Acute urinary retention (AUR) is defined as a painful inability to pass urine, fol-
lowed by relief on draining the bladder through utilising a catheter. It is normally
associated with >500 ml of urine being drained.
AUR can be classified as either being spontaneous or precipitated by an event.
If the precipitating cause (e.g., infection) is treated, the retention usually resolves;
however, spontaneous retention usually requires more definitive management.
Definition of Chronic Urinary Retention
Defined as a non-painful bladder that is still palpable after voiding and post-void
residual volumes in excess of 300 ml being present within the bladder.
Definition of Acute-on-Chronic Retention
Defined as a painful inability to pass urine, followed by relief on draining the

bladder through utilising a catheter. It is normally associated with bladder
volumes far in excess of 500 ml, typically 1000 ml or more.
Causes of Urinary Retention
Prostatic Enlargement
Both benign and malignant prostatic enlargement can cause urinary retention.
These patients commonly present with lower urinary tract symptoms (LUTS);
however, they may present more acutely with urinary retention.
Urethral Strictures
Due to a narrowing of the urethra, an outflow obstruction can occur secondary to
a stricture that results in urinary retention.
Constipation
Faecal constipation can cause urinary retention by obstructing the urethra.
Infection
Infection or inflammation of the bladder, urethra, or prostate can cause obstruc-
tion of the urethra and lead to urinary retention.
Haematuria leading to Clot Retention

Urinary retention is precipitated by the obstruction of the urethra by clots formed
secondary to haematuria. Any amount of macroscopic haematuria can result in
clot retention; however, the subset of patients at greatest risk are those without
sufficient bladder irrigation post-operatively.
16 Urethral Catheters and Ambulatory Management of Urinary Retention 187
Drugs
Drugs can be a precipitating cause of urinary retention. Drugs that commonly
cause urinary retention include anaesthetics, anticholinergics, and sympathomi-
metic agents.
Pain
Abdominal pain and associated pelvic floor contraction can make it difficult for
patients to pass urine, and adequate analgesic control is important in order to
allow the patient to pass urine.
Post-operative Retention
There are a number of risk factors for urinary retention post-operatively. These
include surgery involving the anorectum or perineum, bladder over-distension,
instrumentation of the lower urinary tract, the use of epidural anaesthesia, and
immobility in the post-operative period.
Pelvic Fracture and Urethral Injury

Pelvic fracture and urethral injury will cause urinary retention because the urine
is unable to pass down a disrupted urethra.
Neurological Conditions (Parkinson’s Disease, Multiple Sclerosis,

Fowler’s Syndrome)
Conditions that cause central nervous system disfunction can cause detrusor areflexia
or detrusor sphincter dyssynergia. Fowler’s syndrome is thought to cause impaired
relaxation of the external urethral sphincter and can also cause urinary retention.
Cauda Equina
Cauda equina compression can be caused by a prolapsed lumbar disc, trauma, and
benign or malignant masses. Compression or damage to the S2–S4 nerve roots can
result in areflexia of the detrusor muscles and ultimately urinary retention.
Prolapse in Women
Women with cystoceles can suffer from urinary retention if the cystocele obstructs
or creates a kink in the urethra. A vaginal support pessary provides a simple
solution to correct anatomical position and relieve the issue.
Pelvic Masses
Pelvic masses can cause obstruction of the urethra and result in outflow obstruc-
tion and urinary retention.
Post-surgery for Stress Incontinence

Injury to the pelvic plexus can cause loss of motor innervation of the detrusor
muscle and ultimately urinary retention.
Post-obstructive Diuresis
Defined as a condition of increased urine production of >200 ml for two consecu-

tive hours following relief of retention or a total of 3000 ml over 24 hours.
Post-obstructive diuresis is a possibility when over 1000 ml is drained from the
bladder using a catheter. This is a result of solute and fluid accumulation occur-
ring due to prolonged renal obstruction, leading to a diuresis and polyuria through
multiple mechanisms.
Post-obstructive diuresis will normally cease once homeostasis is achieved, but
can become pathological and may cause electrolyte abnormalities, hypotension,
dehydration leading to hypovolaemic shock and even death. Typical supportive
management includes replacing 50% of the urine output by volume with intrave-
nous fluids, but if the patient can freely drink according to their thirst, this can be
a more physiologically accurate way of achieving the correct rate of fluid replace-
ment in less severe diuresis.
Clinical Assessment of a Patient with Urinary Retention
Taking a full history and examination are central to the initial management of a
patient with urinary retention. The most important factors to identify when
taking a history from the patient include:
●● Symptoms of prostatic enlargement: Frequency, urgency, nocturia, hesitancy,
poor stream, intermittent flow, terminal dribbling.
●● Symptoms of infection: Frequency, urgency, dysuria, visible haematuria.
●● Constipation.
●● Presence of visible clots and haematuria.
●● Recent operative procedures, particularly those involving epidural and spinal
anaesthesia.
●● Symptoms of neurological conditions: Lower limb weakness, saddle anaesthe-

sia, paraesthesia, faecal incontinence.
●● Medications history: Anticholinergics, opiates, anti-histamines, tricyclic
antidepressants.
Important factors when examining a patient with urinary retention are examina-
tion of the abdomen for a palpable bladder and performing a digital rectal exam in
order to ascertain whether prostatic enlargement is a contributing factor in men.
It is paramount to make sure that the drained volume and fluid balance is
clearly documented for any patient with urinary retention, particularly in those
patients who drain more than 1000 ml of urine when a catheter is inserted. The
patient’s urine should also be tested using urine dip and sent for culture if
positive.
Blood tests to monitor the patient’s urea and electrolytes is also of key impor-
tance in order to correct any subsequent electrolyte abnormalities, before they
become life threatening.
Catheter Insertion
Types of Urethral Catheters

Indwelling urethral catheters are composed of a semi-rigid tube that blocks the
urethra but drains the bladder, they involve multiple lumens, with one controlled
by an external valve that allows for the inflation of a balloon to maintain the cath-
eters position in the bladder. Indwelling catheters can be broadly divided into two
types; two-way catheters and three-way catheters. Two-way catheters are used for
all types of urinary retention; three-way catheters are reserved for patients who
require irrigation of their bladders either after suffering from clot retention sec-
ondary to haematuria or post-operatively.
Indwelling catheters come in a range of sizes and are described by the term
‘French’. This relates to the catheters external circumference and was devised by
the Parisian manufacturer of surgical instruments, Joseph-Frédéric-Benoît
Charrière. Therefore, both two-way and three-way catheters will have the same
external diameter if they have the same ‘French’ size. However, the three-way
catheter will have the smaller drainage lumen, given the space occupied by the
irrigation lumen.
Both two-way and three-way catheters have a further sub-type, which comes
with a curved tip called either a Coudé tip or Tiemann tip catheter. This curved tip
helps the catheter navigate any areas of constriction particularly constriction
caused by an enlarged prostate in men.
Catheter Insertion Technique

Verbal consent is imperative to obtain from the patient, and this involves
explaining the need for a catheter as well as what a catheter insertion will
involve. The smallest sized catheter that will provide adequate drainage should
be used.
The technique utilised is aseptic. Sterile water or saline should be used to pre-
pare the skin around the urethral meatus. Lubricant jelly should then be applied
to the urethra and this typically contains local anaesthetic. The catheter should be
inserted until the flow of urine confirms it is situated in the bladder. The catheter
balloon can then be inflated; however, care must be taken not to inflate the bal-
loon whilst it is intra-urethral because this may cause damage to the patient’s
urethra and even urethral rupture.
The absence of urinary flow from the catheter indicates either the catheter is
not in the bladder or that the diagnosis of urinary retention is incorrect.
In men, a curved-tip catheter can be used in order to facilitate entry of the cath-
eter into the bladder. However, if the catheter will not pass into the bladder and it
is certain that the patient is in urinary retention, then a flexible cystoscopy guided
catheter insertion or supra-pubic catheter insertion is the next step in manage-
ment. In extremis, a supra-pubic needle aspiration of urine can be used to drain
enough urine to improve the patient’s comfort whilst arrangements are put in
place for a more definitive solution.
Flexible Cystoscopy Guided Catheter Insertion

If a flexible cystoscope is available, this should be the first choice when faced
with a difficult catheterisation where a catheter cannot be placed into the
bladder.
The flexible cystoscope can be used to enter the bladder under vision and site a
guide-wire into the bladder. A catheter (an open Council-tip catheter for example)
can then be ‘rail-roaded’ over the guide wire to achieve drainage.
Suprapubic Catheter Insertion

There are several things to consider before attempting supra-pubic catheterisa-
tion. Whether the patient may have bladder cancer and the risk of spread through
the created tract, previous abdominal surgery that may have caused adhesions,
pelvic fractures, and the presence of a pelvic haematoma, anticoagulation, vascu-
lar graft in situ in the pelvic region.
Antibiotic prophylaxis is recommended if there is a concurrent urine infection.

Abdominal examination to check for a distended bladder and a BAUS (British
Association of Urological Surgeons) recommended ultrasound to identify any
interposing bowel in the planned tract. Commence with aspiration of urine using
a 21G needle, 2 cm superior to the pubic symphysis.
The suprapubic trocar should then be placed 2 cm above the pubic symphysis
and inserted following infiltration of local anaesthetic in the same direction that
urine was aspirated.
Patients with Urinary Retention requiring Admission

Patients with chronic or acute-on-chronic urinary retention must be considered
for admission to monitor their urine output for post obstructive diuresis and blood
tests the following day to assess for any electrolyte abnormalities.
Any patient with a difficult catheterisation requiring the use of flexible cystos-
copy guidance or the insertion of a suprapubic catheter should be admitted to
hospital for monitoring and a decision on definitive treatment.
Ambulatory Urology and Urinary Retention

Patients with a simple ambulatory urinary retention (AUR) (500–800 ml drained
volume) will usually be manageable in an ambulatory fashion. Once the precipi-
tating cause is identified and reversed following the insertion of a catheter, the
patient can be safely discharged if there are no abnormalities on blood tests and
they are not in diuresis. They can be seen in urology outpatients or in a trial-
without-catheter clinic in order to further assess their needs and the next steps in
their management.
The ‘outpatient’ catheter service requires careful planning in order to be able
to prevent the need for the patient to re-attend prior to the planned catheter
removal and avoid unnecessary stress and anxiety for the patient. This involves
adequate explanation and education of catheter care prior to discharge and the
means for the patient to have a point-of-contact within the department in case
of difficulties or need for supplies. Catheter removal should be timed for a point
that minimises indwelling catheter time (thus reducing risk of infection) whilst
allowing sufficient time for recovery to optimise chances of successful voiding.
For the majority of male AUR, two weeks is considered the standard catheter
indwelling time. Medication such as tamsulosin (further discussed in the pros-
tatic obstruction chapter) can lower bladder outlet resistance and maximise
chances of success.
Further Reading
Fisher, E., Subramonian, K., Omar, M.I. et al. (2014). The role of alpha blockers prior
to removal of urethral catheter for acute urinary retention in men. Cochrane
Database Syst. Rev. 6: Cd006744.
Gonzalez, C.M. (2004). Pathophysiology, diagnosis, and treatment of the post
obstructive diuresis. In: Management of Benign Prostatic Hypertrophy (ed.
M.V. KT), 35–45. New York: Humana Press.
Gravas S., Cornu JN., Gacci M. et al. (2019). EAU Guidelines on the management of
non-neurogenic male lower urinary tract symptoms. European Association of
Urology. http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts.
Harrison, S.C.W., Lawrence, W.T., Morley, R. et al. (2010). British Association of
Urological Surgeons’ suprapubic catheter practice guidelines. BJU Int.
107 (1): 77–85.
193
17
Paediatric Urology
Tharani Nitkunan and Sylvia Yan
Much like adult urology, a focused history and examination should be taken
from the child and parents/caregiver to aid diagnosis and management in pae-
diatric urology. In this section, we will aim to discuss clinical investigations and
management of paediatric urological conditions commonly seen in the clinic
setting.
Recurrent Urinary Tract Infections
Urinary tract infections (UTIs) are the most common bacterial infection in the
paediatric population. The incidence is initially higher in boys, affecting up to
20.3% of uncircumcised boys and 5% of girls at the age of 1. There is a gradual
shift, with UTIs affecting 3% of prepubertal girls and 1% of prepubertal boys.
The National Institute for Health and Care Excellence (NICE) have defined a
recurrent UTI as two or more episodes of pyelonephritis, or one episode of pye-
lonephritis plus one or more episodes of cystitis, or three or more episodes of
cystitis.
Diagnostic investigations include urinalysis, which may require suprapubic
bladder aspiration or bladder catheterisation in infants. A urine culture and
microscopy should be carried out if there is evidence of infection. The role of fur-
ther imaging is to differentiate between an uncomplicated and complicated UTI,
but should also be considered in those with haematuria. A UTI is complicated in
the presence of an abnormal urinary tract including upper tract dilatation,
atrophic or duplex kidneys, ureterocoele, posterior urethral valves, intestinal con-
nections, and vesico-ureteric reflux (VUR). NICE guidelines recommend an
urgent ultrasound of the urinary tract for all those with recurrent UTI under six
months. For children six months and older, NICE in the UK recommends an
ultrasound within six weeks of the latest infective episode. All children with
recurrent UTIs should be referred to a paediatric specialist and have a dimercapto-
succinic acid (DMSA) scan within four to six months of an acute infection to
evaluate for renal scarring. European Association of Urology (EAU) guidelines
recommend a renal tract ultrasound in febrile UTIs if there is no clinical
improvement, as an abnormal result is seen in 15% of these patients.
Antimicrobial treatment for each episode should be guided by the local antimi-
crobial guidelines to avoid contributing to resistance. In principle, antibiotic
prophylaxis should not be prescribed following a first episode of UTI. In those
with recurrent UTIs, trimethoprim and nitrofurantoin are the recommended first
line antibiotics by NICE. If unsuitable or second line treatment is needed,
cephalexin and amoxicillin should be considered. This should be reviewed on a
regular basis and behavioural, personal hygiene measures and self-care treat-
ments should always be discussed prior to antibiotic prophylaxis.
Reflux
Vesico-ureteric reflux is a common cause of complicated UTIs and is seen in up to

50% of children presenting with UTIs. The incidence is higher in boys (29%) com-
pared to girls (14%) and they also tend to have higher grades of VUR. Although it
can be asymptomatic, VUR is seen in 16.2% of those found to have hydronephrosis
in-utero. There is a hereditary risk, in those with parents with VUR having an
incidence of 35.7%, and a 22% sibling risk.
Basic investigations should include a detailed history to establish risk factors,
clinical examination with blood pressure assessment, urinalysis to evaluate for
proteinuria, urine culture, and serum creatinine, if indicated. Imaging such as an
ultrasound of kidneys and bladder will evaluate for evidence of hydronephrosis.
Diagnosis of VUR is made on voiding cystourethrography (VCUG), which also
allows assessment of the grade of reflux (Table 17.1) and bladder and urethral
configuration. A DMSA nuclear medicine scan can be considered at baseline to
detect any renal scarring and as a comparison for subsequent future imaging. In
concurrence, lower urinary tract assessment is essential; it is known that treating
lower urinary tract dysfunction (LUTD) can aid resolution of VUR.
For infants presenting with hydronephrosis diagnosed on antenatal scanning,
ultrasound of the urinary tract is the recommended imaging modality to
commence with. This is usually done after the first week of birth, as there is a
period of oliguria in the neonate. Two normal successive post-natal ultrasound
examinations within two months of life is reassuring, indicating that if there is
any VUR, it is likely to be of low grade. If ultrasound reveals any cortical
abnormality or signs of LUTD, then a VCUG would be recommended for further
evaluation.
Table 17.1 Grading system for VUR on VCUG, according to the International Reflux Study
Committee.
Grade I Reflux does not reach the renal pelvis; varying degrees of ureteric
dilatation
Grade II Reflux reaches the renal pelvis; no dilatation of the collecting
system; normal fornices
Grade III Mild to moderate dilatation of the ureter, with or without kinking;
moderated dilatation of the collecting system; normal or minimally
deformed fornices
Grade IV Moderate dilatation of the ureter with or without kinking; moderate
dilatation of the collecting system; blunt fornices, but impressions of
the papillae still visible
Grade V Gross dilatation and kinking of the ureter, marked dilatation of the
collecting system; papillary impressions not visible,
intraparenchymal reflux
Source: Adapted from Tekgül et al. (2012).
Table 17.2 Percentage of patients found to have spontaneous resolution of VUR

in accordance to grade of VUR.
% spontaneous resolution with 4–5 years of follow-up
Grade I – II 80%

Grade III – V 30–50%
Source: Modified from Tekgül et al. (2012).
Treatment for VUR is dependent on the grade of reflux and symptoms such as
febrile UTIs. Parameters that are favourable for spontaneous resolution include
age of less than one year at time of presentation, male gender, grade I–III reflux,
and asymptomatic presentation. In those with unilateral grade I–II reflux, patient
and parents can be reassured there is up to 80% likelihood that there will be com-
plete resolution of VUR by five years (Table 17.2). As previously suggested, treat-
ment for LUTD, such as a circumcision in those with VUR and UTI is recommended
because it may lead to resolution of VUR.
Regular follow up with imaging and symptom review is the mainstay of con-
servative treatment. There is no current guideline on frequency of imaging, but
EAU guidelines recommend biannual ultrasound scans of the renal tract with
annual cystography and DMSA scans. In patients with a history of UTI or recur-
rent UTI and high grade of reflux, antibiotic prophylaxis should be administered.
Amoxicillin and trimethoprim are recommended for those less than two months
and trimethoprim-sulfamethoxazole or nitrofurantoin can be used in older infants.
Although there is no clear evidence regarding the suitable duration of prophylaxis,

some trials suggest a renal protective effect in those with VUR having prophylaxis.
Failing conservative treatment, surgical options include endoscopic sub ure-
teral bulking injections and ureteric reimplantation. Bulking agents can be
injected submucosally inferior to the intramural portion of the ureter to increase
coaptation. This success rates are in the range of 78.5%, 72%, 63,% and 52% for
grades I, II, III, and IV reflux, respectively. Various techniques have been described
for paediatric ureteric reimplantation, with laparoscopic approaches being
adopted in some centres. They have all been reported to have excellent success
rates between 92 and 98%.
Undescended Testes
Cryptorchidism, or undescended testes (UDT), affects up to 4.6% of full-term male

infants and they remain undescended in 1% of boys by age 1. The classification for
UDT is mainly categorised into palpable and non-palpable testes (Table 17.3).
History and clinical examination (supine and standing positions) is crucial for
assessing for UDT. Careful examination with sweeping warm fingers along the
inguinal canal towards the pubic tubercle can occasionally allow palpation of the
inguinal UDT. It is also important to examine the common areas for ectopic testes
including the superficial inguinal pouch, femoral, perineal, pubic, penile, or con-
tralateral side. There is currently no role for imaging in the diagnostic evaluation
Table 17.3 Classification of undescended testes.
Undescended testes Palpable Inguinal

Ectopic
●● Superficial inguinal pouch
●● Femoral
●● Perineal
●● Pubic
●● Penile
●● Contralateral
Retractile
Non-palpable Inguinal
Ectopic
Intra-abdominal
Absent
Acquired/re-ascended
Source: Adapted from Radmayr et al. (2016).

of UDT. Retractile testes carry a 7–32% risk of re-ascent and should be followed up
clinically on an annual basis until puberty.
It is rare for the UDT to descend after 6 months of age; therefore, the current
British Association for Paediatric Urologists recommends treatment to be com-
plete by 12 months as transformation of germ cells are usually complete by this
time point. The EAU guidelines extend this up to 18 months at the latest. For pal-
pable UDT, an examination under anaesthetic (EUA) and inguinal orchidopexy is
the widely accepted surgical approach with a 92% success rate. Parents should be
warned of the risks of postoperative testicular atrophy and risk of re-ascent.
For those with non-palpable testes, a EUA is the first step of treatment. If under
anaesthetic, the testis is identified, an inguinal orchidopexy could be undertaken.
If the testis is still not identified, proceeding to inguinal exploration or a diagnos-
tic laparoscopy with either subsequent orchidectomy or orchidolysis and orchi-
dopexy as is appropriate. Seventy-five percent of testes identified laparoscopically
will be viable, with some cases requiring a two-stage Fowler-Stephens approach,
which carries an 80% success rate. Orchidopexy for the contralateral testis is rec-
ommended. These cases are usually conducted by a specialist paediatric urologist
at a dedicated paediatric unit.
Some patients may present post-pubertally with an UDT. A previous study with
51 men presenting with a unilateral inguinal UDT and a normal contralateral
testis demonstrated that the incidence of intratubular germ cell neoplasia in the
UDT was 2%. In this group of patients, they should be counselled regarding risk of
malignancy and benefits of orchidopexy or orchidectomy.
Patients and parents will often enquire about the impact of UDT on fertility and
risk of malignancy. It is known that early surgical intervention will reduce the
impact on germ cell and Leydig cell loss. Following surgical treatment of unilat-
eral UDT, the fertility rate remains lower than those with bilateral descended tes-
tes. However, the paternity rate remains comparable. For those with treated
bilateral UDT, both the fertility and paternity rates are lower. The principle for
early surgical intervention applies to the risk of testicular malignancy. A study of
17 000 patients found that the relative risk of testicular cancer in those treated
before age 13 was twofold, compared to those treated after age 13 with a risk more
than fivefold. Patients and parents should be fully counselled about the above
risks, and patients should be encouraged to undertake regular self-examination.
Phimosis
In the paediatric clinic, this is a very common presentation and much of it is in the
counselling of the natural history of the foreskin. During the first year of age, only
50% of boys will have a retractile foreskin. This increases to 92% by age 7 and by
age 16, only 1% of boys will be troubled by phimosis.
Current indications for circumcision are pathological phimosis with evidence

of lichen sclerosis of the foreskin, 3 or more episodes of recurrent balanoposthitis
within 6–12 months and recurrent febrile UTIs, and an abnormal urinary tract
(complicated UTIs). Establishing the occurrence of balanoposthitis can be chal-
lenging and a focused history is key. Balanoposthitis is inflammation of the glans
and prepuce, which is speculated to be secondary to irritation from the break-
down of urea in urine, liberating ammonia.
For those that do not require a circumcision, foreskin care advice and reassur-
ance regarding the natural history of the foreskin is advised. To prevent episodes
of balanoposthitis, parents should be advised to continue with simple bathing
with avoidance of perfumed soaps. The foreskin can be gently retracted on a regu-
lar basis and dabbing post-voiding will help reduce the risk of urinary trapping
and irritation. During a flare of balanoposthitis, topical steroids and antibiotics
should be used. Discussing the criteria for circumcision can aid in follow-up plan-
ning and allows parents to look out for any change in condition that may require
re-referral for surgical intervention.
Enuresis
This is a common condition, affecting up to 10% of children attending school.

There is a reported association with constipation, obstructive airway disease, obe-
sity, and behavioural disorders such as attention deficit disorder and autism spec-
trum disorder. Enuresis can be divided into primary (those who have never been
dry) and secondary enuresis (those that have previously had a period of six months
or more of being dry). In secondary enuresis, it is important to identify any poten-
tial psychological or social trigger. Enuresis is also further classified into mono-
symptomatic (MEN) and non-monosymptomatic (NMEN) enuresis. Patients with
NMEN will present with associated urinary symptoms such as UTIs, stress uri-
nary incontinence (SUI) or even signs of ectopic ureters.
Important things to elicit in the history and examination include daytime void-
ing symptoms, suggestions of Vincent’s curtsey (indicator of overactive bladder),
whether the patient is a deep sleeper, examination of bladder, external genitalia,
and signs of spinal abnormalities. First line investigations include urinalysis to
exclude infection and a bladder and bowel diary. A child’s bladder capacity in mil-
lilitres can be calculated by the formula = (age × 30) + 30. Ultrasound scan be used
for patients with suspected congenital malformations and those refractory to ini-
tial treatment. It can also obtain a post void residual urine volume.
Treatment is recommended in a step-wise approach, starting with fluid and
stool charts if applicable. The child and parents should be encouraged to ensure
adequate hydration and good urinary habits, especially at school. For MEN, alarm
systems can be used, providing up to 80% success rate. The use of desmopressin
can be considered and if there is a particular event that the child/parent would
like the child to be dry for, it is recommended to commence treatment in the two
weeks leading up to it. The success rate is quoted at 70% but has a high relapse
rate, unlike the alarm system. Dosage starts at 120 mcg and can be increased to
240 mcg. There is no risk of hyponatraemia.
Patients with NMEN should have their daytime symptoms addressed, and if
there is evidence of overactive bladder, antimuscarinics such as oxybutynin,
tolterodine, and solifenacin can be used.
Enuresis can be stressful for the child and their families, and if there is no
response to treatment, any missed comorbidities, anatomical, or functional causes
should be examined for.
Further Reading
Gairdner, D. (1949). The fate of the foreskin, a study of circumcision. Br. Med. J. 2:
1433–1437.
Haid, B. and Tekgül, S. (2017). Primary and secondary enuresis: pathophysiology,
diagnosis, and treatment. Eur. Urol. Focus 3: 198–206.
Okarska-Napierała, M., Wasilewska, A., Kuchar, E. et al. (2017). Urinary tract
infection in children: diagnosis, treatment, imaging – comparison of current
guidelines. J. Pediatr. Urol. 13 (6): 567–573.
Radmayr, C., Dogan, H., Hoebeke, P. et al. (2016). EAU guideline for management of
undescended testes: European Association of Urology/European Society for
Paediatric Urology Guidelines. J. Pediatr. Urol. 12 (6): 335–343.
Tekgül, S., Riedmiller, H., Hoebeke, P. et al. (2012). EAU guidelines on vesicoureteral
reflux in children. Eur. Urol. 62 (3): 534–542.
201
18
Urothelial Bladder Cancer

Diagnosis and Management in the Outpatient Clinic
Jordan Durrant
Bladder Cancer Investigation
Due to the concerning nature of haematuria for patients and the value of making
an early diagnosis, the concept of ‘One‐Stop’ clinics for the investigation of sus-
pected urothelial bladder cancer is now well established.
A ‘One‐Stop’ service will normally aim to offer a patient all the necessary inves-
tigations with the minimum number of hospital attendances possible, with every-
thing ideally being done for the patient on the same day. On receipt of a referral of
a patient with haematuria, a urology department will normally organise:
●● Upper Urinary Tract Imaging
●● Clinical Assessment – urine dipstick test, history, and examination
●● Flexible Cystoscopy
●● Urine Cytology in some circumstances
Upper urinary tract imaging is normally dependent on the nature of the haematu-
ria. Non‐visible haematuria (NVH) (microscopic haematuria) is investigated with a
renal tract ultrasound scan, whereas visible (macroscopic) haematuria is investigated
with a computerized tomography intravenous urogram (CT IVU), including excretory
phase urography). This is based on the fact that visible haematuria (as compared to
non‐visible) confers virtually twice the risk of finding an underlying urothelial tumour.
Clinical Assessment
Initial assessment requires determination of the type of haematuria:
●● Visible haematuria
●● Persistent non‐visible haematuria on multiple tests
●● Symptomatic non‐visible haematuria (associated with pain or lower urinary
tract symptoms)
Careful history‐taking is valuable, particularly in cases of symptomatic NVH, in

order to determine whether urinary tract infections are a potential cause of the
haematuria. Urine dipstick testing will help to identify patients with ongoing
signs of infection; however, review of previous MSU microscopy and culture
results, if available, can be more useful.
Urine dipstick testing also allows detection of proteinuria. This finding then
requires further clarification with protein‐creatinine ratio testing but an abnor-
mal level (>50 mg/mmol) can indicate the cause of haematuria being glomerulo-
nephritis, IgA nephropathy, or another nephrological condition requiring renal
medicine/nephrology specialist input.
Initial physical examination may suggest an underlying pathology – a ballotable
renal mass may suggest renal cell cancer, a distended bladder may suggest bladder
outflow obstruction and associated urinary tract infection (UTI). An abnormal
prostate on digital rectal examination (DRE) is indicative of prostate cancer.
Particular attention should be paid to any history of tobacco usage and smoking
as this may influence levels of suspicion and prompt more rigorous investigation
(CT scanning or urine cytology) on the basis of the increased risk of urothe-
lial cancer.
Cystoscopy
Ideally, the patient will attend for flexible cystoscopy after completion of neces-
sary upper tract imaging. If imaging clearly demonstrates a urothelial bladder
cancer, flexible cystoscopy is rarely required and the patient should instead be
counselled to proceed directly to trans‐urethral resection in the operating theatre
at the earliest opportunity.
Flexible cystoscopy is carried out using flexible fibre‐optic flexible cystoscopes
with the use of intra‐urethral lidocaine lubricant. Use of a full syringe of anaes-
thetic lubricant in females is not necessary and risks obscuring vision in the blad-
der. In male patients, it has been demonstrated that cooled anaesthetic lubricant
is associated with less discomfort on instillation, as is very slow instillation of the
lubricant also. Studies have indicated that maximum analgesic effect from lido-
caine lubricant occurs after an indwelling time of >15 minutes, this is impractical
in most haematuria clinics however.
Most urology departments have an adopted policy of deferring flexible cystos-
copy in the event of signs of a urine infection being found on urine dipstick test-
ing. Midstream urine specimen (MSU) is sent for microscopy, culture, and
sensitivity and empirical antibiotics are commenced, and the cystoscopy is
rebooked for a later date. It is important to be aware that almost 50% of bladder
tumours are colonised by bacteria, and persistent infection despite antibiotic
18 Urothelial Bladder Cancer 203
treatment must not be allowed to lead to repeated deferral and delayed diagnosis
in such cases. If such a scenario is a concern, then proceeding with flexible cystos-
copy whilst giving antibiotic cover (e.g. IV gentamicin) may be the best course of
action, if safe to do so.
Further Steps
Ideally a ‘complete’ set of investigations for haematuria should include blood tests
(including renal function testing) and urine cytology. Availability of urine cytol-
ogy is variable, however, and in some cases it’s use may be restricted to patients
with visible haematuria only. Urine cytology is only a reliable indicator of high‐
grade disease.
Patients with a confirmed finding of a bladder tumour in clinic should be
offered trans‐urethral resection for definitive diagnosis, and a staging CT scan
should ideally be arranged prior to this. For patients with NVH but a positive
smoking history that prompts a high level of clinical suspicion, it may be prudent
to organise CT urography for further reassurance.
Further support to the patient should ideally be made available at this stage
from a member of the cancer team (e.g. a cancer nurse specialist).
Transurethral Resection of a Bladder Tumour Surgery
In most cases, transurethral resection of a bladder tumour (TURBT) surgery will

require an overnight stay with an indwelling catheter for the patient, but smaller
tumours may allow same‐day discharge of the patient. In cases of apparent superfi-
cial tumour, intravesical Mitomycin C as a single post‐operative dose has been shown
to result in a relative risk reduction of recurrence by 39%. If systems and protocols are
in place for this to be administered in the operating theatre at the end of the proce-
dure or in the anaesthetic recovery area, this can still allow drainage of Mitomycin
and removal of the catheter one hour later to facilitate same‐day discharge.
isk Stratification and Further Treatment and

R
Follow-Up for Non-muscle Invasive Disease
Histological analysis of a TURBT specimen, in conjunction with radiological stag-

ing, allows determination of whether the urothelial bladder cancer is muscle inva-
sive, or non‐muscle invasive. This is the most significant factor determining future
care. Failure to sample detrusor muscle at the time of surgery should immediately
prompt a repeat TURBT procedure after six weeks. Histology and scan results
should be discussed at a multi‐disciplinary team meeting so that treatment plan-
ning can take place.
Low Risk
Patients with pTa G1 (<3 cm), pTa G2 low (<3 cm) and papillary urothelial neo-
plasm of low malignant potential (PUNLMP) are stratified because low‐risk will
be recommended to have a flexible cystoscopy at 3 months and 12 months follow-
ing initial diagnosis. Evidence suggests that these patients can be safely discharged
at the end of one year, and this is current UK practice. Urine cytology is not useful
in the follow‐up of low‐risk disease.
Intermediate Risk
Patients with intermediate risk will be offered a six‐dose course of intravesical
Mitomycin C. It should be explained that a course of Mitomycin C is associated
with a relative risk reduction in recurrence rate of 11%. Side effects include uri-
nary tract infection, bladder irritation/pain, and dysuria. Neutropenia is a very
rare side effect.
Recurrence following six weeks’ intravesical Mitomycin C is concerning and
should prompt re‐discussion in a multidisciplinary team (MDT) setting.
Cystoscopic surveillance is usually offered on a reducing schedule and UK guide-
lines recommend cystoscopy at 3, 9, and 18 months from the time of diagnosis.
Annual cystoscopy is offered thereafter.
Patients who have been followed up for at least five years can be considered
discharge in selected cases. (e.g. Solitary G1 and G2 [low] disease with no recur-
rence and no ongoing tobacco use); however, individual urology units may have
different approaches to this.
High Risk
Patients with a new diagnosis of high‐risk non‐muscle invasive disease should be
offered a repeat TURBT (re‐resection) at six weeks. These are patients with pTa
G3, pT1 disease and carcinoma in situ (CIS). The rationale for re‐resection is that
it has been found that 75% of patients with high‐risk disease have residual tumour
at re‐resection and 20% of those will have muscle‐invasive disease. Furthermore,
it is known that for disease that is not ‘up‐staged’ on re‐resection, the future risk
of recurrence is halved after a six‐week re‐resection.
18 Urothelial Bladder Cancer 205
After cases of high‐risk disease have been discussed at an MDT, patients will
typically be offered a choice between intra‐vesical immunotherapy using BCG
(Bacillus Calmette‐Guerin) or Radical Cystectomy surgery. Fifteen‐year data
shows that half of patients choosing BCG will experience progression, but just
under one‐third will survive with an intact bladder. Cystoscopic surveillance typi-
cally takes place at three‐month intervals for the first two years, then six‐month
intervals for two years, and annual thereafter. Urine cytology can also be a useful
tool for surveillance of high‐grade disease.
Low Risk Intermediate Risk High Risk
pTa G1 < 3 cm pTa G1 > 3 cm pTa G3

pTa G2(low) <3 cm pTa G1 multifocal pT1 G2
PUNLMP pTa G2(low) >3 cm pT1 G3
pTa G2(low) multifocal pTis/CIS
pTa G2(high) micropapillary/nested
pTa G2(grade not further
stated)
Low‐Risk recurrence
within 12 months
Muscle Invasive Disease
Patients with muscle invasive disease will be offered either radical radiotherapy or
radical cystectomy surgery via an MDT. A number of protocols exist for radio-
therapy, but mostly consist of fractions being delivered over the course of four to
six weeks. The standard of care for radical cystectomy is to offer ileal conduit uri-
nary diversion at the same time. Some centres offer continent urinary diversion in
select cases, but this can be associated with higher complication rates and is gen-
erally reserved for highly motivated patients with minimal co‐morbidities. With
either treatment, outcomes over a five‐year period are extremely similar with
overall survival being 50–60%.
Further Reading
National Institute for Health and Care Excellence (2015). Bladder cancer: diagnosis and
management. NICE guideline. (February 25, 2015). www.nice.org.uk/guidance/ng2.
207
19
Prostate Cancer
David Thurtle
Prostate cancer is the commonest male solid organ malignancy. Approximately

50 000 men are diagnosed every year in the UK. Its prevalence and the high profile
of the disease, means it represents a fair proportion of the workload for most
practising adult urologists.
Most patients will first be referred with a raised prostate specific antigen (PSA)
test. This simple and cheap blood test can lead to a multitude of investigations and
treatments with significant potential morbidity, so it is important to be able to
counsel men thoroughly. Unlike many cancers, some forms of non‐metastatic
prostate cancer can very reasonably be monitored by ‘active surveillance’ (AS)
rather than requiring universal treatment – creating decision dilemmas for
patients and clinicians and emphasising the importance of understanding the
disease thoroughly.
Pathology
The vast majority of prostate cancer is adenocarcinoma – from the glandular

structures in the epithelial tissue. Very rarely, the prostate can be a site for
sarcomas or secondary metastases. Most prostate adenocarcinomas occur in the
peripheral zone (~75%), whereas the transitional zone is more commonly affected
by benign enlargement. Prostate cancer is usually considered to be a multifocal
disease.
Two histological lesions have traditionally been considered to be pre‐ or peri‐
malignant lesions, namely, prostatic intraepithelial neoplasia (PIN) and atypical
small acinar proliferation (ASAP). Only high‐grade PIN (HGPIN) should be
recorded by pathologists. Isolated HGPIN or ASAP may lead to repeated biopsies,
or longer PSA monitoring, but does not in itself require treatment.
Tumour Grading
Prostate cancer is graded using the Gleason score (GS), composed of two scores
ranging from 1 to 5 based upon the morphology of the dominant and the
non‐dominant cell pattern. Gleason score of 3 + 3 and above are considered to be
cancer. In 2014 the International Society of Urological Pathologists published a
revised cancer ‘Grade Group’ system which seeks to make the grading more intui-
tive – with grade groups 1 (GS 3 + 3), 2 (GS 3 + 4), 3 (GS 4 + 3), 4 (GS 8), and 5 (GS
9–10) ranging from the lowest to highest‐risk disease.
Biopsy characteristics have prognostic significance, as a surrogate for disease
volume and multifocality. Proportion of biopsy cores involved, maximum tumour
length, and total biopsy percentage are sometimes used.
History
History‐taking for a man suspected to have prostate cancer can be considered in

two parts – risk factors for the disease and symptoms of the disease:
Risk Factors
Age – Prostate cancer prevalence increases with age. Incidence rates are highest in
men aged between 75 and 79. The disease is very rare under the age of 40, whereas
cadaveric studies have shown the prevalence to be in excess of 50% by age
80 – though much of this will not be indolent.
Hormones – Benign or malignant growth of the prostate is under the influence
of testosterone and it’s active metabolite dihydrotestosterone (DHT). Therefore,
men who take additional testosterone may be at higher risk of the disease. Men on
testosterone replacement therapy, tend to have their PSA monitored for this
reason. Conversely, 5‐alpha reductase inhibitors (5‐ARI) (e.g., finasteride) have
the effect of shrinking the prostate reducing PSA values. PSA values among men
on 5‐ARIs are usually doubled to compensate for this effect. Impact of long term
5‐ARIs on prostate cancer is debated.
Race – The disease is more common and aggressive among black men than
Caucasians. Men of Asian or Oriental origin tend to be at lower risk.
Family history – Carriers of the breast cancer susceptibility protein (BRCA)
gene mutations are at increased risk, and may have more aggressive, prostate can-
cer. Family history should therefore enquire about breast and ovarian malignan-
cies among relatives, as well as prostate cancer. Men with one first degree relative
19 Prostate Cancer 209
affected by prostate cancer are approximately twice as likely to develop prostate

cancer, with the risk increasing with more affected relatives.
Obesity – Emerging research suggests obese men are at higher risk of prostate
cancer, and have worse outcomes from the disease, with the effect thought to be
multifactorial.
Diet and lifestyle – Prostate cancer is not thought to have a direct association
with smoking. Some foods, such as lycopenes (e.g., tomatoes) and cruciferous veg-
etables (e.g., broccoli) are thought to have protective effects against prostate cancer.
Symptoms of the Disease
As prostate cancer tends to affect the peripheral zone of the prostate, it is often
completely asymptomatic.
Lower urinary tract symptoms (LUTS) such as nocturia, frequency, hesitancy,
urgency, or retention are more likely to be a result of benign prostatic enlarge-
ment, but can suggest underlying malignancy. Regardless, existing LUTS may
have an impact on eventual treatment decisions. Primary care guidelines often
suggest considering a PSA test in men with LUTS, as well as those with erectile
dysfunction.
Haematuria and haematospermia, have been associated with prostate cancer,
although more common causes for both exist. Isolated haematospermia is gener-
ally benign and self‐limiting.
Symptoms of advanced disease may be more systemic, such as weight loss and
lethargy. Localised extension can lead to perineal pain, renal failure and anuria
and rarely even malignant priapism or rectal obstruction. Symptoms of bone
metastases such as back pain, bone pain, anaemia, and neurological symptoms in
the lower limbs suggest advanced disease.
Sex and fertility are important considerations, and erectile function should be
documented, as potential treatments may affect these.
Examination and Investigation
In addition to a history, examination, and PSA, most new patients with PSA < ~30
are best investigated with upfront pre‐biopsy multi‐parametric magnetic reso-
nance imaging (mpMRI) (see below). If subsequent biopsy demonstrates low‐risk
disease, further staging investigations can be omitted. For high‐risk cases, bone
scan and computed tomography (CT) are used for staging. A patient presenting
with symptoms or high PSA (>50) suggestive of advanced disease could proceed
directly to bone scan without need for an mpMRI.
Digital rectal examination (DRE) of the prostate is a quick and simple test that
should not be omitted, although it is widely appreciated that correlation between
DRE and MRI or pathological findings is poor. DRE can be useful to detect
obviously malignant prostates, which tend to feel hard, fixed, craggy, nodular, and
asymmetric. DRE can also help roughly quantify prostate volume to contextualise
the PSA value, and to identify competing diagnoses such as a tender boggy prostate
suggesting prostatitis.
PSA remains the mainstay for prostate cancer detection. It is specific to the
prostate, but not to prostate cancer. PSA rises with increasing age and prostate
size, hence the increasing interest in PSA‐density (PSA/prostate volume). PSA is
also raised by prostatitis or urinary tract infection, catheterisation, retention or
instrumentation to the urinary tract. Patients are advised to avoid intercourse or
cycling for a few days before a PSA test, which may also raise the PSA value to a
lesser extent. In cases of infection or retention it is advisable to retest the PSA
approximately six weeks later.
The PSA test measures the total of both free and bound PSA. There has been
significant research interest in PSA‐isoforms such as free‐PSA and pro‐PSA, or the
ratios of free: total. The hope is that these may be more specific to prostate cancer
itself, but none have yet become widely used in clinical practice. In undiagnosed
men and those on surveillance, ‘PSA kinetics’ are of interest including PSA dou-
bling time and PSA velocity.
Multiparametric MRI
Magnetic resonance imaging has been the biggest advance in prostate cancer
management in recent years. ‘Multiparametric’ refers to the addition of at least
one ‘functional’ sequence to the standard anatomical T1‐ and T2‐weighted imag-
ing. The most commonly used functional sequences are dynamic contrast
enhanced (DCE) and diffusion‐weighted imaging (DWI). Magnetic resonance
spectroscopy is another example but is now rarely used. Magnetic resonance
imaging should generally be reserved for those who might potentially be eligible
for radical treatment.
Multiparametric magnetic resonance imaging (mpMRI) has two key roles in
modern practice, first in detection and targeting, and second in staging (Table 19.1).
Radiologists report MRI lesions on a five‐point scale – most commonly version 2
of the PI‐RADS (prostate imaging –reporting and data system) classification.
Scores of 1, 3, and 5 suggest ‘very low,’ ‘intermediate,’ and ‘very high’ likelihood of
clinically significant prostate cancer. Biopsy is generally offered to those with
PIRADs score 3 or more, and can be omitted in those with a score of 1 or 2, after
reaching a shared decision with the patient. MRI‐staging can also be useful to
inform surgical decision making – including whether to attempt a nerve‐sparing
Table 19.1 Prostate cancer staging.
Clinical/Pathological
Tumour Staging Cancer Stage Grouping
TX: The primary tumour

cannot be evaluated.
T0 (T plus zero): There is no
evidence of a tumour in the
prostate
T1: The tumour cannot be felt Stage I: Cancer in this early stage is usually slow
during a DRE and is not seen growing. The tumour cannot be felt and involves
during imaging tests. It may be one‐half of one side of the prostate or even less
found when surgery is done for than that. PSA levels are low. The cancer cells are
another reason, usually for BPH well differentiated, meaning they look like healthy
or an abnormal growth of cells (cT1a–cT1c or cT2a or pT2, N0, M0, PSA level
noncancerous prostate cells. is less than 10, Grade Group 1).
●● T1a: The tumour is in 5% or
less of the prostate tissue
removed during surgery.
●● T1b: The tumour is in more
than 5% of the prostate tissue
removed during surgery.
●● T1c: The tumour is found
during a needle biopsy,
usually because the patient
has an elevated PSA level.
T2: The tumour is found only in Stage II: The tumour is found only in the prostate.
the prostate, not other parts of PSA levels are medium or low. Stage II prostate
the body. It is large enough to cancer is small but may have an increasing risk of
be felt during a DRE. growing and spreading.
●● T2a: The tumour involves ●● Stage IIA: The tumour cannot be felt and
one‐half of 1 side of the involves half of 1 side of the prostate or even less
prostate. than that. PSA levels are medium, and the cancer
●● T2b: The tumour involves cells are well differentiated (cT1a–cT1c or cT2a,
more than one‐half of 1 side N0, M0, PSA level is between 10 and 20, Grade
of the prostate but not both Group 1). This stage also includes larger tumours
sides. confined to the prostate as long as the cancer
●● T2c: The tumour has grown
cells are still well differentiated (cT2b–cT2c, N0,
into both sides of the M0, PSA level is less than 20, Group 1).
prostate. ●● Stage IIB: The tumour is found only inside the
prostate, and it may be large enough to be felt
during DRE. The PSA level is medium. The
cancer cells are moderately differentiated (T1–T2,
N0, M0, PSA level less than 20, Grade Group 2).
●● Stage IIC: The tumour is found only inside the
prostate, and it may be large enough to be felt
during DRE. The PSA level is medium. The
cancer cells may be moderately or poorly
differentiated (T1–T2, N0, M0, PSA level is less
than 20, Grade Group 3–4).
(Continued)
Table 19.1 (Continued)
Clinical/Pathological
Tumour Staging Cancer Stage Grouping
T3: The tumour has grown Stage III: PSA levels are high, the tumour is
through the prostate on 1 side growing, or the cancer is high grade. These all
and into the tissue just outside indicate a locally advanced cancer that is likely to
the prostate. grow and spread.
●● T3a: The tumour has grown ●● Stage IIIA: The cancer has spread beyond the
through the prostate either on outer layer of the prostate into nearby tissues. It
1 or both sides of the prostate. may also have spread to the seminal vesicles. The
This called extra prostatic PSA level is high. (T1–T2, N0, M0, PSA level is 20
extension (EPE). or more, Grade Group 1–4).
●● T3b: The tumour has grown ●● Stage IIIB: The tumour has grown outside of the
into the seminal vesicle(s), prostate gland and may have invaded nearby
the tube(s) that carry semen. structures, such as the bladder or rectum (T3–T4,
N0, M0, any PSA, Grade Group 1–4).
●● Stage IIIC: The cancer cells across the tumour
are poorly differentiated, meaning they look very
different from healthy cells (any T, N0, M0, any
PSA, Grade Group 5).
T4: The tumour is fixed, or it is Stage IV: The cancer has spread beyond the
growing into nearby structures prostate.
other than the seminal vesicles, ●● Stage IVA: The cancer has spread to the regional
such as the external sphincter, lymph nodes (any T, N1, M0, any PSA, any Grade
the part of the muscle layer that Group).
helps to control urination; the ●● Stage IVB: The cancer has spread to distant
rectum; the bladder; levator lymph nodes, other parts of the body, or to the
muscles; or the pelvic wall. bones (any T, N0, M1, any PSA, any Grade
Group).
Source: AJCC Cancer Staging Manual, 8th Edition © 2017 Springer Nature.
approach. Clearly MRI also has the ability to assess pelvic lymph nodes, and bone
metastases in the imaged skeleton.
Bone scan/single photo emission computed tomography (SPECT) radionucleo-
tide scans, or bone scintigraphy, are nuclear medicine scans to assess the whole
skeleton. Patients should be warned to expect a number of hours wait between
attending for an injection of radionucleotide tracer and returning for the scan
itself which takes 30–60 minutes. The radioisotope technetium‐99 is taken up by
metabolically active bone, including areas of sclerotic bone metastases. Previous
trauma, or rheumatological conditions can lead to false positives. Some centres
combine CT with bone scans, to allow for three‐dimensional interpreta-
tion – known as ‘single photo emission computed tomography’ (SPECT).
CT of the chest, abdomen and pelvis is used to stage for nodal and distant
metastases.
Prostate specific membrane antigen (PSMA) positron emission tomography
(PET) is starting to translate into clinical practice not only in the assessment of
biochemical recurrence (PSA rise >0.02 after radical treatment) but also for pri-
mary staging and treatment planning.
Biopsy
Biopsy of the prostate should be ‘influenced’ by MRI findings. This may mean a
‘cognitive’ biopsy, whereby the clinician targets the suspicious area, or a targeted
biopsy using a fusion technique combining real‐time trans‐rectal ultrasound with
the MRI‐defined target. It is routine practice to combine an approach of targeted
biopsy with systematic biopsy – of non‐suspicious areas. However, the multi‐cen-
tre PRECISION study suggested that omitting systematic biopsy would reduce the
number of low‐risk diagnoses without significantly reducing detection of clini-
cally significant disease.
Techniques
Trans‐rectal biopsy is effective for targeting most of the peripheral zone, but is asso-
ciated with infection and sepsis in up to 5% of patients, some of whom will require
hospitalisation. The apex, and lesions in very large prostates can also be difficult to
reach. Trans‐perineal (TP) biopsies are safer because the biopsy needle traverses the
perineum, which can be sterilised and has potential advantages in accessing the
whole prostate. Traditionally TP biopsies required general anaesthesia, and often
employed a ‘template’ grid placed in front of the perineum. ‘Mapping’ biopsies or
‘saturation’ biopsies used numerous biopsies (up to 48) to sample most of the pros-
tate, but should no longer be used in initial assessment. However, increasingly, TP
biopsies can be performed under local anaesthesia (LA), either by employing LA
blocks, or by using TP access systems such as ‘Precision Point’ to minimise the
amount of LA required and maintain an ambulatory service. Most biopsy protocols
include 2–4 cores from each target and between 12 and 24 systematic cores.
Risk Categorisation
Localised prostate cancer is generally differentiated into low, intermediate, and
high‐risk according to derivations of the D’Amico classification (Table 19.2). Some
stratification criteria further divide groups into based upon GS 7 differences (GS
3 + 4 vs GS 4 + 3) or biopsy characteristics.
Table 19.2 National Institute for Health and Care Excellence (NICE) risk classification.
Level of risk PSA Gleason score Clinical stage
Low risk < 10 ng/ml and ≤6 and T1 toT2a

Intermediate risk 10–20 ng/ml or 7 or T2b
High risk >20 ng/ml or 8–10 or 2 ≥ T2c
Treatment
Non-metastatic Disease
Prostate cancer treatment decisions rely upon adequate staging of the disease and
thorough counselling of the patient. Treatment options include active surveil-
lance (AS), radical prostatectomy (open, laparoscopic, or robotic, which is by far
the most common approach), external beam radiotherapy, and brachytherapy. ‘All
options’ may be reasonable for low and intermediate‐risk disease, AS should not
be recommended for high‐risk disease. Brachytherapy is rarely offered to patients
with significant LUTS or a very large prostate gland. No superiority of one treat-
ment against another has been demonstrated in randomised controlled trials
(Hamdy et al. 2016) such that decision‐making is often driven by patient percep-
tions towards treatment side effects and burden. It is good practice for patients to
meet with oncologists and surgeons in making their decision. Radiotherapy is
more effective following a time on androgen deprivation therapy. Androgen dep-
rivation monotherapy is a potential option for men unfit for other treatment.
Focal therapies such as High intensity focused ultrasound (HIFU) or cryotherapy
are available at some centres – long term outcome data are awaited.
The predominant side effects of treatment are urinary symptoms, sexual dys-
function and bowel dysfunction. Radiotherapy has higher rates of bowel dysfunc-
tion, whereas surgery has higher rates of impotence or incontinence. However,
side‐effect outcomes from all treatments are improving with modern surgical
techniques (including robotic approaches) and better targeting. Individual deci-
sion aids are advised for use with patients, one example is the Predict Prostate tool
(http://prostate.predict.nhs.uk).
Advanced or Metastatic Disease

Management of advanced disease is predominantly led by oncologists, with
androgen deprivation therapy remaining the workhorse of treatment. In recent
years, numerous new chemotherapeutic and hormonal treatments (including
docetaxel, enzalutamide, abiraterone) have been added to the armoury of

oncologists, with strong evidence of beneficial effect. Novel bone‐targeting thera-
pies and increasing use of focused radiotherapy, such as radium‐223 and stereo-
tactic ablative radiotherapy (SABR), respectively, have provided improved
outcomes even in advanced disease. Newly diagnosed men starting on androgen
blockade should be commenced on an anti‐androgen (e.g., bicalutamide) if a lute-
inizing hormone‐releasing hormone (LHRH) agonist (e.g., goserelin acetate) is to
be used for medical castration. This avoids the potential risk of ‘tumour‐flare’
related to starting on an LHRH agonist. LHRH agonists (e.g. Degarelix) or surgical
castration are other rapid mechanisms for androgen blockade.
Key Points
1) PSA is an imprecise tool. Be aware of causes of false positives.
2) Prostate cancer will often be completely asymptomatic
3) mpMRI is invaluable before prostate biopsy in men likely to be suitable for
radical treatments.
4) Clinicians should move towards using the more intuitive 1–5 Grade
Group system.
5) Treatment decision‐making in localised disease is often complex, requiring
good patient counselling via a multi‐disciplinary approach.
6) Treatment options available for advanced disease continue to improve.
Further Reading
Drost, F.J.H., Osses, D.F., Nieboer, D. et al. (2019). Prostate MRI, with or without
MRI‐targeted biopsy, and systematic biopsy for detecting prostate cancer. Cochrane
Database of Systematic Reviews: CD012663.
Hamdy, F.C., Donovan, J.L., Lane, J.A. et al. (2016). 10‐year outcomes after
monitoring, surgery, or radiotherapy for localized prostate cancer. (The ProtecT
trial). New England Journal of Medicine 375: 1415–1424.
Kasivisvanthan, V., Rannikko, A.S., Borghi, M. et al. (2018). MRI‐targeted or standard
biopsy for prostate cancer diagnosis. New England Journal of Medicine 378:
1767–1777.
Mottet, N., Cornford, P., van den Bergh, R.C.N. et al. (2018). Prostate Cancer.
European Association of Urology. http://uroweb.org/guideline/prostate‐cancer.
Meyer, A.R., Joice, G.A., Schwen, Z.R. et al. (2018). Initial experience performing
in‐office ultrasound‐guided transperineal prostate biopsy under local anaesthetic
using the precision point trans perineal access system. Urology 115: 8–13.
217
20
Renal Cancer
Karan Wadhwa
With the rise in use of cross-sectional imaging, renal masses are increasingly
being diagnosed and present a common referral to the urologist both acutely and
on an outpatient basis. This chapter will present a brief overview of the diagnosis
and provide guidance on the management of renal masses.
Incidence
Renal cancer makes up 2–3% of all cancer diagnoses with an increase in 2% over
the past 20 years. 40% are diagnosed at a late stage, and renal cancer accounts for
3% of all cancer deaths, however kidney cancer survival overall has increased over
the last 40 years. Men are more likely to be diagnosed than women (1.5 : 1), with
a peak incidence between the ages of 60–70 and more likely in white races than
Asians or black races.
Aetiology
The main risk factors for developing renal cancer appear to be hypertension,
smoking, and obesity. The genomic changes for the development of renal can-
cer start in childhood or adolescence and there is an increased risk with an
affected first-degree relative. Several genetic conditions also predispose to renal
cancer such as Von-Hippel Lindau disease, but only 8–10% of renal cancers are
hereditary.
Subtypes
The most common histological subtype of renal cancer is clear cell renal cell car-
cinoma (ccRCC), which also has the worst overall survival compared to papillary
or chromophobe cancers. Papillary type renal cancer can be divided into type 1
and type 2 with distinct genetic features but overall with a higher survival rate
than ccRCC. Lastly, chromophobe renal cancer has a myriad of genetic changes
but has the best recurrence free and overall survival of the three main subtypes
(see Table 20.1). Several other subtypes exist, but these make up only 10–15% of
renal cancers and have variable clinical courses.
Signs and Symptoms
Onset of renal cancer is usually insidious, and over half of renal cancers are diag-
nosed incidentally. The classic triad of loin pain, palpable flank mass, and visible
haematuria is fortunately rare (6–8%) and usually indicates a poor prognosis. Up
to one-third of patients may suffer a paraneoplastic syndrome for example
deranged LFTS (Stauffer’s syndrome). Breathlessness or cough may indicate lung
metastases or pulmonary emboli and likewise back pain may indicate a metastatic
process.
Abdominal signs are usually absent, but one must be mindful to examine for
chest/abdominal lymphadenopathy, a flank mass, or a varicocele (particularly
right-sided).
Investigation
Alongside clinical examination, urine should be dipped for haematuria, and base-
line bloods including full blood count, urea, and electrolytes, liver function tests,
bone profile, and lactate dehydrogenase should be measured in clinic. Aside from
clinically diagnosed tumours, the patient usually comes to hospital with imaging
Table 20.1 Subtypes of renal cancer.
Cancer-specific survival 5 years (%) 10 years (%) 15 years (%) 20 years (%)
Clear-cell RCC 71 (69–73) 62 (60–64) 56 (53–58) 52 (49–55)

Papillary RCC 91 (88–94) 86 (82–89) 85 (81–89) 83 (78–88)
Chromophobe RCC 88 (83–94) 86 (80–92) 84 (77–91) 81 (72–90)
Source: Adapted from EAU guidelines (Ljungberg et al. 2018).

20 Renal Cancer 219
such as an abdominal/renal ultrasound or CT scan. To accurately stage a patient

with suspected renal cancer, a dedicated CT of chest, abdomen, and pelvis should
be performed with contrast. The key features of a renal mass are size, location,
enhancement (>20–30 Hounsfield units), invasion e.g. renal vein/IVC or adrenal,
lymph node status, and metastases (lung/liver/bone). It is also important to con-
sider the contralateral kidney in terms of presence, size, and shape.
In case of any diagnostic doubts, or if the patient has poor renal function, an
MRI can be considered. Magnetic imaging resonance can also be used for opera-
tive planning in the case of inferior vena cava (IVC) thrombus, to assess extent of
invasion and the need to mobilise the liver if the caval tumour thrombus
encroaches the hepatic veins.
Dimercaptosuccinic acid (DMSA) may be useful in the case of a small contralat-
eral kidney or if the patient has poor renal function to predict the need for peri or
post-operative renal replacement therapy.
Staging
Staging is performed using the TNM (tumour location, lymph node involvement,
metastatic spread) classification.
2017 TNM classification system
T – Primary tumour
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour

T1 Tumour <7 cm or less in greatest
dimension, limited to the kidney
T1a Tumour <4 cm or less
T1b Tumour >4 cm but <7 cm
T2 Tumour >7 cm in greatest dimension,
limited to the kidney
T2a Tumour >7 cm but <10 cm
T2b Tumours >10 cm, limited
to the kidney
T3 Tumour extends into major veins or
perinephric tissues but not into the
ipsilateral adrenal gland and not
beyond Gerota fascia
(Continued )
(Continued )
T3a Tumour grossly extends
into the renal vein or its
segmental (muscle-
containing) branches, or
tumour invades perirenal
and/or renal sinus fat
(peripelvic fat), but not
beyond Gerota fascia
T3b Tumour grossly extends
into the vena cava below
diaphragm
T3c Tumour grossly extends
into vena cava above the
diaphragm or invades the
wall of the vena cava
T4 Tumour invades beyond Gerota fascia
(including contiguous extension into
the ipsilateral adrenal gland)
N – Regional lymph nodes
NX Regional lymph nodes cannot be
assessed
N0 No regional lymph node metastasis
N1 Metastasis in regional lymph node(s)
M – Distant metastasis
M0 No distant metastasis
M1 Distant metastasis
Role of Biopsy
The role of biopsy for renal cancer has been controversial in the past; however,
it has recently seen a resurgence and can be safely performed as an ambulatory
procedure. Biopsy is mainly indicated for those in whom we are considering
active surveillance, ablative therapy, or if there is diagnostic uncertainty in the
context of metastatic disease. Cystic masses are not ideal for biopsy. Concordance
between biopsy histology and final specimen pathology is greater than 95%,
and with the coaxial approach, biopsy yield is high. Although biopsy is gener-
ally a safe procedure, it does carry with it the risk of bleeding (4%) but clinically
significant haemorrhage is rare. Biopsy tract seeding, although described, is
very rare.
20 Renal Cancer 221
Management
The management of renal masses can be divided into small renal mass (T1), renal
mass (T2), or metastatic RCC (mRCC). The multidisciplinary team comprising
radiology, pathology, and urology renal cancer surgeons are vital in the decision-
making process, taking into account patient, tumour, and resource factors.
Studies have shown no difference in cancer specific outcomes between radical
and partial nephrectomy, and preservation of GFR has been shown to increase
overall survival (Go et al. 2004), but studies have yet to prove an overall survival
benefit from partial nephrectomy. Despite this, many authors propose doing a par-
tial nephrectomy when possible, especially for a T1 mass. However, active surveil-
lance is a valuable option, particularly for the more elderly or co-morbid patient.
Progression on active surveillance to metastatic disease is rare (1%), and tumours
are generally slow growing. Minimally invasive treatment such as renal radiofre-
quency ablation or cryotherapy may have a role in management of the small renal
mass. Treatment such as RFA or cryotherapy may be indicated in the unfit or
elderly patient, by patient choice, or for example, if there is radiological or clinical
progression whilst on surveillance in a patient who does not want surgery.
Laparoscopic radical nephrectomy is the accepted standard of care for the >T1
renal mass and it is widely performed. The ipsilateral adrenal gland or lymph
nodes are not routinely taken, unless there is clinical indication such as radiologi-
cal extension. Open nephrectomy is now reserved for the very large renal mass, or
if renal vein/IVC thrombus is suspected.
In the unfit patient with haematuria or flank pain, embolization of the tumour
may be deployed in a palliative setting.
In the context of mRCC, systemic therapy such as tyrosine kinase inhibitors are
generally preferred if the disease burden outside of the kidney is high. Newer
agents such as the Programmed death-ligand 1 (PDL1) inhibitor Nivolumab have
shown promise in clinical trials. Cytoreductive nephrectomy is reserved for pallia-
tion but may still have a role, for example, in those with low volume metastatic
disease with a good performance status and favourable risk scores (Memorial
Sloan Kettering Cancer Center/International Metastatic RCC Database
Consortium [MSKCC/IMDC] <4). Evidence for surgical management of mRCC is
poor as trials are difficult to run and recruit to.
Enhanced Recovery After Renal Surgery
Laparoscopic/robotic partial or radical nephrectomy is an operation conducive for

short stay surgery. Many patients can be discharged the next post-operative day.
This relies on a motivated, appropriately counselled patient and functional
enhanced recovery programme. Techniques such as catheter-less nephrectomy,

mobilising the patient very early the next post-operative day and consultant-
review-driven discharge can reduce length of stay.
Further Reading
Go, A.S., Chertow, G.M., Fan, D. et al. (2004). Chronic kidney disease and the risks of
death, cardiovascular events, and hospitalization. New England Journal of
Medicine 351: 1296–1305. https://doi.org/10.1056/NEJMoa041031.
Ljungberg, B., Albiges, L., Bensalah, K. et al. (2019). Renal cell carcinoma. European
Association of Urology. http://uroweb.org/guideline/renal-cell-carcinoma.
223
21
Penile Cancer
Karen Randhawa and Hussain Alnajjar
Penile cancer is a rare disease (<1 per 100 000 men) that constitutes 0.2% of all
male malignancies with the most common age of presentation in the sixth decade.
Early diagnosis is key as the disease can result in devastating disfigurement and a
five‐year survival rate of approximately 50%.It can be cured in over 80% of cases if
diagnosed early and hence the need for thorough assessment and prompt treat-
ment. There is clear evidence that centralisation of penile cancer care in the UK
has led to improved outcomes; as a result, a number of other countries have fol-
lowed the UK model.
Pathology
Over 95% are subtypes of squamous cell carcinoma most commonly arising from
the inner prepuce or glans penis.
Risk Factors
Presence of a phimotic foreskin/chronic inflammation. Phimosis is strongly

associated with invasive penile cancer.
Penile cancer is rarely seen in populations where neonatal or childhood circum-
cision is routinely performed. The protective effect is probably due to a decreased
risk of human papilloma virus (HPV) infection in addition to reduced risk of
phimosis and chronic inflammation.
Human papilloma virus: HPV types 16 and 18 are associated with approxi-
mately 45–80% of penile cancers. HPV DNA has been identified in 70–100% of
intra‐epithelial neoplasia and in 30–40% of invasive penile cancer.
Lichen sclerosus: The incidence of lichen sclerosus is relatively high in penile

cancer but is not associated with adverse histopathological features, including
penile intraepithelial neoplasia (PeIN).
Smoking/tobacco use: The risk of penile cancer is increased fivefold in smokers
versus non‐smokers. Similarly chewing tobacco is a significant risk factor.
Exposure to ultraviolet radiation: Psoriasis patients undergoing psoralen plus
ultraviolet A (PUVA) treatment have an increased penile cancer incidence of 286
times compared to the general population. Patients treated for psoriasis with
immunosuppressive drugs also appear to have an increased risk of developing
penile cancer.
Human immunodeficiency viruses (HIV) infection: There is reported to be an
eightfold increased risk of penile cancer in patients with HIV.
Multiple sexual partners/early age of first intercourse: Evidence suggests that
there is a three‐ to fivefold increased risk of penile cancer associated with multiple
sexual partners.
Other epidemiological risk factors are low socioeconomic status and a low level
of education.
Presentation
Pre‐malignant lesions and benign penile dermatoses may present as a rash, small
red lesions or raised area on the penis. It is important that clinicians are aware of
the need for biopsy and a prompt referral on to a specialist centre where
appropriate.
Patients may also present with phimosis, making it difficult to visualise the
lesion, in addition to penile pain, palpable lesion, problems voiding, foul odour,
bleeding, or discharge from the penis.
Presentation can also be late, with obvious fungating penile lesions and/or met-
astatic groin node masses.
History
It is important to assess the overall health of the patient in terms of co‐morbidities

including past medical and surgical history.
Ask specific questions relating to:
●● Location and size of the lesion
●● Duration
●● Is the lesion growing?
21 Penile Cancer 225
●● Previous similar lesions?

●● Any voiding symptoms?
●● Associated pain
●● Bleeding/Discharge?
●● Any problems retracting the foreskin?
●● Previous surgery to penis/foreskin
●● Sexual history – sexually active?
Examination
General examination should be performed to assess the overall health of the

patient.
Primary Lesion (May Be Hidden Under Phimosis)

If it is possible to retract the foreskin, perform a visual examination of the glans
assessing the size, location, and morphology of any glans lesions (exophytic or
ulcerative). Proximity to the meatus should also be assessed. Palpation of the
lesion, glans penis, and penile shaft should be performed to assess for corporal
involvement.
Assess foreskin for lichen sclerosis, warts, scarring, change in colour, or any
evidence of pre‐malignant disease.
Lymph Nodes
Palpate both groins for any palpable lymph nodes. If palpable lymph nodes
identified – document number, laterality and whether fixed or mobile. Oedema of
the penis, scrotum, and/or legs may occur.
Investigation
Role of Penile Biopsy

In practice, for suspected inflammatory penile lesions, early biopsy is required to
confirm diagnosis and exclude carcinoma, if there a is lack of early and adequate
response to appropriate medical therapy. For suspicious raised lesions and obvi-
ous cancers, immediate biopsy can both confirm malignancy and offer informa-
tion on cancer subtype, grade, and stage to guide further investigation and
management. The procedure may be carried out under local anaesthetic penile
block or general anaesthetic and may require a dorsal slit to visualise the lesion fully
prior to biopsy. Lesions inside the meatus may be difficult to biopsy endoscopically
and may therefore require a meatotomy to expose the lesion before performing a
biopsy. In any event, this can normally be achieved as an ambulatory procedure.
Although a punch biopsy may be sufficient for superficial lesions, an excisional
biopsy deep enough to properly assess the degree of invasion and stage is prefer-
able. It is also helpful to include normal adjacent tissue to allow examination of
the interface between normal tissue and tumour.
Imaging
Penis
Magnetic resonance imaging (MRI) with a pharmacologically induced (e.g.,
alprostadil) erection has a role in penile‐preserving surgery, and it is a useful tool
when assessing for corporal involvement.
Magnetic resonance imaging may also be helpful in advanced local disease to
assess extent of invasion and presence of skip lesions; this can help with surgical
planning pre‐operatively.
Ultrasound may accurately determine the degree of corporal invasion; however,
it cannot predict invasion of corpus spongiosum in smaller glans tumours.
Regional Lymph Nodes

Penile cancer demonstrates a step‐wise lymphogenic spread, primarily to nodes in
the inguinal region. Following this, metastasis to the pelvic nodes can then occur
with subsequent haematogenic dissemination.
Cancer staging by early assessment for regional lymph node metastases is key to
determining disease prognosis and appropriate lymph node management.
Impalpable Lymph Nodes

In patients with no palpable nodes, approximately 20% will have micro‐metastatic
disease. However, the role of CT and MRI in the nodal staging of the disease is
limited when the nodes are impalpable.
European Association of Urology (EAU) guidelines state that imaging studies
are not helpful in staging clinically normal inguinal regions, although they may
be used in obese patients where palpation is unreliable. Further management of
patients with normal inguinal nodes should be guided by pathological risk factors
of the primary tumour. Lympho‐vascular invasion, local stage, and grade of the
primary tumour are predictive of lymphatic metastasis. Invasive lymph node

staging is required in patients at intermediate or high risk of lymphatic spread.
Dynamic sentinel node biopsy (DSNB) has become established as an accurate
technique for assessment of inguinal lymph node status. In experienced hands,
sensitivity may be increased when combined with preoperative groin node ultra-
sound with fine needle aspiration cytology for nodal staging. (95% sensitivity).
Dynamic sentinel node biopsy technique involves intradermal technetium‐99 m
radio‐isotope injection to the distal penis, followed by SPECT–CT imaging to
localise the sentinel node. Identification of sentinel node/s at surgery is optimised
by combined use of a gamma probe and penile intradermal patent bleu injection
intraoperatively. The technique is relatively simple with low post‐operative com-
plication rate.
Alternatively, superficial modified inguinal lymphadenectomy maybe per-
formed where medial superficial inguinal lymph nodes and those from the central
zone are removed preserving the long saphenous vein. This can be performed
with frozen section examination, where, if any positive lymph nodes are identi-
fied, patients proceed to radical inguinal lymphadenectomy on the ipsilateral side
at the same time.
Palpable Lymph Nodes

Imaging for palpable disease by computerized tomography (CT) or MRI may be
used to assess the size, extent, location, and structures that are in close proximity
to the involved node, as well as the presence of pelvic and retroperitoneal lymph
nodes and distant metastasis.
Distant Metastases
The presence of metastatic pelvic lymph nodes is associated with a poor prognosis
in penile cancer patients. Therefore, CT staging is often in practice carried out
pre‐operatively.
The EAU guidelines advocate staging for systemic metastases in patients with
positive inguinal nodes. Abdominal and pelvic CT is recommended in addition to
a chest X‐ray or thoracic CT. Positron emission tomography/CT (PET/CT) is also
an option with a diagnostic accuracy of 96%.
Management
Management options are determined by the stage of disease taken in conjunction

with patient factors such as age, comorbidities, and performance status.
Management of the Primary Lesion

The aims of treatment of the primary tumour are complete tumour removal
with as much organ preservation as possible and without compromising onco-
logical control. A clearance of 3–5 mm from the surgical margin is deemed
adequate. Local recurrences have been shown to have little influence on long‐
term survival justifying the adoption of organ preservation strategies in order
to minimise the disfiguring effects of the surgery and its devastating psycho-
logical effects.
Treatment options are determined principally by the site of the lesion and
degree of invasion.
Superficial Non-invasive Disease

Even in the absence of foreskin involvement, circumcision should be performed
to facilitate treatment, surveillance, and reduce potential recurrence. Other
treatment options are:
Topical chemotherapy with imiquimod or 5‐FU can be offered. This is an
outpatient self‐applied treatment. Significant and uncomfortable inflammatory
response can occur to treatment. Complete response rates of 57% are reported.
Laser treatment with Nd: YAG or CO2 laser. This can be performed under
local or short general anaesthetic as a day‐case procedure; however, it is not
routinely used.
Partial or Total Glans Resurfacing

This involves excision of part or all of the glans epithelium and subepithelial layer
with application of a split skin graft under general anaesthesia. It is an effective
primary treatment or following failure of topical/laser therapy.
Invasive Disease
Disease confined to the foreskin can be dealt with by circumcision alone pro-
viding that negative surgical margins can be achieved. Small invasive glans
lesions can be treated effectively by partial glansectomy and glans reconstruc-
tion for optimal functional results. Larger lesions (>T2) necessitates total
glansectomy with or without extra‐genital split skin graft reconstruction to the
corporal heads.
Lesions invading the distal corpora are typically managed with partial penec-
tomy with good cosmetic results by split skin graft application to the repaired
corporal bodies.
For the majority of lesions invading corpora, either standard partial or total
penectomy with perineal urethrostomy is appropriate, the choice depending
on whether a useful functional penile length can be achieved by partial
penectomy.
Most surgery for primary penile cancer is feasible as ambulatory day‐case or
overnight‐stay surgery, depending largely on social and home circumstances.
Traditionally postoperative care of procedures involving split‐skin grafting dic-
tated a longer inpatient stay; however, secure fixation of the penile graft dressings
using sutures tied over the dressing can allow early mobilisation and completion
of care as ambulatory surgery.
Lymph Node Management
Early treatment of inguinal node disease is a critical factor influencing prognosis.

Patients with clinically positive nodes and those with positive fine needle aspira-
tion cytology (FNAC) or positive sentinel node biopsy require a radical inguinal
node dissection on the affected side. Open radical inguinal node dissection carries
a significant risk of post‐operative complications, reported in up to 55% in some
studies often resulting in prolonged inpatient care.
Minimally invasive video‐endoscopic inguinal lymphadenectomy (VEIL) has
been developed using laparoscopic/robotic‐assisted techniques to reduce associ-
ated morbidity and hospital stay for patients with small‐volume nodal disease.
Reported series have shown 20% overall morbidity with significantly reduced
rates of wound problems and lymphoedema.
Ipsilateral iliac node dissection is indicated when two or more nodes are
involved or where there is extracapsular nodal disease on histopathology of the
sentinel node. Laparoscopic iliac node dissection reduces post‐operative recovery
time and reduces hospital stay.
Adjuvant chemotherapy has been shown to improve survival for patients with
stage N2/N3 disease.
Follow-Up after Treatment
The aim of follow‐up is the early detection of both local and regional nodal recur-
rence. Both occur most commonly within two years and are rare after five years.
Outpatient assessment and surveillance of penile cancer patients is by physical
examination of the penis and groins. Groin ultrasound ± FNAC can be used as an
adjunct to physical examination for early detection of regional node recurrence.
Table 21.1 summarises the follow‐up protocol adopted from EAU guidelines
(Hakenberg et al. 2019).
Table 21.1 Guidelines for follow-up in penile cancer.
Minimum duration
Interval of follow-up Examinations and Investigations of follow-up Strength rating
Years Years
one to two three to five
Recommendations tor follow‐up of the primary tumour

Penile‐preserving Three months Six months Regular physician or self‐examination. Five years Strong
treatment Repeat biopsy after topical or laser treatment
for penile intraepithelial neopilasia.
Amputation Three months One year Regular physician or self‐examination. Five years Strong
Recommendations for follow‐up of the inguinal lymph nodes
Surveillance Three months Six months Regular physician or self‐examination. Five years Strong
pN0 at Initial Three months One year Regular physician or self‐examination. Five years Strong
treatment Ultrasound with fine‐needle aspiration
biopsy optional.
pN+ at initial Three months Six months Regular physician or self‐examination. Five years Strong
treatment Ultrasound with fine‐needle aspiration
cytology optional, computed tomography/
magnetic resonance Imaging optional.
Source: From EAU guidelines on Penile Cell © 2017 Uroweb.

Summary of Key Points
●● Have a high index of suspicion for penile lesions and arrange prompt biopsy to
confirm diagnosis.
●● Accurate local staging with physical examination, biopsy, and MRI can guide
appropriate penile‐sparing surgical treatment to optimise functional and cos-
metic outcomes.
●● Early invasive inguinal node assessment with DSNB can allow appropriate stag-
ing and early treatment for inguinal node metastases whilst minimising mor-
bidity from unnecessary negative inguinal node dissection.
●● The early detection and treatment of inguinal node metastases is vital to
improve chances of survival.
Further Reading
Alnajjar, H.M., Lam, W., Bolgeri, M. et al. (2012). Treatment of carcinoma in situ of
the glans penis with topical chemotherapy agents. Eur. Urol. 62: 923.
Barocas, D. and Chang, S. (2010). Penile cancer: clinical presentation, diagnosis, and
staging. Urol. Clin. North Am. 37 (3): 343–352.
Bloom, J.B., Stern, M., Patel, N.H. et al. (2018). Detection of lymph node metastases
in penile cancer. Transl. Androl. Urol. 7 (5): 879–886.
Clark, P.E., Spiess, P.E., Agarwal, N. et al. (2013). Penile cancer: clinical practice
guidelines in oncology. J. Natl. Compr. Canc. Netw. 11 (5): 594–615.
Hakenberg, O.W., Compérat, E., Minhas, S. et al. (2019). Penile Cancer. European
Association of Urology. http://uroweb.org/guideline/penile‐cancer.
Sharma, P., Djajadiningrat, R., Zargar‐Shoshtari, K. et al. (2015). Adjuvant
chemotherapy is associated with improved overall survival in pelvic node‐positive
penile cancer after lymph node dissection: a multi‐institutional study. Urol. Oncol.
33: 496 e17.
233
22
Testis Cancer
Benjamin Patel
Testicular cancer (TC) is the most common solid cancer in men aged 20–45 with
around 2400 new cases in 2016 in the UK. It constitutes 1% of male cancers and
5% of urological tumours. Since the early 1990s, the incidence has increased by
28% in males in the UK. The incidence is projected to further rise by 12% in the
UK between 2015 and 2035 to 10/10 000 males. There is a peak incidence between
30 and 34 and it is rarely found in those below 15 years and above 60 years. (See
Figure 22.1.) Encouragingly, mortality has fallen since the introduction of
platinum‐based chemotherapy, with a 98% 10‐year survival in the UK. Indeed, in
2016 there were less than 60 deaths.
Aetiology
Aetiological factors are largely non‐modifiable. TC is more common in white

western Caucasians. The most commonly affected age group is 20–45 years and
there is a variable histological pattern of disease according to age. Non‐seminoma-
tous germ cell tumours (NSGCTs) affect a slightly younger cohort (20–35 years)
compared to seminomas (35–45 years). Infants and children below 10 years most
commonly develop yolk sac tumours and 50% of TCs in those >60 years are
lymphoma.
A previous diagnosis of TC is associated with a 12‐fold increased risk of
metachronous TC, with bilateral TCs occurring in 1–2% of cases. 5–10% of TC
patients have a history of cryptorchidism. In unilateral cryptorchidism, TC risk is
6 times greater in the undescended testicle and 1.7 times increased in the
descended testicle. One large study indicated that those who undergo early orchi-
dopexy (<13 years) have a twofold increased risk of TC, compared to a fivefold
increased risk in those undergoing late orchidopexy (>13 years).
90+
80 to 84
70 to 74
60 to 64
Age Range
50 to 54
40 to 44
30 to 34
20 to 24
10 to 14
0 to 04
0 50 100 150 200 250 300 350 400 450 500
New cases per 100,000 males
Figure 22.1 Average number of new cases per year per 100,000 males, UK. Source:
Based on graphic created by Cancer Research UK.
Genetic factors have also been identified. TC is 5 times higher in men with an
affected father and 8–9 times higher in men with an affected brother. Additionally,
Kleinfelter’s syndrome and Kallman’s syndrome are associated with increased
TC risk.
In general, TC is not clearly linked to preventable factors. Human immunodefi-
ciency virus HIV appears to increase risk of TC by 30–40%. There is weak evidence
for chemical carcinogens and rural residence increasing risk. However, there is no
strong evidence for smoking, alcohol, vasectomy, or trauma increasing risk.
Finally, Testicular carcinoma in situ, also known as intratubular germ cell neo-
plasia (ITGCN) or testicular intraepithelial neoplasia (TIN), is a precursor for TC;
around 50% of men with cancer in situ (CIS) will develop TC within five years
without treatment.
Symptoms and Signs
Testicular cancer most commonly presents as a hard, painless lump. It is slightly

more common on the right side and bilateral in 1–2% of cases. Five percent of
TCs present with acute scrotal pain, secondary to intra‐tumoral haemorrhage.
Ten percent unfortunately present with symptoms of advanced disease, includ-
ing weight loss, lumps in the neck, bone pain, chest symptoms and neurological
symptoms. Lumbar back pain may occur if the psoas muscles and nerve roots
are affected.
22 Testis Cancer 235
A proportion of TCs present during routine clinical examination, casual

ultrasound (US) findings, or are revealed by scrotal trauma. On examination by
bimanual palpation, testicular asymmetry may be identified. A hard, non‐tender,
irregular and non‐trans illuminable mass may be felt in the testis. An associated
hydrocele may be present if the tunica albuginea is breached. The epididymis,
spermatic cord, and scrotal wall may be normal or involved in a small proportion
of cases. Endocrine manifestations of certain TCs may results in gynaecomastia.
Metastatic disease may result in supraclavicular lymphadenopathy, abdominal
masses, hepatomegaly, lower limb oedema, chest signs, and cachexia.
Pathology and Subtypes
The majority of TCs are germ cell tumours (GCTs), subcategorised into semino-
matous germ cell tumour (SGCT) and non‐seminomatous germ cell tumour
(NSGCT) (see Table 22.1). Classic seminomas are well circumscribed, homoge-
nous firm pale tumours. Anaplastic seminomas are similar to classic seminomas
but have increased numbers of mitoses. Spermatocytic seminomas are found in
an older cohort of men and are generally benign. Teratomas are heterogenous
tumours composed of elements of fully differentiated tissue: mesoderm (bone,
cartilage, muscle), ectoderm (neural tissue and stratified squamous including
skin and derivatives such as hair follicles) and endoderm (including mucus
glands).
Investigation
Ultrasound (US) is the first line investigation of scrotal lumps, with a sensitivity of
almost 100% and will confirm whether a lump is intra‐ or extra testicular. It is
inexpensive and should be performed to explore the abnormal and contralateral
testes. Magnetic resonance imaging (MRI) of the scrotum has a greater sensitivity
and specificity than US in diagnosing TC, but its high cost obviates its routine use.
Serum tumour markers play a role in diagnosis and differentiation, and they
also have a prognosticating role. Alpha‐fetaprotein (AFP) (produced by yolk sac
cells), human chorionic gonadotropin (hCG) (produced by trophoblasts) and lac-
tate dehydrogenase (LDH) should all be measured before and seven days after
orchidectomy. Beta‐hCG is elevated in 100% of choriocarcinomas, 40% of terato-
mas, and 10% of pure seminomas. Alpha‐fetaprotein can be elevated by embryo-
nal carcinoma, teratoma, and yolk sac tumours. Pure seminomas and
choriocarcinomas are not associated with raised AFP. Lactate dehydrogenase is
elevated in half of TCs and is used to assess tumour burden. It is the only elevated
Table 22.1 Testicular cancer classification and distribution.
Germ cell tumours (90–95%) Other tumours (5–10%)
Seminoma (60%) Stromal:

●● Spermatocytic ●● Leydig
●● Classical ●● Sertoli
●● Anaplastic ●● Gonadoblastoma
Non‐seminomatous (40%) Lymphoma
●● Teratoma (mature, immature) Metastatic from other site (<1%)
●● Yolk sac tumour Rhabdomyosarcoma
●● Embryonal Adenomatoid tumour
●● Choriocarcinoma Epidermoid cyst (benign)
●● Mixed
marker in 10% of non‐seminomas. PLAP is elevated in 40% of patients with

advanced germ cell tumours (GCTs), but is non‐specific and falsely elevated in
smokers.
Imaging plays an important role. Computerized tomography (CT) is generally
undertaken of the abdomen and pelvis to analyse extra‐testicular metastasis and
lymph node involvement. Chest X‐ray (CXR) is utilised to exclude pulmonary dis-
ease, with further imaging of chest, brain, spine, and bones where clinically indi-
cated. Importantly, biopsy is not generally advised for the evaluation of testicular
masses. Diagnosis is instead established by histological analysis of the testis after
removal.
All patients with suspected testicular mass should undergo inguinal explora-
tion, alongside exteriorisation of the testis within its tunics. If a malignant tumour
is identified, orchidectomy and division of the spermatic cord at the internal
inguinal ring should be carried out. This is routinely performed in the ambulatory
setting.
Staging of TC includes the anatomical extent of the primary tumour (pT),
regional nodes (N) and distant metastases (M), alongside the assessment of serum
tumour markers after orchidectomy (S).
anagement of Seminomatous Germ Cell

M
Tumours (SGCTs)
Stage I non‐locally invasive disease can be managed with surveillance, with a

relapse rate of 15–20% at five years. In low‐risk groups (tumour size <4 cm and no
rete testis invasion), the recurrence rate may be much lower. Chemotherapy may
22 Testis Cancer 237
be utilised in the case of relapse under surveillance, although the majority of

patients are suitable for radiotherapy alone because of the small volume of disease
at the time of recurrence. Alternatively, stage I non‐locally invasive seminomas
can be managed with single agent carboplatin chemotherapy. Whilst seminoma
cells are extremely radiosensitive, the increased risk of radiation‐induced second-
ary non‐germ cell malignancies means that adjuvant radiotherapy is rarely used
in stage I disease and has no role in young patients <40 years. Retroperitoneal
lymph node dissection (RPLND) is not recommended in stage I seminoma.
Stage IIA/B seminomas may be managed with radiotherapy, with reported
relapse rates of 9–24%, although long‐term radiotherapy‐associated morbidity
such as secondary malignancies and cardiovascular events are a concern.
Chemotherapy is an alternative, with similar reported relapse rates. Three cycles
of bleomycin, etoposide, and cisplatin (‘BEP’) chemotherapy are generally
employed, with four cycles of EP in cases where bleomycin toxicity is a concern.
anagement of Non-seminomatous Germ Cell

M
Tumours (NSGCTs)
Options for stage I patients include active surveillance, adjuvant chemotherapy,

and RPLND. Patients should be informed about all options, including recurrence
rates and potential side effects, and the ultimate decision should take into account,
risk based on vascular invasion. The largest studies of surveillance strategies sug-
gest a cumulative relapse rate of 30%. Alternatively, patients may receive adjuvant
chemotherapy with BEP, which appears to reduce relapse to under 5% with mini-
mal long‐term toxicity. Salvage treatment of patients with recurrence during sur-
veillance generally consists of three to four courses of BEP chemotherapy,
followed by RPLND if necessary. The role of primary RPLND has now diminished
in stage I disease, in view of the high cancer‐specific survival rates of surveillance
with salvage treatment and the low relapse rates if adjuvant chemotherapy is
employed.
In stage IIA/B NSGCTs, chemotherapy is generally employed, except for stage
II disease without elevated tumour markers, in which RPLND or surveillance can
be undertaken to clarify stage of disease.
Management of Metastatic Testicular Cancer
Metastatic SGCT and NSGCT are generally managed with three cycles of chemo-
therapy, alongside RPLND for residual or recurrent masses and salvage chemo-
therapy for relapsing disease.
Further Reading
Kier, M.G., Lauritsen, J., Mortensen, M.S. et al. (2017). Prognostic factors and
treatment results after bleomycin, etoposide, and cisplatin in germ cell cancer: a
population‐based study. Eur. Urol. 71: 290.
Laguna, M.P., Albers, P., Algaba, F. et al. (2019). Testicular Cancer. European
Association of Urology. http://uroweb.org/guideline/testicular‐cancer.
Tandstad, T., Ståhl, O., Håkansson, U. et al. (2014). One course of adjuvant BEP in
clinical stage I nonseminoma mature and expanded results from the
SWENOTECA group. Ann. Oncol. 25: 2167.
239
23
Plain X-Ray, Computed Tomography Scanning,

and Nuclear Imaging in Urology
Tharani Mahesan
Imaging and radiological investigation are important tools in the urologist’s arma-
mentarium, and access various modalities and sound working theory for their
usage is key to running an ambulatory service. Historically X‐rays were the most
widely used imaging modality in urology, however in recent decades computed
tomography (CT) scanning is often preferred to ‘plain’ X‐ray imaging. An X‐ray is
a type of transmission radiology in which an electromagnetic beam is passed
through the body. Tissue‐ energy reactions alter the beam as it is transmitted and
energy is absorbed by different tissues, to differing degrees. This varied absorption
leads to production of an image at a detector or plate, but could be considered as
taking a ‘measurement’ of those differing tissues using X‐ray absorption.
Computerized tomography (CT) scanning employs an X‐ray transmission
source and detector that rotate about the patient, essentially taking multiple X‐ray
‘measurements’ from multiple angles. This data is then compiled, reconstituted,
and reconstructed as cross‐sectional imaging.
Computerized tomography scanning allows for measurement of tissue or struc-
ture density and this is measured in Hounsfield units (HU). The higher the HU,
the ‘brighter’ a structure appears on CT. This linear scale assigns the tissue a score
relative to distilled water at standard pressure and temperature (being 0 HU) and
air at standard pressure and temperature (being −1000 HU).
The Hounsfield scale is only applied to the density of tissues on medical CT
scans. (See Table 23.1.)
Non‐contrast CT scanning of the kidneys, ureters and bladder (so‐called CT
KUB) is now the gold‐standard imaging modality for suspected ureteric colic.
For other diagnoses, the additional use of iodinated contrast allows for further
enhancement and delineation of the entire urinary tract, which can assist in
identifying mass lesions, ‘filling defects’ or causes of ureteric obstruction. The
use of intravenous contrast agents can allow some determination of the
Table 23.1 Hounsfield values of tissues on CT scan.
Tissue HU
Fat −120 to −90

Bone +1800 to 1900
Kidney +20 to +45
Blood +13 to +50
Blood clot +50 to +75
Urine −5 to +15
function of the kidney; however nuclear medicine (NM) imaging is a far supe-
rior modality for this purpose.
Clinicians need to be mindful that use of X‐ray and CT is not without risk. As
radiation passes through the body it is absorbed. The effect of ionising radiation
on human tissues is measured in Sieverts, a derived unit that is representative of
the stochastic health risk attached to the radiation. Medical scans typically have
their radiation effects defined in millisieverts (mSv). It is worth noting that some
tissues absorb more radiation than others. This can mean that the effective dose of
radiation (whole body radiation absorbed) is higher for certain studies. (See
Table 23.2.)
The ALARA (As Low As Reasonably Achievable) principle should be kept in
mind when considering the necessity for use of ionising radiation for the purposes
of investigation. In younger patients particularly, it should be considered whether
ultrasound could reasonably answer the diagnostic question instead of an X‐ray
based scan. Furthermore, intravenous administration of iodinated contrast also
poses its own risks – largely due to its nephrotoxicity. Patients who take met-
formin are at risk of developing metabolic acidosis, but this risk is dependent on
level of renal function and volume of contrast given. Radiology departments will
have protocols for either omitting metformin prior to or after a scan to reduce this
risk. In some cases, it may be safe to continue taking metformin. Anaphylactoid
reaction to injected contrast media is a rare but serious event. Previous reactions
to IV contrast present a contraindication to a further contrast CT scan.
X-ray
An X‐ray of the KUB can be used to look for the presence of renal or ureteric cal-
culi. Although around 90% of renal stones are radio‐opaque, most studies confirm
the sensitivity of plain KUB X‐ray to be around 50% for detecting stones. Due to
23 Plain X-Ray, Computed Tomography Scanning, and Nuclear Imaging in Urology 241
Table 23.2 Radiation dose (in mSv) of imaging modalities.
Type of imaging mSv
Chest X‐ray 0.02

Abdominal X‐ray 0.07
IVU 3
CT KUB (low dose) <3.5
CT KUB (ultra‐low dose) <1.9
CT abdomen and pelvis (no contrast) 10
CT abdomen and pelvis (contrast) 20
CT Urogram 15.9
the speed and simplicity of plain X‐ray, however, this modality is still commonly
used for re‐assessment of a known stone burden or to demonstrate the passage of
a known ureteric calculus.
I ntravenous Pyelogram (IVP) or Intravenous

Urogram (IVU)
Intravenous urogram (IVU) or intravenous pyelogram (IVP) is now becoming

somewhat historic, having been supplanted by the superior sensitivity and speci-
ficity of CT for the assessment of ureteric colic. The IVU protocol consists of a
pre‐contrast control, followed by administration of intravenous (IV) contrast and
series of plain KUB X‐rays to assess the uptake of contrast into the kidneys and the
excretion. The contrast delineates the shape of the kidney (nephrogram) and can
demonstrate hydronephrosis and delayed drainage via a ‘standing column’ of con-
trast in a poorly draining ureter.
A single shot IVU continues to have a role in the operating theatre for ‘on table’
investigation of renal trauma and suspected collecting system injuries and can
occasionally be useful in Shockwave Lithotripsy to help identify the location of a
ureteric stone at the distal‐most point of a ‘standing column.’
CT KUB
CT KUB is a non‐contrast, low‐dose CT scan that is used most commonly for the
identification of nephrolithiasis. CT KUB offers near 99% sensitivity for urinary tract
calculi and allows assessment of concomitant hydronephrosis and hydroureter.
CT KUB allows for reasonable assessment of urinary tract anatomy, and for
patients with a contra‐indication to intravenous contrast (e.g., chronic kidney dis-
ease) it remains a useful investigation for presentations of other conditions such
as haematuria and urinary tract sepsis.
CT Urogram (CTU)
CT urography is employed most commonly for the investigation of visible haema-

turia and involves three scan phases. A non‐contrast phase (CT KUB), a further
scan sequence at 60–90 seconds post‐injection of contrast and a delayed scan
sequence at approximately 10–15 minutes. At 60–90 seconds, the uptake of IV
within the renal parenchyma produces a ‘nephrographic phase.’ It is in this phase
that renal masses may be identified. The delayed sequence allows clinicians to
visualise the drainage of the contrast from the kidney to the bladder and can iden-
tify filling defects, hydroureter, or delayed drainage.
Renal Protocol CT Scan
This scan protocol is used to characterise renal lesions. There is a pre‐contrast phase
followed by three further phases: the cortico‐medullary phase, the nephrogenic
phase, and excretory phase. The cortico‐medullary phase takes place 25–40 seconds
after injection of contrast. The degree of uptake of contrast within a lesion (seen as
increased ‘brightness’) is defined as ‘enhancement.’ A change of greater than 20 HU
is considered significant. The nephrogenic scan sequence; taken 100 seconds post
contrast, allows visualisation of the vascularity of the lesion as well as presence of
thrombus within the vein. As with a CT urogram (CTU), the delayed excretory
phase allows delineation of the entire urinary tract and is useful in patients where
transitional cell carcinoma is suspected within the collecting system.
Staging CT Scans
In patients with significant malignancy, contrast CT scans of the chest, abdomen,

and pelvis are performed in order to stage the cancer. Staging is important to
determine whether the disease is confined to an organ and thereby establish treat-
ment and prognosis.
Percutaneous Procedures
Imaging guided percutaneous procedures provide an important tool in diagnostic

and interventional urology. Procedures may be ultrasound, fluoroscopy, or CT
guided. In most centres the renal procedures are performed by radiologists.
Renal Biopsy
Widely shunned for many years due to concerns about seeding, we are now seeing
an increase in renal biopsy. Given the number of renal masses being identified
incidentally, especially in younger patients, it offers the benefit of avoiding
nephrectomy (partial or radical) in those that are found to benign. This is further
discussed in Chapter 20, Renal Cancer.
Renal Cyst Aspiration

These are normally ultrasound guided. They are not commonly performed due to
the high risk of recurrence as well as the small risk of seeding if the cyst is incor-
rectly characterised. All cysts must be characterised on CT using the Bosniak clas-
sification before aspiration is considered.
Aspiration and sclerosant instillation should be reserved for those who are
symptomatic with very large cysts but who are not candidates for surgery either
due to patient choice or fitness.
Nephrostomy and Antegrade Procedures

A nephrostomy is a drain placed percutaneously directly into the renal collecting
system. It is sited by interventional radiologists under ultrasound and fluoroscopic
guidance.
Common indications for nephrostomy insertion include renal obstruction sec-
ondary to malignant conditions, ureteric injuries, and impassable structuring of
the ureter. Nephrostomy represents a valuable ‘rescue’ option where retrograde
stenting has failed.
If a guide‐wire can be advanced into the bladder via a nephrostomy tract, ‘ante-
grade’ ureteric stent insertion can be attempted.
Nuclear Medicine Scans
Nuclear medicine (NM) scans rely on radioactive tracers injected into the body. As the
tracer decays, radiation is emitted and can be detected. This allows sensitive measure-
ments of the quantity of tracer within the renal tract, based on the radiation emission
and therefore accurate representation of renal uptake and function as well as excretion.
The most commonly used tracer isotope in urology is technetium 99, which
decays to emit gamma radiation.
The use of radioactive tracers does expose the patient to a small amount of radi-
ation that does minimally increase their cancer risk. There is a small risk of allergy
to the tracer. Nuclear medicine scans are not suitable for those who are pregnant,
trying for pregnancy, or breast feeding.
MAG3 Renogram
Relying on the tracer 99mTc labelled Mercapto‐Acetyl Triglycine (MAG3) reno-
grams are dynamic scans that allow for the assessment of renal uptake, process-
ing, and excretion.
It is used to diagnose functional renal obstruction, but can also identify ureteric
reflux. MAG‐3 provides an estimation of split renal (right vs left) function but this
is not as accurate as a dimercaptosuccinic acid (DMSA) (see next section). Perhaps
the most common use is for patients with pyelo‐ureteric junction obstruction
(PUJO) or for assessment of outcomes in those who have undergone previous
pyeloplasty.
DMSA
Like MAG 3, DMSA is labelled with 99mTc. Unlike MAG3, it is not excreted by the
proximal tubules and the image obtained is a static one. By obtaining an image at
three to four hours post‐injection, clinicians are able to quantify the number of
functioning nephrons in each kidney relative to the other side.
DMSA scans are useful for assessing split function and for monitoring for the
presence of scars where nephrons may have been damaged. DMSAs may be used
in patients with stag horn calculi or long standing PUJO where benign nephrec-
tomy is being considered, or in those with renal lesions for whom a radical or
partial nephrectomy is being pursued.
Bone Scan
Another static scan, bone scans are used in urology for assessment of prostatic
bony metastases. Patients are injected with technetium labelled methylene
diphosphonate (MDP). Methylene diphosphonate is preferentially taken up in
areas with increased osteoblastic activity such as metastatic deposits.
Positron Emitting Tomography (PET)/PET CT

A positron emitting tomography (PET) scan or PET/CT scan uses radioactive trac-
ers to identify areas of increased or altered metabolism. It is widely used in the
identification and surveillance of malignancy as well as assessing response to
treatment. Combining PET scans and CT scans offers both metabolic and ana-
tomical detail. The most widely used radiotracers for PET scans in urology are
18F‐fluorodeoxyglucose (FDG) and 11c‐choline. These radio‐isotopes decay emit-
ting positrons, and as these travel through tissues they slow down. As they slow,
they are able to interact with electrons that destroy both of them and produce
gamma photons. These gamma photons are detected by a gamma camera. FDG is
used in the assessment for metastases in renal and bladder cancer, as well as the
staging and spread of testicular cancer. Choline PET can be used for the diagnosis,
staging, and surveillance of prostate cancer.
Further Reading
Payne, S. and Eardley, I. (2012). Imaging and Technology in Urology: Principles and
Clinical Applications. New York: Springer.
Tublin, M.E. and Nelson, J. (2018). Imaging in Urology. New York: Elsevier.
247
24
Magnetic Resonance Imaging in Urology

Benjamin Patel
In the last decade, magnetic resonance imaging (MRI) has become pivotal in the
staging and investigation of urological malignancy and has had a transformative
effect on prostate cancer care pathways.
Basic Principles
Nuclei, made up of protons and neutrons, are charged particles with a specific
motion or ‘precession.’ When a human body is placed in a strong magnetic field,
many of the free, randomly aligned hydrogen nuclei align themselves with the
direction of the magnetic field. This behaviour is termed Larmor precession. To
generate a magnetic resonance (MR) image, a radio-frequency pulse with a fre-
quency equal to the Larmor frequency is applied perpendicular to the magnetic
field, causing the net magnetic moment to tilt away from the direction of the mag-
netic field. Once the radio-frequency signal is halted, the nuclei realign them-
selves with their net magnetic moment parallel to the strong magnetic field.
During this ‘relaxation’, the nuclei lose energy and emit their own radiofrequency
signal, referred to as the ‘free-induction decay (FID) response signal.’ The FID
response signal can then be measured by a field coil placed around the body being
imaged. This measurement can be reconstructed to generate three-dimensional
MR images.
There are two types of relaxation: longitudinal (T1) and transverse (T2). T1
measures the time taken for the magnetic moment of the displaced nuclei to return
63% to thermal equilibrium. Water and cerebrospinal fluid (CSF) have long T1 val-
ues, appearing dark on T1 weighted images, whereas fat has a short T1 value and
appears bright. T1-weighted imaging (T1WI) is particularly useful in identifying
post-biopsy haemorrhage and detecting the status of lymph nodes and skeletal
metastases, especially in combination with IV gadolinium-based contrast. T2 on

the other hand measures the time required for the FID response signal to decay.
Clinical Applications
Multi-Parametric MRI in Prostate Cancer
The utility of single sequence T1WI in evaluating the prostate is limited by poor
differentiation between prostate and surrounding tissues, artefact from bowel
motility and poor intra-prostatic tissue resolution. Multi-parametric MRI
(mpMRI) aims to obtain an ideal three-dimensional prostate image by combining
T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and dynamic
contrast-enhanced imaging (DCEI). In general, intestinal motility-reducing drugs
and endorectal coils are used to reduce signal artefact associated with intestinal
peristalsis.
T2WI detects the low intensity of neoplastic tissue. Its high resolution provides
a sharp demarcation in the prostate capsule. However, in isolation, it is poor at
detecting transitional zone and central zone cancers. Diffusion-weighted imaging
provides an ‘apparent diffusion coefficient’ (ADC) map and high b-value images.
Clinically significant cancers appear hypointense in the ADC maps due to
restricted diffusion. DWI is better at identifying transitional zone and central zone
tumours, as well as cancer aggressiveness, but has poor resolution. DCEI uses
gadolinium-based contrast agent to visualise angiogenesis and thus evaluate the
vascularity of tumour.
Prostate Imaging Reporting and Data System (PI-RADS) was established in
2012 by the European Society of Urogynaecologic Radiology to standardise report-
ing of prostate MRI and was updated in 2015 with the release of PI-RADSV2. A
score from 1 to 5 is assigned, with 1 indicating that clinically significant cancer is
highly unlikely, 3 indicating that clinically significant cancer is equivocal, and 5
indicating that clinically significant cancer is highly likely. Interest in mpMRI has
accelerated following publication of PROMIS (Prostate MR Imaging Study),
which evaluated the diagnostic accuracy of mpMRI before biopsy and concluded
that mpMRI might allow 27% of patients with raised prostate-specific antigen
(PSA) to avoid biopsy.
Evaluation of Renal Masses

As detection rates of renal masses continue to increase, clinicians have aimed to
improve characterisation of these lesions. The first step is to differentiate benign
cysts from solid masses, which contain little or no fluid. This can generally be done
with ultrasound, with indeterminate or solid masses then undergoing further
24 Magnetic Resonance Imaging in Urology 249
characterisation with contrast-enhanced CT or MRI. The most common solid

malignant renal masses are renal cell carcinoma and urothelial carcinoma, whereas
the most common solid benign renal masses are angiomyolipoma (AML) and
oncocytoma.
Magnetic resonance imaging is a useful imaging tool for diagnosis and charac-
terisation of renal lesions because it provides excellent soft-tissue contrast. In
renal cell carcinoma, a hypointense pseudo capsule may be seen on both T1 and
T2-weighted images. Interruption of this capsule correlates with invasion of peri-
renal fat. DWI and dynamic contrast enhanced (DCE) can provide further infor-
mation regarding the tumour histology: there appears to be an inverse relationship
between the apparent diffusion coefficient (ADC) value and Fuhrman grade. MRI
is thus useful in differentiating benign from malignant lesions as well as predict-
ing the subtype and tumour grade.
Classic angiomyolipomas (AMLs) are identified on MRI because they manifest
with the hallmark of bulk fat, providing a high T1 signal. Lipid-poor AMLs are
more difficult to distinguish from renal cell carcinoma (RCC). The typical
enhancement pattern is of early intense enhancement with subsequent washout,
high signal-intensity index, and low tumour-to-spleen signal-intensity ratio.
Staging Investigations
MRI is utilised in the staging of many urological cancers, according to the tumour/
node/metastases (TNM) classification.
In prostate cancer, T2WI is fundamental in assessing extra-capsular extension,
seminal vesicle invasion, and lymph node metastasis. Staging accuracy is
enhanced using endorectal surface coil and the evolving role of DWI and DCE.
MRI is increasingly used in the staging of bladder cancer to assist in the differ-
entiation of T2 and T3 disease, having been demonstrated to better assess intra-
mural and extravesicular tumour invasion compared with CT. High resolution
T2WI of the bladder in three planes with a small field of view and large matrix are
used to evaluate the detrusor muscle. Potential artefacts include inappropriate
bladder distension, chemical shift, and motion artefact. Optimal bladder disten-
sion is achieved by having the patient void two hours before imaging. Bowel peri-
stalsis can be minimised by administrating anti-motility agents. Chemical shift is
reduced by increasing the bandwidth and selecting the frequency-encoding gradi-
ent direction that least interferes with examination of the bladder wall.
Staging of penile cancer can be improved with MRI in combination with
induced erection using prostaglandin E1, to exclude tumour invasion of the cor-
pora cavernosa. However, imaging is not a reliable tool for detecting abnormal
inguinal nodes. Distant metastases are generally assessed using computerized
tomography/proton emission tomography (CT/PET).
Advantages and Disadvantages
MRI has the obvious advantage of not using ionising radiation. It provides excelled
contrast between different soft tissues and higher resolution than CT. It can also
scan in any plane. However, machines remain significantly more expensive and
scans take more time than CT. More artefacts are encountered in MRI. In addi-
tion, MRI is contraindicated in patients with internal ferrous objects, such as
aneurysm clips. In children, a general anaesthetic may be required. It is also less
useful in patients with claustrophobia, due to the enclosed space.
Further Reading
Payne, S. and Eardley, I. (2012). Imaging and Technology in Urology: Principles and
Clinical Applications. New York: Springer.
Tublin, M.E. and Nelson, J. (2018). Imaging in Urology. New York: Elsevier.
251
Index
Page locators in bold indicate tables. Page locators in italics indicate figures.
This index uses letter-by-letter alphabetization.
a ALARA principle 240, 241

abdominal examination 39 alcohol 100
abdominal leak point pressure alpha-adrenoceptor agonists 77–78
(ALPP) 50–51 alpha-fetoprotein (AFP) 235
abdominal pain 187 5-alpha reductase inhibitors
abdominal sacro-colpopexy 106 (5-ARI) 208
Accreditation Council for Graduate ALPP see abdominal leak point pressure
Medical Education (ACGME) 142 ambulatory evaluation 33–52
acetaminophen 104 abdominal examination 39
ACGME see Accreditation Council for cough stress test 44–45
Graduate Medical Education cystoscopy 51
acute-on-chronic urinary retention 186 external gynaecological
acute urinary retention (AUR) 185 examination 39, 40
ADC see apparent diffusion coefficients family history 37–38
advanced training skills modules general examination 38
(ATSM) 138, 141 general medical history 36–37, 36
AFP see alpha-fetoprotein gynaecological history 37
age internal gynaecological
ambulatory surgery service 5 examination 41–42, 42–43
pelvic floor dysfunction 22 investigations 44–51, 47, 49
prostate cancer 208 neurological examination 38–39
Ajust 90, 91 obstetric history 37
252 Index
ambulatory evaluation (cont’d ) American Urogynaecologic Society

pad test 45–46 (AUGS) 141
pelvic muscle function AML see angiomyolipoma
assessment 43, 43 anaesthesia
pelvic organ prolapse 34–41, 42–43, ambulatory surgery service 5–6, 7–8
44–47, 51 ambulatory surgical procedures in
physical examination 38–43, POP 102–103
40, 42–43 benign prostatic obstruction 181
presenting symptoms 33–34 early recovery: emergence from
quality of life 38 anaesthesia 8
sexual dysfunction 38 paediatric urology 197
urethral pressure profile 45, 50–51 physical selection criteria 5–6
urethro-vesical mobility 45 anal/faecal incontinence
urinary diary 44 childbirth pelvic floor
urinary incontinence 33–38, 44–51, 49 trauma 128–130, 130
urine analysis 44 faecal incontinence severity
urodynamic testing 48–50 index 128, 130
uroflowmetry 47–48, 49 non-surgical management of pelvic
urogynaecological floor disorders 69–72, 79–80
ultrasound 46–47, 47 pelvic floor dysfunction 20, 22
urological history 34–38, 36 analgesia
ambulatory surgery service 3–15 ambulatory surgery service 8
anaesthesia 7–8 ambulatory surgical procedures in
complication rates 12 POP 101–102, 104
early recovery: emergence from urothelial bladder cancer 202
anaesthesia 8 androgen deprivation therapy 214–215
economics of ambulatory angiomyolipoma (AML) 249
surgery 11–12 anorectal manometry 131–132
history and context 3 antegrade procedures 243
infrastructure 3–4 anterior vaginal repair 105–106
intermediate recovery: discharge antibiotics
criteria 8–9 paediatric urology 194, 195–196, 198
late recovery: care after discharge 10 recurrent urinary tract infections
physical selection criteria 5–6 171
pre-operative assessment 4–5 urinary retention 191
preparation for surgery 6–7 anticholinergics 77–78
setting up an ambulatory antiemetics 7–8
centre 10–12 antimuscarinics 199
social selection criteria 5 anxiolytics 101
American Society of Anaesthesiologists apparent diffusion coefficient (ADC)
(ASA) 5–6 maps 248–249
Index 253
arcus tendineus fascia pelvis International Prostate Symptom

(ATFP) 26–30, 30 Score 180
arcus tendineus levator ani medical management 180–181
(ATLA) 24–25, 25, 29 presentation and differential
5-ARI see 5-alpha reductase inhibitors diagnosis 175–176, 176
ASA see American Society of prostate examination and PSA 178
Anaesthesiologists surgical management 181–183
ASAP see atypical small acinar ultrasound and post-void residual
proliferation volume 179–180
ATFP see arcus tendineus fascia pelvis urine dipstick testing 177, 177
ATLA see arcus tendineus levator ani urodynamic studies 178–179
ATSM see advanced training uroflowmetry 178, 179
skills modules benign renal masses 248–249
atypical small acinar proliferation benign urogynaecological
(ASAP) 207 lesions 109–122
AUGS see American Bartholin’s cyst 118–120, 119
Urogynaecologic Society embryology and anatomy of
AUR see acute urinary retention urethra 109–110
epithelial inclusion cysts 121
b Gartner’s and Müllerian duct cysts 120
Bacillus Calmette-Guerin (BCG) 205 introduction 109
bacteriuria 168 leiomymomas 121
BADS see British Association of pathogenesis 116–117
Day Surgery Skene’s duct cyst 120–121
balanitis xerotica obliterans (BXO) urethral caruncle 110–111
156 urethral
balanoposthitis 198 diverticulum 112–116, 113–114
Bartholin’s cyst 118–120, 119 urethral lesions 110–118, 121
Bartholin’s glands 109 urethral prolapse 111, 112
BCG see Bacillus Calmette-Guerin urethrovaginal fistulae 114–115,
benign prostatic hyperplasia (BPH) 116–118, 117
benign prostatic obstruction 175, urothelial cysts 121
180, 182 vaginal lesions 118–121
urinary retention 186 biofeedback 71–72
benign prostatic obstruction biofilms 170
(BPO) 175–184 biopsy
choice of surgery 183 imaging guided percutaneous
flexible cystoscopy 179 procedures 243
further assessment and penile cancer 225–226, 227
investigations 176–180 prostate cancer 208, 210, 213, 214
history 176–177 renal cancer 220
254 Index
bladder cancer see urothelial insertion technique 190

bladder cancer patients requiring admission 191
bladder cystoscopy 57–58 suprapubic catheter
bladder pain syndrome (BPS) 58, 59 insertion 190–191
bladder re-training 72–73 types of urethral catheters 189
blood stained ureteric efflux 57–58 urinary retention 189–191
body mass index (BMI) cauda equina compression 187
ambulatory evaluation 38 ccRCC see clear cell renal cell carcinoma
ambulatory surgery service 5 Centers for Medicare and Medicaid
non-surgical management of pelvic Services (CMS) 99
floor disorders 69–70 cervical cancer 57
pelvic floor dysfunction 23 chemotherapy
renal stone disease 164 penile cancer 229
bone scans 209, 212, 244 prostate cancer 214–215
Botulinum toxin 60 testicular cancer 233, 236–237
bowel habit evaluation 35–36 chest X-ray (CXR) 236
bowel symptom evaluation 35 childbirth pelvic floor trauma
BPH see benign prostatic hyperplasia 123–136
BPO see benign prostatic obstruction birth mode subsequent to
BPS see bladder pain syndrome OASIs 131–132
brachytherapy 214 introduction 123–124
breast cancer susceptibility protein levator ani muscle
(BRCA) mutations 208–209 avulsion 132–133, 133–135
British Association of Day Surgery obstetric anal sphincter
(BADS) 10 injuries 128–132, 130
bulge symptoms 35 perineal wound
Bulkamid 86, 86 complications 124–127, 126
bulking agents see urethral superficial dyspareunia post-
bulking agents childbirth 127–128, 129
BXO see balanitis xerotica obliterans chronic obstructive pulmonary disease
(COPD) 6
c chronic urinary retention 186
caesarean section 132 circumcision
carcinoma in situ (CIS) 204 paediatric urology 198
cardiovascular status 6 penile and inguino-scrotal ambulatory
caruncles 110–111 surgery 156
catheterisation penile cancer 223, 229–230
ambulatory urology and urinary CIS see carcinoma in situ
retention 191 clear cell renal cell carcinoma
flexible cystoscopy guided (ccRCC) 218
insertion 190 clot retention 186
Index 255
CLPP see cough leak point pressure CST see cough stress test
CMS see Centers for Medicare and CT see computed tomography
Medicaid Services cube pessary 75
Coaptite 87, 87 CXR see chest X-ray
coccygodynia 20 cystitis
colporrhaphy 105–106 interstitial cystitis 58, 59, 145
computed tomography (CT) 239–243 paediatric urology 193–194
comparison with magnetic resonance recurrent urinary tract
imaging 249–250 infections 167–168
Hounsfield scale 239, 241 cystocele 187
imaging guided percutaneous cystogram 114
procedures 242–243 cysto-lithotripsy 60
kidneys, ureters and cystoscopy 53–61
bladder 239–240, 241–242 ambulatory evaluation 51
penile cancer 226–227 as a surgical tool 60
prostate cancer 212–213 benign prostatic obstruction 179
radiation exposure 240, 241 benign urogynaecological
renal cancer 219 lesions 113
renal protocol CT scan 242 bladder pain syndrome 58, 59
staging CT scans 242 history and context 53
testicular cancer 236 indications 56
urography 201, 242 instrumentation 53–55, 54–55
urothelial bladder cancer 201–203 intra-operative cystoscopy 59
consent 6–7 pre-procedure 55
conservative management side effects and complications 60
benign urogynaecological technique 56–59, 57, 59
lesions 114 urothelial bladder
childbirth pelvic floor trauma 128 cancer 202–203, 205
non-surgical management of pelvic
floor disorders 71–72 d
renal stone disease 162 day-surgery unit (DSU) 8
constipation 186 decompression 161–162
continuous antimicrobials 171 deep perineal pouch 26, 27
continuous urinary incontinence 34 dehiscence 127
COPD see chronic obstructive desmopressin 199
pulmonary disease detrusor overactivity (DO) 175
cough leak point pressure dexamethasone 7–8, 103
(CLPP) 50–51 DHT see dihydrotestosterone
cough stress test (CST) 44–45 diabetes mellitus 6
cryotherapy 214, 221 DIAPPERS mnenomic 37
cryptorchidism 233 diet and nutrition 164, 209
256 Index
digital rectal examination (DRE) nurse practitioner role 67

benign prostatic obstruction 178 renal stone disease 161–162
prostate cancer 210 endoanal ultrasound (EAUS) 130
urothelial bladder cancer 202 endopelvic fascia 27–31, 28, 28, 30
dihydrotestosterone (DHT) 208 end-stage renal failure 6
dimercaptosuccinic acid (DMSA) enhanced recovery after surgery
scans 194, 195–196, 219, 244 (ERAS) 99–104, 101–102
dish pessary 73 first stage 100–101
diverticula fourth stage 104
cystoscopy 58 renal cancer 221–222
localisation and second stage 101–102
diagnosis 112–114, 113–114 third stage 102–103
management 114–115 enuresis 198–199
marsupialisation 115–116 epidural nerve blockade 103
transurethral saucerisation 116 epithelial inclusion cysts 121
transvaginal diverticulectomy 115 ERAS see enhanced recovery
urethral diverticulum after surgery
112–116, 113–114 erectile dysfunction (ED)
D-mannose 172 benign prostatic obstruction 181–182
DMSA see dimercaptosuccinic acid penile and inguino-scrotal ambulatory
DO see detrusor overactivity surgery 156–157
doughnut pessary 74 prostate cancer 209
DRE see digital rectal examination estrogens 77
drug-related urinary retention 187 ESWL see extracorporeal shock wave
DSNB see dynamic sentinel node lithotripsy
biopsy ethnicity 22–23, 208
DSU see day-surgery unit EUA see examination under
duloxetine 77 anaesthetic
Durasphere 87–88, 88 European Association of Urology
dutasteride 180 (EAU)
dynamic sentinel node biopsy paediatric urology 194–196
(DSNB) 227 penile and inguino-scrotal ambulatory
surgery 155
e penile cancer 226–227, 229, 230
EAU see European Association examination under anaesthetic
of Urology (EUA) 197
EAUS see endoanal ultrasound external gynaecological
ectopic ureters 198 examination 39, 40
ED see erectile dysfunction extracorporeal shock wave lithotripsy
electrical stimulation 72 (ESWL) 162–163
emergency procedures extrinsic sphincter 109
Index 257
f g
faecal incontinence see anal/faecal GAG see glycosaminoglycan
incontinence Gartner’s duct cysts 120
family history/genetics Gellhorn pessary 74
ambulatory evaluation 37–38 generalist gynaecologist 137–139
pelvic floor dysfunction 22 general medical history
prostate cancer 208–209 ambulatory evaluation 36–37, 36
recurrent urinary tract infections benign prostatic obstruction
169 176–177
testicular cancer 234 recurrent urinary tract
Female Pelvic Medicine and infections 167–168
Reconstructive Surgery (FPMRS) genetics see family history/genetics
Fellowship 141–142 genitourinary syndrome of
Fenton procedure 128, 129 menopause (GSM)
fertility 154, 197 ambulatory evaluation 39, 40
FIGO see International Federation of ambulatory procedures 93
Gynaecology and Obstetrics glans resurfacing 228
finasteride 180–181, 208 Gleason score (GS) 208
fistulae glycosaminoglycan (GAG) layer
classification 117–118 treatments 172
clinical features 117, 117 granulation tissue 127
cystoscopy 58 GS see Gleason score
pathogenesis 116–117 GSM see genitourinary syndrome of
pelvic organ prolapse 107 menopause
urethrovaginal fistulae 114–115, gynaecological history 37
116–118, 117
flexible cystoscopy h
benign prostatic obstruction 179 haematospermia 209
catheter insertion for urinary haematuria
retention 190 benign prostatic obstruction 177,
instrumentation 54–55, 55 181, 183
urothelial bladder cancer paediatric urology 193
202–203 prostate cancer 209
floppy iris syndrome 180 recurrent urinary tract
fluids and electrolytes 161–162, 169 infections 168, 170
5-fluorouracil (5-FU) 228 urinary retention 186
Fowler’s syndrome 187 urothelial bladder cancer 201–203
FPMRS see Female Pelvic Medicine and hammock hypothesis 82–83
Reconstructive Surgery hCG see human chorionic gonadotropin
free-standing ambulatory units 3–4 health-related quality of life
5-FU see 5-fluorouracil (HRQoL) 88–89, 93, 96
258 Index
high-grade prostatic intraepithelial integrated self-contained ambulatory

neoplasia (HGPIN) 207 units 3–4
high uterosacral ligament suspension International Association for
(HUSL) 59 Ambulatory Surgery (IAAS) 3
HIV/AIDS 224, 234 International Continence Society
Hounsfield scale 239, 240 (ICS) 19, 44–45
Ho:YAG lasers 163, 183 International Federation of Gynaecology
HPV see human papilloma virus and Obstetrics (FIGO) 142–144
HRQoL see health-related quality of life International Prostate Symptom Score
human chorionic gonadotropin (IPSS) 180
(hCG) 235 interstitial cystitis 58, 59, 145
human papilloma virus (HPV) 223 intra-operative cystoscopy 59
HUSL see high uterosacral ligament intravenous fluid resuscitation 161–162
suspension intravenous pyelogram (IVP) 241
hydration see fluids and electrolytes intravenous urogram (IVU) 241
hydrocele 153–154 intrinsic sphincter 109
hydro-distension 60 intrinsic sphincter deficiency (ISD)
hypoestrogenism 39, 40 ambulatory evaluation 45, 50–51
stress urinary incontinence 83
i ipsilateral iliac node dissection 229
IAAS see International Association for IPSS see International Prostate
Ambulatory Surgery Symptom Score
ICS see International Continence Society irritative voiding 168
immunisation see vaccination ISD see intrinsic sphincter deficiency
immunotherapy 205 IVC see inferior vena cava
infection IVP see intravenous pyelogram
perineal wound IVU see intravenous urogram
complications 124–125, 126
renal stone disease 161–162 k
urinary retention 186 ketamine 103
see also individual infections kidneys see renal
inferior vena cava (IVC) 219
infertility 154, 197 l
inflatoball pessary 75 labial fusion 39, 40
informed consent 6–7 lactate dehydrogenase (LDH) 235–236
inguino-scrotal ambulatory surgery see laparoscopy
penile and inguino-scrotal ambulatory surgical procedures in
ambulatory surgery POP 105–106
integral theory 83 radical nephrectomy 221–222
integrated non-self-contained training and qualification 144
ambulatory units 3–4 laryngeal mask airway (LMA) 103
Index 259
laser therapy magnetic resonance imaging

benign prostatic obstruction 183 (MRI) 247–250
penile cancer 228 advantages and disadvantages 252
renal stone disease 163 basic principles 247–248
stress urinary incontinence 93, benign prostatic obstruction 178
94–95 benign urogynaecological lesions 114
LDH see lactate dehydrogenase childbirth pelvic floor trauma 133
leiomymomas 121 clinical applications in
levator ani muscle urology 248–249
avulsion 132–133, 133–135 comparison with computed
levator syndrome 20 tomography 249–250
LHRH see luteinizing hormone- penile cancer 226–227
releasing hormone prostate cancer 209, 210–213, 248
lichen sclerosus of the foreskin 198, renal masses 248–249
224, 225 staging investigations 249
lidocaine lubricant 202 testicular cancer 235
lifestyle malignant prostatic hyperplasia 186
benign prostatic obstruction 180 marsupialisation 115–116
non-surgical management of pelvic maximum urethral closure pressure
floor disorders 69–70 (MUCP) 45, 50–51
prostate cancer 209 MDP see methylene diphosphonate
LMA see laryngeal mask airway MDT see multidisciplinary team
lower urinary tract dysfunction MEN see monosymptomatic enuresis
(LUTD) 194–195 menopause/post-menopausal
lower urinary tract symptoms (LUTS) patients 111, 169
benign prostatic metastatic disease
obstruction 175–176, 176 magnetic resonance imaging 249
prostate cancer 209, 214 penile cancer 226–227
recurrent urinary tract prostate cancer 214–215
infections 168, 170 renal cancer 220, 221
Lue’s procedure 157 testicular cancer 235, 237
luteinizing hormone-releasing hormone methenamine hippurate 172
(LHRH) agonists 215 methylene diphosphonate (MDP) 244
LUTS see lower urinary tract mid-urethral theory 83
symptoms mirabegron 77–78
lymph nodes 225, 226–227, 229 mitomycin C 203–204
mixed urinary incontinence (MUI)
m ambulatory evaluation 34
Macroplastique 85–86, 85 non-surgical management of pelvic
MAG3 renogram 244 floor disorders 70–71
magnetic chair 72 pelvic floor dysfunction 20
260 Index
modified Aldrete scoring system 8 non-surgical management of pelvic floor

modified Oxford grading scale disorders 69–80
non-surgical management of pelvic bladder re-training 72–73
floor disorders 70, 70 general lifestyle interventions
pelvic muscle function 69–70
assessment 43, 43 pelvic floor exercises 70–72, 70
monosymptomatic enuresis percutaneous posterior tibial nerve
(MEN) 198–199 stimulation 78–80, 79
mpMRI see multiparametric magnetic pessaries 73–77, 73–75
resonance imaging pharmacotherapy 77–78
MRI see magnetic resonance imaging supervised PFMT and
MUCP see maximum urethral closure biofeedback 71–72
pressure non-visible haematuria (NVH)
MUI see mixed urinary incontinence 201–202
Müllerian duct cysts 120 NP see nurse practitioner
multidisciplinary teams (MDT) NSGCT see non-seminomatous germ
nurse practitioner role 66–67 cell tumours
urothelial bladder cancer 204–205 nuclear medicine (NM) 243–244
multiparametric magnetic resonance bone scans 209, 212, 244
imaging (mpMRI) 209, dimercaptosuccinic acid scans 194,
210–213, 248 195–196, 219, 244
multiple sclerosis 187 MAG3 renogram 244
nurse practitioner (NP)
n ambulatory urogynaecological care
nephrostomy 243 roles 63–68
Nesbitt’s procedure 157 assessments and procedures
neuraxial blockade 7 performed by NPs 65, 65
neurological conditions 187 documentation 66, 67
neurological examination 38–39 expanding roles of NPs 64
nivolumab 221 history and context 63
NM see nuclear medicine managing risks and governance
NMEN see non-monosymptomatic requirements 67
enuresis operational policy and treatment
nocturnal enuresis 34 protocol 66, 67
non-monosymptomatic enuresis training and qualification 65–66
(NMEN) 198–199 NVH see non-visible haematuria
non-racetrack model 11
non-seminomatous germ cell tumours o
(NSGCT) 233, 235, 237 OAB see overactive bladder
nonsteroidal anti-inflammatory drugs OASIs see obstetric anal sphincter
(NSAID) 104 injuries
Index 261
obesity papillary urothelial neoplasm of low

ambulatory surgery service 6 malignant potential
non-surgical management of pelvic (PUNLMP) 204
floor disorders 69–70 paradoxical puborectalis contraction 20
pelvic floor dysfunction 23 Parkinson’s disease 187
prostate cancer 209 patient selection 5–6
obliterative colpocleisis 107 PCNL see percutaneous nephrolithotomy
obstetric anal sphincter injuries PeIN see penile intraepithelial
(OASIs) 128–132, 130 neoplasia
anorectal manometry 131 pelvic floor distress inventory
birth mode subsequent to 131–132 (PFDI) 76
faecal incontinence severity pelvic floor dysfunction (PFD)
index 128, 130 19–31
primary repair and follow-up 128 anal incontinence 20, 22
ultrasound 130–132 coccygodynia 20
obstetric history 37 epidemiology 21–23
obstetric injuries 22 introduction 19
see also childbirth pelvic floor trauma levator syndrome 20
Ophira 90, 92 non-surgical management of pelvic
opioids 101–102 floor disorders 69–80
overactive bladder (OAB) paradoxical puborectalis
ambulatory evaluation 48–50 contraction 20
benign prostatic obstruction 175 pelvic organ prolapse 19, 21–23,
non-surgical management of pelvic 27–31, 28
floor disorders 70, 72–73, 77–80 pelvic organ support 23–31,
paediatric urology 198–199 25–28, 28, 30
pelvic floor dysfunction 20, 22 predisposing factors 22–23
oxybutynin 77–78 proctalgia fugax 20–21
pudendal neuralgia 21
p training and qualification 145–147
PACU see post-anaesthesia care unit types of PFD 19–21
pad test 45–46 urinary incontinence 20,
paediatric urology 193–199 22–23, 29, 31
enuresis 198–199 pelvic floor exercises (PFE/
phimosis 197–198 PFMT) 70–72, 70
recurrent urinary tract pelvic floor impact questionnaire
infections 193–196 (PFIQ) 76
undescended testes 196–197, 196 pelvic fracture 187
vesico-ureteric reflux 194–196, 195 pelvic masses 187
pain evaluation 35 pelvic muscle function
pain management see analgesia assessment 43, 43
262 Index
pelvic organ prolapse (POP) 99–108 varicocele 154–155

ambulatory evaluation 34–41, 42–43, vasectomy 157–158
44–47, 51 penile cancer 223–233
anterior and posterior vaginal repair/ biopsy 225–226, 227
colporrhaphy 105–106 examination 225
enhanced recovery after follow-up after treatment 229, 230
surgery 99–104, 101–102 history 224–225
epidemiology of pelvic floor imaging 226–227
dysfunction 19, 21–23 incidence 223
general requirements of ambulatory invasive and metastatic
surgical procedures 99–100 disease 226–227, 228–229
growing an ambulatory surgery lymph nodes 225, 226–227, 229
practice 107 management 227–229
introduction 99 pathology 223
non-surgical management of pelvic presentation 224
floor disorders 69, 71–76 risk factors 223–224
pelvic organ support 27–31, 28 staging 227
training and qualification 145–146 penile intraepithelial neoplasia
urogynaecological (PeIN) 224
procedures 104–107 penile straightening surgery 156–157
vaginal hysterectomy 105 percutaneous nephrolithotomy
vault suspension (PCNL) 163–164
procedures 106–107 percutaneous posterior tibial nerve
pelvic organ support 23–31 stimulation (PTNS) 78–80, 79
fascial support 26–31, 28, 28, 30 perineal body/membrane 25–26, 26
level I support 29 perineal wound complications
level II support 29–30, 30 childbirth pelvic floor
level III support 30–31 trauma 124–127, 126
muscular support 24–26, 25–27 dehiscence 127
pelvic floor 23–24 granulation tissue 127
Pelvic Organ Support Study infection 124–125, 126
(POSST) 23 peripheral nerve blockade 7
penile and inguino-scrotal ambulatory personal hygiene 169
surgery 153–158 pessaries
background 153 non-surgical management of pelvic
hydrocele 153–154 floor disorders 73–77, 73–75
Peyronie’s disease and penile urinary retention 187
straightening surgery 156–157 PET see positron emission tomography
phimosis and circumcision 156 petechial haemorrhagic spots 59
testicular cancer and radical inguinal Peyronie’s disease 156–157
orchidectomy 155–156 PFD see pelvic floor dysfunction
Index 263
PFDI see pelvic floor distress inventory proctalgia fugax 20–21

PFE/PFMT see pelvic floor exercises prostate cancer 207–215
PFIQ see pelvic floor impact advanced or metastatic
questionnaire disease 214–215
pharmacotherapy 77–78 biopsy 208, 210, 213, 214
see also individual drugs/drug classes examination and
phimosis investigation 209–213, 248
paediatric urology 197–198 history 208
penile and inguino-scrotal ambulatory incidence and prevalence 207
surgery 156 management 207, 214–215
penile cancer 223–225 non-metastatic disease 214
photovaporisation of the prostate pathology 207
(PVP) 183 risk factors 208–209
physical examination 38–43, 40, 42–43 staging 210–212, 211–212
PIN see prostatic intraepithelial symptoms 209
neoplasia tumour grading 208
PONV see post-operative nausea and prostate specific antigen (PSA)
vomiting benign prostatic obstruction 175, 178
POP see pelvic organ prolapse prostate cancer 207–210, 213
positron emission tomography prostatic intraepithelial neoplasia
(PET) 244–245 (PIN) 207
penile cancer 227 proteinuria 202
prostate cancer 213 PSA see prostate specific antigen
POSST see Pelvic Organ Support Study psoralen plus ultraviolet A (PUVA) 224
post-anaesthesia care unit (PACU) 8 psoriasis 224
posterior vaginal repair 105–106 PTNS see percutaneous posterior tibial
post-menopausal patients see nerve stimulation
menopause/post-menopausal pubovisceral muscle (PVM) 132–133
patients pudendal neuralgia 21
post-obstructive diuresis 188 PUJO see pyelo-ureteric junction
post-operative nausea and vomiting obstruction
(PONV) 7–8, 103, 104 PUNLMP see papillary urothelial
post-operative urinary retention 187, 188 neoplasm of low malignant
post-recovery rooms 104 potential
post-void residual volume PUVA see psoralen plus ultraviolet A
(PVR) 178, 179–180 PVM see pubovisceral muscle
pregnancy 23 PVP see photovaporisation of the
pre-operative assessment 4–5 prostate
preparation for surgery 6–7 PVR see post-void residual volume
prepubertal patients 111 pyelo-ureteric junction obstruction
see also paediatric urology (PUJO) 244
264 Index
q paediatric urology 193–196

QIR see quiescent intracellular reservoirs penile and inguino-scrotal ambulatory
QoL see quality of life surgery 156
Q-tip test 45 personal hygiene 169
quality of life (QoL) risk factors and patient
ambulatory evaluation 38 discussion 168–171
health-related quality of sexual intercourse 169
life 88–89, 93, 96 vesico-ureteric reflux 194–196, 195
non-surgical management of pelvic REEDA score 125, 126
floor disorders 69, 79–80 renal biopsy 243
quiescent intracellular reservoirs renal cancer 217–222
(QIR) 170 aetiology 217
biopsy 220
r enhanced recovery after
racetrack model 11 surgery 221–222
radiation exposure 240, 241 incidence 217
radical cystectomy surgery 205 investigation 218–219, 249
radical inguinal management 221
lymphadenectomy 227, 229 signs and symptoms 218
radical inguinal orchidectomy 155–156 staging 219–220
radiofrequency ablation (RFA) 221 subtypes 218, 218
radiofrequency therapy 95–96 renal cyst aspiration 243
radiotherapy 214–215 renal cystoscopy 57–58
RANZCOG see Royal Australian and renal masses 248–249
New Zealand College of Obstetrics renal stone disease 159–165
and Gynaecology aetiology 159–160
RCOG see Royal College of Obstetricians conservative management 162
and Gynaecologists emergency management of infected
recurrent urinary tract infections obstructed system 161–162
(rUTI) 167–173 epidemiology 159
biofilms and quiescent intracellular extracorporeal shock wave
reservoirs 170 lithotripsy 162–163
definitions 168 investigation 161
fluid intake 169 long-term management and
further advice to the patient 170 prevention 164
genetics 169 percutaneous nephrolithotomy 163–164
history 167–168 risk factors 160–161
introduction 167 symptoms and signs 161
investigation 170 treatment 162–164
management strategies 171–172 types of stones 160
menopause 169 uretero-renoscopy 163
Index 265
research 145 SGCT see seminomatous germ

retrograde ejaculation 180, 182 cell tumour
retroperitoneal lymph node dissection shelf pessary 74
(RPLND) 237 SIMS see single incision mini-slings
Rezūm 182 single incision mini-slings
RFA see radiofrequency ablation (SIMS) 89–93, 90–92
rigid cystoscopes 53–55, 54 single photo emission computed
ring pessary 73 tomography (SPECT) 212–213, 227
Royal Australian and New Zealand Situation-Background-Assessment-
College of Obstetrics and Recommendation (SBAR) tool 10
Gynaecology (RANZCOG) 138, Skene’s duct cyst 120–121
139–140, 146 Skene’s glands 109
Royal College of Obstetricians and sling procedures
Gynaecologists (RCOG) 138, single incision mini-
140–141, 146 slings 89–93, 90–92
RPLND see retroperitoneal lymph node synthetic mid-urethral slings 92–93
dissection training and qualification 144–145
rUTI see recurrent urinary tract smoking
infections ambulatory surgical procedures
in POP 100
s non-surgical management of pelvic
SABR see stereotactic ablative floor disorders 70
radiotherapy pelvic floor dysfunction 23
sacrospinous ligament fixation penile cancer 224
(SSLF) 106 SNRI see serotonin nor-adrenaline
SBAR see re-uptake inhibitors
Situation-Background-Assessment- Solyx 90, 90
Recommendation SPECT see single photo emission
scarring 118 computed tomography
SCC see squamous cell carcinoma Spence procedure see marsupialisation
self-directed prophylaxis 171 spinal nerve blockade 103
seminomatous germ cell tumour squamous cell carcinoma (SCC) 223
(SGCT) 235, 236–237 squamous metaplasia 57
serotonin nor-adrenaline re-uptake SSLF see sacrospinous ligament fixation
inhibitors (SNRI) 77 stereotactic ablative radiotherapy
SEST see supine empty stress test (SABR) 215
sexual dysfunction stress urinary incontinence
ambulatory evaluation 35, 38 (SUI) 81–97
benign prostatic obstruction 180–182 ambulatory evaluation 34, 44–45, 51
prostate cancer 209 ambulatory procedures 83–96, 84
sexual intercourse 169, 224 epidemiology 81–82
266 Index
stress urinary incontinence (SUI) pathology and subtypes 235, 236

(cont’d ) penile and inguino-scrotal ambulatory
introduction 81 surgery 155–156
laser therapy 93, 94–95 seminomatous germ cell
non-surgical management of pelvic tumour 235, 236–237
floor disorders 70–78 symptoms and signs 234–235
paediatric urology 198 testicular intraepithelial neoplasia
pathophysiology 82–83, 82 (TIN) 234
pelvic floor dysfunction 20, testosterone 208
22–23, 29, 31 thermomodulation 93
post-operative urinary retention 188 TIN see testicular intraepithelial
radiofrequency therapy 95–96 neoplasia
single incision mini- TNM classification 219–220,
slings 89–93, 90–92 227, 249
synthetic mid-urethral slings 92–93 tomographic ultrasound imaging
thermomodulation 93 (TUI) 130–131, 133, 133, 135
training and qualification 146 TPUS see transperineal ultrasound
urethral bulking agents 84–89, training and qualification
84, 85–90 Australia 138, 139–140, 146–147
superficial dyspareunia post- formal urogynaecological
childbirth 127–128, 129 training 139–142
superficial modified inguinal introduction 137
lymphadenectomy 227 low-resource countries: FIGO
supine empty stress test (SEST) 45 recommendations 142–144
suprapubic catheterisation 190–191 nurse practitioner 65–66
synthetic mid-urethral slings 92–93 research 145
role of generalist gynaecologist in
t urogynaecology 137–139
tamsulosin 180–181, 191 South Africa 144
TC see testicular cancer teaching and training in
TCA see tricyclic antidepressants urogynaecology 137–147
tension-free vaginal tape (TVT) 45, technology and simulation 144–145
91–93, 146–147 training status 146–147
testicular cancer (TC) 233–238 United Kingdom 138, 140–141, 146
aetiology 233–234 United States of
incidence 233, 234 America 139, 141–142
investigation 235–236 vaginal mesh products 145–147
management 233, 236–237 transperineal ultrasound
metastatic disease 235, 237 (TPUS) 130–131, 133, 134
non-seminomatous germ cell transurethral resection of a bladder
tumours 233, 235, 237 tumour (TURBT) surgery 203–204
Index 267
transurethral resection of prostate Bulkamid 86, 86

(TURP) 181–182 Coaptite 87, 87
transurethral saucerisation 116 cystoscopy 60
transvaginal diverticulectomy 115 Durasphere 87–88, 88
transvaginal ultrasound 114 Macroplastique 85–86, 85
traumatic injury paediatric urology 196
pelvic floor dysfunction 23 stress urinary incontinence 84–89, 84
urinary retention 187 Urolastic 88–89, 89
see also childbirth pelvic floor trauma Urolon 89, 90
trial without catheter (TWOC) 175 urethral catheterisation 189–191
tricyclic antidepressants (TCA) 77 urethral embryology and
TUI see tomographic ultrasound anatomy 109–110
imaging urethral injury 187
TURBT see transurethral resection of a urethral lesions 110–118
bladder tumour urethral caruncle 110–111
TURP see transurethral resection of urethral
prostate diverticulum 112–116, 113–114
TVT see tension-free vaginal tape urethral prolapse 111, 112
TWOC see trial without catheter urethrovaginal fistulae 114–115,
tyrosine kinase inhibitors 221 116–118, 117
urothelial cysts 121
u urethral pressure profile 45, 50–51
UDS see urodynamic studies urethral prolapse 111, 112, 187
UI see urinary incontinence urethral strictures 186
ulceration 77 urethro-vesical mobility 45
ultrasound urge urinary incontinence (UUI)
ambulatory evaluation 46–47, 47 ambulatory evaluation 34
benign prostatic obstruction 179–180 non-surgical management of pelvic
benign urogynaecological floor disorders 70–71, 72,
lesions 114 77, 79–80
childbirth pelvic floor pelvic floor dysfunction 20, 22–23
trauma 130–132, 133, 133–135 urinalysis 44
paediatric urology 193–195 urinary diary 44
penile cancer 226 urinary evaluation 35
testicular cancer 235 urinary incontinence (UI)
undescended testis ambulatory evaluation 33–38,
paediatric urology 196–197, 196 44–51, 49
testicular cancer 233 ambulatory surgical procedures in
ureteric orifice 57, 57 SUI 81–97
uretero-renoscopy 163 non-surgical management of pelvic
urethral bulking agents floor disorders 69–80
268 Index
urinary incontinence (UI) (cont’d ) Urolon 89, 90

nurse practitioner role 63 urothelial bladder cancer 201–205
pelvic floor dysfunction 20, bladder cancer investigation 201
22–23, 29, 31 clinical assessment 201–202
training and qualification 146 cystoscopy 202–203, 205
urinary retention 185–192 further steps 203
acute-on-chronic urinary muscle invasive disease 205
retention 186 non-muscle invasive disease
acute urinary retention 185 203–205
ambulatory surgical procedures recurrent urinary tract
in POP 103 infections 168, 170
ambulatory urology and urinary risk stratification, further treatment
retention 191 and follow-up 203–205
catheterisation 189–191 transurethral resection of a bladder
causes 186–188 tumour surgery 203–204
chronic urinary retention 186 urothelial cysts 121
clinical assessment 188–189 USI see urodynamic stress incontinence
definitions 185–186 UTI see urinary tract infection
introduction 185 UUI see urge urinary incontinence
patients requiring admission 191
post-obstructive diuresis 188 v
risk factors 185 vaccination 172
urinary tract infection (UTI) vaginal cones 71–72
ambulatory evaluation 44, 51 vaginal hysterectomy 105
pelvic floor dysfunction 20 vaginal lesions 118–121
urothelial bladder cancer 202 Bartholin’s cyst 118–120, 119
see also recurrent urinary tract epithelial inclusion cysts 121
infections Gartner’s and Müllerian duct
urine dipstick testing 177, 177, 202 cysts 120
urodynamic stress incontinence leiomymomas 121
(USI) 38 Skene’s duct cyst 120–121
urodynamic studies vaginal mesh products 145–147
(UDS) 48–50, 178–179 Valsalva leak point pressure
uroflowmetry (VLPP) 50–51
ambulatory evaluation 47–48, 49 Valsalva manoeuvre 39–41,
benign prostatic obstruction 178, 179 42–43, 50–51
urogenital hiatus 24, 25 varicocele 154–155
urogynaecological vasectomy 157–158
ultrasound 46–47, 47 vault suspension procedures 106–107
Urolastic 88–89, 89 VCUG see voiding cystourethrography
Urolift 182 VEIL see video-endoscopic inguinal
urolithiasis see renal stone disease lymphadenectomy
Index 269
vesico-ureteric reflux (VUR) 194–196, 195 w

video-endoscopic inguinal weight loss 69–70
lymphadenectomy (VEIL) 229 Women’s Health Initiative
Vincent’s curtsey 198 (WHI) 21
VLPP see Valsalva leak point pressure
voiding cystourethrography x
(VCUG) 194, 195 X-ray 239–241, 241
VUR see vesico-ureteric reflux see also chest X-ray
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Ambulatory Urology and

Ajay Rane, OAM, MD, FRCOG, FRCS, FRANZCOG, CU, PhD,

Arjunan Tamilselvi, MBBS, DGO, FRCOG

Sandhya Gupta, MBBS, DGO, FRCOG, Dip Endoscopy

Limit of Liability/Disclaimer of Warranty

Library of Congress Cataloging-in-Publication Data

Cover Design: Wiley

Set in 9.5/12.5pt STIXTwoText by SPi Global, Pondicherry, India

Section I Basic Principles of an Ambulatory Service 1

1 Principles of an Ambulatory Surgery Service 3

Section II Ambulatory Urogynaecology 17

2 Introduction and Epidemiology of Pelvic Floor Dysfunction 19

3 Ambulatory Evaluation of Pelvic Organ Prolapse and Urinary

5 Role of Nurse Practitioners in Ambulatory Urogynaecological Care 63

6 Non-Surgical Management of Pelvic Floor Disorders 69

7 Ambulatory Surgical Procedures in Stress Urinary Incontinence 81

8 Pelvic Organ Prolapse Surgery as an Ambulatory Procedure 99

9 Common Urethral and Vaginal Lesions in Ambulatory Urogynaecology 109

10 Ambulatory Management of Childbirth Pelvic Floor Trauma 123

11 Teaching and Training in Urogynaecology 137

Section III Ambulatory Urology 149

12 Ambulatory Penile and Inguino-Scrotal Surgery 153

13 Ambulatory Management of Renal Stone Disease 159

14 The Management of Recurrent Urinary Tract Infections 167

15 An Ambulatory Approach to Benign Prostatic Obstruction 175

16 Urethral Catheters and Ambulatory Management

17 Paediatric Urology 193

18 Urothelial Bladder Cancer: Diagnosis and Management

19 Prostate Cancer: Diagnosis and Management

20 Renal Cancer: Diagnosis and Management in the Outpatient Clinic 217

21 Penile Cancer: Diagnosis and Management in the Outpatient Clinic 223

22 Testis Cancer: Diagnosis and Management in the Outpatient Clinic 233

23 Plain X-Ray, Computed Tomography Scanning, and Nuclear Imaging

24 Magnetic Resonance Imaging in Urology 247

Editors Jordan Durrant, MBBS, FRCS (Urol)

Vladimir Kalis, MD, PhD Ashiv Patel, MBBS

Mugdha Kulkarni, MBBS, FRANZCOG

Arjunan Tamilselvi, MBBS, DGO, FRCOG

Basic Principles of an Ambulatory Service

Principles of an Ambulatory Surgery Service

According to the International Association for Ambulatory Surgery (IAAS),

Free-standing units, separate to inpatient units, are common in the United

The pre-operative assessment begins with gathering information about health,

­Social Selection Criteria

Several social factors must be considered before ambulatory surgery. Patients or

­Physical Selection Criteria

The patient must be given appropriate information regarding the perioperative

in patients with lymphoma because of risk of tumour lysis syndrome. Ondansetron

Early Recovery: Emergence from Anaesthesia

Intermediate Recovery: Discharge Criteria

Late Recovery: Care After Discharge

­Setting Up an Ambulatory Centre

Planning a new ambulatory unit is a major undertaking. A board team, consisting

Economics of Ambulatory Surgery

Redistributing surgical procedures from the inpatient setting to ambulatory cen-

Aboutorabi, A., Ghiasipour, M., Rezapour, A. et al. (2014 Spring). A cost-

Introduction and Epidemiology of Pelvic Floor

­Types of Pelvic Floor Dysfunction

Pelvic Organ Prolapse (POP)

Social Selection Criteria

Physical Selection Criteria

Setting Up an Ambulatory Centre

Types of Pelvic Floor Dysfunction

Pelvic Organ Prolapse

Pelvic Organ Support

Cystoscopy as Surgical Tool

Side Effects and Complications

Who is a Nurse Practitioner (NP)?

What Can a Urogynaecology Nurse Practitioner Do?

Managing Risks and Governance Requirements

General Life-Style Interventions

Pelvic Floor Exercises