A New Approach to Managing
Atrophic Vaginitis
Dr. Angelika Borozdina
MBBS. PhD. FRANZCOG
Obstetrician and Gynaecologist
CVOGS
URINARY INCONTINENCE
Definition:
 Involuntary urine leakage during
activity (ef fort/exertion).
 Occurs with loss of normal rise in
urethral closure pressure in
response to rising abdominal
pressure.
 Anatomic and physiologic factors
result in disordered pressure
transmission.
Distinguished from URGE
Incontinence
.
THREE COMMON TYPES OF URINARY
INCONTINENCE
Urge
Urge incontinence
is the strong, sudden need to urinate due to bladder spasms or
contractions5
Stress
Mixed
Stress incontinence
is an involuntary loss of urine that occurs during physical
activity, such as coughing, sneezing, laughing, or exercise5
Mixed incontinence
is the combination of both urge and stress incontinence6
URGE VS. STRESS VS. MIXED
INCONTINENCE
 Of the 1 in 3 adult women
who have urinary
incontinence 7 :
SUI
50%
Mixed
36%
Urge
11%
SUI: 4 T YPES OF ETIOLOGIC RISK FACTORS
Predispose
• Female Gender
• Race, Culture and
Environment
• Anatomy
• Neurologic
Incite
•
•
•
•
Vaginal childbirth
Nerve Damage
Muscle Damage
Radiation
Promote
•
•
•
•
•
•
•
Constipation
Physical work
Obesity
Smoking
Menopause
Fluid Intake
Toilet Habits
Continent
Incontinent
Intervene
• Behavioral
• Pharmacologic
• Devices
• Surgical
Decompensate
• Aging
• Comorbid disease
• Dementia
• Medications
• Environment
COMPONENTS OF SUI PATHOPHYSIOLOGY
1. Loss of anatomic urethral support
Urethral Hypermobility (UH) - weakness of pelvic
structures that support urethral compression
during increased abdominal pressure
2. Intrinsic Sphincter Deficiency (ISD)
 Deficiency of urethral intrinsic closing
mechanism
INCONTINENCE EVALUATION
HISTORY
CLINICAL
ASSESSMENT
Incontinence on Physical Activity
• History and Physical examination:
abdominal, pelvic, neurological
• Assess effect on quality of life
• Bladder diary
• MSU, if UTI treat
• Assess for pelvic organ mobility / prolapse
• Ultrasound of detrusor muscle, bladder neck and
residual volume of urine post void
• Urodynamics
SUI Assessment
Pelvic Examination
•
•
•
•
•
Prolapse may mask incontinence
Pelvic floor muscle tone
Voluntary pelvic floor contraction
Perineal skin condition
Palpation of anterior vaginal wall
and urethra
• Determine degree of
estrogenization
• May observe leakage on coughing
.
SUI Assessment (continued)
Urinalysis 1
Tests of detrusor function
• Postvoid residual (PVR) volume 1
• Flow rate 1
• Filling cystometrogram (CMG) 1
Tests of urethral sphincter function
• Valsalva leak point pressure (VLPP) 2
• Maximum urethral closure pressure (MUCP) 1
1. Abrams P, et al. he Standardisation of Terminology of Lower Urinary Tract Functioning: Report from the Standardisation Sub-committee of the Int’l Continence Society.
Neurourol Urodyn. 2002;21:167-178.
2. Blaivas JG, Groutz A. In: Retik AB, Vaughan ED Jr, Wein AJ, et al, eds. Urinary Incontinence: Pathophysiology, Evaluation, and Management Overview. Philadelphia, Pa: WB Saunders;
2002:1027–1052.
SUI MANAGEMENT
HISTORY/
Clinical
examination
Incontinence on physical activity
History and urodynamic study confirm Stress incontinence
•Pelvic floor muscle training
•Oestrogen therapy of vagina
•Pessary management
TREATMENT
•Sling operation or vaginal prolapse surgery
• Lifestyle interventions
SUI SURGICAL TREATMENTS
Modern
Traditional
vs.
1. Elevate bladder neck and
proximal urethra
2. Support bladder neck and
prevent funnelling
3. Increase outflow resistance
Integral Theory’ of urinary
incontinence*
1. Control of urethra
depends:
• pubourethral ligaments
• suburethral vaginal
hammock
• pubococcygeus muscle
NON SURGICAL TREATMENT
 Neotonus MR Chair
Based on Extracorporeal Technology produces
highly focused pulsing magnetic fields
MID-URETHRAL SLINGS
Goals
1. Restore and/or reinforce the pubourethral ligaments at the mid-urethra
2. Restore and/or reinforce the suburethral vaginal hammock at the midurethra
3. Reinforce the paraurethral connective tissue
pubourethral
ligament
urethropelvic
ligament
ADVANTAGES OF MID-URETHRAL SLINGS
Patient and Physician Benefits
1.
2.
3.
4.
5.
6.
7.
Easily reproducible
Long-term successful clinical results
Minimal complication risk
Minimally invasive
Minimal tissue dissection
Can be performed under regional, or general anesthesia
Most patients can be discharged the same day w/o
catheter
8. Shorter patient recovery than traditional open procedure
SUCCESS RATE
Studies show that most patients are
continent following the sling procedure and
can resume normal, non-strenuous activities
within a few days .
85-94%
Clinical data on AMS slings shows: 19-22
*In a MiniArc study 90% of patients had negative cough stress
test and 85% had a 1-hour pad weight test less than 1 gm at
1 year.
*In a MiniArc study 94% of patients had significant
improvement in pad use at 1 year.
*In a Monarc study 90% of patients had a negative cough
stress test and improvement in pad use at 1 year follow -up.
*In a SPARC study 88% of patients had significantly reduced
symptoms according to the Kings Health Questionnaire at 1
year.
WARNINGS AND PRECAUTIONS
Known risks of surgical procedures for the treatment of
urinary incontinence include:
• Pain/Discomfort/Irritation
• Inflammation (redness, heat, pain, or swelling resulting from surgery)
• Infection
• Mesh erosion (presence of suture or mesh materials within the organs surround
the vagina)
• Mesh extrusion (presence of suture or mesh material within the vagina)
• Fistula formation (a hole/passage that develops between organs or anatomic
structures that is repaired by surgery)
• Foreign body (allergic) reaction to mesh implant
• Adhesion formation (scar tissue)
• Urinary incontinence (involuntary leaking of urine)
WARNINGS AND PRECAUTIONS
Known risks of surgical procedures for the treatment of
urinary incontinence include:
•Urinary retention/obstruction (involuntary storage of urine/blockage of
urine flow)
•Voiding dysfunction (difficulty with urination or bowel movements)
•Contracture (mesh shortening due to scar tissue)
•Wound dehiscence (opening of the incision after surgery)
•Nerve damage
•Perforation (or tearing) of vessels, nerves, bladder, ureter, colon, and
other pelvic floor structures
•Hematoma (pooling of blood beneath the skin)
•Dyspareunia (pain during intercourse)
NOTE: Some of these adverse reactions are specific to procedures involving mesh repair (e.g. mesh extrusion).
DETRUSOR OVERACTIVITY
INCONTINENCE
Involuntary loss of urine associated with a
sudden, strong desire to void.
 Urge Incontinence ( bladder muscle problem )

 Life style changes, bladder retraining




Reduce caffeine , Vaginal Estrogen
Magnetic chair
Anticholinergic medication( SE)
Neuromodulators
Basic Prolapse Stats
50% of parous women (Swift 2000, DeLancey 1993,
Beck 1991)
30 – 40% of women in general population (SliekertenHove 2004,
Samuelsson 1999)
Only 8.8% symptomatic (McLennan 2000)
11.1% lifetime risk of surgical repair
29 – 40% reoperation within 3 years (Clark 2003,
Olson 1997)
PROLAPSE
HERNIATION OF URO-GENITAL TRACT
 Pelvic organ prolapse (PLP) a common condition among female
population ~ 60%
 Life time risk of surgery for POP 19% in WA (Smith FJ et al.,
2010) higher than USA( 11%)
 Recurrence surgery 50%
 Prolapse surgery challenging
- Multifunctionality of the vagina
 Pelvic organ prolapse (PLP) is a common condition among
female population.
 Life time risk of surgery for POP was estimated to be 19% in
the Western Australia (Smith FJ et al., 2010) which is higher
than 11-12% reported from US.
TYPES OF PELVIC ORGAN
PROLAPSE
Cystocele
Bladder prolapses or protrudes
into the vagina
Enterocele
Small bowel prolapses or
protrudes into the vagina
Rectocele
Rectum prolapses or protrudes
into the vagina
Uterine Prolapse
Uterus prolapses or protrudes
into the vagina
Vaginal Vault
Prolapse
Vaginal vault occurs when the
upper portion of the vagina (the
apex) descends into the vaginal
canal
History
White 1910
So let’s POP-Q this (hymen
= 0):
• Aa = -3
• Ba = -3
• C = -6
• D = -10
• Ap = -3
• Bp= -3
Simply put, this vagina
receives a POPQ of:
-3, -3,-3, -3, -6, -10 (Aa, Ba,
Ap, Bp, C, D)
One line – loads of
information
So, what is this?
• Here’s a hint
• Here’s the answer:
+3, 0, -1, -3, -6, -9
C
D
A
B
B
p
A
p
• It’s a cystocele
SURGICAL TREATMENT OPTIONS
• Reconstructive surgical options include 24
– Vaginal colporrhaphy and apical
suspensions using native tissue
– Sacrocolpopexy
– Transvaginal mesh (TVM) repair systems
ELEVATE ® PROLAPSE REPAIR
SYSTEM
Elevate ® is designed to:
Offer a minimally invasive solution
Minimize tissue trauma
Restore normal anatomy with a faster
recovery than open abdominal approaches
Minimize pain compared to more invasive
procedures
ELEVATE PROLAPSE REPAIR
SYSTEM
Typically, procedures to correct prolapse take place on an
in-patient basis and are performed under general
anesthesia.
In clinical studies, 91 -96% of patients felt their prolapse
symptoms were some or a lot improved following surgery
with Elevate. 28,29
91-96%
WARNINGS AND PRECAUTIONS
Known risks of surgical procedures for the
treatment
of POP(presence
includingofthe
following:
• Mesh extrusion
suture
or mesh material within
the vagina)
• Mesh migration
• Nerve damage
• Obstruction of ureter
• Pain/Discomfort/Irritation
• Perforation (or tearing) of vessels, nerves, bladder, ureter,
colon, and other pelvic floor structures
• Urinary tract infection
• Vaginal contracture (tightening of the vagina)
• Voiding dysfunction
• Wound dehiscence (opening of the incision after surgery)
FDA NOTIFICATION: TRANSVAGINAL
MESH
23
 On October 20, 2008, the FDA issued a PHN
regarding serious complications associated with
transvaginal placement (meaning placement
through the vagina) of transvaginal surgical mesh
to treat POP and SUI.
 From Jan. 2008 to Dec. 2010 there were 2, 874
reports of complications associated with surgical
mesh devices
1,503 POP
1,371 SUI
 In July of 2011, the FDA issued an update to the
PHN and provided physicians the following
recommendations:
 Seek specialized training in transvaginal mesh
procedures
 Advise their patients about the potential for serious
complications associated with these procedures
 Be vigilant for potential complications from the
mesh
TGA AND SOCIETY RESPONSES
 In 2012, the TGA(Therapeutic Guidelines Australia)
released a statement³² which in summary stated:
 Since 2006, the TGA has received 63 adverse event
reports for all Uro-gynaecological surgical meshes.
 The Uro-gynaecological Society of Australia (UGSA)
reinforced their view that the issues were about the
use of these meshes rather than the meshes
themselves. In light of this, the Royal Australian and
New Zealand College of Obstetrics and Gynaecology
(RANZCOG) and UGSA are advising that surgeons
should have special training on performing these
procedures and patient selection.
The TGA urges any patients with mesh
implants who are concerned to contact their
surgeon.
UGSA has released a statement supporting
the use of mid-urethral slings for SUI.
HOMEWORK BEFORE THE OPERATION
Urodynamic study
Quality of life assessment (POP-Q)
Sexual function assessment(PISQ-12)
Who needs urodynamic work-up ?
Why do they get this work-up ?
Can we obtain that information ?
less effort
less discomfort
less site dependent
less cost
pre-operatively
incontinence surgery
detect
detrusor
or voiding
problems
severe prolapse
aims
differ
detect occult
incontinence
detect
detrusor
or voiding
problems
the
issue
is
detect occult
incontinence
Can these be detected in any other way ?

standardised history
examination
questionnaire




bladder diary
24-hour-pad test
pelvic ultrasound
urinary flow-metry
Can these be detected in another way?

standardised history
examination
questionnaire




bladder diary
24-hour-pad test
pelvic ultrasound
urinary flow-metry
WHO DEFINITION OF HEALTH
Quality of life assessment (POP-Q)
“Stage of complete physical, mental and
social well-being and not merely the
absence of infirmity and disease.”
QOL IS PERCEPTION OF:
Emotional
and sexual
wellbeing
Material
Well-being
Physical
Well-being
Self
Determination
MALE AND FEMALE SEXUAL FUNCTION
BY MASTER AND JOHNSON
Sexual
responseexcitementplateau
Orgasmresolution
IS SEX A MATTER OF HEALTH ??
Sexual responseexcitementplateau
Orgasmresolution




Three times per week
don’t feel like it, do it anyway – Working , washing
A matter of health more than pleasure
Heart protection - 30% less heart attack for men and women
PELVIC ORGAN PROLAPSE (POP) &
PESSARIES
 Pessaries used for treatment since beginning of recorded
history
 1800BC Kahun Papyrus Ebers Papyrus (1500 B.C.) which
portrayed the uterus as an independent animal, usually a
tortoise, newt or crocodile, capable of movement within its
host.
 Hippocrates – halved pomegranite soaked in wine!
Hippocrates perpetuated this animalistic concept stating
that the uterus often went wild when deprived of male
semen
 1625- Stromayr’s Practica Coposium – sponge and twine
 Latex products-1800’s
 Silicon now used
INDICATIONS
Pt preference
Medical comorbidities
Delayed surgery
Recurrence
Vaginal ulceration
POP in pregnancy
Desiring future fertility
CONTRAINDICATIONS
Vaginal/pelvic infection
Mesh exposure
Noncompliance
FOLLOW UP EVERY 3 MONTHS
EROSION AND INFECTION
PROLAPSE REPAIR
Vaginal repair +/_ hysterectomy
Native tissue repair( midline, site specific)
Biological mesh repair
Synthetic mesh repair ( Elevate Mesh kit)
Laproscopic pelvic floor repair
Mesh scaro-hysteropexy
Suture hysteropexy
+/_ vaginal repair
TAKE HOME MESSAGES
Abdominal sacral colpopexy was associated with a
lower
rate of recurrent vault prolapse and less
dyspareunia than the vaginal sacrospinous colpopexy
Use of mesh or graft inlays at the time of anterior
vaginal
wall repair reduces risk of objective
recurrence
Posterior repair better performed vaginally
No evidence to suggest that the addition of any graft
material
at the posterior compartment repair results
in improved outcomes
Value of adding a continence procedure is uncertain
ATROPHIC VAGINA
VAGINAL SKIN
The upper 2/3 of Vagina is Mullerian origin
The lower 1/3 is urogenital fold
Vaginal skin is estrogen and progesterone
dependent
Estrogen thickens the skin and progesterone
thins the skin
The lower 1/3 is less estrogen sensitive
VAGINAL FUNCTION
Passage of blood flow during the periods
Birth canal
Supports function and position of bladder
Supports function and position of bowel
Connects the abdominal cavity with outside via
cervix
Vaginal lubrication
Sexual activity
Reproduction
VAGINAL LUBRICATION
No vaginal glands
Paracervical glands and Bart gland provide
discharge at the time of orgasm
Vaginal epithelium stratified squamous
epithelium and responsible for lubrication
Balancing vaginal flora and pH
Avoiding possible infection eg thrush
ATROPHIC VAGINITIS
 Decrease in Oestrogen after menopause
 Up to 40% of postmenopausal women suffer from
Atrophic Vaginitis 1
 Decreased quality of life and direct impact on
women’s sex life
- Vaginal dryness, painful sex, low libido,
sluggish orgasm, urinary problems, vaginal
infection
ATROPHIC VAGINITIS
Decrease in oestrogen levels
Less Connective Tissue
Less capacity to retain water
Increased risk of fissuring &ulceration 3
Decrease in glycogen in vagina tissue
Change in vaginal flora
Change in vagina pH
Increased risk of UTI& thrush
ATROPHIC VAGINITIS
Normal Pap Smear
• Abundant Cytoplasm
• Low Nuclear
Cytoplasmic Ratio
Atrophic Vaginitis Pap Smear
• Enlarged Nuclei
• Inflammatory Exudate
• Amorphous Basophillic
Structurs (Blue Bulbs)
• Loss of Gylcogen in the
Squamous Cells
CURRENT BEST PRACTICE
Oestrogen Replacement 4
 Systemic or Local
 Can reverse or prevent symptoms
Moisturizers and Lubricants
 Can be independently or with oestrogen replacement
therapy
Sexual Activity- 3 times per week
CURRENT BEST PRACTICE DRAWBACKS
Oestrogen Replacement
 10-25% of women do not respond 5
 Physical limitation in older women
 Small increase risk of endometrial ca
 Oestrogen therapy in ER+ Breast cancer!
Moisturizers and Lubricants
 Short term benefit
Sexual Activity
 No firm understanding of mechanism
NON-SURGICAL, NON-HORMONAL
OPTIONS
Platelet Rich Plasma Therapy
- 27 gauge needle and vaginal gel
V2 LR Laser Therapy
- using a vaginal probe
PLATELETS RICH PLASMA
High concentration of platelets
Increased release of growth factors from
platelets
Promotes regeneration of connective tissue
Suggested applications in Dentistry,
Maxillofacial Surgery, Plastic Surgery, and
Orthopaedic Surgery.
WHAT IS A LASER?
LASER - Light Amplification by
Stimulated Emission of Radiation
An intense beam of light
Highly directional
A single wavelength or colour
HOW DOES IT WORK?
Pump some energy into it – electrically or
with light
 The material naturally emits light (of a
characteristic colour)
 Feedback (between the mirrors) build the intensity
 Light ‘leaks’ out a partially reflecting mirror
Energy in
Light
Mirror
Laser material
excited
Mirror
Laser beam
REFERENCES
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m a n a g e m e n t . J A m G e r i a t r S o c . 1 9 9 3 ; 41 : 4 2 6 – 3 6
2 . P a n d i t L , O u s l a n d e r J G . Po s t m e n o p a us a l v a g i n a l a t r o p hy a n d a t r o p hi c
v a g i ni t i s . A m J M e d S c i . 1 9 97 ; 314 :2 2 8 – 31 .
3 . R i g g L A . E s t r o ge n r e p l ac e m e n t t h e r a py f o r a t r o p h i c v a g i n i t is . I n t J
Fe r t i l . 1 9 8 6 ;31 :2 9 – 3 4 .
4 . H a n d a V L , B a c h us K E , J o h n s to n W W, Ro b b oy S J , H a m m o n d C B . Va g i n a l
a d m i n i s t r a t io n o f l o w - d o s e c o n j ug a te d e s t r o g e n s : s y s te m ic a b s o r p t io n a n d e f f e c t s o n
t h e e n d o m et r i um . O b s tet G y n e c o l . 1 9 9 4 ;8 4 :21 5 – 8 .
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H o s p M e d . 1 9 9 3 ;4 9 : 7 9 9 – 8 0 8 .
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O r a l P a t h o l o g y, O r a l R a d i o l o g y, a n d E n d o d o n to l o g y Vo l 8 5 , I s s u e 6 , J u n e 1 9 9 8 , 6 3 8 646
7. E p p l ey, B a r r y L . M . D . , D . M .D . ; P i et r z a k , W i l l i a m S . P h . D . ; B l a n to n , M a t t h ew M . D . ,
P l a te l et - Ri c h P l a s m a : A Rev i ew o f B i o l o g y a n d A p p l i c a t io n s i n P l a s t i c S u r g er y,
P l a s t i c a n d Re c o n s t r uct i v e S u r g e r y. N o v 2 0 0 6 Vo l 1 1 8 I s s u e 6 1 47 - 1 5 9
8 . T i m ot hy E . Foste r, MD † * , Br i an L . P u skas, MD† , Be r t R. Mand e lb aum , MD‡ , Michae l B. G e r har d t , MD ‡ and S cot t A . Rod e o,
MD P l a te let - R ic h P l a s m a
9 Fr o m B a s ic S c i e n c e t o C l i n i c a l A p p l ic a t i o n s , T h e A m e r ic a n J o u r n a l o f S p o r t s
M e d ic i n e N o v 2 0 0 9 Vo l 37 n o 1 1 2 2 5 9 - 2 27 2