Female urinary incontinence in sub-Saharan Africa.

Urinary incontinence (UI) is highly prevalent amongst women around the world. In this review article we explore UI, its consequences and treatment in sub-Saharan Africa, providing specific examples from Uganda and Malawi. In sub-Saharan Africa the prevalence of UI is difficult to assess because of the wide variation in reporting resulting from patients hiding their condition due to the associated stigma in many communities. Whilst much of the literature from low- or low-middle-income countries focuses on UI from pelvic floor fistula, recent evidence demonstrates that non-fistulous stress, urgency and mixed UI are highly prevalent in sub-Saharan Africa. Incontinence secondary to vesico-vaginal fistula can be related to obstetric causes, mainly obstructed labour. The risk factors for non-fistulous incontinence are similar to those identified in high-income countries, including high parity, vaginal and assisted delivery, gestational age, constipation, obesity, chronic cough and ageing. Urinary incontinence has significant social and emotional consequences, with a high proportion of women in African countries reporting relationship problems, depression and suicidal ideation. There is poor understanding of the perceived aetiology of incontinence in sub-Saharan Africa, which may, in part, act as a barrier for women to seek medical advice. Innovative solutions have been found to manage the large number of obstetric fistulas that are prevalent across Africa, but a lack of capacity in specialists trained to treat women with UI means that more doctors, medical officers and better resource prioritization will be required to help the, as yet unquantified, number of women with non-fistulous leakage. Better patient peri-natal education may reduce the incidence of fistula still further, especially if the stigma felt by women with incontinence is overcome and they are encouraged to seek treatment.

Use of a Simulated Model to Teach Male Adult Circumcision in Sub-Saharan Africa.

Male adult circumcision (MC) has been shown to reduce the risk of HIV transmission in men by 50-60 %. An upscaling in the training of providers to perform circumcision is necessary to meet demand since MC is a key component of essential surgery in the context of universal health coverage. We piloted a low-cost, high-fidelity model for training adult circumcision. Multi-centre, multinational data were collected on 74 trainees and clinicians (trainers) in sub-Saharan Africa. Both trainers and trainees gave excellent feedback for the model (content and face validity). The simulated model enables a safe and realistic simulation experience to perform MC. The model is quick to set up and easily transportable to multiple teaching sites.

The past, present and future of augmentation cystoplasty.

What's known on the subject? And what does the study add? There is a wealth of evidence on the development, indications, outcomes and complications of augmentation cystoplasty (AC). Over the last decade, new evidence has been emerging to influence our clinical practice and application of this technique. AC is indicated as part of the treatment pathway for both neurogenic and idiopathic detrusor overactivity, usually where other interventions have failed or are inappropriate. The most commonly used technique remains augmentation with a detubularised patch of ileum (ileocystoplasty). Controversy persists over the role of routine surveillance following ileocystoplasty for the detection of subsequent bladder carcinoma; however the indication for surveillance after gastrocystoplasty is clearer due to a rising incidence of malignancy in this group. Despite a reduction in the overall numbers of AC operations being performed, it clearly still has a role to play, which we re-examine with contemporary studies from the last decade.

Routine surveillance cystoscopy for patients with augmentation and substitution cystoplasty for benign urological conditions: is it necessary?

OBJECTIVE: To evaluate screening cystoscopy as the long-term follow up in patients with an enterocystoplasty for > or =10 years. PATIENTS AND METHODS: We performed a prospective analysis of 92 consecutive patients who attended our endoscopy suite for regular check cystoscopy as per standard follow-up. This is performed for all patients with cystoplasty performed at our institute after 10 years. The data were recorded on patient demographics, original diagnosis and type of cystoplasty. In all, 53 of these patients consented to undergo bladder biopsies at the same time. RESULTS: The median (range) follow-up was 15 (10-33) years. No cancer was identified with either surveillance cystoscopy or on routine biopsies. Chronic inflammation was identified in 25 biopsies (27%). Villous atrophy was present in 12 (55%) ileal patch and three (12.5%) colonic patch biopsies. During this study, the first and only case of malignancy in a cystoplasty at our institution was diagnosed in a symptomatic patient. She had intermittent haematuria and recurrent urinary tract infections (UTIs). She previously had a normal surveillance cystoscopy. CONCLUSIONS: We feel that it is not necessary to perform yearly check cystoscopies in patients with augmented bladders at least in the first 15 years, as cancer has not yet been detected with surveillance cystoscopy in this patient group. However, if the patient develops haematuria or other worrisome symptoms including suprapubic pain and recurrent unexplained UTIs a full evaluation, including cystoscopy and computerized tomography should be undertaken.

The current role of the artificial urinary sphincter for the treatment of urinary incontinence.

PURPOSE: The introduction of the artificial urinary sphincter (AUS) in 1972 was heralded as a revolution for the treatment of genuine stress incontinence. Initial enthusiasm was tempered by disappointment as complications occurred. The device has now been in routine clinical use for more than 30 years, and the indications and surgical principles involved in its use along with short-term and long-term outcomes are more clearly defined. Hence, we reviewed the literature to clarify the role of the AUS and offer a possible solution to its problems in the guise of a new sphincter. MATERIALS AND METHODS: A MEDLINE search was performed and all articles relating to the role of the AUS for the treatment of urinary incontinence were reviewed. RESULTS: The AMS 800 (American Medical Systems, Minnetonka, Minnesota) provides urinary continence in 73% of cases (range 61% to 96%) and it has a complication rate of 12% (range 3% to 33%) for mechanical failure, 4.5% to 67% for early infection/erosion, 15% for late erosion and 7% for delayed recurrent incontinence. The literature supports the role of the AUS as an important and reliable treatment modality for stress urinary incontinence and intrinsic sphincter deficiency. However, it is not suitable in all patients and its use for the management of hypermobility is controversial. Hence, careful patient selection according to indication is required with full preoperative counseling. CONCLUSIONS: Despite its reliability for achieving urinary continence the AMS 800 is not perfect. Newer devices, such as that being developed at our institution, may offer improved outcomes and decreased complication rates.

Bladder reconstruction: urothelial augmentation, trauma, fistula.

Urothelial augmentation in the form of augmentation enterocystoplasty continues to be the mainstay of surgical treatment for neuropathic bladder dysfunction and detrusor instability. The outcome of the procedure is satisfactory, but a number of complications are becoming more clearly defined. Computed tomography cystography is now the investigation of choice for diagnosing bladder rupture. The indications for computed tomography cystography are discussed. The current management of enterovesical fistula is reviewed.