Role of Nursing in Urogynaecology

Abstract

Nursing role in urogynaecology has expanded in the modern practice especially with emerging of formulated protocols and guidelines In urogynaecology. Furthermore, conservative approaches and its success in improving patients quality of life is currently led by trained nursing staff, these areas includes pelvic floor training, bladder retraining, fluid intake modification such as explanation of the impact of caffeinated drinks on bladder activity. The adoption of pessary led nurse clinics are well established model in the current urogynaecology with significant improvement in patients flow rate across urogynaecology service provision. On the investigation side of practice, nurse led uroflowmetry and urodynamics are currently expanding with good outcomes for the patients and service capacity. Nursing role in teaching patients how self catheterise is important in those with voiding dysfunction and also prior to incontinence surgery due to associated risk of voiding difficulty.

1. Introduction

The expanding practice of urogynaecology in outpatient settings has flourished the role of specialised nurses in the field mainly in the areas related to initial assessment and investigations, conducting urodynamics studies as well as initiating the management plans of stress incontinence, over active bladder syndrome as well as running nurse led pessary clinic for managing pelvic organ prolapse.

These are currently established models both in tertiary centres and district hospitals. Further more, trained nursing staff can perform Percutaneous nerve stimulation and diagnostic cystoscopic assessment in tertiary centres.

2. Initial assessment

In the UK, 3.5 millions women suffer from urogynaecological problem however not every patient has symptoms that impact their quality of life and led them to seek medical attention. One in every ten women over the age of 35 suffers a degree of urinary incontinence [1, 2]. Specialised urogyanecology nurse are able to stratify the patient symptoms according to lower urinary tract symptoms groups which mainly are;

Stress urinary incontinence defined as involuntary leakage of urine with effort or exertion, or on sneezing or coughing [3].

Urge urinary incontinence defined as involuntary leakage of urine accompanied by a strong desire to pass urine (void) [3].

Mixed urinary incontinence defined as involuntary leakage of urine associated both with urgency and with exertion, effort, sneezing or coughing. Commonly, one of the two elements are predominant and most bothersome [3].

Daytime frequency is defined when a woman perceives that she voids too often during the day [3].

Nocturia is defined wake at night more than one time at night to void up to the age of 70 years [3].

Nocturnal enuresis defined as incontinence occurring during sleep [3].

Urgency defined as sudden compelling desire to pass urine, which is difficult to defer [3].

Over active bladder syndrome defined as occurrence of combination of urgency, frequency, urge incontinence and potentially nocturne and nocturnal enuresis.

Overflow incontinence defined as involuntary loss of urine without warning or precipitating factor and it occurs when the bladder becomes large and flaccid and has little or no detrusor tone or function [3].

Incontinence due to a fistula which can be vesicovaginal, ureterovaginal or urethrovaginal fistula [3].

Voiding difficulties includes hesitancy; that is, difficulty in initiating micturition, straining to void and slow or intermittent urinary stream, or post micturition ripples and feeling of incomplete emptying. They are indicative for urethral obstruction muscle, or loss of coordination between detrusor contractions and urethral relaxation [3].

Absent or reduced bladder sensation is usually due to denervation caused by spinal cord injuries or pelvic surgery. It leads to infrequent micturition and a large-capacity bladder, and is often associated with overflow incontinence [3].

Haematuria defined as presence of blood in the urine. This can be microscopic or macroscopic (frank). It is always warrants further investigation [3]

Bladder pain is common with urinary tract infections but also can indicate chronic inflammatory changes that is present in interstitial cystitis where the bladder pain is usually better with emptying [4]

The initial assessment should also gathering the relevant information about; Weight and body mass index (BMI), blood pressure, Signs of systemic disease especially neurological problems and Mobility and mental state [5].

Urinary incontinence and other lower urinary tract has significant impact on women’s life starting from a lower emotional wellbeing up to social isolation and planning daily activities around places with toilet availability. There are questioners that assess the impact of lower urinary tract symptoms on quality of life which is a vital aspect in the initial assessment. A well trained nursing staff should be able to analyse such questionnaire [4, 5, 6, 7, 8, 9].

3. Basic investigations

1. Urine analysis; Urinary tract infection (UTI) can simulate over active bladder symptoms. Urine strip testing of urine is a cost effective screening for UTI and cases with positive nitrates and leucocytes on strip test should be sent for microscopy and culture [10].

2. Post-void residual check either by ultrasound scan or by catheterisation should be done if there are voting dysfunction symptoms. Post void residuals more than 150 ml is considered abnormal [5].

3. Bladder diary (frequency/volume chart) provides objective method for quantification of fluid intake, functional bladder capacity and voiding pattern. Patient records frequency and times of voids, type of fluid intake and voided volume along with any leakage episodes every 24 hours for 3 days [11].

4. Urodynamic studies

Urodynamic studies include uroflowmetry and cystometry. A well trained urogynaecology nurse specialist can perform urodynamic studies.

Clinically urodynamics are need in the following cases [12, 13].

1. Mixed urinary symptoms (urge incontinence and stress incontinence) prior to surgery for stress incontinence

2. Symptoms suggestive of detrusor overactivity unresponsive to medical treatment

3. Voiding dysfunction with incomplete bladder emptying.

4. Symptoms suggest neuropathic bladder disorder

4.1 Uroflowmetry

The test is conducted by requesting the patient to void on a commode that has urinary flow meter that measures voided volume over time. It is indicated whenever the patient history is indicative for presence of voting dysfunction especially those with recurrent UTI history and patients with over active bladder symptoms and voiding dysfunction symptoms prior starting anticholinergic medications as they can lead to urine retention as side effects. It is also important to consider uroflometry as preliminary test prior cystometry studies test in patients who have voiding dysfunction symptoms and considered for surgery for prolapse or stress incontinence as they would be at high risk postoperatively [14].

Normal finding includes a voided volume of more than 150 ml voided over 16 seconds with maximum flow rate above 15 ml/sec with smooth bell shape curve.

4.2 Cystometry

It is a test involving placement of catheter in the bladder that measures the intravesical pressure (Pves) and catheter in the vagina or the rectum that measures (Pabd). The bladder is then with water at rate of 50–100 ml per min with an aim to reproduce the woman’s symptoms and helps to obtain pathophysiological explanation. The pressure generated by the depressor muscle (Pdet) is calculated automatically by subtraction of (Pabd) from (Pves) [14, 15].

The test is conducted through two phases, the filling phase and then the voiding phase. During the filling phase the patient is asked to mention first desire to void (FDV) and also when they feel a strong desire to void when they would normally go to the toilet at that stage (SDV) and finally when they cannot hold urine anymore and that’s taken as maximum cystometric capacity (MCC). Normal bladder function involve FDV at 150–200 ml, SVD at 300–600 ml, MCC at 400–700 ml of the volume infused [14, 15].

During the filling phase the patient is asked to cough regularly every 100 ml or 150 ml to identify any stress incontinence. Leakage without rising detrusor pressure is indicative for stress incontinence. The earlier the leakage is detected in the test the more severe the degree of stress incontinence. During the test patient is asked to report any feeling of urgency and that’s counter checked with rising in the (Pdet). Normally during filling phase (Pdet) should not exceed 15 cm H₂O. Rising of (Pdet) beyond 15 cm H₂O indicates detrusor over activity [14, 15].

It is important to note patient with severe detrusor overactivity has less bladder compliance and the MCC is usually low. Those patients can also have very low FDV and SDV and the test at that stage should be done at lower infusion rate of the filing fluid [14, 15].

Filling phase monitoring can identify rising in the detrusor pressure with cough in some patients. Those patient presents with leakage in while coughing and the initial impression from the history is stress incontinence while the urodynamic diagnosis would be in fact bladder overactivity [3, 15].

Once the MCC is reached and patients point out that they cannot hold anymore without voiding otherwise she would leak, fluid infusion would be stooped and patient is moved while the catheter in place to void on a commode with built in uroflowmetry to assess any voiding dysfunction and calculate the voided volume, Maximum flow rate [14, 15].

4.3 Ambulatory urodynamics

The test is useful to consider when the conventional urodynamics fails to reproduce the patient symptoms and the results are inconclusive. Micro tip pressure transducer is used to messure the pressures and the bladder is filled naturally (mostly at rate of 1 ml/min compared to the unphysiological filling in the conventional test at rate of 50 ml/min. The patient carry out her normal daily activities, including those that commonly provoke symptoms. The test availability in vary in various units and that’s in itself is a limiting factor for its use [12, 13].

5. Diagnostic cystoscopy

Nurse led diagnostic cystoscopy in outpatient setting using either flexible or rigid cystoscopes has been successful in tertiary centres and it has proved to help service provision and improves patient flow. Patient referred for diagnostic cystoscopy are mainly those having recurrent urinary tract infections, haematuria to exclude bladder stones or tumours, bladder pain to exclude interstitial cystitis and patients with suspected urinary tract injury or fistula. The limiting factors nurse led cystoscopy is the resource availability and training curve required.

6. Management of stress urinary incontinence

Approximately one-half of all women with urinary incontinence complain of pure stress incontinence and 30–40% have mixed symptoms of stress and urge incontinence. Urogynaecology nurse role in managing stress incontinence fall into two areas;

6.1 Advice on life style modifications

Smoking cessation is encouraged as chronic cough exacerbates the stress incontinence. If the patient is over weight, the nurse should provide advice on weight reduction as it would lead to reduction in the intrabdominal pressure and in turn the intravesical pressure. Advice to seek medical help and rectify exacerbating conditions such as chronic cough from pulmonary diseases and asthma and similarly any constipation should be rectified.

6.2 Advice and guidance on pelvic floor exercises

Pelvic floor exercises improve contractility and coordination of pelvic floor muscles. An assessment of pelvic floor strength should be done in women with stress incontinence The pelvic floor musculature consists of slow twitch fibres, which are involved in posture, and a smaller element of fast twitch fibres, which are used during exertion such as coughing. Slow twitch fibres are trained with long sustained repetitive pelvic floor exercises whereas fast twitch fibres are trained with fast powerful contractions. If the pelvic floor musculature is weak, then a pelvic floor exercise improves the muscle strength and endurance and in turn less mobility of the bladder neck on straining and coughing and subsequently lesser degree of incontinence. The pelvic floor exercise are conducted as 3 sets every day of 8–12 contractions. Slow velocity contractions sustained for 6–8 seconds each. The response usually notable in 3–4 months. Additional measures such as weighted vaginal cones and pudendal nerve stimulation may be used [3, 16].

It is important to realise the limitation of pelvic floor exercise in patient with stress incontinence as it helps more the patients mild and moderate leakage with approximate improvement of 30–40% in their symptom profile after completion of 3–4 months course. Further management is needed if no improvement is notable beyond this period [16].

7. Management of overactive bladder syndrome

7.1 Life style changes and bladder retraining

Urogynaecology nurse specialist can provide and follow up with the patient the necessary life style changes that helps to improve the bladder overactivity these include, avoidance of bladder irritants such as tea and coffee and use of decaffeinated brands, lesser use of fizzy drinks such as cola. Reduction or preferably cessation of alcohol intake. Smoking cessation is advisable especially in those with mixed stress and over active components. Fluid restriction to 2–3 a day helps to minimise symptoms of detrusor overactivity [14, 15].

Further more, the nurse guides the patient through the bladder retraining which entails education of timed voiding and systematic delay of voids according to a time table. Starting with an aim for resisting the feeling of urgency and hence the voids every 30 mins that’s extends gradually to reach a void every 2–3 hours [15].

7.2 Pharmacotherapy

The urogynaecology nurse provides the patient with information that is relevant to various medication used in the treatment of the bladder overactivity. The medications are prescribed by the clinicians and response to the treatment can be followed by the specialised nurse.

The first line of treating the bladder overactivity is the use of anticholinergics. Block the muscarinic receptors that mediate detrusor smooth muscle contraction and in turn relaxing effect on the detrusor muscle. The response to anticholinergics is notable on 6–8 weeks. They vary in the response based on their on selectivity for various muscaric receptos. Oxybutinin is usually the recommended first line in slow release form. It is none selective and hence has higher side effect profile compared to other variants but it is cost effective. Solifenacin, Darifenacin, Tolterodine, Trospium are more selective on the muscarinic receptors in the bladder and hence lesser systemic side effects. The most notable side effects of antimuscarinics are dry eye, dry mouth, constipation and urine retention. The nurse can check with patient if there is any contraindication for the anticholinergics such as acute open angle glaucoma, mythesga gravis or any voiding dysfunction [14, 15, 16, 17].

Patients with voiding dysfunction along with bladder overactivity may be benefit of using mirabegrone which relaxes the bladder wall smooth muscles through stimulation of beta adrenergic receptors and blockage of alfa adrenergic receptors. The main contraindication is uncontrolled hypertension and hence it is important for nurse specialist check the patient’s blood pressure prior they start on mirabegrone [15, 18].

7.3 The role of oestrogen’s

Postmenopausal women who has atrophic vaginitis are usually having some degree of atrophic cystitis. The use of local of oestrogen to treat atrophic vaginitis helps to reduces the over active bladder symptoms to some egress in those patients. Urogynaecology nurse specialist should highlight such benefits of oestrogen cream to the patient and ensure the prescription given by the clinician is followed by the patient [19].

7.4 Use of botulinum toxin a in the of overactive bladder

Patients who has refractory overactive bladder symptoms are over by clinicians Botulinum toxin A by the clinician and at this stage the patient case would have have had urodynamic studies that confirms detrusor overactivity and have her case discussed in the multidisciplinary team meeting that include urogynaecologist, urogynaecoogology nurse Specilaist, phythiotherapist and may include also a urologist [19].

Botulinum toxin A is an extremely potent neurotoxin and its Intravesical injection under local or general anaesthesia via cystoscopy improves the over active bladder symptoms up to 90%. The most commonly applied regimen is use of 100 units of botox in 20 injection points through the bladder sparing the trigone area. The effect of botox injection wears off in 3–12 months depends on the severity of overactive bladder symptoms. Approximately 5–10% of patients receiving botox injection can develop urine retention postoperatively and hence preoperative teaching of the patient how to self catheterise and empty the bladder twice a day is very important [20, 21, 22].

The role of urogynaecology nurse at this stage is participating in patient education about about the botox benefits and help the patient to obtain the relevant information leaflets. Also, nurse specialist should be able to teach the patient self catheterisation and ensure it is done promptly especially in old patients with joint movement or rheumatoid arthritis difficulty who has difficulty in reaching out to able to self catheterise. In tertiary units with cavities of training and supervision urogynaecology nurses can perform outpatient cystoscopic botox injection.

7.5 Percutaneous posterior tibial nerve stimulation

Percutaneous posterior tibial nerve stimulation (PTNS) is the least invasive surgical method used in management of refractory symptoms of urgency and urge incontinence. It is mediated by retrograde stimulation of the sacral nerve plexus. The posterior tibial nerve contains mixed sensory motor nerve fibres that originate from the same segment in the spinal cord as the nerves to the bladder and pelvic floor [23, 24].

7.6 Long term catheterisation

Patients with severe over active bladder symptoms that is unresponsive to treatment options especially with old age and presence of multiple medical co-morbidties can be offered long term catheterisation as an option to improve the quality of life. The catherisation in such cases can be urethral with a narrow catheter attached to small leg bag that can be worn under cloth or suprabubic as this does not irritate the urethra or trigone, and the urethra cannot be traumatised by the woman pulling on her catheter. The use of long term catheterisation can be a potential risk of recurrent urinary tract infection and clinician can prescribe long term low dose antibiotic prophylaxis [20, 22].

The role of the urogynaecology nurse in those cases is to ensure regular catheterisation care for example changing the catheter and adjust the size to ensure the right fit without urine leakage from around the catheter and look for any elements of skin care required in the perineal area from potential continuous leakage and irritation.

8. Management of pelvic organ prolapse

Pelvic organ prolapse is the descent of the pelvic organs into the vagina.The about half of multiparous women have some loss of pelvic floor support however 10–20% of them seek medical advice. The prolapse can be anterior (bladder and urethral) prolapse or posterior (rectal) prolapse or mid compartment (uterine or vault) prolapse. The degree of decent is classified through “The Baden-Walker classification” into four grades [25, 26].

• First degree—descent to a point 2 cm above the introitus

• Second degree—descent to point within 2 cm from the Introitus

• Third degree—descent to a point within 2 cm beyond the Introitus

• Fourth degree—descent to point beyond 2 cm outside the interotus

Prolapse patient presents usually with variety of symptoms including vaginal lump and discomfort, dragging sensation, backaches as well as lower urinary tract symptoms such as urgency and frequency and feeling of incomplete emptying and needing to adjust position to help bladder emptying. Bowel symptoms associated with prolapse vary from constipation to obstructive defecation and needs for vaginal digitation to help bowel emptying [27, 28].

Prolapse has it is impact on the quality of life from physical point of view as well as implications on sexual life [25].

Urogynaecology nurse specialist should be able to assess the patient symptoms and and the assess the degree of prolapse which can be counter checked by the clinician if needed. Provide the patient with leaflets and identify any predisposing factors that participate in making the prolapse worth such as high BMI, chronic cough in patients with chronic lung disease and chronic constipation as well as implication of the prolapse on managing day to day activity and patients sexual life.

8.1 Conservative management

Conservative treatment may be appropriate, although prolapse is a mechanical problem that in general, when patients are fit, is treated surgically [25, 28].

8.1.1 Pelvic floor exercise

Pelvic floor exercises helps limit the progression of mild prolapse and relief milder prolapse symptoms. However, pelvic floor exercises on its own does not to restore normal support and are not useful if the prolapse extends to or beyond the vaginal introitus. It is reported to salivate 42–53% of mild and moderate prolapses up to grade two descent but it is unlikely to have any improvement in patients with more than grade two descent [25, 27, 28].

Urogynaecology nurse specialist should be able to guide the patient through pelvic floor exercises along with the physiotherapist and assess the response in 3–4 months.

8.1.2 Pessary management

Vaginal pessaries offer help to women who decline surgery, who are unfit for surgery, or for whom surgery is contraindicated [29].

Long-term pessary use has a high drop rate because of side effects such as vaginal ulceration, discharge and bleeding. It has been reported that only 15–20% of women uses pessaries as long term approach [30, 31].

Fitting the correct pessary size requires a trial and error. A digital examination allows some estimate of vaginal size. In general, it is best to start with smaller pessaries, increasing the size if not staying in place. Change of pessaries usually with in 6 months if no complications such as ulceration and bleeding. If the vagina is atrophic, topical oestrogen cream should be used twice to reduce the risk of ulceration and bleeding. Pessaries can ring pessaries ranging in diameter from 52 to 129 mm and they placed between the back of symphysis pubis and posterior fornix. They usually help with prolapsed when there is uterus as the cervix fits in the middle of the ring. However patients who had hysterectomy they are more likely to benefit off shelf pessaries compared to the ring pessaries as the shape of those provides better support for the vaginal vault where shape and axis could have changed by the hysterectomy [32, 33].

Urogynaecology nurse specialist should be able to fit the pessaries and change them and identify any ulceration and bleeding caused by pessary use. The nurse led pesky clinic in primary and secondary care is a well established model and proved to be cost effective and reduces patient loads on the outpatients clinics with high patient satisfaction rate [34].

9. Conclusion

The role of specialist urguanrcology nurses are expanding and it is a future prospect talking into consideration the world wide pressure on health service.

The limiting factor are the opportunity of training and initial period of supervised practice. Various units have various set up but the core of practice is nearly standard due to national guidelines from the NICE “National Institute of Clinical Excellence” and IUGA “International urogynaecologist association”.

Development local protocol, pathways, SOPs “Standards of operations” that the specialists nurses can follow with involvement of the urogynaecology clinicians and the primary services in the community present the corner stone for steady and sustainable nurse led Urogynecology practice.