Obstetrics & Gynaecology Forum Volume 29 | Issue 3 | 2019

Introduction: Part one of this article deals with the assessment and medical management of the disease. The following will delve into surgical techniques in the armamentarium of treatment for both urge and stress urinary incontinence. 1. Urge Urinary Incontinence (UUI): The International Urogynaecological Association/International Continence Society (IUGA/ICS) joint report defines UUI as the state of involuntary loss of urine that is associated with urgen- cy. 1 Overactive bladder is the clinical diagnosis based on patient symptomatology, namely increased daytime frequency and urinary urgency. 2 Behavioural and medical management is the mainstay of treatment for OAB. However, the fall off for use of the above techniques is high, due to the poor adherence to the adverse side effect profile of most anticholinergics. Other treatment modalities are discussed below. 1.1. Botox Behavioural therapy remains first line for OAB, as recommended by the ICS. 3 Anti-muscarinic medication and the newer B 3 adrenergic receptors can be used in combination with behavioural therapy, but their use is limited in view of the side effect profile of the former and the cost and availability issues of the latter. Produced by the bacteria Clostridium Perfringens, Onabotu- linumtoxin A inhibits the pre-synaptic release of acetylcholine in motor neurons. In addition, it decreases adenosine triphosphate (ATP) and substance P release and causes the down-regulation of capsaicin and purinergic receptors on afferent neurons. 4 It has long been approved for a number of ophthalmic and aesthetic proce- dures. In 2011, it was then approved for the use in the treatment of OAB. In the same year, a Cochrane review on the subject was published, finding that Botox is a suitable treatment for refracto- ry OAB. 5 Subsequently, there have been multiple review articles published on the subject leading the American Urological Associa- tion and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU) to release a joint guide- line stating that they consider BOTOX injections for OAB as third line options for those patients who have failed or are not suitable candidates for the first and second line medications outlined above. Exact dosages for the use of BOTOX in the literature vary, but the general consensus suggests 200u, and 300u for neurogenic OAB. 1.2. Neuromodulation: Peripheral Neuromodulation: The lower urinary tract is innervated by nerves arising in the lumbar, sacral and coccygeal regions of the spinal cord, specifically L2-S4. The posterior tibial nerve comprises part of the sciatic nerve that arises from L4 to S3. Other nerves which innervate the pelvis are the dorsal genital nerve (DGN) and the pudendal nerve. Peripheral neuromodulation attempts to stimulate these nerves and therefore e ect a change in lower urinary tract symptoms. is can be per- formed in one of two ways: either by means of dermatomal stimula- tion, or by stimulating the nerve through the overlying skin. 6 Approach to female urinary incontinence: Part 2: Surgical Management Correspondence F Paterson email: drfpaterson@gmail.com F Paterson, P Swart, Z Abdool Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa O&G Forum 2019; 29: 7 - 10 REVIEW OBSTETRICS & GYNAECOLOGY FORUM 2019 | ISSUE 3 | 7