VOLUME 2; ISSUE 2 2023 UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE This publication is intended for registered healthcare professionals only.
Replenish Restore Revive Sterile sodium hyaluronate solution Pharmaco Distribution (Pty) Ltd. 3 Sandown Valley Crescent, South Tower, 1st Floor, Sandton, 2196 P.O.Box 786522, Sandton, 2146, South Africa. Tel: +27 11 784 0077. Website: www.pharmaco.co.za References: 1. Cicione A, Cantiello F, Ucciero G, et al. Intravesical treatment with highly-concentrated hyaluronic acid and chondroitin sulphate in patients with recurrent urinary tract infections: Results from a multicentre survey. Can Urol Assoc J. 2014;8(9-10):E721-7 1 BPS/ INTERSTITIAL CYSTITIS For full prescribing information, please refer to package insert S4 CYSTISTAT® Solution (40mg Sodium hyaluronate Each 50 ml of solution contains 40 mg Sodium hyaluronate Reg. No: A40/18.10/0062 Restored GAG layer Bladder muscle Damaged GAG layer Lumen of the bladder GAG layer Irritants (eg. urine) HA
VOLUME 2; ISSUE 2 2023 Editor Prof Shingai Mutambirwa - Urologist MBChB, MMed (Urology) Medunsa Head of Urology - Sefako Makgatho Health Sciences University Chairman - The South African Urological Association Academic committee Chairman - Medical and Scientic Advisory Board of The Prostate Cancer Foundation Editorial Board Dr. Sheynaz Bassa - Clinical and Radiation Oncologist MBChB (Univ of Natal), FC Rad (Onc) SA Head of Department: Radiation Oncology Steve Biko Academic Hospital and The University of Pretoria Dr Jireh Serfontein - Medical Sexologist MBChB (Pret.), Dip HIV Management, MMed Sexual Health (Univ. Sydney) Clinical head: My Sexual Health Pretoria Editorial and Publishing Ofce Maria Philippou Randburg 2194 Enquiries 082 3355 444 Publisher Maria Philippou Andrew Oberholzer Disclaimer All rights reserved. No editorial matter published in Urology, Urooncology and Sexology Update may be reproduced in any form or language without written permission from the publishers. While every effort is made to ensure accurate reproduction, the Prostate Cancer Foundation, the authors, publishers and their employees or agents shall not be responsible or in any way liable for any errors, omissions or inaccuracies in the publication whether arising from negligence or for any consequences arising there from. The inclusion or exclusion of any product does not mean that the Prostate Cancer Foundation, the publisher or the editorial board advocates or rejects its use either generally or in any particular eld or elds. This publication is intended for registered healthcare professionals only. If you received this publication or a link to this publication in error, please do not directly or indirectly use, print, copy, forward, or disclose any part of this publication. Please delete the copy or link to the publication and notify the publisher. UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE CONTENTS 1 The Safety of Hyperthermic Intravesical Chemotherapy Part 3 Pelvic oor dysfunction has a complex aetiology and therefore a complex set of solutions and mindfulness plays a vital role in these solutions “Rocking but Rusty”: Expectations of Male Sexual Function by Decade Localised prostate cancer: the role of radiation therapy The prole of Black South African men diagnosed with prostate cancer in the Free State, South Africa Interview with Dr. Matthew Olukayode Abiodun Benedict Advanced Penile Length Restoration Techniques at the time of Penile Prosthesis Placement 2 8 14 18 24 35 38 UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE Supported by:
2 UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE The Safety of Hyperthermic Intravesical Chemotherapy Part 3 Dr S Cornish Urologist “Is it safe?” This was the question that Laurence Olivier asked of Dustin Hoffman in the great movie Marathon Man. Unfortunately for Dustin he could not answer the question and Laurence took great delight in drilling holes in his healthy teeth with the panache born of years spent as a Gestapo dentist. I hope in this article that I will convince the reader that Hyperthermic chemotherapy of the bladder is not only safe but is better tolerated than the gold standard of BCG therapy. This is a dry subject at best, but I hope to make the subject less painful to digest than a freshly drilled dental nerve. I have added some pearls to this article which I hope the reader will nd of some use when treating patients with hyperthermic bladder therapy. In this article I am going to look at the safety of hyperthermic therapy and review the various papers on this subject that have been published in the last twenty years. I will rst deal with the drugs that have been used for intravesical therapy other than BCG in the room temperature setting. Just about every urologist is familiar with BCG immunotherapy, but for many entering the arena of chemotherapy is a new experience and challenge. Different protocols need to be understood when working with these drugs. For a long time mitomycin C was the only drug used for thermal intravesical therapy. The drug had a long track record of use in the cold setting (room temperature) when BCG had failed, or it was not available, or when adverse reactions accompanied its use. Urologists have had a relatively long experience of using this drug in either the post cystoscopy setting for prophylaxis or using it to treat non-muscle invasive disease. Its use was rst described in the 1970's. I am not sure if everyone is aware of how toxic this substance can be. In terms of handling, the drug is not very nice. It is classied as a hazardous substance because it is a mutagen. It can affect the kidney of handlers of the drug. It is important to wear protective clothes and gloves when handling the drug. A pregnant person should not handle the drug. Getting it on your skin or in your eyes requires immediate washing of the affected surface. The crystals when mixed, give off fumes which can be inhaled. Therefore, one should make sure to mix the drug in its ampoule and not spill any of the uid. Patients should be instructed to void urine sitting down, for six hours after treatment so as not to splash, and the toilet bowel should be ushed twice with the lid down. Oddly enough according to OSHA, an organisation that quanties drug hazards, drinking mitomycin C is not too dangerous and there has been a study looking at its absorption across the GIT in 1976. Patients may experience no symptoms from the use of mitomycin C in their bladders. The urine may turn blue green for up to forty-eight hours; dysuria can occur as well as abdominal cramps and diarrhoea. Mitomycin C can produce a skin rash on the palms of the hands, soles of the feet, and genitals. If this side effect occurs, the mitomycin C management should be abandoned. Sometimes steroids are needed to resolve the rash. A very rare side effect is reduction in bladder capacity. Some people may develop a urinary infection after mitomycin C therapy and this needs to be managed appropriately. Rarely the drug can cause a pancytopaenia. The overall incidence of adverse events has been reported at between 22 and 25% with dysuria making up 5.5%, or about a quarter of the total cases. Gemcitabine has been used in an intravesical setting from around 2010. When handling the drug, His urological interests lie in cancer therapies and diagnosis, urinary incontinence, prostate enlargement therapy and fertility management.
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4 safety precautions should be similar to mitomycin C. It is not quite as toxic and is more likely to target the lungs. As with mitomycin C it should be washed off the skin or the eyes immediately. Pregnant staff should not handle the drug. Gemcitabine is currently becoming the most commonly used chemotherapeutic drug in intravesical therapy because of a shortage of mitomycin C. The difculty in accessing mitomycin C started in 2019 and was attributed to manufacturing problems. Gemcitabine is an antimetabolite that targets components of the cell division process. In 2011 Cao et al reported that gemcitabine's adverse event rate was similar to Mitomycin C. In 2020 Li et al published work comparing gemcitabine to mitomycin C. The researchers looked at chemical cystitis; haematuria; rash and hepatorenal toxicity. There was a clear advantage in terms of side effects visually demonstrated on forest plots in favour of gemcitabine. A meta-analysis by Zigi Ye et al published in 2018 looked at the adverse rates of gemcitabine versus BCG and they concluded that there was a signicant difference in favour of gemcitabine for the categories of dysuria, fever, haematuria, and miscellaneous adverse events. However, a study published in 2021 by J. Kuperus showed that gemcitabine had a greater incidence of fatigue and chills compared with BCG, although duration of symptoms was longer with BCG and haematuria was a lot worse. Very rarely gemcitabine, as with mitomycin C can cause a reduction in bladder volume. A study published in 2014 looked at the safety and efcacy of valrubicin. A drug that had been reintroduced to the medical world after having been withdrawn at the beginning of the century because of concerns over manufacturing procedures. Valrubicin is a anthracycline antibiotic. Simplistically this group of antibiotics damages DNA in cancer cells. In handling the drug, the usual rules will apply concerning protective clothing when drawing up this red coloured solution. It should not be used with PVC products because a component of the drug leaches PVC. Instead, administration sets using polypropylene or polyolen should be used. The commonest side effects were the usual suspects of haematuria and pollakiuria. Four percent dropped off the study because of serious adverse events. A rash on the palms and genitalia from voiding urine containing the drug is common. It is important to wash one's hands and genitalia carefully for the rst forty-eight hours after the drug administration. Valrubicin can also cause a generalised rash, but treatment can be continued on topical steroids. A noteworthy side effect is red urine, not to be confused with haematuria. It can be ignored unless it continues for more than a day. Other side effects include nausea, vomiting, abdominal pain, diarrhoea, backache, and headache. Overall, more than 90% of patients will have some form of symptoms during the six-week induction phase. The largest study to date, reported 60% of patients having irritable bladder symptoms. The rate for urinary tract infections is 15%. Pirarubicin and epirubicin are other red anthracycline drugs with very similar side effects to valrubicin. Similar precautions and safety aspects apply to these drugs. Docetaxel has been used successfully in sequential combination with gemcitabine for nearly fteen years. Until recently, both drugs have been administered in the room temperature setting. However, in 2020 a paper appeared by Rao et al who had reported on their experience of thermal gemcitabine and docetaxel that began in 2007. They had sixty patients in the study, all who had refused radical cystectomy. Thirty-one patients had some local symptoms, and all patients completed their treatment course. The commonest symptoms reported were mild fatigue (20%), haematuria (20%), mild urinary frequency/urgency (13%), dysuria (10%), and nocturia (7%). Gemcitabine is given before docetaxel because gemcitabine induces cell cycle arrest and docetaxel provides the coup de gras by promoting cell death. UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
5 So, I must add docetaxel to the drugs used in thermotherapy. Docetaxel in a microtubule inhibitor that hinders cancer cell replication. The drug was rst reported in intravesical therapy in 2006 by McKiernan et al in a phase 1 study. There was no systemic absorption, so the classical side effects of docetaxel did not occur. Protein size greater than 300 Daltons cannot penetrate the bladder wall and docetaxel weighs in at 862 Daltons. Once again, as with the other chemotherapeutic drugs there were local side effects mostly of the grade 1 variety. In terms of handling the drug there again are hazards. It is a ammable liquid and vapourises. It is suspected of causing genetic defects. The drug may damage fertility, or the unborn child and it may cause harm to breastfed babies. Docetaxel will cause eye irritation. It needs to be handled with protective clothing and washing of hands afterwards is essential. When is heat added to the equation, is the safety of each of the drugs mentioned altered? The rst trial of MMC HIVEC was conducted by Colombo et al. in 1995. The complete response rate was 70% and after a mean follow-up of 24 months, 16% recurred. Multiple studies have since followed. No one has been reporting any serious consequences of heating up these drugs in terms of patient safety from the drug itself. In a meta-analysis of twelve trials involving 888 patients published in 2020 by Liu et al, the forest plot for all the recorded adverse events slightly favoured thermal therapy over the control. The drugs looked at in the various studies analysed included mitomycin C, gemcitabine and pirarubicin. Systemic side effects were minimal, and this makes sense. In my previous article covering the basic science of thermal therapy, it has been shown that there is very little systemic absorption of these drugs placed into the bladder during above body thermal conditions. The machinery for heating up the intravesical solutions also need to be considered in the realm of patient safety. My articles have been written for the urologist and not large oncology units, so I am not going to consider the hugely expensive external radio frequency units like the Pyrexar which cost many hundred of thousands of dollars and require a specialist physicist to run them. The Synergo system which falls under the classication of a RITE system (Radiofrequency-induced thermochemotherapy effect) is also expensive and will probably only be affordable in large private or academic units. This device uses a catheter with a radio frequency transmitter built in it to heat the uid bathing the bladder. It was on this device however where most of the original intravesical research was performed using mitomycin C. Devices, like the Combat, that heated the uid outside and circulated it through the bladder continuously came later. These devices fall under the classication of CHT (conductive thermochemical therapy). These machines are a lot more affordable, and the outcomes from these devices are now appearing more often in the literature. Comparison between the radio frequency catheter systems and recirculating heated systems have shown similar clinical results. I discussed their delivery methods and the positives and negatives of each system in the last article. NICE published an article in 2021 on various aspects of the Synergo system including its safety. The report was based on 19 separate studies. The item that was highlighted, was pain that built up over the course of treatment. In most patients however, the pain could be tolerated and managed by the nursing personnel. Implanted metal in the pelvis was associated with pain during the procedure. The posterior bladder wall tended to be burnt by the catheter, but the burn was supercial and would heal without incident or medical therapy. Patients with pacemakers needed to be monitored by a cardiologist during the treatment period. With the Combat and other systems such as Unithermia, the side effects are mostly some enhancements of the effects seen with cool intravesical chemotherapy, most notably with bladder pain, or bladder spasm, haematuria, and dysuria. It has been noticed that men tend to have more pain than women during the treatment, regardless of the device used. There have not been any head-to-head to head comparisons with RITE devices and CHT devices but in a pooled analysis by Zhou et al in 2022 there was a slight bias in favour of CHT over RITE, but no fair direct comparison could be made. In this analysis of 15 studies consisting of 1190 patients, thermal therapy adverse events were slightly worse than normothermia patients. On the forest plots the RITE arms showed a greater difference in adverse events to the normothermia arm compared with a smaller noticeable difference between CHT and normothermia arms. When one looks at the physical devices, they have multiple safety mechanisms built in to monitor overheating, pump failure or over pressurisation etc. So once switched on they do not have to be monitored on a continuous basis for fault monitoring. Lastly, I would like to give some general hints for practitioners wishing to employ HIVEC in their clinical practice. These points would include the following: • Handlers and patients receiving these drugs should not be pregnant or planning to be pregnant. • After the procedure sexual activity should involve the use of a condom for the rst fortyeight hours in male patients and a female UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
6 patient's male partner should also use a condom. • Women of childbearing age should all be on some form of contraception for the duration of the treatment. • Ladies breast feeding will need to stop during the period of treatment. • Patients should all receive counselling prior to the procedure in terms of providing information about the drugs, what to expect during catheterisation and what can be experienced during the hyperthermic treatment. • Patients should be provided with a list of the possible side effects. This form should contain guidance on when it becomes imperative to contact the prescribing urologist. • Patients should all uid restrict for eight hours so that during the procedure they are not producing large volumes of urine which would dilute the chemotherapeutic solution. • Patients on routine diuretic therapy are asked to avoid these medications for six hours prior to the procedure and then to take the drug after the procedure. • Afterwards patients are asked to drink large volumes of water to wash the drug out of their system. In patients with heart failure this advice would need to be somewhat tempered. The exception to this last rule is mitomycin C. • Men should sit and void for the rst day after treatment to avoid splashes. • Caffeine, carbonated drinks, acidic drinks, alcohol and spicey foods should be avoided for the rst forty-eight hours after treatment because of these products irritant effect on the bladder. • Do not administer these drugs when a patient has an active urinary infection. As I stated at the beginning of the article, this is not an exciting topic but there is ample proof that these devices are safe, and the side effect prole of the various drugs used with the devices is more than acceptable. When compared with standard BCG therapy there is a lot of data now that shows the drugs are better tolerated. Urologists need to become au fait with handling toxicities. I leave with a quote from one of my heroes, Albert Einstein. “Concern for man himself and his safety must always form the chief interest of all technical endeavour”. In the next article I will discuss the question of whether the treatment actually works to prevent patients from needing to take the step of last resort which is the cystectomy. Bibliography Safety and efcacy of intravesical chemotherapy and hyperthermia in the bladder: results of a porcine study: Tan, WP; Chang, A; Brousell, SC; Grimberg, DC; Fantony, JJ; Longo, TA; Etienne, W; Spasojevic, I; Maccarini, P; Inman, BA; Int J Hyperthermia; Vol 37/1, 854 – 860, 2020 Salvage Hyperthermic Gemcitabine and Docetaxel Combination Chemotherapy After BCG Failure in Non-Muscle Invasive Bladder Cancer Patients: Rao, Mounica Y. Kang, Paul Tarajkowski, Jamaka C. Mobley, Debra L. Lamm, Donald L. Bladder Cancer, vol. 6, no. 1, pp. 25-32, 2020 Comparison of Side Effects and Tolerability Between Intravesical Bacillus Calmette-Guerin, Reduced-Dose BCG and Gemcitabine for Non-Muscle Invasive Bladder Cancer: Joshua M. Kuperus, Ross D. Busman, Susan K. Kuipers, Helen T. Broekhuizen, Sabrina L. Noyes, Christopher M. Brede, Conrad M. Tobert, and Brian R. Lane; UROLOGY 00: 1-8, 2021. Heated Intravesical Chemotherapy: Biology and Clinical Utility. Wei Phin Tan, MD, Thomas Longo, MD, and Brant A. Inman, MD, MS; Urol Clin North Am. 2020 Feb; 47(1): 55–72. COMPLICATIONS OF INTRAVESICAL THERAPY: Basir Tareen MD, Samir S. Taneja MD, in Complications of Urologic Surgery (Fourth Edition), 2010 Intravesical radiofrequency induced hyperthermia enhances mitomycin C accumulation in tumour tissue: F. Johannes P. van Valenberg, Antoine G. van der Heijden, Rianne J. M. Lammers, Johannes Falke, Tom J. H. Arends, Egbert Oosterwijk & J. Alfred Witjes; International Journal of Hyperthermia; 01 Dec 2017. Intravesical device-assisted therapies for non-muscle invasive bladder cancer: Wei Shen Tan1,2 and John D. Kelly; Nat Rev Urol; 2018 Nov; 15 (11):667-685. Long-Term Experience with Radiofrequency-Induced Hyperthermia Combined with Intravesical Chemotherapy for Non-Muscle Invasive Bladder Cancer : Iris S. G. Brummelhuis, Yvonne Wimper, Hilde G. J. M. Witjes-van Os, Tom J. H. Arends, Antoine G. van der Heijden, and J. Alfred Witjes ; Cancers (Basel). 2021 Feb; 13(3): 377. Phase I Trial of Intravesical Docetaxel in the Management of Supercial Bladder Cancer Refractory to Standard Intravesical Therapy: James M. McKiernan, Puneet Masson, Alana M. Murphy, Manlio Goetzl, Carl A. Olsson, Daniel P. Petrylak, Manisha Desai, and Mitchell C. Benson; J Clin Oncol 24:30753080. Medical technologies consultation document – GID-MT553 Synergo for non-muscle-invasive bladder cancer Issue date: June 2021 © NICE 2021 The clinical efcacy and safety of equipment-assisted intravesical instillation of mitomycin C after transurethral resection of bladder tumour in patients with nonmuscular invasive bladder cancer: A meta-analysis: Weijian Zhou, Jianping Liu, Dongdong Mao, Changying Hu, Dianjun Gao; PLoS One. 2022; 17(10) The efcacy and safety of intravesical gemcitabine vs Bacille Calmette-Guérin for adjuvant treatment of non-muscle invasive bladder cancer: a meta-analysis: Ziqi Ye,1,* Jie Chen,2,* Yun Hong,1 Wenxiu Xin,3 Si Yang,1 and Yuefeng Rao; Onco Targets Ther. 2018; 11: 4641–4649. Thermal Intravesical Chemotherapy Reduce Recurrence Rate for Non-muscle Invasive Bladder Cancer Patients: A Meta-Analysis: Kang Liu,† Jun Zhu,† Yu-Xuan Song, Xiao Wang, Ke-Chong Zhou, Yi Lu, and Xiao-Qiang Liu; Front Oncol. 2020; 10: 29 Value of an Immediate Intravesical Instillation of Mitomycin C in Patients with Non–muscle-invasive Bladder Cancer: A Prospective Multicentre Randomised Study in 2243 patients: Judith Bosschieter a, Jakko A. Nieuwenhuijzen a, Tessa van Ginkel a, Andre´ N. Vis a, Birgit Witte b, Don Newling a, Goedele M.A. Beckers a, R. Jeroen A. van Moorselaar ; Eur Urol; . 2018 Feb;73(2):226-232. Read Chapter 1 and Chapter 2 UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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8 UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE Introduction Wellbeing is analogous to a puzzle, where each piece represents an integral aspect of an individual's overall health and happiness. No single piece is more important than another, and to complete the puzzle, all dimensions of wellbeing must be addressed. In the case of pelvic oor dysfunction (PFD) which is often resistant to treatment, considering the general wellbeing of patients becomes imperative for effective treatment. Healthcare professionals typically specialize and see the body part that they specialize in under the spotlight and it's easy to forget to shift the spotlight to include the whole person in a presenting patient. This makes any intervention offered less effective than it could be. As a physiotherapist working in the eld of chronic pelvic pain, the need to see the whole person who is suffering pain or dysfunction has been driven (5) home relentlessly . The layers of causative factors for a pelvic problem are so complex and interconnected that it is vital to have a system through (13) which to understand it . This system requires a broad-rst and narrowed-down-second approach, and it could be integrated into all patient care. The biopsychosocial wellbeing status and the lifestyle factors that are contributory to a patient’s condition must be considered. The outcomes of the biopsychosocial experience the patient is having (27) may be the cause of pelvic girdle dysfunction . Failing to consider this, will certainly leave any treatment lacking and possibly make it ineffective. The team approach is helpful, because one team member may pick up a critical element that (7) another misses . Medical practitioners know this, but the question is; do they do what they know they need to do? Maybe not always, especially when under time pressure. The construct of wellbeing needs to be unpacked. Richie Davidson called wellbeing a skill. Just as when attempting to perform a perfect golf swing, hundreds of small tweaks and adjustments are required, when developing wellbeing, a series of multiple well-made choices made over an extended period of time are necessary. Integral to wellbeing is the ability to use the pelvic oor muscle (PFM) effectively. The PFM is an often forgotten, small, but crucial and over demanded of muscle. When this muscle doesn’t work, there are so many functions that fall out. Functions which in their (3) absence, make living well impossible . Practitioners who work with patients suffering from problems in the pelvic region, have a huge PELVIC FLOOR DYSFUNCTION HAS A COMPLEX AETIOLOGY AND THEREFORE A COMPLEX SET OF SOLUTIONS AND MINDFULNESS PLAYS A VITAL ROLE IN THESE SOLUTIONS. By Sue Fuller-Good BSc Hons (Physio) UCT MSc (Physio) WITS Physiotherapist with a special interest in chronic pain and pelvic function Sue graduated from UCT and did her MSc through WITS in Orthopaedic Manual Therapy (OMT). She has worked in private practice for most of her working life, concentrating on manual therapy and pain. Her interest in the pelvis, pelvic oor, women's health and the craniomandibular junction (which is often a co-morbidity with pelvic pain) brought her many patients suffering from stress, anxiety, sexual dysfunction as well as sports injuries. She has had a lifelong culture of ongoing learning and has delved into many other elds through her career, including nutrition, yoga and motion control among others. She started practicing mindfulness herself 30 years ago and has been to many places in the East to study. She did her training through the Cambridge Health Alliance and Harvard University. She also studied coaching to upskill herself to serve her patients and help them shift their lifestyles to support their healing and wellbeing. Sue believes that effective treatment demands high levels of presence, active listening, inquiry and agility as well as a tool box lled with techniques and approaches. She believes in the therapeutic alliance as the basis for all treatment. Sue is part of the My Sexual Health Team and lectures extensively through many platforms around SA. She has spoken at numerous global conferences and has just published a book about wellbeing, called The Sweet Spot.
FIND CREDIBLE SEXUAL HEALTH PROVIDERS FOR YOUR PATIENTS WITH MY SEXUAL HEALTH Unlock the door to safe and effective sexual health care with our platform of credible providers s you know, Sexual health is fundamental to your patient's overall well-being, but it can be time-consuming to manage in your practice. A www.mysexualhealth.co.za My Sexual Health (MSH) is here to offer a solution. You can transform the sexual health outcomes of your patients with confidence by referring them to a platform of credible sexual health providers. MSH provides a platform service to some of the most qualified Sexual Health professionals in South Africa and abroad. The MSH Team is an elite multidisciplinary group of 58 individuals, including Medical Doctors, Clinical and Counseling Psychologists, Registered Counselors, Social Workers, Occupational Therapists, Speech Therapists, Pelvic Function Physiotherapists and Nurse Therapists who each have a special interest in sexual health and are trained to support patients in this area. You can rest assured that your patient will be in safe hands because every MSH Team member has the skills, resources, sensitivity and experience to serve your patients' sexual health needs. Registered - with the local regulatory body for their field as a healthcare provider Trained - each Team Member has the required qualifications for their role Supervised - every member is required to work under ongoing supervision by highly trained and experienced providers Accountable for their work - all Team Members attend compulsory monthly team meetings All MSH Team Members are: Referring your patient to MSH is easy. Direct them to our website (www.mysexualhealth.co.za). Our highly trained Clinical Manager will be their primary contact. Your patient will be guided to the correct Team Member for their needs. Each sexual health provider has a profile on our website that you or potential patients can review. Each profile provides detailed information about their level of training, qualifications, services, and location. MSH has three licenced practices based in Stellenbosch, Johannesburg, and Pretoria. We have Team Members covering most parts of South Africa and abroad. Plus, patients can receive care in virtual sessions booked online. Dr Jireh Serfontein (featured photo) is a great example of one of our credible sexual health providers. She is the Clinical Head of the MSH Licensed Practice in Pretoria and serves as a Medical Sexologist on the Prostate Cancer Foundation's Medical and Scientific Advisory Board. She is a medical doctor with a Mater’s Degree in Sexual Health from the University of Sydney. Dr Serfontein has more than ten years of experience and takes a holistic approach to sexual health that considers patients' physical, mental and emotional health. She is committed to helping people achieve their sexual health goals and works with her patients to develop individualised treatment plans tailored to their needs. We are confident that our team of credible sexual health providers will provide your patients with the highest level of care and support, helping them overcome their sexual health challenges and achieve a better quality of life. Stellenbosch Phone: +27(0)21 137 1856 // +27(0)61 302 6730 Address: Unit 4A Stellenpark Business Park, Stellenbosch, 7600 Western Cape, South Africa Email: winelands@mysexualhealth.co.za Johannesburg Phone: +27(0)61 302 6730 Address: 51 Platina Street, Jukskei Park, Johannesburg, Gauteng, South Africa Email: reception@mysexualhealth.co.za Pretoria Phone: +27 (0)12 816 8240 // +27(0)61 302 6730 Address: First Floor, Med Ahead, 21 Wattle Crescent, The Willows Ext 14, Pretoria, Gauteng, South Africa (next to Die Wilgers Hospital) Email: admin@mysexualhealth.co.za
10 responsibility. They may serve their patients best with a visionary approach, informed by a holistic and multidisciplinary approach. Mindfulness is one treatment approach that offers the possibility to enhance awareness of the pelvic region as well as to change unconscious patterns of (15) muscle use, through bringing them conscious . This makes it an effective treatment for restoring pelvic function. Although it has been extensively tested as an isolated treatment modality and found to be effective, it’s value as part of a basket treatment regime remains relatively untested. Discussion The brain has two goals: survival of the individual and survival of the species. One of its tools for ensuring this survival is the motor system, which consists of the voluntary and the emotional and involuntary motor systems. Pelvic oor dysfunction (PFD), refers to a broad constellation of symptoms and anatomic changes, related to abnormal function of the PFM. The disordered function is broadly divided into two groups: hypotonicity (diminished activity in the PFM) and the problems associated with this (pelvic organ prolapse and incontinence) and hypertonicity (increased activity in the PFM). Non-relaxing PFM dysfunction, may present with a broad range of nonspecic symptoms: pain, problems with defecation and urination and problems with sexual function. The retraining here requires relaxation and coordination of PFM and (1) anal and urinary sphincters . PF tension myalgia (PFTM) may result from hypertonicity, and may be the cause of pelvic pain. Sometimes, the PFD is neither hypertonicity nor hypotonicity, but is instead faulty recruitment, inadequate control or co-ordination of the muscle. Just as a lift, needs to be able to go from the ground oor to the tenth oor in a building, the PFM needs to be able to contract partially, fully or anywhere in between. Neither lift nor PFM contraction can work effectively if it gets stuck on any “oor” or is unable to go all the way to the top or all the way to the bottom. A precise diagnosis of any dysfunction that presents, needs to be made and treatment must be deliberately directed at that exact problem. PFD can't be handled like elephant dung which sprays seeds into the earth in the hope that some of those (31) seeds will germinate . Effective PFD management requires insight, expertise and laser-focused treatment with ongoing reassessment. The results of PFD may be urologic, gynecologic or colorectal. All health care professionals working in these elds need to be specically trained and educated in PFD and the symptoms it produces as well as the treatments that are available to rectify the dysfunctions. This will enable them to refer where needed and not use a recipe-type mindset when dealing with pelvic patients. (17) A study by Khan et al in 2013 found a high correlation between depression, anxiety, and failure to respond to PF retraining. Baraa Mazi et al in (24) 2019 concluded that there was a signicant association between depression and PFD. Stress can lead to nonrelaxing PFD. Persisting pelvic pain is a common outcome of pelvic dysfunction. Patients with PPP, often have co-existing factors that disrupt (28) the usual cortisol cycle . These studies show the inextricable entwinement of mental health, and PFD. Since psychological or even psychiatric factors may be the outcome as well as the cause of PFD, they need to be part of the treatment, along with (19) the rehabilitation . Psycho-social questionnaires may be needed to assess the variety of stressors that may be impacting the patient’s pelvic health. Mindfulness offers effective treatment for depression, anxiety, Persistent Pelvic Pain (PPP) and PFD and offers agency to patients suffering from stress. The PFM is Integral to Sexual Pleasure The PFM is active in both male and female genital arousal and orgasm. Inadequate or excessive PFM tone may impact negatively on these phases of function. Evidence suggests a close relationship between the (9) tone of the PFM and male sexual dysfunction . The impact of PPP on sexual function in men is underestimated. The incidence of PPP in men was found to be 2,7% (not age dependent) in a large (1) (22) cohort study performed by Marszalek et al . They found that PPP syndrome had a negative effect on erectile function. A strong therapeutic benet has been demonstrated from pelvic oor (PF) therapy for men who suffer from erectile dysfunction and ejaculatory or orgasmic problems as well as ejaculatory pain and decreased libido. This PF therapy includes pelvic muscle trigger point release concomitant with paradoxical relaxation training. Benet was seen in urinary problems in men as well, using PF trigger point therapy and mindful release of (1) the muscle . An association has also been found between the PF and chronic prostatitis/Pelvic Pain syndrome with rehabilitation demonstrating a signicant benecial effect. This comprehensive bioneuromusculoskeletal-psychosocial approach to the treatment of male sexual dysfunction and pelvic pain is best described as mindfulness informed rehabilitation and is most effectively (12) carried out through a mindfulness training format . Pelvic Floor Function The pelvic oor muscle was “assigned” so many crucial and nely tuned functions to perform. In order to support this function, neural control of the muscle and pelvic organs is affected by a (20) combined, nely coordinated, dual innervation . UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
11 This dual innervation is through the autonomic nervous system (ANS) and the somatic nervous (33) system (S1-4) . The sacral parasympathetic motoneurons are controlled by a specic group of neurons in the pontine brainstem, the pelvic organ stimulating center (POSC). This POSC generates micturition, defecation and sexual activities through different groups of sacral parasympathetic (PS) motoneurons. The POSC is driven by the periaqueductal gray (PAG) which receives precise information regarding the pelvic organs. The PAG, receives instructions from the amygdala, bed nucleus of the stria terminalis (a limbic forebrain structure) and various regions of the hypothalamus. In humans, the brain region with the most access to the PAG is the medial orbitofrontal cortex. This region of the brain acts as a focal point for sensory integration, modulation of visceral responses as well as prediction and decision making for emotional and reward related behaviors, (which involves learning). The neurological system receives inputs from several higher centres, including the brain, spinal cord, and ANS, which enable both complex voluntary and involuntary control of the PFM. These inputs allow for socially adapted behaviours, such as voluntary control over passing of gas, urination or defecation, as well as involuntary responses to stimuli, such as reex contractions during sexual arousal or the relaxation of muscles during voiding. Optimal functioning of the PFM relies on healthy ANS (23) function as well as ne-tuned function of the somatic nervous system. The latter requires accurate proprioception and body awareness. These in turn, rely on the ability to hold attention on the body, on adequate feedback from body to brain, and on sufcient mobility. These functions are inhibited by injury, stress, fatigue and a sedentary lifestyle. Neurons within the PFM demonstrate high concentrations of various neurotransmitters and neuromodulators, including amino acids, neuropeptides, norepinephrine, serotonin, and dopamine. These neurotransmitters and neuromodulators, play a role in the neuropharmacologically affected responses of the neurons within the PFM. For example, norepinephrine and serotonin are involved in the regulation of muscle tone, while dopamine is implicated in the reward and pleasure pathways associated with sexual function and PFM response to sexual arousal. The parasympathetic bers, constitute the pelvic plexus, and the somatic bers come from the sacral plexus and form the pudendal nerve (S2-4). The pudendal nerve and it's three branches innervate the anterior pelvis (the dorsal nerve to the clitoris/penis, the perineal branch and the inferior (33) hemorroiodal nerve) . The complex interplay between these sensory inputs, higher centres, and neurochemical signalling within the PFM contributes to emotional responses in (26) this region . For example, during sexual arousal, the PFM may contract involuntarily in response to pleasurable sensations, contributing to the experience of orgasm. In contrast, during periods of stress or anxiety, the PFM may become tense or (4) tight, leading to discomfort or pain. Mindfulness Practice and the skilled use of biofeedback have been found to be very effective in modulating the emotional responses of the muscle. The PFM is made up of a pair of compound muscular sheets mostly comprised of striated muscle. The supercial PF or urogenital diaphragm includes bulbocavernosus, ischiocavernosis and transverse perinei. The deep PF or levator ani (LA) is divided into four parts: iliococcygeus, pubococcygeus, puborectalis, and ischiococcygeus (part of the sacrospinous ligament). Puborectalis originates from the back of the symphysis pubis and loops around the rectoanal exure. It forms the deep part of the external anal sphincter muscles (EAS). The EAS is a circular muscle with the left and right halves functioning together but innervated independently. The piriformis and obturator internus muscles are considered associated muscles. The deep transversus abdominis, lumbar multidi and diaphragm are considered synergistic groups as they together form the circle of integrity. The muscles of the pelvic region, work in unison with each other to provide pelvic stability. The core muscles, as they are often called, operate together, just as the instruments in an orchestra, where the brain serves as the conductor. Ideally, it brings about coordinated ring of these muscles as a team of musicians, making resonant and beautiful music through their interplay. When all is functioning well, the brain brings in the perfect amount of contraction of any one muscle at the perfect time. If one group of musicians from the orchestra played without “governance” disconcordant sound would ensue. When the muscles work in perfect harmony with each other and the brain is operating as a “present” conductor, the movement produced is smooth and uid. Conversely, when a dysfunction exists the poetry of movement and ne function is lost, and dysfunction and pain set in. Training, informed by this knowledge is called motion control and it is a form of mindful movement practice. It is often assumed that if a problem exists, it is always weakness, but it may be overactivity or delayed or over-zealous ring of any or all the core muscles. In the face of stress, overload, emotional overwhelm, fatigue, inadequate nutrition and other stressors, the PFM and diaphragm, (which operate like dance partners), are often rendered overactive. The circle of integrity is left non-circular and the abdominals and lower back muscles or only the abdominals are inhibited. The result is faulty movement patterns, inadequate stability, and overload with consequential pain in certain structures. The conductor (brain) needs to be retrained and the PFM needs to be taught to relax UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
12 and not “jump in” and work in isolation. This is best done with mindfulness training. A high degree of interoception (a lesser known sense that enables understanding and feeling what is happening inside the body), is required to change these unconscious patterns. The multiple functions assigned to the PFM include: 1. Holding the pelvic organs in place in an upright posture, under the force of gravity. 2. Closing the circle of integrity and providing stability to the pelvis and the lower quarter, by making up its oor. 3. Working as an integral stabilizer of the body as a bipedal organism. 4. Allow for urination, defecation, and birth in the female. And facilitate urinary, fecal and atal continence. 5. Allow for sexual arousal, and contract during orgasm to provide sexual appreciation. 6. Support penile function in the male and allow for penetration. With so many different functions, it is easy for things to go wrong. The list is long, but just for the sake of completeness, they include: Anterior dysfunctions Urologic: • Difcult urination: hesitancy, delay in the urinary stream • Cystocoele: bulging or herniation of the bladder into the vagina • Urethrocele (urethral prolapse): bulging of the urethra into the vagina • Urinary incontinence: involuntary leakage of urine. Gynecologic: • Dyspareunia: pain with or following sexual intercourse. • Uterine prolapse (herniation of the uterus beyond the introitus of the vagina) • Vaginal prolapse (herniation of the vaginal apex beyond the introitus) • Enterocoele (bulging of the intestines into the vagina) • Rectocoele (bulging of the rectum into the vagina) Colorectal: • Constipation: dyssynergic defecation (inadequate relaxation of the PFM) • Fecal incontinence (involuntary leakage of stools) • Rectal prolapse • PPP (chronic pain unrelated to other conditions) • Levator ani spasm (which may cause PPP) • Proctalgia fugax (sporadic or momentary LA pain) • Perineal descent (bulging of the perineum below the pelvic outlet). For PFM function to be optimal, the “conductor” needs to know precisely where the muscles ligaments and fascia are in space and in the motor sensory cortex. The brain’s internal somatic represenentation, perceived in the sensory homunculus needs to be accurate and clear. This builds good body awareness, and is crucial to generating functional ring of the core muscles and accurate proprioception and motor control of the pelvic region. This forms accurate interoceptive awareness. Interoception is often called the seventh sense. This interoception may be interrupted in victims of sexual abuse or in patients suffering PPP, PFD or in people suffering from sexual dysfunction. It is best trained and restored with mindfulness techniques and mindful movement practice. Conclusion Successful rehabilitation of any aspect of the pelvic region or the pelvic girdle requires intervention on the multidimensional level. Resolution of PFD and restoration of pelvic health and wellbeing demands input into the mind, body and lifestyle simultaneously. Lifestyle interventions need to include diet, weight, gut health, mindful eating, sleep hygiene, stress interventions, self-efcacy coaching as well as selfawareness training. In addition, developing agency in the presence of pain and dysfunction is essential. Where exhaustion overwhelms or an internal message of being unsafe and unsupported exists, this needs to be changed, through mindfulness-type interventions and where needed psychotherapy. Unconscious holding patterns (non-relaxing PFD) need to be brought conscious and using mindfulness training and active relaxation, they need to be re-wired. This allows a new default pattern to set in. Core muscles need training in a global context so that the mindset that underlies posture and muscle tone can be altered, making change sustainable and not short lived. In addition, the body awareness capacity of the brain must be enhanced, which requires motion control rehabilitation. Medical practitioners need to work together in a multidisciplinary-team-style-approach to enable patients to get the results they deserve. Every member of the team is integral, but the role of the pelvic health trained physiotherapist must not be overlooked and wherever possible mindfulness training as well as mindfulness based cognitive behavioural therapy (MBCBT) must be introduced to facilitate enhanced awareness and therefore agency for the patient. UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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