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AUFMED

Dr. Armando L. Gopez, M.D. | July 09, 2015 | GYNECOLOGY

OUTLINE:
Urogynecology
The Pelvic Floor
Common Pelvic Floor Disorders
Urinary Incontinence
o Stress Incontinence
o Genuine Stress Incontinence
o Urge Incontinence
o Mixed Incontinence
o Dyssynergic Bladder
o Over-active Bladder
o Overflow Incontinence
o Functional Incontinence
Therapy Urinary Incontinence
o Bladder Training
o Kegels Exercises
Pelvic Organ Prolapse
o Uterine Prolapse
o Cystocele
o Rectocele
Objectives:
The student must demonstrate knowledge of the following:

Predisposing factors for urinary incontinence and pelvic


organ prolapse

Anatomic changes, fascial defects, and neuro-muscular


pathophysiology

Signs and symptoms of urinary incontinence and pelvic


organ prolapse

Physical Examination
Urinary Incontinence
Cystocele
Rectocele
Uterine Prolapse

UROGYNECOLOGY
Urogynecology is a surgical subspecialty of urology
and gynecology
Urogynecology involves the diagnosis and treatment of
urinary incontinence and female pelvic floor
disorders
It is dedicated to treatment of women w/ pelvic floor
disorders like urinary or fecal incontinence &
prolapse of vagina, bladder &/or uterus
Incontinence and pelvic floor problems are remarkably
common but many women are reluctant to receive help
because of the stigma associated with these conditions
Pelvic floor conditions are more common than
hypertension, depression, or diabetes
One in three adult women have hypertension
One in ten adult women have diabetes
More than one in two adult women suffer from
pelvic floor dysfunction.
Urinary incontinence affecting at least 10-20% of
women under 65 yrs; up to 56% over 65 yrs
Prolapse means displacement from normal position
Prolapse & incontinence frequently occur together; both
are believed the result from damage to the pelvic floor
after delivery
Diagnostic tests and procedures performed:
Cysto-Urethroscopy
Urodynamic Testing
Ultrasound

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UROGYNECOLOGY
PELVIC FLOOR

Pelvic floor is a term to describe the muscles, ligaments and


connective tissue that provide support for internal organs
(bladder, uterus, & rectum)

Functions:
Prevents the organs from falling down or out
Play a role in making these organs function
properly

The brain controls the muscles by way of nerves; any


conditions of injuries that impair the nerves like
Alzheimers, back injury or stroke can result in
weakness of the muscles
The main support of the pelvic floor is the LEVATOR ANI
MUSCLE. Although named such, this structure is made up of
three (3) important individual components:
a. Puborectalis
b. Pubococcygeus
c. Iliococcygeus
The PELVIC DIAPHRAGM is composed of the LEVATOR ANI
MUSCLE and the COCCYGEUS MUSCLE.

COMMON PELVIC FLOOR DISORDERS


Urinary Incontinence leakage of urine
Stress Incontinence involuntary loss of urine during
activities
Urge Incontinence involuntary loss of urine preceded
by strong urge (over-active bladder)
Dysuria painful urination
Urgency powerful need to urinate immediately
Urinary Frequency more than every 2 hrs (more than
7x)
Nocturia urinate after waking up frequently
Cystocele prolapse/bulging of bladder into vagina
Rectocele prolapse of rectum into vagina
Uterine Prolapse descent of uterus into vagina

The pelvic floor disorders are most commonly observed during


the early period of menopause, usually around the 4th to 5th
decade of life. WHY? Loss of estrogen plays a role in the
maintenance of the strength of the bones (prevention of bone
resorption; without estrogen, the bones become pliable, and
ligamentous connections of the levator ani become weakened).

Page 1 of 18

URINARY INCONTINENCE
Defined as unintentional loss of urine that is sufficient
enough in frequency & amount to cause physical &/or
emotional disturbances
Also defined as involuntary loss of urine that
is objectively demonstrable
Another definition is leakage of urine thru urethra
after sudden increase in abdominal pressure
(coughing, sneezing, etc.) that is so social & hygienic
problem & is objectively demonstrated
The intra-vesical pressure rises higher than the
pressure that urethral pressure mechanism
can w/ stand
It is a symptom & NOT a diagnosis
Not a part of aging & not trivial complaint
It is almost always treatable
o This means one or more other
problems cause urinary leakage
o Some common bladder and pelvic
floor disorders are Pelvic Organ
Prolapse (POP),
urinary tract
infections, interstitial cystitis (IC) and
bladder tumors and cancer
It is a common and distressing problem, which
may have a large impact on quality of life
Urinary incontinence is often a result of an
underlying medical condition
Enuresis is often used to refer to urinary
incontinence primarily in children
When is urinary incontinence a point of concern? WHEN
it causes anxiety to the patient resulting to possible
social embarrassment.
Principle of investigation involve
o History taking
o Physical examination
o Urinalysis w/ urine culture &
cytology
There are four main types of incontinence:
Urge Incontinence due to an overactive
bladder
o The leakage of large amounts of urine
at unexpected times, including during
sleep.
Stress Incontinence due to poor closure of
the bladder
o The leakage of small amounts of
urine during physical movement
(coughing, sneezing, exercising).
Overflow Incontinence due to either poor
bladder contraction or blockage of the
urethra
o Unexpected leakage of small
amounts of urine because of a full
bladder
Functional
Incontinence
due
to
medications or health problems making it
difficult to reach the bathroom
o Untimely urination because of
physical disability, external obstacles,
or
problems
in
thinking
or
communicating that prevent a person
from reaching a toilet
Incidence more frequent than men; 1 in 10 women
under 65 yrs; 20% of women over 65
Symptoms:
Mostly on parous women

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Involuntary loss of urine in spurt associated w/


stress, i.e.- coughing, running, etc.
Show degree of cystocele/rectocele
Major Categories:
Over incontinence
Stress incontinence
Urge incontinence
Functional incontinence
Reflex incontinence
Urinary incontinence may be broadly classified
according to its causes:
Trans-Urethral Cause
o Genuine stress incontinence or
urethral sphincter incompetence the
most common cause
o Detrusor instability can have
neurological basis
o Urethral instability loss of urethral
pressure seen in the absence of
detrusor instability; w/c is rare
o Urinary retention w/ over-flow
common in elderly
o Congenital anomalies common in
infants; epispadias
o Functional
Extra-Urethral Cause
o Congenital dx at childhood; bladder
extrophy
o Fistulas ureteric, vesical; urethral;
complex
The 3 most common types of incontinence:
Stress urinary incontinence (SUI) - is the
complaint of involuntary leakage of urine
during activities such as on effort or exertion,
or on sneezing or coughing or laughing.
Urge urinary incontinence (UUI) - is the
complaint of involuntary leakage accompanied
by or immediately preceded by the urge to
urinate (urgency)
Mixed urinary incontinence (MUI) - is the
complaint of involuntary leakage associated
with urgency and also with exertion, effort,
sneezing or coughing which is a combination
of stress and urge urinary incontinence
Epidemiology
Prevalence of 25 55%
Stress incontinence prevalent on ambulatory
women; 29 - 75%
Detrusor over-activity up to 33% of
incontinence
Remaining incontinence to mixed forms
Incontinence can impair the quality of life,
leading to disrupted social relationships;
psychological
distress
from
embarrassment; urinary tract infection
Causes depends upon the types of incontinence:
The most common types of urinary
incontinence in women are stress urinary
incontinence and urge urinary incontinence
Stress Urinary Incontinence is caused by
loss of support of the urethra which is usually a
consequence of damage to pelvic support
structures as a result of childbirth
o It is characterized by leaking of small
amounts of urine with activities which

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increase abdominal pressure such as


coughing, sneezing and lifting
Urge Urinary Incontinence is caused by
uninhibited contractions of the detrusor muscle
o It is characterized by leaking of large
amounts of urine in association with
insufficient warning to get to the
bathroom in time
Causes wide variety of physical conditions
Childbirth can weaken the pelvic muscles &
the bladder lose some support from muscles
Dysfunction of bladder &/or urinary sphincter
normally, when bladder contracts, bladder
sphincter opens & urine exits; here, bladder
contraction & dilatation of sphincter do not
occur at the same time
Hysterectomy (other surgery) surgery
involving GU tract runs the risk of damaging or
weakening the pelvic muscles causing
incontinence
Neurological conditions CNS sends signal to
bladder telling it when to start & stop emptying\
Menopause absence of estrogen in postmenopausal women can cause bladder to drop
Enlarge prostate (male) can obstruct the
bladder causing over-flow incontinence
Risk Factors:
Age
Pregnancy/childbirth
Menopause
Obesity
Smoking & chronic lung diseases
Hysterectomy
Physical examination involves:

Full P.E. is required but concentrate on:


Gynecologic
Urologic
Neurologic

Testing of S2 S4 nerves is important as


incontinence may have neurologic origin

Assessments of mental state is useful

Ascertain if patient is suitable for behaviour


modifications or conservative Rx that require
comprehension & motivation

When contemplating surgery, integrity of pelvic


floor & degree of atrophy are important for
prognosis

Gynecologic exam should include:


Sims done when patient is standing
Position on her left side
Determine concomitant pathology
Urethra is observed while patient
cough; also inspect for presence of
caruncle or mucosal prolapse

Q-tip test: assess for integrity of the lig.


Supports of the proximal urethra & determine
the presence of urethral hyper-motility:
Sterile lubricated cotton swab is
placed into bladder neck
At rest on lithotomy position, urethra
(thus, the swab) assume a 00 angle to
the horizontal plane
Patient is asked a Valsalve
manuever; if proximal urethra is
normally
supported,
straining

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displaces the distal end of swab only


slightly
Pathophysiology

Bladder is a storage organ of urine w/ capacity


to accommodate large volume of urine w/
minimal or no increase intra-vesicle pressure

Continence requires complex coordination that


include muscle contraction & relaxation,
connective tissue support, & integrated
innervation & communications between these
structures
URINARY INCONTINENCE

During filling, urethral contraction is


coordinated w/ bladder relaxation & urine is
stored & vice-versa in voiding

These mechanisms can be challenged by


Uninhibited detrusor contractions
Marked increase in intra-abdominal
pressure
Changes to various anatomic
components of the continence
mechanisms
URINARY INCONTINENCE
Mechanism of Micturition

Continence and micturition involve a balance


between urethral closure and detrusor muscle
activity

Urethral pressure normally exceeds bladder


pressure, resulting in urine remaining in the
bladder

Intraabdominal pressure increases (from


coughing and sneezing) are transmitted to both
urethra and bladder equally, leaving the
pressure differential unchanged, resulting in
continence

Normal voiding is the result of changes in both


of these pressure factors: urethral pressure
falls and bladder pressure rises

During urination, detrusor muscles in the wall


of the bladder contract, forcing urine out of the
bladder and into the urethra

At the same time, sphincter muscles


surrounding the urethra relax, letting urine
pass out of the body

Incontinence will occur if the bladder muscles


suddenly contract (detrusor muscle) or
muscles surrounding the urethra suddenly
relax (sphincter muscles).
Diagnosis

A careful history taking is essential especially


in the pattern of voiding and urine leakage as it
suggests the type of incontinence faced

The physical examination will focus on looking


for signs of medical conditions causing
incontinence, such as tumors that block the
urinary tract, stool impaction, and poor reflexes
or sensations

A test often performed is the measurement of


bladder capacity and residual urine for
evidence of poorly functioning bladder muscles

Stress test
Urinalysis
UTZ
Cystoscopy
Uro-dynamics

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FREQUENCY VOLUME CHART


Volume voided give an indication whether
voiding is premature or whether there is a true
diuresis; ascertain by amount and type of fluid
drunk
Prone to drinking large amount of fluid,
especially tea or coffee, result in frequency of
urination
URO-FLOWMETRY
It measures rate of urine flow & the most
important Dx variable is the peak flow rate
Peak flow rate declines w/ age; rough guide
peak flow in excess 15 mL/sec are accepted
normal; but prior to voiding, the bladder must
contain more than 200 mL, otherwise the
detrusor is not able to develop adequate
contraction
o After voiding, residual should be less
than 50 mL; if greater than 100 mL,
regard as abnormal
URO-DYNAMIC TEST
The bladder must be full
Urinate into a container, the volume of urine
and the rate at which the bladder empties are
measured
Catheter is then inserted into the bladder
through the urethra, and the volume of any
urine remaining in the bladder is measured
(post-void residual, or PVR)
Bladder is filled with water through the catheter
until you have the first urge to urinate.
o The amount of water in the bladder is
measured at this point, and more
water is added while you resist
urinating until involuntary urination
occurs
Normal - The amount of fluid left in the bladder
after urinating, when you feel the urge to
urinate, and when you can no longer hold back
urine are within normal ranges
Abnormal - One or more of the following may
be found:
o More than a normal amount of fluid
remains in the bladder after urinating.
A large volume of urine
remaining in the bladder
suggests the flow of urine
out of the bladder is partially
blocked or the bladder
muscle is not contracting
properly to force all the urine
out (overflow incontinence).
o The bladder contains less fluid or
more fluid than is considered normal
when the first urge to urinate is felt.
o Unable to retain urine when the
bladder contains less than the normal
amount of fluid for most people.

Any changes that occur in the intra-abd.


pressure will also be reflected in the intravesical pressure; done by measuring pressure
inside upper third of vagina & rectum
o Detrusor pressure = intra-vesical
pressure
minus
intra-abdominal
pressure
Incontinence due to detrusor instability operations design to elevate the bladder neck
is contra-indicated because

Anatomical repositioning of the bladder neck is


not required

Surgery at level of bladder neck often results in


worsening of the instability

Primary objective is to exclude detrusor


instability & the mainstay of the basic
urodynamic studies is cytometry
Prognosis:

If untreated can cause emotional & physical


upheaval; affect self-esteem & cause
depression

Long term incontinence GU infection; skin


rashes

w/ variety of Rx, the prognosis is promising; if


it cannot be stopped, it can be improved
Prevention:

Kegel or PC muscle exercise; pregnant or


women who had bear child can reduce the risk
of stress incontinence by strengthening their
perineal muscles by doing it
General Rx Non-Invasive & Invasive
o Non-invasive training the bladder; invasive
surgery
o Bladder training use to RX urge incontinence;
place patient on a toileting schedule
o Bio-feed-back use of sensors to monitor
temp. & muscle contraction of vagina; to learn
to control their pelvic muscles
o Collagen injection injected around urethra; to
provide urethral support
o Intermittent urinary catheterization
o Pelvic toning exercises tightening the pelvic
muscles known as Kegels exercise (stress
incontinence)
o Anticholinergics, Benadryl medications; if
these do not work, surgery is done by urologist
PELVIC FLOOR SUPPORT

CYTOMETRY
Cytometry is dynamic investigation, in that the
intra-vesical pressure is measured not only
during filling but also at capacity & during
voiding

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ANATOMY
Important so that the urologist would know when to
correct the sphincter

Treatment
o Depends on the assessment; can be treated
medically or surgically
o Depend on the type of incontinence and the
severity of the condition
o Treatments include:

Lifestyle Changes - significant weight


gain can weaken pelvic floor muscle
tone, leading to urinary incontinence

Regulating the time you drink


fluids and avoiding alcohol and
caffeine are also helpful.

Behavioral Techniques - Pelvic floor


exercises (Kegel exercises) can help
strengthen the muscles of the pelvic
floor that support the bladder and
close the sphincter.

Bladder training can help


patients learn to delay urination.

Medications - such as oxybutynin


(Ditropan) and tolterodine (Detrol),
are mainly used to treat urge
incontinence.

Surgery there are several methods

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Classification of Urinary Incontinence


1. Stress Urinary Incontinence (SUI) complain of
involuntary urine leakage
It occurs when pelvic muscles have been
damaged, causing the bladder to leak during
exercise, coughing, sneezing, laughing, or any
body movement which puts pressure on the
bladder
2. Genuine Sress Incontinence when symptoms/signs
of stress incontinence is confined w/ objective testing
3. Overflow Incontinence refers to leakage that occurs
when the quantity of urine produced exceeds the
bladders holding capacity
4. Urge Urinary Incontinence have difficulty postponing
urination urge & promptly empty their bladder on cue w/o
delay
The urgent need to pass urine and the inability
to get to the toilet in time, occurs when nerve
passages along the pathway from the bladder
to the brain are damaged, causing a sudden
bladder contraction that cannot be consciously
inhibited
5. Detrusor Over-activity (DO) previously known as
detrusor instability when urge urinary incontinence is
objectively demonstrated by cytometric evaluation
6. Mixed Urinary Incontinence both stress & urge
components are present
7. Functional Incontinence situation in w/c person
cannot reach a toilet in time due to physical,
psychological or mental limitations
Person who have control over their own
urination & have a fully functional urinary tract
but cannot make it to the CR in time due to a
physical or cognitive disability, are functionally
incontinent like Alzheimers; multiple
sclerosis; Parkinsons
Encountered in elderly medical professions
8. Reflex Incontinence person loss control of their
bladder w/o warning; they usually suffer from
neurological impairment
NB - At times person may suffer acute incontinence & may occur
as symptom or product of illness or complication of drugs or
dietary intake & easily resolve once cause is determined

STRESS INCONTINENCE
Stress incontinence, or effort incontinence is a form of
urinary incontinence
It is due to insufficient strength of the closure of the
bladder; the bladder leaks urine during physical activity
or exertion
It may happen when coughing, lift something heavy, or
exercise
The term stress incontinence refers to 3 distinct entities
a symptom; a sign; & a condition
Symptoms & signs
o Symptom refers to the patients complaint
that she leaks urine on increased
abdominal pressure & can result from
variety of conditions:

Genuine
stress
incontinence
(detrusor contraction provoke by
coughing or change of position)

Incomplete bladder emptying

Urethral diverticulum
The ability to hold urine & control urination depends on
the normal function of lower urinary tract, CNS

Page 5 of 18

Leakage stops when the stress ends.


o If the leakage persists, it is more likely to be
urge incontinence.
In both men and women, the aging process causes a
general weakening of the sphincter muscles and a
decrease in bladder capacity.
Most common type of incontinence
Risk factors for stress incontinence
o Being female
o Childbirth esp. multiple pregnancies
o Chronic coughing (as in asthma)
o Obesity
o Smoking
o In women, it is nearly always due to one or both
of the following:

Intrinsic sphincteric deficiency

All of these maybe due to:

Many children thru vaginal


delivery (underlying cause)

Menopause
estrogen
deficiencies

Injury from surgery or


radiation

Urethral hypermobility - the urethra


does not close properly, allowing it to
move too much
Condition typically occurs when the pelvic floor muscles
in women become weak, and the following events occur:
o The weakened pelvic floor muscles stretch.
This allows the bladder to sag downward within
the abdomen.

If bladder pushes down towards the


vagina, then it is known as an
associated cystocele.

Incontinence and prolapse are


interrelated
o The sagging bladder pulls on the muscles
surrounding the bladder neck (internal
sphincter), which are connected to the urethra
o Intrinsic sphincter deficiency is the other major
cause of stress incontinence in women most
severe form

Cannot hold the intra-vesicular


pressure

It occurs when the bladder neck


muscles are damaged or weakened;
there is laceration that is why
perineum
should
always
be
supported

The result is twofold:

The bladder neck is open


during filling

The closing pressure around


the urethra is low
Symptoms
o Symptoms must be confirmed objectively
o Patient should never undergo surgery on the
basis of symptoms alone
Signs refer to physical demonstration of urine loss
during increased abdominal pressure, while examining
o Incontinence exists when urine loss becomes
a social or hygienic problem
o Merely annoying or inconvenient not
considered incontinent nor need surgery
Most adults can hold over 2 cups of urine in their
bladder.

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250 cc of urine/ water - patient strain, spurt of urine from


urethral meatus + Bonneys or Marchettis - to confirm
Bonneys - 2 fingers on vagina w/ tips on sides of
urethra to make upward pressure. Let patient cough;
test is positive if there is leakage of urine
Note: Make sure that you are not sitting in front of the
patient
o Stress incontinence is due to damage of
supporting tissue of urethra
Marchettis - same but Allis forcep is used instead
Q-TIP TEST - In a normal patient, the angle of the Q-tip
is less than 30 degrees from the horizontal, and will
remain at this angle when the patient strains
o Determines the integrity of the urethra
o In patients with inadequate bladder neck
support and stress incontinence, the Q-tip
angle generally exceeds 30 degrees from
the horizontal.

Diagnosis of stress incontinence caused by detrusor


over-activity confirmed by cystometry
o Rule for all incontinence, demonstrate
incontinence & confirm w/ patient that has
been demonstrated reproduces her complaint
o Subtracted filling cytometrography w/ overactive detrusor should show:

Phasic pressure waves that produce


urgency & urge incontinence
Diagnosis
o Involuntary leakage of urine w/ stress
o Finding of pelvic relaxation
o Positive Bonneys or Marchettis test
o No intrinsic disease of bladder

Urinalysis must be negative


Treatment:
o The general goal for women with stress
incontinence is to strengthen the pelvic
muscles
o Typical steps for treating women are:

Devices and continent aids for


blocking urine in the urethra (vaginal
pessaries, adhesive pads, and
others).

Behavioral
techniques
and
noninvasive devices, including Kegel
exercises, weighted vaginal cones,
and biofeedback.

Medications
Alpha-adrenergic
agonists
and
possibly
anticholinergics.

Surgery

Page 6 of 18

GENUINE STRESS INCONTINENCE


The same as stress incontinence but involves sphincter
incompetence
Defined as urethral sphincter incompetence; then
involuntary loss of urine when intra-vesicle pressure
exceeds the maximum urethral closure pressure in the
absence of detrusor contraction
Causes
o Childbirth
o Radical pelvic surgery
Refers to uro-dynamic diagnosis of stress incontinence;
said to exist when there is demonstrable urinary leakage
when intra-vesicle pressure exceeds the maximum
urethral closure pressure in the absence of detrusor
contraction; hence diagnose:
o She has undergone uro-dynamic testing
o Proved that her urine loss is caused by
ineffective urethral closure during periods of
increased intra-abdominal pressure
Clinical stress urinary incontinence results from the
interaction of 3 distinct components
o Inherent biological strength of the urinary
sphincter
o Level of physical stress placed on the sphincter
o Psycho-social milieu in w/c the patient lives
(expectations about urinary control)
Modifications of any one of these factors may influence
the patients clinical status
Diagnosis by cytometry
Treatment conservative & surgical
Effective urethral closure is maintained by the
interaction of extrinsic urethral support & intrinsic
urethral integrity; each are influenced by several factors,
muscle tone & strength
o Fascial integrity
o Innervation
o Urethral elasticity
o Urethral vascularity
Non-surgical based on manipulations of the factors
that contribute to the condition
o Reducing factors that worsen the problem
(obesity, smoking, excessive fluid intake)
o Intervening actively to enhance the ability of
patients pelvic floor to compensate for the
increased intra-abdominal pressure by:

Rehabilitating pelvic muscles

Improving estrogen status

Using alpha-adrenergic stimulants

Wearing device to improve urethral


support
Non-surgical Collagen injection

Surgical Rx classified into 4 categories


o Traditional Anterior Vaginal Colporrhaphy
o Operations
for
stress
incontinence
resulting from intrinsic sphincter weakness
or dysfunction Sling Operations or PeriUrethral Injections
o Salvage operations (not usually done)
Obstructive Sling Operations, Implantation of
an Artificial Urinary Sphincter, Urinary
Diversion
o Operations
to
correct
incontinence
resulting from anatomic hypermotility
Retro-pubic Bladder Neck Suspension, Needle
Suspension Procedure, Tension-free Vaginal
Tape, or Sling Procedures

Anterior Colporrhaphy oldest operation for stress


incontinence; done when stress incontinence is
associated with prolapsed
o First step in doing vaginal hysterectomy
o Reason it is caused by open vesicle neck
rather than from loss of urethral support
o Technique pulling the bladder neck closed
using peri-urethral Kelly plication sutures

Simple plications of bladder neck

Elevation of bladder neck by plicating


the fascia under the urethra

Elevation & fixation of bladder neck


by passing sutures lateral to urethra &
anteriorly into the back of symphysis
pubis for fixation
Surgery to correct hypermotility
o Retro-pubic urethropexy peri-urethral
fascia is attached to the back of symphysis
pubis; other technique, attachment of the
fascia at the level of bladder neck to iliopectineal ligament
o With paravaginal repair, lateral endopelvic
fascia along urethra & bladder is reattached to
arcus tendinus fascia of pelvis; long term
success of such operation is 70 90 %
o Transvaginal urethropexy vaginal incision
at level of bladder neck, endopelvic fascia is
perforated, space of Retzius is entered &
suture pass thru low abd. incision thru the
space & fix to endopelvic fascia
Surgery to correct hyper-motility bladder neck & urethra
o Tension-free vaginal tape use of
polypropylene mesh placed under the midurethra w/ minimal tension
o Sling procedures
o Salvage operation
In both stress & urge incontinence, urine loss occurs
from an unsuppressed contraction of the bladder
muscle, a failure to suppress the micturition reflex
Treatment:
o Sling Operation

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Page 7 of 18

Rx of detrusor over-activity
o Drug therapy: Anti-cholinergic drugs that block
the activity of acetylcholine at muscarinic
receptor site exerting their effects on bladder;
w/c have short-half life; w/ side-effects dry
mouth, increase H.R due to vagal blockage,
decrease GIT motility
o New drugs

Tolterodine (detrol) muscarinic


receptor antagonist w/ long half-life

Oxy-butynin (Ditropan XL) also long


acting
Rx of detrusor over-activity
o Behavior therapy change the mental attitude

Based on assumption that the underlying patho-physiology is the escape


of the detrusor from cortical control
over micturition that was previously
established during childhood training

Object to re-establish the authority


of the cerebral cortex over bladder
function
Instructed to void on time, start at frequent intervals
When awake, void at 6, 7, 8, etc; if at 7 she does not feel to
void, she must do it; if at 7:55, she must not void but wait for
8:00, even if there is leakage
At night, she is allowed to void only when she is awaken from
sleep by the need to do so

INCONTINENCE
Differential Diagnosis
o Urge incontinence
o Functional or Transient Bladder
o Dyssynergic Bladder

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URGE INCONTINENCE
Also called hyperactive, irritable, or overactive bladder
The main symptom of urge incontinence is the need to
urinate frequently
o More than 8 times over 24 hours, including two
or more times a night, and have subsequent
leakage.
In some cases, urge incontinence occurs only at night.
This is called nocturnal enuresis
Caused be detrusor over-activity; inappropriate bladder
contractions & abnormal nerve signals may be also
cause
Sudden, unexpected loss of large volume of urine or
leakage associated w/ over-whelming desire to empty
bladder that cannot be controlled
She voids till bladder is empty
Involuntary actions of bladder muscles can occur
because of damage to the nerve supply, to the CNS or
to muscles themselves multiple sclerosis Parkinsons
Alzheimers, stroke & injury
All cases of urge incontinence involve an overactive
bladder
This occurs when the detrusor muscle, which surrounds
the bladder, contracts inappropriately during the filling
stage
o When this occurs, the urge to urinate cannot be
voluntarily suppressed, even temporarily
o There is usually one of two types:

Idiopathic Detrusor Overactivity (formerly


called Detrusor Instability)

Neurogenic Detrusor Overactivity (formerly


called Detrusor Hyperreflexia).
Idiopathic Detrusor Overactivity - In this type, the nerves
serving the bladder have signaled the brain
appropriately that the bladder is full, but the detrusor
muscle cannot be suppressed.
Neurogenic Detrusor Overactivity - with this type, a
known neurologic problem impairs the signaling
systems between the bladder and the central nervous
system, and the brain is unable to inhibit the detrusor
muscle controlling urination.
Conditions that can lead to urge incontinence:
o Benign prostatic hyperplasia (BPH).

Detrusor instability occurs in about 75%


of men with BPH and causes frequency,
urgency, and urination during the night
(although occurs only in very severe
cases).

Urge incontinence only at night can be a


sign of severe obstruction in the urinary
tract
o Hysterectomy
o Radiation to the pelvis that involves the bladder.
o Damage to the central nervous system.
o Infections
o The aging process
o Medications
It can mean that your bladder empties during sleep, after
drinking small amount of water or when you touch or
hear water running
Common in cystitis, foreign bodies, stones; older
women
Fluids & medications (diuretics) or emotional state like
anxiety can worsen the condition; Hyperthyroidism &
uncontrolled DM also worsen it
Patho.- neurological difficulty w/ bladder

Page 8 of 18

The goal of most treatments for urge incontinence is to


reduce the hyperactivity of the bladder
The following methods may be helpful:
o Behavioral methods
o Medications (anticholinergics and alpha blockers)
o Procedures that stimulate the pelvic floor or
nerves in the tailbone (the sacral nerves), which
help retrain the bladder

MIXED INCONTINENCE
When they have motor urge incontinence due to
detrusor over-activity along w/ stress incontinence
Effort should be made to confirm the diagnosis &
demonstrate stress & urge incontinence objectively
before establishing such diagnosis; if both
o Determine w/c symptoms is bothersome
o Others advocate to treat 1st urge incontinence
preceding surgery only if urge persist
o Bladder neck suspension is contra-indicated w/
detrusor instability alone as the cause of
incontinence; w/ mixed, a small functional
bladder capacity & high-pressure detrusor
contraction on filling cytometry should undergo
operation for stress incontinence only after
only after careful consideration

DYSSYNERGIC BLADDER
is a consequence of a neurological pathology such as spinal
injury or multiple sclerosis that disrupts central nervous
system regulation of themicturition (urination) reflex resulting in
dyscoordination of the detrusor muscles of the bladder and
the male or female external urethral sphincter muscles.
No prior urge to void. Episodes of voiding w/ no
warning, occurring in spurts as in stress
Triggering mechanism - critical bladder
o Triggered by running water
Diagnosis o History & uro-dynamic study
Treatment o Same as stress incontinence
OVER-ACTIVE BLADDER
It occurs when abnormal nerves sends signals to the
bladder at the wrong time, causing its muscles to
squeeze w/o warning
Special symptoms of over-active bladder
o Urinary Frequency bothersome, 8 or more
times a day or 2 or more times at night
o Urinary Urgency sudden, strong, need to
urinate immediately
o Urge Incontinence leakage or gushing of
urine that follows a strong urge
o Nocturia awakening at night to urinate
The most common symptoms of an overactive bladder are
urinary urgency (sudden, compelling desire to pass urine),
frequency (greater than 8 times a day), and nocturia.

OVER-FLOW INCONTINENCE
It happens when the normal flow of urine is blocked and
the bladder cannot empty completely
It can be due to a number of conditions:
o A partial obstruction. In this case the urine
cannot flow completely out of the bladder, so it
never fully empties.
o An inactive bladder muscle

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In contrast to urge incontinence, the bladder is


less active than normal, not more.
It cannot empty properly and so becomes
distended, or swells.
Eventually this distention stretches the internal
sphincter until it opens partially and leakage
occurs
Conditions leading to over-flow incontinence:
o Tumors (common cause in women)
o Constipation
o BPH
o Scar tissue
o Nerve damage to bladder
o Certain
medications
(anticholinergics,
antidepressants, antipsychotics, sedatives,
narcotics)

FUNCTIONAL INCONTINENCE
Patients with functional incontinence have mental or
physical disabilities that keep them from urinating
normally, although the urinary system itself is intact
Conditions that can lead to functional incontinence
include:
o Parkinson's disease
o Alzheimer's disease and other forms of
dementia
o Medical conditions involving thinking, moving
& communicating thus having trouble
reaching the CR
o Severe depression
o Arthritis associated w/ age
o Persons on wheel chair
Functional incontinence is the result of physical &
medical conditions
o Person in wheel chair
o Alzheimers disease
o Medical conditions involving thinking, moving
or communicating have trouble reaching
the CR
o Arthritis associated w/ age
BLADDER TRAINING
Bladder training involves a specific and graduated
schedule for increasing the time between urinations
Patients start by planning short intervals between
urinations, then gradually progressing with a goal of
voiding every 3 - 4 hours. You are training the sphincter
to hold the pressure
If the urge to urinate arises between scheduled voidings,
patients should remain in place until the urge subsides.
At the time, the patient moves slowly to a bathroom.
This system uses a set of weights to improve pelvic floor
muscle control:
Typical set includes five cones of graduated weights
ranging from 20 grams (less than 1 ounce) to 65 grams
(slightly over 2 ounces).
Starting with the lightest, the woman places the cone in
her vagina while standing and attempts to prevent the
cone from falling out
The muscles used to hold the cone are the same ones
needed to improve continence.

Page 9 of 18

KEGELS EXERCISE
Every patient who is suffering from incontinence should learn
this
Since the muscles are sometimes difficult to isolate, the
best method is to first learn while urinating
The patient begins to urinate and then contracts the
muscle in the pelvic area with intention of slowing or
stopping the flow of urine
Women should contract the vaginal muscles as well
o
They can detect this by inserting a finger
inside the vagina.
o
When the vaginal walls tighten, the pelvic
muscles are being correctly contracted.
o Patients should place their hands on their
abdomen, thighs, and buttocks to make sure
there is no movement in these areas while
exercising.
An alternate approach is to isolate the muscles used in
Kegel contractions by sensing then squeezing and lifting
the muscles in the rectum that are used in passing gas.
(Again, women should contract the vaginal muscles as
well.)
The first method is used for strengthening the pelvic
floor muscles.
o The patient slowly contracts and lifts the
muscles and holds for 5 seconds, then
releases them. There is a rest of 10 seconds
between contractions.
The second method is simply a quick contraction and
release.
o The object of this exercise is to learn to shut off
the urine flow rapidly.
In general, patients should perform 5 - 15 contractions,
three to five times daily.
PHYSIOLOGY OF URINATION
The process of urination is a combination of automatic
and conscious muscle actions.
There are two phases:
o
The emptying phase and
o
The filling and storage phase.
The Filling and Storage Phase
o
When a person has completed urination, the
bladder is empty.
This triggers the filling and storage phase, which includes
both automatic and conscious actions
Automatic Actions
o The automatic signaling process in the brain
relies on a pathway of nerve cells and chemical
messengers (neurotransmitters) called the
cholinergic and adrenergic systems.
o Important neurotransmitters include serotonin
and noradrenaline.
o This pathway signals the detrusor muscle
surrounding the bladder to relax.
o As the muscles relax, the bladder expands and
allows urine to flow into it from the kidney.
o As the bladder fills to its capacity (about 8 - 16
oz of fluid) the nerves in the bladder send back
signals of fullness to the spinal cord and the
brain
Conscious Actions
o As the bladder swells, the person becomes
conscious of a sensation of fullness.
o In response, the individual holds the urine back
by voluntarily contracting the external sphincter

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muscles, the muscle group surrounding the


urethra.
o These are the muscles that children learn to
control during the toilet training process.
o When the need to urinate becomes greater
than one's ability to control it, urination (the
emptying phase) begins
The Emptying Phase. automatic and conscious
actions:
o Automatic Actions. - When a person is ready to
urinate, the nervous system initiates the
voiding reflex.

The nerves in the spinal cord (not the


brain) signal the detrusor muscles to
contract.

At the same time, nerves are also


telling the involuntary internal
sphincter (a strong muscle encircling
the bladder neck) to relax.

With the bladder neck now open, the


urine flows out of the bladder into the
urethra
o Conscious Actions

Once the urine enters the urethra, a


person consciously relaxes the
external sphincter muscles, which
allows urine to completely drain from
the bladder.
PELVIC ORGAN PROLAPSE
What is pelvic organ prolapse?
o Definition - Pelvic organ prolapse is the
abnormal descent or herniation of the pelvic
organs from their normal attachment sites or
their normal position in the pelvis
o This condition refers to the bulging or
herniation of one or more pelvic organs into or
out of the vagina
o The pelvic organs consist of the

Uterus

Vagina

Bowel and

Bladder
o Pelvic organ prolapse occurs when the
muscles, ligaments and fascia (a network of
supporting tissue) that hold these organs in
their correct positions become weakened
o These organs are said to prolapse if they
descend into or outside of the vaginal canal
or anus

Page 10 of 18

Where can a prolapse occur?


o
A prolapse may arise in the front wall of the vagina
(anterior compartment)
o
Back wall of the vagina (posterior compartment)
o
The uterus or top of the vagina (apical compartment)
o
Many women have a prolapse in more than one
compartment at the same time
Prolapse of the Anterior Compartment
This is the most common type of prolapse, and involves
the bladder and /or urethra bulging into the vagina
Refer to it as cystocele or cysto-urethrocele New
terminology is Anterior Wall Prolapse

(Left: Normal Anatomy;


Right: Bladder Prolapse: Cystocele)

Prolapse of the Posterior Compartment


This is when the lower part of the large bowel (rectum)
bulges into the back wall of the vagina - refer to as
rectocele)
New terminology: Posterior Wall Prolapse
And / or part of the small intestine bulges into the upper
part of the back wall of the vagina - refer to as
enterocele).
Prolapse of the Apical Compartment
Uterine prolapse this occurs when the uterus (womb)
drops or herniates into the vagina
New terminology: Apical Prolapse
This is the second most common form of prolapse

(Left: Anatomy After Hysterectomy;


Right: Vaginal Vault Prolapse)

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CAUSES:
Anything
that
puts
increased
pressure
in
the abdomen can lead to pelvic organ prolapse.
Common causes include:
o Pregnancy, labor, and childbirth (the most common
causes)
o Obesity
o Respiratory problems with a chronic, long-term cough

Page 11 of 18

o
o
o
o

Constipation
Pelvic organ cancers
Surgical removal of the uterus (hysterectomy)
Genetics may also play a role in pelvic organ prolapse.
Connective tissues may be weaker in some women,
perhaps placing them more at risk
PELVIC ORGAN PROLAPSE

Presentation
The condition seldom causes symptoms
Minimal pelvic organ prolapse generally does not
require therapy because the patient is usually
asymptomatic
However, vaginal or uterine descent at or through the
introitus can become symptomatic
-

Notes from lecture:

Apical Prolapse: Uterus

Anterior Wall prolapse: bladder

Posterior Wall prolapse: Rectum

Signs and Symptoms (dependent on the prolapsed organ)


Generally asymptomatic
Backaches (sacral back pain with standing)
Lower abdominal discomfort
A feeling of pressure or fullness in the pelvic region
A feeling that something is falling out of the vagina
(Typically, the patient feels a bulge in the lower vagina
or the cervix protruding through the vaginal introitus.)
Sensation of vaginal fullness /pressure
Vaginal bleeding
Vaginal spotting from ulceration of the protruding cervix
or vagina
Painful intercourse/ dyspareunia
Urinary problems such as leaking of urine or a chronic
urge to urinate
Constipation
-

Notes from lecture:

Any condition that increases the abdominal


pressure, such as pregnancy, may lead to
prolapse

Specific types present specific symptoms


Loss of anterior vaginal support leads to urethral
hyper motility which often leads to stress urinary
incontinence
Vaginal vault eversion: symptoms of voiding difficulty,
the prolapse come out below urethra
Anterior protrusion of rectum: symptoms of inefficient
rectal emptying

In severe cases, patient has to splint the


posterior vagina with fingers during defecation,
reducing the pocket that is trapping the stool

UTERINE PROLAPSE
It means that the uterus has descended from its position
in the pelvis further down into the vagina

It is held in place by muscles & ligaments that


makes up the pelvic floor; when stretched &
weakened, uterine prolapse occur, descending
into the vaginal canal
Often affects post-menopausal women who had one
or more deliveries; plus effects of gravity; loss of
estrogen; & repeated straining weaken pelvic floor

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Mild prolapse needs no treatment; except when it is


uncomfortable & disrupt normal life

Nulliparous women have undamaged pelvic floor, hence are


not at risk.
Weakening of the pelvic muscles that leads to uterine
prolapse can be caused by:
Damage to supportive tissues during pregnancy and
childbirth
Loss of muscle tone
Effects of gravity
Loss of estrogen
Repeated straining over the years
Risk factors:
One or more pregnancies and vaginal births
Giving birth to a large baby
Increasing age
Frequent heavy lifting
Chronic coughing
Prior pelvic surgery
Frequent straining during bowel movements
Genetic predisposition to weakness in connective tissue
Some conditions can place a strain on the muscles and
connective tissue, such as:

Obesity

Chronic constipation

Chronic obstructive pulmonary disease


(COPD)
Symptoms: depends on severity
Sensation of heaviness or pulling in your pelvis
Tissue protruding from your vagina
Urinary problems, such as urine leakage or urine
retention
Trouble having a bowel movement
Low back pain
Feeling as if you're sitting on a small ball or as if
something is falling out of your vagina
Sexual concerns, such as a sensation of looseness in
the tone of your vaginal tissue
Symptoms that are less bothersome in the morning and
worsen as the day goes on
Most urinary problems are related to cystoceles, while majority
of gastrointestinal and anorectal symptoms are related to
rectoceles.
Assessment and Examination
Prolapse is almost invariably worse when the patient is
standing as well as in lithotomy position

She is standing on the floor w/ one foot


elevated on foot-stool

Recto-vaginal exam: in this position is best


way of detecting occult enterocele because
the bowel can be well palpated in the cul-desac between thumb & fore-fingers easily
Aside from traditional speculum exam of vagina
supplemented with site specific exam of vagina using a
single bladed-speculum as a Sims speculum
As a rule, any prolapse that lie within the vaginal lumen
above the plane of hymenal ring is of limited
significance, especially if there is no symptoms

Page 12 of 18

Pathology
Prolapse w/ cystocele or w/ rectocele
Cervical ulceration - due to friction
Hypertrophy of cervix (Tx: Manchester Procedure: also
the treatment of choice for cervical elevation with
anterior vaginal wall prolapse)
Inversion of vagina
Upper ureter dilatation
How will you know that it is cervical hypertrophy or vaginal
prolapse? Vaginal prolapse causes obliteration of the vaginal
fornix, cervical hypertrophy does not.
Degree of Prolapse
1st Degree: cervix is well within vaginal canal
2nd Degree: cervix is at introitus
3rd Degree: cervix is beyond the introitus
STAGES OF PELVIC ORGAN PROLAPSE (basis: HYMEN)
Stage 0: no prolapse is demonstrated
Stage I: most distal portion of the prolapse is >1cm
above level of hymen
Stage II: most distal portion of the prolapse is <1cm
proximal or distal to plane of hymen
Stage III: is >1cm below the planer of hymen but no
further than 2 cm less than the total vaginal length
Stage IV: complete to nearly complete eversion of
vagina

6 points are located w/ reference to the plane of hymen:

2 on ant. vag. wall pint Aa & Ba

2 in the apical vag points C & D

2 in the post. vag. wall points Ap & Bp


All points, except total vag. length, are measured durign
patients Valsalva (at maximum proptrusion)

BADEN-WALKER HALF-WAY SYSTEM GRADING (older,


more clinically useful):
Grade O: Normal position of its respective site
Grade I: descent half-way to the hymen; Minimal
displacement with straining
Grade II: descent to the hymen; Towards introitus with
straining
Grade III: descent half-way past the hymen; To &
beyond level of introitus with straining
Grade IV: maximum possible descent for its site;
Outside introitus at rest
-

PROLAPSE CAN BE GRADED W/ THIS SYSTEM:


Descent of Anterior Vaginal Wall
Posterior Vaginal Wall
Apical Prolapse
POP-Q (newer)
Cumbersome & questionable clinical utility other than for
research (standardization) purposes
Hymenal plane as 0 anatomic positions of these points
from hymen is measured in cm
Points above or proximal to hymen are described w/
negative number
Positions below or distal to hymen are positive number
Degree of prolapse can be quantified
Reports findings in standardized fashion
Contains series of site-specific measurements of a
womans pelvic organ support
Prolapse is measured to the hymen, a fixed anatomic
landmark that can be identified

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Grading:

Stage 0: No prolapse (apex can descend w/in


2 cm of hymen)

Stage I: Leading edge descends to 1 cm


above hymen

Stage II: Leading edge descends to w/in 1 cm


of hymen (range is between 1 cm above and 1
cm below the hymen)

Stage III: Leading edge extends


>1cm
beyond hymen but < 2cm of total vaginal
length is prolapsed

Stage IV: complete eversion, leading edge >


2m of total vaginal length is prolapsed
POP-Q (Other Description)
New standard system of classification a series of 9
site-specific measurement; 6 points along vagina (2
ant., 2 middle & 2 post. compt.) measured in relation to
hymen
o Measured in cm proximal to hymen (-) or distal
to hymen (+) w/ the of hymen as 0
o Genital hiatus is measured from the middle of
ext. urethral meatus to post. midline of hymen
o Perineal body is measured from post. margin
of genital hiatus to mid-anal opening
o Total vaginal length greatest depth in cm in its
full normal position

Page 13 of 18

o
o

All measured in maximal straining except total


vaginal length
Pelvic relaxation is classified by the organ/s involved;
severity is determined in the lithotomy position as
o O no prolapse; pointa Aa, Ap, Ba, Bp are all
at -3 cm & point C is bet. total vag. length (TVL)
& -(TVL-2 cm)
o 1 - site descends past the mid- vaginal axis; or
most distal part of the prolapse is >1cm above
the level of the hymen
o 2 site descends to the hymenal ring; or most
distal part of prolapse is <1 cm proximal or
distal to the plane of hymen
o 3 site descends beyond hymenal ring; or
most distal part of prolapse is >1 cm below the
plane of the hymen but no further than 2 cm
less than total vaginal length
o 4 site is fully outside hymenal ring; or
complete to nearly complete eversion of
vagina, most distal part of prolapse protrudes
at + (TVL-2) cm
Treatment
Surgery depends on type of prolapse
o Goal to relieve her of her symptoms by
repairing each aspect of abnormal pelvic
support is durable & long lasting
-

Should have well estrogenized vagina


Post-menopausal, give HRT or use intravaginal cream on regular basis
Past menopause use intra-vaginal estrogen
cream 4 6 weeks before pessary is inserted
because it makes pessary more comfortable to
wear, & promote long term use

Contraindications:

Marked outlet relaxation

severe vaginitis/cervicitis;

fixed retro displace.

Complications:

Leukorrhea;

Pelvic infection

Ulceration & fistula

Urinary retention

vaginal fistula

For vaginal prolapse


o Vagina Hysterectomy - most suitable
o Manchester/Fothergill Operation - for poor risk
patient
o Uteropexy
o Posterior Culporrhaphy
o Colpectomy via Colpocleisis (LeFort)

Closing of vagina

Done on elderly spinster or widow

Done as a last resort

Preceded by vaginal hysterectomy

Complication: stress incontinence

Historically, the treatment for symptomatic uterine prolapse has


been hysterectomy, which is performed vaginally or abdominally
in combination with an apical suspension procedure, and repair
of coexisting defects. Apical support procedures that have been
described for use when the uterus or cervix is to be kept in place
include Manchester and Gilliam procedures and fixation of the
cervix to the sacrospinous ligament.
Asymptomatic prolapse no need for Rx, except w/
stress incontinence & prolapse who is about to undergo
operation
o Stress incontinence elevate the anterio
vagina; pull the post. vagina forward; this
opens the cul-de-sac, pulling it off the levator
plate; Thus, creating an opening for the
enterocele formation, uterine prolapse or
rectocele
o Under this condition additional surgery is
needed, culdoplasty or even hysterectomy
McCall Culdoplasty is performed by suspending the vaginal wall
to the endopelvic fascia.
-

Symptomatic prolapse conservative or surgical

Conservative fitting w/ pessary


o For poor operative risk & short life span
o Pessary fitted individually

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CYSTOCELE
A cystocele is a medical condition that occurs when the
tough fibrous wall between a woman's bladder and the
vagina (the pubocervical fascia) is torn by childbirth,
allowing the bladder to herniate into the vagina
Prolapse of the urinary bladder

Classification:
Mild (grade 1) - when the bladder droops only a short way into
the vagina
Severe (grade 2) - the bladder sinks far enough to reach the
opening of the vagina
Most advanced (grade 3) - when the bladder bulges out through
the opening of the vagina

Page 14 of 18

o
o

The pelvic floor consists of muscles, ligaments and


connective tissues that support the bladder and other
pelvic organs
The connections between the pelvic floor muscles and
ligaments can weaken over time, as a result of trauma
from childbirth or chronic straining of pelvic floor muscle
Possible causes of anterior prolapse include:
o Pregnancy and vaginal childbirth
o Being overweight or obese
o Repeated heavy lifting
o Straining with bowel movements
o A chronic cough or bronchitis
Risk factors include:
o Childbirth - women who have vaginally
delivered one or more children have a higher
risk of anterior prolapse
o Aging - anterior prolapse increases as you age

This is especially true after


menopause, when the body's
production of estrogen which helps
keep the pelvic floor strong
decreases
o Hysterectomy - may contribute to weakness
in the pelvic floor support
o Genetics - some women are born with weaker
connective tissues, making them more
susceptible to anterior prolapse
o Obesity or over-weight - are at risk
Symptoms - in mild cases of anterior prolapse, there
may not notice any signs or symptoms
When signs and symptoms occur, they may include:
o A vaginal bulge
o The feeling that something is falling out of the
vagina
o A feeling of fullness or pressure in the pelvis
and vagina
o Difficulty starting a urine stream
o Feeling of incomplete urination
o Frequent or urgent urination
o Repeated bladder infections
o Pain or urinary leakage during sexual
intercourse
o In severe cases, a bulge of tissue that
protrudes through your vaginal opening and
may feel like sitting on an egg

against the posterior vaginal wall while patients


are in the lithotomy position
Asking patients to strain makes cystoceles or
cysto-urethroceles visible or palpable as soft
reducible masses bulging into the anterior
vaginal wall
It requires medical tests and a physical exam
of the vagina
If there is difficulty emptying the bladder,
measure the amount of urine left in the
womans bladder after she urinates

The remaining urine is called the post


void residual

Post void residual can be measured


by a bladder ultrasound

Use a catheter to measure a womans


post-void residual of remaining urine
after the she has urinated

A post-void residual of 100 mL or


more is a sign that the woman is not
completely emptying her bladder
You may use a voiding cysto-urethro-gram
(an x-ray exam of the bladder) to diagnose a
cystocele as well

A woman gets a voiding cystourethrogram while urinating

The x-ray images show the shape of


the womans bladder and let you see
any problems that might block normal
urine flow

An x-ray technician performs a


voiding cystourethrogram, and a
radiologist interprets the images

Management:
o Cystocele treatment depends on the severity of
the cystocele and whether a woman has
symptoms
o If it does not bother her, recommend only that
she avoid heavy lifting or straining, which
could worsen her cystocele
o If she has symptoms that bother her and wants
treatment, recommend pelvic muscle
exercises, a vaginal pessary, or surgery
o Pelvic floor, or Kegel, exercises involve
strengthening pelvic floor muscles

It involves tightening and relaxing the


muscles that support pelvic organs.
o A vaginal pessary is a small, silicone medical
device placed in the vagina that supports the
vaginal wall and holds the bladder in place.
o May recommend surgery to repair the vaginal
wall support and reposition the womans
bladder to its normal position

The most common cystocele repair is


an anterior vaginal repairor
anterior colporrhaphy

Diagnosis:
o Cystoceles and cysto-urethroceles are
detected by applying a single-bladed speculum

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Page 15 of 18

Anterior Colporrhaphy:

weakened
delivery

RECTOCELE
Rectocele or posterior prolapse occurs when the thin
wall of fibrous tissue (fascia) that separates the rectum
from the vagina weakens, allowing the vaginal wall to
bulge
o It is the front wall of the rectum that bulges into
the vagina
An enterocele (small bowel prolapse) occurs when
the small bowel presses against and moves the upper
wall of the vagina
Rectoceles and enteroceles develop if the lower pelvic
muscles become damaged by labor, childbirth, or a
previous pelvic surgery or when the muscles are
weakened by aging
A rectocele or an enterocele can be present at birth
(congenital), though this is rare
Take extra measure and caution in diagnosing a
rectocele because it is easily confused with enterocele.
Repairing a rectocele, which is actually an enterocele,
thru posterior perineorrhaphy would warrant the patient
to come back again because of unresolved s/sx. In
enterocele, on the other hand, the cul de sac of Douglas
is repaired.
If in doubt, request for imaging studies such as lower
barium enema. If the barium is visualized at the vaginal
canal, it is an enterocele.
Causes:
o Upright posture - Walking upright places
weight on a woman's pelvic floor and is the
main reason women experience posterior
prolapse
o Increased pelvic floor pressure
o Other conditions and activities that increase
the pressure already on the pelvic floor and
can cause or contribute to posterior prolapse
include:

Chronic constipation or straining with


bowel movements

Chronic cough or bronchitis

Repeated heavy lifting

Being overweight or obese


o Pregnancy and childbirth - because the
muscles, ligaments and fascia that hold and
support your vagina become stretched and

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pregnancy,

labor

and

Risk factors:
o Genetics - Some women are born with weaker
connective tissues in the pelvic area; others
are born with stronger connective tissues.
o Childbirth - If you have vaginally delivered
multiple children, you have a higher risk of
developing posterior prolapse - had tears in the
tissue between the vaginal opening and anus
(perineal tears) and incisions that extend the
opening of the vagina (episiotomies) during
childbirth
o Aging - risk of posterior prolapse increases as
you age because you naturally lose muscle
mass, elasticity and nerve function as you grow
older, causing muscles to stretch or weaken.
o Obesity - a high body mass index is linked to
an increased risk of posterior prolapse - due to
the chronic stress that excess body weight
places on pelvic floor tissues

Symptoms:
o Small posterior prolapse may cause no signs
or symptoms
o Otherwise, you may notice:

A soft bulge of tissue in the vagina


that may or may not protrude through
the vaginal opening

Difficulty having a bowel movement


with the need to press your fingers on
the bulge in the vagina to help push
stool out during a bowel movement
("splinting)

Sensation of rectal pressure or


fullness

A feeling that the rectum has not


completely emptied after a bowel
movement

Sexual concerns, such as feeling


embarrassed or sensing looseness in
the tone of your vaginal tissue

Pathophysiology:
o It is important to note that a rectocele is a
defect of the vaginal supporting tissues; it is not
a defect of the rectum
o The etiology of a rectocele is believed to be
due to stretching and disruption of the rectovaginal septum and surrounding vaginal
tissues during childbirth
o Perhaps the most important fascia within the
recto-vaginal septum is Denonvilliers' fascia,
which is fused to the inner layer of the posterior
vaginal wall
o During childbirth, Denonvilliers' fascia is
believed to be disrupted at its caudal and
lateral attachments to the perineal body
o Good evidence for this theory exists, since
rectoceles are essentially found only in parous
women

Make an incision upwards up until the vaginal vault. Then remove


the anterior vaginal mucosa. Above it, push the bladder upwards.
On the lateral side, the levator ani muscle is located. This will split
or be damaged during delivery. This is also anchored upward.
After its repair thru suturing, the perineum will automatically
contract. This procedure takes about more than an hour.

during

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Prophylaxis:
o Prophylactic measures for preventing
rectocele include

Diagnosis and treatment of chronic


respiratory and metabolic disorders

Correction of constipation, and intraabdominal disorders that may cause


chronic increases in intra-abdominal
pressure
o Counsel patients about

The preventive effects of weight


control

Proper nutrition

Smoking cessation, and

Avoidance of strenuous occupational


and recreational stresses that could
damage the pelvic support system
o Teach and encourage women to perform
pelvic muscle exercises as a method of
strengthening their pelvic diaphragm and as
prophylaxis against the development of
rectocele
o For mild degrees of relaxation, especially in
younger women immediately following
childbirth,
levator
muscle
exercises,
sometimes called Kegel exercises, are helpful
in restoring the tone of the muscles of the
pelvic floor

Patients should repeat this exercise


approximately 75 times during the
day

Treatment:
o For patients without symptoms, expectant
management is recommended
o Currently, no evidence supports the use of
estrogen to prevent or treat prolapse
o Nonsurgical and surgical methods are
available for treating symptomatic patients with
rectocele

One responsibility of the physician is


to inform women of their treatment
options and the potential benefits and
risks of each option
o Generally, treatment is determined by:

The age of the patient

The desire for future fertility

The desire for coital function

The severity of symptoms

The degree of disability, and

The
presence
of
medical
complications
o Medical Rx use of pessaries
o Surgical Rx including:

Posterior colporrhaphy

Defect-directed repair

Posterior fascial replacement

Trans-anal repair, and

Abdominal approach
o Comparison between trans-vaginal and
trans-anal approach:

Both approaches are effective for


posterior compartment defects and
improvement in quality of life

(Left: Rectocele; Right: Enterocele)

Diagnosis:
o Enteroceles and rectoceles are detected by
retracting the anterior vaginal wall while
patients are in the lithotomy position
o Asking patients to strain can make enteroceles
and rectoceles visible and palpable during
recto-vaginal examination
o Patients are also examined while standing with
one knee elevated (eg, on a stool) and
straining
o Sometimes abnormalities are detected only by
recto-vaginal
examination
during
this
maneuver
o Pelvic exam

During the exam, bear down as if


having a bowel movement

This may cause the posterior


prolapse to bulge - can assess its size
and location

To check the strength of the pelvic


muscles, be instructed to tighten
(contract) them, as if you're stopping
the stream of urine

You may be examine while lying


down and while standing up
o Imaging tests usually aren't needed to
diagnose posterior prolapse.

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Page 17 of 18

o
o
o

But there are variations in outcome


Gynecologists
generally
use the vaginal approach
with successful anatomic
results and minimal postprocedure pain, but sexual
dysfunction is a concern
The trans-anal approach
yields better rectal function
and tends to be performed
by general surgeon or
proctologists
The primary surgical therapy for rectocele has
been posterior colporrhaphy
The principal objective of the posterior repair is
to repair perineal tears that occurred during
vaginal delivery
The perineal closure is designed to

Narrow the caliber of the vaginal


introitus

Develop a perineal shelf, and

Partially close the genital hiatus


The original description described

Reduction of the rectocele

Suturing of the levator ani

Correction of existing enterocele or


prevention of potential enterocele.

If you see a cystocele plus rectocele, there is most often


a concomitant degree of uterine prolapse. Moreover, if
you have a third degree uterine prolapse, you can be
sure that there is a concomitant cystocele and urinary
incontinence.

-------------------END OF TRANSCRIPTION------------------References Used:


Novaks Textbook of Gynecology
American Urogynecologic Society
Management of Pelvic Organ Prolapse by Angels
Jacob
Handel LN, Frenkl TL, Kim YH (2007). "Results of
cystocele repair: a comparison of traditional anterior
colporrhaphy, polypropylene mesh and porcine dermis
Medscape General Medicine. 1998

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Page 18 of 18