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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:
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
UROGYNECOLOGY
PELVIC FLOOR
Functions:
Prevents the organs from falling down or out
Play a role in making these organs function
properly
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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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Stress test
Urinalysis
UTZ
Cystoscopy
Uro-dynamics
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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:
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)
Urethral diverticulum
The ability to hold urine & control urination depends on
the normal function of lower urinary tract, CNS
Page 5 of 18
Menopause
estrogen
deficiencies
Behavioral
techniques
and
noninvasive devices, including Kegel
exercises, weighted vaginal cones,
and biofeedback.
Medications
Alpha-adrenergic
agonists
and
possibly
anticholinergics.
Surgery
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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
INCONTINENCE
Differential Diagnosis
o Urge incontinence
o Functional or Transient Bladder
o Dyssynergic Bladder
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:
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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
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.
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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
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
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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
-
UTERINE PROLAPSE
It means that the uterus has descended from its position
in the pelvis further down into the vagina
Obesity
Chronic constipation
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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
Grading:
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o
o
Contraindications:
severe vaginitis/cervicitis;
Complications:
Leukorrhea;
Pelvic infection
Urinary retention
vaginal fistula
Closing of vagina
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
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o
o
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
Diagnosis:
o Cystoceles and cysto-urethroceles are
detected by applying a single-bladed speculum
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:
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:
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
during
Page 16 of 18
Prophylaxis:
o Prophylactic measures for preventing
rectocele include
Proper nutrition
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
The
presence
of
medical
complications
o Medical Rx use of pessaries
o Surgical Rx including:
Posterior colporrhaphy
Defect-directed repair
Abdominal approach
o Comparison between trans-vaginal and
trans-anal approach:
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
Page 17 of 18
o
o
o
Page 18 of 18