DISORDERS OF PELVIC SUPPORT

RECTOVAGINAL FISTULAE

Department of Obstetrics and Gynecology

FEU-NRMF MEDICAL CENTER
ANATOMY OF PELVIC FLOOR
MUSCLES
ANATOMY OF PELVIC FLOOR
MUSCLES
ANATOMY OF PELVIC FLOOR
MUSCLES
The Ligaments and Fascial Support of the
Pelvic Viscera
Disorders of Pelvic Support
Pelvic condition characterized by the failure of
Organ various anatomic structures to support the
pelvic viscera
Prolapse
(POP) common in parous women (30% to 50%)

mostly asymptomatic

In most cases the relaxation affects all the

support structures of the pelvis
Pathophysiology
 Disorders of Pelvic Support
Abnormalities Enterocoele
that result
from pelvic
relaxation Cystocoele
problems
Rectocoele
Uterine prolapse
Vaginal stump prolapse
These abnormalities often occur together
Development of Pelvic Organ Prolapse
Risk Factors Controversial Risk Factors

Vaginal Birth Episiotomy

Aging

Obesity Higher weight of the largest infant

delivered vaginally
Prior pelvic surgery
Chronic cough and respiratory
Hysterectomy
diseases
Constipation
Exercise
Irritable bowel syndrome
Heavy lifting
Genetic conditions
Lower education
Neurologic injury
Pathophysiology
Multifactorial
loss of muscle atrophy from denervation from
childbirth injuries
levator
ani Muscle wasting from muscle insertion
detachment during childbirth
bulk
from decrease in estrogen
 General Symptom Assessment
Urinary Urinary incontinence Sexual Discomfort
Symptoms symptoms
Difficulty voiding
Irritation
Slow urinary stream
Decreased sexual desire
Sensation of incomplete
bladder emptying
Bowel Constipation Local Vaginal heaviness and
Symptoms Symptoms bulge
Straining Low back pain
Incomplete evacuation
Pelvic pain
Anal incontinence
Splinting to achieve bowel Vaginal bleeding
movement
Quantification of Pelvic Organ Prolapse
1st Prolapse into the upper barrel of the
Degree vagina
2nd through vaginal barrel up to the
Degree region of the introitus
3rd cervix and uterus prolapses out
Degree through introitus
4th Complete eversion of the uterus and
Degree cervix (procidentia) or vaginal apex
Degree
 International Continence Society
Terminology (ICST) Staging
• An objective site specific quantitative description of the
prolapse with more precise descriptions based on
anatomic landmarks
Quantitative description of pelvic organ
prolapse six sites
Staging of Pelvic Floor Prolapse Using
ICST
Stage No prolapse is demonstrated. Points Aa, Ap, Ba, and Bp are
all at –3cm and either point C or D is between total vaginal
0 length –2cm.

Stage Criteria for stage 0 are not met, but the most distal portion of
the prolapse is >1cm above the level of the hymen.
I
Stage The most distal portion of the prolapse is less or equal to 1cm
proximal or distal to the plane of the hymen.
II
Stage The most distal portion of the prolapse is >1cm below the
plane of the hymen but protrudes no farther than 2cm less
III than the total vaginal length in cm.

Stage Essentially complete eversion of the total length of the lower

genital tract
IV
Urethrocoele and Cystocoele
Anterior compartment defect

Most common site of primary POP

Descent of urethra (urethrocoele), of bladder neck and bladder (cystocoele) into

the vaginal canal
Fascial breaks in Lateral: paravaginal defect
the fascial
attachments of
the anterior Apical: from pubocervical fascia or vaginal apex (transverse
vaginal wall cystocoele)
Distal: from pubic symphysis (urethrocoele or urethral
hypermobility)
Stress incontinence : urethrocoele

Gynecoid pelvis (wide subpubic arch)

Cystocele
 QuickTime™ and a
decompressor
are needed to see this picture.
Signs and Symptoms
Sensation of fullness
Pelvic pressure or vaginal bulge
“falling out” sensation
Urgency
Incomplete emptying
Urinary symptoms, stress incontinence
Soft, bulging mass on anterior vaginal wall
Symptoms worsen later in the day after upright activities
Diagnosis
History

Physical Lithotomy position

Examination
Depress the posterior vaginal wall with graves speculum

Strain

Palpate the bladder neck

Check for adequacy of pelvic support

Check vaginal tissues for ulceration and bleeding

Standing exam with valsalva maneuver

Differentials
Inflammed and enlarged
Skene’s glands
• tender and pus is expressed
from urethra

Urethral Diverticula
Cystocoele and
• more reducible, very
urethrocoeles
prominent sensation of a
mass
• Pus may be expressed
• softish, pliable
Bladder tumors and
and nontender
diverticula
• less common
 Management
Nonoperative Pessary

large tampons

Kegel’s exercises

estrogen vaginal creams

TAMPONS
Kegel exercise / pelvic floor
exercisess
Management
Anterior and Objective: repair of all existing
posterior support defects
colporrhaphy
Abdominal For anterior vaginal wall
sacral prolapse associated with uterine
or apical prolapse
colpopexy
Midurethral Indicated with anterior
sling colporrhaphy if with concomitant
stress incontinence
Surgical
Colporrhaphy
 Postoperative Care
Drainage of Foley catheter
bladder for 1 –
Suprapubic catheter
2 days
Clean intermittent self catheterization

Patient Straining
education to
heavy lifting
avoid the
following for at prolonged standing
least 3 months:
 Rectocoele
• Protrusion of the rectum into the posterior vaginal wall
due to weakness of rectal supports
RECTOCOELE
 Signs and Symptoms
Pelvic heaviness

“falling out”

Constipation

Incomplete emptying

Vaginal splinting to effect bowel movement

 Diagnosis
History

Physical
Examination Rectum bulge into the vagina when
the patient is instructed to strain
Rectovaginal septum is paper thin

Differentials
for Sigmoidocoele
evacuation
problems Rectal prolapse
Rectal intussuception
 Management
Nonoperative Pessary
kegel’s
estrogen cream
dietary fibers
increased fluids
Regular exercise
colorectal screening test for GI symptoms
 Management
Operative
anterior and posterior
colporrhaphy

correction of concomittant
enterocoele or descensus

perineorraphy
 Enterocele
Herniation of the pouch of douglas between
the uterosacrals into the rectovaginal septum

Usually contains small intestines

Often arises after a hysterectomy

Prevention: incorporation of uterosacrals and

cardinals into the vault repair
ENTEROCELE AND UTERINE PROLAPSE
Elderly patient with vaginal prolapse who proved to have
large enterocele with ulcers on the vagina
 Diagnosis

PE reveals it as a separate
bulge above a rectocele

Transillumination
 Management
• Transabdomination reduction done at the time of the
primary repair
Management
Abdominal Necessary for resuspension and
sacrocolpopexy closure of enterocoele defect

vaginally repair at the time of the posterior

colporrhaphy and apical repair

McCall stitch effectively shortens the cul-de-sac

and supports the enterocele neck

vaginal sacrospinous ligament suspension is

needed for optimal apical repair
Uterine Prolapse
(Descensus, Procidentia)
Protrusion of the cervix and uterus into the barrel of the vagina but often
associated with cystocele, rectocele and enterocele

Injuries of endopelvic fascia, uterosacrals and cardinals, levator ani

leading to pelvic floor relaxation
Childbirth trauma

Associated Increased intraabdominal pressure, sacral nerve

Factors damage, diabetic neuropathy
Women with large transverse diameter inlet
Chronic respiratory disease

Obesity

congenital
 Signs and symptoms
Heaviness, fullness, falling out

“ tumor” bulging out of introitus

Similar symptoms to cystocele and

rectocele
Inflammation and ulcers, pain and
bleeding, infection of prolapsed uterus
 Management
Stage 1 not treated unless there are symptoms

Stage 2 Pessary
estrogen creams
Kegel’s

More Vaginal hysterectomy with vaginal vault

severe suspension and A&P colporrhaphy
degrees Ulcers and infections are treated first and
allowed to heal prior to surgery
 Management
Abdominal hysterectomy If with adhesions and
with AP repair or minilap previous surgery
assisted vaginal
hysterectomy
Manchester cervical hypertrophy
(Donald or Fothergill)

Colpocleisis older non sexually active

women
(Le Fort or Goodall-
Power)
LE FORT
Goodall–Power modification
of Le Fort operation
Apical Vaginal Wall Prolapse
Prolapse of the vaginal apex at some time remote to the
performance of either abdominal or vaginal hysterectomy

Occurs in 0.1 to 18.2 % of cases after an abdominal or

vaginal hysterectomy

May occur with cystocele, rectocele, enterocele

Result of continuing weakness of pelvic support, the

cardinal and uterosacral attachments to the vaginal cuff
 Signs and symptoms
Pelvic heaviness

Backache

Introital mass

Stress incontinence, dribbling, urinary frequency, urgency

Vaginal bleeding, discharge or ulcerations

Difficulty in sitting or walking

 Diagnosis
History determine the contents of the
herniation depending on where the
and vaginal scar is located in relation to the
physical protruding mass and the extent to
which the supports of the pelvis are
exam lost

Rectovaginal examination to delineate

an enterocele from a rectocele
 Management
Principles normal vaginal position in upright
individual is against the rectum with an
angle with the horizontal of not more than
30 degrees
Pelvic relaxation is part of the problem so
cystoceles etc. should also be repaired

perineal body is also weakened and needs

repair
 Management: Surgery
transabdominal Lower vault failure and
(abdominal sacral dyspareunia rate
colpopexy)
Transvaginal (vaginal Shorter operative time,
sacrospinous fewer complications and
colpopexy) quicker return to activities
Laparoscopic

Le Fort (older women)

PLUS perineorrhaphy
 Rectovaginal Fistulas
A common complication of birth and gyne procedures

an abnormal connection between the vagina and rectum

Consider in a patient with fecal and flatal incontinence

Causes Traumatic esp. obstetric injuries (0.1% of vaginal

births)
Inflammatory

Neoplastic
Rectovaginal Fistula
Rectovaginal
Fistula (RVF) true RVF are located
more than 3 cm above
anal verge

Anovaginal
Fistula (AVF) fistula caudad or adjacent
to EAS and is managed
differently from RVF
 RVF from obstetric injury
Lower 3rd of the vagina

Common prolonged second stage

predisposing
factors:
midline episiotomies
perineal lacerations
Mechanisms: Pressure necrosis of rectovaginal septum

Episotomy/ laceration extension directed into the

rectum
May be associated with defects in the sphincter and this must be determined
prior to repair
RVF from other causes

Anywhere in the Maybe more

vagina than one

Mandates
biopsy to rule
out cancer as a
cause
 Clinical manifestations
Small
asymptomatic or small amounts
of flatus passing into the vagina

Large
formed stools from the vagina

Neoplastic
process/ Rectal bleeding
postradiation
Diagnosis
History and Office
Physical Colonoscopy proctoscopy
Exam or anoscopy

Peroxide via
Methylene Barium
angiocatheter
blue infusion Enema
infusion

Vaginography
Management
tract is opened, curreted and left to
AVF heal by secondary intention

transvaginal or transrectal correction

RVF
necessitates healthy, well-vascularized,
uninfected tissue prior to surgery
 Management
Preoperative bowel prep

antibiotic prophylaxis

Postoperative liquid diet

stool softeners

2 weeks of broad spectrum antibiotics

Hot sitz bath followed by blow drying or perilight

INCONTINENCE
STRESS INCONTINENCE
occurs when increased intraabdominal
pressure is not transmitted equally to the
bladder and the functional urethra
separation of the supports that hold the upper
vagina and urethra to the pubic symphysis,
neuromuscular damage to the pelvic fascia and
musculature secondary to childbearing or the
aging process, from some sort of trauma, or
from an altered connective tissue metabolism
causing decreased collagen production.
Normal posterior urethrovesical (PUV)
angle of less than 120° was an important
aspect of the continence mechanism,
because such an angle was
characteristically greater than 120° in
stress incontenince
DIAGNOSIS
• Cotton swab test
• Bead-chain cystourethrogram
• Perineal ultrasound

Stress incontinence may occur with injury or

degeneration to either the urethral support
system or the urethral sphincter mechanism
or both.
Lateral view of the components of the
urethral support system
MANAGEMENT
• Kegel’s exercise
• Α-adrenergic drugs (phenylpropanolamine)
• limited benefit with drugs for treating stress incontinence
SURGICAL
Transvaginal
Anterior needle
colporrhaphy suspensions
(TVNS)

Suprapubic
Burch
approach or a
procedure
vaginal sling
Burch procedure.
The lateral edges of the vagina have been sutured to the
Cooper's ligaments
Other Types of Incontinence
CONTINUOUS continuous leakage of urine
URINARY where the patient does not
INCONTINENCE describe urgency or activity
associated with the leakage

EXTRAURETHRAL the observation of urine

INCONTINENCE leakage through channels
other than the urethra,
including urinary fistulas.
Overflow incontinence
old term used to describe chronic
retention of urine

It occurs when a bladder is

overdistended because of its inability
to empty
caused by a neurologic disorder that
interferes with normal bladder reflexes
or by partial obstruction of the urethra
Clinical Manifestations
complains of voiding small amounts and feeling of incomplete emptying
of the bladder

bladder is nonpainful and may be palpable after the patient has voided

Retention of urine volume is more than 300 mL.

Involuntary loss of small amount of urine

COMMONLY SEEN multiple sclerosis

IN PATIENTS
diabetic neuropathy
trauma
tumors of the central nervous system
DISORDERS OF PELVIC SUPPORT
RECTOVAGINAL FISTULAE

END OF LECTURE