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8th Edition APGO Objectives for Medical Students
Pelvic Relaxation and Urinary Incontinence
Rationale
Patients with conditions of pelvic relaxation and urinary incontinence present in a variety of ways. The physician should be familiar with the types of pelvic relaxation and incontinence and the approach to management of these patients.
Objectives
The student will demonstrate knowledge of the following:
Predisposing factors for pelvic organ prolapse and urinary incontinence
Anatomic changes, fascial defects and neuromuscular pathophysiology
Signs and symptoms of pelvic organ prolapse Physical exam
Cystocele Rectocele Enterocele Vaginal vault or uterine prolapse
Risk factors
Vaginal deliveryLarge baby Prolonged 2nd stage of laborForcepsMultiparous
Risk factors
Increased abdominal pressure ObesityChronic constipation Chronic lung disease
Risk factors
Altered nerve function or tissue strength Diabetes Neurologic diseases Aging Collagen disorders Hypoestrogenism Pelvic surgery
Anatomy Basic
Levator ani muscles • Pubococcygeuas • Puborectalis • Iliococcygeus
Viscerofascial layer • Endopelvic fascia - attaches uterus and vagina to pelvic wall • Parametria - cardinal and uterosacral ligaments
Fascial defects Neuromuscular pathophysiology
Signs and symptoms of pelvic organ prolapse Symptoms - prolapse Asymptomatic Vaginal pressure heaviness (>90%) Vaginal pain Sensation of tissue protruding from the vagina (>90%) Abdominal pain Low back pain Dyspareunia/impaired coitus (37%) Vaginal dryness
Ulceration Bleeding
Urinary incontinence (33%)
Signs and symptoms of pelvic organ prolapse
Symptoms - urinary incontinence - unexpected loss of urine
Stress incontinence - involuntary loss of urine with increased abdominal pressure (valsalva, cough, laugh, sneeze)
Urge incontinence - involuntary loss of urine associated with overwhelming urge to void
Physical exam (definitions)
Cystocele Defect where the bladder and anterior vaginal
wall protrudes through the vaginal introitus Secondary to attenuation or rupture of the
pubovesical cervical fascia Note anterior relaxation with urethral inclination Mobility of bladder base and urethra with
valsalva maneuver
Physical exam (definitions)
Rectocele Protrusion of posterior vaginal wall and
anterior rectal wall Look for bulging of posterior vaginal wall
with valsalva maneuver Insert a finger in rectum and, if vaginal
and rectal tissue are jauxtaposed = rectocele
Physical exam (definitions)
Enterocele Elongation of posterior cul-de-sac along
rectovaginal septum 50% are diagnosed intraoperatively Physical exam (patient standing) - palpate
enterocele sac and small bowel
Physical exam (definitions)
Uterine/vaginal vault prolapse Uterine - descent of uterus and cervix into
the vaginal canal Exam - patient upright, valsalva
Look and fell for prolapse Grade based on location from hymeneal ring
Vaginal vault - loss of support of vagina beginning at apex
Methods of diagnosis
Urine culture Rule out urinary tract infection > 105 organisms
Voiding diary Normal bladder capacity (up to 60cc) Normal frequency (<8 voids/day) Accidents/leaking with physical activity Amount and type of intake
Methods of diagnosis
Standing stress test - note urine loss with cough or valsalva
Q-tip test Looks for hypermobility of the urethrovesical
junction
Resting position -30o or a change of greater than 30o is hypermobile
Methods of diagnosis
Filling cystometrogram - examines the bladder during filling and storage Post-void residual < 100cc First urge - 100 - 200 mL Maximum capacity - 400 - 500 mL Resting bladder pressure < 10 - 15 cm of
H2O
Cystocopy
Nonsurgical and surgical treatments
Pessary Oldest effective treatment If pelvic floor muscle damaged, they
cannot be held in place Adjunctive treatment - estrogen
Nonsurgical and surgical treatments
Medications Stress incontinence
Antagonist to increase smooth muscle tone (phenylpropanolamine)
Estrogen to increase urethral resistance Urge incontinence - anticholinergics to
decrease spasm of the detrusor muscle (oxybutynin, tolterodine)
Nonsurgical and surgical treatments
Pelvic floor muscle exercises Kegels - voluntary contraction of the
pelvic floor Vaginal cones Electrical stimulation
Nonsurgical and surgical treatments
Surgery Hysterectomy - vaginal or abdominal (route
depends on other surgical interventions) For anterior wall prolapse (cystocele)
Vaginal approach • Anterior colporrhaphy (central defect)• Paravaginal repair (lateral defect)
Abdominal approach - paravaginal repair
Nonsurgical and surgical treatments
Surgery For apical defect
Vaginal approach• Sacrospinous ligament fixation• Uterosacral colposuspension
Abdominal approach• Abdominal sacrocolpopexy • Uterosacral colposuspension
Nonsurgical and surgical treatments
Surgery For posterior defect - posterior
colporraphyFor enterocele
Obliterate cul-de-sac with purse string suture in endopelvic fascia
McCall culdoplasty
Colpocleisis (LeFort procedure)
Nonsurgical and surgical treatments
Surgery For stress incontinence
Vaginal approach • Pereyra • Raz • Stamey • Tensionless vaginal tape (TVT)
Nonsurgical and surgical treatments
Surgery For stress incontinence
Abdominal approach • Marshall-Marchetti-Krantz (MMK) • Burch colposuspension
Nonsurgical and surgical treatments
Surgery For stress incontinence
Intrinsic urethral sphincter dysfunction • Suburethral sling • Bulking injections (with collagen) to improve
urethral coaptation (for patients without urethrovesical junction hypermobility)
• Artificial sphincter
References
American College of Obstetricians and Gynecologists Technical Bulletin #214. Pelvic Organ Prolapse. ACOG: Washington DC 1995.
American College of Obstetricians and Gynecologists Technical Bulletin #213. Urinary Incontinence. ACOG: Washington DC 1995.
Mischel DR, ed., Comprehensive Gynecology 3rd ed., Mosby, St. Louis, MO, 1997.
Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997
Clinical Case
Pelvic Relaxation and Urinary Incontinence
Patient presentation
A 75-year-old woman G5P5 presents complaining of “fullness” in the vaginal area. The symptom is more noticeable when she is standing for a long period of time. She does not complain of urinary or fecal incontinence. She has no other urinary or gastrointestinal symptoms. There has been no vaginal bleeding. Her past medical history is significant for well-controlled hypertension and chronic bronchitis. She has never had surgery.
Patient presentationPhysical exam
Pelvic exam reveals normal appearing external genitalia except for generalized atrophic changes. The vagina and cervix are without lesions. A second-degree cystocele and rectocele are noted. The cervix descends to introitus with the patient in an erect position. No rectal masses are noted. Rectal sphincter tone is slightly decreased. Uterus is normal size. Right and left ovaries are not palpable.
Labs or StudiesNone
DiagnosisPelvic organ prolapse
Management plan
Management PlanPatient prefers non-surgical option
Pessary placed and vaginal estrogen used to address atrophic changes
Teaching points
1. The patient’s multiple vaginal deliveries, age and chronic bronchitis places her at risk for pelvic organ prolapse.
2. Patients commonly present with a feeling of “fullness” or are able to touch vaginal or cervical tissue protruding through the introitus. They may or may not experience urinary incontinence.
Teaching points
3. In addition to pelvic muscle exercises, non-surgical management of pelvic organ prolapse mainly involves fitting the patient with a vaginal pessary. There are numerous vaginal pessaries designed to support specific types of pelvic organ prolapse. Pessaries press against the walls of the vagina and are retained within the vagina by the tissues of the vaginal outlet.
Teaching points
4. Pessaries may cause vaginal irritation and ulceration. They are better tolerated when the vaginal epithelium is well estrogenized; exogenous estrogen may be required in the hypoestrogenic patient. Periodically, vaginal pessaries should be removed, cleaned and reinserted. Failure to do so may result in serious consequences, including fistula formation.
Teaching points
5. Patients may be managed successfully with a pessary for years. Indications for surgery include the desire for definitive surgical correction, recurrent vaginal ulcerations with a pessary or stress incontinence that the patient finds unacceptable.