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.