JC104 (O&G) - Urinary Incontinence in Females, Genital Prolapse

Question 1

Female pelvic floor structures

Answer 1

Structures connected to bony pelvis:

- peritoneum, pelvic viscera, endopelvic fascia, levator ani muscles, perineal membrane, superficial genital muscles

Question 2

Function of levator ani muscles

Answer 2

Levator ani muscles:

• form horizontal shelf for pelvic organ support
• Pubococcygeal portion: constant tone to coapt the urogenital hiatus and hold the pelvic floor closed

Question 3

3 major function of the pelvic floor

Answer 3

1. Support for viscera
2. Sphincteric control
3. Sexual function

Question 4

Mechanisms of pelvic viscera support

Answer 4

1. Constriction: muscles at outlet of pelvic cavity
2. Suspension: ligaments hold viscera in position
3. Vaginal axis: usually posteriorly deviated (can lessen the force of increased pelvic/ intraabdominal pressure exerted on pelvic organs, reduce genital prolapse)

Pelvic floor had to be anatomically and neurologically intact to maintain viscera positions

Question 5

Define the 3 compartments of the female pelvic space

Answer 5

Anterior = Bladder and urethra

Central/ Apical = Uterus, vagina

Posterior = Rectum

Question 6

Define the 3 levels of pelvic floor support

Effect of damage to each level

Answer 6

Level 1 support = over upper vagina, uterus and cervix

Level 2 support - Middle vagina and bladder

Level 3 support - lower vagina, rectum

Damage to level 1 = uterine descent or vaginal vault prolapse (apical compartment)
Damage to level 2 or 3 = Anterior compartment prolapse- bladder, urethra / Posterior compartment prolapse - rectum

Question 7

Level 1 pelvic support

• Supporting structures/ ligaments
• Organs attached to pelvic sidewalls
• Effect of damage

Answer 7

Supporting structures/ ligaments

• Uterosacral ligament
• Cervical/cardinal ligament
• Paracolpium (downward continuation of tissue)

Organs attached to pelvic sidewalls
- Uterus, cervix, upper vagina

Effect of damage: Central/apical prolapse:

• Uterine descent/ prolapse
• Vaginal vault prolapse

Question 8

Level 2 pelvic support

• Supporting structures/ ligaments
• Organs attached to pelvic sidewalls
• Effect of damage

Answer 8

Supporting structures/ ligaments
- Paracolpium & parametrium: attachment forms the:
 ‘Pubocervical fascia’
 ‘Rectovaginal fascia’ (back))

Organs attached to pelvic sidewalls
 Mid-portion of
vagina
 Bladder

Effect of damage
Anterior prolapse:
 Cystocele (prolapsed bladder)
 Urethrocele
Posterior prolapse: rectocele

Question 9

Level 3 pelvic support

• Supporting structures/ ligaments
• Organs attached to pelvic sidewalls
• Effect of damage

Answer 9

Supporting structures/ ligaments : No intervening paracolpium (directly
attached to surrounding structures):
 Anteriorly: urethra
 Posteriorly: perineal body
 Laterally: levator ani muscles

Organs attached to pelvic sidewalls
 Distal vagina
 Rectum

Effect of damage:
Anterior prolapse: urethrocele
Posterior prolapse:
 Perineal deficiency
 Rectocele

Question 10

Structures in the lower urinary tract that maintain continence

Answer 10

Intrinsic to lower urinary tract
 Smooth muscles
 Urethral connective tissue
 Urethral submucosal vascular plexus
 Urethral mucosa

Extrinsic to lower urinary tract
 Connective tissue supports (endopelvic fascia)
 Muscular supports (levator ani muscles)
 Striated urogenital sphincter

Question 11

Describe the role of the pelvic floor in maintaining urinary continence

Answer 11

Proximal urethra and bladder neck are normally positioned above the pelvic floor

• increases in intra-abdominal pressure will be transmitted equally to the bladder and the proximal urethra
• CLOSE URETHRA to prevent urinary leakage

Poor pelvic support causes bladder neck and proximal urethra to drop below the pelvic floor

• Causes hypermobility of bladder neck
• pressure transmission to the proximal urethra does not occur&raquo_space;> stress incontinence

Question 12

Define the integral theory of the female pelvic floor

Answer 12

Symptoms of stress, urge, and abnormal emptying mainly derive from laxity in the vagina or its supporting ligaments (due to altered connective tissue)

• The vagina is supported by the muscles and suspensory ligaments
• Any defects of suspensory ligaments over the vagina, the imbalance of force over the vagina and the ligaments cause incontinence

Restoration of form (structure) leads to restoration of function

Question 13

Most common anatomical anomaly that causes stress incontinence in females

Answer 13

Poor support of proximal urethra and bladder neck

1. Vaginal delivery damaged pelvic floor muscles, ligaments, fascia
2. weakened pelvic floor support to proximal segment of urethra and bladder neck
3. descent of bladder neck outside the zone of intraabdominal pressure - hypermobility of bladder neck
4. If the proximal urethra prolapses beyond the pelvic floor, the pressure is transmitted
   to the bladder but not the proximal urethra&raquo_space;> incontinence

Question 14

Detrusor overactivity

• Possible etiologies

Answer 14

 Urethral outflow obstruction, ?primary urethral pathology

 Poor potty training/ childhood nocturnal enuresis

 Altered contractile activity of detrusor cells

Question 15

Factors that adversely affect pelvic floor function

Answer 15

Vaginal delivery* (single most important risk factor)

• Esp. macrosomic baby, long second stage of labor
• Damages the pelvic floor muscles, ligaments and fascia, pudendal nerve damage

Others:
 (Post)menopause (lack of estrogen)
 Increasing age
 Obesity
 Increased abdominal pressure: chronic cough (e.g. COPD), constipation, occupational stress
 Congenital weakness of connective tissue (e.g. Marfan syndrome)
 Prior hysterectomy (suspensory ligaments may be cut)
 Racial factor (Whites more prone than Blacks)

Question 16

Organ prolapse definition

Answer 16

Prolapse = protrusion of an organ/ structure outside its normal anatomical boundaries

Question 17

Genital prolapse

• Clinical presentation: S/S, aggravating and relieving factors, associated symptoms…etc
• COmplication

Answer 17

Presentation:
 Asymptomatic

 See/ feel a bulge of tissue protruding to/ past the vaginal opening
 Dragging sensation
 Ulceration, bleeding, discharge from the tissue

 Aggravating factors: e.g. stand/ walk for whole day
 Relieving factors: smaller when lie down

Associated symptoms:
 Anterior prolapse causing urinary symptoms, e.g. difficulty in urination, slow stream
 Posterior prolapse causing bowel symptoms (constipation), e.g. splinting (woman uses her fingers to press on the vagina as a way to try to evacuate stool)

Complication:
- Severe genital prolapse causes ureteric obstruction&raquo_space; hydroureter and hydronephrosis&raquo_space; renal damage

Question 18

Structures that may prolapse through female pelvis

Answer 18

Anterior compartment = cystourethrocele

Central compartment = uterine or vault prolapse

Posterior compartment = rectocele

Question 19

3 Grading systems for severity of female genital prolapse

Answer 19

1. Degree of uterine descent = relative position of the cervix to the introital opening during maximal straining:

 1st degree: cervix down into vagina below the ischial spine, not as far as the introitus
 2nd degree: cervix down to the introital opening or just beyond
 3rd degree: cervix and uterine body both beyond the introitus

2. Pelvic organ prolapse quantitation (POP-Q): Measure 9 different points
3. Ordinal staging system: prolapse relative to hymen

Question 20

Define the measurement points in Pelvic organ prolapse quantitation (POP-Q) for organ prolapse

Answer 20

Ba = lowest position of upper anterior wall
Ba +ve = cystocoele beyond level of hymen
Ba -ve = cystocoele above hymen

Bp = lowest position of upper posterior vaginal wall 
\+ve = rectocele beyond hymen
-ve = rectocele above hymen

C = Most distal edge of cervix/ vaginmal cuff
- +ve = prolapse of central compartment

Question 21

Outline the ordinal staging system for female genital prolapse (not important)

Answer 21

Ordinal stages:
 0: no prolapse
 I: >1cm above the hymen
 II: ≤1 cm proximal or distal to the hymen
 III: >1 cm distal to hymen but no further than (tvl-2cm)
 IV: at least (tvl-2cm)

Question 22

Genital prolapse P/E

• List of P/E

Answer 22

P/E:
General:
 Obesity (BMI)
 Lower limb edema (kinking of ureter cause hydronephrosis, renal damage)

Respiratory system: chronic cough

Abdominal examination:
 Hysterectomy scar (uterine or vault prolapse)
 Abdominal/pelvic mass (e.g. malignancy or ascites increase intra-abdominal pressure and cause prolapse)
 Palpable bladder

Pelvic exam

Question 23

Pelvic exam for genital prolapse

• P/E positions
• List of tests

Answer 23

Pelvic examination:

a. Lithotomy position (uterine speculum)
b. Sims’ (left lateral) position (right knee raised above the left): Use Sims speculum to retract the anterior and posterior vaginal wall

1. Assess degree of descent in each compartment during straining (measure distance of prolapse beyond/ above hymen)
2. Cough test (reduce prolapse to detect occult stress incontinence)
3. Assess condition of vaginal wall
4. Take cervical smear if indicated
5. Uterine assessment
6. Look for adnexal mass

Question 24

Treatment options for pelvic organ prolapse in women

Answer 24

Asymptomatic/ Conservative treatments:

• Ring pessary (needs fitting for right size)
• Individualized pelvic floor muscle training
• Manage risk factors (e.g. weight reduction, control COPD/ constipation, avoid heavy lifting…)

Surgical treatments:
 Central compartment, e.g. uterine prolapse: vaginal hysterectomy + pelvic floor repair
 Cystocele: anterior vaginal wall repair

Question 25

Ring pessary for pelvic organ prolapse in women

• Indication
• Effectiveness
• Cons
• Complications

Answer 25

• Indication: For patients who decline surgery/ unfit for surgery/ temporary relief while awaiting surgery/ pregnant
• Effectiveness = 60%
• Cons: trial and error to find the appropriate size
• Complications: pressure ulcer, bleeding, infection (with discharge)
• Give estrogen cream for pressure ulcers

Question 26

Individualized pelvic floor muscle training

• Indication
• Drawbacks

Answer 26

Indication: Improves symptom in mild prolapse (less helpful in moderate to severe prolapse)

Drawbacks:
 Requires good compliance (every day for 3 months)
 Unsure of long-term benefit

Question 27

Types of urinary incontinence

Answer 27

a) Stress urinary incontinence
b) Urgency urinary incontinence (overreactive bladder)
c) Overflow incontinence (e.g. neurological deficit: reduced urge sensation)
d) Functional incontinence (e.g. stroke  cannot go to toilet)
e) Congenital anomaly (e.g. duplex ureter with insertion below external sphincter)
f) Fistula (e.g. birth injury - vesicovaginal fistula)

Question 28

Questions for ddx types of urinary incontinence

Answer 28

Question 29

Outline history taking questions for urinary incontinence

Answer 29

a) Irritative voiding symptoms
b) Severity of the problem and effect on quality of life

c) Any associated symptoms:
 Genital prolapse
 Urinary/ bowel/ sexual dysfunction

d) Amount of fluid intake, caffeine intake
e) Drug history: diuretics, painkillers, cough medication

Question 30

Outline P/E and first-line investigations for urinary incontinence

Answer 30

P/E:
1) Cough test
2) Pelvic examination:
 Assess pelvic floor support (each compartment) and function
 Presence of uterine and adnexal pathology
3) Neurological examination: assess S2-4 nerve roots (bladder innervation; e.g. anal wink)

Ix:
1. Bladder diary (record fluid intake, urinary output, frequency of voiding, time of incontinence, feeling of urge)

2. MSU for routine, microscopy +/- culture (UTI)
3. Urodynamic study: distinguish between anatomical or functional cause of incontinence/ confirm either USI or detrusor overactivity

Question 31

Difference between dry vs wet over-reactive bladder

Answer 31

(dry OAB (frequency, urgency) vs. wet OAB (urgency, leakage))

Question 32

Urodynamic study

• What is measured?

Answer 32

Measure pressure-flow relationship between the bladder & urethra during

1) Storage/ filling phase: with cystometry
2) Voiding phase of bladder

Metrics measured during the 2 phases:

• Vesical pressure (inside bladder)
• Vaginal/rectal pressure (i.e. intraabdominal pressure)
• Detrusor pressure (i.e. vesical pressure – intraabdominal pressure)

Question 33

Compare the different urodynamic results for stress incontinence and detrusor overactivity incontinence:

Answer 33

Stress incontinence:
Involuntary leakage during filling cystometry:
 Associated with increased intra-abdominal pressure
 In the absence of detrusor contraction

Detrusor overactivity incontinence:
Involuntary detrusor muscle contractions occur during filling cystometry
 NOT associated with increased intra-abdominal pressure

Question 34

Treatment for stress incontinence

Answer 34

General:
 Behavioural therapy (fluid advice)
 Pelvic floor exercise +/- biofeedback
 Pharmacotherapy (not first line)

Surgery
 To restore the bladder neck back to the intra- abdominal pressure zone; and/or
 To increase outflow resistance

Question 35

Treatment options for detrusor overactivity

Answer 35

General:
 Behavioural therapy: deferment technique, bladder retraining
 Pelvic floor exercise
 Pharmacotherapy:
1. Beta-3 adrenoceptor agonist (mirabegron)
2. Anti-muscarinic agents (e.g. oxybutynin, tolterodine, solifenacin)

Surgery:
 Inject Botox into bladder every 6-9 months
 Bladder augmentation