JC104 (O&G) - Urinary Incontinence in Females, Genital Prolapse Flashcards
Female pelvic floor structures
Structures connected to bony pelvis:
- peritoneum, pelvic viscera, endopelvic fascia, levator ani muscles, perineal membrane, superficial genital muscles
Function of levator ani muscles
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
3 major function of the pelvic floor
- Support for viscera
- Sphincteric control
- Sexual function
Mechanisms of pelvic viscera support
- Constriction: muscles at outlet of pelvic cavity
- Suspension: ligaments hold viscera in position
- 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
Define the 3 compartments of the female pelvic space
Anterior = Bladder and urethra
Central/ Apical = Uterus, vagina
Posterior = Rectum
Define the 3 levels of pelvic floor support
Effect of damage to each level
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
Level 1 pelvic support
- Supporting structures/ ligaments
- Organs attached to pelvic sidewalls
- Effect of damage
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
Level 2 pelvic support
- Supporting structures/ ligaments
- Organs attached to pelvic sidewalls
- Effect of damage
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
Level 3 pelvic support
- Supporting structures/ ligaments
- Organs attached to pelvic sidewalls
- Effect of damage
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
Structures in the lower urinary tract that maintain continence
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
Describe the role of the pelvic floor in maintaining urinary continence
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»_space;> stress incontinence
Define the integral theory of the female pelvic floor
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
Most common anatomical anomaly that causes stress incontinence in females
Poor support of proximal urethra and bladder neck
- Vaginal delivery damaged pelvic floor muscles, ligaments, fascia
- weakened pelvic floor support to proximal segment of urethra and bladder neck
- descent of bladder neck outside the zone of intraabdominal pressure - hypermobility of bladder neck
- If the proximal urethra prolapses beyond the pelvic floor, the pressure is transmitted
to the bladder but not the proximal urethra»_space;> incontinence
Detrusor overactivity
- Possible etiologies
Urethral outflow obstruction, ?primary urethral pathology
Poor potty training/ childhood nocturnal enuresis
Altered contractile activity of detrusor cells
Factors that adversely affect pelvic floor function
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)
Organ prolapse definition
Prolapse = protrusion of an organ/ structure outside its normal anatomical boundaries
Genital prolapse
- Clinical presentation: S/S, aggravating and relieving factors, associated symptoms…etc
- COmplication
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»_space; hydroureter and hydronephrosis»_space; renal damage
Structures that may prolapse through female pelvis
Anterior compartment = cystourethrocele
Central compartment = uterine or vault prolapse
Posterior compartment = rectocele
3 Grading systems for severity of female genital prolapse
- 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
- Pelvic organ prolapse quantitation (POP-Q): Measure 9 different points
- Ordinal staging system: prolapse relative to hymen
Define the measurement points in Pelvic organ prolapse quantitation (POP-Q) for organ prolapse
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
Outline the ordinal staging system for female genital prolapse (not important)
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)
Genital prolapse P/E
- List of P/E
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
Pelvic exam for genital prolapse
- P/E positions
- List of tests
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
- Assess degree of descent in each compartment during straining (measure distance of prolapse beyond/ above hymen)
- Cough test (reduce prolapse to detect occult stress incontinence)
- Assess condition of vaginal wall
- Take cervical smear if indicated
- Uterine assessment
- Look for adnexal mass
Treatment options for pelvic organ prolapse in women
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
Ring pessary for pelvic organ prolapse in women
- Indication
- Effectiveness
- Cons
- Complications
- 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
Individualized pelvic floor muscle training
- Indication
- Drawbacks
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
Types of urinary incontinence
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)
Questions for ddx types of urinary incontinence
Outline history taking questions for urinary incontinence
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
Outline P/E and first-line investigations for urinary incontinence
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)
- MSU for routine, microscopy +/- culture (UTI)
- Urodynamic study: distinguish between anatomical or functional cause of incontinence/ confirm either USI or detrusor overactivity
Difference between dry vs wet over-reactive bladder
(dry OAB (frequency, urgency) vs. wet OAB (urgency, leakage))
Urodynamic study
- What is measured?
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)
Compare the different urodynamic results for stress incontinence and detrusor overactivity incontinence:
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
Treatment for stress incontinence
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
Treatment options for detrusor overactivity
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
