O&G JC104: I Felt A Lump Below: Urinary Incontinence In Females, Genital Prolapse

Question 1

Structure of Female Pelvic floor

Answer 1

Pelvic floor:
- broad term to include ALL structures supporting the pelvic cavity
- rather than Levator ani group of muscles
1. Peritoneum
2. Pelvic viscera
3. Endopelvic fascia
4. Levator ani muscles (i.e. Puborectalis, Pubococcygeus, Iliococcygeus)
5. Perineal membrane
6. Superficial genital muscles
—> all these are connected to bony pelvis

Question 2

***Function of Female Pelvic floor

Answer 2

Functions:
1. **Support (defect —> prolapse)
2. **Sphincteric (defect —> urinary + faecal incontinence)
3. Sexual

***Defective pelvic floor:
- Anatomically
or
- Neurologically
—> viscera cannot be maintained in normal position —> ↑ intra-abdominal pressure —> displaced
—> location of support defects will determine which structures will prolapse (Vagina / Bladder / Rectum)

RMB:
- In ALL forms of pelvic organ prolapse –> ***Primary problem is in Pelvic floor!!! (but NOT in the displaced organs)

Question 3

Support of viscera organs

Answer 3

Combination of:
1. Constriction
- ***contraction of muscles at outlet of pelvic cavity + sphincters

2. Suspension
   - ***suspensory ligaments
3. ***Structural geometry
   - posterior deviation of vaginal axis when ↑ intra-abdominal / pelvic pressure –> lessen force exerted on pelvic organ –> ↓ chance of genital prolapse

Question 4

***Structural prolapse of Female pelvis

Answer 4

1. Anterior compartment: Bladder
   - Cystocele (prolapsed bladder)
   - Urethrocele (prolapsed urethra)
2. Central / Apical compartment: Uterus
   - Uterine prolapse
   - Vault prolapse (vaginal wall prolapse)
   - Enterocele (prolapsed small bowel)
3. Posterior compartment: Rectum
   - Rectocele (prolapsed rectum)

Question 5

3 levels of support for Vagina by Pelvic floor

Answer 5

Level 1 (**Suspension):
- **Cardinal (Cervical) + **Uterosacral ligament
–> Suspend Uterus + Cervix + Upper vagina to pelvic sidewalls
–> Continues downward over Upper vagina to attach to pelvic sidewalls (Paracolpium)
- Damage: Uterine descent / Vaginal vault prolapse (i.e. **Central compartment prolapse)

Level 2 (**Attachment):
- **Parametrium + **Paracolpium attaches Mid-portion of Vagina to pelvic sidewall forming:
–> **Pubocervical fascia (ligament between bladder and vagina)
–> ***Rectovaginal fascia (ligament between rectum and vagina)
–> Support Bladder
- Damage: Cystocele, Urethrocele, Rectocele (i.e. Anterior / Posterior prolapse)

Level 3 (**Fusion):
- Distal vagina directly attached to surrounding structures without intervening Paracolpium
–> Anteriorly fused with **Urethra
–> Posteriorly fused with **Perineal body
–> Laterally fused with **Levator ani muscles
–> Support Rectum + Fix Vagina to adjacent structures
- Damage: Rectocele, Urethrocele, Perineal deficiency (i.e. Anterior / Posterior prolapse)

Question 6

Levator ani muscles

Answer 6

• Constant muscle tone (contraction) of pubococcygeal portion is responsible for holding the pelvic floor closed –> by coapting Urogenital hiatus
• Forms a relatively horizontal shelf on which pelvic organs are supported

Question 7

Structures involved in Continence

Answer 7

Intrinsic to Lower urinary tract:
1. Smooth muscles
2. Urethral CT
3. Urethral submucosal vascular plexus
4. Urethral mucosa

Extrinsic to Lower urinary tract:
1. CT support (Endopelvic fascia)
2. Muscular support (Levator ani muscles)
3. Striated ***urogenital sphincter

Question 8

Mechanisms that lead to incontinence

Answer 8

1. **Hypermobility of Bladder neck
   - **Loss of proper pelvic floor support to **Bladder neck + **Urethra
   –> Descent of bladder neck outside the zone of intra-abdominal pressure
   –> Proximal urethra now not above pelvic floor
   –> Abdominal pressure only exerts on bladder (originally exert on urethra as well to close it)
   –> Incontinence
2. ***Intrinsic sphincter deficiency
   - Loss of urethral closure function despite normal anatomical support to bladder neck

Integral theory:
- an interrelated + dynamic anatomical framework for understanding pelvic floor function + dysfunction
- fundamental principle: **Restoration of structure –> Restoration of function
- symptoms of stress, urge, abnormal emptying mainly derived from laxity in vagina / its supporting ligaments, a result of altered CT
- **imbalance of force between vagina and ligaments (anterior vs posterior force)
–> pull open urethra
–> once intra-abdominal pressure ↑
–> incontinence

• Portion of Pelvic floor that support + surround lower urinary tract is important to maintain urinary continence
• Important structures that support urethra + bladder neck have their attachment to the ***paraurethral tissues
• Poor support of Proximal urethra + Bladder neck: most common cause of stress incontinence

Question 9

Detrusor overactivity in incontinence

Answer 9

Pathophysiology:
- unknown
- usually **idiopathic
- associated with:
–> **Urethral outflow obstruction
–> Poor potty training / Childhood nocturnal enuresis
–> Primary urethral pathology?
–> ***Altered contractile activity of detrusor cells

Question 10

***Risk factors that adversely affect Pelvic floor function

Answer 10

1. **Vaginal delivery (most common)
   - >90% prolapse being parous
   - esp. **instrumental delivery + **macrosomic baby + **long 2nd stage labour
   - vaginal birth damage Pelvic floor muscles, ligaments, fascia –> ***Pudendal nerve damage

Other factors:
2. **Menopause (∵ Lack of estrogen)
3. ↑ Age
4. **Obesity (∵ ↑ abdominal pressure)
5. **Chronic cough / constipation (∵ ↑ abdominal pressure)
6. **Occupational stress (∵ ↑ abdominal pressure)
7. Congenital weakness of CT (e.g. Marfan’s) (lead to young presentation of genital prolapse e.g. 50s)
8. Prior hysterectomy (∵ suspensory ligaments ligated)
9. ***Racial factor (whites > blacks)

Question 11

Genital prolapse

Answer 11

Protrusion of an organ / structure outside of its normal anatomical boundaries (protrude out of vagina)

Prevalence:
- ***~50% parous women have prolapse, 20% symptomatic
- Vaginal vault prolapse:
–> up to 2% of women who had hysterectomy for benign diseases
–> but up to 12% when hysterectomy performed for prolapse

Classification:
1. Anterior compartment: Bladder
- Cystocele (prolapsed bladder)
- Urethrocele (prolapsed urethra)

2. Central / Apical compartment: Uterus
   - Uterine prolapse
   - Vault prolapse (vaginal wall prolapse)
   - Enterocele (prolapsed small bowel)
3. Posterior compartment: Rectum
   - Rectocele (prolapsed rectum)

Question 12

Degree of Genital prolapse

Answer 12

Many grading systems but none ideal

Degree of uterine descent: described by relative position of **Cervix to **Introital opening during maximal straining

1st degree:
- Cervix down into Vagina below ischial spine but not as far as Introitus

2nd degree:
- Cervix down to Introital opening / just beyond

3rd degree:
- Cervix + Uterine body both beyond Introitus

**POP-Q (Pelvic Organ Prolapse Quantitation)
- measure 9 points to describe severity of genital prolapse
–> gh (genital hiatus): Hymen (as reference level: at this level: 0, below this level: +, above this level: -) (middle of urethral meatus to posterior midline hymen)
–> **Ba: Anterior vagina wall / **Cystocele (normal: -3)
–> **Bp: Posterior vagina wall / **Rectocele (normal: -3)
–> **C: Cervix / ***Central compartment prolapse
–> D: Posterior fornix
–> Aa: 3cm proximal to the external urethral meatus (-3 to +3)
–> Ap: Posterior vaginal wall, 3cm proximal to hymen (-3 to +3)
–> tvl (total vagina length): Greatest depth of vagina when C / D is reduced to its full normal position
–> pb (perineal body): Posterior margin of genital hiatus to midanal opening

Ordinal stages:
0: no prolapse
1: >1 cm above hymen
2: <=1 cm proximal / distal to hymen
3: >1 cm distal to hymen but no further than tvl -2 cm
4: >= tvl -2 cm

Question 13

***Clinical presentations of Genital prolapse

Answer 13

Very variable in magnitude + Depend on sites of involvement
1. A bulge of tissue seen / felt that protrude to / past Introitus (**most specific symptom)
2. Anterior prolapse: **Urinary symptoms (e.g. **difficulty in urination, slow stream)
3. Posterior prolapse: **Bowel symptoms (e.g. **splinting)
4. Non-specific symptoms e.g. Pelvic pressure / Back pain –> cannot assume that they can be alleviated with prolapse treatment
5. **Bleeding (e.g. Post-menopausal bleeding due to ulcer by prolapse)
6. May be asymptomatic

Question 14

***History taking of Genital prolapse

Answer 14

Lump (SpC OG):
1. Duration
2. Size
3. **Reducible
4. **Provocative / Relieving factors
- Increase in intraabdominal pressure (e.g. cough)
5. Associated symptoms (e.g. Urinary incontinence)
- Stress vs Urge
- **Urinary symptoms: e.g. Voiding frequency, Nocturia
- **Bowel symptoms: e.g. Constipation
- ***Fluid intake
- Double voiding
6. Treatment received

Presence of risk factors
1. Defect in pelvic floor
- **Vaginal delivery (most common)
–> **instrumental delivery
–> **macrosomic baby
–> **long 2nd stage labour
–> **perineal tear
- **Menopause (∵ Lack of estrogen)
- **↑ Age
- **Obesity (∵ ↑ abdominal pressure)
- **Chronic cough / constipation (∵ ↑ abdominal pressure)
- **Occupational stress (∵ ↑ abdominal pressure)
- Congenital weakness of CT (e.g. Marfan’s) (lead to young presentation of genital prolapse e.g. 50s)
- Prior hysterectomy (suspensory ligaments ligated)
- ***Racial factor (whites > blacks)

2. **Concomitant stress urinary incontinence
   –> prolapse may **mask severity of incontinence (∵ urethra kinked / urethral opening obstructed)
   –> when prolapse reduced –> incontinence present again (no obstruction of urethral opening)
3. **Renal damage (Hydronephrosis, Hydroureters) / **Urinary retention
   –> occur in presence of severe genital prolapse (∵ ureteric obstruction)

Question 15

***Physical examination of Genital prolapse

Answer 15

1. ***BMI
2. Respiratory system (***chronic cough)
3. Abdominal examination
   - Abdominal / Pelvic mass
4. Pelvic examination
   - Lithotomy position
   - Left lateral position / Sims (right knee raised above left knee, using **Sims speculum to retract anterior + posterior vaginal wall) (Bivalve speculum can only examine central compartment ∵ blade will press against anterior + posterior wall —> cannot see anterior + posterior vaginal wall)
   - Assess:
   —> **Degree of descent in each compartment during straining
   —> **Condition of vaginal wall (Estrogenisation, lack when menopause —> petechiae / pale colour of vagina)
   —> **Any ulcers caused by prolapse (SpC)
   —> Take Cervical smear if indicated
   —> ***Uterine assessment (e.g. uterine mass)
   —> Look for adnexal mass

Question 16

***Treatment of Genital prolapse

Answer 16

Observation (if asymptomatic / not bothered by symptoms)

Conservative: (if symptomatic but decline surgery / unfit for surgery / as a temporary measure while awaiting surgery)
1. **Ring pessary
- size chosen so that it gives support to prolapsed organ but does not cause discomfort
- measure from **posterior fornix to **pubic symphysis
- complications: **pressure ulcer, **bleeding, **infection with discharge, **chance of fall out
- following: need to see if patient can urinate
- change every **6 months
- effective in 60% (gh size ↓ significantly), but no consensus on use of different types of ring pessary, indications not pattern of replacement / follow-up care

2. ***Pelvic floor muscle training
   - effective for reducing prolapse symptoms
   - but lack long-term data about long-term benefits

Surgery:
- more definitive
- aim to restore vaginal anatomy + function
- usually through vaginal route
- under regional / general anaesthesia
- nature of surgery depends on organ prolapsed
- beware of common association of **stress urinary incontinence which may require surgical treatment on its own
1. **Uterine prolapse
- **Vaginal Hysterectomy (for accessing ligaments for repair) + **Pelvic floor repair
- **Sacrohysteropexy (rare) (子宮頸薦骨後壁固定術)
- **Colpocleisis (SpC OG) (陰道閉合術)
- Amputation of cervix (Manchester operation)

2. **Vault prolapse (SpC OG)
   - **Sacrospinous ligament fixation (薦骨坐骨棘韌帶懸吊術)
   - **Sacrocolpopexy (陰道薦骨後壁固定術)
   - **Colpocleisis
3. Cystocele: **Anterior vaginal wall repair (*Anterior colporrhaphy) (陰道前壁修補術)
4. Rectocele: **Posterior vaginal wall repair (*Posterior colporrhaphy) (陰道後壁修補術)

Question 17

Urinary incontinence (UI)

Answer 17

Complaint of any involuntary leakage of urine

Prevalence:
- highly variable (∵ differences in definitions, method of enquiry, nature of population)
- 40% women stress urinary incontinence
- 20% urge urinary incontinence
- 15% mixed urinary incontinence
- seems ↑

Causes:
1. Stress incontinence (壓力性失禁)
2. Urge incontinence (急迫性失禁 / 過動性膀胱)
3. Mixed incontinence
4. Overflow incontinence (reduce in urge sensation, usually associated with neurological deficits)
5. Functional incontinence (normal urge sensation, but functional limitations e.g. stroke cannot make it to toilet)
6. Congenital anomalies
7. Fistula (esp. constant urinary leakage without aggravating / relieving factors) (e.g. Vesico-vaginal fistula)

Question 18

***Diagnosis of Urinary incontinence

Answer 18

Clinical diagnosis:
1. Stress UI (壓力性失禁)
- Involuntary loss of urine on effort / physical exertion / sneezing / coughing
- UI when ***↑ abdominal pressure / physical activity

2. Urgency UI (急迫性失禁 / 過動性膀胱)
   - Overactive bladder (OAB)
   —> Dry OAB: Urinary frequency + urgency
   —> Wet OAB: Urinary frequency + urgency + leakage
   - Involuntary loss of urine associated with urgency
   - preceded with ***sudden urge sensation
   - urinary frequency
   - ↓ voiding interval
   - nocturia
3. Mixed UI
   - UI when ↑ abdominal pressure / physical activity
   - preceded with sudden urge sensation
   - urinary frequency
   - ↓ voiding interval
   - nocturia
4. Overflow UI
   - **↑ voiding interval
   - **sense of incomplete emptying (large residual volume)
   - cannot notice bladder is full
5. Transient UI (e.g. UTI)
   - dysuria / haematuria / suprapubic pain

Urodynamic diagnosis:
1. **Urodynamic stress incontinence
- Finding of **involuntary urine leakage during filling cystometry, associated with ↑ intra-abdominal pressure, in the absence of detrusor contraction

2. **Detrusor overactivity
   - Lower urinary tract symptoms when **involuntary detrusor muscle contractions occur during filling cystometry

Question 19

***History taking in Urinary incontinence

Answer 19

Irritative voiding symptoms:
1. **Frequency: >7 voids in daytime
2. **Urgency: sudden / strong desire to void
3. ***Nocturia: waking at night once / more to void
4. Urgency urinary incontinence

Additional:
1. UI when **↑ abdominal pressure / physical activity
2. ↑ / ↓ Voiding interval
3. **Sense of incomplete emptying
4. Cannot notice bladder is full
5. ***UTI symptoms: Dysuria / Haematuria / Suprapubic pain

Associated symptoms:
1. Any relation to **genital prolapse, urinary / bowel / sexual dysfunction —> Ask about risk factors for **defect in pelvic floor
- Vaginal delivery
- Menopause
- Obesity
- Occupation
- Chronic cough / constipation
- Age
- Congenital weakness of CT
2. Amount / Severity of leaking, effect on QOL
3. **Associated bowel symptoms e.g. **Faecal incontinence / **Constipation
4. **Fluid intake (caffeine containing beverage)
5. **Pad for protection
6. **Effect on daily life

Drug history:
1. Diuretics
2. Analgesics / **Cough suppressants (urinary retention)
3. **Anticholinergics (urinary retention)
etc.

Past medical history:
1. Chronic cough
2. Condition which affects mobility
3. Metabolic disease (e.g. DM, diabetes insipidus)
4. Neuropathy
5. CVS disease (e.g. fluid overload)

Past surgical history:
1. Surgery for pelvic organ prolapse / urinary incontinence (TVT, colposuspension)

Social history:
1. Occupation: Heavy manual work

Question 20

***P/E of Urinary incontinence

Answer 20

1. Abdominal examination
2. Pelvic examination
   - Uterine / Adnexal pathology
3. ***Cough test (to see any urine leakage)
   - may need reduction of prolapse to detect occult stress incontinence
4. Assess ***pelvic floor support + function (for each compartment)
5. ***Neurological examination
   - assess S2-4 nerve roots (innervate bladder)

NB: ***No specific clinical signs for detrusor overactivity

Question 21

***Investigations in Urinary incontinence

Answer 21

Initial investigations
1. ***Bladder diary
- amount of fluid intake
- amount of urine output
- frequency of voiding
- timing of UI

2. ***MSU
   - routine
   - microscopy +/- culture (to rule out UTI)

Further investigations
1. **Urodynamics (i.e. **Cystometry)
- confirm whether leakage was related to **Urodynamic stress incontinence (USI) / **Detrusor overactivity
- measurement of pressure-flow relationship between bladder and urethra
- 2 phases: storage / **filling phase + **voiding phase of bladder
- Cystometry: measure storage function and sensation of bladder at filling phase
—> filling catheter (record 1st desire to void —> 可以忍 —> strong urge —> 忍唔到)
—> bladder pressure catheter (measure bladder pressure change)
—> vaginal / rectum pressure catheter (measure intra-abdominal pressure)
—> ***Bladder pressure - Intra-abdominal pressure = Detrusor pressure (normally 0 / slowly ↑ during water infusion)

USI:
- **stable detrusor pressure
- urine leakage during **↑ intra-abdominal pressure (in absence of detrusor contraction)

Detrusor overactivity:
- **unstable detrusor pressure / **involuntary detrusor contractions (spontaneous / provoked) during filling phase
- urine leakage due to detrusor contraction
- ***no ↑ intra-abdominal pressure during urine leakage

Question 22

***Treatment of Urodynamic stress incontinence

Answer 22

Initial management:
1. Behavioural therapy
- **smoking cessation
- **weight reduction
- **reduce caffeine intake
- **fluid intake advice (drinking ***200ml at regular interval, total 1.5-2L per day) (8 glasses of water is a myth!!!)

Conservative:
1. Behavioural therapy
2. **Fluid advice
3. **Physiotherapy: ***Pelvic floor exercise +/- biofeedback (mind-body technique that involves using visual or auditory feedback to gain control over involuntary bodily functions)
4. Drugs (not 1st line)

Surgery:
1. **Restore bladder neck back to intra-abdominal pressure zone
- **Sling / **TVT (Tension-Free Vaginal Tape) / **Artificial urinary sphincter
2. ***↑ Outflow resistance
- Bulking agents
3. Both

Question 23

***Treatment of Detrusor overactivity incontinence

Answer 23

Initial management:
1. Behavioural therapy
- **smoking cessation
- **weight reduction
- **reduce caffeine intake
- **fluid intake advice (drinking ***200ml at regular interval, total 1.5-2L per day) (8 glasses of water is a myth!!!)

Specific management:
1. Behavioural therapy
- Deferment technique and ***bladder retraining –> try to hold urine when have urge sensation (15-30s)

2. ***Fluid advice
3. ***Pelvic floor exercise
4. Drugs
   - Anti-muscarinic e.g. **Oxybutynin, **Tolterodine, **Solifenacin (SE: dry mouth, dry eyes, constipation, CI in glaucoma)
   - **β3 agonist: Mirabegron (no above SE, only CI in uncontrolled severe high BP)
5. Surgery
   - only in refractory cases
   - **Botox injection into bladder –> ↓ detrusor muscle contraction –> ↑ bladder capacity
   - SE: urinary retention, long effect (6-9 months)
   - **Bladder augmentation (only for very refractory cases)

Question 24

Role of primary care

Answer 24

Patients usually do not volunteer incontinence symptoms
- embarrassment
- accept as part of ageing and childbirth
- not aware that treatment is available
- symptom not troublesome enough

Always take note of symptoms and refer if indicated

Question 25

Summary

Answer 25

• Weakened pelvic floor support is the basic pathophysiology
• Vaginal childbirth is the single most important risk factor
• ***Common associations of prolapse and urinary incontinence in elderly women
• Rmb the possibility of ***occult SI in case of severe prolapse
• Conservative treatment available but rarely curative
• if surgery indicated, both prolapse and continence surgery may be required in the same setting

Question 26

SpC OG video: Multichannel filling and voiding cystometry (aka Urodynamic)

Answer 26

Indications:
1. Symptoms / Past history of voiding difficulty
2. Mixed symptoms + Cystocele considering surgery (perform investigation with ring pessary in-situ if possible)
3. Pure stress incontinence with failed physiotherapy (rule out undiagnosed detrusor overactivity)
4. Pure urge symptoms with failed bladder training and anticholinergic (rule out undiagnosed stress incontinence)
5. Failed continence surgery

Before cystometry:
1. Calibration of instrument
2. Review patient’s symptoms + exclude active UTI
3. Explain test to patient
4. Perform free uroflowmetry
5. Check initial residual urine volume (normal <50ml)
6. Insert filling line + vesical pressure recording line to bladder
7. Insert abdominal pressure recording line to rectum

During cystometry:
1. Bladder filled with sterile warm water at a rate of 80ml/min
- 1st desire to void (normal: 150-200ml)
- Normal desire (a person would stop work and go to toilet: 350-400ml)
- Maximum cystometry capacity (a patient cannot tolerate any more fluid: 450-500ml)
2. Remove filling line
3. **Supine cough test (test for stress leak)
4. Ask patient to stand with legs widely apart
5. Transducer adjusted to level of pubic symphysis
6. **Erect cough test
7. Sit down on uroflow commode and adjust level of transducer
8. Start of voiding cystometry

Voiding cystometry:
- Uroflowmetry curve: normal bell shape, only meaningful if voided volume >150ml

Pathologies:
1. Outflow obstruction
- High detrusor pressure, Low flow
- Evidence of abdominal straining

2. Atonic bladder
   - Filling cystometry: Very late first desire to void (>400-500ml) + Large maximum cystometry capacity (>650-750ml)
   - Voiding cystometry: Low detrusor pressure + Low flow