Pelvic Relaxation Flashcards
The pelvic floor is made up of the ____ and _______
diaphragm and perineal membrane
The pelvic diaphragm consists of the _____ and ______
levator ani and coccygeus muscles.
This is a triangular sheet of dense fibromuscular tissue that spans
the anterior half of the pelvic outlet. The vagina and the urethra pass through this
Perineal membrane.
The main structures that support the uterus are the
1
2
3
cardinal ligaments, the uterosacral ligaments, and the endopelvic fascia.
The etiology of pelvic relaxation is most commonly related to _____
childbirth
Types of pelvic relaxation
The components of pelvic relaxation include uterine prolapse, cystocele, rectocele,
and enterocele.
Lesser forms of pelvic relaxation include vaginal or vault prolapse.
Grades of uterine prolapse
– Grade I: Cervix descends half way to the introitus.
– Grade II: Cervix descends to the introitus.
– Grade III: Cervix extends outside the introitus.
– Grade IV or procidentia: The entire uterus, as well as the anterior and posterior
vaginal walls, extends outside the introitus
Herniation or bulging of the anterior vaginal wall and overlying bladder base into the vaginal lumen
Cystocele
Herniation or bulging of the posterior vaginal wall and underlying rectum into the vaginal lumen
Rectocele
Herniation of the pouch of Douglas containing small bowel into the vaginal lumen
Enterocele
Mx of prolapse
______involve voluntary contractions of the pubococcygeus muscle
Kegel exercises
Mx of prolapse
______may be useful in postmenopausal women.
Estrogen replacement
Mx of prolapse
_____ are objects inserted into the vagina that elevate the pelvic structures into their more normal anatomic relationships
Pessaries
Mx of Prolapse
The _____ repairs the uterine prolapse, the anterior vaginal repair repairs the cystocele,
and the posterior vaginal repair repairs the rectocele.
vaginal hysterectomy
The _______ uses the endopelvic fascia that supports the bladder and the rectum, and a
plication of this fascia restores normal anatomy to the bladder and to the rectum
anterior and posterior colporrhaphy
Urinary incontinence is the inability to hold urine, producing involuntary urinary
leakage.
URINARY INCONTINENCE
These are found primarily in the urethra and when stimulated cause contraction of urethral smooth muscle, preventing micturition
a-adrenergic receptors
a-adrenergic receptors agonists
Drugs: ephedrine, imipramine (Tofranil), and estrogens
a-adrenergic receptors antagonists
relax the urethra, enhancing micturition. Drugs: phenoxybenzamine (Dibenzyline).
These are found primarily in the detrusor muscle and when stimulated cause relaxation of the bladder wall, preventing micturition
b-adrenergic receptors.
b-adrenergic receptors agonst.
Drugs: flavoxate (Urispas) and progestins.
These are found primarily in the detrusor muscle and when stimulated cause contraction of the bladder wall, enhancing micturition
Cholinergic receptors
Cholinergic receptor agonists
Drugs:bethanecol (Urecholine) and neostigmine (Prostigmine)
Anticholinergic medications
block the receptors, inhibiting micturition. Drugs:_________
oxybutynin (Ditropan) and propantheline
Pro-Banthine
A urinary catheter is first used to empty the bladder and then left in place to infuse saline by gravity, with a syringe into the bladder
Cystometric studies
What is measured in Cystometric studies
Residual volume
Sensation-of-fullness volume
Urge-to-void volume
How to assess involuntary bladder contractions
By watching the saline level in the syringe rise or fall, involuntary detrusor contractions can be detected.
The absence of contractions is normal
Involuntary rises in bladder pressure occur owing to detrusor contractions
stimulated by irritation from any of the following bladder conditions: infection, stone,
tumor, or a foreign body
Sensory Irritative Incontinence
Sensory Irritative Incontinence
Cystometric studies (which are usually unnecessary) would reveal
normal residual volume with involuntary
detrusor contractions present.
This is the most common incontinence in young women.
Genuine Stress Incontinence
History of pts with Genuine Stress Incontinence
Loss of urine occurs in small spurts simultaneously with coughing or sneezing.
It does not take place when the patient is sleeping
Genuine Stress Incontinence Q tip test results
The Q-tip test is positive when a lubricated cotton-tip applicator is placed in
the urethra and the patient increases intraabdominal pressure, the Q-tip will rotate
>30 degrees.
Genuine Stress Incontinence Stress test results
Cystometric studies are normal with no involuntary detrusor contractions seen.
Mx of Genuine Stress Incontinence
Surgical therapy aims to elevate the urethral sphincter so that it is again an intraabdominal location (urethropexy
Procedures of (urethropexy)
This is done by attachment of the
sphincter to the symphysis pubis, using the Burch procedure as well as the Marshall-
Marchetti-Kranz (MMK) procedure.
Minimally invasive procedure for genuine stress incontinence
A minimally invasive surgical procedure is the tension-free vaginal tape procedure
in which a mesh tape is placed transcutaneously around and under the mid
urethra
_____This is the most common incontinence in older women.
Motor Urge (Hypertonic) Incontinence.
Motor Urge (Hypertonic) Incontinence Etiology
Involuntary rises in bladder pressure occur from idiopathic detrusor contractions
that cannot be voluntarily suppressed
Cystometric studies of Motor Urge (Hypertonic) Incontinence
Cystometric studies show normal residual volume, but involuntary detrusor contractions are present even with small volumes of urine in the bladder.
Mx of Motor Urge (Hypertonic) Incontinence
Anticholinergic medications (e.g., oxybutynin [Ditropan]); nonsteroidal antiinflammatory drugs (NSAIDs) to inhibit detrusor contractions; tricyclic antidepressants; calcium-channel blockers
Rises in bladder pressure occur gradually from an overdistended, hypotonic
bladder.
When the bladder pressure exceeds the urethral pressure, involuntary urine
loss occurs but only until the bladder pressure equals urethral pressure
Overflow (Hypotonic) Incontinence
Overflow (Hypotonic) Incontinence causes
This may be caused by denervated
bladder (e.g., diabetic neuropathy, multiple sclerosis) or systemic medications (e.g.,
ganglionic blockers, anticholinergic
History Overflow (Hypotonic) Incontinence
Loss of urine occurs intermittently in small amounts. This can take place
both day and night. The patient may complain of pelvic fullness.
Neuro exam of pts with Overflow (Hypotonic) Incontinence
however, the neurologic examination will show decreased pudendal nerve sensation.
Overflow (Hypotonic) Incontinence
Cystometric studies show
markedly increased residual volume, but involuntary detrusor contractions do not occur
Mx of overflow incontinence
Intermittent self-catheterization may be necessary. Discontinue the offending systemic medications.
Cholinergic medications to stimulate bladder contractions and a-adrenergic blocker to relax the bladder neck
The patient usually has a history of radical pelvic surgery or pelvic radiation
therapy.
Loss of urine occurs continually in small amounts. This can take place both
day and night
Fistula
Dx of Fistula
An intravenous pyelogram (IVP) will demonstrate dye leakage from a urinary tract fistula
