Transcript 8th Edition APGO Objectives for Medical Students

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:
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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
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Cystocele
Rectocele
Enterocele
Vaginal vault or uterine prolapse
Risk factors
Vaginal delivery
 Large baby
 Prolonged 2nd stage of labor
 Forceps
 Multiparous
Risk factors
Increased abdominal pressure
 Obesity
 Chronic constipation
 Chronic lung disease
Risk factors
Altered nerve function or tissue strength
 Diabetes
 Neurologic diseases
 Aging
 Collagen disorders
 Hypoestrogenism
 Pelvic surgery
Anatomy

Basic
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Levator ani muscles
• Pubococcygeuas
• Puborectalis
• Iliococcygeus

Viscerofascial layer
• Endopelvic fascia - attaches uterus and vagina to pelvic wall
• Parametria - cardinal and uterosacral ligaments
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Fascial defects
Neuromuscular pathophysiology
Signs and symptoms of pelvic
organ prolapse
Symptoms - prolapse
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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
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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
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Antagonist to increase smooth muscle tone
(phenylpropanolamine)
 Estrogen to increase urethral resistance
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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)
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Vaginal approach
• Anterior colporrhaphy (central defect)
• Paravaginal repair (lateral defect)
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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
colporraphy
 For enterocele
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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
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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 presentation
Physical 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 Studies
None
Diagnosis
Pelvic organ prolapse
Management plan
Management Plan
Patient 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, nonsurgical 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.