GYNEPrelims - Urogynecology

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AUFMED

Dr. Armando L. Gopez, M.D. | July 09, 2015 | GYNECOLOGY

OUTLINE: − Urogynecology − The Pelvic Floor − Common Pelvic Floor Disorders − Urinary Incontinence o Stress Incontinence o Genuine Stress Incontinence o Urge Incontinence o Mixed Incontinence o Dyssynergic Bladder o Over-active Bladder o Overflow Incontinence o Functional Incontinence − Therapy Urinary Incontinence o Bladder Training o Kegel’s Exercises − Pelvic Organ Prolapse o Uterine Prolapse o Cystocele o Rectocele Objectives: The student must demonstrate knowledge of the following:  Predisposing factors for urinary incontinence and pelvic organ prolapse  Anatomic changes, fascial defects, and neuro-muscular pathophysiology  Signs and symptoms of urinary incontinence and pelvic organ prolapse  Physical Examination –  Urinary Incontinence  Cystocele  Rectocele  Uterine Prolapse • • • • •

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UROGYNECOLOGY Urogynecology is a surgical subspecialty of urology and gynecology Urogynecology involves the diagnosis and treatment of urinary incontinence and female pelvic floor disorders It is dedicated to treatment of women w/ pelvic floor disorders like urinary or fecal incontinence & prolapse of vagina, bladder &/or uterus Incontinence and pelvic floor problems are remarkably common but many women are reluctant to receive help because of the stigma associated with these conditions Pelvic floor conditions are more common than hypertension, depression, or diabetes – − One in three adult women have hypertension − One in ten adult women have diabetes − More than one in two adult women suffer from pelvic floor dysfunction. Urinary incontinence – affecting at least 10-20% of women under 65 yrs; up to 56% over 65 yrs Prolapse – means displacement from normal position Prolapse & incontinence frequently occur together; both are believed the result from damage to the pelvic floor after delivery Diagnostic tests and procedures performed: − Cysto-Urethroscopy − Urodynamic Testing − Ultrasound

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UROGYNECOLOGY PELVIC FLOOR

Pelvic floor is a term to describe the muscles, ligaments and connective tissue that provide support for internal organs (bladder, uterus, & rectum) • Functions: − Prevents the organs from falling down or out − Play a role in making these organs function properly • The brain controls the muscles by way of nerves; any conditions of injuries that impair the nerves like Alzheimer’s, back injury or stroke can result in weakness of the muscles The main support of the pelvic floor is the LEVATOR ANI MUSCLE. Although named such, this structure is made up of three (3) important individual components: a. Puborectalis b. Pubococcygeus c. Iliococcygeus The PELVIC DIAPHRAGM is composed of the LEVATOR ANI MUSCLE and the COCCYGEUS MUSCLE.          

COMMON PELVIC FLOOR DISORDERS Urinary Incontinence – leakage of urine Stress Incontinence – involuntary loss of urine during activities Urge Incontinence – involuntary loss of urine preceded by strong urge (over-active bladder) Dysuria – painful urination Urgency – powerful need to urinate immediately Urinary Frequency – more than every 2 hrs (more than 7x) Nocturia – urinate after waking up frequently Cystocele – prolapse/bulging of bladder into vagina Rectocele – prolapse of rectum into vagina Uterine Prolapse – descent of uterus into vagina

The pelvic floor disorders are most commonly observed during the early period of menopause, usually around the 4th to 5th decade of life. WHY? Loss of estrogen plays a role in the maintenance of the strength of the bones (prevention of bone resorption; without estrogen, the bones become pliable, and ligamentous connections of the levator ani become weakened).

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URINARY INCONTINENCE Defined as unintentional loss of urine that is sufficient enough in frequency & amount to cause physical &/or emotional disturbances − Also defined as involuntary loss of urine that is objectively demonstrable Another definition is leakage of urine thru urethra after sudden increase in abdominal pressure (coughing, sneezing, etc.) that is so social & hygienic problem & is objectively demonstrated − The intra-vesical pressure rises higher than the pressure that urethral pressure mechanism can w/ stand It is a symptom & NOT a diagnosis − Not a part of aging & not trivial complaint − It is almost always treatable o This means one or more other problems cause urinary leakage o Some common bladder and pelvic floor disorders are Pelvic Organ Prolapse (POP), urinary tract infections, interstitial cystitis (IC) and bladder tumors and cancer − It is a common and distressing problem, which may have a large impact on quality of life − Urinary incontinence is often a result of an underlying medical condition − Enuresis is often used to refer to urinary incontinence primarily in children When is urinary incontinence a point of concern? WHEN it causes anxiety to the patient resulting to possible social embarrassment. Principle of investigation involve – o History taking o Physical examination o Urinalysis – w/ urine culture & cytology There are four main types of incontinence: − Urge Incontinence due to an overactive bladder o The leakage of large amounts of urine at unexpected times, including during sleep. − Stress Incontinence due to poor closure of the bladder o The leakage of small amounts of urine during physical movement (coughing, sneezing, exercising). − Overflow Incontinence due to either poor bladder contraction or blockage of the urethra o Unexpected leakage of small amounts of urine because of a full bladder − Functional Incontinence due to medications or health problems making it difficult to reach the bathroom o Untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet Incidence – more frequent than men; 1 in 10 women under 65 yrs; 20% of women over 65 Symptoms: − Mostly on parous women

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Involuntary loss of urine in spurt associated w/ stress, i.e.- coughing, running, etc. − Show degree of cystocele/rectocele Major Categories: − Over incontinence − Stress incontinence − Urge incontinence − Functional incontinence − Reflex incontinence Urinary incontinence may be broadly classified according to its causes: − Trans-Urethral Cause o Genuine stress incontinence or urethral sphincter incompetence – the most common cause o Detrusor instability – can have neurological basis o Urethral instability – loss of urethral pressure seen in the absence of detrusor instability; w/c is rare o Urinary retention w/ over-flow – common in elderly o Congenital anomalies – common in infants; epispadias o Functional − Extra-Urethral Cause o Congenital dx at childhood; bladder extrophy o Fistulas – ureteric, vesical; urethral; complex The 3 most common types of incontinence: − Stress urinary incontinence (SUI) - is the complaint of involuntary leakage of urine during activities such as on effort or exertion, or on sneezing or coughing or laughing. − Urge urinary incontinence (UUI) - is the complaint of involuntary leakage accompanied by or immediately preceded by the urge to urinate (urgency) − Mixed urinary incontinence (MUI) - is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing which is a combination of stress and urge urinary incontinence Epidemiology − Prevalence of 25 – 55% − Stress incontinence – prevalent on ambulatory women; 29 - 75% − Detrusor over-activity – up to 33% of incontinence − Remaining incontinence to mixed forms − Incontinence can impair the quality of life, leading to disrupted social relationships; psychological distress from embarrassment; urinary tract infection Causes depends upon the types of incontinence: − The most common types of urinary incontinence in women are stress urinary incontinence and urge urinary incontinence − Stress Urinary Incontinence is caused by loss of support of the urethra which is usually a consequence of damage to pelvic support structures as a result of childbirth o It is characterized by leaking of small amounts of urine with activities which

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increase abdominal pressure such as coughing, sneezing and lifting − Urge Urinary Incontinence is caused by uninhibited contractions of the detrusor muscle o It is characterized by leaking of large amounts of urine in association with insufficient warning to get to the bathroom in time Causes – wide variety of physical conditions – − Childbirth – can weaken the pelvic muscles & the bladder lose some support from muscles − Dysfunction of bladder &/or urinary sphincter – normally, when bladder contracts, bladder sphincter opens & urine exits; here, bladder contraction & dilatation of sphincter do not occur at the same time − Hysterectomy (other surgery) – surgery involving GU tract runs the risk of damaging or weakening the pelvic muscles causing incontinence − Neurological conditions – CNS sends signal to bladder telling it when to start & stop emptying\ − Menopause – absence of estrogen in postmenopausal women can cause bladder to drop − Enlarge prostate (male) – can obstruct the bladder causing over-flow incontinence Risk Factors: − Age − Pregnancy/childbirth − Menopause − Obesity − Smoking & chronic lung diseases − Hysterectomy Physical examination involves: • Full P.E. is required but concentrate on:  Gynecologic  Urologic  Neurologic • Testing of S2 – S4 nerves is important as incontinence may have neurologic origin • Assessments of mental state is useful • Ascertain if patient is suitable for behaviour modifications or conservative Rx that require comprehension & motivation • When contemplating surgery, integrity of pelvic floor & degree of atrophy are important for prognosis • Gynecologic exam should include:  Sim’s done when patient is standing  Position on her left side  Determine concomitant pathology  Urethra is observed while patient cough; also inspect for presence of caruncle or mucosal prolapse • Q-tip test: assess for integrity of the lig. Supports of the proximal urethra & determine the presence of urethral hyper-motility:  Sterile lubricated cotton swab is placed into bladder neck  At rest on lithotomy position, urethra (thus, the swab) assume a 00 angle to the horizontal plane  Patient is asked a Valsalve manuever; if proximal urethra is normally supported, straining

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displaces the distal end of swab only slightly Pathophysiology • Bladder is a storage organ of urine w/ capacity to accommodate large volume of urine w/ minimal or no increase intra-vesicle pressure • Continence requires complex coordination that include muscle contraction & relaxation, connective tissue support, & integrated innervation & communications between these structures  URINARY INCONTINENCE • During filling, urethral contraction is coordinated w/ bladder relaxation & urine is stored & vice-versa in voiding • These mechanisms can be challenged by –  Uninhibited detrusor contractions  Marked increase in intra-abdominal pressure  Changes to various anatomic components of the continence mechanisms  URINARY INCONTINENCE Mechanism of Micturition • Continence and micturition involve a balance between urethral closure and detrusor muscle activity • Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder • Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence • Normal voiding is the result of changes in both of these pressure factors: urethral pressure falls and bladder pressure rises • During urination, detrusor muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra • At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body • Incontinence will occur if the bladder muscles suddenly contract (detrusor muscle) or muscles surrounding the urethra suddenly relax (sphincter muscles). Diagnosis • A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced • The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations • A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles –  Stress test  Urinalysis  UTZ  Cystoscopy  Uro-dynamics

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FREQUENCY VOLUME CHART Volume voided give an indication whether voiding is premature or whether there is a true diuresis; ascertain by amount and type of fluid drunk Prone to drinking large amount of fluid, especially tea or coffee, result in frequency of urination URO-FLOWMETRY It measures rate of urine flow & the most important Dx variable is the peak flow rate Peak flow rate declines w/ age; rough guide peak flow in excess 15 mL/sec are accepted normal; but prior to voiding, the bladder must contain more than 200 mL, otherwise the detrusor is not able to develop adequate contraction o After voiding, residual should be less than 50 mL; if greater than 100 mL, regard as abnormal URO-DYNAMIC TEST The bladder must be full Urinate into a container, the volume of urine and the rate at which the bladder empties are measured Catheter is then inserted into the bladder through the urethra, and the volume of any urine remaining in the bladder is measured (post-void residual, or PVR) Bladder is filled with water through the catheter until you have the first urge to urinate. o The amount of water in the bladder is measured at this point, and more water is added while you resist urinating until involuntary urination occurs Normal - The amount of fluid left in the bladder after urinating, when you feel the urge to urinate, and when you can no longer hold back urine are within normal ranges Abnormal - One or more of the following may be found: o More than a normal amount of fluid remains in the bladder after urinating. − A large volume of urine remaining in the bladder suggests the flow of urine out of the bladder is partially blocked or the bladder muscle is not contracting properly to force all the urine out (overflow incontinence). o The bladder contains less fluid or more fluid than is considered normal when the first urge to urinate is felt. o Unable to retain urine when the bladder contains less than the normal amount of fluid for most people.

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Any changes that occur in the intra-abd. pressure will also be reflected in the intravesical pressure; done by measuring pressure inside upper third of vagina & rectum o Detrusor pressure = intra-vesical pressure minus intra-abdominal pressure − Incontinence due to detrusor instability operations design to elevate the bladder neck is contra-indicated because – • Anatomical repositioning of the bladder neck is not required • Surgery at level of bladder neck often results in worsening of the instability • Primary objective is to exclude detrusor instability & the mainstay of the basic urodynamic studies is cytometry Prognosis: • If untreated – can cause emotional & physical upheaval; affect self-esteem & cause depression • Long term incontinence – GU infection; skin rashes • w/ variety of Rx, the prognosis is promising; if it cannot be stopped, it can be improved Prevention: • Kegel or PC muscle exercise; pregnant or women who had bear child can reduce the risk of stress incontinence by strengthening their perineal muscles by doing it General Rx – Non-Invasive & Invasive o Non-invasive – training the bladder; invasive – surgery o Bladder training use to RX urge incontinence; place patient on a toileting schedule o Bio-feed-back – use of sensors to monitor temp. & muscle contraction of vagina; to learn to control their pelvic muscles o Collagen injection – injected around urethra; to provide urethral support o Intermittent urinary catheterization o Pelvic toning exercises – tightening the pelvic muscles known as Kegel’s exercise (stress incontinence) o Anticholinergics, Benadryl – medications; if these do not work, surgery is done by urologist PELVIC FLOOR SUPPORT

CYTOMETRY Cytometry is dynamic investigation, in that the intra-vesical pressure is measured not only during filling but also at capacity & during voiding

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ANATOMY Important so that the urologist would know when to correct the sphincter

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Treatment o Depends on the assessment; can be treated medically or surgically o Depend on the type of incontinence and the severity of the condition o Treatments include:  Lifestyle Changes - significant weight gain can weaken pelvic floor muscle tone, leading to urinary incontinence  Regulating the time you drink fluids and avoiding alcohol and caffeine are also helpful.  Behavioral Techniques - Pelvic floor exercises (Kegel exercises) can help strengthen the muscles of the pelvic floor that support the bladder and close the sphincter.  Bladder training can help patients learn to delay urination.  Medications - such as oxybutynin (Ditropan) and tolterodine (Detrol), are mainly used to treat urge incontinence.  Surgery – there are several methods

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Classification of Urinary Incontinence 1. Stress Urinary Incontinence (SUI) – complain of involuntary urine leakage It occurs when pelvic muscles have been damaged, causing the bladder to leak during exercise, coughing, sneezing, laughing, or any body movement which puts pressure on the bladder 2. Genuine Sress Incontinence – when symptoms/signs of stress incontinence is confined w/ objective testing 3. Overflow Incontinence – refers to leakage that occurs when the quantity of urine produced exceeds the bladder’s holding capacity 4. Urge Urinary Incontinence – have difficulty postponing urination urge & promptly empty their bladder on cue w/o delay The urgent need to pass urine and the inability to get to the toilet in time, occurs when nerve passages along the pathway from the bladder to the brain are damaged, causing a sudden bladder contraction that cannot be consciously inhibited 5. Detrusor Over-activity (DO) – previously known as detrusor instability – when urge urinary incontinence is objectively demonstrated by cytometric evaluation 6. Mixed Urinary Incontinence – both stress & urge components are present 7. Functional Incontinence – situation in w/c person cannot reach a toilet in time due to physical, psychological or mental limitations Person who have control over their own urination & have a fully functional urinary tract but cannot make it to the CR in time due to a physical or cognitive disability, are functionally incontinent – like Alzheimer’s; multiple sclerosis; Parkinson’s Encountered in elderly medical professions 8. Reflex Incontinence – person loss control of their bladder w/o warning; they usually suffer from neurological impairment NB - At times person may suffer acute incontinence & may occur as symptom or product of illness or complication of drugs or dietary intake & easily resolve once cause is determined

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STRESS INCONTINENCE Stress incontinence, or effort incontinence is a form of urinary incontinence It is due to insufficient strength of the closure of the bladder; the bladder leaks urine during physical activity or exertion It may happen when coughing, lift something heavy, or exercise The term stress incontinence refers to 3 distinct entities – a symptom; a sign; & a condition Symptoms & signs o Symptom refers to the patient’s complaint that she leaks urine on increased abdominal pressure & can result from variety of conditions:  Genuine stress incontinence (detrusor contraction provoke by coughing or change of position)  Incomplete bladder emptying  Urethral diverticulum The ability to hold urine & control urination depends on the normal function of lower urinary tract, CNS

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Leakage stops when the stress ends. o If the leakage persists, it is more likely to be urge incontinence. In both men and women, the aging process causes a general weakening of the sphincter muscles and a decrease in bladder capacity. Most common type of incontinence Risk factors for stress incontinence o Being female o Childbirth – esp. multiple pregnancies o Chronic coughing (as in asthma) o Obesity o Smoking o In women, it is nearly always due to one or both of the following:  Intrinsic sphincteric deficiency  All of these maybe due to:  Many children thru vaginal delivery (underlying cause)  Menopause estrogen deficiencies  Injury from surgery or radiation  Urethral hypermobility - the urethra does not close properly, allowing it to move too much Condition typically occurs when the pelvic floor muscles in women become weak, and the following events occur: o The weakened pelvic floor muscles stretch. This allows the bladder to sag downward within the abdomen.  If bladder pushes down towards the vagina, then it is known as an associated cystocele.  Incontinence and prolapse are interrelated o The sagging bladder pulls on the muscles surrounding the bladder neck (internal sphincter), which are connected to the urethra o Intrinsic sphincter deficiency is the other major cause of stress incontinence in women – most severe form  Cannot hold the intra-vesicular pressure  It occurs when the bladder neck muscles are damaged or weakened; there is laceration that is why perineum should always be supported  The result is twofold:  The bladder neck is open during filling  The closing pressure around the urethra is low Symptoms o Symptoms must be confirmed objectively o Patient should never undergo surgery on the basis of symptoms alone Signs refer to physical demonstration of urine loss during increased abdominal pressure, while examining o Incontinence exists when urine loss becomes a social or hygienic problem o Merely annoying or inconvenient – not considered incontinent nor need surgery Most adults can hold over 2 cups of urine in their bladder.

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250 cc of urine/ water - patient strain, spurt of urine from urethral meatus + Bonney’s or Marchetti’s - to confirm Bonney’s - 2 fingers on vagina w/ tips on sides of urethra to make upward pressure. Let patient cough; test is positive if there is leakage of urine Note: Make sure that you are not sitting in front of the patient o Stress incontinence is due to damage of supporting tissue of urethra Marchetti’s - same but Alli’s forcep is used instead Q-TIP TEST - In a normal patient, the angle of the Q-tip is less than 30 degrees from the horizontal, and will remain at this angle when the patient strains o Determines the integrity of the urethra o In patients with inadequate bladder neck support and stress incontinence, the Q-tip angle generally exceeds 30 degrees from the horizontal.

Diagnosis of stress incontinence caused by detrusor over-activity – confirmed by cystometry o Rule for all incontinence, demonstrate incontinence & confirm w/ patient that has been demonstrated reproduces her complaint o Subtracted filling cytometrography w/ overactive detrusor should show:  Phasic pressure waves that produce urgency & urge incontinence Diagnosis o Involuntary leakage of urine w/ stress o Finding of pelvic relaxation o Positive Bonney’s or Marchetti’s test o No intrinsic disease of bladder  Urinalysis must be negative Treatment: o The general goal for women with stress incontinence is to strengthen the pelvic muscles o Typical steps for treating women are:  Devices and continent aids for blocking urine in the urethra (vaginal pessaries, adhesive pads, and others).  Behavioral techniques and noninvasive devices, including Kegel exercises, weighted vaginal cones, and biofeedback.  Medications Alpha-adrenergic agonists and possibly anticholinergics.  Surgery

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GENUINE STRESS INCONTINENCE The same as stress incontinence but involves sphincter incompetence Defined as urethral sphincter incompetence; then involuntary loss of urine when intra-vesicle pressure exceeds the maximum urethral closure pressure in the absence of detrusor contraction Causes o Childbirth o Radical pelvic surgery Refers to uro-dynamic diagnosis of stress incontinence; said to exist when there is demonstrable urinary leakage when intra-vesicle pressure exceeds the maximum urethral closure pressure in the absence of detrusor contraction; hence diagnose: o She has undergone uro-dynamic testing o Proved that her urine loss is caused by ineffective urethral closure during periods of increased intra-abdominal pressure Clinical stress urinary incontinence results from the interaction of 3 distinct components – o Inherent biological strength of the urinary sphincter o Level of physical stress placed on the sphincter o Psycho-social milieu in w/c the patient lives (expectations about urinary control) Modifications of any one of these factors may influence the patient’s clinical status Diagnosis – by cytometry Treatment – conservative & surgical Effective urethral closure is maintained by the interaction of extrinsic urethral support & intrinsic urethral integrity; each are influenced by several factors, muscle tone & strength o Fascial integrity o Innervation o Urethral elasticity o Urethral vascularity Non-surgical – based on manipulations of the factors that contribute to the condition o Reducing factors that worsen the problem (obesity, smoking, excessive fluid intake) o Intervening actively to enhance the ability of patient’s pelvic floor to compensate for the increased intra-abdominal pressure by:  Rehabilitating pelvic muscles  Improving estrogen status  Using alpha-adrenergic stimulants  Wearing device to improve urethral support Non-surgical – Collagen injection

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Surgical Rx – classified into 4 categories o Traditional Anterior Vaginal Colporrhaphy o Operations for stress incontinence resulting from intrinsic sphincter weakness or dysfunction – Sling Operations or PeriUrethral Injections o Salvage operations (not usually done) – Obstructive Sling Operations, Implantation of an Artificial Urinary Sphincter, Urinary Diversion o Operations to correct incontinence resulting from anatomic hypermotility – Retro-pubic Bladder Neck Suspension, Needle Suspension Procedure, Tension-free Vaginal Tape, or Sling Procedures

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Anterior Colporrhaphy – oldest operation for stress incontinence; done when stress incontinence is associated with prolapsed o First step in doing vaginal hysterectomy o Reason – it is caused by open vesicle neck rather than from loss of urethral support o Technique – pulling the bladder neck closed using peri-urethral Kelly plication sutures  Simple plications of bladder neck  Elevation of bladder neck by plicating the fascia under the urethra  Elevation & fixation of bladder neck by passing sutures lateral to urethra & anteriorly into the back of symphysis pubis for fixation Surgery to correct hypermotility o Retro-pubic urethropexy – peri-urethral fascia is attached to the back of symphysis pubis; other technique, attachment of the fascia at the level of bladder neck to iliopectineal ligament o With paravaginal repair, lateral endopelvic fascia along urethra & bladder is reattached to arcus tendinus fascia of pelvis; long term success of such operation is – 70 – 90 % o Transvaginal urethropexy – vaginal incision at level of bladder neck, endopelvic fascia is perforated, space of Retzius is entered & suture pass thru low abd. incision thru the space & fix to endopelvic fascia Surgery to correct hyper-motility bladder neck & urethra o Tension-free vaginal tape – use of polypropylene mesh placed under the midurethra w/ minimal tension o Sling procedures o Salvage operation In both stress & urge incontinence, urine loss occurs from an unsuppressed contraction of the bladder muscle, a failure to suppress the micturition reflex Treatment: o Sling Operation

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Rx of detrusor over-activity – o Drug therapy: Anti-cholinergic drugs that block the activity of acetylcholine at muscarinic receptor site exerting their effects on bladder; w/c have short-half life; w/ side-effects – dry mouth, increase H.R due to vagal blockage, decrease GIT motility o New drugs  Tolterodine (detrol) – muscarinic receptor antagonist w/ long half-life  Oxy-butynin (Ditropan XL) – also long acting − Rx of detrusor over-activity – o Behavior therapy – change the mental attitude  Based on assumption that the underlying patho-physiology is the escape of the detrusor from cortical control over micturition that was previously established during childhood training  Object – to re-establish the authority of the cerebral cortex over bladder function − Instructed to void on time, start at frequent intervals When awake, void at 6, 7, 8, etc; if at 7 she does not feel to void, she must do it; if at 7:55, she must not void but wait for 8:00, even if there is leakage At night, she is allowed to void only when she is awaken from sleep by the need to do so −

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INCONTINENCE Differential Diagnosis o Urge incontinence o Functional or Transient Bladder o Dyssynergic Bladder

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URGE INCONTINENCE Also called hyperactive, irritable, or overactive bladder The main symptom of urge incontinence is the need to urinate frequently o More than 8 times over 24 hours, including two or more times a night, and have subsequent leakage. In some cases, urge incontinence occurs only at night. This is called nocturnal enuresis Caused be detrusor over-activity; inappropriate bladder contractions & abnormal nerve signals may be also cause Sudden, unexpected loss of large volume of urine or leakage associated w/ over-whelming desire to empty bladder that cannot be controlled She voids till bladder is empty Involuntary actions of bladder muscles can occur because of damage to the nerve supply, to the CNS or to muscles themselves – multiple sclerosis Parkinson’s Alzheimer’s, stroke & injury All cases of urge incontinence involve an overactive bladder This occurs when the detrusor muscle, which surrounds the bladder, contracts inappropriately during the filling stage o When this occurs, the urge to urinate cannot be voluntarily suppressed, even temporarily o There is usually one of two types:  Idiopathic Detrusor Overactivity (formerly called Detrusor Instability)  Neurogenic Detrusor Overactivity (formerly called Detrusor Hyperreflexia). Idiopathic Detrusor Overactivity - In this type, the nerves serving the bladder have signaled the brain appropriately that the bladder is full, but the detrusor muscle cannot be suppressed. Neurogenic Detrusor Overactivity - with this type, a known neurologic problem impairs the signaling systems between the bladder and the central nervous system, and the brain is unable to inhibit the detrusor muscle controlling urination. Conditions that can lead to urge incontinence: o Benign prostatic hyperplasia (BPH).  Detrusor instability occurs in about 75% of men with BPH and causes frequency, urgency, and urination during the night (although occurs only in very severe cases).  Urge incontinence only at night can be a sign of severe obstruction in the urinary tract o Hysterectomy o Radiation to the pelvis that involves the bladder. o Damage to the central nervous system. o Infections o The aging process o Medications It can mean that your bladder empties during sleep, after drinking small amount of water or when you touch or hear water running Common in cystitis, foreign bodies, stones; older women Fluids & medications (diuretics) or emotional state like anxiety can worsen the condition; Hyperthyroidism & uncontrolled DM also worsen it Patho.- neurological difficulty w/ bladder

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The goal of most treatments for urge incontinence is to reduce the hyperactivity of the bladder The following methods may be helpful: o Behavioral methods o Medications (anticholinergics and alpha blockers) o Procedures that stimulate the pelvic floor or nerves in the tailbone (the sacral nerves), which help retrain the bladder

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MIXED INCONTINENCE When they have motor urge incontinence due to detrusor over-activity along w/ stress incontinence Effort should be made to confirm the diagnosis & demonstrate stress & urge incontinence objectively before establishing such diagnosis; if both o Determine w/c symptoms is bothersome o Others advocate to treat 1st urge incontinence preceding surgery only if urge persist o Bladder neck suspension is contra-indicated w/ detrusor instability alone as the cause of incontinence; w/ mixed, a small functional bladder capacity & high-pressure detrusor contraction on filling cytometry should undergo operation for stress incontinence only after only after careful consideration

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DYSSYNERGIC BLADDER is a consequence of a neurological pathology such as spinal injury or multiple sclerosis that disrupts central nervous system regulation of themicturition (urination) reflex resulting in dyscoordination of the detrusor muscles of the bladder and the male or female external urethral sphincter muscles. − No prior urge to void. Episodes of voiding w/ no warning, occurring in spurts as in stress − Triggering mechanism - critical bladder o Triggered by running water − Diagnosis o History & uro-dynamic study − Treatment o Same as stress incontinence OVER-ACTIVE BLADDER It occurs when abnormal nerves sends signals to the bladder at the wrong time, causing its muscles to squeeze w/o warning − Special symptoms of over-active bladder – o Urinary Frequency – bothersome, 8 or more times a day or 2 or more times at night o Urinary Urgency – sudden, strong, need to urinate immediately o Urge Incontinence – leakage or gushing of urine that follows a strong urge o Nocturia – awakening at night to urinate The most common symptoms of an overactive bladder are urinary urgency (sudden, compelling desire to pass urine), frequency (greater than 8 times a day), and nocturia. −

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OVER-FLOW INCONTINENCE It happens when the normal flow of urine is blocked and the bladder cannot empty completely It can be due to a number of conditions: o A partial obstruction. In this case the urine cannot flow completely out of the bladder, so it never fully empties. o An inactive bladder muscle

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In contrast to urge incontinence, the bladder is less active than normal, not more.  It cannot empty properly and so becomes distended, or swells.  Eventually this distention stretches the internal sphincter until it opens partially and leakage occurs Conditions leading to over-flow incontinence: o Tumors (common cause in women) o Constipation o BPH o Scar tissue o Nerve damage to bladder o Certain medications (anticholinergics, antidepressants, antipsychotics, sedatives, narcotics)

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FUNCTIONAL INCONTINENCE Patients with functional incontinence have mental or physical disabilities that keep them from urinating normally, although the urinary system itself is intact Conditions that can lead to functional incontinence include: o Parkinson's disease o Alzheimer's disease and other forms of dementia o Medical conditions involving thinking, moving & communicating – thus having trouble reaching the CR o Severe depression o Arthritis associated w/ age o Persons on wheel chair Functional incontinence is the result of physical & medical conditions – o Person in wheel chair o Alzheimer’s disease o Medical conditions involving thinking, moving or communicating – have trouble reaching the CR o Arthritis associated w/ age BLADDER TRAINING Bladder training involves a specific and graduated schedule for increasing the time between urinations Patients start by planning short intervals between urinations, then gradually progressing with a goal of voiding every 3 - 4 hours. You are training the sphincter to hold the pressure If the urge to urinate arises between scheduled voidings, patients should remain in place until the urge subsides. At the time, the patient moves slowly to a bathroom. This system uses a set of weights to improve pelvic floor muscle control: Typical set includes five cones of graduated weights ranging from 20 grams (less than 1 ounce) to 65 grams (slightly over 2 ounces). Starting with the lightest, the woman places the cone in her vagina while standing and attempts to prevent the cone from falling out The muscles used to hold the cone are the same ones needed to improve continence.

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KEGEL’S EXERCISE Every patient who is suffering from incontinence should learn this − Since the muscles are sometimes difficult to isolate, the best method is to first learn while urinating − The patient begins to urinate and then contracts the muscle in the pelvic area with intention of slowing or stopping the flow of urine − Women should contract the vaginal muscles as well o They can detect this by inserting a finger inside the vagina. o When the vaginal walls tighten, the pelvic muscles are being correctly contracted. o Patients should place their hands on their abdomen, thighs, and buttocks to make sure there is no movement in these areas while exercising. − An alternate approach is to isolate the muscles used in Kegel contractions by sensing then squeezing and lifting the muscles in the rectum that are used in passing gas. (Again, women should contract the vaginal muscles as well.) − The first method is used for strengthening the pelvic floor muscles. o The patient slowly contracts and lifts the muscles and holds for 5 seconds, then releases them. There is a rest of 10 seconds between contractions. − The second method is simply a quick contraction and release. o The object of this exercise is to learn to shut off the urine flow rapidly. − In general, patients should perform 5 - 15 contractions, three to five times daily. PHYSIOLOGY OF URINATION The process of urination is a combination of automatic and conscious muscle actions. − There are two phases: o The emptying phase and o The filling and storage phase. − The Filling and Storage Phase – o When a person has completed urination, the bladder is empty. This triggers the filling and storage phase, which includes both automatic and conscious actions − Automatic Actions – o The automatic signaling process in the brain relies on a pathway of nerve cells and chemical messengers (neurotransmitters) called the cholinergic and adrenergic systems. o Important neurotransmitters include serotonin and noradrenaline. o This pathway signals the detrusor muscle surrounding the bladder to relax. o As the muscles relax, the bladder expands and allows urine to flow into it from the kidney. o As the bladder fills to its capacity (about 8 - 16 oz of fluid) the nerves in the bladder send back signals of fullness to the spinal cord and the brain − Conscious Actions – o As the bladder swells, the person becomes conscious of a sensation of fullness. o In response, the individual holds the urine back by voluntarily contracting the external sphincter −

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−

−

muscles, the muscle group surrounding the urethra. o These are the muscles that children learn to control during the toilet training process. o When the need to urinate becomes greater than one's ability to control it, urination (the emptying phase) begins The Emptying Phase. – automatic and conscious actions: o Automatic Actions. - When a person is ready to urinate, the nervous system initiates the voiding reflex.  The nerves in the spinal cord (not the brain) signal the detrusor muscles to contract.  At the same time, nerves are also telling the involuntary internal sphincter (a strong muscle encircling the bladder neck) to relax.  With the bladder neck now open, the urine flows out of the bladder into the urethra o Conscious Actions –  Once the urine enters the urethra, a person consciously relaxes the external sphincter muscles, which allows urine to completely drain from the bladder. PELVIC ORGAN PROLAPSE What is pelvic organ prolapse? o Definition - Pelvic organ prolapse is the abnormal descent or herniation of the pelvic organs from their normal attachment sites or their normal position in the pelvis o This condition refers to the bulging or herniation of one or more pelvic organs into or out of the vagina o The pelvic organs consist of the • Uterus • Vagina • Bowel and • Bladder o Pelvic organ prolapse occurs when the muscles, ligaments and fascia (a network of supporting tissue) that hold these organs in their correct positions become weakened o These organs are said to prolapse if they descend into or outside of the vaginal canal or anus

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− Where can a prolapse occur? o A prolapse may arise in the front wall of the vagina (anterior compartment) o Back wall of the vagina (posterior compartment) o The uterus or top of the vagina (apical compartment) o Many women have a prolapse in more than one compartment at the same time Prolapse of the Anterior Compartment − This is the most common type of prolapse, and involves the bladder and /or urethra bulging into the vagina − Refer to it as cystocele or cysto-urethrocele New terminology is Anterior Wall Prolapse

(Left: Normal Anatomy; Right: Bladder Prolapse: Cystocele)

Prolapse of the Posterior Compartment − This is when the lower part of the large bowel (rectum) bulges into the back wall of the vagina - refer to as rectocele) − New terminology: Posterior Wall Prolapse − And / or part of the small intestine bulges into the upper part of the back wall of the vagina - refer to as enterocele). Prolapse of the Apical Compartment − Uterine prolapse – this occurs when the uterus (womb) drops or herniates into the vagina − New terminology: Apical Prolapse − This is the second most common form of prolapse

(Left: Anatomy After Hysterectomy; Right: Vaginal Vault Prolapse)

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CAUSES: − Anything that puts increased pressure in the abdomen can lead to pelvic organ prolapse. Common causes include: o Pregnancy, labor, and childbirth (the most common causes) o Obesity o Respiratory problems with a chronic, long-term cough

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o o o o

Constipation Pelvic organ cancers Surgical removal of the uterus (hysterectomy) Genetics may also play a role in pelvic organ prolapse. Connective tissues may be weaker in some women, perhaps placing them more at risk PELVIC ORGAN PROLAPSE

Presentation The condition seldom causes symptoms Minimal pelvic organ prolapse generally does not require therapy because the patient is usually asymptomatic However, vaginal or uterine descent at or through the introitus can become symptomatic -

Notes from lecture: ∘ Apical Prolapse: Uterus ∘ Anterior Wall prolapse: bladder ∘ Posterior Wall prolapse: Rectum

Signs and Symptoms (dependent on the prolapsed organ) Generally asymptomatic Backaches (sacral back pain with standing) Lower abdominal discomfort A feeling of pressure or fullness in the pelvic region A feeling that something is falling out of the vagina (Typically, the patient feels a bulge in the lower vagina or the cervix protruding through the vaginal introitus.) Sensation of vaginal fullness /pressure Vaginal bleeding Vaginal spotting from ulceration of the protruding cervix or vagina Painful intercourse/ dyspareunia Urinary problems such as leaking of urine or a chronic urge to urinate Constipation -

Notes from lecture: ∘ Any condition that increases the abdominal pressure, such as pregnancy, may lead to prolapse

Specific types present specific symptoms Loss of anterior vaginal support leads to urethral hyper motility which often leads to stress urinary incontinence Vaginal vault eversion: symptoms of voiding difficulty, the prolapse come out below urethra Anterior protrusion of rectum: symptoms of inefficient rectal emptying ∘ In severe cases, patient has to splint the posterior vagina with fingers during defecation, reducing the pocket that is trapping the stool

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UTERINE PROLAPSE It means that the uterus has descended from its position in the pelvis further down into the vagina ∘ It is held in place by muscles & ligaments that makes up the pelvic floor; when stretched & weakened, uterine prolapse occur, descending into the vaginal canal Often affects post-menopausal women who had one or more deliveries; plus effects of gravity; loss of estrogen; & repeated straining weaken pelvic floor

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Mild prolapse needs no treatment; except when it is uncomfortable & disrupt normal life

Nulliparous women have undamaged pelvic floor, hence are not at risk. Weakening of the pelvic muscles that leads to uterine prolapse can be caused by: Damage to supportive tissues during pregnancy and childbirth Loss of muscle tone Effects of gravity Loss of estrogen Repeated straining over the years Risk factors: One or more pregnancies and vaginal births Giving birth to a large baby Increasing age Frequent heavy lifting Chronic coughing Prior pelvic surgery Frequent straining during bowel movements Genetic predisposition to weakness in connective tissue Some conditions can place a strain on the muscles and connective tissue, such as: ∘ Obesity ∘ Chronic constipation ∘ Chronic obstructive pulmonary disease (COPD) Symptoms: depends on severity Sensation of heaviness or pulling in your pelvis Tissue protruding from your vagina Urinary problems, such as urine leakage or urine retention Trouble having a bowel movement Low back pain Feeling as if you're sitting on a small ball or as if something is falling out of your vagina Sexual concerns, such as a sensation of looseness in the tone of your vaginal tissue Symptoms that are less bothersome in the morning and worsen as the day goes on Most urinary problems are related to cystoceles, while majority of gastrointestinal and anorectal symptoms are related to rectoceles. Assessment and Examination Prolapse is almost invariably worse when the patient is standing as well as in lithotomy position ∘ She is standing on the floor w/ one foot elevated on foot-stool ∘ Recto-vaginal exam: in this position is best way of detecting occult enterocele because the bowel can be well palpated in the cul-desac between thumb & fore-fingers easily Aside from traditional speculum exam of vagina supplemented with site specific exam of vagina using a single bladed-speculum as a Sim’s speculum As a rule, any prolapse that lie within the vaginal lumen above the plane of hymenal ring is of limited significance, especially if there is no symptoms

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Pathology Prolapse w/ cystocele or w/ rectocele Cervical ulceration - due to friction Hypertrophy of cervix (Tx: Manchester Procedure: also the treatment of choice for cervical elevation with anterior vaginal wall prolapse) Inversion of vagina Upper ureter dilatation How will you know that it is cervical hypertrophy or vaginal prolapse? Vaginal prolapse causes obliteration of the vaginal fornix, cervical hypertrophy does not. Degree of Prolapse 1st Degree: cervix is well within vaginal canal 2nd Degree: cervix is at introitus 3rd Degree: cervix is beyond the introitus STAGES OF PELVIC ORGAN PROLAPSE (basis: HYMEN) − Stage 0: no prolapse is demonstrated − Stage I: most distal portion of the prolapse is >1cm above level of hymen − Stage II: most distal portion of the prolapse is 1cm below the planer of hymen but no further than 2 cm less than the total vaginal length − Stage IV: complete to nearly complete eversion of vagina

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6 points are located w/ reference to the plane of hymen: ∘ 2 on ant. vag. wall – pint Aa & Ba ∘ 2 in the apical vag – points C & D ∘ 2 in the post. vag. wall – points Ap & Bp All points, except total vag. length, are measured durign patient’s Valsalva (at maximum proptrusion)

BADEN-WALKER HALF-WAY SYSTEM GRADING (older, more clinically useful): − Grade O: Normal position of its respective site − Grade I: descent half-way to the hymen; Minimal displacement with straining − Grade II: descent to the hymen; Towards introitus with straining − Grade III: descent half-way past the hymen; To & beyond level of introitus with straining − Grade IV: maximum possible descent for its site; Outside introitus at rest -

PROLAPSE CAN BE GRADED W/ THIS SYSTEM: Descent of Anterior Vaginal Wall Posterior Vaginal Wall Apical Prolapse POP-Q (newer) Cumbersome & questionable clinical utility other than for research (standardization) purposes Hymenal plane as 0 – anatomic positions of these points from hymen is measured in cm Points above or proximal to hymen are described w/ negative number Positions below or distal to hymen are positive number Degree of prolapse can be quantified Reports findings in standardized fashion Contains series of site-specific measurements of a woman’s pelvic organ support Prolapse is measured to the hymen, a fixed anatomic landmark that can be identified

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Grading: ∘ Stage 0: No prolapse (apex can descend w/in 2 cm of hymen) ∘ Stage I: Leading edge descends to 1 cm above hymen ∘ Stage II: Leading edge descends to w/in 1 cm of hymen (range is between 1 cm above and 1 cm below the hymen) ∘ Stage III: Leading edge extends >1cm beyond hymen but < 2cm of total vaginal length is prolapsed ∘ Stage IV: complete eversion, leading edge > 2m of total vaginal length is prolapsed POP-Q (Other Description) New standard system of classification – a series of 9 site-specific measurement; 6 points along vagina (2 ant., 2 middle & 2 post. compt.) measured in relation to hymen o Measured in cm proximal to hymen (-) or distal to hymen (+) w/ the of hymen as 0 o Genital hiatus is measured from the middle of ext. urethral meatus to post. midline of hymen o Perineal body is measured from post. margin of genital hiatus to mid-anal opening o Total vaginal length greatest depth in cm in its full normal position

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o

o o

All measured in maximal straining except total vaginal length Pelvic relaxation is classified by the organ/s involved; severity is determined in the lithotomy position as o O – no prolapse; pointa Aa, Ap, Ba, Bp are all at -3 cm & point C is bet. total vag. length (TVL) & -(TVL-2 cm) o 1 - site descends past the mid- vaginal axis; or most distal part of the prolapse is >1cm above the level of the hymen o 2 – site descends to the hymenal ring; or most distal part of prolapse is 1 cm below the plane of the hymen but no further than 2 cm less than total vaginal length o 4 – site is fully outside hymenal ring; or complete to nearly complete eversion of vagina, most distal part of prolapse protrudes at ≥ + (TVL-2) cm Treatment Surgery – depends on type of prolapse o Goal to relieve her of her symptoms by repairing each aspect of abnormal pelvic support is durable & long lasting -

o

Should have well estrogenized vagina Post-menopausal, give HRT or use intravaginal cream on regular basis Past menopause – use intra-vaginal estrogen cream 4 – 6 weeks before pessary is inserted because it makes pessary more comfortable to wear, & promote long term use

o

Contraindications:  Marked outlet relaxation  severe vaginitis/cervicitis;  fixed retro displace.

o

Complications:  Leukorrhea;  Pelvic infection  Ulceration & fistula  Urinary retention  vaginal fistula

For vaginal prolapse – o Vagina Hysterectomy - most suitable o Manchester/Fothergill Operation - for poor risk patient o Uteropexy o Posterior Culporrhaphy o Colpectomy via Colpocleisis (LeFort)  Closing of vagina  Done on elderly spinster or widow  Done as a last resort  Preceded by vaginal hysterectomy  Complication: stress incontinence

Historically, the treatment for symptomatic uterine prolapse has been hysterectomy, which is performed vaginally or abdominally in combination with an apical suspension procedure, and repair of coexisting defects. Apical support procedures that have been described for use when the uterus or cervix is to be kept in place include Manchester and Gilliam procedures and fixation of the cervix to the sacrospinous ligament. Asymptomatic prolapse – no need for Rx, except w/ stress incontinence & prolapse who is about to undergo operation o Stress incontinence – elevate the anterio vagina; pull the post. vagina forward; this opens the cul-de-sac, pulling it off the levator plate; Thus, creating an opening for the enterocele formation, uterine prolapse or rectocele o Under this condition additional surgery is needed, culdoplasty or even hysterectomy McCall Culdoplasty is performed by suspending the vaginal wall to the endopelvic fascia. -

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Symptomatic prolapse – conservative or surgical

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Conservative – fitting w/ pessary o For poor operative risk & short life span o Pessary fitted individually

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CYSTOCELE A cystocele is a medical condition that occurs when the tough fibrous wall between a woman's bladder and the vagina (the pubocervical fascia) is torn by childbirth, allowing the bladder to herniate into the vagina Prolapse of the urinary bladder

Classification: Mild (grade 1) - when the bladder droops only a short way into the vagina Severe (grade 2) - the bladder sinks far enough to reach the opening of the vagina Most advanced (grade 3) - when the bladder bulges out through the opening of the vagina

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o

o o

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-

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The pelvic floor consists of muscles, ligaments and connective tissues that support the bladder and other pelvic organs The connections between the pelvic floor muscles and ligaments can weaken over time, as a result of trauma from childbirth or chronic straining of pelvic floor muscle Possible causes of anterior prolapse include: o Pregnancy and vaginal childbirth o Being overweight or obese o Repeated heavy lifting o Straining with bowel movements o A chronic cough or bronchitis Risk factors include: o Childbirth - women who have vaginally delivered one or more children have a higher risk of anterior prolapse o Aging - anterior prolapse increases as you age • This is especially true after menopause, when the body's production of estrogen — which helps keep the pelvic floor strong — decreases o Hysterectomy - may contribute to weakness in the pelvic floor support o Genetics - some women are born with weaker connective tissues, making them more susceptible to anterior prolapse o Obesity or over-weight - are at risk Symptoms - in mild cases of anterior prolapse, there may not notice any signs or symptoms When signs and symptoms occur, they may include: o A vaginal bulge o The feeling that something is falling out of the vagina o A feeling of fullness or pressure in the pelvis and vagina o Difficulty starting a urine stream o Feeling of incomplete urination o Frequent or urgent urination o Repeated bladder infections o Pain or urinary leakage during sexual intercourse o In severe cases, a bulge of tissue that protrudes through your vaginal opening and may feel like sitting on an egg

o

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against the posterior vaginal wall while patients are in the lithotomy position Asking patients to strain makes cystoceles or cysto-urethroceles visible or palpable as soft reducible masses bulging into the anterior vaginal wall It requires medical tests and a physical exam of the vagina If there is difficulty emptying the bladder, measure the amount of urine left in the woman’s bladder after she urinates  The remaining urine is called the post void residual  Post void residual can be measured by a bladder ultrasound  Use a catheter to measure a woman’s post-void residual of remaining urine after the she has urinated  A post-void residual of 100 mL or more is a sign that the woman is not completely emptying her bladder You may use a voiding cysto-urethro-gram (an x-ray exam of the bladder) to diagnose a cystocele as well  A woman gets a voiding cystourethrogram while urinating  The x-ray images show the shape of the woman’s bladder and let you see any problems that might block normal urine flow  An x-ray technician performs a voiding cystourethrogram, and a radiologist interprets the images

Management: o Cystocele treatment depends on the severity of the cystocele and whether a woman has symptoms o If it does not bother her, recommend only that she avoid heavy lifting or straining, which could worsen her cystocele o If she has symptoms that bother her and wants treatment, recommend pelvic muscle exercises, a vaginal pessary, or surgery o Pelvic floor, or Kegel, exercises involve strengthening pelvic floor muscles  It involves tightening and relaxing the muscles that support pelvic organs. o A vaginal pessary is a small, silicone medical device placed in the vagina that supports the vaginal wall and holds the bladder in place. o May recommend surgery to repair the vaginal wall support and reposition the woman’s bladder to its normal position  The most common cystocele repair is an anterior vaginal repair—or anterior colporrhaphy

Diagnosis: o Cystoceles and cysto-urethroceles are detected by applying a single-bladed speculum

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Anterior Colporrhaphy:

weakened delivery

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RECTOCELE Rectocele or posterior prolapse occurs when the thin wall of fibrous tissue (fascia) that separates the rectum from the vagina weakens, allowing the vaginal wall to bulge o It is the front wall of the rectum that bulges into the vagina An enterocele (small bowel prolapse) occurs when the small bowel presses against and moves the upper wall of the vagina Rectoceles and enteroceles develop if the lower pelvic muscles become damaged by labor, childbirth, or a previous pelvic surgery or when the muscles are weakened by aging A rectocele or an enterocele can be present at birth (congenital), though this is rare Take extra measure and caution in diagnosing a rectocele because it is easily confused with enterocele. Repairing a rectocele, which is actually an enterocele, thru posterior perineorrhaphy would warrant the patient to come back again because of unresolved s/sx. In enterocele, on the other hand, the cul de sac of Douglas is repaired. If in doubt, request for imaging studies such as lower barium enema. If the barium is visualized at the vaginal canal, it is an enterocele. Causes: o Upright posture - Walking upright places weight on a woman's pelvic floor and is the main reason women experience posterior prolapse o Increased pelvic floor pressure o Other conditions and activities that increase the pressure already on the pelvic floor and can cause or contribute to posterior prolapse include:  Chronic constipation or straining with bowel movements  Chronic cough or bronchitis  Repeated heavy lifting  Being overweight or obese o Pregnancy and childbirth - because the muscles, ligaments and fascia that hold and support your vagina become stretched and

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pregnancy,

labor

and

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Risk factors: o Genetics - Some women are born with weaker connective tissues in the pelvic area; others are born with stronger connective tissues. o Childbirth - If you have vaginally delivered multiple children, you have a higher risk of developing posterior prolapse - had tears in the tissue between the vaginal opening and anus (perineal tears) and incisions that extend the opening of the vagina (episiotomies) during childbirth o Aging - risk of posterior prolapse increases as you age because you naturally lose muscle mass, elasticity and nerve function as you grow older, causing muscles to stretch or weaken. o Obesity - a high body mass index is linked to an increased risk of posterior prolapse - due to the chronic stress that excess body weight places on pelvic floor tissues

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Symptoms: o Small posterior prolapse may cause no signs or symptoms o Otherwise, you may notice:  A soft bulge of tissue in the vagina that may or may not protrude through the vaginal opening  Difficulty having a bowel movement with the need to press your fingers on the bulge in the vagina to help push stool out during a bowel movement ("splinting“)  Sensation of rectal pressure or fullness  A feeling that the rectum has not completely emptied after a bowel movement  Sexual concerns, such as feeling embarrassed or sensing looseness in the tone of your vaginal tissue

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Pathophysiology: o It is important to note that a rectocele is a defect of the vaginal supporting tissues; it is not a defect of the rectum o The etiology of a rectocele is believed to be due to stretching and disruption of the rectovaginal septum and surrounding vaginal tissues during childbirth o Perhaps the most important fascia within the recto-vaginal septum is Denonvilliers' fascia, which is fused to the inner layer of the posterior vaginal wall o During childbirth, Denonvilliers' fascia is believed to be disrupted at its caudal and lateral attachments to the perineal body o Good evidence for this theory exists, since rectoceles are essentially found only in parous women

Make an incision upwards up until the vaginal vault. Then remove the anterior vaginal mucosa. Above it, push the bladder upwards. On the lateral side, the levator ani muscle is located. This will split or be damaged during delivery. This is also anchored upward. After its repair thru suturing, the perineum will automatically contract. This procedure takes about more than an hour.

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during

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•

Prophylaxis: o Prophylactic measures for preventing rectocele include –  Diagnosis and treatment of chronic respiratory and metabolic disorders  Correction of constipation, and intraabdominal disorders that may cause chronic increases in intra-abdominal pressure o Counsel patients about –  The preventive effects of weight control  Proper nutrition  Smoking cessation, and  Avoidance of strenuous occupational and recreational stresses that could damage the pelvic support system o Teach and encourage women to perform pelvic muscle exercises as a method of strengthening their pelvic diaphragm and as prophylaxis against the development of rectocele o For mild degrees of relaxation, especially in younger women immediately following childbirth, levator muscle exercises, sometimes called Kegel exercises, are helpful in restoring the tone of the muscles of the pelvic floor  Patients should repeat this exercise approximately 75 times during the day

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Treatment: o For patients without symptoms, expectant management is recommended o Currently, no evidence supports the use of estrogen to prevent or treat prolapse o Nonsurgical and surgical methods are available for treating symptomatic patients with rectocele  One responsibility of the physician is to inform women of their treatment options and the potential benefits and risks of each option o Generally, treatment is determined by:  The age of the patient  The desire for future fertility  The desire for coital function  The severity of symptoms  The degree of disability, and  The presence of medical complications o Medical Rx – use of pessaries o Surgical Rx – including:  Posterior colporrhaphy  Defect-directed repair  Posterior fascial replacement  Trans-anal repair, and  Abdominal approach o Comparison between trans-vaginal and trans-anal approach:  Both approaches are effective for posterior compartment defects and improvement in quality of life

(Left: Rectocele; Right: Enterocele)

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Diagnosis: o Enteroceles and rectoceles are detected by retracting the anterior vaginal wall while patients are in the lithotomy position o Asking patients to strain can make enteroceles and rectoceles visible and palpable during recto-vaginal examination o Patients are also examined while standing with one knee elevated (eg, on a stool) and straining o Sometimes abnormalities are detected only by recto-vaginal examination during this maneuver o Pelvic exam – • During the exam, bear down as if having a bowel movement • This may cause the posterior prolapse to bulge - can assess its size and location • To check the strength of the pelvic muscles, be instructed to tighten (contract) them, as if you're stopping the stream of urine • You may be examine while lying down and while standing up o Imaging tests usually aren't needed to diagnose posterior prolapse.

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

o o o

o

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But there are variations in outcome –  Gynecologists generally use the vaginal approach with successful anatomic results and minimal postprocedure pain, but sexual dysfunction is a concern  The trans-anal approach yields better rectal function and tends to be performed by general surgeon or proctologists The primary surgical therapy for rectocele has been posterior colporrhaphy The principal objective of the posterior repair is to repair perineal tears that occurred during vaginal delivery The perineal closure is designed to –  Narrow the caliber of the vaginal introitus  Develop a perineal shelf, and  Partially close the genital hiatus The original description described –  Reduction of the rectocele  Suturing of the levator ani  Correction of existing enterocele or prevention of potential enterocele.

If you see a cystocele plus rectocele, there is most often a concomitant degree of uterine prolapse. Moreover, if you have a third degree uterine prolapse, you can be sure that there is a concomitant cystocele and urinary incontinence.

-------------------END OF TRANSCRIPTION------------------References Used: Novak’s Textbook of Gynecology American Urogynecologic Society Management of Pelvic Organ Prolapse by – Angels Jacob Handel LN, Frenkl TL, Kim YH (2007). "Results of cystocele repair: a comparison of traditional anterior colporrhaphy, polypropylene mesh and porcine dermis“ Medscape General Medicine. 1998

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