urogynecology-review-for-up-college-.pdf

A Review of

UROGYNECOLOGY UPCM Interns’ Refresher Course 15 June 2015

Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPS Clinical Associate Professor Section of Urogynecology and Pelvic Reconstructive Surgery Department of Obstetrics and Gynecology UP College of Medicine Philippine General Hospital 1

OUTLINE I. Pelvic Organ Prolapse II. Urinary Incontinence

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I. PELVIC ORGAN PROLAPSE A. B. C. D.

Definition Pathophysiology Risk Factors Diagnosis i. ii. iii.

Presentation Scoring and Staging Ancillary tests

E. Management

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I. PELVIC ORGAN PROLAPSE Definition POP is defined as the downward descent of the pelvic organs towards or through the vaginal opening.

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I. PELVIC ORGAN PROLAPSE Etiology POP comes about with the failure of the suspensory and supportive structures of the pelvic organs.

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I. PELVIC ORGAN PROLAPSE Pelvic support structures Bony pelvis –provides the surfaces of attachment for the muscles and the ligaments

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I. PELVIC ORGAN PROLAPSE Pelvic support structures Pelvic diaphragm – the dynamic floor of the pelvis that contracts tonically and reflexly to support the pelvic organs as well as maintain urinary and fecal continence • Levator ani muscles (puborectalis, pubococcygeus, & iliococcygeus) • Coccygeus muscles

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I. PELVIC ORGAN PROLAPSE Pelvic support structures Pelvic diaphragm • Levator plate • Innervated by the branches of the S1-S3 nerves and the pudendal nerve

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I. PELVIC ORGAN PROLAPSE Pelvic support structures Endopelvic fascia – a fibromuscular sheath composed collagen, elastin, and smooth muscles that is continuous with the vagina, cervix and lower portion of the uterus. - It envelops these organs and attaches and suspends them to the pelvic walls, aligning them 30o above horizontal over the levator plate. copyright_joanneaguinaldomd_manilaphilippines_june2015

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I. PELVIC ORGAN PROLAPSE De Lancey Levels of Pelvic support Level 1 – parametrium -the uterosacral and cardinal ligament complex

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I. PELVIC ORGAN PROLAPSE De Lancey Levels of Pelvic support Level 2 – paracolpium -attaches the anterior and posterior vaginal walls to the lateral pelvic sidewall

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I. PELVIC ORGAN PROLAPSE De Lancey Levels of Pelvic support Level 3 – fusion of the endopelvic fascia of the vaginal walls with the surrounding structures, namely: with the urethra, urogenital diaphragm, and the pubis inferiorly, with the levator ani fascia laterally and with the perineal body posteriorly

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I. PELVIC ORGAN PROLAPSE Mechanism of pelvic support is this: Endopelvic fascia stabilizes the pelvic organs above the levator plate, preventing their herniation into the vagina. Pelvic diaphragm maintains the levator plate, a horizontal shallow basin, at the most dependent portion of the pelvis and consequently prevents the herniation of the vagina and its adjacent structures through the genital hiatus.

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I. PELVIC ORGAN PROLAPSE Mechanism of pelvic support is this: Endopelvic fascia stabilizes the pelvic organs above the levator plate Pelvic diaphragm maintains the levator plate

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I. PELVIC ORGAN PROLAPSE Patholophysiology of pelvic organ prolaspe is this: Weakness of Pelvic diaphragm (Neurologic compromise, Tissue damage) Downward rotation of the levator plate from its horizontal position Stress on the Endopelvic fascia (Pelvic organs no longer supported by the levator plate) Descent of Pelvic Organs

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I. PELVIC ORGAN PROLAPSE Patholophysiology of pelvic organ prolaspe is this: Weakness of Pelvic diaphragm Downward rotation of the levator plate from its horizontal position Stress on the Endopelvic fascia Descent of Pelvic Organs

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I. PELVIC ORGAN PROLAPSE Risk factors Predisposing (congenital)

Skeletal, muscular, neurological, connective tissue, racial, gender

Inciting

Vaginal delivery, surgery, neurological

Promoting

Obesity, smoking, lung disease, constipation, recreational and occupational stresses, surgery

Decompensating

Ageing, menopause and hormonal deprivation, progressive or acquired neuropathy, progressive or acquired myopathy, debilitation, medication

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I. PELVIC ORGAN PROLAPSE Symptoms Local

Vaginal pressure of heaviness Vaginal or perineal pain Sensation of tissue protrusion from the vagina Low back pain Abdominal pressure or pain

Observation or palpation of a bulge Urinary

Stress incontinence Frequency Urgency Urge incontinence Hesitancy Weak or prolonged stream Feeling of incomplete emptying Manual reduction to start or complete bladder emptying Positional changes to start or complete bladder emptying

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I. PELVIC ORGAN PROLAPSE Symptoms Bowel

Difficulty with defecation Incontinence Fecal staining Urgency of defecation Discomfort with defecation Digital manipulation of the vagina, perineum and anus to complete defecation Feeling of incomplete defecation Rectal protrusion during or after defecation

Sexual

Inability to have sexual activity Infrequent coitus Dyspareunia Lack of sexual satisfaction or orgasm Incontinence during sexual activity

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I. PELVIC ORGAN PROLAPSE A. B. C. D.

Definition Pathophysiology Risk Factors Diagnosis i. ii. iii.

Presentation Scoring and Staging Ancillary tests

E. Management

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I. PELVIC ORGAN PROLAPSE Scoring and Staging : POP-Quantification System (POP-Q) • Introduced in July 1996 by the International Continence Society • Aimed to standardize the terminology and reporting of POP

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I. PELVIC ORGAN PROLAPSE Scoring and Staging : POP-Quantification System (POP-Q) • Prolapse should be examined at maximum descent. • The hymen is the fixed reference point used throughout the system. • The anatomic position of the 6 defined points for evaluation should be measured as centimeters above or below the hymen, with the plane of the hymen defined as zero (0). • If the defined point is observed above or proximal to the hymen, it is assigned a negative number (e.g. -1 or 1 cm above the hymen). • If the defined point is observed below or distal to the hymen, it is assigned a positive number (e.g. +1 or 1 cm below the hymen).

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I. PELVIC ORGAN PROLAPSE

(-) 0

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I. PELVIC ORGAN PROLAPSE Anterior compartment

Point Aa Point Ba

Located in the midline if the anterior vaginal 3 cms “Urethro-vesical crease” proximal to the external urethral meatus -3 to +3 Represents the most distal or dependent position of Middle to proximal third of the the anterior vaginal wall from the cuff or anterior anterior vaginal wall fornix to point Aa.

Superior or Apical compartment Point C

Represents either the most distal or dependent edge of the cervix or the leading edge of the vaginal cuff

Point D

Represents the location of the posterior fornix in a Used to differentiate suspensory woman who still has a cervix. failure of the uterosacral ligament from cervical elongation. Omitted in the absence of the cervix

Posterior compartment Located in the midline of the posterior vaginal wall 3 -3 to +3 cms proximal to the hymen Represents the most distal or dependent position of Middle to proximal third of the Point Bp the posterior vaginal wall from the posterior fornix or posterior vaginal wall the cuff to point Ap 24 copyright_joanneaguinaldomd_manilaphilippines_june2015

Point Ap

I. PELVIC ORGAN PROLAPSE

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I. PELVIC ORGAN PROLAPSE

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I. PELVIC ORGAN PROLAPSE Ordinal stages Stage 0

No prolapse demonstrated A, B points are at -3 cm C,D points are at –TVL cm or –(TVL-2) cm

Stage I

Criteria for Stage 0 are not met but the most distal or dependent portion of the prolapse is more than 1 cm above the hymen (< -1 cm)

Stage II

The most distal or dependent portion of the prolapse is less than or equal to 1 cm above or below the hymen (> -1 cm or < +1 cm)

Stage III

The most distal or dependent portion of the prolapse is more than 1 cm below the hymen but protrudes no further than 2 cms less than the total vaginal length [ > +1 cm to < (TVL – 2) cm ]

Stage IV

Essentially complete eversion, the most distal portion of the prolapse protrudes to at least (TVL-2) cm

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I. PELVIC ORGAN PROLAPSE Ancillary testing

1. Supplemental PE - Vaginal inspection: - Loss of rugae - Atrophy : loss of labial fullness, pallor of vagina and urethra, minimal vaginal moisture

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I. PELVIC ORGAN PROLAPSE Ancillary testing

1. Supplemental PE - Vaginal examination: - Check pelvic floor muscle strength - Modified Oxford Scale - 0 : no contraction - 1 : flicker - 2 : weak squeeze, no lift - 3 : fair squeeze, definite lift - 4 : good squeeze, with lift - 5 : strong squeeze with a lift copyright_joanneaguinaldomd_manilaphilippines_june2015

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I. PELVIC ORGAN PROLAPSE Ancillary testing

1. Supplemental PE - Rectovaginal examination (enterocoele, rectocoele)

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I. PELVIC ORGAN PROLAPSE Ancillary testing

2. Bladder testing Screen for infection – urinalysis, urine culture Determine post void residual urine Assess bladder function Cystometry with Cough stress test (with prolapse reduced) : 15-80% occult stress incontinence

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I. PELVIC ORGAN PROLAPSE Ancillary testing

3. Pelvic floor muscle testing - Biofeedback machine 4. Imaging Studies - Ultrasound : pelvic, KUB - CT scan/ MRI

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I. PELVIC ORGAN PROLAPSE Ancillary testing

5. Endoscopy/ Cystoscopy - Bladder symptoms/ conditions : hematuria, urolithiases - Bowel symptoms/ conditions: obstipation, painful defecation, rectal prolapse

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CASE 60 G4P4 (4004) presents with sensation of Aa something coming out of her vagina. She reports a palpable bulge at the introitus on occasion. All her pregnancies were delivered GH vaginally except for the last, for which she underwent a CS-hysterectomy for placenta accreta. On physical examination, the vagina Ap was pale and smooth and measured 6 cms long. The vaginal cuff most dependent, noted 1 cm above the hymen. The urethrovesical crease was 2 cms above the hymen and there was no displacement of the posterior vaginal wall.

Ba

C

PB

TVL

Bp

D

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CASE 60 G4P4 (4004) presents with sensation of something coming out of her vagina. She reports a palpable mass at the introitus on occasion. All her pregnancies were delivered vaginally except for the last, for which she underwent a CS-hysterectomy for placenta accreta. On physical examination, the vagina was pale and smooth and measure 6 cms long. The vaginal cuff most dependent, noted 1 cm above the hymen. The urethrovesical crease was 2 cms above the hymen and there was no displacement of the posterior vaginal wall.

Aa -2

Ba -1

C -1

GH

PB

TVL 6

Ap -3

Bp -3

D N/A

Most dependent : Cuff -1 SCORE and STAGE Stage II copyright_joanneaguinaldomd_manilaphilippines_june2015

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CASE What level of support is most compromised in this case? A. B. C. D.

Level 1 Level 2 Level 3 Level 4

- Parametrium (uterosacral/cardinal ligament complex)

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Aa -2

Ba -1

C -1

GH

PB

TVL 6

Ap -3

Bp -3

D N/A

Most dependent : Cuff -1 Stage II

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I. PELVIC ORGAN PROLAPSE A. B. C. D.

Definition Pathophysiology Risk Factors Diagnosis i. ii. iii.

Presentation Scoring and Staging Ancillary tests

E. Management

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I. PELVIC ORGAN PROLAPSE Aims of surgery 1. Reestablish the anatomic position and support of the pelvic organs 2. Return of normal function of pelvic organs 3. Achieve patient satisfaction 4. Avoid complication or reoperation

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I. PELVIC ORGAN PROLAPSE COMPARTMENT

VAGINAL ROUTE

ABDOMINAL ROUTE

ANTERIOR Compartment Cystocele/ Cystourethrocele

Anterior Colporrhaphy Paravaginal Repair

Burch Colposuspension Paravaginal Repair Sacrocolpopexy

Posterior Colporrhaphy (fascial repair; levator myorrhaphy; site-specific repair; post-anal repair)

Sacrocolpopexy

(Vaginal Hysterectomy) Le Fort Colpocleisis Sacrospinous Ligament Fixation (SSLF) / Prespinous / Iliococcygeal Fixation USL Suspension/Plication McCall’s Culdoplasty

Sacrohysteropexy Sacrocolpopexy USL Fixation / Moschowitz Procedure / Halban’s Procedure

POSTERIOR Compartment Rectocele

MIDDLE/APICAL Uterovaginal Prolapse Vault Prolapse Enterocele

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II. URINARY INCONTINENCE A. B. C. D.

Definition Mechanism of continence Micturition cycle Classification Basic evaluation Specific conditions Genuine Stress Incontinence Overactive Bladder

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II. URINARY INCONTINENCE Definition Urinary incontinence is defined as the involuntary loss of urine that is objectively demonstrable and a social or hygiene problem.

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II. URINARY INCONTINENCE Mechanism of continence Continence is maintained when the maximum urethral pressure exceeds the maximum bladder pressure or when urethral closure pressure is positive.

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II. URINARY INCONTINENCE Mechanism of continence Intra-urethral pressure > Intravesical pressure = Continence • Low intravesical pressure >> Accommodation • High intra-urethral pressure >> Sphincter mechanism >> Pelvic floor contraction

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II. URINARY INCONTINENCE Micturition cycle Accommodation (Detrusor relaxed)

Contraction of the urethral sphincter ( Contraction of the pelvic floor (

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II. URINARY INCONTINENCE Storage Sympathetic (T10-T12) via hypogastric nerve -detrusor contraction inhibited -urethral sphincter closed

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II. URINARY INCONTINENCE Emptying Parasympathetic (S2-S4) via pelvic nerve -detrusor contraction -urethral sphincter relaxation Somatic via Pudendal nerve -external urethral sphincter contraction -pelvic floor contraction

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II. URINARY INCONTINENCE Classification Urethral sphincter incompetence Detrusor instability (Neuropathic or Non-neuropathic)

Urethral

Incontinence

Retention with overflow Congenital Miscellaneous Congenital

Extra-urethral Fistula

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II. URINARY INCONTINENCE A. B. C. D. -

Definition Mechanism of continence Micturition cycle Classification Basic evaluation Specific conditions Urodynamic Stress Incontinence Overactive Bladder

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II. URINARY INCONTINENCE

Evaluation Gynecologic 40% with urethral sphincter incompetence has anterior vaginal wall prolapse Fistulas may be observed with speculum exam Neurologic S2-S4 most important to assess - perineal sensation, anal wink, pelvic floor contraction, anal sphincter tone

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II. URINARY INCONTINENCE Evaluation • Urinalysis and urine culture - urge incontinence and irritative symptoms - infection, stones, urothelial disease

• Estimation of postvoid residual urine - adequate bladder emptying 200 mL - overflow incontinence

• Voiding diary - 3 day clinical record of input and output, urine volume and frequency, leak episodes and triggering factors

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II. URINARY INCONTINENCE Evaluation • Office cystogram with CST Simple bladder filling test that provides presumptive diagnosis of incontinence First sensation, first desire to void, strong desire to void, and maximum cystometric capacity are recorded Cough stress test (CST) is performed when nearing maximum capacity

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II. URINARY INCONTINENCE Evaluation • Office cystogram with CST Cough stress test (CST) Positive : Immediate non-sustained urine loss,; suggestive of stress incontinence Equivocal : Delayed sustained urine loss that cannot be inhibited is suggestive of detrusor instability (or overactive bladder)

*Immediate sustained may be suggestive of urethral sphincter incompetence

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II. URINARY INCONTINENCE Evaluation • Q-tip Test A sterile cotton tip is placed with the urethra and, upon straining or coughing, any deflection greater than 30’ from the horizontal is considered an indication of urethral hypermobility. - Does not correlate with urodynamic testing

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II. URINARY INCONTINENCE Evaluation • Cystometrogram Gold standard in evaluating bladder function Measures of the pressure/volume relationship of the bladder during filling and voiding Distinguishes between detrusor instability and genuine stress incontinence

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II. URINARY INCONTINENCE Stress incontinence Definition: Involuntary urine loss with physical exertion; when the intra-vesical pressure exceeds the urethral pressure in the absence of a detrusor contraction (Genuine stress incontinence)

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II. URINARY INCONTINENCE Stress incontinence Definition: Involuntary urine loss with physical exertion Urodynamic stress incontinence: Symptom of stress incontinence is confirmed by a urodynamic test Etiology: Descent or inadequate support of the bladder neck and mid-urethra as well as loss of urethral resistance

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II. URINARY INCONTINENCE Stress incontinence Urodynamic stress incontinence Etiology: Descent or inadequate support of the bladder neck and mid-urethra as well as loss of urethral resistance Treatment: Increase urethral resistance Physiotherapy Alpha-adernergic stimulants Restore bladder neck support Surgery copyright_joanneaguinaldomd_manilaphilippines_june2015

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II. URINARY INCONTINENCE Urge incontinence Definition: Involuntary urine loss associated with a strong desire to void (urgency) Overactive bladder syndrome: urinary urgency, frequency with or without urge incontinence

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II. URINARY INCONTINENCE Urge incontinence Overactive bladder syndrome: Urinary urgency, frequency with or without urge incontinence (exclude infection and other bladder pathologies with similar symptoms) Etiology: Results from uninhibited bladder contractions, either provoked or unprovoked

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II. URINARY INCONTINENCE Urge incontinence Overactive bladder syndrome: Urinary urgency, frequency with or without urge incontinence Etiology: Uninhibited bladder contractions Treatment: Lifestyle modifications (avoidance of triggers) Bladder retraining Anticholinergics Electrical stimulation Surgery copyright_joanneaguinaldomd_manilaphilippines_june2015

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II. URINARY INCONTINENCE Overactive Bladder Treatment: Conservative (Medical Therapy) Mechanism of Action Antimuscarinic

Drug Propantheline Br

Dosage 7.5-60 mg

Frequency 3-5 times/day  

Smooth muscle relaxant, antimuscarinic, local anaesthetic  

Smooth muscle relaxant, antimuscarinic

Oxybutynin

2.5-10 mg

2-3 times/day

 

 

 

Tolterodine Trospium Cl

1-4 mg 20 mg

2 times/day 2 times/day

Propiverine

15 mg

2-4 times/day

Dicyclomine HCl

10-20 mg

3 times/day

Imipramine HCl

25-75 mg

1-3 times/day

DDAVP (synthetic vasopressin)

100-200 mg

Once At bedtime

 

Antimuscarinic, calcium channel antagonist  

Smooth muscle relaxant (antispasmodic)  

Tricyclic antidepressant, antimuscarinic, alphaadrenergic agonist, antihistaminic  Antidiuretic

 

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REFERENCES Pelvic organ prolapse 1. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. http://www.ajog.org/pb/assets/raw/Health% 20Advance/journals/ymob/12_Bump.pdf 2. Pelvic organ prolapse (ICS committee report) http://www.ics. org/Publications/ICI_2/chapters/Chap05.pdf

Urinary incontinence 1. The neural control of micturition. http://www.ncbi.nlm.nih. gov/pmc/articles/PMC2897743/ 2. The standardisation of terminology of lower urinary tract function. http: //www.ics.org/Publications/ICI_3/v2.pdf/abram.pdf

Others 1. Evaluation and treatment of Urinary Incontinence, Pelvic organ Prolapse and Faecal Incontinence. http://www.ics.org/Publications/ICI_4/filesbook/recommendation.pdf 63

A Review of

UROGYNECOLOGY UPCM Interns’ Refresher Course 15 June 2015

Good Luck!

Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPS Clinical Associate Professor Section of Urogynecology and Pelvic Reconstructive Surgery Department of Obstetrics and Gynecology UP College of Medicine Philippine General Hospital 64