Urogynaecology & Prolapse. Alexander Denning and Leifa Jennings

Transcription

1 + Urogynaecology & Prolapse Alexander Denning and Leifa Jennings

2 + Contents What even is prolapse / urogynaecology? Pelvic floor anatomy Prolapse Urinary incontinence Prevention The end (woot)

3 + Urogynaecology and Prolapse Urogynaecology: The investigation and treatment of prolapse and bladder problems in women 1 Prolapse: The bulging of one or more pelvic organs into the vagina 2 Both are very common Lower urinary tract dysfunction and genital prolapse affects over 20% of the adult population C 1 in 8 women will undergo a urogynaecological operation during their lifetime A

4 + Pelvic Anatomy

5 + Pelvic Floor

6 + Prolapse Descent of one or more of the pelvic organs Anterior compartment: Bladder Cystocele Urethra Urethrocele Middle compartment: Uterus Uterine prolapse Vaginal vault Vaginal prolapse (Hysterectomy) Small/Large intestine - Enterocele Posterior compartment: Rectum Rectocele In the Women's Health Initiative Study, 41% of women aged showed some degree of pelvic organ prolapse. 3 34% cystocele, 19% rectocele, 14% uterine prolapse

7 + Cystocele

8 + Rectocele

9 Utero Vaginal Prolapse +

10 + Enterocele

11 + Causes The pelvic organs are supported by the levator ani muscles (pelvic floor muscles) and the endopelvic fascia Genitourinary prolapse occurs when this support structure is weakened via Direct muscle trauma, Neuropathic injury, Disruption or stretching The orientation and shape of the bones of the pelvis have also been implicated in the pathogenesis of genitourinary prolapse. Confirmed Risk Factors Increasing age Vaginal delivery Increasing parity Overweight and obesity Possible Risk Factors Fetal Macrosomia Use of forceps during delivery Prolonged labour Race Family history Hysterectomy Oxytocin and epidural during labour

12 + Symptoms Vaginal/general symptoms Sensation of pressure, fullness or heaviness. Sensation of a bulge/protrusion or 'something coming down'. Seeing or feeling a bulge/protrusion. Difficulty retaining tampons. Spotting (in the presence of ulceration of the prolapse). Urinary symptoms Incontinence. Frequency and/or urgency. Feeling of incomplete bladder emptying. Weak or prolonged urinary stream. The need to reduce the prolapse manually before voiding. The need to change position to start or complete voiding. Coital difficulty Dyspareunia. Loss of vaginal sensation. Vaginal flatus. Bowel symptoms Constipation Urgency of stool. Incontinence of flatus or stool. Incomplete evacuation. The need to apply digital pressure to the perineum or posterior vaginal wall to enable defecation (splinting). Digital evacuation necessary in order to pass a stool.

13 + Investigations Diagnosis is usually clinical and based on history and examination. If there are urinary symptoms consider the following: Urinalysis ± a mid-stream specimen of urine. Post-void residual urine volume testing using a catheter or bladder ultrasound scan. Urodynamic investigations. Urea and creatinine. Renal ultrasound scan. If there are bowel symptoms consider the following: Anal manometry. Defecography. Endo-anal ultrasound scan (to look for an anal sphincter defect if faecal incontinence is present).

14 + Grading the Prolapse The Pelvic Organ Prolapse Quantification (POPQ) system is the recognised grading system for the severity/degree of genital prolapse. It is based on the position of the most distal portion of the prolapse during the Valsalva manoeuvre Stage 0: no prolapse. Stage 1: more than 1 cm above the hymen. Stage 2: Stage 3: Stage 4: within 1 cm proximal or distal to the plane of the hymen. more than 1 cm below the plane of the hymen but protrudes no further than 2 cm less than the total length of the vagina. complete eversion of the vagina.

15 + Management Watchful waiting if the patient is suffering few symptoms. Pelvic floor exercises Kegel exercises. Vaginal pessary - provide support and relieve pressure on the bladder and bowel. Many varieties but a ring pessary is normally the first choice. Surgery - failure of pessary, patient who wants definitive treatment, prolapse combined with urinary or faecal incontinence. Pelvic floor repair - if prolapse of the anterior or posterior walls of the vagina. The walls of the vagina are tightened up to support the pelvic organs. Some surgeons use mesh to support tissues. Sacrocolpopexy or sacrospinous fixation - operations that lift up and attach uterus or vagina to the sacrum or a ligament within pelvis. Hysterectomy - sometimes performed for uterine prolapse. Colpocleisis surgical closure of the vagina. This is rare and only seen if the patient is in very poor medical health or has had several unsuccessful operations previously.

16 + Urogynaecology The 3 most common urogynaecological complaints are: Urinary incontinence Frequency Urgency Urinary Incontinence: Involuntary urine loss that is objectively demonstrable and that is a social or hygienic problem. 4

17 + Urinary Incontinence: Epidemiology Can be due to neurological problems, age, functional problems, cognitive deficits, and medication side effects 5 Urinary incontinence has been estimated to affect 5-69% of all women More prevalent with increasing age. 6 Affects 30-60% of pregnant women.5 Also affects men

18 + Urinary Incontinence: Effects Why is urinary incontinence such a problem? Medical side effects: Risk of recurrent UTIs Cellulitis Candida infection Sleep interruptions Falls & fractures Psychological side effects: Embarrassment Social isolation Depression

19 + Types of Urinary Incontinence 90% is stress incontinence or urge incontinence. 7 Stress incontinence is leakage of urine due to raised intra-abdominal pressure, usually due to weakened pelvic floor muscles. Urge incontinence is urine leakage accompanied or immediately preceded by urgency, often caused by detrusor overactivity. 8 Mixed incontinence shows symptoms of both types. Overflow incontinence is rarer in women, and usually occurs due to bladder outflow obstruction and is treated by catheterization. Overactive bladder syndrome is a combination of urgency + frequency + nocturia, and can sometimes present with urge incontinence too.

20 + Risk Factors For Developing Urinary Incontinence Increasing age Pregnancy & increased parity Smoking (chronic cough) Increased BMI (in morbidy obese patients dramatic weight loss has been shown to improve urinary incontinence) 9 Diabetes Mellitus Neurological conditions

21 + Investigations for Urinary Incontinence (NICE, 2013) History Digital examination of pelvic floor muscle strength Urine dipstick Check for residual urine with bladder scan / catheterization QOL questionnaires Bladder diary Urodynamic studies

22 + Urodynamic Studies Urodynamic studies assess the function of the bladder and urethra and help aid diagnosis of the pathophysiology behind the incontinence.

23 + Conservative Treatment (NICE, 2013) Reduce caffeine intake Reduce fluid intake overall (last drink at 6pm) Reduce BMI if overweight Pelvic floor exercises (see later slides) Bladder retraining for urge / mixed incontinence (hold on!)

24 + Medical Treatment (NICE, 2013) May be suitable for overactive bladder and urge incontinence Oxybutynin Tolterodine Darifenacin All block muscarinic acetylcholine receptors which decreases bladder contractions. Side effects include dry mouth and constipation Desmopressin can be used to reduce severe nocturia (increases water reabsorption in renal collecting ducts, meaning that you pee less)

25 + Invasive Treatment (NICE, 2013) Botulinum toxin A injections to bladder Paralyses over-active detrusor muscle Need to be repeated every 6-9 months May need to self-catheterise Sacral nerve stimulation 10 aka bladder pacemaker Contracts urethral sphincter and pelvic floor muscles which in turn inhibits bladder contractions. 12 months after insertion 45% of patients were totally dry, and 82% felt an improvement in the degree of urgency. 11 Airport scanners can cause problems!

26 + Surgical Treatments (NICE, 2013) Synthetic mid-urethral tape (used for stress incontinence) Animation 12 Can be either retropubic or transobturator 88% of patients highly satisfied with result 13 Autologous rectus fascial sling (similar to the tape, but uses a piece of rectus fascia to form the sling)

27 + Surgical Treatments Cont. Colposuspension rarely used now Pulls the neck of the bladder into its rightful place Stitch anterior vaginal wall to fascia of pubic bone Used for stress incontinence Intramural bulking agents (e.g. silicone, collagen) Injected into urethral wall, causing it to tighten Around 50% had no incontinence after 12 months 14 Effectiveness reduces over time

28 + Prevention of Urinary Incontinence Aim for a healthy body weight Reduce constipation Keep active Reduce alcohol and caffeine Kegel / pelvic floor exercises (especially in pregnancy)

29 + References Hendrix SL, Clark A, Nygaard I, et al; Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol Jun;186(6): Gupta, J.K, Mires, G., and Khalid, S.K. (2006). Core clinical cases in obstetrics and gynaecology. (2nd Ed.) Birmingham: Hodder Arnold Cristofi, N. and Hextall, A. (2008). Obesity and urinary incontinence. Menopause International, 14:

30 + Image Credits All prolapse diagrams from: Pelvic floor pictures from: Photo of lady doing Kegel exercises - Ring pessary - Bladder Diary image from: Bladder pacemaker image from: Image Colposuspension image from: Tena image from: Espresso image from: Male and female toilet image from: Medication boxes images from: Jagerbomb image from: Pelvic floor exercises image from: