John Laughlin 4 th year Cardiff University Medical Student
Prolapse/incontinence You need to know: Pelvic floor anatomy in relation to uterovaginal support and continence The classification of uterovaginal prolapse, its clinical features and management options The different types of urinary incontinence, their clinical features, investigations and management options Additional reading: NICE Guideline Urinary Incontinence RCOG Consent Advice - Vaginal Surgery for Prolapse (Consent Advice 5)
Image Source Elesevier. Drake et al: Gray s Anatomy for Students www.studentconsult.com
Structure Function Result of inadequacy Cardinal and Uterosacral Ligaments Attach to cervix and suspend the uterus Uterine Prolapse Levator Ani Muscle Forms the pelvic floor Vaginal wall prolapse
Uterine Vaginal Wall Anterior Wall Cystocele Bladder prolapse Urethrocele Urethral prolapse Posterior Wall Rectocele Rectal prolapse Enterocele Pouch of Douglas Prolapse Often can be mixed
1st degree: cervix visible when the perineum is depressed -prolapse is contained within the vagina 2nd degree: cervix prolapsed through the introitus with the fundus remaining in the pelvis 3rd degree: procidentia (complete prolapse) -entire uterus is outside the introitus
http://www.afayyad.co.uk/siteimages/large/dsc_0002.jpg Image Source http://www.beltina.org/pics/uterine_prolapse.jpg Image Source http://img.medscape.com/fullsize/migrated/editorial/c asecme/2006/5780/5780-fig5.jpg
Anterior Wall/Cystocele Posterior Wall/Rectocele Image Source http://www.mdguidelines.com/images/illustrations/cys_rect.jpg
Urethrocele Image source: http://64.143.176.9/library/healthguide/enus/support/topic.asp?hwid=zm5069 Enterocele (Pouch of Douglas) Image source: http://www.nvscc.com/enterocele.htm
Weakened support of the pelvic organ supports due to Age Vaginal Delivery Risk increases with parity Oestrogen Deficiency Iatrogenic eg post hysterectomy Genetic Predisposition Collagen weakness Increased strain on supports Obesity Pelvic Masses Chronic Cough Ascites Straining due to constipation or heavy lifting
Often asymptomatic if mild Symptoms can seriously affect QoL Common to all Dragging/pressure/fullness/heaviness sensation Something coming down Visible bulge/ protrusion Difficulty with tampon use Urethrocele Stress Incontinence, Frequency, Urgency, Incomplete bladder voiding Manual reduction of the prolapse before voiding Requirement to alter position to commence or end voiding
Rectocele Constipation/straining, urgency, mass felt in vagina, incomplete evacuation, splinting, digital evacuation Enterocele Bowel Obstruction
Conservative if asymptomatic prolapse. Little consensus of opinion or evidence. Poorer prognosis with age, obesity, respiratory disease, co-morbidities Watchful waiting lifestyle advice Pessary (ring or shelf) Oestrogen creams Pelvic floor (Kegel) exercises Physiotherapy Surgery Wall repair Hysterectomy
Continence Urethral pressure must be higher than bladder pressure Bladder pressure Detrusor pressure Intra-abdominal pressure Urethral pressure Internal urethral sphincter muscle tone External pressure: pelvic floor and intra-abdominal pressure
Bladder Pressure > Urethral Pressure Pelvic floor relaxes (Urethral pressure drops) Detrusor muscle contracts (Bladder pressure increase)
Over active bladder Uncontrolled increase in detrusor muscle contraction Genuine Stress Incontinence (GSI) Intra-abdominal pressure increase applied to bladder but not urethra Pressure difference between bladder and urethra = flow Some other rarer causes e.g. Fistula
Urgency sometimes with urge incontinence Usually with frequency and nocturia Urine leakage due to detrusor overactivity Urodynamics important in diagnosis Aetiology Idiopathic Iatrogenic following surgery for GSI Associated with neuro disease e.g. MS Rx Bladder retraining 6 weeks Behavioural therapy reduce caffeine and fluid intake Hypnotherapy and acupuncture Anticholinergics main side effect Dry mouth Oestrogen cream Synthetic ADH Desmopressin (for nocturia) Botulinum toxin A into detrusor muscle
50% of cause of incontinence in women Very common 10% of women Pregnancy and vaginal delivery risk increased with forceps Obesity Increasing age, especially post-menopausal (oestrogen association) Pelvic floor weakness bladder neck passes through Increased intra-abdominal pressure not equally applied to bladder and urethra e.g. by sneezing, bearing down, coughing, running Increased pressure gradient results in urine leakage
History Examination Sim s Speculum inspection may reveal cystocoele or Urethrocele Urine leakage on coughing Abdominal palpation exclude distended bladder Investigation Urine dipstick Cystometry (urodynamic studies)
Conservative Similar to prolapse weight loss, address chronic cough PF exercises Weight loss Vaginal cones Medical Duloxetine licensed but poor evidence Surgery Cystometry required to exclude overactive bladder Tension-Free Vaginal Tape/Trans-Obturator Tape Genuine Stress Incontinence vs Stress Incontinence
Periurethral injections bulking agents Colposuspension Open or laparascopic Lower long term success rate Tension Free Vaginal Tape Quicker, less invasive 85% success rate Decreases with time Side affects FDA warnings Transobturator Sling Lower incidence of bladder/bowel injury Image Source http://www.mayoclinic.com/health/urinaryincontinence-surgery/wo00126
Prolapse and incontinence very common Many women suffer in silence Affects quality of life High morbidity Conservative treatment possible Surgical success rates variable Debate about efficacy and safety
Impey L, Child T. Obstetrics and Gynaecology. 3rded. Wiley-Blackwell; 2008. http://www.urogynaecology.com.au/cm.htm http://www.mayoclinic.com/health/urinaryincontinence/ds00404 http://www.kentgynaecologist.com/tvt.html http://www.fda.gov/medicaldevices/safety/al ertsandnotices/ucm262435.htm