Prolapse & Urogynaecology Hester Mannion and Fabi Sica
Take home messages Prolapse and associated incontinence is very common It has a devastating effect on the QoL of the patient and their partner Strategies for prevention Conservative management should be considered before surgery
Prolapse- A prolapse is defined as one or more pelvic organs descending through the vaginal fascia in a downward displacement and out of the vaginal opening. 1
Prolapse is common Occurs in 50% of parous women 3 Prolapse and incontinence co-exist in up to 80% of women with pelvic floor dysfunction 3 10% of women >55yrs will undergo a hysterectomy for the treatment of prolapse 4
Prolapse and Incontinence Prolapse and incontinence have a devastating effect of peoples quality of life. There is an increased incidence of depression in patients with prolapse and incontinence, as shown by many studies. Ghetti et al 2010 found that women seeking surgery for pelvic organ prolapse were 5 times more likely to have depressive symptoms than the control 5.
How the patient feels? I feel like there is something down below, getting in my way I don t feel like I can have sex my partner because there s something there and I don t want him to see it or feel it all of a sudden I have no control over when I go the toilet! I m in my 40 s and I can t believe this is happening to me
History and Examination
History and Examination Begins with an abdominal examination. Followed by bimanual examination to exclude masses. A large prolapse can be visualised from the outside of the body. A Cusco s speculum can be used to assess the vaginal walls. A Sims speculum allows for inspection of the anterior and posterior vaginal walls, independently of each other.
Symptoms General/Vaginal symptoms: Sensation of fullness/ pressure Sensation of protrusion bulging down Seeing or even feeling the protrusion Coital difficulty: Loss of vaginal sensation Dyspareunia Vaginal flatus Bowel symptoms: Constipation/straining Urgency of stool Incomplete evacuation Self-digitation to evacuate stool Urinary symptoms: Incontinence, increased frequency and urgency Feeling of incomplete emptying
Types of prolapse
Urinary continence Image from http://sketchymedicine.com/about/ ali@sketchymedicine.com Continence depends on pressure in the urethra being greater than that in the bladder. Bladder pressure is influenced by detrusor pressure and external (intraabdominal) pressure. Urethral pressure is influenced by inherent urethral muscle tone and by external pressure from the pelvic floor in conjunction with intra-abdominal pressure.
Investigating incontinence Cystometry
Cystometry Image from Impey Ref 2
Physiology of urinary continence The bladder is innervated by the pelvic nerves which connect to the sacral plexus, cord segments S2 and 3. Sensory fibres detect the degree of stretch in the bladder wall Motor fibres then activate the detrusor muscle Skeletal motor fibres transmitted through the pudendal nerve supply the external bladder sphincter.
Physiology of urinary continence As the bladder fills micturation contractions occur The contractions relax spontaneously when the bladder is partially filled. As the bladder continues to fill, micturation reflexes become more frequent. Image from Guyton and Hall Ref no 7
Bladder training Mainly used for women with overactive detrusor muscles The aim is to slowly stretch the bladder so that it can retain larger volumes of urine. It begins by filling in a voiding chart and recording the patients normal habits for 2-3 days A person with an overactive bladder may go as often as once every hour and pass no more than 100-200mls each time The aim is to pass urine only 5-6 times in 24hours and to pass at least 250mls
Diagnosis and management A presumptive diagnosis of stress incontinence, prolapse and or urge incontinence can be made on a good history and physical examination alone. Conservative management is the first step. Pelvic floor supervised physiotherapy muscle exercise Dietary and weight loss advice Managing urinary urge incontinence- bladder training.
Diagnosis and management Pessaries are used in women who are normally unwilling or unfit for surgery. They stay behind the symphysis pubis and in front of the sacrum. A shelf pessary is more effective when the prolapse is more prominent/severe. Image from Wikipedia as acccessed on the 1/10/2014 http://en.wikipedia.org/wiki/file:pessary.png
Sacral nerve stimulation Effective treatment for urinary urge incontinence (overactive bladder) A small neurostimulator (about the size of a pacemaker) is inserted just beneath the skin. It can help restore coordination between brain, pelvic floor, bladder and sphincter muscles.
Posterior Tibial Nerve Stimulation (PTNS) Conducted as an outpatient appointment. Small acupuncture needle is inserted in to the ankle near the tibial nerve and connected to a stimulator. As many as twelve, 30 minute appointments may be required before improvements are seen.
Surgical management The type of prolapse will determine the type of surgery the patient will require Indicated when there is a failure with the pessary, when a prolapse shows combined urinary and faecal incontinence or when the patient wants a definitive treatment. Anterior/posterior vaginal wall repair Synthetic mid-urethral tape Open colopsuspension Autologous rectus fascial sling
Take home messages Prolapse and associated incontinence is very common It has a devastating effect on the QoL of the patient and their partner Strategies for prevention Conservative management should be considered before surgery
References 1. NICE guidelines on urinary incontinence in women Internet source, available at: http://guidance.nice.org.uk/cg171 Accessed: 09/09/14 2. Impey and Child (2012). Obstetrics and gynaecology. 4th ed. West Sussex: Wiley-Blackwell. 55. 3. Genitourinary Prolapse Patient.co.uk Internet source, available at http://www.patient.co.uk/doctor/genitourinary-prolapse-pro Accessed: 09/09/14 4. Bladder training and urge urinary incontinence Patient.co.uk Internet source, available at http://www.patient.co.uk/health/overactive-bladder-syndrome Accessed: 17/09/2014 5. Open Colposuspension Internet source, available at http://www.webmd.boots.com/urinary-incontinence/stress-incontinence-colposuspension Accessed: 17/09/2014 6. Khan ZA, Nambiar A, Morley R, Chapple CR, Emery SJ, Lucas MG. (2014). Long term follow-up of a multicentre randomised controlled trial comparing TVT, Pelvicol TM and autologous fascial slings for the treatment of stress urinary incontinence in women. BJU international. Epub ahead of print. 7. Guyton and Hall (2006) Guyton and hall textbook of medical physiology. 12 th edition. Saunders Elsiver USA.