Prolapse and Urogynae. By Sarah Rangan & Daniel Warrell

Prolapse and Urogynae By Sarah Rangan & Daniel Warrell

Anatomy and physiology of the pelvic supports The pelvic floor supports the pelvic viscera and vaginal, urethral and rectal openings Endopelvic fascial attachments support the vagina at three levels Level 1: cardinal and uterosacral ligaments support the cervix and upper third of vagina Level 2: mid vagina is attached to the pelvic sidewalls via the endopelvic fascia Level 3: lower third of the vagina is supported by the levator ani and perineal body

Types of Prolapse Prolapse is classified anatomically Urethrocoele : lower anterior vaginal wall involving urethra Cystocoele : upper anterior vaginal wall involving bladder and often urethra Apical Prolapse : uterus, cervix and upper vagina (or vault if uterus removed) Enterocoele : upper posterior wall of vagina or pouch of Douglas (can contain loops of bowel) Rectocoele : lower posterior wall of vagina involving rectum

Grading Of prolapse Most widely achieved by the ICS s (International Continent Society) Pelvic Organ Prolapse (POP) scoring system Conditions of measurement must be specified : position, rest/straining, traction

Aetiology of prolapse Up to half of parous women have some degree of prolapse Prolapse is the most common reason for hysterectomy in women aged over 50. Causes of Prolapse: Vaginal delivery and Pregnancy, risk increased with large infants, instrumental deliveries and prolonged second stage Congenital Factors such as connective tissue disorders (due to abnormal collagen metabolism) Menopause possibly due to deterioration of collagenous tissue following oestrogen withdrawal Chronic predisposing factors such as raised intre abdominal pressure in chronic cough, obesity constipation or pelvic mass. Iatrogenic factors such as pelvic surgery (hysterectomy) or continence procedures

Clinical Features of Prolapse HISTORY Dragging sensation or sensation of a lump Worsens on standing or at the end of the day Interference with intercourse Bleeding and discharge possible due to ulceration Urinary frequency and incomplete bladder emptying Associated stress continence Necessity to digitally manipulate prolapse to pass stool or urine EXAMINATION Abdomen and Bimanual to exclude pelvic masses Use Sim s Speculum and ask patient to bear down To separate enterocoele from rectocoele place a finger in the rectum it will cause a rectocoele to bulge! Test stress continence by asking patient to cough while reducing the prolapse.

Investigation and Prevention of Prolapse Investigations Consider pelvic US if a mass is suspected Consider Urodynamic testing Assess fitness for surgery often elderly patients Prevention Good intrapartum care to avoid prolonged labour Pelvic floor exercises

Management of Prolapse CONSERVATIVE Watchful waiting Weight loss Smoking cessation Physiotherapy and pelvic floor exercises MEDICAL Ring pessary Shelf pessary HRT or topical oestrogen to prevent ulceration

Management of Prolapse SURGICAL Very effective but a combination of procedures may be required Indications for surgery are: failure of pessary, a patient who wants definitive treatment, prolapse combined with urinary or faecal incontinence. The choice of procedure depends on whether the woman is sexually active, whether her family is complete, her general fitness, and surgeon's preference. Surgery may be by the abdominal route, or vaginal. Evidence supports the greater efficacy of the abdominal route. Surgery may use a mesh or not. There are many types of mesh used, including biological grafts. Types of surgery which necessitate the use of mesh include sacrocolpopexy, infracoccygeal sacropexy, uterine suspension sling, and colpoperineopexy. Types of surgery which do not use mesh include hysterectomy, cervical amputation, and uterine/vault suspension.

Disorders of the Urinary Tract

Anatomy and function Normal filling requires adequate bladder capacity and urethral sphincter function Normal voiding requires detrusor muscle contraction coordinated with urethral relaxation

Anatomy and function Smooth wall of bladder detrusor muscle Bladder can normally store 500ml 500 ml

Anatomy and function Smooth wall of bladder detrusor muscle Bladder can normally store 500ml Void urge starts at 200ml 200 ml

Anatomy and function Smooth wall of bladder detrusor muscle Bladder can normally store 500ml Void urge starts at 200ml Drain by 4cm long urethra

Anatomy and function Smooth wall of bladder detrusor muscle Bladder can normally store 500ml Void urge starts at 200ml Drain by 4cm long urethra External orifice is the vestibule just above vaginal introitus

Anatomy and function Neural control

Anatomy and function Neural control Parasympathetic Nerves aid voiding Sympathetic Nerves prevent voiding

Anatomy and function Neural control

Anatomy and function Neural control Reflex afferent fibres detect stretch

Anatomy and function Neural control Efferent parasympathetic Contraction of detrusor muscle Pelvic nerve ACH binds to M3 receptor Relaxation of external sphincter Pudendal nerve ACH binds to nicotinic receptor

Continence Continence Pressure of the urethra higher than the pressure in the bladder Bladder pressure influenced by detrusor muscles pressure intra abdominal pressure (external pressure) i.e. a cough, sneeze Urethra pressure influenced by muscle tone of urethra Intra abdominal pressure Pelvic floor muscles

Continence Continence Pressure of the urethra higher than the pressure in the bladder Detrusor muscle is expandable No increase in pressure as fills Increase in intra abdominal pressure distributed equally between urethra and bladder as both lie within abdominal cavity Normally a cough would not lead to incontinence

Micturition Bladder pressure exceeds urethral pressure achieved through voluntary coordination

Incontinence Generally two types Uncontrolled increase in detrusor pressure overactive bladder

Incontinence Generally two types Uncontrolled increase in detrusor pressure detrusor overactivity overactive bladder Increase in intra abdominal pressure transmitted to bladder rather than both bladder and urethra urinary stress incontinence

Urinary tract investigations Urine dipstick Nitrates suggest infection sent for microscopy and culture to confirm Glucose diabetes Haematuria calculi, carcinoma, infection

Urinary tract investigations Urine dipstick Nitrates suggest infection sent for microscopy and culture to confirm Glucose diabetes Haematuria calculi, carcinoma, infection Urinary diary record of fluid intake and micturition, drinking habits, frequency and bladder capacity Ultrasound excludes incomplete bladder emptiness, congenital abnormalities, calculi, tumours, cortical scaring of the kidneys Abdo x ray foreign bodies and calculi Abdo CT with contrast examine ureter integrity and route Cystoscopy inspection of bladder, tumour, stones, fistula etc.

Urinary tract investigations Cystometry Detects pressure in the bladder and intraabdominal pressure to work out the pressure generated by the detrusor muscle. This test can determine whether the incontinence is urinary stress incontinence (USI) or detrusor overactivity (DOA) Usually not indicated unless lifestyle and drug therapies have failed, or considering surgery for stress incontinence.

Urinary tract investigations Cystometry Bladder Pressure Intra abdo Pressure Detrusor Pressure Urine Flow Cough Filling A Cough Filling B Cough Filling C A normal bladder, No increase in detrusor muscle when filling No detrusor contraction when cough No urine flow when cough B Urinary stress incontinence No increase in detrusor muscle when filling No detrusor contraction when cough Urine flow when cough C Detrusor overactivity Detrusor contraction after cough Urine flow with detrusor contraction if pressure is so much to overcome urethral pressure

Urinary stress incontinence Involuntary leakage of urine on effort or exertion, or sneezing and coughing Can be confirmed by excluding DOA using cystometry. Epidemiology almost 50% of all causes of incontinence, in more than 10% of all women Pelvic floor Urethra Bladder pressure Bladder A Ureter Urethral pressure Aetiology pregnancy, prolonged vaginal delivery, forceps delivery, obesity, age, and previous hysterectomy Bladder pressure Normally during an increase in abdominal pressure both the bladder and urethra experience it equally. However if the bladder neck slips down due to a weak pelvic floor, the remainder of the urethra and the pelvic floor will be unable to compensate which will result in incontinence. Pelvic floor Urethra Bladder B Ureter Bladder pressure

Urinary stress incontinence Clinical features History Frequency, urgency, and urge incontinence, I leak when I cough Examination Speculum may reveal cystocoele or urethrocele, leakage of urine may be seen when coughing. Palpate abdomen to exclude distended bladder

Urinary stress incontinence Management Generally conservative lose weight, eliminate causes of cough and sneezing allergies, smoking etc, advise on excessive fluid intake Pelvic floor training exercises Drugs duloxetine. For severe USI, serotonin and noradrenaline reuptake inhibitor to enhance urethral sphincter muscle activity side effects, dyspepsia, dry mouth, dizziness, insomnia Surgery when conservative measures have failed. Tans obturator tape usually first line. Cure rates up to 90%. Complications include perforations, post operative voiding difficulty, bleeding, infection.

Overactive bladder Urgency with or without urge incontinence, usually with frequency or nocturia, in the absence of infection. Usually caused by detrusor overactivity during the filling phase. This can occur spontaneously or provoked i.e. with coughing therefore can be confused for USI Result of 35% of female incontinence Most commonly idiopathy, but can occur in underlying neuropathy such as multiple sclerosis or spinal cord injury

Overactive bladder Clinical features History urgency, urge incontinence, frequency and nocturia. Stress incontinence is common, coughing, sneezing, orgasm. Childhood history of enuresis is common Examination normally normal, incidental cystocoele may be present. Investigations Urinary diary, cystometry

Overactive bladder Management Conservative advise of fluid intake, caffeine restriction, bladder training delaying going to toilet Drugs review current medication diuretics and antipsychotics Anticholinergics to supress detrusor activity Oestrogen in postmenopausal women can reduce symptoms of urgency Bo tox into detrusor muscle, very effective 60 93%, though can cause urinary retention. Surgery ileocystoplasty, increases bladder capacity

Other disorders of the Urinary Tract Acute urinary retention unable to pass urine for 12 hours Causes epidural, post vulval/perineal surgery, anticholinergics, retroverted gravid uterus, pelvic mass, neurological disease (MS) Treatment catheterisation whilst cause is treated. Chronic retention/urinary overflow overdistension causing overflow Causes masses or detrusor inactivity. Presentation may mimic USI, examination reveals non tender distended bladder. Diagnosis confirmed by ultrasound. Treatment self catheterisation

Other disorders of the Urinary Tract Fistulae very rear 0.3% 1. Urethrovaginal fistulae Uterus 3 Ureter 2. Vesicovaginal fistulae Bladder 3. Vesicouterine fistulae Urethra 4. Ureterovaginal fistulae 1 Vaginal canal 2 4

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