8th Edition APGO Objectives for Medical Students

1. 8th Edition APGO Objectives for Medical Students Pelvic Relaxation and Urinary Incontinence

2. Rationale Patients with conditions of pelvic relaxation and urinary incontinence present in a variety of ways. The physician should be familiar with the types of pelvic relaxation and incontinence and the approach to management of these patients.

3. Objectives The student will demonstrate knowledge of the following: • Predisposing factors for pelvic organ prolapse and urinary incontinence • Anatomic changes, fascial defects and neuromuscular pathophysiology • Signs and symptoms of pelvic organ prolapse • Physical exam • Cystocele • Rectocele • Enterocele • Vaginal vault or uterine prolapse

4. Risk factors Vaginal delivery • Large baby • Prolonged 2nd stage of labor • Forceps • Multiparous

5. Risk factors Increased abdominal pressure • Obesity • Chronic constipation • Chronic lung disease

6. Risk factors Altered nerve function or tissue strength • Diabetes • Neurologic diseases • Aging • Collagen disorders • Hypoestrogenism • Pelvic surgery

7. Anatomy • Basic • Levator ani muscles • Pubococcygeuas • Puborectalis • Iliococcygeus • Viscerofascial layer • Endopelvic fascia - attaches uterus and vagina to pelvic wall • Parametria - cardinal and uterosacral ligaments • Fascial defects • Neuromuscular pathophysiology

8. Signs and symptoms of pelvic organ prolapse Symptoms -prolapse • Asymptomatic • Vaginal pressure heaviness (>90%) • Vaginal pain • Sensation of tissue protruding from the vagina (>90%) • Abdominal pain • Low back pain • Dyspareunia/impaired coitus (37%) • Vaginal dryness • Ulceration • Bleeding • Urinary incontinence (33%)

9. Signs and symptoms of pelvic organ prolapse Symptoms - urinary incontinence - unexpected loss of urine • Stress incontinence - involuntary loss of urine with increased abdominal pressure (valsalva, cough, laugh, sneeze) • Urge incontinence - involuntary loss of urine associated with overwhelming urge to void

10. Physical exam (definitions) Cystocele • Defect where the bladder and anterior vaginal wall protrudes through the vaginal introitus • Secondary to attenuation or rupture of the pubovesical cervical fascia • Note anterior relaxation with urethral inclination • Mobility of bladder base and urethra with valsalva maneuver

11. Physical exam (definitions) Rectocele • Protrusion of posterior vaginal wall and anterior rectal wall • Look for bulging of posterior vaginal wall with valsalva maneuver • Insert a finger in rectum and, if vaginal and rectal tissue are jauxtaposed = rectocele

12. Physical exam (definitions) Enterocele • Elongation of posterior cul-de-sac along rectovaginal septum • 50% are diagnosed intraoperatively • Physical exam (patient standing) - palpate enterocele sac and small bowel

13. Physical exam (definitions) Uterine/vaginal vault prolapse • Uterine - descent of uterus and cervix into the vaginal canal • Exam - patient upright, valsalva • Look and fell for prolapse • Grade based on location from hymeneal ring • Vaginal vault - loss of support of vagina beginning at apex

14. Methods of diagnosis Urine culture • Rule out urinary tract infection • > 105 organisms Voiding diary • Normal bladder capacity (up to 60cc) • Normal frequency (<8 voids/day) • Accidents/leaking with physical activity • Amount and type of intake

15. Methods of diagnosis Standing stress test - note urine loss with cough or valsalva Q-tip test • Looks for hypermobility of the urethrovesical junction Resting position -30o or a change of greater than 30o is hypermobile

16. Methods of diagnosis Filling cystometrogram - examines the bladder during filling and storage • Post-void residual < 100cc • First urge - 100 - 200 mL • Maximum capacity - 400 - 500 mL • Resting bladder pressure < 10 - 15 cm of H2O Cystocopy

17. Nonsurgical and surgical treatments Pessary • Oldest effective treatment • If pelvic floor muscle damaged, they cannot be held in place • Adjunctive treatment - estrogen

18. Nonsurgical and surgical treatments Medications • Stress incontinence •  Antagonist to increase smooth muscle tone (phenylpropanolamine) • Estrogen to increase urethral resistance • Urge incontinence - anticholinergics to decrease spasm of the detrusor muscle (oxybutynin, tolterodine)

19. Nonsurgical and surgical treatments Pelvic floor muscle exercises • Kegels - voluntary contraction of the pelvic floor • Vaginal cones • Electrical stimulation

20. Nonsurgical and surgical treatments Surgery • Hysterectomy - vaginal or abdominal (route depends on other surgical interventions) • For anterior wall prolapse (cystocele) • Vaginal approach • Anterior colporrhaphy (central defect) • Paravaginal repair (lateral defect) • Abdominal approach - paravaginal repair

21. Nonsurgical and surgical treatments Surgery • For apical defect • Vaginal approach • Sacrospinous ligament fixation • Uterosacral colposuspension • Abdominal approach • Abdominal sacrocolpopexy • Uterosacral colposuspension

22. Nonsurgical and surgical treatments Surgery • For posterior defect - posterior colporraphy • For enterocele • Obliterate cul-de-sac with purse string suture in endopelvic fascia • McCall culdoplasty • Colpocleisis (LeFort procedure)

23. Nonsurgical and surgical treatments Surgery • For stress incontinence • Vaginal approach • Pereyra • Raz • Stamey • Tensionless vaginal tape (TVT)

24. Nonsurgical and surgical treatments Surgery • For stress incontinence • Abdominal approach • Marshall-Marchetti-Krantz (MMK) • Burch colposuspension

25. Nonsurgical and surgical treatments Surgery • For stress incontinence • Intrinsic urethral sphincter dysfunction • Suburethral sling • Bulking injections (with collagen) to improve urethral coaptation (for patients without urethrovesical junction hypermobility) • Artificial sphincter

26. References American College of Obstetricians and Gynecologists Technical Bulletin #214. Pelvic Organ Prolapse. ACOG: Washington DC 1995. American College of Obstetricians and Gynecologists Technical Bulletin #213. Urinary Incontinence. ACOG: Washington DC 1995. Mischel DR, ed., Comprehensive Gynecology 3rd ed., Mosby, St. Louis, MO, 1997. Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997

27. Clinical Case Pelvic Relaxation and Urinary Incontinence

28. Patient presentation A 75-year-old woman G5P5 presents complaining of “fullness” in the vaginal area. The symptom is more noticeable when she is standing for a long period of time. She does not complain of urinary or fecal incontinence. She has no other urinary or gastrointestinal symptoms. There has been no vaginal bleeding. Her past medical history is significant for well-controlled hypertension and chronic bronchitis. She has never had surgery.

29. Patient presentation Physical exam Pelvic exam reveals normal appearing external genitalia except for generalized atrophic changes. The vagina and cervix are without lesions. A second-degree cystocele and rectocele are noted. The cervix descends to introitus with the patient in an erect position. No rectal masses are noted. Rectal sphincter tone is slightly decreased. Uterus is normal size. Right and left ovaries are not palpable. Labs or StudiesNone DiagnosisPelvic organ prolapse

30. Management plan Management PlanPatient prefers non-surgical option Pessary placed and vaginal estrogen used to address atrophic changes

31. Teaching points • The patient’s multiple vaginal deliveries, age and chronic bronchitis places her at risk for pelvic organ prolapse. • Patients commonly present with a feeling of “fullness” or are able to touch vaginal or cervical tissue protruding through the introitus. They may or may not experience urinary incontinence.

32. Teaching points • In addition to pelvic muscle exercises, non-surgical management of pelvic organ prolapse mainly involves fitting the patient with a vaginal pessary. There are numerous vaginal pessaries designed to support specific types of pelvic organ prolapse. Pessaries press against the walls of the vagina and are retained within the vagina by the tissues of the vaginal outlet.

33. Teaching points • Pessaries may cause vaginal irritation and ulceration. They are better tolerated when the vaginal epithelium is well estrogenized; exogenous estrogen may be required in the hypoestrogenic patient. Periodically, vaginal pessaries should be removed, cleaned and reinserted. Failure to do so may result in serious consequences, including fistula formation.

34. Teaching points • Patients may be managed successfully with a pessary for years. Indications for surgery include the desire for definitive surgical correction, recurrent vaginal ulcerations with a pessary or stress incontinence that the patient finds unacceptable.