John Laughlin

4th 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

Image Source http://www.beltina.org/pics/uterine_prolapse.jpg

http://www.afayyad.co.uk/siteimages/large/DSC_0002.JPG

Image Source http://img.medscape.com/fullsize/migrated/editorial/casecme/2006/5780/5780-fig5.jpg

Anterior Wall/Cystocele Posterior Wall/Rectocele

Image Source http://www.mdguidelines.com/images/Illustrations/cys_rect.jpg

Urethrocele Enterocele (Pouch of Douglas)

Image source: http://www.nvscc.com/enterocele.htm Image source: http://64.143.176.9/library/healthguide/en-us/support/topic.asp?hwid=zm5069

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/urinary-incontinence-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/urinary-incontinence/DS00404

http://www.kentgynaecologist.com/tvt.html

http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm262435.htm