Urogynecology Done by: Thaer Omar Alqatish - PowerPoint Presentation

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Urogynecology

Done by: Thaer Omar Alqatish

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Pelvic organ prolapse (POP)

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Pelvic organ prolapse (POP)

Definition Decent of one or more of the pelvic organs (uterus, urinary bladder, urethra, rectum , and loops of bowel), downwards into the vagina.Epidemiology

Common problem in women(12-30% of women) Increase significantly by both age and

multiparity

(or large birth)

.

Surgery

, 5-7% develop post-hysterectomy vault prolapseIncrease intra-abdominal pressure (obesity, straining, chronic cough, chronic constipation,….)

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Anatomy

** Structures that supports the pelvic organs: a. Transverse cervical ligament b. Uterosacral ligament c. Pubocervical

ligamentd. Pelvic floor muscles: The levator

ani

muscles (

Ischio-coccygeus

muscle,

Ilio-coccygeus muscle, Pubo-coccygeus muscle)

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Types of POP

1) Anterior vaginal wall prolapse (anterior compartment) - Urethrocele, Cystocele

, cysto-urethrocele. 2) Posterior vaginal wall prolapse (posterior compartment) -

Rectocele

,

Enterocele

.

3) Apical vaginal prolapse (central compartment) - Utero-vaginal prolapse, Vault prolapse

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Presentation & dx

They all present with > vaginal fullness & back pain Presentation specific to the type: Cystocele (urine incontinence), rectocele (constipation, fecal incontinence)Dx > clinically (speculum examination)

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Cystocele

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Rectocele

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Uterine prolapse

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POP grading system

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Baden Walker Grading of POP

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Congenital POP

Congenital weakness of the pelvic supports associated with:

1) Short vagina 2) Spina

bifida

3) Deep

uterovaginal

, and uterosacral pouches

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Treatment of POP

1. Conservative Pelvic floor physiotherapy (Kegal exercises)Vaginal pessary

2. Surgical:basically, remove or repair the uterus (Hysterectomy or hysteropexy

)

Rectocele or cystocele repair (

colporrhaphy

, anterior & posterior repair)

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Pessary

A pessary is a prosthetic device that can be inserted into the vagina to support its internal structure (either lifts the bladder or apply compression to the urethra preventing leakage).

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Indications for surgical tx

1. Failed conservative 2. Severe degree 3. Pt. doesn’t desire to preserve fertility

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Anterior repair

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Posterior repair Perineal reconstruction

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Hysterectomy or hysteropexy

To preserve fertility > go for hysteropexy.If no worries about fertility > you can go for Hysterectomy (also

eliminates risk of cervical / uterine pathology)

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Complications of surgical tx:

1. General complications Anesthetic problemsBleeding: Serious requiring transfusion ( < 1%)

Post operative infectionUTI : 6% if a catheter has been used2. Specific complications

Injury to bladder, urethra, ureters, rectum

Postoperative stress urinary Incontinence

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Urinary incontinence

Definition is the inability to hold urine, producing involuntary urinary leakage > resulting in hygiene & social concerns.

EpidemiologyThe prevalence increases with age

,

with approximately

5 % of women between 15 and 44 years of age being affected, rising to 10 % of those aged between 45 and 64 years, and approximately 20 % of those older than 65 years

.

SmokingPregnancy & childbirth

Increase

intrabdominal

pressure > chronic cough, constipation, occupational lifting.

Menopause

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Physiology of continence

Mechanical

Neural

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Classification of Incontinence

Urodynamic stress incontinence (USI)Motor Urge (Hypertonic) IncontinenceOverflow (Hypotonic) IncontinenceSensory

Irritative IncontinenceFistula

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Dissecting incontinence case

1- History > is there an urge to void ? is there nocturnal symptoms? 

2- pay attention to the PE, UA, cystometry

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The following are parameters of normal bladder function:

Residual urine of <50 mL.First desire to void between 150 and 200mL.

Capacity between 400 and 600 mL.

Detrusor pressure rise of <15 cmH2O during filing and

standing.

Absence of systolic detrusor contractions.

No

leakage on coughing.

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Urodynamic stress incontinence

is defined as the involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction (the pressure rise forms outside the bladder

).This is the most common incontinence in young women

.

Causes

: loss of pelvic support (birth, menopause, congenital) , increasing

intrabdominal

pressure (chronic cough, constipation, etc..)28

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History

No urge > loss of urine occurs in small spurts simultaneously with coughing or sneezing. No nocturnal symptoms > it

does not take place when the patient is sleeping. Examination

Pelvic

examination may reveal a cystocele

.

Neurologic

examination is normal. Q tip test??Investigative studies

.

Urinalysis

and culture are normal.

Cystometric

studies are normal with no involuntary

detrusor contractions

seen.

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Management

Conservative > Kegel exercises & pessariesSurgical tx >

(Burch procedure or Marshall

Marchetti-Kranz

(MMK)

procedure) {basically

elavate

& attach the urethral sphincter to the symphysis pubis} > A minimally invasive surgical procedure is the tension-free vaginal tape procedure in which a mesh tape is placed

transcutaneously

around and under the mid

urethra.

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Motor Urge (Hypertonic) Incontinence

This is the most common incontinence in older womenEtiology: involuntary rises in bladder pressure occur from idiopathic detrusor contractions that cannot be voluntarily suppressed.

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History

Loss of urine occurs in large amounts often without warning. This can take place both day and night. The most common symptom is urgency.Examination Pelvic examination shows normal anatomy. Neurologic examination is normal.

Investigative studies Urinalysis

and culture

are normal

.

Cystometric

studies show normal residual volume, but involuntary detrusor contractions are present even with small volumes of urine in the bladder.

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Management

Anticholinergic medications (e.g., oxybutynin [Ditropan]) Side effects??; nonsteroidal anti-inflammatory drugs (NSAIDs) to inhibit detrusor contractions; tricyclic antidepressants; calcium-channel

blockers.Second-line treatmentEndoscopic injection of botulinum toxin at different points in the bladder wall

Sacral nerve stimulation

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Overflow (Hypotonic) Incontinence

It’s leakage secondary to over-distended bladder, which becomes higher than urethral pressure. There is no or poor bladder contractionEtiology: Denervated

bladder (e.g., diabetic neuropathy, multiple sclerosis)Medication

like anti-cholinergic or

alpha agonist

Urethral

obstruction

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History

Loss of urine occurs intermittently in small amounts. This cantake place both day and night. The patient may complain of pelvic fullness. Examination

Pelvic examination may show normal anatomy; however, the neurologic examination will show decreased pudendal nerve sensation.

Investigative studies

Urinalysis

and culture are usually normal, but may show

an infection. Cystometric studies show markedly increased residual volume, but involuntary detrusor contractions do not occur.

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Management

Treatment of underlying conditionintermittent self-catheterizationCholinergic medications to stimulate bladder contractions

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Sensory Irritative Incontinence

Etiology: Detrusor contractions stimulated by irritation from any

of the following bladder conditions: infection, stone, tumor, or a foreign body.

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History

Loss of urine occurs with urgency, frequency, and dysuria. This can take place day or night.Examination Suprapubic

tenderness may be elicited, but otherwise the pelvic examinationis unremarkable. Investigative

studies

A urinalysis will show the following abnormalities: bacteria and white blood cells (suggest an infection) or red blood cells (suggest a stone, foreign body, or tumor

).

A urine culture is positive if an infection is present. Cystometric

studies (which are usually unnecessary) would reveal normal residual volume with involuntary detrusor contractions present.

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Management

Treat the underlying problemInfections are treated with antibiotics. Cytoscopy is used to diagnose and remove stones, foreign bodies, and tumors.

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Fistula incontinence

Caused by inflammation, radiation, surgery, Ca, IBD. Can be uretrovaginal, vesicovaginal

and urethrovaginal.History

The

patient usually has a history of radical pelvic surgery or pelvic

radiation therapy

. Loss of urine occurs continually in small amounts. This can take place both day and night

.

Examination

Pelvic

examination may show normal anatomy and normal neurologic

findings

Investigative studies

Urinalysis

and culture are normal.

Tampon test ??

Management

: surgical (

fistulotomy

or

fistulectomey

)

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Tampon test

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Congenital causes

EpispidiasHypospadiasBladder exstrophyEctopic ureter

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