Anatomy review

Abdominal anatomy
Rectus abdominus
External Oblique
Internal oblique
Transverse

Know the blood vessels and where they come from

- Ilioinguinal nerve:
- iliohypogastric nerves

Don't go past lateral border of rectus with c-sections because risk injurying the nerves

Median umbilical fold- urachus

Medial umbilical fold- umbilical artery - there are two of them (two arteries one vein in the chord)
Lateral umbilical fold - has the epigastrics

Folds are important because when we put our ports in - can be preperitoneum or intraabdominal bleeding

Low transverse incision and long midline one are most common

Innervation
- Anterior vagina: Ilioinguinal, genital branch of genital femoral nerve
- Posteriori vagina: Perineal nerve and posterior cutaneous nerves of the thigh

Important nerves:
● Ilioinguinal - anterior vagina
● Iliohypogastric
● Femoral - can be injured by open retractor during open surgery, or if hyperflexed at the hip. Flexes at the hip
and extends at the knee, lose some sensation
● Common peroneal - pressure in the boots where it comes over the head of the fibula. Causes foot drop and
dorsal foot numbess
● Ulnar - When arms are tucked at sides during surgery
● Brachial plexus
○ Should be abducted < 90 degrees during surgery

Abdominal c-section
- The iliohypogastric nerve provides cutaneous
sensation to the groin and the skin overlying
the pubis. The ilioinguinal nerve follows a
similar, although slightly lower, course as the
iliohypogastric nerve where it provides
cutaneous sensation to the groin, symphysis,
labium and upper inner thigh. These nerves
may become susceptible to injury when a low
transverse incision is extended beyond the
lateral border of the rectus abdominus
muscle, into the internal oblique muscle.
-

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 Pelvic Anatomy

Muscles
- Levator ani: from medial to lateral, includes puborectalis, pubococcygeus, iliococcygeus

Blood vessels
- Branches of the internal iliac:
- Posterior: Superior gluteal
- Anterior: obdurato
- Anterior: uterine artery → may branch to superior vesical arteries, or they may come off on their own
- Anterior: vaginal artery → inferior vesical arteries
- Posterior: Inferior gluteal
- Posterior: Internal pudendal → vuvla (along with external pudendal)

Uterine Anatomy

Vagina
- Blood supply:
- internal iliac artery anastamotic network
- vaginal branch of uterine artery, from ilioinguinal artery
- Middle rectal and inferior vaginal branches of ilioinguinal artery
- Nerves:

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UROGYNECOLOGY

Prolapse

50% of women have mild asymptomatic prolapse. 3-7% have symptomatic prolapse. Approximately 1 in 9 will require
surgery for vaginal prolapse or related disorder.

Vaginal support: from levator ani, endopelvic fascia, and horizontal orientation of upper ⅔ of vagina

Three levels of fascial support to vagina

1) Level 1: upper third = cardinal uterosacral complex
- Loss = cervical, uterine, or vault prolapse
2) Level 2: middle third = arcus tendineus fascia pelvis
- Cystocele or rectocele
3) Level 3: Distal third = anterior: pubo urethral structures and arcus tendineus fascia pelvis, posterior = arcus
tendineus fascia rectovaginalis
- low rectocele and/or deficient perineum
Etiology
- Usually initial injury, most often during labor or childbirth, in “susceptible women.”
- Susceptibility increases with
- age, menopause
- pregnancy regardless of mode of delivery, forceps delivery, young age at first delivery, prolonged 2nd
stage, infant birth > 4500 grams, vaginal parity,
- obesity,
- occupations with lots of heavy lifting, conditions with repetitive bearing down,
- hysterectomy,
- collagen disorders (decreased type 1, increased type 3)
- Bony pelvis with more horizontal inlet
- Less common in African Americans
- NOT diabetes, running

Symptoms of prolapse:
- pelvic heaviness, pelvic pressure or bulge, sensation of sitting on a mass such as an egg. Pain is not a usual
complaint!
- Can be associated with urinary incontinence or fecal incontinence, constipation, need to splint

Types of prolapse:
- Cystocele: anterior vaginal prolapse - loss of level 2 support
- Rectocele: posterior vaginal prolapse - loss of level 2 support
- Apical or uterine: uterus slides down - loss of level 1 support
- Procidentia: complete descent - uterus falls out!
- Enterocele: Prolapse of any area of the vagina when the prolapsing wall is a sac filled with small bowel -
especially common in women who have undergone hysterectomy

POP Quantification exam (POP-Q):

Examine 6 points on the vaginal wall (Aa, Ba, C, D, Ap, Bp) along with the
length of the vaginal opening/genital hiatus (gh), perineal body (pb), and total
vaginal length (tvl).

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Maximum prolapse of the 6 points is recorded relative to the hymen during maximal straining
- Stage 0: None
- Stage 1: Within vagina, more than 1 cm above hymen
- Stage 2: Prolapse to the hymen (< 1cm inside or outside)
- Stage 3: External prolapse > 1cm outside hymen
- Stage 4: Complete prolapse = beyond tvl - 2 cm. TVL is usually around 9 cm.

Treatment
- Watchful observation is indicated if patient is asymptomatic.
- Pessary: require fitting and surveillance to manage urinary incontinence, pessary falling out, or pressure
ulcers
- Surgery:
- Anterior repair/anterior colporrhaphy: open anterior vaginal epithelium and plicate the deeper
redundant tissues
- Support the anterior wall with biologic or synthetic grafts
- Retach the sides of the vagina if prolapse due to loss of lateral vaginal support
- Colpocleisis is indicated if the patient isn’t a good surgical candidate. Just obliterate the vagina, can
be done quickly and w/out general anesthesia.e
- Topical estrogen won’t do anything for prolapse, only vaginal dryness - and remember that it’s contraindicated
if the patient has a uterus!

Urinary System

Physiology of micturition and storage

● Detrusor contraction = cholinergic from the pelvic parasympathetic plexus, from S2–S4.
● Distal ureters, trigone, bladder neck = sympathetic adrenergic fibers originating at the T10–L2
● Voluntary sphincter contraction = pudendal nerve, from the S2–S4 nerve roots.
● Generally sympathetic makes you store, parasympathetic makes you pee
● Three layers of muscle for urethra
○ striated urogenital sphincter
○ vaginal wall is behind the urethra - presses against the urethra
○ Levator ani
○ Highest pressure is at midurethra level

Storage: When bladder distends,

● Afferent sympathetic input to hypogastric nerve inhibit the parasympathetic input to the detrusor and increase
tone at the bladder neck → continence
● Afferent pelvic nerve sends info to efferent pudendal nerve, which contracts the external urethral sphincter

Voiding: Afferent pelvic nerves ascend in spinal cord and synapse in the pontine micturition center, which coordinates
voiding with descending pathways:
● Inhibit pudendal firing to relax external sphincter
● Inhibit sympathetic firing to open bladder neck, permit parasympathetic input to detrusor
● Parasympathetic input to detrusor → contraction

Stopping voiding voluntarily: Descending corticospinal pathways from pudendal nucleus → contract external
sphincter, so urethral pressure increases above detrusor pressure and stream is interrupted

Painful Bladder

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Primary UTI
- Can treat based on symptoms alone! If not complicated, treat for 3 days. Test of cure not needed.

Recurrent urinary tract infections

- Definition: 3+ UTIs in one year. > 50% of women will have this happen at least once.
- Risk factors:
- Genetics - easy for bugs to adhere to bladder.
- Anatomic - short distance from urethra to anus
- Physiologic - immunosuppression, urinary retention, menopause
- Personal - hygeine
- Sex - UTI often 24-48 hours
- Diagnosis:
- Nitrites are more specific (87%) than leukocyte esterase (54%). If both are present, sensitivity of 94%.
But can still have UTI even if they are absence.
- Culture is gold standard!
- Infection confirmed w/ 100k colony forming units on clean catch culture. But less severe UTI
can be associated with lower colony counts and may be significant - especially if obtained w/
transurethral catheter.
- If many epithelial cells → contamination. Get a catheterized culture.
- Management
- Obtain urine culture before starting empiric abx! This confirms abx coverage and distinguishes
from interstitial cystitis.
- Treat for 3 days
- Consider prophy
- 1 dose abx after sex
- Postmenopausal with genital atrophy: vaginal estrogen prevents recurrent UTIs
- Cranberry juice is helpful! Tablets unknown
- Not helpful - wiping front to back, voiding after sex.

Recurrent pyelonephritis
- Get an U/S of the kidneys to look for stones or anatomic problems

Overactive bladder syndrome

- Definition: Urgency, frequency, and nocturia (> 1 void per night) +/- urge incontinence. Cuased by
uninhibited bladder contractions. Often leak with orgasm..
- 15-17% of women
- Risk factors:
- Aging - bigget risk factor!
- Neuro disease or spinal cord injury
- UTI
- Anatomic - prior incontinence surgery, pelvic surgery, radiation
- Prolapse does not cause OAB, but often coexist in older women
- Diagnosis
- Imaging not necessary!
- Treatment
- NO SURGERY FOR URGE INCONTINENCE!
- Lifestyle: Decrease/eliminate caffeine, stop smoking, limit alcohol, control fluid intake, kegels for
stress AND urge incontinence
- Meds:
- Anticholinergics (oxybutinin, terodine).

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 - CI’ed if urinary retention, narrow angle glaucoma
- SE: dry mouth, blurred vision, dry eyes, tachycardia, upset stomach, constipation,
confusion in old people

Painful bladder syndrome/Interstitial Cystitis

- Definition: Pain with bladder filling - classically relieved when bladder is empty (contrast UTI), urinary
frequency (> 8 voids while awake), no infection or obvious pathology.
- Common cause of pelvic pain.
- Specific cause unknown! More of a syndrome than a disease. Maybe neuronal cross sensitization by
inflammatory mediators from other diseased organs. Maybe disruption of protective GAG layer.
- Associated with IBS, dyspareunia
- Management
- Initially: diet modification - avoid bladder irritants
- Cystoscopy - can be normal. Bx can also be normal. Not required for dx.
- Look for decreased capacity,
- Glomerulations = petechial hemorrhages (but nonspecific, found in 45% of healthy people!)
- Hunner’s ulcers. Do hydrodistention for diagnosis and treatment
- Meds:
- Elmiron
- TCAs like amitryptiline
- Bladder instilations
- Refractory → sacral neurostimulation

Evaluation of patients with urinary urgency-frequency disorders

- History:
- How many times do you urinate in the day? At night?
- How many UTIs? Proven by culture?
- Dysuria?
- Pain when bladder is full?
- Trouble controlling bladder?
- Urge, stress, or mixed?
- Do you have to wear a pad?
- Always looking for bathroom?
- Sensation that bladder is not empty?
- Change or limiting activities? Avoid public places or social activites?
- Constipation? Accidents with stool or flatus?
- PMH: diabetes, neuro diseases, spinal injury
- PSH: back/spine surgery, pelvic surgery
- Meds: Diuretics, cholinergics, anticholinergics
- Allergies
- Social History: Smoking, drugs, alcohol
- Exam:
- Suprapubic/urethral tenderness, CVA tenderness, PVR, cough stress test for stress incontinence,
atrophic vaginitis can be associated with frequency, vulvar hypersensitivity to Q-tip
- Labs: urinalysis and culture.
- Other: voiding diary, imaging

Urinary incontinence

Approx. ⅓ of adult women have urinary incontinence - 50% stress. 11% of women will have surgery for UI or
proloapse. ⅓ will require follow up operation

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 - Increased frequency with low estrogen (but supplementing doesn’t treat), obesity, FH, pelvic surgery, forceps
vaginal delivery, smoking,
- Risk factors for incontinence:
- Predisposition: women more than men until age 70
- Inciting factors: childbirth - even more important for prolapse, hysterectomy, vaginal surgery, radical
surgery, radiation, injury
- Promoting: constipation, occupation, recreation, obesity, lung disease, smoking, infection, meds (beta
blockers - can't relax the bladder!), menopause
- Decompensating: aging, dementia, debility, disease, environment, meds

Define incontinence when it happens > 1x per month

Reversible vs. treatable

● Reversible: meds, uti, stool impaction (bowel spasms --> bladder spasms), hypercalcinuria, hyperglycemia,
volume overload, delirium, decreased mobility, psychological
● Treatable: detrusor overactivity, stress incontinence, mixed incontinence, fistula

Nocturia: voiding > once per night

● In older people, can be a marker for a cardiovascular disease! If have mild CHF, then lay down at night and
not pumping against gravity - get increased return of fluids

How much should we drink per day? At least 1500 cc per day

Normal threshholds
● First sensation: > 75 ccs (above normal PVR of < 50 ccs).
● First urge: 150 cc’s (3x PVR)
● Bladder capacity: 300 cc’s while awake, 1L under anesthesia

1) Stress incontinence

- Caused by urethral hypermobility (aging, childbirth) or by intrinsic sphincter deficiency (congenital,

trauma, radiation, spinal cord injury, surgery)
- Q-tip test: Normal is < 30 degrees of movement with straining - more = hypermobility
- Dx with filling cystometry
- Treatment:
- First try lifestyle changes (quit smoking, lose weight), kegels and biofeedback, and pelvic floor muscle
physiotherapy
- Second, surgery:
- If urethral hypermobility + ISD
- Tension free urethral support system = tension free tape at mid-urethra
- Risks include bleeding (hematoma, external iliac, femoral, obturator, inferior
epigastric), de novo urgency and voiding dysfunction, and tape erosion and
bladder perforation. Also bowel injury
- TVT is better than burch for continence
- Burch retropubic urethropexy
- Pubovaginal sling at bladder neck
- Efficacy similar to TVT
- If only intrinsic sphincter deficiency
- Urethral injections of bulking agents (myoblast, fibroblast)

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 - Post op care: May have urinary retention after surgery. If able to void a bit, can place a catheter and send
home with follow up in several days. It should improve with time. If can’t void at all, loosen the sling prior to
hospital discharge.

2) Urge incontinence and overactive bladder

- Overactive bladder syndrome (OAB) includes urinary urgency with or without incontinence. Associated with
increased frequency and nighttime voiding. Everyone has bladder spasms to some extent, but usually urethra
is strong enough to inhibit release of urine
- Lifestyle modifications: Start thinking about what she is drinking, how much she is drinking. decrease caffeine,
2L fluid limit, void by schedule, bladder retraining - waiting to void 3-4 hours, follow up in 6 weeks
- Second line: antimuscarinics (M1-M5, M3 most important), have roughly equal efficacy
- Trospium and Tolterodine: nonselective
- Solifenacin and oxybutynin: moderate selectivity for M3
- Darifenacin: highly selective for M3 subtype
- Third line: sacral neuromodulation: stimulates sacral plexus, usually S3. Exact mechanism poorly understood.
Reversible. Do only if failed meds.

3) Detrusor Instability

4) Genitourinary fistulas

Number one cause is pelvic surgery - especially abdominal hysterectomy, followed by vaginal hysterectomy.Childbirth
is 8% of cases. Has a delayed presentation of days to weeks.

5) Overflow incontinence

Caused by decreased bladder wall compliance (radiation, IC, recurrent uti) or obstruction. PVR > 100, increased risk
of UTIs. Look for anticholinergics, calcium channel blockers, alpha adrenergics, and beta agonists

Treatment: Generally ISC is best. Can also consider bethanecol, a cholinergic med that selectively activates bladder
muscarinic receptions. Retention may resolve with correction of prolapse if > Stage II, but may not.

6) Functional and transient

Transient - delirium, infection, atrophic vaginitis, alpha blockers, antipsychotics, antidepressants, benzos, psych,
uncontrolled DM, stool impaction

Evaluation
- PVR - above 200 is abnormal, below 50 is reassuring
- UA - do culture if blood, nitrates, or leukocytes
- Q tip test measures the mobility of the urethra and bladder from the horizontal axis - normal is < 30 degrees
- Lack of hypermobility with stress incontinence - may be intrinsic sphincter deficiency
- Single channel office cystometry: fill bladder with saline- estimates bladder capacity and detrusor
contractions.
- Standing stress test: remove catheter and ask patient to cough - see if leakage occurs
- Multichannel urodynamic testing: do if dx is unclear or if at risk of treatment failure or complications

Evaluation

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 ● history - when did it start, what was her largest baby
● physical exam, voiding diary
○ sacral reflexes, estrogen status
● PVR
● urine culture
● stress test
○ Note if bladder is full or empty, the position of the patient,
● single channel cystometrogram
○ measures detrusor activity, sensation, capacity, compliance, DI vs. GSI, leak points
● q-tip test for hypermobility, but biggest factor for urge and stress is urethral strength
● advanced testing

START WITH PADS: PVR, urinalysis, diary, stress test

● diary: frequency of urination, en route loss, stress incontinence, nocturia, insensible loss, intake

Therapy:
● Behavioral therapy - fluid (1 cc per kcal), management, voiding frequency, scheduled toileting, bladder
retraining (wait 15 minutes after urge to go), pelvic floor exercises (don't do while urinating - maybe just once
to know that it's the right muscles, because don't want to disrupt the relaxation), biofeedback (probe or sensor
to tell you that you're doing the right thing)

Defecation

Normal physiology
- Rectosigmoid distention → rectorectal reflex = bowel before bolus contracts and bowel after bolus relaxes.
- Stool in rectum triggers rectaanal inhibitory reflex - internal anal sphincter relaxes to enable rectum to
accommodate feces (urge to go) and increase in external sphincter tone. Sensory nerves in upper anal canal
perform “sampling” to distinguish solid/liquid/gas.
- Defer:
- Muscles of continence:
- Internal anal sphincter - smooth muscle inner layer, responsible for majority of resting tone
and passive continence
- Sympathetic input from L5 via hypogastric plexus and parasympathetic branches
from S2-S4.
- External anal sphincter - striated muscle, encircles anal canal and IAS. Plays a maor role
in maintaining continence under stress - increased pressure, urgency.
- Inferior branch of pudendal nerve (S2-S4)
- Puborectalis (part of levator ani, muscular sling from pubis around anorectal junction, see
atlas p. 166)
- Volitionally contraction puborectalis and external anal sphincter. Internal anal sphincter relaxation
reflex will fade in 15 seconds, urge resolves until triggered again.
- External sphincter also tenses in response to small colonic contractions via spinal cord reflex
modulated by higher centers
- Increased colonic time disrupts the normal pressure gradient - the rapid transport of large volumes
produces urgency & incontinence even in healthy people
- Volitional defecation:
- Contract levator ani → relaxes external sphincter and puborectalis to allow straighter anorectal
passage

Bristol stool chart

- Type 1 = separate hard lumps, type 4 = ideal, smooth, soft; type 7 = entirely liquid

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 Anal Incontinence

Anal incontinence = uncontrolled loss of liquid, solid, or gas from rectum > 1 month
- Minor incontinence: Flatus, a little feces
- Major incontinence: Normal consistency
- Urge incontinence: Involuntary passage of gas. solid, or liquid in spite of attempt to stop
- Passive incontinence: Unrecognoized leakage

Causes of incontinence
- Systemic
- Metabolic/endocrine: DM, thyroid
- Neuro: CNS and PNS
- Infectious: Bacteria, virus, parasite
- Idiopathic/Autoimmune: Inflammatory bowel, food allergy
- Meds: Prescription, OTC
- Anatomic/structural
- Pelvic outlet obstruction (POP, rectal prolapse, neoplasia, hemorrhoids)
- Anal sphincter disruption/fistula: Obstetrics, surgical, trauma, radiation
- Obstetrics is #1 cause! 30-40% of women with anal tear during delivery report anal
incontinence.
- Tear the internal and external sphincters → early onset of incontinence. Risk in first
delivery, large baby, forceps, episiotomy
- Dennervate the pelvic floor (pudendal neuropathy) → late onset of incontinence. Risk
with lots of babies, big babies, forceps, prolonged active labor, third degree tears
- Functional causes
- Functional limits
- Motility

Detailed history is important!

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Anorectal studies:
- Manometry, rectal compliance, EMG studies - EAS and pelvic neuropathy, motor nerve conduction studies
- Endoanal ultrasound - can see defects in EAS, IAS, and puborectalis.Especially good for obstetric or surgical
injuries

Treatment
- Diet: Increase fiber, avoid irritants that cause diarrhea in some people - pepper, lactose, citrus, beer, coffee
- Meds: Reduce frequency, improve consistency, enhance sphincter tone
- Bulking agents = metamucil
- Constipating agents = loperimide, diphenoxylate hydrochloride, codeine
- Laxatives and enemas if constipated with overflow incontinence
- Enhance tone of sphincter - phenylephrine (research only)
- Biofeedback: strengthen EAS, coordinate distention and contraction, improve sensation of stool in rectum.
Very successful in short term, unclear in long term
- Pelvic floor exercises = kegels: minimal data
- Surgery
- Anal spincteroplasty: Often after obstetric trauma or surgical procedures. Even if good initial results,
poor long term results - repairs deteriorate, maybe due to aging, stretching scar, nerve degeneration
- Postanal pelvic floor repair - Rarely done. Used with patients with intact but poorly functioning
sphincters and pelvic floor. Reestablish the anorectal angle, tighten the canal. Best if incontinent from
loss of angleor from stretch of canal. Poor long term improvement
- Encirclement procedures: muscle transpositions (sartorius, gracilis, gluteus max). Option if can’t
repair the sphincter. Lots of morbidity.
- Colostomy and ileostomy: For very difficult cases
- Emerging options - sacral neuromodulation, injectable bulking agents, artificial sphincter
- Prevention: Manage labor, appropriate use of episiotomy and assisted vaginal delivery

Sexual function

Sexual sensations
● Afferents from the pudendal nerve
● Bulbocavernosus reflex: pudendal nerve stimulation → S2-4 contract pelvic floor muscles
● Vaginal and clitoral cavernosal autonomic nerve stimulation: clitoral, labial, and vaginal engorgement

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