Pop, Rev

UROGYNECOLOGY
PELVIC ORGAN PROLAPSE
1
ANATOMY OF THE PELVIC
FLOOR
2
External Genital Organ
Vulva
3
Anatomy of the Pelvic Floor
• Boundaries of the perineum
• Anterior: Pubic symphysis
• Anterolateral: Ischiopubic rami and Ischial tuberosities
• Posterolateral: Sacrotuberous ligaments
• Posterior: Coccyx
• Blood supply:
• Internal pudendal artery (inferior rectal artery and posterior

labial artery)
4
TRIANGLES
UROGENITAL TRIANGLE
ANAL TRIANGLE
5
Pelvic Outlet
6
Diaphragm
7
Diaphragms
8
Pelvic Diaphragm
• A wide but thin muscular layer of tissue that forms
the inferior border of the abdominopelvic cavity
• Endopelvic fascia is interchangeably used
• The pelvic diaphragm and endopelvic fascia are

terms used to characterize the connective tissue,
the support for the pelvis, and the pelvic floor.
• The pelvic diaphragm is composed of collagen,

elastic tissue, and muscle.
9
Pelvic Diaphragm
• The levator ani muscles - Constitute the greatest bulk of the pelvic
diaphragm
• Three components :
• Pubococcygeus ( Pubovisceral muscle )
• intermediate component of the levator ani muscle lies posterior to the

pubic bone and may be visualized as pubovaginalis, puboanalis, and
puboperinealis muscle bundles
• Puborectalis - dorsal to the rectum and helps form the sling supporting
the rectum
• Iliococcygeus
• The Coccygeus - a triangular muscle that occupies the area between the
ischial spine and the coccyx.
10
Urogenital Diaphragm
• Also called triangular ligament
• Anteriorly, the urethra is suspended from the pubic bone

by continuations of the fascial layers of the urogenital
diaphragm. The free edge of the diaphragm is
strengthened by the superficial transverse perineal
muscle.
• Posteriorly, it inserts into the central point of the perineum.
• Situated farther posteriorly is the ischiorectal fossa.
• Located more superficially are the bulbocavernosus

and ischiocavernosus muscles.
11
Urogenital Diaphragm
• This muscle surrounds both the vagina and the
urethra, which pierce the diaphragm.
• The pudendal vessels and nerves, the external

sphincter of the membranous urethra, and the
dorsal nerve to the clitoris are also found within the
urogenital diaphragm.
• The major function of the urogenital diaphragm is to

support the urethra and maintain the
urethrovesical junction.
12
13
Normal Support of Pelvic Organs
14
• Level I (suspension) - the paracolpium (uterosacral
ligaments) suspends the vagina from the lateral pelvic
walls. Fibers of level I extend both vertically and
posteriorly toward the sacrum.
• Level II (attachment) - the vagina is attached to the

arcus tendineus fasciae pelvis and superior fascia of the
levator ani by condensations of the levator fascia (e.g.,
endopelvic and pubocervical fascia).
• Level III - the vaginal wall is attached directly to adjacent

structures without intervening paracolpium (i.e., urethra
anteriorly, perineal body posteriorly, and levator ani
muscles laterally).
15
16
• Anterior vaginal wall prolapse (cystocele,

urethrocele, paravaginal defect),
• Posterior vaginal wall prolapse (rectocele or

enterocele),
• Uterine/cervical prolapse, or vaginal vault prolapse

(after hysterectomy, often with an enterocele)
17
The most frequently cited risk factor for pelvic organ
prolapse is
a. Childbirth
b. Age
c. Obesity
d. Menopause
18
RISK FACTORS
19
Risk Factors
• Possible Associations with Pelvic Organ Prolapse
• Vaginal childbirth
• Prior pelvic surgery Hysterectomy Constipation
• Aging
• Irritable bowel syndrome
• Obesity • Episiotomy
• Diabetes • Higher weight of the largest infant delivered

vaginally Chronic cough and respiratory
diseases
• Genetic
conditions/connective • Exercise
tissue disorders
• Heavy lifting
• Neurologic injury • Lower education
20
Development of Pelvic Floor Dysfunction
21
PATHOPHYSIOLOGY
22
Pathophysiology of POP
• Muscle atrophy
• from denervation from childbirth injuries
• muscle wasting from muscle insertion detach- ment (

from childbirth, age and hormonal status)
• Levator muscle defects and increased size of the levator

hiatus
• more vertical vaginal axis and wider genital hiatus
• upper two thirds portion of the vagina is nearly horizontal
23
SYMPTOMS
24
POP Symptom Categories
Lower urinary tract symptoms Bowel symptoms
Urinary incontinence Constipation
Frequency Straining
Nocturia Incomplete evacuation
Urgency Bowel splinting
Voiding difficulty: Slow stream, Anal incontinence
Incomplete emptying, obstruction
Urinary Splinting
Sexual symptoms
Other symptoms Interference with sexual activity
Pelvic pressure Dyspareunia
Heaviness Decreased sexual desire
Pain
Presence of vaginal bulge/mass
Low back pain
Tampon not retained
Quality of life impacts
25
EVALUATION
26
Proper Evaluation
• Imaging studies ( UTZ and MRI )

• Complete history
• Physical examination
• Dorsal lithotomy
• Left lateral decubitus
• Squatting
• Standing
27
Quantification of POP
Pelvic Organ Prolapse Quantitative, Bump, 1996
28
Maximum prolapse - observed
with a full bladder in the
standing position
Focus on the most prominent

prolapse
29
Support of the bladder neck
• first degree - prolapse into the upper barrel of the

vagina
• second degree - prolapse is to the introitus
• third degree - prolapse pass through the introitus
• fourth degree prolapse - complete eversion of the

vagina
30
(Bayden Walker System)
• grade 0 is normal position,
• grade 1 is descent halfway to the hymen,
• grade 2 is descent to the hymen,
• grade 3 is descent halfway past the hymen,
• grade 4 is maximum possible descent
31
32
33
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL -2cm )
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
34
POP - Q System
• stage 0: no prolapse,
• stage 1: the most distal prolapse is more than 1 cm

above (inside) the hymen,
• stage 2: prolapse between 1 cm above and 1 cm

below the hymen,
• stage 3: prolapse more than 1 cm beyond the hymen

but no farther than TVL − 2 cm, and
• stage 4: complete eversion/procidentia.
35
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL -2cm )
Stage I
+4 +3 +2 +1 0 -‐1 -‐2 -‐3
36
Aa Ba C
-3 -3 -6
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
37
ABOVE = NEGATIVE (-‐) NUMBER
BELOW = POSITIVE (+) NUMBER
38
Aa Ba C
-3 -3 -6
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
39
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL - 2cm )
Stage I
+4 +3 +2 +1 0 -‐1 -‐2 -‐3

Aa Ba C
-3 -3 -6
C or D
LESS than OR EQUAL NEGATIVE -‐
(TVL -‐2 ) cm Gh Pb Tvl
6 3 8
C or D (8 -‐2) NEGATIVE -‐(6)cm Ap Bp D

+4 +3 +2 +1 0 -‐1 -‐2 -‐3 -‐4 -‐5 -‐6 -3 -3 -6
40
Aa Ba C
-3 -3 -7
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
41
Stage I
Aa Ba C
+4 +3 +2 +1 0 -‐1 -‐2 -‐3 -3 -3 -7
C or D Gh Pb Tvl
LESS than OR EQUAL NEGATIVE -‐ 6 3 8
(TVL -‐2 ) cm
C or D (8 -‐2) NEGATIVE -‐(6)cm Ap Bp D
+4 +3 +2 +1 0 -‐1 -‐2 -‐3 -‐4 -‐5 -‐6 -‐7 -3 -3 -6
42
Aa Ba C
-3 -3 -5
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
43
Stage I
+4 +3 +2 +1 0 -‐1 -‐2 -‐3 -‐4 -‐5 -‐6

Aa Ba C
-3 -3 -5
C or D Gh Pb Tvl
LESS than OR EQUAL Negative (TVL -‐2) cm 6 3 8
C or D (8 -‐2) Negative -‐6cm
Ap Bp D
+4 +3 +2 +1 0 -‐1 -‐2 -‐3 -‐4 -‐5 -‐6
-3 -3 -6
44
Aa Ba C
-2 -3 -6
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
45
Stage I
Aa Ba C
-2 -3 -6
+2 +1 0 -‐1 -‐2 -‐3 -‐4 -‐5 -‐6
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
46
Aa Ba C
-2 -3 -6
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
47
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL - 2cm)
Stage I
Aa Ba C
-2 -3 -6
+4 +3 +2 +1 0 -‐1 -‐2 -‐3 Gh Pb Tvl

6 3 8
Ap Bp D
-3 -3 -6
48
Aa Ba C
-2 -1 -5
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
49
Stage I
Aa Ba C
-2 -1 -5
+4 +3 +2 +1 0 -‐1 -‐2 -‐3 Gh Pb Tvl

6 3 8
Ap Bp D
-3 -3 -6
50
Aa Ba C
-2 +1 -5
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
51
Stage I
Aa Ba C
-2 +1 -5
+4 +3 +2 +1 0 -‐1 -‐2 -‐3 Gh Pb Tvl

6 3 8
Ap Bp D
-3 -3 -6
52
Aa Ba C
-1 0 -5
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
53
Stage I
Aa Ba C
-1 0 -5
+4 +3 +2 +1 0 -‐1 -‐2 -‐3 Gh Pb Tvl

6 3 8
Ap Bp D
-3 -3 -6
54
Aa Ba C
+2 +4 +5
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -2
55
Stage I
+6 +5 +4 +3 +2 +1 0 -‐1 -‐2 -‐3 Aa Ba C

+2 +4 +5
Less than POSITIVE (TVL -‐2 ) CM Gh Pb Tvl

8 -‐2 Equals POSITIVE 6cm 6 3 8
Ap Bp D
-3 -3 -2
56
Aa Ba C
+2 +4 +6
Gh Pb Tvl
6 3 8
Ap Bp D
+2 +2 +2
57
Stage I
Aa Ba C
+6 +5 +4 +3 +2 +1 0 -‐1 -‐2 -‐3 +2 +4 +6
Gh Pb Tvl
MORE THAN OR EQUAL to POSITIVE (TVL -‐2 ) CM 6 3 8
8 -‐2 Equals POSITIVE 6cm
Ap Bp D
+2 +2 +2
58
POP CLASSIFICATION SYSTEMS
59
QUESTION
In POP Q system all of the measurements are
performed while the patient strains (bears down)
EXCEPT
A. TVL
B. GH
C. Point D
D. Point Aa
E. Point Bp
60
If surgical management of
prolapse is being
considered, the physician
may want to perform a
preoperative prolapse
reduction standing stress
test to evaluate for stress
urinary .
61
BLADDER & URETHRA
ANATOMY & FUNCTION
62
Bladder & Urethra
Anatomy & Function
• Anatomically, the exact border between the bladder and
urethra is difficult to determine.
• The functional length of the urethra, however, is that part in

which the urethral pressure exceeds the bladder pressure.
• The anatomic urethral length is approximately 3 to 4 cm.
• The resting pressure in the bladder is between 20 and 30

cm H2O due to surrounding intraabdominal pressure with
little or no pressure added from tension in the bladder wall
in normal bladders (i.e., the detrusor pressure) is 0 cm
H2O.
63
Intravesical pressure depends on the following:
• (1) the volume of fluid in the bladder,
• (2) the part of the intraabdominal pressure

transmitted to the bladder, and
• (3) the tension in the bladder wall related to

muscular and nervous system activity and elastic
properties.
The bladder’s subfunction being to store urine and
the urethra’s to allow it to pass.
64
Bladder & Urethra
Anatomy & Function
• For continence to be present, the UCP must be higher
than the bladder pressure.
• This high-pressure zone is located at approximately 0.5

cm proximal to the urogenital diaphragm
• Most of the functional urethral length is actually above the

urogenital diaphragm.
• The submucosal cavernous plexus of vessels, the bulk of

the smooth and striated muscle, and the bulk of the
autonomic nerve supply are most prominent in the area in
which they record the maximum urethral pressure.
65
The intraurethral pressure depends on the following:
(1) striated muscle fibers of the urethral wall,
(2) smooth muscle fibers of the urethral wall (a circular and

longitudinal layer),
(3) vascular content of the urethral submucosal cavernous

plexus,
(4) passive elasticity of the urethral wall, and
(5) the part of the intraabdominal pressure transmitted to the

urethra
66
Topography of Urethral and
Paraurethral structures
67
Bladder & Urethra
Anatomy & Function
• At rest, the urethra is supported by its attachment to
the arcus tendineus fasciae pelvis and the tone of the
pelvic diaphragm muscles.
• Two striated muscle arches, the compressor

urethrae and urethrovaginal sphincter, support the
distal urethra in the region of the urogenital
diaphragm.
• These muscles help compress the distal urethra,

helping to maintain continence during a cough.
68
69
• Level I (suspension) - the paracolpium (uterosacral
ligaments) suspends the vagina from the lateral pelvic
walls. Fibers of level I extend both vertically and
posteriorly toward the sacrum.
• Level II (attachment) - the vagina is attached to the

arcus tendineus fasciae pelvis and superior fascia of the
levator ani by condensations of the levator fascia (e.g.,
endopelvic and pubocervical fascia).
• Level III - the vaginal wall is attached directly to adjacent

structures without intervening paracolpium (i.e.,
urethra anteriorly, perineal body posteriorly, and levator
ani muscles laterally).
70
INNERVATION OF THE
BLADDER & URETHRA
71
INNERVATION OF
BLADDER AND URETHRA
M3 receptor - Bladder wall
72
INNERVATION OF
BLADDER AND URETHRA
SYMPATHETIC PARASYMPATHETIC
Neurotransmitter Norepinephrine Achetylcholine
Receptor alpha, beta Muscarinic (M3)
Detrussor Muscle
Relaxation Contraction
Bladder
Striated Muscle
External Urethral Contraction Relaxation
sphincter
Net effet Prevent Micturition Voiding
73
PHYSIOLOGY OF
MICTURITION
74
NEUROLOGIC CONTROL
OF MICTURITION
75
CNS FEEDBACK LOOPS
76
Physiology of Micturition
• Bladder detrusor contractility is stimulated by the activity of the
parasympathetic nervous system, mediated primarily through the
neurotransmitter acetylcholine.
• This stimulates muscarinic (primarily M3) receptors in the bladder

wall, which then activate detrusor contraction.
• Sympathetic nerve α receptors within the bladder cause bladder

relaxation when stimulated. Bladder contraction may also be
affected by irritation and inflammation of the bladder wall lining,
causing uninhibited contractions. Inhibitory input to the urethral
smooth muscle is conveyed by nitric oxide via parasympathetic
nerves. Somatic cholinergic motor nerves supply the striated
muscles of the external urethral sphincter from the sacral spinal
cord.
77
PHYSIOLOGY OF MICTURITION
• The first loop (loop I) involves a circuit from the cerebral cortex to
the brain stem, which inhibits micturition by modifying sensory
stimuli emanating from loop II.
• Loop II, which originates in the sacral micturition center (S2 through
S4) and the detrusor muscle wall itself, represents sensory fibers to
the brain stem, where modulation of the stimuli by loop I takes place.
• Loop III involves sensory flow from the bladder wall to the sacral
micturition center with returning motor fibers to the urethral
sphincter striated muscle, which allows the voluntary relaxation of
the urethral sphincter as the detrusor contracts.
• Loop IV originates in the frontal lobe of the cerebral cortex and runs
to the sacral micturition center and then to the urethral striated
muscle, allowing urethral voluntary muscles to relax, thus leading to
the initiation of voiding.
78
DIAGNOSTIC
PROCEDURES
79
Diagnostic Procedures
• Urinalysis and Culture
• Residual Urine
• Bladder diary
• Office Cystometrics
• Cough Stress Test and Pad Weight Test
• Urodynamics
• Cystourethroscopy or Cystoscopy
80
Urinalysis and Culture
• Useful as a screening tool whether the patient is continent

or with infection
• A formal microscopic urinalysis should be carried out to

confirm screening results because urine dipstick tests can
often yield a false-positive result and actual RBCs need to
be identified
• A catheterized specimen should be obtained if abnormal

results are questioned because of vaginal contamination.
Esp in women with pelvic organ prolapse, obesity,
postmenopausal bleeding, menses, or in older women with
arthritis and poor hand function
81
Test for Residual Urine
• Help to differentiate woman with incontinence with

POP, Voiding symptoms ( frequency or incomplete
bladder emptying ) or recurrent UTI
• Normal postvoid residual volumes (PVR - the

amount of residual urine should be less than 150
mL or less than one third (<1/3) of the bladder
volume
• RSV can be measured by UTZ however results

maybe affected by fibroids or large adnexal mass
82
Bladder diary
• SUI can be correctly

diagnosed
• Adjunct for diagnosing

detrussor overactivity
• done for 1 to 3 days
83
Urodynamics ( Cystometry)
• measures bladder pressure during the filling phase of the
micturition cycle.
• First urge to void, normal desire to void, and bladder
capacity are noted
84
Office Cystometry
• 1st Sensation of filling after saline infusion: 150 - 200ml
• Controllable Urge to void: 400-500ml
• Functional Capacity = 400-600ml
85
Office Cystometry
• with catheter attached to a
50-ml syringe w/o plunger
held 15cm above
symphysis pubis
• bladder is filled by pouring

water/saline into syringe
86
Office Cystometry
•NORMAL
water level in the syringe
CONSTANT
• OAB
water level in the syringe
(listening to running water,
washing of hands)
FLUCTUATION
87
Cough Stress Test
• Instill 250 to 300 ml of saline
• Once max. bladder capacity is
reachedà remove catheter
• à STRESS TEST (provocative
measures: coughing, heel
bouncing)
• (+) stress test (SUI): immediate spurts of urine w/

cough or any increases in intra-abdominal pressure
• (-) stress test (OAB): delayed loss ie. leaking 5-10secs

after coughing
88
One Hour Pad Weight Test

• Instill 250 to 300 ml of saline
• Asked to complete a series of

activities over the hour
• (+) Pad Weigh Test (SUI) - pad

weighs more than 2 to 3 g
89
Urodynamics ( Multichannel Recorder - ideal )
• For greatest accuracy, these should be measured with the woman
in the sitting position as well as standing, at rest, and with
straining.
• To use a multichannel recorder that permits pressure
determinations
• at two points within the urethra (proximal and midpoint to distal),
one within the bladder,
• one intraabdominally as recorded by an intrarectal sensor or by a
sensor within the vagina if the vagina is in a relatively normal
position (not prolapsed)
• Indicate intrinsic sphincter deficiency.
• Abdominal Leak Point Pressure (ALPP) - less than 60 cm H2O
• Maximal urethral closure pressure (MUCP) - below 20 cm H2O
90
Diagnostic Procedure
• Cystourethroscopy (
Cystoscopy )
• allows visualization of
the urethra, bladder,
and ureteral orifices in
an office setting
91
Urethral hypermobility
• Q-tip test
• A maximum Q-tip excursion angle greater than

30 degrees suggests hypermobility and
• is associated with higher success rates after

midurethral sling surgery
92
RISK FACTORS
URINARY INCONTINECE
93
FACTORS INDEPENDENTLY ASSOCIATED
WITH INCONTINENCE IN WOMEN
94
SYMPTOMS
95
Stress Urinary Incontinence
(SUI)
• the involuntary loss of urine with physical exertion

such as exercise, cough, or sneeze
• RISK FACTORS parous vs nulliparous( 3x), after

NSD vs CS( 2x ), forceps (36%) vs NSD (21%), low
impact vs high impact athletes NO difference,
96
Over Active Bladder Syndrome
• Urgency, with or without urge incontinence,
usually with frequency and nocturia
• Urgency is the complaint of a sudden, compelling desire to

pass urine, which is difficult to defer
• Urge incontinence is the complaint of involuntary leakage of

urine accompanied by or immediately preceded by urgency.
• Frequency is the complaint of voiding 8 or more times during

the day
• Nocturia is the complaint that the individual has to wake at

night more than once to void
97
Urge Incontinence (UI)
• Urge incontinence is the complaint of involuntary

leakage of urine accompanied by or immediately
preceded by urgency.
• Generally chronic and may wax and wane, but it is

slowly progressive and associated with an
urgency-frequency problem that is often
accompanied by painless, involuntary urine loss
98
Typical Symptom Differences in
Stress and Urge Incontinence
Symptom SUI UI
Leakage with exertion, cough, sneeze, activity Yes No
Leakage with sensation or urgency No Yes
Frequency, nocturia No Yes
Large volume urine loss No Yes
Leakage with running water, key in the door No Yes
Leakage with position change from sitting to standing Possible Yes
Leakage while recumbent No Possible
History of childhood bedwetting No Yes
99
Detrusor Overactivity
• Previous terms: detrusor dyssynergia, unstable bladder, or
detrussor instability
• Idiopathic detrusor overactivity is used as a urodynamic

definition when there is no defined cause of the condition
• Neurogenic detrusor overactivity if caused by neurologic

disorder, such as stroke, Parkinson disease, multiple
sclerosis, spinal cord injury, or other CNS pathology
• Detrussor hyperactivity with impaired contractile function

(DHIC) - seen in older women where urgency and incomplete
bladder emptying can coexist thus dribbling results.
100
MANAGEMENT
STRESS INCONTINENCE
1. Conservative
2. Surgical
101
Stress Urinary Incontinence
Methods of Pelvic Muscle ( Levator Ani and
Pubococcygeal ) Strengthening
• Kegel exercises
• Biofeedback
• Isometric with vaginal cones (weights)
• Electrical stimulation of pelvic floor
102
Methods of Pelvic Muscle ( Levator
And and Pubococcygeal ) Strengthening
• Kegel exercise - teach the woman to contract

these muscles slowly, 8 to 12 times, for a count of 6
to 8 seconds each, and to repeat this series for
three sets daily.
103
• Biofeedback
• Electrical stimulation
Nice c linical guidelines for Urinary Incontinence 0 ct 2 006

Borello-‐France D, Burgio KL, Clin Obstet Gynecol, 2 004; 4 7:70-‐8 2, Gross M et al, Curr Urol Rep. 2002;3:338-‐3 95
Rovner ES,et al. Women’s Health in Primary Care, 2 000;3: 1 79-‐
104 1 86, Sahai A, et al. neurourol Urodyn.2005;24:2-‐1 2
• Vaginal cone is involves a set of cones of

increasing weight that require pelvic muscle
contraction to hold them within the vagina.
• A correlation was noted between decreased urine

loss and the ability to retain cones of increased
weight
105
Incontince Pessary
106
Incontinence Pessary
• An incontinence pessary is a silicone ring device
with a knob placed in the vagina, with the goal of
stabilizing the urethra to eliminate hypermobility
and increase urethral pressure during increases in
intraabdominal pressure.
• Women with stress incontinence may have greatly

reduced leakage when wearing the insert, it is not
popular because a new device needs to be placed
after each void
107
Effects of Other Modalities
• Weight Loss significantly reduces urinary leakage
• Xanthines and Oral Estrogen therapy worsened

stress incontinence
• Drugs with possible effects on the lower urinary

tract
108
Drugs with Possible Effects
on the Lower Urinary Tract
• Estrogen orally, Xanthines, Neuroleptics , anti
hypertensives ( All causes incontinence )
• Dopamine agonist bladder neck obstruction
• Cholinergic agonists, decreases bladder capacity

and increased intravesical pressure
• Alcohol - frequency , urgency
• B adrenergic - urinary retention

109
Surgical Management
• Kelly plication , plication of the bladder neck (Kelly
plication procedure) with anterior colporrhaphy
• Retropubic urethropexy
• Transvaginal needle suspensions (TVNSs)
• Marshall-Marchetti-Krantz suprapubic urethrovesi-

cal suspension operation
• Burch colposuspension or Burch procedure

110
Marshall-Marchetti-Krantz suprapubic
urethrovesical suspension operation
• The space of Retzius is
entered, the bladder neck is
identified, generally with a
30-mL bulb Foley catheter in
the bladder, and the
paravaginal tissue adjacent
to the bladder neck is
identified
• And sutured to the pubic

symphysis using two or
three interrupted sutures on
each side of the bladder
neck.
111
Burch Procedure
• Modification of the
suprapubic bladder neck
suspension by
suspending the vaginal
wall to Cooper’s
ligament, now referred
to as a Burch
colposuspension or
Burch procedure
112
Mid Urethral Sling
Tension-free vaginal tape (TVT) permanent
sling with Prolene mesh placed midurethrally,
without the need for fixation . For stress
incontinence.
Cystoscopy was performed to evaluate for

bladder perforation before the sling was
brought into place.
The sling was a monofilament polypropylene

synthetic mesh, 1 cm wide and 40 cm long.
113
MANAGEMENT
OVERACTIVE BLADDER
1. Conservative
2. Surgical
114
Over Active Bladder (OAB)
• Behavioral is the first line treatment
• Fluid management, avoidance of bladder irritants, bladder

training, scheduled voiding, bedside commode ( older
women)
• Bladder training
• Women need to be taught urge suppression using

distraction, relaxation techniques, or pelvic floor muscle
contractions.
• The goal is to increase the voiding interval to 2 to 3 hours with

normal fluid intake
115
• Pharmacologic
• Anti muscarinics or beta 3 adrenergic receptor

agonist drugs- currently the treatment of choice
in OAB management
• Symptom relief is attained by:

• Increase in bladder storage capacity
• Effective and immediate control of the
abnormal bladder contractions
116
Medications for Overactive Bladder
Drug Dosage
5mg BID,TID,QID
Oxybutynin 5 to 30 mg daily
1 or 2 mg BID
Tolterodine 4mg daily
Oxybutynin transdermal 3.9-mg patch (2x week)
Darifenacin 7.5 or 15 mg daily
Solifenacin 5 or 10 mg daily
Trospium 20mg BID or 60 mg daily
Fesoterodine 4mg to 8mg daily
Mirabergron 25 to 50 mg daily
117
Treatment
algorithm for
urge
incontinence
118
Neuromodulation
• beneficial for women with refractory symptoms (failed
behavioral treatments and medications over roughly 3
months).
• It includes direct sacral neuromodulation of S3 and

peripheral neuromodulation through peripheral tibial
nerve stimulation (PTNS) to the sacral nerve plexus.
• PTNS is done weekly for 30 minutes for 12 weeks and

then every 3 to 4 weeks for maintenance therapy.
119
Effective Treatment Options for Women with
Urinary Incontinence by Type of Incontinence
Treatment Option SUI UI
Pelvic floor muscle training Pelvic floor muscle training

Bladder training Prompted
Nonpharmacologic Bladder training Prompted voiding
voiding Incontinence pessary Posterior tibial nerve stimulation
Anticholinergic drugs
Pharmacologic (antimuscarinic)
Beta agonist
Midurethral synthetic sling Botulinum toxin A

Surgical Retropubic colposuspension injection
Suburethral fascial sling Sacral neuromodulation
120
MANAGEMENT
1. Conservative
2. Surgical
121
CONSERVATIVE
• mild or asymptomatic uterine prolapse - no needed
treatment or with pelvic floor muscle strengthening
• Pessary is encouraged in women who is not fit for

surgery due to her medical conditions and in
women who have not completed childbearing
• Gellhorn pessaries may be more successfully fit for

stage IV POP more often than rings, but it is
reasonable to start with the smallest and easiest to
use shapes first.
122
PESSARY - EFFECTS
• It reduced symptoms of POP, • relieved urinary symptoms
such as
• general symptoms of a
vaginal bulge.
• bowel evacuation in 28%,
• relieved urinary symptoms
such as • fecal urgency in 23%
• voiding problems in 40% of • urge fecal incontinence

women, by 20%.
• urinary urgency in 38%,
• There was no
• urgency urinary improvement in stress
incontinence in 29%, urinary incontinence.
123
PESSARY - COMPLICATION
• Rare with proper use
• Vaginal infections,
• Bleeding,
• Discomfort,
• Vaginal erosion and ulceration
• Pessary incarceration
• Erosion into bladder or rectum
124
Surgical
• Common surgical options to treat uterovaginal prolapse include
vaginal hysterectomy with vault suspension to the uterosacral or
sacrospinous ligaments, abdominal (open, laparoscopic, or
robotic)
• Supracervical hysterectomy with sacrocolpopexy, and

colpocleisis.
• Other surgeries including abdominal (open laparoscopic, or

robotic) uterosacral ligament suspension with or without
hysterectomy,
• Transvaginal hysteropexy with or without mesh

sacrohysteropexy,
125
126
127
Surgical
• Manchester procedures
• For hypertrophied cervix
• This operation combines an anterior and posterior colporrhaphy

with the amputation of the cervix and the use of the cardinal
ligaments to support the anterior vaginal wall and bladder
• Colpocleisis
• For elderly who is not sexual active
• An obliterative procedure that involves the removal of a strip of

anterior and posterior vaginal wall, with approximation of the
anterior and posterior walls to each other. Almost completely
closed vagina.
128
Surgical
• Goodal Power Modification of the Le Fort operation
• allows for the removal of a triangular piece of

vaginal wall beginning at the cervical reflection or
1 cm above the vaginal scar at the base of the
triangle, with the apex of the triangle just beneath
the bladder neck anteriorly and just at the
introitus posteriorly.
• Relatively for small prolapse , whereas the LeFort

is for larger ones
129
Le Fort Procedure.
A, Incision of anterior vaginal wall

strip.
B, Incision of posterior wall strip.
C, Removal of vaginal strip.
D and E, Placement of sutures.
F, Appearance of vagina a er
procedure is completed but before
perineorrhaphy is performed.
130
Goodall-Power modification of Le
Fort operation.
A, Representation of vaginal incision

on anterior and posterior wall.
B, Early placement of sutures.
C, Later placement of sutures.
D, Vaginal incision completely

closed; perineorrhaphy being
performed.
E, Appearance at completion of
procedure 131
132
CLASSIC ANTERIOR COLPORRHAPY
A. The initial midline anterior vaginal wall incision is
demonstrated
B. The midline incision is extended using scissors
C. Dissection of the vaginal epithelium off the

underlying connective tissue and fibromuscular layer
D. The dissection is complete
E, The initial plication layer is placed.
F, The second plication layer is placed, if needed.
G, Trimming of excess vaginal epithelium.
H, Closure of vaginal epithelium
133
Rectocoele
• Management
• None operative
• Pessaries, Kegels exercise, estrogen
• Dietary fiber ( 25g fiber), adequate

hydration, regular exercise, allowing
time for defecation as first line, PEG
134
REPAIR OF RECTOCOELE
A, Placement of Allis clamps at

margins of perineal incision; perineal
incision is being made.
B, Reflected vaginal epithelium with

rectum bulging.
C, Depression of rectum identifying

margins of levator ani muscle.
D, Placement of sutures in perirectal

tissue and levator ani bundles.
135
136
137
A, Appearance of enterocele
sac with vaginal wall
reflected.
B, Appearance of open
enterocele sac with sac neck
identified.
C, Placing of purse-string
suture at the neck of the
enterocele sac.
D, Excision of enterocele
sac. 138
End of Lecture
139

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UROGYNECOLOGY

PELVIC ORGAN PROLAPSE

• Anterior: Pubic symphysis

• Anterolateral: Ischiopubic rami and Ischial tuberosities

• Posterolateral: Sacrotuberous ligaments

• Internal pudendal artery (inferior rectal artery and posterior

• Endopelvic fascia is interchangeably used

• The pelvic diaphragm and endopelvic fascia are

• The pelvic diaphragm is composed of collagen,

• Pubococcygeus ( Pubovisceral muscle )

• intermediate component of the levator ani muscle lies posterior to the

• Anteriorly, the urethra is suspended from the pubic bone

• Posteriorly, it inserts into the central point of the perineum.

• Situated farther posteriorly is the ischiorectal fossa.

• Located more superficially are the bulbocavernosus

• The pudendal vessels and nerves, the external

• The major function of the urogenital diaphragm is to

• Level II (attachment) - the vagina is attached to the

• Level III - the vaginal wall is attached directly to adjacent

• Anterior vaginal wall prolapse (cystocele,

• Posterior vaginal wall prolapse (rectocele or

• Uterine/cervical prolapse, or vaginal vault prolapse

• Diabetes • Higher weight of the largest infant delivered

• Neurologic injury • Lower education

• from denervation from childbirth injuries

• muscle wasting from muscle insertion detach- ment (

• Levator muscle defects and increased size of the levator

• more vertical vaginal axis and wider genital hiatus

• upper two thirds portion of the vagina is nearly horizontal

• Imaging studies ( UTZ and MRI )

Focus on the most prominent

• first degree - prolapse into the upper barrel of the

• second degree - prolapse is to the introitus

• third degree - prolapse pass through the introitus

• fourth degree prolapse - complete eversion of the

• grade 0 is normal position,

• grade 1 is descent halfway to the hymen,

• grade 2 is descent to the hymen,

• grade 3 is descent halfway past the hymen,

• grade 4 is maximum possible descent

• stage 1: the most distal prolapse is more than 1 cm

• stage 2: prolapse between 1 cm above and 1 cm

• stage 3: prolapse more than 1 cm beyond the hymen

• stage 4: complete eversion/procidentia.

+4 +3 +2 +1 0 -­‐1 -­‐2 -­‐3

BELOW = POSITIVE (+) NUMBER

+4 +3 +2 +1 0 -­‐1 -­‐2 -­‐3

C or D (8 -­‐2) NEGATIVE -­‐(6)cm Ap Bp D

+4 +3 +2 +1 0 -­‐1 -­‐2 -­‐3 -­‐4 -­‐5 -­‐6

+4 +3 +2 +1 0 -­‐1 -­‐2 -­‐3 Gh Pb Tvl

+4 +3 +2 +1 0 -­‐1 -­‐2 -­‐3 Gh Pb Tvl

+4 +3 +2 +1 0 -­‐1 -­‐2 -­‐3 Gh Pb Tvl

+4 +3 +2 +1 0 -­‐1 -­‐2 -­‐3 Gh Pb Tvl

+6 +5 +4 +3 +2 +1 0 -­‐1 -­‐2 -­‐3 Aa Ba C

Less than POSITIVE (TVL -­‐2 ) CM Gh Pb Tvl

• The functional length of the urethra, however, is that part in

• The anatomic urethral length is approximately 3 to 4 cm.

• The resting pressure in the bladder is between 20 and 30

• (1) the volume of fluid in the bladder,

• (2) the part of the intraabdominal pressure

• (3) the tension in the bladder wall related to

• This high-pressure zone is located at approximately 0.5

• Most of the functional urethral length is actually above the

+4 +3 +2 +1 0 -‐1 -‐2 -‐3

+4 +3 +2 +1 0 -‐1 -‐2 -‐3

C or D (8 -‐2) NEGATIVE -‐(6)cm Ap Bp D

+4 +3 +2 +1 0 -‐1 -‐2 -‐3 -‐4 -‐5 -‐6

+4 +3 +2 +1 0 -‐1 -‐2 -‐3 Gh Pb Tvl

+4 +3 +2 +1 0 -‐1 -‐2 -‐3 Gh Pb Tvl

+4 +3 +2 +1 0 -‐1 -‐2 -‐3 Gh Pb Tvl

+4 +3 +2 +1 0 -‐1 -‐2 -‐3 Gh Pb Tvl

+6 +5 +4 +3 +2 +1 0 -‐1 -‐2 -‐3 Aa Ba C

Less than POSITIVE (TVL -‐2 ) CM Gh Pb Tvl

• (-) stress test (OAB): delayed loss ie. leaking 5-10secs

• (+) Pad Weigh Test (SUI) - pad