CREOG

REVIEW
PELVIC ORGAN
PROLAPSE
TYPES OF PROLAPSE

• Anterior – cystocele
• Apical – uterine or vaginal vault
• Posterior – rectocele, enterocele

• Procidentia = complete uterine prolapse

CYSTOCELE
 VAGINAL Procidentia
VAULT
PROLAPSE

•Vaginal vault eversion occurs in 0.5% of patients who have undergone

hysterectomy
RECTOCELE
LEVELS OF SUPPORT
LEVEL I
cervix
• The cardinal ligaments
blend with the utero-
sacral ligaments
• These fibers attach the
upper vagina, cervix, and
LUS to the sacrum and
lateral pelvic side walls
Uterosacral/cardinal
ligament complex
LEVEL II
• These are the
To arcus paravaginal attachments
tendineus
• Found
fascia pelvis at the level of the
ischial spines
• Functions to keep the
vagina in the midline,
directly over the rectum
To arcus
tendineus
rectovaginalis
LEVEL III
• Provided by the perineal
body and membrane,
superficial and deep
Obturator perineal muscles and
foramen
endopelvic fascia
Perineal
• These structures support
membrane and maintain the normal
position of the distal 1/3
Perineal body of vagina and introitus
PROLAPSE STAGING
• There are two systems
used to quantify amount
of prolapse
• Baden-Walker system
POP-Q SYSTEM
• Pelvic Organ Prolapse –
Quantification
• Stage is based on
position of vaginal walls
relative to hymen
• Stage 2 is -1 to +1
PROLAPSE TREATMENT

• Observation
• Estrogen treatment
• Kegels/ pelvic floor therapy - more likely to prevent, rather than
improve
• Pessaries
• Surgery
• Level B evidence to support conservative or surgery
PESSARIES
FITTING PESSARIES

• Be prepared to try various sizes & shapes

• Trial and error
• Empty bladder and rectum
• Fit snugly, not too tight
• Should fit patient comfortably
• Pt. should void prior to leaving
• Examine standing after fitting and after voiding
• Should be visible at introitus, & not descend beyond hymen
FITTING PESSARY

Estimating size of pessary required

• (A) A bimanual examination is performed to judge the distance from the posterior fornix to the posterior pubic symphysis. (B) The
spot where the pubic symphysis rests on the examining hand is mentally marked. Sample pessaries are then held up to the examining
hand to estimate the proper pessary size. (www.uptodate.com)
FITTING A RING PESSARY
SURGICAL MANAGEMENT

• Based on
 Which compartment has prolapse
 Route of surgery planned
 Surgeon preference
VAGINAL APEX – LEVEL I
 Vaginal or abdominal route
 Based on concomitant repairs
 Patient factors (age, comorbidities)
 Surgeon preference
 Sacrocolpopexy (ASC) the gold standard
 Fixation via sacrospinous, uterosacral ligament or iliococcygeus
 Level B evidence- ASC less prolapse but higher complication rates
VAGINAL APEX
ANTERIOR COMPARTMENT – LEVEL II

• Can be either midline or lateral. This is

determined via exam.
• Anterior colporrhaphy (AR) – can be done
with or without graft
• Paravaginal defect repair (PVDR)
POSTERIOR COMPARTMENT – LEVEL III
• Posterior colporrhaphy
(PR)
• Site-specific vs. repair of
entire area
COLPOCLEISIS
• Only used in women who no longer desire sexual activity because the
vaginal vault is closed off
• More durable and lower risk than other repairs
• Could potentially
be done under local/
Sedation
Level B evidence
INCONTINENCE
URODYNAMICS
• Not required for most SUI cases
• SUI evaluation
– H&P
– + cough stress test
– Negative UA
– PVR < 150 cc
– Urethral hypermobility
• Consider UDS if
– Prior pelvic surgery
– Failed treatment
– Prolapse beyond the hymen
– Unable to demonstrate SUI
– Unclear history
STRESS URINARY INCONTINENCE

• SUI
– Involuntary leakage of urine on effort, exertion, sneezing or coughing
• ISD
– Maximal urethral closure pressure <20
– Leak point pressure <60
 FIRST LINE
TREATMENT
LIFESTYLE ALTERATIONS

• Timed bladder emptying

• Reduce fluid intake or caffeine
• Protective pads
• Optimize pulmonary diseases
• Smoking Cessation
• Weight loss
• Obesity: 4.2 x higher risk SUI
• -8% reduction in weight sig. improvement
BEHAVIORAL INTERVENTION

• Pelvic floor muscle training

– Kegel, gynecologist, popularized in 1940’s
– Combine behavioral and physical therapy
– Effective in reducing SUI, UUI, MUI
– At least 12 weeks therapy
• 50% vs 12% improvement
MECHANICAL DEVICES

• Pessaries
Can be used in patients with hypermobile bladder neck
 Incontinence dishes
 Incontinence knobs
 impressa

• Urethral Devices
– Occlusive plugs
• Reliance Insert, FemSoft
SECOND LINE
TREATMENT
ESTROGEN
• Local estrogen: Cochrane Review 2012 9
• 34 trials (19,676 total, 9599 received estrogen with 1464 local estrogen)
• Local estrogen
– Improved incontinence (RR 0.74, CI 0.64-0.86)
– 1-2 fewer voids/ day
– Less frequency and urgency
• Systemic estrogen
– CCE+MPA and CEE only
– Increased SUI and UUI in those with no baseline complaint
– Increased frequency, limited daily activities, and bothered them more in baseline UI group
TRICYCLIC ANTIDEPRESSANTS

• Imipramine 10mg qhs in elderly, 25mg TID, 75mg BID

– Decrease bladder contractility and increase urethral resistance
– Central and peripheral anticholinergic
– Block active transport of norepi and serotonin
– Lin et al small study (n=40)
• 35% cure rate by negative pad test and 50% improvement

• SE: dry mouth, blurred vision, urinary retention, constipation, orthostatic hypotension,
sedation, tremors, sexual, jaundice
THIRD LINE
TREATMENT
BURCH COLPOSUSPENSION
Burch’s

Success rate
• 39 trials, 3,301 women
• 1st year 85 – 90%
• 5 year 70%
• No significant difference between open and laparoscopic approach

Lapitan et al, Cochrane Database Systematic Reviews 2008

Burch’s Colposuspension

Complications

• Detrusor overactivity 5 – 10%

• Voiding difficulty 10 – 15%

• Apical / posterior 5 – 17%

compartment prolapse
RECTUS FASCIAL SLING
 BURCH VS FASCIAL SLING
• Albo et al 2007
• Multi-center RCT (n=655)
• 24 months, success for SUI
– 66% for sling
– 49% for Burch, p<0.001
• Sling: higher UTIs, voiding difficulty, post-op UUI
• Adverse events similar
• Treatment satisfaction at 24 months
– 86% sling
– 78% burch, p=0.02
MIDURETHRAL-SLINGS

• Three major slings available

- Tension-free vaginal tape (retropubic approach)
- Tension-free vaginal tape (transobturator approach)
- Mini-sling
lower cure then TVT or TOT
Peri-urethral Injection
ARTIFICIAL SPHINCTER
OAB
OAB
• Overactive bladder(OAB) syndrome
– Urgency, with or without urge incontinence, usually with frequency and nocturia
without evidence of UTI or other pathology. (International Continence Society)
• The pathophysiology of overactive bladder syndrome is complex, and
involves both peripheral and CNS factors.

Haylen et al. An international urogynecological association

(IUGA)/international continence society (ISC) joint report on the
terminology for female pelvic floor dysfunction. Neuro and
Urodyn 2010;29:4-20
ADDITIONAL SYMPTOMS

 Urgency
 A sudden, compelling desire to pass urine, which is difficult to defer

 Frequency
 >7 voids daytime

 Nocturia
 Interruption of sleep 1 or more times to void

 Urge incontinence
 Involuntary leakage associated with sudden compelling desire to void

Haylen et al. An international urogynecological association

(IUGA)/international continence society (ISC) joint report on the
terminology for female pelvic floor dysfunction. Neuro and
Urodyn 2010;29:4-20
TREATMENT OPTIONS
1. Conservative:
 Bladder retraining, Biofeedback
 Behavior modification, fluid management
 Pelvic floor exercises

2. Pharmacology:
 Anti-muscarinics
 B3 agonists
 Contraindicated uncontrolled HTN, end stage renal disease, live disease

3. Procedures:
 Percutaneous tibial nerve stimulation
 Interstim neuromodulator
 Botox: inhibits presynaptic release Ach
PHARMACOLOGY
 Non-selective Muscarinic receptor antagonists:
 Tolterodine-IR, ER
 Oxybutynin-IR, ER, transdermal, topical gel
 Trospium Chloride-IR, ER
 Solifenacin succinate
 Fesoterodine

 Selective: M3
 Darifenacin

 Beta 3 agonists

 mirabegron
MUSCARINIC RECEPTOR
Receptor subtype Distribution Potential impact
M1 Brain Cognitive
dysfunction,impaired
learning

M2 Heart tachycardia
M3 Salivary glands Dry mouth
M3 GI tract Decreased bowel
motility
M3 Bladder Bladder SM control

M4 Brain unclear
M5 Ciliary eye muscle Loss of visual
accommodation
 MICROBIOLOGY

• Gram (–) bacilli

Enterobacteriaceae family responsible for 90% UTI
E. coli accounts for 80- to 90% of uncomplicated UTI
Others: Klebsiella, Enterobacter, Serratia, Proteus
Pseudomonas often occurs in institutionalized patients

• Staphylococcus saprophyticus
Second most common cause of UTI
10% infections in sexually active females
 ANTIBIOTIC THERAPY
Drug Dose Minor Toxicity Major Toxicity

TMP-SMX 160mg/800, 1PO bid x 3 Allergic Serious skin reactions, blood

days dyscrasia
Nitrofurantoin 100mg, 1 PO bid x 5 days GI upset Peri. neuropathy,pneumonitis

Ampicillin 250-500mg, q6hrs x 3 Allergic, candida Pseudomembranous colitis

days

Tetracycline 250-500 mg, q6hrs x 3 GI upset, skin rash, Hepatic dysfunction, nephrotoxicity
days candida

Cephalexin 250-500mg, q6hrs x 3 Allergic Hepatic dysfunction

days

Ciprofloxacin 250mg, q12 hrs x 3 days Nausea, vomiting, Arrhythmias, angina, convulsions, GI
diarrhea, abdominal bleeding, nephritis
pain, headache, skin rash
 DEFINITIONS
Reinfection
•Culture documented UTI caused by
different strain than original infecting
bacteria
•Most common cause of recurrence
•Ascending from vaginal introitus
Persistent
– Patients whom one cannot obtain
culture documented sterile urine
– Require cystourethroscopy and/or
radiographic evaluations
 PROPHYLAXIS ANTIBIOTIC THERAPY18

Antibiotic Dose Frequency Expected UTI/yr

TMP-SMX 40mg/200mg Daily or 3xweek 0-0.2

Trimethoprim 100mg Daily 0-0.15

Nitrofurantoin 50-100mg Daily 0-0.7

Cephalexin 125-250mg Daily 0.1-0.2

Ciprofloxacin 125mg Daily 0

18. Aydin et al, Recurrent UTIs in women Int Urogynecol J (2015)26:795-804

Norfloxacin 200mg Daily 0

Ofloxacin 100mg Daily -

Fosfomycin 3g Every 10 days -

URETHRAL DIVERTICULUM

• Diverticulum is an epithelium lined pouch that is the result of

either a distention of a segment of the urethra or the attachment
of a structure to the urethra by a narrow neck
SYMPTOMS—THE 3 D’s

• Dysuria
• Dribbling (Post void) 25%
• Dyspareunia 10%
• Most common symptoms 50%
– Urinary frequency
– Urgency
– Dysuria
– Infection
 ASSOCIATED CONDITIONS

• Recurrent UTI’s 33%-50%

• Outlet obstruction 8%
• Incontinence 60%
• Stones 1-10%
• Malignancy rare
– Adenocarcinoma
– Transitional cell carcinoma
– Squamous cell carcinoma
ALGORYTHM FOR EVALUATION
DIVERTICULUM VS. SKENES

A CT scan circumferential
diverticulum at the bladder neck
B CT scan thickened partially
decompressed with complex fluid
C MRI low attenuation lesion
around the urethra
MRI
 URETERAL INJURY

Gilmour DT. Obstet Gynecol 2006;107:1366-72.

LOCATION & LENGTH OF
INJURY
• Distal ureter
– Stenting, de-ligation, ureteroneocystostomy
– Longer: Psoas hitch, Boari flap
• Proximal or mid
– Stenting, de-ligation, ureteroureterostomy
– Longer: Boari flap, ileal ureter, mobilization of kidney
URETERONEOCYSTOTOMY

•If the injury is in the distal 2 cm

•Double J stent for 2-6 weeks
•Non-refluxing vs. refluxing
PSOAS HITCH
•If the ureteral reimplant can
not be done tension free
•Cystotomy should be done on
anterior wall of bladder
•Avoid genitofemoral nerve
BOARI FLAP

•Bladder must be mobilized

•Graft length of 3:2 ratio
•Base must be 4 cm wide
URETEROURETEROSTOMY
• If the injury is 3-4 cm above the
ureterovesical junction
• Resect tissue from both ends
• Spatulate
• Leave in stent for 2-6 weeks
• Leave in drain post-op
 INCIDENCE OF BLADDER
INJURY
• Among women undergoing hysterectomy among 49.8 million
gynecologic procedures, the incidence of bladder injury was:
 LAVH (13.8 per 1000 women)
 VH (13.1 per 1000 women)
 TAH (6.9 per 1000 women)
 SAH (10.3 per 1000 women),
 RAH (2.2 per 1000 women),
 LSH (0 per 1000 women).

Frankman EA et al. Am J Obstet Gynecol 2010;202:495

REPAIR

• Assess location or ureteral orfices

• May need to place ureteral catheters/stents
• Double layer closure with 3-0 or 2-0 Vicryl running or intermittent
• Drain bladder from 3 to 14 days depending upon the size of the repair
• Consider cystogram before removing Foley
 REPAIR

http://www.atlasofpelvicsurgery.com/3BladderandUreter/10WedgeResectionOfBladder/chap3sec10.html
HEMATURIA
DEFINITION
• Microscopic hematuria:
– 3+ RBC/HPF by microscopy of urine sediment
– 1 properly collected samples
– no infection & absence of benign reason
– Identified in 2-31% samples
• Why change?
– AMH caused by a serious underlying condition such as malignancy
can be highly intermittent – may result missing a malignant dx
• Studies series and meta-analysis of studies that worked up patients after 1
positive sample resulted malignancy rate of 3.6% (95% CI; 2.3 to 5.5%) 1
• Comparable analysis of studies that required > 1 positive sample – 1.8% (95%
CI = 1.0-3.0%)1

Davis R, Jones JS, et al. AUA Guidelines 2012

1
UROLOGIC EVALUATION

☐ • History and physical

 • Urinalysis
 • Urine microscopy
 • Culture and sensitivity
• Urine cytology /markers
☐ • BUN/ creatinine
• Radiographic imaging of upper tract
• Cystoscopic examination of bladder
ACOG & AUGS EVALUATION

• No evaluation needed
– asymptomatic, low-risk, never-smoking women aged 35–50
– < 25 red blood cells per high-power field.
– Cancer risk < 0.05%
• Evaluation
– High risk (smoker, dye exposure, gross hematuria, male)
– Gross hematuria with no UTI
– Age > 50 with > 3 RBC per HPF
• Multiphasic CT Urogram
• Best modality for complete evaluation
• Multiphasic with and w/o IV contrast
• 4 phases:
– Pre-enhancement
– Arterial
– Cortico-medulary
– Excretory
• 17 different publications reviewed by the
panel:
– Sensitivity/specificity >90% in all
MULTICHANNEL
URODYNAMICS
RESIDENT LECTURE
WHO NEEDS TESTING?

• Women with a confusing or unclear history

• Women unable to give a good history
• Patients who have failed prior therapies or have recurrent problems
• Any other concerns
BASIC PARTS

• Simple Uroflowmetry – no catheters

• Filling and voiding cystometrogram (CMG)
• Urethral pressure profile (MUCP)
• Complex uroflowmetry- catheters in place
• Video option – same test but with fluoro
 UROFLOWMETRY
• Ideally done at start of test before any instrumentation
• Info we get:
– Flow rate is the volume of fluid expelled via the urethra per unit time and is expressed in ml per second
– Q max is the maximum measured value of the flow rate
– Voided volume is the total volume expelled per the urethra
– Flow time is the time over which measurable flow occurs. Voiding time is the total duration of micturition,
including interruptions. If flow is continuous, flow time = voiding time.
– Q average is the average flow rate = voided volume divided by flow time
– Time to max flow is the elapsed time from onset of flow to maximum flow
UROFLOW
UROFLOW
• If we see an abnormal uroflow,
ask the patient if she feels like
today’s void is normal
• If it’s a low volume void (<200),
consider repeating it at the end of
the test
• If it’s interrupted, does she still
empty at the end of the day?
• Is prolapse keeping her from
emptying? Consider repeating
the test with a pessary in place.
CYSTOMETRY

• Used to study both the storage and voiding phase of micturition

• Simple cystometry is what you can do in any office with a catheter, tumi syringe and saline or
sterile water
• During filling phase, we are going to slowly retrograde fill the bladder (50-70 mL/min)
• Watch for DO and do provocative testing
CYSTOMETRY
Normal desire – 150-200
Strong desire – 200-250
Capacity – 300-500

Stress test throughout, I

do every 100cc and
capacity.

Standing only if I don’t

get a response sitting.
With and without prolapse
reduced.
CYSTOMETRY
LEAK POINT PRESSURES

• Leak point pressure (LPP) is a measurement of the amount abdominal pressure or detrusor
pressure required to overcome outlet resistance and produce incontinence.
• VLPP is the precise pressure at which leakage occurs. Less than 60 is c/w ISD. Calculated
measurement (Pves with valsalva at leak – Pves at rest)
 URETHRAL PRESSURE PROFILE
• Urethral pressure profilometry is a graphic representation of pressure within the urethra at successive
points along its length. There is no general consensus on how best to evaluate urethral function in
women with lower urinary tract dysfunction.
• Maximum urethral closure pressure (MUCP) -- is the difference between the maximum urethral
pressure and the intravesical pressure. Values less than 20 are c/w ISD
UPP
URETHRAL PRESSURE PROFILE
UPP
UPP

Pclo
VOIDING CYSTOMETRY OR PRESSURE-
FLOW STUDIES
• Looks at the 2nd half of cystometry – the voiding phase
• How should the coordinated efforts of the bladder work?
• Lots of room for artifact here but at least get a sense of detrusor function (y/n), straining to
void, and whether they empty.
PRESSURE FLOW STUDY
PRESSURE FLOW STUDY
QUESTIONS?