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Reyes Memorial Medical Center
Pelvic Diaphragm Levator ani + connective
tissue Spans anteriorly from symphysis pubis to the coccyx, laterally attaches to the pelvis via the arcus tendinus fascia
Perineal membrane Triangular sheet of dense fibromuscular tissue Covers the anterior half of the pelvic outlet Urogenital diaphragm Supports the vagina and urethra .
and rectum pass .Genital hiatus Space through which the urethra. vagina.
The Continence Mechanism .
ureter. to bladder No increase in intravesical pressure due to accomodation (elasticity of bladder) There is stimulation of the sympathetic mechanism by alpha-adrenergic receptors of bladder neck and urethra and additional stimulation by the striated muscle of the sphincter urethra .Continence mechanism Urethra lies on the anterior vaginal wall Anterior vaginal wall supports the urethra and bladder neck Filling phase: Inhibition of the parasymphathetic mechanism Urine flows down from the kidney.
Voiding phase (bladder is full) There is mild contraction of the detrussor muscle thus urge to urinate Pelvic floor relaxes Bladder neck opens funnelling of bladder neck to facilitate flow of urine from bladder to urethra simultaneous contraction of detrussors Continence mechanism .
etc) May be provoked by detrusor contraction “genuine” stress incontinence – involuntary urethral loss of urine when the intravesical pressure exceeds the maximum urethral pressure in the absence of detrusor activity STRESS INCONTINENCE – due to urethral sphincter incontinence . laughing.Urinary Stress Incontinence Involuntary loss of urine through an increase in intraabdominal pressure (coughing. sneezing.
runs. jumps. trauma from other causes. s/p pelvic surgery or radiotherapy Signs & symptoms: leakage of urine when patient coughs. estrogen deficiency. sneezes.Stress Incontinence Occurs when the intravesical pressure exceeds the closing pressure on the urethra Childbirth is the most common causative factor denervation of the pelvic wall during trauma of delivery Other causes: congenital weakness of the bladder neck. carry Incidence higher in multiparous. older patients .
Patient is asked to urinate into a toilet with flow-measuring device in the pan.Stress Incontinence Tests: Midstream urine to exclude infection or glycosuria Uroflowmetry – simple non-invasive test that will exclude voiding difficulties. Normal flow rate = 15ml/second Bladder outflow obstruction is rare in women Cystometry and videocystourethrography – used to assess leakage and exclude detrusor instability. Bladder is filled with radioopaque fluid with urethral catheter and pressure is measured by subtracting rectal pressure from bladder pressure .
urgency.Tests for Lower Urinary Tract Dysfunction Bladder storage or filling – for complains of frequency. and urge incontinence Bladder / voiding diary record for at least 3 days Records amount of urine using toilet cup with gradiations Records leaking urine associated with activity Strong urge Amount of water input .
not quantitative Ordinary catheter connected to IV tubing (water runs through into the bladder) Patient tells first sensation of bladder filling Patient tells she has to urinate but able to hold it Patient says she could no longer hold urine Stress test done in between . weigh again after use May not be accurate Simple office bladder filling Screen detrussor overactivity Qualitative. Pad test Evaluate incontinence intervention Quantifies urine loss Weigh the pad before using.
Normal cystometric values Residual Urine Volume < 50 mL 1st sensation to void – 150-250 mL 2nd desire to void – 400 – 600 mL .
Conservative treatment of Urinary Stress Incontinence Treatment of: Obesity Chronic cough Chronic constipation Urogenital estrogen deficiency Pelvic floor muscle exercises .
anchoring it to the pubocervical fascia and tying the upper end on the rectus sheath Tension-free vaginal tape – proline mesh inserted on either side of the urethra Burch colposuspension – 2 or 3 sutures placed in the vaginal tissue and fascia on each side of the bladder neck and tied to each side of the bladder neck. Marshal-Marchetti-Krantz – sutures inserted between the periurethral tissues along the proximal half of the urethra Sling procedure Periurethral injections – collagen injected to act as cushion to tissue reduce caliber of the bladder neck.Surgical treatment of urinary stress incontinence Anterior colporrhaphy – women with combined stress incontinence and vaginal prolapse Endoscopic bladder neck suspension – suture done on either side of the bladder neck. .
The paracolpium attaches the vagina laterally and more directly to pelvic wall (midportion) Pubocervical fascia Rectovaginal fascia III.Levels of vaginal support I. Vaginal wall is directly attached to the surrounding structures (distal part) . Superior and lateral connective tissue attachments (cardinal and uterosacral ligaments) II.
Most distal portion of prolapse protrudes more than 2cm of the total vaginal length .Stages of Pelvic Organ Prolapse Stage 0 – No prolapse demonstrated Stage I – Most distal portion of the prolapse is > 1cm above the level of the hymen Stage II – Most distal portion of the prolapse is < 1 cm proximal or distal to the plane of the hymen Stage III – Most distal portion of the prolapse is > 1 cm below the plane of the hymen but no further than 2cm less than the total vaginal length Stage IV – Complete to nearly complete eversion of the vagina.
cervix and upper vagina. This term is used to describe prolapse of the uterus. prolapse of the urethra is also associated and hence the term cystourethrocele is often used. Prolapse of the upper anterior vaginal wall involving downward displacement of bladder.Female genital prolapse Urethrocele Cystocele Prolapse of the lower anterior vaginal wall involving the urethra only. Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the posterior vaginal lumen Uterovaginal Prolapse Enterocele Rectocele . Generally. Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel.
dyspareunia. allowing the bladder to herniate into the vagina Most Gr 1 and 2 cystoceles are asymptomatic High grade cystoceles are associated with vaginal buldging. urinary retention A high grade cystocele may mask urethral hypermobility and stress incontinence . obstructive voiding.Cystocele occurs when the pubocervical fascia between a woman's bladder and her vagina is torn by childbirth. vaginal pressure. UTI.
Physical examination of Cystocele .
MRI of Cystocele .
associated with vault prolapse and anterior or posterior vaginal prolapse Cause vaginal pressure. symptoms of bowel obstruction . low back pain.Enterocele protrusion of the small intestines and peritoneum into the vaginal canal Simple enterocele Complex enterocele. dyspareunia. constipation.
MRI of Enterocele .
and rectovaginal septum Rectal tissue bulges through this tear and into the vagina as a hernia Present in 80% asymptomatic patients Vaginal mass.Rectocele Defect of prerectal and pararectal fascia. dyspareunia. constipation . vaginal pressure.
Physical examination of Rectocele .
MRI of Rectocele .
Uterine Prolapse Laxity of uterosacral ligaments May present with vaginal mass. back pain Grade 4 prolapse is associated with ureteral obstruction . dyspareunia. urinary retention.
Physical examination of Uterine Prolapse .
MRI of Uterine Prolapse .
Complete Eversion of Vaginal Vault .
Non-surgical treatment Physiotherapy Pelvic floor exercises Vaginal cones or pessary Hormone replacement therapy Functional electrical stimulation .
cholinergics.Medical Treatment Anticholinergics Smooth muscle relaxants. local anesthetics .
Surgical Treatment Obliterative Colpocleisis – obliterate the vagina For those not fit for surgery for those with no desire for sexual function. Restorative Colporrhaphy – anterior/posterior vaginal repair Abdominal sacral colpopexy Sacrospinous ligament fixation .
Surgical Treatment Compensatory Repair with mesh Paravaginal repair .
Thank you .