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Kathleen S. Chua, M.D. Jose R.

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

Levator ani
Diaphragmatic
Ileococcygeus Coccygeus

Pubovisceral
Pubococcygeus Puborectalis

Perineal membrane
Triangular sheet of dense fibromuscular tissue Covers the anterior half of the pelvic outlet Urogenital diaphragm Supports the vagina and urethra

Genital hiatus
Space through which the urethra, vagina, and rectum pass

The Continence Mechanism

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, 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

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

Urinary Stress Incontinence


Involuntary loss of urine through an increase in intraabdominal pressure (coughing, sneezing, laughing, 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

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, trauma from other causes, estrogen deficiency, s/p pelvic surgery or radiotherapy Signs & symptoms: leakage of urine when patient coughs, sneezes, runs, jumps, carry Incidence higher in multiparous, older patients

Stress Incontinence
Tests:
Midstream urine to exclude infection or glycosuria Uroflowmetry simple non-invasive test that will exclude voiding difficulties. Patient is asked to urinate into a toilet with flow-measuring device in the pan. 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

Tests for Lower Urinary Tract Dysfunction


Bladder storage or filling for complains of frequency, urgency, 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

Pad test

Evaluate incontinence intervention Quantifies urine loss Weigh the pad before using, weigh again after use May not be accurate

Simple office bladder filling


Screen detrussor overactivity Qualitative, 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

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

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, 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.

Levels of vaginal support


I. Superior and lateral connective tissue attachments (cardinal and uterosacral ligaments) II. The paracolpium attaches the vagina laterally and more directly to pelvic wall (midportion)
Pubocervical fascia Rectovaginal fascia

III. Vaginal wall is directly attached to the surrounding structures (distal part)

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; Most distal portion of prolapse protrudes more than 2cm of the total vaginal length

Female genital prolapse


Urethrocele Cystocele Prolapse of the lower anterior vaginal wall involving the urethra only. Prolapse of the upper anterior vaginal wall involving downward displacement of bladder. Generally, prolapse of the urethra is also associated and hence the term cystourethrocele is often used. This term is used to describe prolapse of the uterus, cervix and upper vagina. Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel. Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the posterior vaginal lumen

Uterovaginal Prolapse Enterocele Rectocele

Cystocele
occurs when the pubocervical fascia between a woman's bladder and her vagina is torn by childbirth, allowing the bladder to herniate into the vagina Most Gr 1 and 2 cystoceles are asymptomatic High grade cystoceles are associated with vaginal buldging, vaginal pressure, dyspareunia, UTI, obstructive voiding, urinary retention A high grade cystocele may mask urethral hypermobility and stress incontinence

Physical examination of Cystocele

MRI of Cystocele

Enterocele
protrusion of the small intestines and peritoneum into the vaginal canal
Simple enterocele Complex enterocele- associated with vault prolapse and anterior or posterior vaginal prolapse

Cause vaginal pressure, dyspareunia, low back pain, constipation, symptoms of bowel obstruction

MRI of Enterocele

Rectocele
Defect of prerectal and pararectal fascia,and rectovaginal septum Rectal tissue bulges through this tear and into the vagina as a hernia Present in 80% asymptomatic patients Vaginal mass, vaginal pressure, dyspareunia, constipation

Physical examination of Rectocele

MRI of Rectocele

Uterine Prolapse
Laxity of uterosacral ligaments May present with vaginal mass, dyspareunia, urinary retention, back pain Grade 4 prolapse is associated with ureteral obstruction

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

Medical Treatment
Anticholinergics Smooth muscle relaxants, cholinergics, 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

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