Presentation on theme: "8th Edition APGO Objectives for Medical Students"— Presentation transcript:
18th Edition APGO Objectives for Medical Students Pelvic Relaxation and Urinary Incontinence
2RationalePatients with conditions of pelvic relaxation and urinary incontinence present in a variety of ways. The physician should be familiar with the types of pelvic relaxation and incontinence and the approach to management of these patients.
3Objectives The student will demonstrate knowledge of the following: Predisposing factors for pelvic organ prolapse and urinary incontinenceAnatomic changes, fascial defects and neuromuscular pathophysiologySigns and symptoms of pelvic organ prolapsePhysical examCystoceleRectoceleEnteroceleVaginal vault or uterine prolapse
4Risk factors Vaginal delivery Large baby Prolonged 2nd stage of labor ForcepsMultiparous
6Risk factors Altered nerve function or tissue strength Diabetes Neurologic diseasesAgingCollagen disordersHypoestrogenismPelvic surgery
7Anatomy Basic Fascial defects Neuromuscular pathophysiology Levator ani musclesPubococcygeuasPuborectalisIliococcygeusViscerofascial layerEndopelvic fascia - attaches uterus and vagina to pelvic wallParametria - cardinal and uterosacral ligamentsFascial defectsNeuromuscular pathophysiology
8Signs and symptoms of pelvic organ prolapse Symptoms - prolapseAsymptomaticVaginal pressure heaviness (>90%)Vaginal painSensation of tissue protruding from the vagina (>90%)Abdominal painLow back painDyspareunia/impaired coitus (37%)Vaginal drynessUlcerationBleedingUrinary incontinence (33%)
9Signs and symptoms of pelvic organ prolapse Symptoms - urinary incontinence - unexpected loss of urineStress incontinence - involuntary loss of urine with increased abdominal pressure (valsalva, cough, laugh, sneeze)Urge incontinence - involuntary loss of urine associated with overwhelming urge to void
10Physical exam (definitions) CystoceleDefect where the bladder and anterior vaginal wall protrudes through the vaginal introitusSecondary to attenuation or rupture of the pubovesical cervical fasciaNote anterior relaxation with urethral inclinationMobility of bladder base and urethra with valsalva maneuver
11Physical exam (definitions) RectoceleProtrusion of posterior vaginal wall and anterior rectal wallLook for bulging of posterior vaginal wall with valsalva maneuverInsert a finger in rectum and, if vaginal and rectal tissue are jauxtaposed = rectocele
12Physical exam (definitions) EnteroceleElongation of posterior cul-de-sac along rectovaginal septum50% are diagnosed intraoperativelyPhysical exam (patient standing) - palpate enterocele sac and small bowel
13Physical exam (definitions) Uterine/vaginal vault prolapseUterine - descent of uterus and cervix into the vaginal canalExam - patient upright, valsalvaLook and fell for prolapseGrade based on location from hymeneal ringVaginal vault - loss of support of vagina beginning at apex
14Methods of diagnosis Urine culture Rule out urinary tract infection > 105 organismsVoiding diaryNormal bladder capacity (up to 60cc)Normal frequency (<8 voids/day)Accidents/leaking with physical activityAmount and type of intake
15Methods of diagnosisStanding stress test - note urine loss with cough or valsalvaQ-tip testLooks for hypermobility of the urethrovesical junctionResting position -30o or a change of greater than 30o is hypermobile
16Methods of diagnosisFilling cystometrogram - examines the bladder during filling and storagePost-void residual < 100ccFirst urge mLMaximum capacity mLResting bladder pressure < cm of H2OCystocopy
17Nonsurgical and surgical treatments PessaryOldest effective treatmentIf pelvic floor muscle damaged, they cannot be held in placeAdjunctive treatment - estrogen
18Nonsurgical and surgical treatments MedicationsStress incontinence Antagonist to increase smooth muscle tone (phenylpropanolamine)Estrogen to increase urethral resistanceUrge incontinence - anticholinergics to decrease spasm of the detrusor muscle (oxybutynin, tolterodine)
19Nonsurgical and surgical treatments Pelvic floor muscle exercisesKegels - voluntary contraction of the pelvic floorVaginal conesElectrical stimulation
20Nonsurgical and surgical treatments SurgeryHysterectomy - vaginal or abdominal (route depends on other surgical interventions)For anterior wall prolapse (cystocele)Vaginal approachAnterior colporrhaphy (central defect)Paravaginal repair (lateral defect)Abdominal approach - paravaginal repair
24Nonsurgical and surgical treatments SurgeryFor stress incontinenceAbdominal approachMarshall-Marchetti-Krantz (MMK)Burch colposuspension
25Nonsurgical and surgical treatments SurgeryFor stress incontinenceIntrinsic urethral sphincter dysfunctionSuburethral slingBulking injections (with collagen) to improve urethral coaptation (for patients without urethrovesical junction hypermobility)Artificial sphincter
26ReferencesAmerican College of Obstetricians and Gynecologists Technical Bulletin #214. Pelvic Organ Prolapse. ACOG: Washington DC 1995.American College of Obstetricians and Gynecologists Technical Bulletin #213. Urinary Incontinence. ACOG: Washington DC 1995.Mischel DR, ed., Comprehensive Gynecology 3rd ed., Mosby, St. Louis, MO, 1997.Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997
27Pelvic Relaxation and Urinary Incontinence Clinical CasePelvic Relaxation and Urinary Incontinence
28Patient presentationA 75-year-old woman G5P5 presents complaining of “fullness” in the vaginal area. The symptom is more noticeable when she is standing for a long period of time. She does not complain of urinary or fecal incontinence. She has no other urinary or gastrointestinal symptoms. There has been no vaginal bleeding. Her past medical history is significant for well-controlled hypertension and chronic bronchitis. She has never had surgery.
29Patient presentation Physical exam Pelvic exam reveals normal appearing external genitalia except for generalized atrophic changes. The vagina and cervix are without lesions. A second-degree cystocele and rectocele are noted. The cervix descends to introitus with the patient in an erect position. No rectal masses are noted. Rectal sphincter tone is slightly decreased. Uterus is normal size. Right and left ovaries are not palpable.Labs or Studies NoneDiagnosis Pelvic organ prolapse
30Management plan Management Plan Patient prefers non-surgical option Pessary placed and vaginal estrogen used to address atrophic changes
31Teaching pointsThe patient’s multiple vaginal deliveries, age and chronic bronchitis places her at risk for pelvic organ prolapse.Patients commonly present with a feeling of “fullness” or are able to touch vaginal or cervical tissue protruding through the introitus. They may or may not experience urinary incontinence.
32Teaching pointsIn addition to pelvic muscle exercises, non-surgical management of pelvic organ prolapse mainly involves fitting the patient with a vaginal pessary. There are numerous vaginal pessaries designed to support specific types of pelvic organ prolapse. Pessaries press against the walls of the vagina and are retained within the vagina by the tissues of the vaginal outlet.
33Teaching pointsPessaries may cause vaginal irritation and ulceration. They are better tolerated when the vaginal epithelium is well estrogenized; exogenous estrogen may be required in the hypoestrogenic patient. Periodically, vaginal pessaries should be removed, cleaned and reinserted. Failure to do so may result in serious consequences, including fistula formation.
34Teaching pointsPatients may be managed successfully with a pessary for years. Indications for surgery include the desire for definitive surgical correction, recurrent vaginal ulcerations with a pessary or stress incontinence that the patient finds unacceptable.