Urogynecology Cytocele & rectocele urinary ioncontenence Prepared by Mrs. Raheegeh Awni 24/02/2011 4/20/2017

URINARY INCONTINENCE Introduction Urinary incontinence is a health and social problem in both the developed and developing worlds. It is often considered a natural consequence of ageing and childbirth, and misguidedly Urinary incontinence is the end result of many different disease processes. 4/20/2017

Urinary Incontinence (UI) Occurs when the bladder pressure exceeds the urethral pressure. The ICS defines incontinence as the involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem. Incontinence is a symptom that requires a specific diagnosis to be amenable to treatment. UI starts slowly and comes and goes for a long period of time before it becomes persistent. 4/20/2017

Definitions [as suggested by the International Continent Society (ICS) in 2002] Frequency: Greater than 8 voids in a 24-hour period Urgency: A sudden, strong desire to void that is difficult to defer. Nocturia: Being awakened from sleep with the urge to urinate at night Enuresis: Involuntary loss of urine during sleep (bed-wetting) in adults 4/20/2017

Classification. Although multiple etiologies exist for UI, the symptom of UI falls into one of three types: stress, urge, unconscious incontinence. These types of UI can present alone or in combination. 4/20/2017

1- Stress urinary incontinence (SUI) SUI is the most common type of UI among ambulatory incontinent women, accounting for 50% to 70% of cases. SUI occurs when the abdominal pressure exceeds bladder pressure, overcoming the watertight seal of the bladder neck and urethra. Increased abdominal pressure can occur with coughing, sneezing, laughing, and so forth. Bladder capacity and post void residual (PVR) are within normal limits. 4/20/2017

Etiology. urethral hypermobility or Urethral hypermobility is thought to occur due to loss of integrity of the musculofascial attachments that support the bladder neck and urethra. low-pressure urethra, is when the sphincteric mechanism is compromised and fails to close the ureterovesical junction (UVJ). These patients are often severely incontinent. 4/20/2017

2- Urge UI is involuntary leakage accompanied by or immediately preceded by the urge to void. Inability to reach the toilet in time. Involuntary detrusor contractions are typically the cause; they may be occasional or frequent but involve complete emptying. 4/20/2017

Mixed incontinence describes symptoms of both stress and urge incontinence. Detrusor abnormalities and mixed incontinence are more common in younger ambulatory women. 30% of women with mixed incontinence become dry after nonsurgical therapy alone. 4/20/2017

Functional incontinence is associated with cognitive, psychological, or physical impairments that make it difficult to reach the toilet or interfere with appropriate toileting. causes of functional or transient UI is DIAPPERS: Delirium, Infection, Atrophy, Pharmacology, Psychology, Endocrinopathy, Restricted mobility, and Stool impaction. 4/20/2017

Risk factors for urinary incontinence. Pregnancy and childbirth Gender. UI is two to three times more common in women than in men. Age and the menopause Race Obesity Hysterectomy Genital prolapse Functional impairment Constipation Diuretics and other prescribed medications Pelvic radiation therapy 4/20/2017

CONT, Childbirth. Damage to the pelvic tissues during a vaginal delivery is thought to be a key factor in the development of SUI and other pelvic support abnormalities, which is especially significant with operative delivery. Women who have undergone cesarean deliveries have greater pelvic muscle strength during and after the postpartum period than women who delivered vaginally. Nevertheless, cesarean section has not been shown to be protective and pregnancy in and of itself may be detrimental to the pelvic floor, regardless of the route of delivery. 4/20/2017

Previous pelvic surgery with resultant scar formation. Underlying medical conditions, such as diabetes, obesity, dementia, stroke, depression, Parkinson's, or multiple sclerosis, are risk factors for UI. Previous pelvic surgery with resultant scar formation. Pharmacologic agents, such as diuretics, caffeine, anticholinergics, and alpha-adrenergic blockers, may affect urinary tract function. Chronically increased intra-abdominal pressure results from obesity, chronic obstructive pulmonary disease, asthma, constipation, severe cases of uterine fibroids, and occupations that involve heavy lifting, and is a risk factors for UI. 4/20/2017

Diagnosis of UI 1- History: medical, surgical, gynecologic, and obstetric history, duration, frequency, severity, precipitating factors, social impact, effect on hygiene, on quality of life, 4/20/2017

Cont. Nocturia Urgency (a difficult-to-control desire to pass urine) Urge incontinence (leakage with urgency) Stress incontinence (leakage with an increase in intra-abdominal pressure) Voiding difficulties (poor stream, difficulty voiding, hesitancy, post-micturition dribble) Urinary tract infection (cystitis/dysuria) Haematuria Nocturnal enuresis (bed wetting) Incontinence coping strategies (e.g. use of pads). 4/20/2017

2-Urinary Diary: The patient records the volume and frequency of fluid intake and voiding as well as symptoms of frequency and urgency and episodes of incontinence for 1 to 7 days. 4/20/2017

3-Physical Examination including: A- Neurologic: neurologic examination to evaluate mental status, sensory, and motor function of the lower extremities should be performed. Anal sphincter tone reflects pelvic floor innervation (pudendal). 4/20/2017

B- Pelvic Examination: a systematic evaluation of all components of the pelvic floor, including innervation, vulvar architecture, muscular and connective tissue support, and perineal scars. Particular attention should be given to urethral anatomy. 4/20/2017

C- Speculum exam: to assess support and the presence of scarring, hormonal status and erosions. D- The bimanual exam: location, size, and tenderness of the bladder, uterus, cervix, and adnexa. 4/20/2017

E- A rectal examination: pelvic pathology, fecal impaction, F- A positive result on a stress test is essential to the diagnosis of SUI. The stress test is performed by looking for urine leakage from the urethral meatus when abdominal pressure is increased. It can be done while standing or in the dorsal lithotomy position and is very sensitive. 4/20/2017

Treatment of UI Stress Urinary Incontinence (SUI) Nonsurgical Pharmacologic. The limited available medications for SUI are aimed toward increasing urogenital sphincter tonE In women with urinary tract atrophy, combining estrogen with an alpha-sympathetic agonist can produce an additive effect. Pelvic Muscle Exercises. 4/20/2017

Surgical. The etiology of SUI may be multifactorial and may not always be able to be corrected by surgery. General cure rates are 60% to 90%, and there may be a significant improvement in quality of life. Long-term voiding dysfunction occurs in 1% to 5% and the operative morbidity is 5% to 10%. 4/20/2017

Pelvic Organ Prolapse (POP) 4/20/2017

Pelvic Organ Prolapse (POP) Pelvic organ prolapse (POP) is a bulge or protrusion of pelvic organs and their associated vaginal segments into or through the vagina . It is a common and costly affliction of older Women. It has been estimated that over the next 30 years, the demand for treatmentof POP will increase 45%, 4/20/2017

In this study, a significant risk factor associated with prolapse was Data from the Women's Health Initiative revealed anterior pelvic organ prolapse in 34.3%, posterior wall prolapse in 18.6%, and uterine prolapse in 14.3% of women in the study. In this study, a significant risk factor associated with prolapse was vaginal delivery. After adjusting for age, ethnicity, and body mass index, women with at least one vaginal delivery were twice as likely as nulliparous women to have pelvic organ prolapse. 4/20/2017

Pathophysiology Pelvic organ prolapse results from attenuation of the supportive structures, whether by actual tears or “breaks” or by neuromuscular dysfunction or both. Support of the vaginal canal is provided by the enveloping endopelvic connective tissue and its condensations at the vaginal apex, which form the cardinal uterosacral ligament complex. THE endopelvic connective tissue is the first line of support buttressed intimately with the pelvic diaphragm, composed of the levator ani and coccygeus muscles. 4/20/2017

These muscles provide a supportive diaphragm through which the urethra, vagina, and rectum egress. The muscular support provides basal tonicity and support of the pelvic structures; when contracted as in the setting of increased abdominal pressure, the rectum, vagina and urethra are pulled anteriorly toward the pubis. 4/20/2017

UTERROSACRAL LIGAMENTS 4/20/2017

Definitions The more common pelvic support disorders include rectoceles and cystoceles, enteroceles, and uterine prolapse. A rectocele is a protrusion of the rectum into the vaginal lumen resulting from weakness in the muscular wall of the rectum and the paravaginal musculoconnective tissue, which holds the rectum in place posteriorly. 4/20/2017

An enterocele is a herniation of the peritoneum and small bowel and is the only true hernia among the pelvic support disorders. Most enteroceles occur downward between the uterosacral ligaments and the rectovaginal space, but they may also occur primarily apically, especially in the setting of a previous hysterectomy. 4/20/2017

A cystocele is a herniation of the urinary bladder through the anterior vaginal wall. Cystoceles usually occur when the pubocervical musculoconnective tissue weakens midline or detaches from its lateral or superior connecting points. 4/20/2017

Uterine prolapse is generally the result of poor cardinal or uterosacral ligament apical support, which allows downward protrusion of the cervix and uterus toward the introitus. 4/20/2017

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ENTEROCELE 4/20/2017

Etiology of Pelvic Floor Damage 1- vaginal parity with POP implicates obstetric trauma as an etiology. Cesarean section appears to be protective if performed without labor. 2- pregnancy itself may injure endopelvic fascial support. 3-History of previous surgical procedures for POP 4- Congenital Factors. Patients with muscular dystrophy, meningomyelocele, spina bifida 4/20/2017

risk factors increasing age, hypoestrogenic states, high impact occupational and recreational activities, chronic illnesses or treatments that raise intra-abdominal pressure, Caucasian race. 4/20/2017

Abnormal Support Defects. The pathophysiology of POP is multifactorial. It can result from genetic predisposition followed by failures of either the connective tissue or muscular support, or a combination of both. Tears in the endopelvic fascia permit the opposing soft tissues to bulge through the vaginal wall. 4/20/2017

This additive effect helps explain the progression of POP. Loss of muscular support places the endopelvic fascia under constant strain that results in damage to the connective tissue. Tears in the endopelvic fascia can also cause stretch injury to the innervation of the muscular support. This additive effect helps explain the progression of POP. 4/20/2017

Apical Defects Uterovaginal prolapse occurs secondary to damage of the cardinal-uterosacral ligament complex. Vaginal vault prolapse refers to descent of the vaginal apex in a woman who has had a hysterectomy and is usually associated with an enterocele. The turning completely inside out of the vagina is called vaginal eversion or procidentia. 4/20/2017

Anterior Wall Defects (Cystoceles). Anterior wall defects are present when descent of the anterior vaginal wall occurs. resulting in herniation of the bladder into the vagina. 4/20/2017

Posterior Wall Defects (Rectoceles) Posterior wall defects occur at lateral, superior, and inferior attachments, as well as within the rectovaginal fascia itself, resulting in herniation of the rectum or small bowel into the posterior wall of the vagina. 4/20/2017

Enterocele is the result of detachment of the rectovaginal septum at the level of uterosacral ligaments, with small bowel filling the hernia sac between rectum and vagina. Perineal descent occurs when the perineal body becomes detached from the rectovaginal septum and becomes mobile 4/20/2017

Diagnosis/Evaluation. History. Herniation symptoms are the most specific and include pressure, heaviness, fullness, protruding tissues, bulging, and pelvic or back pain. Aching in the lower back is thought to be caused by traction on the bowel mesentery. This discomfort typically resolves when the patient lies down. Associated symptoms may include UI, voiding dysfunction, defecatory dysfunction, fecal incontinence, or sexual dysfunction. Rectoceles can produce various symptoms, including herniation symptoms and defecatory dysfunction. They may complain of inability to evacuate the rectum without straining or splinting (applying pressure between the vagina and the rectum to defecate). 4/20/2017

Diagnostic Tests. bladder and rectal function clinical examination and POPQ staging. IVP provides anatomic and functional information about obstructive uropathy. Urethrogram is performed with a double balloon catheter and is useful for urethral diverticulum. Cystogram is the visualization of the bladder by retrograde filling with contrast media. 4/20/2017

Urodynamic studies objectively delineate the storage and emptying function of the bladder. They are commonly used for patients who have UI, with or without POP. MRI 4/20/2017

Treatment of POP .The goal of treatment for POP is relief of associated symptoms. The three broad therapeutic categories are surgical, nonsurgical, and expectant management. 4/20/2017

1- Nonsurgical. useful in patients with a mild degree of prolapse, who desire future childbearing, have frail health, or are unwilling to undergo surgery. A- - Pelvic muscle exercises can alleviate the symptoms of prolapse. Kegel B- Pessaries are the most commonly used nonsurgical treatment for prolapse. the two basic types are supportive (most commonly a ring, with or without support) and space-occupying (most commonly a Gellhorn). Little data exist on which to base pessary selection, thus appropriate fit and patients' desire to remove their pessary are key. 4/20/2017

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C- Hormone replacement therapy, such as topical estrogens, will not relieve a patient's prolapse but is beneficial before a surgical repair. 4/20/2017

THANK YOU 4/20/2017