Urogynecology Review For Up College PDF

A Review of
UROGYNECOLOGY
UPCM Interns Refresher Course
15 June 2015
Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPS

Clinical Associate Professor
Section of Urogynecology and Pelvic Reconstructive Surgery
Department of Obstetrics and Gynecology
UP College of Medicine
Philippine General Hospital
1
OUTLINE
I. Pelvic Organ Prolapse
II. Urinary Incontinence
2
copyright_joanneaguinaldomd_manilaphilippines_june2015
I. PELVIC ORGAN PROLAPSE
A. Definition
B. Pathophysiology
C. Risk Factors
D. Diagnosis
i. Presentation
ii. Scoring and Staging
iii. Ancillary tests
E. Management
3
Definition
POP is defined as the

downward descent of
the pelvic organs
towards or through
the vaginal opening.
4
Etiology
POP comes about

with the failure of the
suspensory and
supportive structures
of the pelvic organs.
5
Pelvic support structures
Bony pelvis provides the

surfaces of attachment
for the muscles and the
ligaments
6
Pelvic diaphragm the

dynamic floor of the pelvis
that contracts tonically and
reflexly to support the pelvic
organs as well as maintain
urinary and fecal continence
Levator ani muscles

(puborectalis,
pubococcygeus, &
iliococcygeus)
Coccygeus muscles
7
Pelvic diaphragm
Levator plate
Innervated by the
branches of the S1-S3
nerves and the pudendal
nerve
8
Endopelvic fascia
a fibromuscular sheath
composed collagen, elastin,
and smooth muscles that is
continuous with the vagina,
cervix and lower portion of
the uterus.
- It envelops these organs and

attaches and suspends them
to the pelvic walls, aligning
them 30o above horizontal
over the levator plate.
9
De Lancey Levels of Pelvic support
Level 1 parametrium
-the uterosacral and cardinal
ligament complex
10
Level 2 paracolpium
-attaches the anterior and posterior
vaginal walls to the lateral pelvic
sidewall
11
Level 3 fusion of the endopelvic

fascia of the vaginal walls with the
surrounding structures, namely: with
the urethra, urogenital diaphragm,
and the pubis inferiorly, with the
levator ani fascia laterally and with
the perineal body posteriorly
12
Mechanism of pelvic support is this:
Endopelvic fascia stabilizes the pelvic organs above the levator

plate, preventing their herniation into the vagina.
Pelvic diaphragm maintains the levator plate, a horizontal

shallow basin, at the most dependent portion of the pelvis and
consequently prevents the herniation of the vagina and its
adjacent structures through the genital hiatus.
13
Mechanism of pelvic support is this:
Endopelvic fascia stabilizes the pelvic organs above the levator

plate
Pelvic diaphragm maintains the levator plate
14
Patholophysiology of pelvic organ prolaspe is this:
Weakness of Pelvic diaphragm

(Neurologic compromise, Tissue damage)
Downward rotation of the levator plate from its horizontal position
Stress on the Endopelvic fascia

(Pelvic organs no longer supported by the levator plate)
Descent of Pelvic Organs
15
Patholophysiology of pelvic organ prolaspe is this:
Weakness of Pelvic diaphragm
Downward rotation of the levator plate from its horizontal position
Stress on the Endopelvic fascia
Descent of Pelvic Organs
16
Risk factors
Predisposing Skeletal, muscular, neurological, connective tissue, racial, gender

(congenital)
Inciting Vaginal delivery, surgery, neurological
Promoting Obesity, smoking, lung disease, constipation, recreational and

occupational stresses, surgery
Decompensating Ageing, menopause and hormonal deprivation, progressive or

acquired neuropathy, progressive or acquired myopathy, debilitation,
medication
17
Symptoms
Local Vaginal pressure of heaviness
Vaginal or perineal pain
Sensation of tissue protrusion from the vagina
Low back pain
Abdominal pressure or pain
Observation or palpation of a bulge
Urinary Stress incontinence
Frequency
Urgency
Urge incontinence
Hesitancy
Weak or prolonged stream
Feeling of incomplete emptying
Manual reduction to start or complete bladder emptying
Positional changes to start or complete bladder emptying
18
Symptoms
Bowel Difficulty with defecation
Incontinence
Fecal staining
Urgency of defecation
Discomfort with defecation
Digital manipulation of the vagina, perineum and anus to complete
defecation
Feeling of incomplete defecation
Rectal protrusion during or after defecation
Sexual Inability to have sexual activity

Infrequent coitus
Dyspareunia
Lack of sexual satisfaction or orgasm
Incontinence during sexual activity
19
A. Definition
B. Pathophysiology
C. Risk Factors
D. Diagnosis
i. Presentation
E. Management
20
Scoring and Staging : POP-Quantification System (POP-Q)
Introduced in July 1996 by the International Continence Society
Aimed to standardize the terminology and reporting of POP
21
Scoring and Staging : POP-Quantification System (POP-Q)
Prolapse should be examined at maximum descent.
The hymen is the fixed reference point used throughout the

system.
The anatomic position of the 6 defined points for evaluation should be

measured as centimeters above or below the hymen, with the plane of
the hymen defined as zero (0).
If the defined point is observed above or proximal to the hymen, it is

assigned a negative number (e.g. -1 or 1 cm above the hymen).
If the defined point is observed below or distal to the hymen, it is

assigned a positive number (e.g. +1 or 1 cm below the hymen).
22
(-)
(+)
23
Anterior compartment
Located in the midline if the anterior vaginal 3 cms Urethro-vesical crease
Point Aa proximal to the external urethral meatus -3 to +3
Represents the most distal or dependent position of Middle to proximal third of the
Point Ba the anterior vaginal wall from the cuff or anterior anterior vaginal wall
fornix to point Aa.
Superior or Apical compartment
Point C Represents either the most distal or dependent edge
of the cervix or the leading edge of the vaginal cuff
Point D Represents the location of the posterior fornix in a Used to differentiate suspensory
woman who still has a cervix. failure of the uterosacral ligament
from cervical elongation. Omitted in
the absence of the cervix
Posterior compartment
Point Ap Located in the midline of the posterior vaginal wall 3 -3 to +3
cms proximal to the hymen
Point Bp Represents the most distal or dependent position of Middle to proximal third of the
the posterior vaginal wall from the posterior fornix or posterior vaginal wall
the cuff to point Ap 24
25
26
Ordinal stages
Stage 0 No prolapse demonstrated
A, B points are at -3 cm
C,D points are at TVL cm or (TVL-2) cm
Stage I Criteria for Stage 0 are not met but the most distal or dependent portion
of the prolapse is more than 1 cm above the hymen (< -1 cm)
Stage II The most distal or dependent portion of the prolapse is less than or equal
to 1 cm above or below the hymen (> -1 cm or < +1 cm)
Stage III The most distal or dependent portion of the prolapse is more than 1 cm
below the hymen but protrudes no further than 2 cms less than the total
vaginal length [ > +1 cm to < (TVL 2) cm ]
Stage IV Essentially complete eversion, the most distal portion of the prolapse
protrudes to at least (TVL-2) cm
27
Ancillary testing
1. Supplemental PE
- Vaginal inspection:
- Loss of rugae
- Atrophy : loss of labial fullness, pallor of vagina
and urethra, minimal vaginal moisture
28
Ancillary testing
1. Supplemental PE
- Vaginal examination:
- Check pelvic floor muscle strength
- Modified Oxford Scale
- 0 : no contraction
- 1 : flicker
- 2 : weak squeeze, no lift
- 3 : fair squeeze, definite lift
- 4 : good squeeze, with lift
- 5 : strong squeeze with a lift
29
Ancillary testing
1. Supplemental PE
- Rectovaginal examination (enterocoele,
rectocoele)
30
Ancillary testing
2. Bladder testing
Screen for infection urinalysis, urine culture
Determine post void residual urine
Assess bladder function
Cystometry with Cough stress test (with prolapse
reduced) : 15-80% occult stress incontinence
31
Ancillary testing
3. Pelvic floor muscle testing

- Biofeedback machine
4. Imaging Studies
- Ultrasound : pelvic, KUB
- CT scan/ MRI
32
Ancillary testing
5. Endoscopy/ Cystoscopy
- Bladder symptoms/ conditions : hematuria,
urolithiases
- Bowel symptoms/ conditions: obstipation,
painful defecation, rectal prolapse
33
CASE
60 G4P4 (4004) presents with sensation of
Aa Ba C
something coming out of her vagina. She
reports a palpable bulge at the introitus on
occasion. All her pregnancies were delivered
vaginally except for the last, for which she GH PB TVL
underwent a CS-hysterectomy for placenta
accreta. On physical examination, the vagina
was pale and smooth and measured 6 cms Ap Bp D
long. The vaginal cuff most dependent, noted 1
cm above the hymen. The urethrovesical
crease was 2 cms above the hymen and there
was no displacement of the posterior vaginal
wall.
SCORE and STAGE
34
CASE
60 G4P4 (4004) presents with sensation of Aa Ba C
something coming out of her vagina. She -2 -1 -1
reports a palpable mass at the introitus on
occasion. All her pregnancies were delivered
GH PB TVL
vaginally except for the last, for which she 6
underwent a CS-hysterectomy for placenta
accreta. On physical examination, the vagina
Ap Bp D
was pale and smooth and measure 6 cms long.
-3 -3 N/A
The vaginal cuff most dependent, noted 1 cm
above the hymen. The urethrovesical crease
was 2 cms above the hymen and there was no
displacement of the posterior vaginal wall.
Most dependent : Cuff -1
SCORE and STAGE
Stage II
35
CASE
What level of support is Aa Ba C
-2 -1 -1
most compromised in
this case? GH PB TVL
6
- Parametrium
A. Level 1 (uterosacral/cardinal Ap Bp D
ligament complex) -3 -3 N/A
B. Level 2
C. Level 3
D. Level 4 Most dependent : Cuff -1
Stage II
36
A. Definition
B. Pathophysiology
C. Risk Factors
D. Diagnosis
i. Presentation
E. Management
37
Aims of surgery
1. Reestablish the anatomic position and support of the pelvic

organs
2. Return of normal function of pelvic organs
3. Achieve patient satisfaction
4. Avoid complication or reoperation
38
COMPARTMENT VAGINAL ROUTE ABDOMINAL ROUTE
ANTERIOR Compartment
Cystocele/ Anterior Colporrhaphy Burch Colposuspension
Cystourethrocele Paravaginal Repair Paravaginal Repair
Sacrocolpopexy
POSTERIOR Compartment
Rectocele Posterior Colporrhaphy Sacrocolpopexy
(fascial repair;
levator myorrhaphy;
site-specific repair;
post-anal repair)
MIDDLE/APICAL
Uterovaginal Prolapse (Vaginal Hysterectomy) Sacrohysteropexy
Vault Prolapse Le Fort Colpocleisis Sacrocolpopexy
Sacrospinous Ligament Fixation USL Fixation /
Enterocele (SSLF) / Moschowitz Procedure / Halbans
Prespinous / Iliococcygeal Fixation Procedure
USL Suspension/Plication
McCalls Culdoplasty
39
II. URINARY INCONTINENCE
A. Definition
- Mechanism of continence
- Micturition cycle
B. Classification
C. Basic evaluation
D. Specific conditions
Genuine Stress Incontinence
Overactive Bladder
40
Definition
Urinary incontinence is
defined as the involuntary
loss of urine that is
objectively demonstrable
and a social or hygiene
problem.
41
Mechanism of continence
Continence is maintained when

the maximum urethral pressure
exceeds the maximum bladder
pressure or when urethral
closure pressure is positive.
42
Mechanism of continence
Intra-urethral pressure >

Intravesical pressure = Continence
Low intravesical pressure

>> Accommodation
High intra-urethral pressure

>> Sphincter mechanism
>> Pelvic floor contraction
43
Micturition cycle
Accommodation
(Detrusor relaxed)
Contraction of the urethral

sphincter
(
Contraction of the pelvic
floor
(
44
Storage
Sympathetic (T10-T12) via
hypogastric nerve
-detrusor contraction inhibited
-urethral sphincter closed
45
Emptying
Parasympathetic (S2-S4) via pelvic
nerve
-detrusor contraction
-urethral sphincter relaxation
Somatic via Pudendal nerve

-external urethral sphincter
contraction
-pelvic floor contraction
46
Classification
Urethral sphincter incompetence

Detrusor instability
(Neuropathic or Non-neuropathic)
Urethral Retention with overflow
Incontinence Congenital
Miscellaneous
Congenital
Extra-urethral
Fistula
47
A. Definition
- Mechanism of continence
- Micturition cycle
B. Classification
C. Basic evaluation
D. Specific conditions
- Urodynamic Stress Incontinence
- Overactive Bladder
48
Evaluation
Gynecologic
40% with urethral sphincter incompetence has anterior
vaginal wall prolapse
Fistulas may be observed with speculum exam
Neurologic
S2-S4 most important to assess
- perineal sensation, anal wink, pelvic floor contraction,
anal sphincter tone
49
Evaluation
Urinalysis and urine culture

- urge incontinence and irritative symptoms
- infection, stones, urothelial disease
Estimation of postvoid residual urine

- adequate bladder emptying <50 mL
- significant residual >200 mL
- overflow incontinence
Voiding diary
- 3 day clinical record of input and output, urine volume and frequency,
leak episodes and triggering factors
50
Evaluation
Office cystogram with CST

Simple bladder filling test that provides
presumptive diagnosis of incontinence
First sensation, first desire to void, strong

desire to void, and maximum cystometric
capacity are recorded
Cough stress test (CST) is performed when

nearing maximum capacity
51
Evaluation
Office cystogram with CST

Cough stress test (CST)
Positive : Immediate non-sustained urine
loss,; suggestive of stress incontinence
Equivocal : Delayed sustained urine loss that

cannot be inhibited is suggestive of detrusor
instability (or overactive bladder)
*Immediate sustained may be suggestive

of urethral sphincter incompetence
52
Evaluation
Q-tip Test
A sterile cotton tip is placed with the urethra
and, upon straining or coughing, any deflection
greater than 30 from the horizontal is
considered an indication of urethral
hypermobility.
- Does not correlate with urodynamic testing
53
Evaluation
Cystometrogram
Gold standard in evaluating bladder function
Measures of the pressure/volume relationship of the bladder during
filling and voiding
Distinguishes between detrusor instability and genuine stress
incontinence
54
55
Stress incontinence
Definition:
Involuntary urine loss with physical exertion;
when the intra-vesical pressure exceeds the
urethral pressure in the absence of a detrusor
contraction (Genuine stress incontinence)
56
Stress incontinence
Definition:
Involuntary urine loss with physical exertion
Urodynamic stress incontinence:

Symptom of stress incontinence is confirmed
by a urodynamic test
Etiology:
Descent or inadequate support of the bladder
neck and mid-urethra as well as loss of
urethral resistance
57
Stress incontinence
Urodynamic stress incontinence
Etiology:
Descent or inadequate support of the bladder
neck and mid-urethra as well as loss of urethral
resistance
Treatment:
Increase urethral resistance
Physiotherapy
Alpha-adernergic stimulants
Restore bladder neck support
Surgery
58
Urge incontinence
Definition:
Involuntary urine loss associated with a
strong desire to void (urgency)
Overactive bladder syndrome: urinary

urgency, frequency with or without urge
incontinence
59
Urge incontinence
Overactive bladder syndrome:
Urinary urgency, frequency with or without
urge incontinence
(exclude infection and other bladder
pathologies with similar symptoms)
Etiology:
Results from uninhibited bladder
contractions, either provoked or unprovoked
60
Urge incontinence
Overactive bladder syndrome:
Urinary urgency, frequency with or without
urge incontinence
Etiology:
Uninhibited bladder contractions
Treatment:
Lifestyle modifications (avoidance of
triggers)
Bladder retraining
Anticholinergics
Electrical stimulation
Surgery
61
Overactive Bladder
Treatment: Conservative (Medical Therapy)
Mechanism of Action Drug Dosage Frequency
Antimuscarinic Propantheline Br 7.5-60 mg 3-5 times/day

Smooth muscle relaxant, Oxybutynin 2.5-10 mg 2-3 times/day

antimuscarinic, local
anaesthetic

Smooth muscle relaxant, Tolterodine 1-4 mg 2 times/day
antimuscarinic Trospium Cl 20 mg 2 times/day

Antimuscarinic, calcium Propiverine 15 mg 2-4 times/day
channel antagonist

Smooth muscle relaxant Dicyclomine HCl 10-20 mg 3 times/day
(antispasmodic)

Tricyclic antidepressant, Imipramine HCl 25-75 mg 1-3 times/day
antimuscarinic, alpha-
adrenergic agonist,
antihistaminic
Antidiuretic DDAVP (synthetic 100-200 mg Once At bedtime
vasopressin)

62
REFERENCES
Pelvic organ prolapse
1. The standardization of terminology of female pelvic organ prolapse and
pelvic floor dysfunction. http://www.ajog.org/pb/assets/raw/Health%
20Advance/journals/ymob/12_Bump.pdf
2. Pelvic organ prolapse (ICS committee report) http://www.ics.
org/Publications/ICI_2/chapters/Chap05.pdf
Urinary incontinence
1. The neural control of micturition. http://www.ncbi.nlm.nih.
gov/pmc/articles/PMC2897743/
2. The standardisation of terminology of lower urinary tract function. http:
//www.ics.org/Publications/ICI_3/v2.pdf/abram.pdf
Others
1. Evaluation and treatment of Urinary Incontinence, Pelvic organ Prolapse
and Faecal Incontinence. http://www.ics.org/Publications/ICI_4/files-
book/recommendation.pdf 63
A Review of
UROGYNECOLOGY
UPCM Interns Refresher Course
15 June 2015
Good Luck!
Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPS
Clinical Associate Professor
Section of Urogynecology and Pelvic Reconstructive Surgery
Department of Obstetrics and Gynecology
UP College of Medicine
Philippine General Hospital
64

Urogynecology Review For Up College PDF

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Urogynecology Review For Up College PDF

Diunggah oleh

Hak Cipta:

Format Tersedia

A Review of

Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPS

I. Pelvic Organ Prolapse

II. Urinary Incontinence

POP is defined as the

POP comes about

Pelvic support structures

Bony pelvis provides the

Pelvic support structures

Pelvic diaphragm the

Levator ani muscles

Pelvic support structures

Pelvic support structures

- It envelops these organs and

Level 3 fusion of the endopelvic

Endopelvic fascia stabilizes the pelvic organs above the levator

Pelvic diaphragm maintains the levator plate, a horizontal

Endopelvic fascia stabilizes the pelvic organs above the levator

Weakness of Pelvic diaphragm

Downward rotation of the levator plate from its horizontal position

Stress on the Endopelvic fascia

Descent of Pelvic Organs

Weakness of Pelvic diaphragm

Downward rotation of the levator plate from its horizontal position

Stress on the Endopelvic fascia

Descent of Pelvic Organs

Predisposing Skeletal, muscular, neurological, connective tissue, racial, gender

Inciting Vaginal delivery, surgery, neurological

Promoting Obesity, smoking, lung disease, constipation, recreational and

Decompensating Ageing, menopause and hormonal deprivation, progressive or

Sexual Inability to have sexual activity

Introduced in July 1996 by the International Continence Society

Aimed to standardize the terminology and reporting of POP

The hymen is the fixed reference point used throughout the

The anatomic position of the 6 defined points for evaluation should be

If the defined point is observed above or proximal to the hymen, it is

If the defined point is observed below or distal to the hymen, it is

3. Pelvic floor muscle testing

SCORE and STAGE

1. Reestablish the anatomic position and support of the pelvic

Continence is maintained when

Intra-urethral pressure >

Low intravesical pressure

High intra-urethral pressure

Contraction of the urethral

Somatic via Pudendal nerve

Urethral sphincter incompetence

Urinalysis and urine culture

Estimation of postvoid residual urine

Office cystogram with CST

First sensation, first desire to void, strong

Cough stress test (CST) is performed when

Office cystogram with CST

Equivocal : Delayed sustained urine loss that

*Immediate sustained may be suggestive

- Does not correlate with urodynamic testing

Urodynamic stress incontinence:

Urodynamic stress incontinence

Overactive bladder syndrome: urinary

Antimuscarinic Propantheline Br 7.5-60 mg 3-5 times/day

Smooth muscle relaxant, Oxybutynin 2.5-10 mg 2-3 times/day

Anda mungkin juga menyukai