Urogynecology

Pelvic organ prolapse and urinary incontinence

Pelvic facia, ligaments, and muscle become attenuated, increased intra-abdominal pressure, or atrophy

Pathophys for Pelvic organ prolapse

Multiparity, Age, macrosomic infant, prolonged 2nd stage of labor, mother under 25, AMA+, obesity, hysterectomy, elevated internal abdominal pressure (constipation, COPD), collagen abnormality, fam hx

Risk factors for prolapse

Cystocele (bladder prolapse, anterior)

A herniation of the anterior vaginal wall associated with descent of the bladder

Heaviness, sensation of a bulge, or fullness in the pelvis; sensation of something falling out, symptoms worsen with standing, Relieved when lying down, associated symptoms of frequency, urgency, incontinence or retention

Symptoms of Cystocele (anterior)/ apical (uterine/vaginal vault)

Rectocele (rectal prolapse, posterior)

Herniation of the posterior vaginal segment associated with descent of the rectum

Perineal pressure, obstructive defecation (digital reduction), genital looseness, palpable bulge

Symptoms of rectocele (posterior)

Urethrocele

Descent of the uterus towards or into the vaginal canal

Stage 1

Which stage of prolapse am I describing - in the upper half of the vagina?

Stage 2

Which stage of prolapse am I describing - descending nearly to the vaginal opening?

Stage 3

Which stage of prolapse am I describing - protrudes out of the vagina on valsalva

Stage 4 (procidentia)

Which stage of prolapse am I describing - completely outta the vagina 

Normal external genitalia, generalized atrophic changes, visualization of a cystocele and rectocele, cervix descends to the introitus, uterus is normal in size, rectal sphincter tone is decreased, EMB or U/S to evaluate bleeding

Pelvic exam findings for prolapse

cardinal ligaments blend with utero-sacral ligaments (attach to upper vagina, cervix, LUS)

Level I (that girl - major) support is made up of

Paravaginal attachment (keeps it midline and over the rectum) at the level of the ischial spine

Level II supports

Perineal body and membrane, superficial and deep perineal muscles, and endopelvic fascia

Level III (last line - normal position of the distal 1/3) supports are made up of

Baden-Walker System (out), POP-Q (IN)

Staging systems of Prolapse

Pelvic Organ Prolapse Quantification (measure vaginal length and the compartments)

Staging is based on position of vaginal walls relative to the hymen (stage II is -1 - + 1)

Conservative Therapy (pessary, kegels), surgical treatment is indicated with symptomatic or failure of conservative

Treatment of a Prolapse - based on QoL and Associated Symptoms

Prolapse with symptoms and they don’t want surgery or aren't current candidates

Indications for Pessaries

vaginal or abdominal route, Sacrocolpopexy (ASC) 🏆, fixation via sacrospinous, uterosacral ligament or iliococcygeus

Surgeries for Level 1s at the vaginal apex

Midline or lateral (determined by exam), anterior colporrhaphy, paravaginal defect repair (PVDR)

Surgical management of the Anterior Compartment - level II

Posterior colporrhaphy (PR), site specific vs. repair of entire area

Surgical management of the Posterior Compartment - level III

Colpocleisis

A surgical repair of prolapse that is only used in women who no longer desire sexual activity because the vaginal vault is closed off - more durable and lower risk

filling and Storage

Which function of the badder is due to the sympathetic innervation?

Voiding (Pee)

Which function of the bladder is due to the parasympathetic innervation?

Stress Incontinence

Involuntary leakage of urine that occurs if abdominal pressure exceeds urethral pressure or resistance or urine flow (most common in those under 45)

Urethral hyperactivity, laxity of pelvic floor muscles

Etiologies of Stress Incontinence

urine leakage during laughing, cough, sneezing, lifting etc, NO URGE TO PEE

Clinical findings of Stress Incontinence

Kegels (initial 1st line), topical estrogens if postmenopausal, pessaries, Midurethral sling, alpha agonists (midodrine and pseudoephedrine)

Management of Stress Incontinence

Urge incontinence

Involuntary urinary leakage preceded by or accompanied by a sudden urge to urinate (most common in older women)

detrusor muscle OVERactivity leads to uninhibited contractions during filling

Pathophys for Urge incontinence

Increased age, idiopathic, bladder infection, stones or tumor

Etiologies for Urge incontinence

increased urgency, frequency, small volume voids, nocturia - wants to pee can’t make it to the bathroom on time → get a UA to r/o UTI

Clinical findings for Urge incontinence

Bladder training, Lifestyle mods (stop spicy foods, citrus, chocolate, EtOH, and caffeine), Kegels, Antimuscarinics (oxybutynin, tolterodine), Beta-3 agonists (mirabegron), TCAs (imipramine), Botox injections, bladder augmentation

Management of Urge incontinence

Overflow Incontinence

Urinary retention and incomplete bladder emptying leads to involuntary urine leakage once the bladder is full (least common)

Bladder detrusor UNDERactivity or bladder outlet obstruction

Pathophys for Overflow Incontinence

Neurological disorders/autonomic dysfunction (DM, MS, spinal injuries, spinal stenosis, peripheral neuropathy), BPH, uterine fibroids, prolapse, overcorrection of urethra

Etiology for Overflow Incontinence

Loss of urine w/o warning or triggers; leakage/dribbling in the setting of incomplete emptying, weak or intermittent urinary stream, hesitancy, frequency, nocturia

Clinical findings for Overflow Incontinence

Post void residual over 200 mLs, urodynamic testing to r/o urethral obstruction

Diagnostics for Overflow Incontinence

Intermittent/indwelling cath (1st line), Cholinergics (Bethanechol - increases detrusor activity)

Management of bladder atony in Overflow Incontinence

Activates Beta 3 receptors in the detrusor muscle in the bladder, leads to muscle relaxation and increase in bladder capacity - WATCH FOR CARDIAC

MOA for beta 3 agonist

anticholinergics and antispasmodics increase bladder capacity

MOA for Antimuscarinics (oxybutynin, tolterodine)

Stress + urge

Mixed incontinence is made up of