Pelvic support defects and urinary incontinence

pelvic support defect

weakness, injury, or failure of the pelvic floor support structures (muscles, fascia, ligaments), resulting in abnormal descent of pelvic organs.

Levator ani muscles

Endopelvic fascia

Uterosacral & cardinal ligaments

Perineal body

structures involved in a pelvic support defect

Vaginal childbirth (especially large babies, operative delivery)

Chronic ↑ intra-abdominal pressure (obesity, cough, constipation)

Menopause (estrogen deficiency → tissue atrophy)

Connective tissue disorders

Prior pelvic surgery

common risk factors for pelvic support defect

downward descent of pelvic organs into or beyond the vaginal canal due to pelvic support defects.

what is the clinical definition of pelvic organ prolapse

vaginal apex

organ involved in prolapse post-hysterectomy

Vaginal bulge/pressure

"Something falling out"

Pelvic heaviness

Urinary or bowel dysfunction

patient presentation in pelvic organ prolapse

POP-Q

Pelvic organ prolapse quantification. Quantifies the extent and location of defects

cystocele

Herniation of the bladder into the anterior vaginal wall.

anterior vaginal wall prolapse

cystocele is aka

Stress urinary incontinence

Urinary frequency

Incomplete bladder emptying

symptoms associated with cystocele

rectocele

Herniation of the rectum into the posterior vaginal wall.

Constipation

Need to splint (apply pressure to vagina) for bowel movement

Incomplete evacuation

symptoms associated with rectocele

vaginal vault prolapse

Descent of the vaginal apex (vaginal cuff) after hysterectomy.

vaginal vault prolapse

Apex descends toward or beyond introitus

No cervix present

Often associated with cystocele/rectocele

Pelvic pressure

Bulge sensation

Urinary or bowel symptoms

symptoms of vaginal vault prolapse

uterine prolapse

Descent of the uterus and cervix into the vaginal canal due to uterosacral/cardinal ligament failure.

uterosacral/cardinal ligament failure

what causes a uterine prolapse?

Graded by stage (I-IV)

Stage I: above hymen

Stage II: to hymen

Stage III: beyond hymen

Stage IV: complete procidentia

staging of a uterine prolapse

cystocele

anterior vaginal prolapse

pelvic organ prolapse

Multiparous, postmenopausal woman + vaginal pressure → think

rectocele splinting

a technique, often using fingers or a special device, to physically support the vaginal wall or perineum to help push the rectum back into place, making it easier to have a bowel movement and relieve constipation caused by a rectocele

occult stress urinary incontinence

New stress incontinence after prolapse repair → evaluate for

Pelvic floor muscle training (Kegels) → stress > urge

Bladder training / timed voiding → urge

Weight loss

behavioral management for incontinence

Pelvic floor PT

Pessary (excellent for poor surgical candidates)

Vaginal estrogen (postmenopausal tissue support)

behavioral management of pelvic organ prolapse

urge incontinence

involuntary leakage of urine with a sudden, strong desire to urinate

-Antimuscarinics

Oxybutynin

Tolterodine

-β3-agonist

Mirabegron

medical management of urge incontinence

❌ No effective medication

Manage mechanically or surgically

management of stress incontinence

Mid-urethral sling (gold standard)

surgical management for stress incontinence

anterior colporrhaphy

surgical management of cystocele

Posterior colporrhaphy

surgical management of rectocele

Uterosacral ligament suspension / sacrocolpopexy

surgical management of apical prolapse

“Do you feel a sudden, strong urge to urinate and can’t make it to the bathroom?”

“Do you wake up at night to urinate?”

questions to screen for urge incontinence

“Do you feel like you never fully empty your bladder?”

“Do you have constant dribbling?”

questions to ask to screen for overflow incontinence

urethral sphincter weakness

pathophys of stress incontinence

detrusor overactivity

pathophys of urge incontinence

elderly

population associated with urge incontinence

Bladder outlet obstruction or detrusor underactivity

pathophys of overflow incontinence

Diabetic, neurogenic bladder

population associated with overflow incontinence

UA: leukocyte esterase, nitrites

Urine culture if recurrent or complicated

UA findings of cystitis

Nitrofurantoin

TMP-SMX

Fosfomycin

treatment of uncomplicated cystitis

oral floroquinolone

treatment for outpatient (mild) pyelonephritis

IV ceftriaxone

IV piperacillin-tazobactam

IV fluoroquinolone

treatment for inpatient (severe) pyelonephritis

no

are meds effective for stress incontinence

Antimuscarinics

med class indicated for urge incontinence

pessary

a great non-surgical POP option