PELVIC ORGAN

PROLAPSE(POP)AND
URINARY INCONTINENCE

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 INTRODUCTION

POP is the downward displacement

of the
structures that are normally located
adjacent to the vaginal vault.
Protrusion of the pelvic organs into or
out the vaginal canal
Defects in the pelvic supporting
structures result in a variety of
clinically evident pelvic relaxation
abnormalities
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 It's estimated that half of women
who have children will experience
some form of prolapse in later life,
but because many women don't seek
help , the actual number of women
affected by prolapse is unknown.

POP occurs when the pelvic floor

muscles become weak or damaged
and can no longer support the pelvic
organs.
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 Epidemiology
Most are parous, older women.
History of increased intra-abdominal
pressure
Postmenopausal
History of trauma to pelvic
supporting structures
11% of women up to the age of 80 in
USA have surgery for POP &/or
Incontinence.
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Elements comprising the Pelvis

Bones
Ilium, ischium and pubis fusion
Ligaments
Muscles
Obturator internus muscle
Levator ani muscles
Urethral and anal sphincter muscles

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 Endopelvic fascia
Meshwork of collagen, elastin and
smooth muscle
Extends from the level of uterine
artery to the fusion of the vagina and
levator ani.
Attached to uterus is parametrium
cardinal-uterosacral ligament complex
Attached to vagina is paracolpium
pubocervical and rectovaginal fasciae.

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 Three levels of vaginal support
Apical suspension
Upper paracolpium suspends apex to pelvic walls and
sacrum.
Damage results in prolapse of vaginal apex.
Midvaginal lateral attachment
Vaginal attachment to arcus tendineus fascia and
levator ani muscle fascia.
Pubocervical and rectovaginal fasciae support bladder
and anterior rectum
Avulsion results in cystocele or rectocele
Distal perineal fusion
Fusion of vagina to perineal membrane, body and
levators
Damage results in deficient perineal body or
urethrocele

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 Pelvic Relaxation
Cystocele
Stress urinary incontinence
Rectocele
Enterocele
Uterine and vaginal prolapse

Result of weakness or defect in supporting

tissues-
endopelvic fascia and neuromuscular
damage

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 PROLAPSE
Multifactorial involving both
neuromuscular and endopelvic
fascial damage
Relaxation of the tissues supporting
the pelvic organs may cause
downward displacement of one or
more of these organs into the vagina,
which may result in their protrusion
through the vaginal introitus.

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 Factors promoting
prolapse
Acute and chronic trauma of vaginal
delivery
Aging
Estrogen deprivation
Intrinsic collagen abnormalities
Chronic increase in intraabdominal
pressure
Heavy lifting
Coughing
Constipation

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 Clinical Evaluation
Symptom:
Variable & not associated with degrees
Feeling of something coming down
Back ache or dragging sensation
Urinary symptoms like difficulty in passing
urine, frequency, etc
Bowel symptoms like constipation
Excessive white or blood stained discharge

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P/E
Composite examination needed
Straining & different positions
Prolapsed uterus with cervix as
leading point
Prolapse of one organ is associated
with other prolapses

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 Hormonal and neurologic evaluation
Quantitative site-specific assessment of
pelvic floor components
In lithotomy position, patient sitting
At rest and with valsalva.
Ability to contract levator and anal
sphincter muscles

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 Investigations
Hct/ Hgb, blood group & Rh status
U/A, culture & sensitivity
RBS/FBS
RFT
IVU
Ultrasound
Urodynamic studies
CXR, etc

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 Complications
1.Vaginal mucosa: keratinization &
decubitus ulcer
2.Cervix: hypertrophied & elongated
3.Urinary symptom:
-Bladder: cystitis, trabeculation,
incomplete evacuation
-Ureters: hydroureter, pyelonephritis
4. Incarceration
5. Peritonitis
6. Carcinoma: rarely develops on decubitus
ulcer.
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 DDX

Cystocele versus Gartners cyst

(wolffian remnant)
Congenital elongation of the cervix.
Chronic uterine inversion.
Fibroid or polyp.
Tumors.

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 UVP

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 Cervical elongation

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 Anterior compartment
defects
Urethral hypermobility
Distal 4 cm of anterior vaginal wall
It describes an arc greater than 30
degrees from horizontal with valsalva
Results in genuine stress incontinence
Cystocele

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 Cystocele
Main support of urethra and bladder is the
pubo-vesical-cervical fascia
Essentially a hernia in the anterior vaginal wall
due to weakness or defect in this fascia
Midline weakness allows bladder to
descend causing central cystocele
Tearing of endopelvic fascial
connections from lateral sulci to arcus
tendinii causes lateral or displacement
cystocele
Detachment of pubocervical fascia from
pericervical ring causes a transverse or
apical cystocele
Symptoms include pelvic pressure and bulge or
mass in the vagina
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 Cystocele
Surgical repair is treatment of choice
Anterior Colporrhaphy
Paravaginal repair
Colpocleisis
Vaginal pessary

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 Posterior compartment
defects
Rectocele
Perineal descent
Sagging and funneling of the levator ani
around the perineum such that anus
becomes most dependent
Difficulty with defecation

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 Rectocele
Chiefly a hernia in the posterior
vaginal wall secondary to weakness
or defect in the rectovaginal septum
or fascia of Denonvilliers
Symptoms include difficulty
evacuating stool, a vaginal mass,
and fullness sensation
Rectovaginal exam confirms
diagnosis

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 Rectocele
Damage generally due to excessive
pushing in childbirth or chronic
constipation
Surgical treatment if symptomatic
Posterior Colporrhaphy, defect repair
Laxatives and stool softeners
Temporary relief

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 Apical defects
Uterine prolapse
Normal cervix located in upper third of
vagina
Degree of prolapse measured by position
of cervix at maximum intraabdominal
pressure, without traction
Complete uterovaginal prolapse is called
procidentia
Vault prolapse
Enterocele

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 Uterine prolapse
Weakness of endopelvic fascia and
detachment of cardinal and uterosacral
ligaments
Complains of severe pelvic or abdominal
pressure, bulge or mass, and low back
pain
Surgical management includes
hysterectomy and vaginal cuff or apex
suspension

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 Enterocele
A true hernia of the rectouterine or cul-de-sac
pouch (pouch of Douglas) into the rectovaginal
septum
Descent of bowel in a peritoneum-lined sac
between posterior vaginal apex and anterior
rectum
Can occur anteriorly as well
Generally after a surgical change in vaginal
axis
Symptoms of fullness and vaginal pressure or
palpable mass
Bowel peristalsis confirms diagnosis
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 Commonly found in association with other
defects
Surgical approach
Vaginal
Abdominal
Laparoscopic
Ligation of hernia sac and obliteration of
the pouch of Douglas

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 Grading/staging/degrees
of POP
Three systems
Degree system: three degrees
1. 1st degree: external cervical os below the
ischial spines but within the vagina
2. 2nd degree: external os reaches or
protrudes out of the interoitus but fundus
inside the vagina
3. 3rd degree: uterine body outside of the
interoitus. It is also called as PROCEDENTIA

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 Baden-Walker half way system:
1. Grade 0: normal position
2. Grade 1: Halfway between ischial
spine to hymen
3. Grade 2: In to hymen
4. Grade 3: halfway past hymen to
maximal descent
5. Grade 4: Maximal descent past
hymen
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 Pelvic organ prolapse quantification system
(POP-Q)
Four stages
1. Stage 0: no prolapse
2. Stage 1: maximal descent is 1cm above
hymenal ring
3. Stage 2: up to 1cm beyond the hymenal
ring
4. Stage 3: up to 2cm from total vaginal
length from hymenal ring
5. Stage 4: beyond the hymenal ring to the
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 Principles of reconstructive
pelvic surgery
Site-specific repair
Rebuild weakened endopelvic fascia,
repair fascial tears, and reattach
prolapsed tissues to stronger sites
Goal is a vagina of normal depth,
width and axis: function follows form
Denervation or muscle trauma
cannot be corrected surgically

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Conservative treatments
Pessary: can be fitted in most women
regardless of the stage or site of predominant
prolapse
Obstetric care to protect pelvic floor
Decreased pushing times
Avoid forceps, major lacerations
Permit passive descent
General lifestyle changes
Smoking cessation and cough cessation
Routine use of Kegel pelvic floor exercises
Regular physical activity
Proper nutrition
Weight loss
Avoid constipation and repetitive heavy lifting
Hormone replacement therapy
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 Urinary incontinence
Physiology of Micturation
Bladder & urethra should be
considered as a single unit for
storage of urine & voiding
Storage & emptying of urine depends
on a complex interplay between the
brain, spinal cord, bladder, urethra
&pelvic floor

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 Physiology of micturation

Storage phase:
Filling rate: 0.5-5 ml/min
As bladder fills, walls stretch to
maintain a constant tone
Intra-vesical pressure is maintained
to a steady level of 10cmH2O even
with a volume of 500ml.

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 Voiding Phase
When volume of 250 ml reached, a
sensation of bladder filling perceived.
Desire to void is not by increased
intravesical pressure but by
stimulation of stretch receptors in
the bladder wall
Involves both spinal and higher
centers

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 Urinary incontinence (UI)
Definition: urinary incontinence (UI) is an
involuntary loss of urine that is social and
hygienic problem which is demonstrable
objectively.
A common problem of women of all ages.
Affects womens social and sexual activity.
Only <50% of women with UI seeks help.
Women tries to ameliorate symptoms by
frequent toilet visiting and fluid restriction.
Of 50% of women with significantly affected
QoL ,only 77% seeks help.
UI increases with aging.
Prevalence :(11-57)%.
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Negative impact on quality of life.
Social embarrassment.
Avoids physical activity.

low self esteem.

Sexual dysfunction.
Anxiety.
Depression in 80%.

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 Pathogenesis
Continence depends on integrity of LUT, pelvic
support and neurological system
Intact functional ability to toilet oneself
Mobility and manual dexterity
Cognitive ability
Impairment of one of these leads to UI
In UI one of four things go wrong
Bladder over activity
Bladder under activity
Sphincter obstruction
Sphincter doesnt close
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 Classification of UI
Transurethral
Extra urethral: Stress urinary
Congenital incontinence
Ectopic ureter (SUI)
Bladder Urge urinary
extrophy incontinence
(UUI)
Aquired (fistulas)
Mixed urinary
Ureterovaginal
incontinence
Vesicovaginal( (MUI)
VVF) Overflow
Urtherovaginal incontinence
complex
combinations.
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 Functional and transient
incontinence (DIAPPERS)
Delirium
Infection
Atrophic vaginitis
Pharmacologic agents
Psychological
Endocrine
Restricted mobility
Stool impaction

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 Clinical evaluation of urinary
incontinence
History:
Urgency, dysuria, frequency.
Leakage with intraabdominal pressure.
Dribbling.
Frequency >7-8x/day, Nocturia
>2x/day,
hesitancy, poor streaming, interrupted
voiding.
-Precipitants
Coital incontinence.
Giggle incontinence.
Exercise.

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 Physical examinations:
Mental status
Bladder distention.
Rectal mass/fecal impaction.
Gynecologic evaluation Evaluation
of urethral support (pt standing, full
bladder).
Neurological evaluation
Perianal sensation.
Anal sphincter tone

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 Laboratory evaluation
Urinalysis/ culture.
Serum glucose level.
Cystoscopy .
Urine cytology (age >50, hematuria)
RFT
Trans-vaginal endosonography
Other tests
- Pad test

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 Urodynamic tests
1) Bladder filling test
- urinate, catheterize (measure post void
volume), fill the bladder with N/S at a rate
of 60-75 ml/min till functional capacity.
2) Cystometry 2 types
A Filling cystometry --- measures bladder
pressure while filling.
B Voiding cystometry (pressure flow study)
Bladder filled with water or saline

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 Normal cystomerty values
Residual volume <50 ml.
First desire to void is b/n 150-250 ml.
Strong desire to void be after 250 ml.
Bladder capacity 400ml- 600 ml.
No detrusor contraction on filling
phase.
No leakage on coughing.
No provoked detrusor contraction.
Maximum detrusor pressure < 50
cmH2O.
Maximum flow rate >15 ml/sec.

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 Stress urinary incontinence (SUI)

Definition: is leakage of urine that occurs when

intravesical pressure exceeds MUCP (mean urethral
closure pressure) in the absence of detrusor
contraction (sneezing, coughing, exercise).
Causes:
urethral hyper mobility.
Intrinsic sphincter deficiency (ISD).
Prevalence:
SUI-50%
MUI-30-40 %
UUI-10-20%
SUI is more common in young and middle age groups.
UUI is common in older women.

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 Factors associated with SUI:
Pelvic floor damage (denervation)
Parturition.
Pelvic surgery.
Urethral damage
Vaginal/urethral surgery.
Urethrotomy.
Increased intraabdominal pressure.
Pregnancy.
Chronic cough.
Fecal impaction
. Pelvic mass, obesity, ascites.
Diagnosis:
history.
Stress test.
Urodynamic study;
Gold standard.
Diagnose DO, ISD, Overflow incontinence

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 Treatment

1) Non surgical
a) Avoid aggravating factors decrease
obesity, Rx of cough, stop smoking,
etc.
b) Strengthen pelvic muscles
-Kegel exercise (pubococygeus m.)
-improve estrogen status
c) Drugs -adrenergic drugs.
d) Electrical stimulation experimental.

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2) Surgical treatment
a) anterior colporrhaphy
b) Operation for urethral hyper mobility
b.1 -Retro pubic urethropexy
b.2) Trans-vaginal urethropexy
b.3) Tension free vaginal tape
C) Operation for IUSD
c.1) Sling operation
c.2) Periurethral Injection
c.3) Urethral Plugs
c.4) Artificial sphincter

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 Detrusor Over activity (DO)
Definition
- spontaneous or provoked detrusor
contraction during filling phase of bladder.
- characterized by urge incontinence
Treatment :
Bladder training
Is to reestablish cortical control over detrusor.
Patient will have scheduled voiding.
Cure rate 47-90%.
Biofeedback training
Perineal vaginal or anal electrodes is used.
Cure rate 40-70%.
Pelvic floor exercise

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 Pharmacologic treatment
Anticholinergics
-Oxybutynin, Tolterodine,
Imipramine, Propantheline
bromide.
-are smooth muscle relaxants.
Estrogen
Improves urethral mucosal
seal, muscle tone.
Improves -adrenergic
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 Mixed incontinence (MUI)
The predominant feature guides the
line of management i.e. SUI/UUI.
Generally safer management is to
treat DO first medically and then
surgery for failed cases.

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 Overflow incontinence
Is a result of detrusor weakness or bladder out let
obstruction.
Typically the leakage is small in volume.
Poor streaming, dribbling, hesitancy.
Causes of obstruction;
Anti incontinence surgery.
Cystocele.
Spinal cord injury.
Detrusor under activity;
contributes 5-10% of UI.
Causes;
Replacement of detrusor smooth muscle by fibrous
tissue.
Peripheral neuropathy.
Damage to spinal detrusor afferent.

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 Diagnosis;
Leakage occurs typically with stress.
Dribbling , hesitancy, frequency, prolonged voiding.
Have distended bladder.
Neurologic evaluation.
Investigations;
Ultrasound for bladder volume.
Voiding study.
Electromyography.
Cystoscopy.
Urethroscopy.
Treatment;
Correct causes of mechanical obstruction.
Intermittent self catheterization.
Implantation of nerve root electrical stimulator(S2-S4).

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 GENITOURINARY FISTULA
Definition- a hole (communication)
between bladder and vagina and/or
rectum.
Causes
Obstructed labor as a result of early
marriage and conception with small
pelvis.
Poverty.
Lack of skilled attendance at birth.
Lack of emergency obstetric care &
transportation.
Limited awareness about fistula
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 Etiology:
Grave social
Congenital
consequence of
Acquired
fistula are
child birth
divorce. Radiotherapy.
depression. Surgery
Poverty. Malignancy.
Suicide. Childhood
Penetrating
trauma.
Foreign body.
Surgery.

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 Clinical feature of VVF
Continuous urine leakage vaginally.
Occur in the first 10 days of procedures.
Have foul ammoniac odor.
Depression.
Insomnia
Disrupted sexual relationship.
Low self esteem
Assessment;
VVF;
present as leakage of excessive volume of fluid per vagina with
no voided urine.
Ureterovaginal fistula;
Small amount of urine leakage via vagina .
Has regular voiding.
Urethrovaginal fistula;
Leakage during and after voiding via vagina.

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 Investigation
Vaginal fluid analysis for urea.
Urine culture
Dye test 3-swab test.
IVP (ureterovaginal fistula, hydronephrosis).
Cystourethroscopy.
Treatment
Preoperative care
Treat any infection or inflammation.
Correct nutritional status.
Perineal skin care
Surgical technique
It is mainstay of treatment, vaginal approach.
Principles
Wide mobilization of bladder.
Excise scar
Tension free closure.
Good homeostasis.
Minimize tissue trauma

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 The best result is with the first attempt.
Vaginal approach;
Safer and convenient to the patient.
98-100% success rate.
Abdominal approach
Large fistula
Fistula adjacent to ureter
involving ureter.
Success rate 71-100 %
Others ;urethral reconstruction
,Diversion can be done.

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 Thank
you
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