Urogynecology

and
Pelvic Reconstruction
 Daftar Riwayat Hidup

Tmpt/ Tgl Lahir : Semarang,

19 Mei 1977
Jenis Kelamin : Perempuan
Agama : Islam
Hobby : Yoga
Marital: Menikah
Alamat: Puri Langen Estate Blok
A No.8-9 Kutasari,
Baturraden, Purwokerto
Jawa Tengah
 PENDIDIKAN
1983-1989 : SD Santa Maria Purwokerto
1989-1992 : SMP Negeri 1 Purwokerto
1992-1995 : SMA Negeri 1 Purwokerto
1995-2001 : UNDIP Semarang, FK Dokter Umum
2011-2014 : Universitas Sam Ratulangi Manado,
PPDS 1 Obstetri dan Ginekologi

PENGALAMAN KERJA
2006-sekarang RS Ananda Purwokerto
2016-sekarang RSUD Prof.Dr. Margono Soekarjo
 dr. Setya Dian Kartika,Sp.OG

UROGYNECOLOGY AND PELVIC RECONSTRUCTION

Lower Urinary Tract Disorder

Pelvic Organ Prolapse
Anorectal Dysfunction
 dr. Setya Dian Kartika,Sp.OG

Bladder storage and emptying depend on a complex

interplay between the brain, spinal cord, bladder, urethra,
and pelvic floor

Urinary incontinence is common in women and generally is

treated succesfully with a range of nonsurgical and surgical
treatments
 Stress urinary incontinence occurs with increases in
abdominal pressure (such as coughing, running, lifting) and
can be treated with pelvic muscle exercise, vaginal devices,
lifestyle changes, and surgery

Urgency urinary incontinence occurs with a sudden sense of

urgency (such as on the way to the bathroom or when
washing hands) and can be treated with bladder training,
medication, lifestyle changes, and surgery.

Bladder pain remains a challenging and poorly understood

entity
 dr. Setya Dian Kartika,Sp.OG
LOWER URINARY TRACT DISORDER
Physiology of Micturition
Normal Urethral Closure
Normal urethral closure is maintenance by a combination
of instrinsic
and extrinsic factors. The extrinsic factors include the
elevator ani
muscle, the endopelvic fascia, and their attachments to
pelvic sidewalls
and the urethra. This structure forms a hammock beneath
the urethra
that respond to increases in intra-abdominal pressure by
tensing,
allowing the urethra to be closed against the posterior
supporting shelf
 dr. Setya Dian Kartika,Sp.OG
The intrisic factor contributing to urethral closure include the striated
muscle of the urethral wall, vascular congestion of the submucosal venous
plexus, the smooth muscle of the urethral wall and associated blood
vessels, the epithelial coaptation of the folds of the urethral lining,
urethral elasticity, and the tone of the urethra as mediated by -
adrenergic receptor of the sympathetic nervous system.

Effective urethral closure is maintenaied by the interaction of extrinsic

urethral support and intrinsic urethral integrity, each of which is influenced
by several factor (muscle tone and strength, innervation, fascial integrity,
urethral elastic, coaptation of urothelial folds, urethral vasculary)

Clinical appreciation of the importance of extrinsic urethral function led to

the separation of stress incontinence into two broad types :
1. Incontinence caused by anatomic hypermobility of the urethra
2. Incontinence caused by intrinsic sphincteric weakness or deficiency

Minimally invasive synthetic midurethral slings have largely replaced

pubovanginal slings and retropubic urethropexy as the most commonly
performed surgical procedures for stress urinary incontinence. It appears
that women with poor urethral funciton are more likely to experience
treatment failure irrespective of the type of procedure performed.
 dr. Setya Dian Kartika,Sp.OG
The Bladder
the bladder is a bag of smooth muscle that stores urine and contracts
to expel urine under voluntary control. It is a low-pressure sysstem
that ecpands to accommodate increasing volume urine without an
appreciable rise in pressure. The function appears to be mediated
primarily by the sympathetic nervous system.

Innervation
The lower urinary tract recieves its innervation from three sources : (i)
the sympathetic and (ii) parasympathetic division of the autonomic
nervous system, and (iii) the neurons of the somatic nervous system
(external urethral sphincter.
The sympathetic nervous system of receptor : -receptors, located
principally in the urethra and bladder neck, and -reseptors, located
principally in the bladder body. Stimulation of -receptors increases
urethral tone and thus promotes closure, whereas -adrenergic
receptor blockers have the opposie effect. Stimulation of -receptors
decreases tone in the bladder body.
The parasympathetic nervous system controls bladder motor
function-bladder contraction and bladder emptying. Became
acetylcholine is the main neurotransmitter used in bladder mucle
contraction, virtually all drugs used to control detrusor muscle
 dr. Setya Dian Kartika,Sp.OG
Micturition
Micturition is triggered by the peripheral nervous system
under the control if the central nervous system. The spinal
cord and higher centers of the nervous system have complex
patterns of inhibition and facilitation. A normal lower urinary
tract is one in which the bladder and urethra store urine
without pain until a socially acceptable time and place arises,
at which point voiding occurs in a coordinated and complete
fashion. Lower urinary tract disorders include disorders of
storage (such as urinary incontinence), emptying (such as
urinary hesitancy and retention), and sensation (such as
urgency or pain)
Urinary Incontinence

Definitions
A joint report from the International Urogynecological
Association and the International Continence Society made
recommendations on the terminology of female pelvi floor
dysfunction in an attempt to update the definitons by female-
specific approach and clinically based consensus. This report
defined incontinences as the complaint of any involuntary
leakage of urine.
If the leakage is distressing into the patient, evaluation and
treatment should be offered. Incontinence can almost always be
improved and frequently can be cured, often using relatively
simple, nonsurgical intervensions.
 dr. Setya Dian Kartika,Sp.OG
Types of Disorders
Stress Urinary Inconteinence : stress urinary incontinence occurs during periods of
increased intra-abdominal pressure (e.g., sneezing, coughing, or exercise) when the
intravesical pressure rises higer than the pressure that the urethral closure mechanism
can withstand. Some advocate the term activity-related incontinence in some
languages to avoid the confusion with psychological.
Stress incontinence is an interesting disease as the same symptoms have varying
effects on different women. This condition is best considered in a biobehavioral model
that examines the interaction of three variables : (i) the biologic strength of the
urethral sphincteric mechanism, (ii) the level of physical stress placed in the closure
mechanism, and (iii) the womans expectation about urinary control. This model
explains the enormous variation that exsits among the symptoms, the degree of
demonstrable leakage, and a patients response to her stress incontinence.
Surgical intervention is only one strategy, and it addresses only the biologic
competence of the sphincteric mechanism rather than either of the other factors that
interact to produce the clinical problem.

Urgency Urinary Incontinence and Overactive Bladder : although stress

incontinence is the most common type of urinary incontinence in all women, urgency
incontinence is the most common from of incontinence in older woman. Urgency
urinary incontinence is the involuntary leakage of urine accompanies bt or immediately
preceded by urgency. The new joint report from the International Urogynecological
Association and International Continence Sociaety recommended this symptom be
called urgency urinary incontinence to differentiate between the normal urge
experienced whennthe bladder is full from the abnormal response that may require
treatment.
 dr. Setya Dian Kartika,Sp.OG

Women may have other related problems such as urgency, nocturia, and
increased daytime frequency. The difinition of nocturia is quantifiable : the
woman wakes one or more times a night to void.
Urgency is the sudden compelling desire to pass urine that is dufficylt to
defer. Data from a broader sample of woman in United States suggest that the
median number of voids per day is eight, and 95% of so-called normal women
void 12 or fewer times per day.
Overactive detrusor function is defined as a urodynamic diagnosis
characterized by involuntary detrusor contractions during the filling phase,
which may be spontaneous or provoked. It is divided into neurogenic detrusor
overactivity, resulting from a relevant neurologic condition and idiopathic
detrusor overactivity, when there is no clear cause.
The term overactive bladder syndrome is defined as urinary urgency, ussually
accompanied by frequancy and nocturia, with or without urgency urinary
incontinence, in the absence of urniary tract infection or the obvios pathology.
It is often referred to as OAB-dry when woman with these symptoms do not
leak urine, and OAB-wet when it is accompanied by incontinence.

Mix Incontinence : As implied by the name, women with mixed incontinence

have symptoms of both stress and urge urinary incontinence. Younger woman
are more likely to have stress incontinence. Younger women are more likely to
have stress incontinence alone, whereas in older woman mixed and urge
incontinence predominate.
 dr. Setya Dian Kartika,Sp.OG

Functional and Transient Incontinence : Functional incontinence is more

common in elderly women and refers to incontinence that occurs because of
factor unrelated to the physiologic voiding mechanism. A woman who
cannot get to the bathroom quickly enough may often become incontinence.
A useful mnemonic to help remember these factors is DIAPPERS.

Extraurethral Incontinence : A traumatic opening between the urinary

tract and the outside is called a fistula. Vesicovaginal fistulas, located
between the bladder and urethra, are most common, but fistulas may occur
between the vagina, uterus, or bowel, and the urethra, ureter, or bladder.
Worldwide, the most common cause of vesicovaginal fistulas is obstructed
labor.
The social and economic costs of this problem are enormous, yet the world
medical community largely ignores it. The morbidity associated with
obstetric fistulas remains, along with the related maternal mortality, one of
the single most neglected issues in international womens health care.
The most common causes of genitourinary fistulas are surgery, malignancy,
and radiation therapy, alone or in combination. Most often a vesicovaginal
fistulas develops after an otherwise uncomplicated vaginal or abdominal
hystrectomy in which a small portion of the bladder was inadvertently
trapped in a surgical clamp or was transfixed by a suture.
 dr. Setya Dian Kartika,Sp.OG

When significant urine leakage occurs, often 10 to 14 days following a laparascopic

hystrectomy, ureterovaginal fistula should be strongly considered in the differential
diagnosis. The classic triad of vaginal urinary leakage, cyclid hematuria, and
amenorrhea is known as Youssefs Syndrom.

Nocturia : Nocturia is the number of viods recorded during a nights sleep; each
void is preceded and followed by sleep. To short out whether nocturia results from
heightened urine production at night, the nocturnal urinary volume can be
assessed from a bladder chart.

Risk Factor for Urinary Incontinence

There is some evidence that age, pregnacy, childbirth, obesity, functional
impairment, and cognitive impairment are associated with increased rates if
incontinence severty. Pregnacy and delivery predispose women to stress urinary
incontinence, at least during their younger years.
Various change happen after delivery that may predispose women to stress urinary
incontinence. Levator ani muscle strength decreases. About 20% of women
develop a visible defect in the levator ani muscles after vaginal delivery. The
bladder neck descends, and the pelvic muscles undergo partial denervation with
punendal neurophaty. In most studies, parity is strongly associated with urinary
incontinence in younger women. In studies of women 60 years and older, parity is
no longer an independent risk factor for incontinence.
Obesity deserves special mention for its role in causing or exacerbating stress
incontinence. Many researchers report an association (that remains after adjusting
for age and parity) between increased weight and BMI and urinary incontinence.
PELVIC ORGAN PROLAPS
Pathophysiologi
Definition
The most common pelvic support disorders include rectoceles and cystoceles,
entroceles, and uterine prolaps.
Procidentia, wich involves prolapse of the uterus and vagina, and total vaginal
vault prolapse, wich can occur after hystrectomy, represent eversion of the
entire vagina.

Surgical Anatomy
Pelvic support structures include :
1. The muscle and connective tissue of the pelvic floor
2. The fibromuscular tissue of the vaginal wall
3. The endopelvic connective tissue
Endopelvic connective tissue include :
a. The cardinal/uterosacral complex, which attaches the upper vaginal and
cervix posteriorly
b. Lateral connective tissue attachment of the anterior vaginal wall to the
arcus tendineus pelvis and of the poterior vaginal wall to the fascia of the
leverator ani and to the posterior arcus tendineus neat the ischial spine.
c. Less dense areolar connective tissue surrounding retroperineal portion of
the pelvic organs.
 Pelvic organ prolapse is an increasingly common condition seen in
women with the aging of the population.
Causes of pelvic organ prolapse are multifactorial amd contribute to the
wakening of the pelvic support connective tissue and muscles as well as
nerve damage.
Patients mau be asymptomatic or have significant symptoms such as
those related to the lower urinary tract, pelvic pain, defecatory
problems, fecal incontinent, back pain, and dyspareunia.
Physical examination includes thoughtful attention to all parts of the
vagina, including the anterior, apical, and posterior compartements,
levator muscle, and anal sphincter complex.
Nonsurgical treatment options includes pelciv floor muscle training and
the use of intravaginal devices.
Surgical treatment involves an individualized, multicompartmental
approach consistent with the patients previous treatment attempts,
activity level, and health status.
Studies are needed to determine the characteristics of those patients
who would derive long-term benefit from vaginal versus abdominal
approaches to the surgical repair of pelvic organ prolapse.
 Apical Compartement
Normal apical support includes the integrity of the cardinal/uterosacral
ligaments, the upper paravaginal fibromuscular connective tissue, and, when the
uterus is present, the paracervical fascia. The fibromuscular tissue of the upper
vagina blends in with the paracervical fascia. Both of these are attached laterally
and posterior laterally to the cardinal ligament and uterosacral ligaments.

Arterior Compartment
The anterior vaginal compartment includes the anterior vaginal wall, its
attachments, the urethra, and the bladder. The support structure for the
rhomboid-shaped anterior vaginal wall (specifically its fibromuscular layer), which
is attached laterally to the arcus tendineus fascia. Inferiorly, the fibromuscular
layer blends in with the connective tissuem which spans the two bands of
puborectalis and pubococcygeus muscles and the public rami. The urethra
appears to be preferentially supported by this conective tissues as well as by the
pubourethral ligaments. In the apical area, the vaginal fibromuscular layer blend
with the precervical fascia and the connective tissue of the cardinal ligament
complex.

Posterior Compartment
The support of the rectum and posterior vagina includes the pelvic floor
musculature and connective tissue posteriorly and Denonvilliers (pararectal)
fascia, which is the fibromuscular layer of the posterior vaginal wall and its
lateral attachments to the lateral pelvic floor (levator) musculature and its fascia.
Evaluation
Altough as many as 50% of woman older than age 50 years have some degree of
pelvic organ prolapse, fewer than 20% seek treatment. This may result from a
number of causes, including lack of symptoms, embarassment, or misperception
about available treatment options. Although pelvic organ prolapse is not life
threatening, it can impose a significant burden of social and physical restrictions
of activities, impact on psychological well-being, and overall quality of life.

Symptoms
Choice of treatment usually depends on severity of the symptoms and the degree
of prolapse consistents general health and level of activity.

Physical Examination
during the evaluation of each compartment, the patient is encourageto perform
Valsava so the full extent of the prolapse can be ascertained. If the finding
determined with Valsava is inconsistent with the patients description of her
symptoms, it may be helpful to perform a standing straining examination with
bladder empty

Pelvic Organ Prolapse Quantitation System : Currently the system approved

by the International Continence Society is the Pelvic Organ Prolapse Quantitation
System. The classification uses six points along the vagina (two points on the
anterior, middle, and posterior compartment)
 measured in centimeters proximal to the hymen (negative number) or distal to
the hymen (positive number), with the plane of the hymen representing zero.
The genital hiatus is measured from the middle of the external urethral meatus
to the posterior midline hymen. The perineal body is measured from the
posterior margin of the genital hiatus to midanal opening. The total vaginal
length is the greatest depth of the vagina in centimeters when the vaginal apex
is reduse to its full normal position. All measurements except the total vaginal
length are measured during maximal straining.

Pelvic Muslce Function Assessment :Pelvic muscle function should be

assessed during the pelvic examination. A recto vaginal examination should also
be performed to assess basal and contraction muscle tone of the anal sphincter
complex. Many women with prolapse will have urethral hypermobility (defined as
a testing urethral angle greater than 30 degrees or a maximal strain angle
greater than 30 degrees)

Bladder Function
Patiens with prolapse exhabit the full range of lower urinary tract symptoms.
Despite the fact that some patiens may not have significant symtoms, it is
important to obtain objektive information about bladder and urethral function.

Bowel Function Evaluation

If the patient has defecatory dysfunction with a rectocele and symptoms of
constipation, pain with defecation, ppain with defection, fecal or flatal
 incontinence, or any signs of levator spasm or anal sphincter spasm,
appropriate elevation and conservative management of concurrent conditions
sould be initiated before repair of the rectocele and continue postoperatively.

Imaging
Diagnostic imaging of the pelvis in women with pelvic organ prolapse is not
routinely performed.

Treatment

Nonsurgical Therapy
1. Conservative Management
2. Mechanical Devices

Surgical Management

Vaginal Procedure
1. The Apical Compartment
a. Sacropinus Ligament Fixtation
b. Iliococcygeal Vaginal Suspension
c. Uterosacral Ligament Suspension
 The Anterior Compartment
1. Anterior Vaginal Colporrhaphy
2. Paravaginal Repair

The Posterior Compartment

1. Traditional Posterior Colporrhaphy
a. Defect Specific Posterior Repair
b. Transvaginal Mesh Procedures

Abdominal Procedures
1. Abdominal Uterosacral Suspension
2. Abdominal Approach to Posterior Repair
3. Laparascopic Approach to Posterior Repair
4. Abdominal Sacrocolpopexy
5. Laparascopic and Robotic Techniques

Vaginal Obliterative Procedures

ANORECTAL DYSFUNCTION
Defacatory dysfunction and fecal incontinence are common conditions for
womn that have tremendous psychosocial and economic implication.
The differential diagnosis for anorectal dysfunction is broad and can be
classified into systemtic factors, anatomic and structural abnormalities
and functional disorders
A thorough history and physical examination are critical for the
evaluation of fecal incontinence and defactory dysfunction, as well as
appropriate anchillary testing
Treatment of anorectal dysfunction should focus on treatment of the
underdying condition, with nonsurgical management attempted before
surgery.
Overlapping sphinctheroplasty is the procedure of choice for fecal
incontinence caused by a disrupted anal sphincter.

Normal Colorectal Fungction :

Stood formation and Colonic Transit
Storage
Continence Mekanism
Muscle, and Nerves
Evacuation
 Epidemiology
Defactory Dysfuncion
Fecal Incontinence

Symptom Based Approach to Colorectal Disordes

Differential Diagnosis
Disorders Defecation, Fetal Incontinence, Combined Disorders of Defacation and Fecal
Incontinence
Structural Versus Fuctional Disorders
Outlet Obstraction : Anismus/Rectosphincteric Dyssynergia, Pelvic Organ Prolapse,
Rectal Intussusception.
Functional Motility Disorders : Functional Bowel Disorders
Fecal Incontinence
Sphincter Disruption : Obstretic Trauma, Surgical Trauma
Sphincter Denervation : Descending Perineum Syndrome
Functional Bowel Disorders : Functional Fecal Incontinence, Irritable Bowel Syndrom,
Functional Diarrhea
Pitfalls for the Pelvic Floor Surgeon

Historical and Phisical Examination

Phisical Examination
Neurologic Examination,Muscle Strength, Vaginal Support, Anorectal Examination
 Fetal Incontinence
Endoanal Ultrasonography, Electromygraphy, Anal
Manometry, Proctoscopy and Flat TireTest.
Disorders Defecation
Sitzmark Study, Pelvic Floor Fluoroscopy and Magnetic
Resonance Imaging, Anal Manometry, Colonoscopy and
Proctoscopy.

Therapeutic Approach to Fecal Incontinence

Nonsurgical Treatment
Pharmacologic Approach
1. Dietary Modification and Fiber
2. Constipating Agens
3. Medications for Irritable Bowel Syndrome

Behavioral Approach
4. Biofeedback
5. Bowel Regimens
 Surgical Treatment
Efficacy
Graciloplasty
Artificial Sphincter
Sacral Nerve Root Stimulaor

Therapeutic Approach to Conctipation

Nonsurgical Treatment
1. Pharmacologic Approach
2. Behavior Approach
3. Efficacy of Nonsurgical Treatment

Surgical Treatment
1. Slow Transit/Colonic Inertia
2. Pelvic Organ Prolapse
3. Posterior Colporrhaphy
4. Defect Directed Repair
5. Rectal Prolapse