Urogynecology Review For Up College

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
copyright_joanneaguinaldomd_manilaphilippines_june2015
I. PELVIC ORGAN PROLAPSE

A.
B.
C.
D.
Definition
Pathophysiology
Risk Factors
Diagnosis
i.
ii.
iii.
Presentation
Scoring and Staging
Ancillary tests
E. Management

Definition
POP is defined as the
downward descent of
the pelvic organs
towards or through
the vaginal opening.

Etiology
POP comes about
with the failure of the
suspensory and
supportive structures
of the pelvic organs.

Pelvic support structures
Bony pelvis provides the
surfaces of attachment
for the muscles and the
ligaments

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

Pelvic diaphragm
Levator plate
Innervated by the
branches of the S1-S3
nerves and the pudendal
nerve

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.

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
(congenital)
Skeletal, muscular, neurological, connective tissue, racial, gender
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.
B.
C.
D.
Definition
Pathophysiology
Risk Factors
Diagnosis
i.
ii.
iii.
Presentation
Scoring and Staging
Ancillary tests
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
(-)
0
(+)
23

Anterior compartment
Point Aa
Point Ba
Located in the midline if the anterior vaginal 3 cms Urethro-vesical crease

proximal to the external urethral meatus
-3 to +3
Represents the most distal or dependent position of Middle to proximal third of the
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
Located in the midline of the posterior vaginal wall 3 -3 to +3
cms proximal to the hymen
Represents the most distal or dependent position of Middle to proximal third of the
Point Bp
the posterior vaginal wall from the posterior fornix or posterior vaginal wall
the cuff to point Ap
24
Point Ap
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
something coming out of her vagina. She
reports a palpable bulge at the introitus on
occasion. All her pregnancies were delivered
GH
vaginally except for the last, for which she
underwent a CS-hysterectomy for placenta
accreta. On physical examination, the vagina
Ap
was pale and smooth and measured 6 cms
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.
Ba
PB
TVL
Bp
SCORE and STAGE

34
CASE
60 G4P4 (4004) presents with sensation of
something coming out of her vagina. She
reports a palpable mass at the introitus on
occasion. All her pregnancies were delivered
vaginally except for the last, for which she
underwent a CS-hysterectomy for placenta
accreta. On physical examination, the vagina
was pale and smooth and measure 6 cms 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.
Aa
-2
Ba
-1
C
-1
GH
PB
TVL
6
Ap
-3
Bp
-3
D
N/A
Most dependent : Cuff -1

SCORE and STAGE
Stage II
35
CASE
What level of support is
most compromised in
this case?
A.
B.
C.
D.
Level 1
Level 2
Level 3
Level 4
- Parametrium
(uterosacral/cardinal
ligament complex)
Aa
-2
Ba
-1
C
-1
GH
PB
TVL
6
Ap
-3
Bp
-3
D
N/A
Most dependent : Cuff -1

Stage II
36

A.
B.
C.
D.
Definition
Pathophysiology
Risk Factors
Diagnosis
i.
ii.
iii.
Presentation
Scoring and Staging
Ancillary tests
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/
Cystourethrocele
Anterior Colporrhaphy
Paravaginal Repair
Burch Colposuspension
Paravaginal Repair
Sacrocolpopexy
Posterior Colporrhaphy
(fascial repair;
levator myorrhaphy;
site-specific repair;
post-anal repair)
Sacrocolpopexy
(Vaginal Hysterectomy)
Le Fort Colpocleisis
Sacrospinous Ligament Fixation
(SSLF) /
Prespinous / Iliococcygeal Fixation
USL Suspension/Plication
McCalls Culdoplasty
Sacrohysteropexy
Sacrocolpopexy
USL Fixation /
Moschowitz Procedure / Halbans
Procedure
POSTERIOR Compartment
Rectocele
MIDDLE/APICAL
Uterovaginal Prolapse
Vault Prolapse
Enterocele
39
II. URINARY INCONTINENCE

A.
B.
C.
D.
Definition
Mechanism of continence
Micturition cycle
Classification
Basic evaluation
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

Continence is maintained when
the maximum urethral pressure
exceeds the maximum bladder
pressure or when urethral
closure pressure is positive.
42

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
Incontinence
Retention with overflow

Congenital
Miscellaneous
Congenital
Extra-urethral
Fistula
47

A.
B.
C.
D.
-
Definition
Micturition cycle
Classification
Basic evaluation
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
Antimuscarinic
Drug
Propantheline Br
Dosage
7.5-60 mg
Frequency
3-5 times/day
Smooth muscle relaxant,

antimuscarinic, local
anaesthetic
Smooth muscle relaxant,

antimuscarinic
Oxybutynin
2.5-10 mg
2-3 times/day
Tolterodine
Trospium Cl
1-4 mg
20 mg
2 times/day
2 times/day
Propiverine
15 mg
2-4 times/day
Dicyclomine HCl
10-20 mg
3 times/day
Imipramine HCl
25-75 mg
1-3 times/day
DDAVP (synthetic
vasopressin)
100-200 mg
Once At bedtime
Antimuscarinic, calcium
channel antagonist
Smooth muscle relaxant

(antispasmodic)
Tricyclic antidepressant,
antimuscarinic, alphaadrenergic agonist,
antihistaminic
Antidiuretic
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/filesbook/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

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A Review of

Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPS

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

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

Vaginal delivery, surgery, neurological

Obesity, smoking, lung disease, constipation, recreational and

Ageing, menopause and hormonal deprivation, progressive or

I. PELVIC ORGAN PROLAPSE

Vaginal pressure of heaviness

Observation or palpation of a bulge

I. PELVIC ORGAN PROLAPSE

Difficulty with defecation

Inability to have sexual activity

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

Located in the midline if the anterior vaginal 3 cms Urethro-vesical crease

Superior or Apical compartment

Represents either the most distal or dependent edge

Represents the location of the posterior fornix in a Used to differentiate suspensory

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

The most distal or dependent portion of the prolapse is more than 1 cm

Essentially complete eversion, the most distal portion of the prolapse

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

3. Pelvic floor muscle testing

I. PELVIC ORGAN PROLAPSE

SCORE and STAGE

Most dependent : Cuff -1

Most dependent : Cuff -1

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

I. PELVIC ORGAN PROLAPSE

II. URINARY INCONTINENCE

II. URINARY INCONTINENCE

II. URINARY INCONTINENCE

II. URINARY INCONTINENCE

II. URINARY INCONTINENCE

Contraction of the urethral

II. URINARY INCONTINENCE

II. URINARY INCONTINENCE

II. URINARY INCONTINENCE