Evaluation and Treatment of Urinary Incontinence and Prolapse Division of Urogynecology/ Reconstructive Pelvic Surgery Department of Obstetrics and Gynecology

Rationale Patients with conditions of pelvic relaxation and urinary incontinence present in a variety of ways. The physician should be familiar with the types of pelvic relaxation and incontinence and the approach to management of these patients.

Objectives The student will demonstrate knowledge of: Predisposing factors for pelvic organ prolapse and urinary incontinence Anatomic changes, fascial defects and neuromuscular pathophysiology Signs and symptoms of pelvic organ prolapse Physical exam Treatment

International Continence Society Definition of Urinary Incontinence Involuntary urine loss that is severe enough to constitute a social or hygiene problem and that is objectively demonstrable

Questions for Patients Do you leak urine when you cough, sneeze, laugh, or exercise? Do you leak on the way to the bathroom? Do you know the locations of bathrooms when you are shopping or travelling? Do you leak during intercourse? Stress or Urge Incontinence?

EPIDEMIOLOGY Estimates of prevalence vary Bias in sample surveys Patient under-reporting Differences in definitions, populations studied and methods used ~ 13 million Americans are incontinent 10-35% of adults

ECONOMICS OF URINARY INCONTINENCE Direct health care costs > $15 billion/yr Indirect health care costs Incontinence products Loss of work/productivity

Classifying Urinary Incontinence Stress Urge Mixed Overflow Other Functional Unconscious or Reflex Fistula

Tenets of Effective Management Assessment of patient Risk factors and reversible causes Treatment of reversible conditions Education Treatment options QOL improvement Management plan

RISK FACTORS Gender Immobility Environmental Barriers Altered Cognition & Delirium Medications Smoking Collagen Disorders Neurologic Disease Diabetes Stroke Menopause Childbirth Increased Abd Pressure Obesity Chronic Constipation Chronic Cough High Impact Physical Activity

PATIENT EVALUATION History Physical Exam Laboratory Tests Urodynamic Testing Voiding Diary

History HPI Mental Status Evaluation Functional Assessment Environmental Assessment Social Factors Voiding Diary

HPI # Incontinent episodes Triggers Volume of urine loss Stress +/- Urge Volume of urine loss Difficulty starting stream (hesitancy) Sensation of incomplete emptying Straining to empty Number of pads/day Frequency Urgency Nocturia Enuresis Dysuria Hematuria Post-void dribbling* *Sign of what?

PMH Parity Birth trauma Length of labor, especially 2nd stage Previous gynecologic and/or incontinence surgery Back injury Medical History MS, DM, CVA, Parkinsons

Medications Alpha-adrenergic Cholinergic Alpha-blocking Retention Alpha-blocking sphincter tone Cholinergic Bladder irritability Anti-cholinergic Retention b b b a TCA’s are both anticholinergic and alpha adrenergic

Diet Caffeine Citrus Foods & Drinks Spicy Foods Alcohol Cranberry Juice! Spicy Foods Alcohol

Functional and Environmental Assessment Manual Dexterity Mobility Patient toilet unaided? Access Distance to toilet or bedside commode (BSC) Chair/bed transfers

Voiding Diary Date and Time Fluid consumption w/ type and volume Voiding episodes w/ volume Leaking episodes Urgency

Physical Examination General GU Neurologic Direct Observation of Urine Loss Post-Void Residual Q-Tip Test

Physical Examination: Gynecologic External Genitalia: excoriation, erythema Vaginal Introitus and Mucosa: caliber, atrophy Anterior Vagina: urethral diverticulum Lateral Vaginal Sidewalls Posterior Vagina Uterine or Vaginal Cuff: procidentia, prolapse Urethra: caruncle Anus and Rectum: rectal prolapse, sphincter integrity

Physical Examination : Neurologic S2 - S4 Sharp and dull touch Perineum and buttocks Reflexes Bulbocavernosus Anal Wink

Physical Examination: Q-Tip Test Assesses bladder neck mobility Sterile technique Anesthetic gel + 30o = UVJ hypermobility SUI often has hypermobility Hypermobility not necessarily SUI - 20o

Urodynamics Uroflowmetry Cystometrogram Electromyography Leak Testing Electromyography Micturition Study Urethral Pressure Profile Videocystourethrography Cystoscopy

Urodynamics Male or Female?

LABORATORY TESTING Urinalysis and Culture Bacterial mucosal irritation Unsuppresible detrusor activity Endotoxin inhibition of alpha-adrenergic receptors in urethra

TREATMENT OPTIONS Treating Reversible Conditions Behavioral Therapy Medications Devices Surgical

Reversible Conditions UTI Atrophic urethritis/vaginitis Stool Impaction Dietary Medications Inadequate/Excess fluid intake How many mL/day?

Reversible Conditions Delirium Psychological Restricted Mobility

Treatment of Detrusor Overactivity Dietary Toileting Habits Scheduled Toileting +/- BSC Urge Strategies Pelvic Muscle Exercises Biofeedback Electrical Stimulation

Treatment of Detrusor Overactivity Bladder has muscarinic receptors (M3) Medications Ditropan Detrol Sanctura Vesicare Enablex Side Effects Dry mouth Dry eyes Constipation Cognitive dysfunction Imipramine

Surgical Treatment of Detrusor Overactivity Refractory cases InterStim Device Percutaneous Tibial Nerve Stim (PTNS) Augmentation Cystoplasty Many associated complications Last resort procedure

Treatment of Stress Incontinence Burch Retropubic Urethropexy Pubovaginal Sling Mesh or Fascial Urethral Bulking Transurethral injection

Nonsurgical Treatment of Stress Incontinence PESSARIES Low morbidity Requires regular care Managed by patient Fem-Soft

When to Refer? Failed trial of conservative therapy Pronounced anatomic defect Persistent infection Desire or need for surgery Associated problems

SUMMARY Investigation of the incontinent patient History Physical Exam Urinalysis and Culture +/- Urodynamic Testing

SUMMARY Despite high prevalence and cost, less than 50% of people with urinary incontinence seek help! So ASK your patients about it!

Definitions of Prolapse ANTERIOR Anterior Wall Defect AKA Cystocele POSTERIOR Posterior Wall Defect AKA Rectocele Small Bowel Herniation AKA Enterocele LATERAL WALLS Paravaginal Defect APICAL Uterine Prolapse Vaginal Vault Prolapse

ETIOLOGY Childbirth Increased Intra-abd Pressure Neurologic Injury Lifting Coughing Obesity Constipation/Straining Neurologic Injury Genetic Predisposition Connective Tissue Abnormalities Estrogen Deficiency

Pelvic Organ Prolapse Repair

Symptoms of Prolapse Pressure Bulging Vaginal irritation/Ulcers PAIN IS NOT A PRESENTING SYMPTOM

Compartment-Specific Prolapse Symptoms ANTERIOR Stress urinary incontinence Incomplete bladder emptying Possible increased frequency of UTIs POSTERIOR Incomplete stool evacuation Splinting to assist defecation

Consequence of Prolapse

Diagnosis: POP-Q

THERAPY Conservative Therapy Pelvic Floor Muscle Exercises Pessary Surgical Therapy

Pelvic Organ Prolapse Repair Anterior Compartment Vesico-vaginal supportive tissue

Pelvic Organ Prolapse Repair Anterior Colporrhaphy Reinforcement and repair of vesico-vaginal supportive tissue Non-permanent plication sutures

Pelvic Organ Prolapse Repair Posterior Compartment Rectovaginal septum Denonvillier’s “fascia”

Pelvic Organ Prolapse Repair Posterior Colporrhaphy Reinforcement and repair of rectovaginal septum Non-permanent plication sutures

Pelvic Organ Prolapse Repair Lateral Compartments Arcus Tendinius Fascia Pelvis (“White line”)

Pelvic Organ Prolapse Repair Lateral Compartments Reattachment of vaginal supportive tissue to white line

Pelvic Organ Prolapse Repair Apical Compartment Uterosacral ligaments to Uterus/cervix Vaginal cuff Cervical Os

Pelvic Organ Prolapse Repair Apical Compartment Attachment of uterosacral ligaments to vaginal cuff

Pelvic Organ Prolapse Repair Apical Compartment Attachment of vaginal cuff to anterior longitudinal sacral ligament using a graft Sacrum Vagina

Robotic Sacrocolpopexy Apical Compartment Robotically-Assisted Laparoscopy da Vinci® surgical system Approved in 2005 Hysterectomy Myomectomy Sacrocolpopexy In the last several years, focus has turned to a minimally invasive approach for the sacrocolpopexy. This was first accomplished with laparoscopy. In 2005 FDA approval was obtained for use of the daVinci® robot in gynecologic surgery. It has developed as a modification of the laparoscopic approach to pelvic surgery, for procedures such as hysterectomy, myomectomy and more recently the sacrocolpopexy. As a newer procedure, there are no comparative trials assessing the efficicacy and safety of the robotic approach to the sacrocolpopexy.

SUMMARY Prolapse is associated with pressure, but not pain Site-specific exam is aided by Q-tip and half of speculum Site-specific approach to repair Treatment focused on symptom improvement, not anatomical correction

Questions?