1. 8th Edition APGO Objectives for Medical Students
Pelvic Relaxation and Urinary Incontinence

2. 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.

3. Objectives The student will demonstrate knowledge of the following:
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
Cystocele
Rectocele
Enterocele
Vaginal vault or uterine prolapse

4. Risk factors Vaginal delivery Large baby Prolonged 2nd stage of labor
Forceps
Multiparous

5. Risk factors Increased abdominal pressure Obesity Chronic constipation
Chronic lung disease

6. Risk factors Altered nerve function or tissue strength Diabetes
Neurologic diseases
Aging
Collagen disorders
Hypoestrogenism
Pelvic surgery

7. Anatomy Basic Fascial defects Neuromuscular pathophysiology
Levator ani muscles
Pubococcygeuas
Puborectalis
Iliococcygeus
Viscerofascial layer
Endopelvic fascia - attaches uterus and vagina to pelvic wall
Parametria - cardinal and uterosacral ligaments
Fascial defects
Neuromuscular pathophysiology

8. Signs and symptoms of pelvic organ prolapse
Symptoms - prolapse
Asymptomatic
Vaginal pressure heaviness (>90%)
Vaginal pain
Sensation of tissue protruding from the vagina (>90%)
Abdominal pain
Low back pain
Dyspareunia/impaired coitus (37%)
Vaginal dryness
Ulceration
Bleeding
Urinary incontinence (33%)

9. Signs and symptoms of pelvic organ prolapse
Symptoms - urinary incontinence - unexpected loss of urine
Stress incontinence - involuntary loss of urine with increased abdominal pressure (valsalva, cough, laugh, sneeze)
Urge incontinence - involuntary loss of urine associated with overwhelming urge to void

10. Physical exam (definitions)
Cystocele
Defect where the bladder and anterior vaginal wall protrudes through the vaginal introitus
Secondary to attenuation or rupture of the pubovesical cervical fascia
Note anterior relaxation with urethral inclination
Mobility of bladder base and urethra with valsalva maneuver

11. Physical exam (definitions)
Rectocele
Protrusion of posterior vaginal wall and anterior rectal wall
Look for bulging of posterior vaginal wall with valsalva maneuver
Insert a finger in rectum and, if vaginal and rectal tissue are jauxtaposed = rectocele

12. Physical exam (definitions)
Enterocele
Elongation of posterior cul-de-sac along rectovaginal septum
50% are diagnosed intraoperatively
Physical exam (patient standing) - palpate enterocele sac and small bowel

13. Physical exam (definitions)
Uterine/vaginal vault prolapse
Uterine - descent of uterus and cervix into the vaginal canal
Exam - patient upright, valsalva
Look and fell for prolapse
Grade based on location from hymeneal ring
Vaginal vault - loss of support of vagina beginning at apex

14. Methods of diagnosis Urine culture Rule out urinary tract infection
> 105 organisms
Voiding diary
Normal bladder capacity (up to 60cc)
Normal frequency (<8 voids/day)
Accidents/leaking with physical activity
Amount and type of intake

15. Methods of diagnosis
Standing stress test - note urine loss with cough or valsalva
Q-tip test
Looks for hypermobility of the urethrovesical junction
Resting position -30o or a change of greater than 30o is hypermobile

16. Methods of diagnosis
Filling cystometrogram - examines the bladder during filling and storage
Post-void residual < 100cc
First urge mL
Maximum capacity mL
Resting bladder pressure < cm of H2O
Cystocopy

17. Nonsurgical and surgical treatments
Pessary
Oldest effective treatment
If pelvic floor muscle damaged, they cannot be held in place
Adjunctive treatment - estrogen

18. Nonsurgical and surgical treatments
Medications
Stress incontinence
 Antagonist to increase smooth muscle tone (phenylpropanolamine)
Estrogen to increase urethral resistance
Urge incontinence - anticholinergics to decrease spasm of the detrusor muscle (oxybutynin, tolterodine)

19. Nonsurgical and surgical treatments
Pelvic floor muscle exercises
Kegels - voluntary contraction of the pelvic floor
Vaginal cones
Electrical stimulation

20. Nonsurgical and surgical treatments
Surgery
Hysterectomy - vaginal or abdominal (route depends on other surgical interventions)
For anterior wall prolapse (cystocele)
Vaginal approach
Anterior colporrhaphy (central defect)
Paravaginal repair (lateral defect)
Abdominal approach - paravaginal repair

21. Nonsurgical and surgical treatments
Surgery
For apical defect
Vaginal approach
Sacrospinous ligament fixation
Uterosacral colposuspension
Abdominal approach
Abdominal sacrocolpopexy

22. Nonsurgical and surgical treatments
Surgery
For posterior defect - posterior colporraphy
For enterocele
Obliterate cul-de-sac with purse string suture in endopelvic fascia
McCall culdoplasty
Colpocleisis (LeFort procedure)

23. Nonsurgical and surgical treatments
Surgery
For stress incontinence
Vaginal approach
Pereyra
Raz
Stamey
Tensionless vaginal tape (TVT)

24. Nonsurgical and surgical treatments
Surgery
For stress incontinence
Abdominal approach
Marshall-Marchetti-Krantz (MMK)
Burch colposuspension

25. Nonsurgical and surgical treatments
Surgery
For stress incontinence
Intrinsic urethral sphincter dysfunction
Suburethral sling
Bulking injections (with collagen) to improve urethral coaptation (for patients without urethrovesical junction hypermobility)
Artificial sphincter

26. References
American College of Obstetricians and Gynecologists Technical Bulletin #214. Pelvic Organ Prolapse. ACOG: Washington DC 1995.
American College of Obstetricians and Gynecologists Technical Bulletin #213. Urinary Incontinence. ACOG: Washington DC 1995.
Mischel DR, ed., Comprehensive Gynecology 3rd ed., Mosby, St. Louis, MO, 1997.
Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997

27. Pelvic Relaxation and Urinary Incontinence
Clinical Case
Pelvic Relaxation and Urinary Incontinence

28. Patient presentation
A 75-year-old woman G5P5 presents complaining of “fullness” in the vaginal area. The symptom is more noticeable when she is standing for a long period of time. She does not complain of urinary or fecal incontinence. She has no other urinary or gastrointestinal symptoms. There has been no vaginal bleeding. Her past medical history is significant for well-controlled hypertension and chronic bronchitis. She has never had surgery.

29. Patient presentation Physical exam
Pelvic exam reveals normal appearing external genitalia except for generalized atrophic changes. The vagina and cervix are without lesions. A second-degree cystocele and rectocele are noted. The cervix descends to introitus with the patient in an erect position. No rectal masses are noted. Rectal sphincter tone is slightly decreased. Uterus is normal size. Right and left ovaries are not palpable.
Labs or Studies None
Diagnosis Pelvic organ prolapse

30. Management plan Management Plan Patient prefers non-surgical option
Pessary placed and vaginal estrogen used to address atrophic changes

31. Teaching points
The patient’s multiple vaginal deliveries, age and chronic bronchitis places her at risk for pelvic organ prolapse.
Patients commonly present with a feeling of “fullness” or are able to touch vaginal or cervical tissue protruding through the introitus. They may or may not experience urinary incontinence.

32. Teaching points
In addition to pelvic muscle exercises, non-surgical management of pelvic organ prolapse mainly involves fitting the patient with a vaginal pessary. There are numerous vaginal pessaries designed to support specific types of pelvic organ prolapse. Pessaries press against the walls of the vagina and are retained within the vagina by the tissues of the vaginal outlet.

33. Teaching points
Pessaries may cause vaginal irritation and ulceration. They are better tolerated when the vaginal epithelium is well estrogenized; exogenous estrogen may be required in the hypoestrogenic patient. Periodically, vaginal pessaries should be removed, cleaned and reinserted. Failure to do so may result in serious consequences, including fistula formation.

34. Teaching points
Patients may be managed successfully with a pessary for years. Indications for surgery include the desire for definitive surgical correction, recurrent vaginal ulcerations with a pessary or stress incontinence that the patient finds unacceptable.