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

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:
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

4. 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

5. 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?

6. 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

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

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

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

10. 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

11. PATIENT EVALUATION History Physical Exam Laboratory Tests
Urodynamic Testing
Voiding Diary

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

13. 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?

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

15. 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

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

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

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

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

20. 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

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

22. 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

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

24. Urodynamics
Male or Female?

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

26. TREATMENT OPTIONS Treating Reversible Conditions Behavioral Therapy
Medications
Devices
Surgical

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

28. Reversible Conditions
Delirium
Psychological
Restricted Mobility

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

30. 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

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

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

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

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

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

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

37. 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

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

39. Pelvic Organ Prolapse Repair

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

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

42. Consequence of Prolapse

43. Diagnosis: POP-Q

44. THERAPY Conservative Therapy Pelvic Floor Muscle Exercises Pessary
Surgical Therapy

45. Pelvic Organ Prolapse Repair
Anterior Compartment
Vesico-vaginal supportive tissue

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

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

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

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

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

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

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

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

54. 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.

55. 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

56. Questions?