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Urinary Incontinence and Pelvic Organ Prolapse
UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series Division of Urogynecology/ Reconstructive Pelvic Surgery
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Objectives Describe normal pelvic anatomy and pelvic support
Describe screening questions to elicit signs and symptoms of urinary incontinence Differentiate the types of urinary incontinence Describe the anatomic changes associated with urinary incontinence and pelvic organ prolapse Describe medical and surgical management options for urinary incontinence and pelvic organ prolapse
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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.
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Definition of Urinary Incontinence
International Continence Society Involuntary urine loss Severe enough to constitute a social or hygiene problem Leakage is objectively demonstrable
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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?
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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
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Economics in Urinary Incontinence
Direct health care costs > $15 billion/yr Indirect health care costs Incontinence products Loss of work/productivity
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Classifying Urinary Incontinence
Stress Loss of bladder support -> leak with cough/sneeze/valsalva Urge Overactive bladder spasms -> leak with urge Mixed Both of above Overflow Hyposensitive bladder -> leak when reach capacity Other Functional – can’t make it to bathroom (physical or cognitive impairment) Unconscious or Reflex – hyperreflexia of detrusor Fistula – tract between bladder and vagina
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Tenants of Effective Management
Assessment of patient Risk factors and reversible causes Treatment of reversible conditions Education Treatment options QOL improvement Management plan
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Risk Factors Gender Neurologic Disease Immobility Diabetes
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
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Patient Evaluation History Physical Exam Laboratory Tests
Urodynamic Testing Voiding Diary
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History HPI Mental Status Evaluation Functional Assessment
Environmental Assessment Social Factors Voiding Diary
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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?
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Length of labor, especially 2nd stage
PMH Parity Birth trauma Length of labor, especially 2nd stage Previous gynecologic and/or incontinence surgery Back injury Medical History MS, DM, CVA, Parkinsons
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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
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Caffeine Citrus Foods & Drinks Spicy Foods Alcohol Diet
Cranberry Juice! Spicy Foods Alcohol
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Functional and Environmental Assessment
Manual Dexterity Mobility Patient toilet unaided? Access Distance to toilet or bedside commode (BSC) Chair/bed transfers
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Fluid consumption w/ type and volume Voiding episodes w/ volume
Voiding Diary Date and Time Fluid consumption w/ type and volume Voiding episodes w/ volume Leaking episodes Urgency
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Physical Examination General GU Neurologic Direct Observation of Urine Loss Post-Void Residual Q-Tip Test
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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
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Physical Examination: Neurologic
S2 - S4 Sharp and dull touch Perineum and buttocks Reflexes Bulbocavernosus Anal Wink
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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
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Urethral Pressure Profile Videocystourethrography Cystoscopy
Urodynamics Uroflowmetry Cystometrogram Leak Testing Electromyography Micturition Study Urethral Pressure Profile Videocystourethrography Cystoscopy
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Urodynamics Male or Female?
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Urinalysis and Culture
Laboratory Testing Urinalysis and Culture Bacterial mucosal irritation Unsuppresible detrusor activity Endotoxin inhibition of alpha-adrenergic receptors in urethra
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Treatment Options Treating Reversible Conditions Behavioral Therapy Medications Devices Surgical
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Reversible Conditions
UTI Atrophic urethritis/vaginitis Stool Impaction Dietary Medications Inadequate/Excess fluid intake How many mL/day?
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Reversible Conditions
Delirium Psychological Restricted Mobility
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Treatment: Detrusor Overactivity
Dietary Toileting Habits Scheduled Toileting +/- BSC Urge Strategies Pelvic Muscle Exercises Biofeedback Electrical Stimulation
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Treatment: Detrusor Overactivity
Bladder has muscarinic receptors (M3) Medications Ditropan Detrol Sanctura Vesicare Enablex Imipramine Side Effects Dry mouth Dry eyes Constipation Cognitive dysfunction
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Surgical Treatment: Detrusor Overactivity
Refractory cases InterStim Device Percutaneous Tibial Nerve Stim (PTNS) Augmentation Cystoplasty Many associated complications Last resort procedure
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Treatment: Stress Incontinence
Burch Retropubic Urethropexy Pubovaginal Sling Mesh or Fascial Urethral Bulking Transurethral injection
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Non-Surgical Treatment: Stress Incontinence
PESSARY Low morbidity Requires regular care Managed by patient Fem-Soft
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When to Refer? Failed trial of conservative therapy Pronounced anatomic defect Persistent infection Desire or need for surgery Associated problems
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Bottom Line Concepts Insert other bottom line concepts here.
Investigation of the incontinent patient History Physical Exam Urinalysis and Culture +/- Urodynamic Testing Despite high prevalence and cost, less than 50% of people with urinary incontinence seek help! So ASK your patients about it!
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Definition: Prolapse ANTERIOR POSTERIOR LATERAL WALLS APICAL
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
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Etiology Childbirth Increased Intra-abd Pressure Neurologic Injury
Lifting Coughing Obesity Constipation/Straining Neurologic Injury Genetic Predisposition Connective Tissue Abnormalities Estrogen Deficiency
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Normal Pelvic Anatomy What is Prolapse? Vesicovaginal septum
- loss of support of vaginal walls Vesicovaginal septum Rectovaginal septum
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Symptoms of Prolapse Pressure Bulging Vaginal irritation/Ulcers PAIN IS NOT A PRESENTING SYMPTOM
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Compartment-Specific Prolapse Symptoms
ANTERIOR Stress urinary incontinence Incomplete bladder emptying Possible increased frequency of UTIs POSTERIOR Incomplete stool evacuation Splinting to assist defecation
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Consequence of Prolapse
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Prolapse Diagnosis: Pop Q
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Pelvic Floor Muscle Exercises Pessary Surgical Therapy
Prolapse Therapy Conservative Therapy Pelvic Floor Muscle Exercises Pessary Surgical Therapy Based on location of prolapse Anterior, Posterior, Apical, Uterine
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Pelvic Organ Prolapse Repair
Anterior Compartment Weakness of vesicovaginal septum
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Pelvic Organ Prolapse Repair
Anterior Colporrhaphy Reinforcement and repair of vesico-vaginal supportive tissue Non-permanent plication sutures
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Pelvic Organ Prolapse Repair
Posterior Compartment Weakness of rectovaginal septum Denonvillier’s “fascia”
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Pelvic Organ Prolapse Repair
Posterior Colporrhaphy Reinforcement and repair of rectovaginal septum Non-permanent plication sutures
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Pelvic Organ Prolapse Repair
Lateral Compartments Detachment of lateral walls of vagina from Arcus Tendinius Fascia Pelvis “White line”
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Pelvic Organ Prolapse Repair
Lateral Compartments Reattachment of vaginal supportive tissue to white line
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Pelvic Organ Prolapse Repair
Apical Compartment Uterosacral ligaments to … Uterus/cervix Vaginal cuff Cervical Os
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Pelvic Organ Prolapse Repair
Apical Compartment Attachment of uterosacral ligaments to vaginal cuff
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Pelvic Organ Prolapse Repair
Apical Compartment Attachment of vaginal cuff to anterior longitudinal sacral ligament using a graft Sacrum Vagina
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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.
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Questions?
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Bottom Line Concepts Many types of Urinary Incontinence Stress Urge
Mixed Overflow Other Functional Unconscious or Reflex Fistula Treatments include Diet Medication Biofeedback Pessary Surgery 55
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Bottom Line Concepts Prolapse is associated with pressure, but not pain Site-specific exam Assess each compartment – anterior, posterior, apical, uterine Use Q-tip and speculum to identify specific prolapse Site-specific approach to repair Anterior, posterior, apical, uterine Treatment focused on symptom improvement, not anatomical correction
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References and Resources
APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 37 (p78-79). Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 28 (p ). Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 23 (p ).
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