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FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY

CHAPTER 23

606

Urinary Incontinence

DEFINITIONS 606

EPIDEMIOLOGY 607

RISKS FOR URINARY INCONTINENCE 607

PATHOPHYSIOLOGY 609

BLADDER FILLING 609

BLADDER EMPTYING . 611

CONTINENCE THEORIES 615

DIAGNOSIS 616

HISTORY 616

PHYSICAL EXAMINATION 618

DIAGNOSTIC TESTING 618

TREATMENT 624

CONSERVATIVE/NONSURGICAL . 624

TREATMENT OF STRESS URINARY INCONTINENCE 625

TREATMENT OF URGE URINARY INCONTINENCE 628

REFERENCES 630

DEFINITIONS

Urinary incontinence is defi ned as any involuntary leakage of

urine In addition to the urethra, urine may also leak from

extraurethral sources, such as fi stulas or congenital

malfor-mations of the lower urinary tract Although incontinence is

categorized into a number of forms, this chapter will focus

on the evaluation and management of stress and urge urinary

incontinence Stress urinary incontinence (SUI) is the

involun-tary leakage of urine with exertion or with sneezing or

cough-ing Urge urinary or “urge”—incontinence is the involuntary

leakage accompanied or immediately preceded by a perceived strong imminent need to void A related condition, overactive

bladder, describes urinary urgency with or without

inconti-nence and usually with increased daytime urinary frequency and nocturia (Abrams, 2009)

According to International Continence Society guidelines, urinary incontinence is a symptom, a sign, and a condition (Abrams, 2002) For example, with SUI, a patient may com-plain of involuntary urine leakage with exercise or laughing

Concurrent with these symptoms, involuntary leakage from the urethra synchronous with cough or Valsalva may be observed during examination by a provider And as a condition, SUI is objectively demonstrated during urodynamic testing if invol-untary leakage of urine is seen with increased abdominal pres-sure and absence of detrusor muscle contraction Under these circumstances, when the symptom or sign of SUI is confi rmed

with objective testing, the term urodynamic stress incontinence (USI), formerly known as genuine stress incontinence, is used.

With urge urinary incontinence, women have diffi culty postponing urination urges and generally must promptly empty their bladder on cue and without delay If urge urinary incontinence is objectively demonstrated during urodynamic testing with cystometric evaluation, the condition is termed

detrusor overactivity (DO), formerly known as detrusor

instabil-ity When both stress and urgency components are present, it

is called mixed urinary incontinence.

Functional incontinence occurs in situations in which a

woman cannot reach a toilet in time because of physical, psy-chological, or mentation limitations Often, this group would

be continent if these issues were absent

CHAPTER 23

nursing home admission An incontinent elderly woman is 2.5 times more likely to be admitted to a nursing home than a conti-nent one (Langa, 2002) Likewise, the monetary ramifi cations of incontinence are considerable An estimated $32 billion is spent annually in the United States caring for community-dwelling and institutionalized patients with urinary incontinence (Hu, 2004) Moreover, population projections from the U.S Census Bureau forecast that the number of American women with uri-nary incontinence will increase 55 percent from 18.3 million to 28.4 million between 2010 and 2050 (Wu, 2009)

RISKS FOR URINARY INCONTINENCE

■ Age

Th e prevalence of incontinence appears to increase gradually during young adult life (Fig 23-1) A broad peak is noted at middle age and then steadily increases after age 65 (Hannestad, 2000) Similarly, data from the 2005-2006 NHANES demon-strate a steady increase in incontinence prevalence with age:

7 percent in those aged 20 to 40 years, 17 percent for ages 40

to 60, 23 percent for ages 60 to 80, and 32 percent for those older than 80 (Nygaard, 2008)

Incontinence should not be viewed as a normal consequence

of aging However, several physiologic age-related changes in the lower urinary tract may predispose to incontinence, over-active bladder, or other voiding diffi culties First, the preva-lence of involuntary detrusor contractions increases with age, and detrusor overactivity is found in 21 percent of healthy,

EPIDEMIOLOGY

In Western societies, epidemiologic studies indicate a prevalence

of urinary incontinence of 15 to 55 percent Th is wide range

is attributed to variations in research methodologies, population

characteristics, and defi nitions of incontinence As part of the

2005-2006 National Health and Nutrition Examination Survey

(NHANES), a cross-sectional group of 1961 nonpregnant,

non-institutionalized women in the United States were questioned

about pelvic fl oor disorders Urinary incontinence that was

characterized by participants as moderate to severe leakage was

identifi ed in 15.7 percent (Nygaard, 2008) However, current

available data are limited by the fact that most women do not

seek medical attention for this condition (Hunskaar, 2000) It is

estimated that only one in four women will seek medical advice

for incontinence due to embarrassment, limited access to health

care, or poor screening by health care providers (Hagstad, 1985)

Among ambulatory women with urinary incontinence,

the most common condition is SUI, which represents 29 to

75 percent of cases Urge urinary incontinence accounts for up

to 33 percent of incontinence cases, whereas the remainder is

attributable to mixed forms (Hunskaar, 2000) In a review of

overactive bladder, 15 percent of 64,528 women met criteria for

overactive bladder with or without incontinence, and 11 percent

had urge urinary incontinence (Hartmann, 2009)

Urinary incontinence can signifi cantly impair a woman’s

quality of life, leading to disrupted social relationships,

psycho-logical distress from embarrassment and frustration,

hospitaliza-tions due to skin breakdown and urinary tract infection, and

0510152025303540

UnknownSlightModerateSevere

85+

80–8475–7970–7465–6960–6455–5950–5445–4940–4435–3930–3425–2920–24

5.75.24.244.83.63.132.41.61.110.60.3

2.65.975.75.67.89.312.313.711.611.510.786.3

8.28.18.18.18.37.68.48.88.37.564.94.52.5

19.316.114.612.18.77.26.86.14.13.32.61.61.61.3

Age (years)

FIGURE 23-1 Prevalence of incontinence by age group (n  8002) (Adapted from Hannestad, 2000, with permission.)

608 Female Pelvic Medicine and Reconstructive Surgery

increased BMI results in a higher intravesical pressure Th is higher pressure overcomes urethral closing pressure and leads to incontinence (Bai, 2002) Accordingly, as a greater portion of our population becomes overweight and obese, we can expect to see an increase in the prevalence of urinary incontinence in the United States (Flegal, 2002) Encouragingly, weight loss for many can be an eff ective treatment In overweight or obese women, the prevalence of urinary incontinence signifi cantly declines follow-ing weight loss achieved by behavior modifi cation or with bariat-ric surgery (Burgio, 2007; Deitel, 1988; Subak, 2009)

■ Menopause

Studies have inconsistently demonstrated an increase in urinary dysfunction after a woman enters her postmenopausal years (Bump, 1998) In those with symptoms, separating hypoestro-genism eff ects from the eff ects of aging is diffi cult

High-affi nity estrogen receptors have been identifi ed in the urethra, pubococcygeal muscle, and bladder trigone but are infrequently found elsewhere in the bladder (Iosif, 1981)

Hypoestrogenic-related collagen changes and reductions in thral vascularity and skeletal muscle volume are factors Th ey are thought to collectively contribute to impaired urethral func-tion via a decreased resting urethral pressure (Carlile, 1988)

ure-Moreover, estrogen defi ciency with resulting urogenital atrophy

is believed to be responsible in part for urinary sensory toms following menopause (Raz, 1993) Despite this current evidence that estrogen plays a role in normal urinary function,

symp-it is less clear whether estrogen therapy is useful in the treatment

or prevention of incontinence (Cody, 2009; Fantl, 1994, 1996)

■ Childbirth and Pregnancy

Many studies reveal the prevalence of urinary incontinence to be higher in parous women compared with nulliparas Th e eff ects of childbirth on incontinence may result from direct injury to pel-vic muscles and connective tissue attachments In addition, nerve damage from trauma or stretch injury may result in pelvic mus-cle dysfunction Specifi cally, rates of prolonged pudendal nerve latency after delivery are higher in women with incontinence compared with asymptomatic puerperal women (Snooks, 1986)

One large epidemiologic study identifi ed vaginal delivery parameters that may aff ect the risk of urinary incontinence later in life First, fetal birthweight 4000 g increased the risk

of all urinary incontinence types (Rortveit, 2003b) Secondly, cesarean delivery may have a short-term protective eff ect for preventing urinary incontinence In this study, the adjusted odds ratio for any incontinence associated with vaginal delivery compared with that with cesarean delivery was 1.7 (Rortveit, 2003a) However, the protective eff ect of cesarean delivery on incontinence may dissipate after additional deliveries, decreases with age, and is not present in older women (Nygaard, 2006)

continent community-dwelling elderly (Resnick, 1995) Total

bladder capacity and the ability to postpone voiding decreases,

and these declines may lead to urinary frequency In addition,

urinary fl ow rates are reduced in both older men and women

and likely due to an age-associated decrease in detrusor

con-tractility (Resnick, 1984) In women, postmenopausal decreases

in estrogen levels result in atrophy of the urethral mucosal seal,

loss of compliance, and bladder irritation, which may

predis-pose to both stress and urge urinary incontinence Finally, there

are age-related changes in renal fi ltration rate and alterations

in diurnal levels of antidiuretic hormone and atrial natriuretic

factor Th ese changes shift the diurnal-predominant pattern of

fl uid excretion toward one with greater urine excretion later in

the day (Kirkland, 1983)

■ Race

Traditionally, white women are believed to have higher rates of

stress urinary incontinence than women of other races In

con-trast, urge urinary incontinence is believed to be more prevalent

among African-American women Most reports are not

popu-lation based and thus are not the best estimate of true racial

diff erences In addition, existing data on racial diff erences are

largely based on small sample sizes (Bump, 1993) However,

data from the Nurse’s Health Study cohorts, which included

more than 76,000 women, did support these racial diff erences

Investigators found the highest 4-year incidence rates in white

participants compared with that in Asian and black women

(Townsend, 2010) It is not yet clear whether these diff erences

are biologic, related to health care access, or aff ected by cultural

expectations and symptom tolerance thresholds

■ Obesity

Several epidemiologic studies have shown that an increased body

mass index (BMI) is a signifi cant and independent risk factor

for urinary incontinence of all types (Table 23-1) Moreover, the

prevalence of both urge urinary and stress incontinence increases

proportionally with BMI (Hannestad, 2003) Th eoretically,

the increase in intraabdominal pressure that coincides with an

CHAPTER 23

mucosa is comprised of a transitional cell epithelium, supported

by a lamina propria With small bladder volumes, the mucosa is thrown into convoluted folds However, with bladder fi lling, it

is stretched and thinned Th e bladder epithelium, termed epithelium, is comprised of distinct cell layers Th e most superfi -cial is the umbrella cell layer, and its impermeability is thought

uro-to provide the primary urine-plasma barrier Covering the uroepithelium is a glycosaminoglycan (GAG) layer Th is GAG layer may prohibit bacterial adherence and prevents urothelial damage by acting as a protective barrier Specifi cally, theories suggest that this carbohydrate polymer layer may be defective

in patients with interstitial cystitis (Chap 11, p 320)

Th e muscular layer, termed the detrusor muscle, is posed of three smooth-muscle layers arranged in a plexiform fashion Th is unique arrangement allows for rapid multidimen-sional expansion during bladder fi lling and is a key component

com-to the bladder’s ability com-to accommodate large volumes

Innervation Overview

Normal function of the lower urinary tract requires tion of peripheral and central nervous systems Th e peripheral nervous system contains somatic and autonomic divisions (Fig

integra-23-3) Of these, the somatic component innervates striated

mus-cle, whereas the autonomic division innervates smooth muscle

Th e autonomic nervous system controls involuntary motion and is categorized into sympathetic and parasympathetic divi-sions Th e sympathetic system mediates its end-organ eff ects through epinephrine or norepinephrine acting on - or

Fig 23-4) Th e parasympathetic sion acts through acetylcholine binding to muscarinic or nico-tinic receptors In the pelvis, autonomic fi bers that supply the pelvic viscera course in the superior and inferior hypogastric plexi (Fig 23-5)

divi-Th e somatic nervous system controls voluntary movement, and the portion of this system that is most relevant to lower urinary tract function originates from Onuf somatic nucleus (p 613) Th is nucleus is located in the ventral horn gray mat-ter of spinal levels S2–S4 and contains the neurons that inner-vate the striated urogenital sphincter complex, described next

Nerves involved with that connection include branches of the pudendal and pelvic nerves

ure-Th ese three muscles function as a single unit and contract to close the urethra Contraction of these muscles circumferentially constricts the cephalad two thirds of the urethra and laterally compresses the distal one third Th e sphincter urethrae is pre-dominantly composed of slow-twitch fi bers and remains toni-cally contracted, contributing substantially to continence at rest

In contrast, the urethrovaginal sphincter and the compressor

of having urinary incontinence Younger sisters of incontinent

women also had a greater likelihood of having any urinary

incontinence (Hannestad, 2004)

■ Smoking and Chronic Lung Disease

In women older than 60 years with chronic obstructive

pul-monary disease, a signifi cantly increased risk of urinary

incon-tinence is found (Brown, 1996; Diokno, 1990) Similarly,

cigarette smoking is identifi ed as an independent risk factor for

urinary incontinence in several studies Both current and former

smokers were noted to have a two- to threefold risk of

inconti-nence compared with nonsmokers (Brown, 1996; Bump, 1992;

Diokno, 1990) In another study, investigators also identifi ed

an association between current and former smoking and

incon-tinence, but only for those who smoked more than 20 cigarettes

daily Severe incontinence was weakly associated with smoking

regardless of cigarette number (Hannestad, 2003) Th eoretically,

persistently increased intraabdominal pressures are generated

from a smoker’s chronic cough, and collagen synthesis is

dimin-ished by smoking’s antiestrogenic eff ects

■ Hysterectomy

Studies have inconsistently shown that hysterectomy is a risk

factor for developing urinary incontinence Th ose that show an

association are retrospective, lack appropriate control groups,

and are often based solely on subjective data (Bump, 1998)

In contrast, studies that include pre- and postoperative

urody-namic testing reveal clinically insignifi cant changes in bladder

function Moreover, evidence does not support avoidance of

clinically indicated hysterectomy or the selection of

supracervi-cal hysterectomy as measures to prevent urinary incontinence

(Vervest, 1989; Wake, 1980)

PATHOPHYSIOLOGY

■ Continence

Th e bladder is a urine storage organ with the capacity to

accom-modate large increases in volume with minimal or no increases in

intravesical pressure Th e ability to store urine coupled with

con-venient and socially acceptable voluntary emptying is continence.

Continence requires the complex coordination of multiple

components that include: muscle contraction and relaxation,

appropriate connective tissue support, and integrated

innerva-tion and communicainnerva-tion between these structures Simplistically,

during fi lling, urethral contraction is coordinated with

blad-der relaxation and urine is stored During voiding, the urethra

relaxes and the bladder contracts Th ese mechanisms can be

chal-lenged by uninhibited detrusor contractions, marked increases

in intraabdominal pressure, and changes to the various anatomic

components of the continence mechanism

■ Bladder Filling

Bladder Anatomy

Th e bladder wall is multilayered and contains mucosal,

submu-cosal, muscular, and adventitial layers (Fig 23-2) Th e bladder

610 Female Pelvic Medicine and Reconstructive Surgery

A

Ureter

Ureteral openings Neck of urinary bladder

Internal urethral sphincter

Urogenital sphincter in the perineal membrane

Median umbilical ligament

Detrusor muscle Peritoneum

B

Detrusor muscle

of muscularis Lamina propria

Lamina propria

Transitional epithelium Transitional epithelium

layers (From McKinley, 2006, with permission.)

urethrae are comprised of fast-twitch muscle fi bers, which allow

brisk contraction and urethra lumen closure when continence

is challenged by sudden increases in intraabdominal pressure

Innervation Important to Storage

Th e urogenital sphincter receives somatic motor innervation

through the pudendal and pelvic nerves (see Figs 23-5 and 23-7)

Th us, pudendal neuropathy, which may follow obstetric injury, can aff ect normal sphincter functioning Additionally, prior pelvic surgery or pelvic radiation therapy may damage nerves, vasculature, and soft tissue Such injury can lead to ineff ective urogenital sphincter action and contribute to incontinence

Sympathetic fi bers are carried through the superior tric nerve plexus and communicate with

hypogas-CHAPTER 23

Th ese eff ects of -stimulation underlie the treatment of SUI with imipramine, a tricyclic antidepressant with adrenergic agonist properties

Urethral Coaptation

One key to maintaining continence is adequate urethral mucosal coaptation Th e uroepithelium is supported by a connective tis-sue layer, which is thrown into deep folds, also known as plica-tions A rich capillary network runs within its subepithelial layer

Th is vascular network aids in urethral mucosal approximation,

also termed coaptation, by acting like an “infl atable cushion”

(Fig 23-9) In women who are hypoestrogenic, this submucosal vasculature plexus is less prominent In part, hormone replace-ment targets this diminished vascularity and enhances coaptation

to improve continence

■ Bladder Emptying

Innervation Related to Voiding

When an appropriate time for bladder emptying arises, thetic stimulation is reduced and parasympathetic stimulation

sympa-is triggered Specifi cally, neural impulses carried in the pelvic nerves stimulate acetylcholine release and lead to detrusor muscle contraction (Fig 23-10) Concurrent with detrusor stimulation, acetylcholine also stimulates muscarinic receptors

in the urethra and leads to outlet relaxation for voiding

Within the parasympathetic division, acetylcholine tors are broadly defi ned as muscarinic and nicotinic Th e bladder is densely supplied with muscarinic receptors, which

recep-receptors within the bladder and urethra

tor stimulation in the bladder dome results in smooth-muscle

relaxation and assists with urine storage (Fig 23-8) In

con-trast, -adrenergic receptors predominate in the bladder base

and urethra Th ese receptors are stimulated by norepinephrine,

which initiates a cascade of events that preferentially leads to

urethral contraction and aids urine storage and continence

Central

nervous system

Peripheralnervous system

Autonomic nervoussystem (ANS)Smooth muscle

Somatic nervoussystemStriated muscle

Parasympathetic divisionMuscarinic receptorsNicotinic receptors

Sympathetic division

α-adrenergic receptors

β-adrenergic receptors

FIGURE 23-3 Divisions of the human nervous system The

peripheral nervous system includes: (1) the somatic nervous

sys-tem, which mediates voluntary movements through its actions

on striated muscle, and (2) the autonomic nervous system, which

controls involuntary motion through its actions on smooth muscle

The autonomic nervous system is further divided into the

sympa-thetic division, which acts through epinephrine and

norepineph-rine binding to adrenergic receptors, and the parasympathetic

division, which acts through acetylcholine binding to muscarinic

or nicotinic receptors

FIGURE 23-4 The bladder dome is rich in parasympathetic muscarinic receptors (M) and sympathetic

bladder neck contains a greater density of sympathetic -adrenergic receptors ( )

612 Female Pelvic Medicine and Reconstructive Surgery

urogeni-Occasionally, in a condition known as detrusor sphincter ergia, the urethral sphincter fails to relax during contraction of

dyssyn-the detrusor, and retention ensues Women with this condition may be treated with pharmacologic agents such as muscle relax-ants Th ese drugs purportedly relax the urethral sphincter and levator ani muscles to improve coordinated voiding

inconti-when stimulated lead to detrusor contraction Of the

musca-rinic receptors, fi ve glycoproteins designated M1–M5 have been

identifi ed M2 and M3 receptor subtypes have been identifi ed as

the ones predominantly responsible for detrusor smooth

mus-cle contraction Th us, treatment with muscarinic antagonist

medication blunts detrusor contraction to improve continence

Specifi cally, continence drugs that target only the M3 receptor

maximize drug effi cacy yet minimize activation of other

mus-carinic receptors and drug side eff ects

Muscular Activity with Voiding

Smooth muscle cells within the detrusor fuse with one another

so that low-resistance electrical pathways extend from one

mus-cle cell to the next Th us, action potentials can spread quickly

throughout the detrusor muscle to cause rapid contraction of

the entire bladder In addition, the plexiform arrangement of

bladder detrusor fi bers allows multidirectional contraction and

FIGURE 23-5 The inferior hypogastric plexus, also known as the pelvic plexus, is formed by visceral efferents from S2 to S4, which

pro-vide the parasympathetic component by way of the pelvic nerves The superior hypogastric plexus primarily contains sympathetic fibers

from the T10 to L2 cord segments and terminates by dividing into right and left hypogastric nerves The hypogastric nerves and rami

from the sacral portion of the sympathetic chain contribute the sympathetic component to the pelvic plexus The pelvic plexus divides

into three portions according to the course and distribution of its fibers: the middle rectal plexus, uterovaginal plexus, and vesical plexus

FIGURE 23-7 Onuf nucleus is found in the ventral horn gray matter of S2 through S4 This nucleus contains the neurons whose fibers

supply the striated urogenital sphincter The urethrovaginal sphincter and compressor urethrae are innervated by the perineal branch of

the pudendal nerve The sphincter urethrae is variably innervated by somatic efferents that travel in the pelvic nerves

614 Female Pelvic Medicine and Reconstructive Surgery

FIGURE 23-8 Physiology of urine storage Bladder distension from filling leads to: (1) -adrenergic contraction of the urethral smooth

muscle and increased tone at the vesical neck (via the T11-L2 spinal sympathetic reflex); (2) activation of urethral motor neurons in Onuf

nucleus with contraction of striated urogenital sphincter muscles (via the pudendal nerve); and (3) inhibited parasympathetic transmission

with decreased detrusor pressure

FIGURE 23-9 Drawing of urethral anatomy A. Urethral anatomy in cross section Urethral coaptation results in part from filling of the rich

subepithelial vascular plexus The urethra contains circular and longitudinal smooth muscle layers B. Vesical neck and urethral anatomy

The striated urogenital sphincter lies external to the urethral smooth muscle layers

CHAPTER 23

FIGURE 23-10 Physiology of urine evacuation Efferent impulses from the pontine micturition center results in inhibition of somatic

fibers in Onuf nucleus and voluntary relaxation of the striated urogenital sphincter muscles These efferent impulses also result in

preganglionic sympathetic inhibition with opening of the vesical neck and parasympathetic stimulation, which results in detrusor

muscarinic contraction The net result is relaxation of the striated urogenital sphincter complex causing decreased urethral pressure,

followed almost immediately by detrusor contraction and voiding

muscarinic (cholinergic)

Anatomic Stress Incontinence

Urethral and bladder neck support is integral to continence

Th is support stems from: (1) ligaments along the urethra’s

lat-eral aspects, termed the pubourethral ligaments; (2) the vagina

and its lateral fascial condensation; (3) the arcus tendineus

fas-cia pelvis; and (4) levator ani muscles A full anatomic

descrip-tion of these ligaments and muscles is found in Chapter 38

(p 925)

In an ideally supported urogenital tract, increases in

intra-abdominal pressure are equally transmitted to the bladder,

blad-der base, and urethra In women who are continent, increases

in downward-directed pressure from cough, laugh, sneeze, and

Valsalva maneuver are countered by supportive tissue tone

pro-vided by the levator ani muscles and vaginal connective tissue

(Fig 23-11) With loss of support, the ability of the urethra and

bladder neck to close against a fi rm supportive “backboard” is

Abdominal cavity

Abdominal cavity

Bladder Bladder

Urethra Urethra

Symphysis

Valsalva

FIGURE 23-11 Drawing describes the pressure transmission

theory In women with normal support (left image), increases in

intraabdominal pressure are equally distributed to contralateral sides of the bladder and urethra In those with poor urethral sup-

port (right image), increases in intraabdominal pressure alter the

urethrovesical angle, and continence may be lost

616 Female Pelvic Medicine and Reconstructive Surgery

clinical example highlights the intimate relationship between urethral support and integrity

urethral integrity include transurethral injection of ing agents, surgical sling procedures, and pelvic fl oor muscle strengthening and are described in later sections of this chap-ter In brief, bulking agents are placed at the urethrovesical junction to elevate the epithelium and promote coaptation

bulk-Alternatively, the partial urethral obstruction created by vaginal sling procedures enhances urethral integrity Lastly, because the urethra exits through urogenital hiatus, condition-ing of the levator ani muscles with Kegel exercises can bolster urethral integrity Th ese muscles can be contracted around the urethra when continence is challenged by sudden increases in intraabdominal pressures

imprac-During inquiry, the number of voids and pads used per day, type of pad, frequency of pad changing, and the degree of pad

diminished Th is results in reduced urethral closing pressures,

an inability to resist increases in bladder pressure, and in turn,

incontinence Th is mechanistic theory is the basis for surgical

reestablishment of this support Procedures such as Burch and

Marshall-Marchetti-Kranz (MMK) colposuspensions attempt

to return this anatomic support to the urethrovesical junction

and proximal urethra

Sphincteric Deficiency

main-tains continence through the combination of urethral

muco-sal coaptation, the underlying urethral vascular plexus, the

combined viscous and elastic properties of the urethral

epi-thelium, and contraction of appropriate surrounding

mus-culature Defects in any of these components may lead to

urine leakage For example, prior surgery in the retropubic

space may cause denervation and scarring of the urethra and

its supporting tissue Th ese eff ects subsequently prevent

ure-thral closure and lead to incontinence Th is urethral state

is termed intrinsic sphincteric defect (ISD) and colloquially

is referred to as a “lead pipe” urethra With ISD,

denerva-tion and/or devascularizadenerva-tion of the urethra are common

underlying fi ndings Specifi c causes are varied and include

prior pelvic reconstructive surgeries, prior pelvic radiation

therapy, diabetic neuropathy, neuronal degenerative diseases,

and hypoestrogenism In women with atrophic lower genital

tracts, vascular changes within the plexus surrounding the

urethra lead to poor coaptation and greater risks of

incon-tinence

As noted earlier, nerve dysfunction following birth trauma

may lead to defective urethral sphincter function In addition,

childbirth also commonly injures urethral fascial support Th is

Leak with stress

Leak with urge

Leak with position changes

Leak with exercise

Leak with intercourse/orgasm

Unconscious leakage

Y/NY/NY/NY/NY/NY/NDuration of symptoms _ week(s) _ month(s)

_ year(s)

Leaks per _ day _ week(s) _ month(s)

Pads per day _ Type of pads _

Duration _ month(s) _ year(s)

Flatus _/week(s) _/month(s)

Liquid _/week(s) _/month(s)

Stool _/week(s) _/month(s)

Digital decompression of bowelDigital decompression of bladderPostvoid dribble

Feeling of incomplete emptyingRecurrent UTI /yrVoid with Valsalva

Urine stream: strong/normal/weakChildhood enuresis

FrequencyUrgencyDysuriaHematuriaBack painPelvic pressure/BulgeDyspareunia

Rectal bleedingDoes heavy liftingInterferes w/lifestyle or quality of life

Y/NY/NY/NY/NY/NY/NY/NY/NY/NY/NY/NY/NY/NY/NY/NY/N

BM  bowel movement; UTI  urinary tract infection

CHAPTER 23

Voiding Diary

Typically, patients may not have an entirely accurate lection of their own voiding habits Accordingly, to obtain a thorough record, a woman should complete a urinary diary (Fig 23-12) With this, women are instructed to record for

recol-3 to 7 days the volumes and type of each oral fl uid intake, volumes of urine with each void, episodes of urinary leak-age, and provokers of incontinence episodes During each 24-hour period, women should also record times of sleep and awakening Th is enables an accurate description of voluntary nocturnal voiding patterns as well as enuresis

Although 5 to 7 days of documentation is desirable, 3 days will suffi ce in determining the general trend of incontinence

Realistically, most patients are typically not compliant for more than 3 days

Th e historical information gained from a voiding/urinary diary is a valuable diagnostic and sometimes therapeutic tool

Th e fi rst morning void is usually the largest of the day and is a good estimate of bladder capacity Patients often can identify patterns in intake and voiding and modify behavior For exam-ple, a patient may recognize increased urinary frequency or urge urinary incontinence episodes after caff eine intake Moreover, this diary information serves as a baseline against which treat-ment effi cacy can be assessed

Urinary Symptoms

or less Without a history that refl ects increased fl uid intake, increased voiding may indicate overactive bladder, urinary tract infection (UTI), calculi, or urethral pathology and should prompt additional evaluation In addition, urinary frequency is commonly associated with interstitial cystitis (IC) In women with IC, the numbers of voids may commonly exceed 20 per day In women with urge urinary incontinence or in those with systemic fl uid management disorders such as congestive heart failure, nocturia may be noted In the latter case, treat-ment of the underlying condition frequently leads to symptom improvement or cure of nighttime frequency

patient adequately empties her bladder Often incomplete tying can result in incontinence associated with either stress or

emp-saturation are important considerations Although these

specif-ics alone may not establish the exact type of incontinence, it

does provide information regarding symptom severity and its

eff ects on patient activities Obviously, if a woman’s symptoms

do not diminish her quality of life, then simple observation is

reasonable Conversely, those with disruptive symptoms

war-rant further evaluation

Specifi c to incontinence, information that describes the

circumstances in which leakage occurs and specifi c maneuvers

that incite or provoke leakage should be sought With SUI,

provokers may include increases in intraabdominal pressure

such as coughing, sneezing, Valsalva maneuver, or thrusting

during intercourse (Table 23-3) Alternatively, women with

urge urinary incontinence may describe a loss of urine after

urge sensations that typically cannot be suppressed Overfl ow

incontinence was a term used in the past to refer to women

who had an inability to empty their bladder and had episodes

of incontinence associated with urgency Currently, however,

this is considered by most to refl ect another presentation of

urge urinary incontinence Th ese women often note a sudden

large loss of urine that is preceded by an inability to empty

their bladder

During questioning, symptoms typically cluster into those

most frequently seen with SUI or with urge urinary

inconti-nence Alternatively, a signifi cant overlap of complaints may

refl ect coexistent SUI and urge urinary incontinence, that is,

mixed urinary incontinence For these reasons, pattern

identi-fi cation is helpful as it may direct diagnostic testing and guide

initial empiric therapy

Stress or Urge IncontinenceSymptom

Urge Incontinence

Stress Incontinence

Please record the time and amount of your oral intake, urine output,

urine leakage, and pad changes FOR 3 DAYS Time Oral Intake Voided Urine Urine Leakage

or Pad Change

FIGURE 23-12 Example of an abbreviated urinary diary

618 Female Pelvic Medicine and Reconstructive Surgery

or urinary frequency Similarly, other disorders of impaired arginine vasopressin secretion or action may cause polyuria and nocturia (Ouslander, 2004) Conditions such as conges-tive heart failure, hypothyroidism, venous insuffi ciency, and the eff ects of certain medications all contribute to peripheral edema, leading to urinary frequency and nocturia when a patient is supine

Finally, stool impaction resulting from poor bowel habits and constipation can contribute to overactive bladder symp-toms Th is is perhaps from local irritation or direct compression against the bladder wall

■ Physical Examination

General Inspection and Neurologic Evaluation

Initially, the perineum is inspected for evidence of atrophy, which may be noted throughout the lower genital tract In addi-tion, suburethral bulging with transurethral expression of fl uid during forward-directed compression suggests a urethral diver-ticulum (Fig 26-3, p 683)

A thorough physical examination for a woman with tinence should also include a detailed neurologic evaluation

incon-of the perineum Because neurologic responses may be altered

in an anxious patient who is in a vulnerable setting, signs elicited during examination may not signify true pathology and should be interpreted with caution Neurologic evalua-

tion begins with an attempt to elicit a bulbocavernosus refl ex

During this test, one labium majora is stroked with a ton swab Normally, both labia equally contract bilater-ally Th e aff erent limb of this refl ex is the clitoral branch of the pudendal nerve, whereas its eff erent limb is conducted through the inferior hemorrhoidal branch of the pudendal nerve Th is refl ex is integrated at the S2-S4 spinal cord level (Wester, 2003) Th us, refl ex absence may refl ect central or peripheral neurologic defi cits Secondly, a normal circumfer-ential anal sphincter contraction, colloquially called an “anal wink,” should follow cotton swab brushing of the perianal skin External urethral sphincter activity requires at least

cot-some degree of intact S2-S4 innervation, and this neous refl ex is mediated by the same spinal neurologic level

anocuta-Th us, an absent wink may indicate defi cits in this neurologic distribution

Pelvic Support Assessment

commonly accompanies pelvic organ prolapse (POP) For example, women with signifi cant prolapse are often unable to completely empty their bladder due to urethral kinking and obstruction Th ese women frequently must digitally elevate or reduce their prolapse to allow emptying Th us, an external eval-uation for POP, as described in Chapter 24 (p 644) is indicated for all women with urinary incontinence Following this evalu-ation for vaginal compartment defects, pelvic muscle strength should also be assessed Women with mild to moderate urinary incontinence often respond well to pelvic fl oor therapy, and under these circumstances, a trial of this therapy is warranted and often curative (p 624)

urgency As described earlier, the term overfl ow incontinence is

no longer used

each episode may also provide diagnostic clues Large volumes

are typically lost following a spontaneous detrusor

contrac-tion associated with urge urinary incontinence and may often

involve loss of the entire bladder volume In contrast, woman

with SUI usually describe smaller volumes lost Moreover, these

women often are able to contract the levator ani muscles to

temporarily stop their urine stream

Postvoid dribbling is classically associated with urethral

diverticulum, which may often be mistaken for urinary

incon-tinence (Chap 26, p 683) Hematuria, although a common

sign of UTI, may also indicate underlying malignancy and can

cause irritative voiding symptoms

Th e onset of symptoms may also provide information

regarding etiology and treatment For example, onset of

symp-toms with the menopause may suggest hypoestrogenism as an

etiology Th ese patients may benefi t from topical vaginal

estro-gen In contrast, symptoms after hysterectomy or childbirth

may refl ect changes in tissue support or innervation

Past Medical History

Obstetric trauma may be associated with damage to

pel-vic fl oor support, which may lead to SUI For this reason,

information describing a prolonged labor, operative vaginal

delivery, macrosomia, postpartum catheterization for urinary

retention, and increased parity may be valuable As alluded

to earlier, urinary incontinence may be associated with

sev-eral medical conditions or their treatments, which could be

modifi ed to improve incontinence To help remember these

potential contributors, a useful mnemonic is “DIAPPERS”:

dementia/delirium, infection, atrophic vaginitis,

psychologi-cal, pharmacologic, endocrine, restricted mobility, and stool

impaction (Swift, 2008)

First, continence requires the cognitive ability to recognize

and react appropriately to the sensation of a full bladder,

moti-vation to maintain dryness, suffi cient mobility and manual

dexterity, and ready access to a toilet Patients with dementia

or signifi cant psychological impairments often do not have the

necessary cognitive ability for continence maintenance Women

with severe physical handicaps or restricted mobility may

sim-ply not have time to reach the toilet, especially in the setting of

urinary urgency/overactive bladder

Urinary tract infections cause bladder mucosal infl

amma-tion Th is infl ammation is thought to increase sensory aff erent

activity, which contributes to an overactive bladder Similarly,

estrogen defi ciency may lead to atrophic vaginitis and

ure-thritis Th ese are associated with increased local irritation and

greater risks of UTI and overactive bladder

A detailed medication inventory should be collected Pertinent

drugs may include estrogen, -adrenergic agonists, and diuretics

(Table 23-4)

Diabetes mellitus can lead to osmotic diuresis and polyuria

if glucose control is poor Polydipsia from diabetes insipidus

or excessive caff eine or alcohol intake can also lead to polyuria

CHAPTER 23

measures 30 degrees above the horizontal plane indicates thral hypermobility Th e utility of this test is controversial given that many asymptomatic women with urethral hypermobility

ure-do not have urinary incontinence

Bimanual and Rectovaginal Examination

In general, these portions of the pelvic examination provide fewer diagnostic clues to underlying incontinence causes However, bimanual examination may reveal an enlarged pelvic mass or a uterus enlarged by leiomyomas or adenomyosis Th ese may cre-ate incontinence through increased external pressure transmitted

to the bladder In addition, stool impaction is easily identifi ed with rectal examination

hypermobility during increases in intraabdominal pressures To

assess mobility, a clinician places the soft end of a cotton swab

into the urethra to the urethrovesical junction Failure to insert

the swab to this depth typically leads to errors in assessment

of urethrovesical junction support Termed the Q-tip test, this

evaluation may be uncomfortable, and application of

intra-urethral analgesia may prove helpful Commonly, 1-percent

lidocaine jelly is placed on the cotton swab prior to insertion

Following placement, a Valsalva maneuver is prompted, and the

swab-excursion angle at rest and with Valsalva maneuver is

mea-sured with a goniometer or standard protractor (Fig 23-13)

An excursion angle from rest and with Valsalva maneuver that

immobility

Polyuria, frequency

␣-Adrenergic agonists Decongestants, diet pills IUS contraction Urinary retention

␣-Adrenergic blockers Prazosin, terazosin, doxazosin IUS relaxation Urinary leakage

Thioridazine, chlorpromazine, haloperidol

Trihexyphenidyl, benztropine mesylate

Dicyclomine, disopyramideOrphenadrine, cyclobenzaprineAmitriptyline, imipramine, nortriptyline, doxepin

Inhibit bladder contraction, sedation, fecal impaction

Urinary retention and/or functional incontinence

ACE inhibitors Enalapril, captopril, lisinopril, losartan Chronic cough Urinary leakage

bumetanide, acetazolamide, spironolactone

Increases urinary frequency, urgency

Polyuria

impaction, sedation

Urinary retention, and/or functional incontinence

Thiazolidinediones Rosiglitazone, pioglitazone,

620 Female Pelvic Medicine and Reconstructive Surgery

of removing the urinary catheter, then a catheter is replaced, and the test is repeated a day or more later

During an active bladder trial, the bladder is actively fi lled with

a set volume, and following patient voiding, residual bladder urine volumes are calculated Initially, the bladder is completely emp-tied by catheterization It may be helpful during catheterization for a woman to stand upright to clear the most dependent por-tions of her bladder Sterile water is infused under gravity into the

■ Diagnostic Testing

Urinalysis and Culture

In all women with urinary incontinence, infection or urinary

tract pathology must be excluded Urinalysis and urine culture

are sent at an initial visit, and infection is treated as described in

Table 3-24 (p 94) Persistent symptoms typically warrant

addi-tional evaluation for stress and urge urinary incontinence or for

other conditions such as interstitial cystitis

Postvoid Residual (PVR)

Th is volume is routinely measured during incontinence

evalu-ation After a woman voids, the PVR may be measured with

a handheld sonographic bladder scanner or by transurethral

catheterization Portable three-dimensional ultrasound devices

are used to scan the bladder and provide numerical results (Fig

23-14) In general, they are quick, easy to use, and more

com-fortable for the patient However, if using a handheld scanner,

care must be taken in women with an enlarged

leiomyoma-tous uterus as this may falsely record a large PVR In these

instances, or if a scanner is not available, transurethral

cath-eterization may be used to confi rm residual bladder volume

A large postvoid residual may often refl ect one of several

problems including recurrent infection, urethral obstruction

from a pelvic mass, or neurologic defi cits In contrast, a

nor-mally small PVR is often found in those with SUI

surgery, PVR measurement is a helpful indicator of a patient’s

ability to completely empty her bladder Th is evaluation may be

completed with a “passive” or an “active” voiding trial

With a passive trial, a urinary catheter is removed, and the

PVR is measured by scanner or by transurethral catheterization

after each voluntary void on two occasions A voided volume

of at least 300 mL and PVR less than 100 mL is desirable

However, adequate bladder emptying is assumed if the PVR is

less than one third of the voided volume If the patient does not

meet these criteria, or if she is unable to void within 4 to 6 hours

FIGURE 23-13 Drawing depicting Q-tip test in a patient with urethral hypermobility A. Angle of the Q-tip at rest B. Angle of the Q-tip

with Valsalva maneuver or other increases in intraabdominal pressure The urethrovesical junction descends, causing upward deflection

of the Q-tip

FIGURE 23-14 Handheld bladder scanner aids estimation of

bladder volume (Photograph courtesy of Dr Heather Gardow.)

CHAPTER 23

Simple cystometrics are easy to perform, require inexpensive equipment, and can typically be completed by most gynecolo-gists One limitation of simple cystometric testing, however, is its inability to assess for intrinsic sphincteric defi ciency (ISD), which may preclude certain surgical options Multichannel cys-tometrics can evaluate for ISD and thus may off er advantages

study provides more information on other physiologic der parameters that are not aff orded by simple cystometrics

blad-Multichannel cystometrics more commonly is performed by urogynecologists or urologists due to the expense and limited availability of the equipment Testing can be performed with

a woman standing or seated upright in a specialized evaluation chair During testing, two catheters are used One is placed into the bladder and the other into either the vagina or rectum Th e vagina is preferred unless advanced prolapse is evident, as stool

in the rectal vault may obstruct catheter sensors and lead to inaccurate readings Additionally, vaginal placement for most women is more comfortable From each of these two cathe-ters, distinct pressure readings are obtained or calculated and include: (1) intraabdominal pressure, (2) vesicular pressure, (3) calculated detrusor pressure, (4) bladder volume, and (5) saline infusion fl ow rate As shown in Figures 23-15 and 23-16, the diff erent forms of incontinence can be diff erentiated

Uroflowmetry Initially, women are asked to empty their

blad-der into a commode connected to a fl owmeter (urofl owmetry)

After a maximal fl ow rate is recorded, the patient is catheterized to measure a postvoid residual and to ensure an empty bladder prior

to further testing Th is test provides information on a woman’s ability to empty her bladder and can identify women with uri-nary retention and other types of voiding dysfunction Presuming that a patient begins with a comfortably full bladder of 200 mL

or greater, most patients can empty their bladders over 15 to

20 seconds with fl ow rates of greater than 20 mL/sec Maximum

fl ow rates of less than 15 mL/sec, with a voided volume greater than 200 mL, are generally considered abnormally slow In this setting—especially if accompanied by urinary retention—voiding dysfunction is identifi ed Th is may result from obstruction from

a kinked urethra in the setting of anterior vaginal wall prolapse or postoperatively after creation of antiincontinence support that is too tight Voiding dysfunction may also occur in settings of neu-rologic dysfunction with poor detrusor contractility, as in those with poorly controlled diabetes

Cystometrography Following urofl owmetry,

cystometrog-raphy is performed to determine whether a woman has dynamic stress incontinence (USI) or detrusor overactivity (DO) Additionally, this test provides information on bladder threshold volumes at which a woman senses bladder capacity

uro-Delayed sensation or sensation of bladder fullness only with large capacities may indicate neuropathy Conversely, extreme bladder sensitivity may suggest sensory disorders such as inter-stitial cystitis

For the cystometrogram, a catheter is inserted transurethrally into the bladder and a second catheter is inserted into the vagina

or rectum (see Fig 23-15) While the patient is seated, the der is fi lled with room-temperature sterile normal saline, and

blad-bladder through the same catheter until approximately 300 mL

is used or until a subjective maximum capacity is reached Th e

patient is then asked to void spontaneously into a urine

collec-tion device Th e diff erence between volume infused and volume

retrieved is recorded as the PVR A residual of less than 100 mL or

less than one third of the instilled volume—if less than 300 mL is

infused—is consistent with adequate bladder emptying

Urodynamic Studies

Surgical correction of incontinence is invasive and not

with-out risk However, the “bladder is an unreliable witness,” and

historical information may not always accurately indicate the

true underlying type of incontinence (Blaivas, 1996) Th us,

if initial conservative management is unsuccessful or surgical

treatment is anticipated, then objective assessment should be

pursued In addition, if symptoms and physical fi ndings are

incongruous, then objective urodynamic studies (UDS), using

simple or multichannel cystometrics, may also be indicated

For example, in women with mixed urinary incontinence, who

have symptoms of both stress and urge urinary incontinence,

UDS may reveal that only the urge component is responsible

for their incontinence Most of these women are treated with

behavioral, physical, and/or pharmacologic therapy initially

Th us, if identifi ed by UDS, these individuals can avoid

unnec-essary surgery Additionally, surgical therapy may be modifi ed

if UDS reveals parameters consistent with intrinsic sphincteric

defect

Despite these indications, UDS remains controversial

Leakage noted during testing is not always clinically

rele-vant In addition, testing may be uninformative if the

origi-nal off ending maneuver or situation that led to incontinence

cannot be reproduced during evaluation Moreover, objective

confi rmation of the diagnosis is not always necessary, since

empiric nonsurgical therapy in women with urge predominant

symptoms is reasonable

function are combined in a battery of tests termed cystometrics,

which may be simple or multichannel Simple cystometrics allows

determination of stress incontinence and detrusor overactivity as

well as measurement of fi rst sensation, desire to void, and bladder

capacity Th is procedure is easily performed with

room-temper-ature sterile normal saline, 60-mL catheter-tipped syringe, and

urinary catheter, either Foley or Robnell Th e urethra is sterilely

prepared, the catheter is inserted, and the bladder is drained A

60-mL syringe with its plunger removed is attached to the

cath-eter and is fi lled upright with sterile water Water is added in

increments until a woman feels a sensation of bladder fi lling,

urge to void, and bladder maximum capacity A normal

blad-der capacity for most women will range from 300 to 700 mL

Changes in the fl uid meniscus within the syringe are monitored

In the absence of a cough or Valsalva maneuver that would raise

intraabdominal pressure, an abrupt meniscus elevation indicates

bladder contraction and suggests a diagnosis of detrusor

overac-tivity Once bladder capacity is reached, the catheter is removed,

and the woman is asked to perform a Valsalva maneuver or

cough while standing Leakage directly linked to these increases

in intraabdominal pressure indicates SUI

622 Female Pelvic Medicine and Reconstructive Surgery

measured Th e patient is asked to perform a Valsalva maneuver, and the pressure generated by the eff ort is measured and evidence

of urine leakage is sought If leakage is seen when a pressure of

60 cm H2O is generated, then criteria have been met for a diagnosis of intrinsic sphincteric defi ciency At our institution, abdominal leak point pressures are measured at a bladder volume

the patient is asked to cough at regular intervals Additionally,

during fi lling, the volumes at which a fi rst desire to void and

maximal bladder capacity is reached are noted From pressure

readings, DO and/or USI may be identifi ed

After cystometrography, once approximately 200 mL of

saline has been instilled, an abdominal leak point pressure is

Pves = Pabd + Pdet

Pdet = Pves – Pabd

b.

FIGURE 23-15 Interpretation of multichannel urodynamic evaluation: cystometrogram A catheter is placed in the bladder to

deter-mine the pressure generated within it (Pves) The pressure in the bladder is produced from a combination of the pressure from the

abdominal cavity and the pressure generated by the detrusor muscle of the bladder Bladder pressure (Pves)  pressure in abdominal

cavity (Pabd)  detrusor pressure (Pdet) A second catheter is placed in the vagina (or rectum if advanced-stage prolapse is present) to

determine the pressure in the abdominal cavity (Pabd) As room-temperature saline is instilled into the bladder, the patient is asked to

cough every 50 mL and the external urethral meatus is observed for leakage of urine around the catheter The volume at first desire

to void and the bladder capacity is recorded Additionally, the detrusor pressure (Pdet) channel is observed for positive deflections to

determine if there is detrusor activity during testing The detrusor pressure (Pdet) cannot be measured directly by any of the catheters

However, from the first equation, we can calculate the detrusor pressure (Pdet) by subtracting the abdominal pressure (Pabd) from the

bladder pressure (Pves):

Detrusor pressure (Pdet)  bladder pressure (Pves)  pressure in abdominal cavity (Pabd)

I Urodynamic Stress Incontinence (USI)

Urodynamic stress incontinence is diagnosed when urethral leakage is seen with increased abdominal pressure, in the absence of

detru-sor pressure

a USI (Column 1): Abdominal pressure is generated with Valsalva maneuver or cough This pressure is transmitted to the bladder, and

a bladder pressure (Pves) is noted The calculated detrusor pressure is zero Leakage is observed, and diagnosis of USI is assigned

b No USI (Column 2): Abdominal pressure is generated with Valsalva maneuver or cough This pressure is transmitted to the bladder,

and a bladder pressure (Pves) is noted The calculated detrusor pressure is zero Leakage is not observed The patient is not diagnosed as

having USI

II Detrusor Overactivity (DO)

Detrusor overactivity is diagnosed when the patient has involuntary detrusor contractions during testing with or without leakage

a DO (Column 3): Although no abdominal pressure is observed, a vesicular pressure is noted A calculated detrusor pressure is

recorded and noted to be present A diagnosis of DO is made regardless of whether leakage is seen

b DO (Column 4): In this example, an abdominal pressure is observed as well as a vesicular pressure Using only the Pabd and the Pves

channels, it is difficult to tell whether or not the detrusor muscle contributed to the pressure generated in the bladder On subtraction, a

calculated detrusor pressure is recorded Thus, a diagnosis of DO is made, again regardless of whether leakage is seen

In addition to these channels, occasionally a channel to detect electromyographic activity is used

Pabd  pressure in abdominal cavity; Pdet  detrusor pressure (calculated); Pves  bladder pressure

CHAPTER 23

Urethral Pressure Profile Th e fi nal part of cystometric ing is the urethral pressure profi le At our institution, we usu-ally perform this test in the seated patient with a volume of

test-200 mL instilled in the bladder However, again, this volume

is often institution dependent A catheter transducer is tioned within the bladder, and the microtip dual-sensor cath-eter is pulled through the urethra with the aid of an automated puller arm at a speed of 1 mm/sec Maximum urethral closure pressure (MUCP) is determined by averaging three pressure profi les Th e functional urethral length and the area of conti- nence zone are also obtained Th ese values provide important information on the intrinsic properties of the urethra and aid in the diagnosis of ISD A diagnosis of ISD is made if the MUCP

posi-is 20 cm H2O or as described in the last section, if the leak point pressure is 60 cm H2O (McGuire, 1981) Th ese terms and concepts provide the rationale for procedures aimed at cor-recting stress incontinence Importantly, however, the values used to defi ne ISD are not well standardized and have not been consistently found to infl uence surgical outcomes (Monga, 1997; Weber, 2001)

of 200 mL, using the true zero of intravesical pressure as the

base-line However, the volume at which this test is performed varies

among institutions, with some choosing to use bladder capacity

and others choosing to use 150 mL as the testing volume

Pressure Flowmetry Th is evaluation usually follows

cys-tometrography and is similar to the urofl owmetry conducted

at the beginning of urodynamic testing A woman is asked to

void into a large beaker that rests on a calibrated weighted

sen-sor Maximum fl ow rate and postvoid residual are once again

recorded Similar to urofl owmetry, the output from the

urody-namics instrumentation provides a graphical representation of

the void However, during voiding, a woman now has a

micro-tip transducer catheter in her bladder, which provides an

addi-tional display of detrusor pressure during the void, including

at the point of maximum fl ow rate Th is is particularly useful

in women who may have incomplete bladder emptying, as the

pressure fl owmetry may suggest either an obstructive scenario

(elevated maximal detrusor pressure with slow fl ow rate) or poor

detrusor contractility (low detrusor pressure and slow fl ow rate)

8060Vaginal catheter

(abdominal

pressure)

cm H2O

402008060Bladder catheter

(bladder

pressure)

cm H2O

402008060Subtracted

(mL/sec) 20

100

↑ Leak visualized

↑ Leak visualized

TIME

A Normal bladderresponse

B Detrusoroveractivity

C Urodynamic stressincontinence

D Normalvoiding

Detrusoroveractivity

Cough

CoughValsalva

FIGURE 23-16 Urodynamic testing Cystometrography is reflected by parts A, B, and C A. In a patient with normal function, note that

provocation by coughing or Valsalva maneuver does not provoke an abnormal rise in detrusor pressure B & C. In a patient with combined

detrusor overactivity and urodynamic stress incontinence First, spontaneous detrusor activity leads to increased bladder pressure reading

in the absence of cough or Valsalva maneuver Second, a cough alone leads to urine leakage, independent of detrusor muscle activity

D. Pressure flowmetry At maximum capacity and on command, a detrusor contraction is generated, and voiding is initiated

624 Female Pelvic Medicine and Reconstructive Surgery

TREATMENT

■ Conservative/Nonsurgical

Pelvic Floor Strengthening Exercises

Conservative management is a reasonable initial approach to

most patients with urinary incontinence Th e rationale behind

conservative management is to strengthen the pelvic fl oor and

provide a supportive “backboard” against which the urethra

may close Options include active pelvic fl oor exercises and

pas-sive electrical pelvic fl oor muscle stimulation For both SUI and

urge urinary incontinence, these fundamentals prove valuable

With SUI, pelvic fl oor strengthening attempts to compensate

for anatomic defects For urge urinary incontinence, it improves

pelvic fl oor muscle contraction strength to provide temporary

continence during waves of bladder detrusor contraction

moderate symptoms, pelvic fl oor muscle training (PFMT) may

improve if not cure urinary incontinence Also known as Kegel

exercises, PFMT entails voluntary contraction of the levator ani

muscles As with any muscle building, isometric or isotonic

forms of exercise may be selected Exercise sets should be

per-formed numerous times during the day, with some reporting up

to 50 or 60 times each day However, specifi c details in

perfor-mance of these exercises are subject to provider preference and

clinical setting

If isotonic contractions are used for PFMT, a woman is

asked to squeeze and hold contracted levator ani muscles

Women, however, often have diffi culty isolating these muscles

Frequently, patients will erroneously contract their abdominal

wall muscles rather than the levators To help localize the correct

group, an individual may be instructed to identify the muscles

that are tightened when snug pants are pulled up and over her

hips Moreover, in an offi ce setting, a provider can determine if

the levator ani group is contracted by placing two fi ngers in the

vagina while Kegel exercises are performed

At our institution, we aim to help patients achieve a sustained

pelvic fl oor contraction of 10 seconds We begin with the

dura-tion of contracdura-tion a patient can sustain (e.g., 3 seconds), and

ask them to hold for this long and then relax for one to two

times this duration (e.g., 6 seconds) Th is squeeze and release

is repeated 10 to 15 times Th ree sets are performed

through-out the day for a total of approximately 45 contractions Over

a series of weeks with frequent follow-up visits, the duration of

contraction is steadily increased Patients, thus, improve the tone

of their pelvic fl oor muscles and are usually able to more

force-fully squeeze their muscles in anticipation of sudden increases of

intraadominal pressure for SUI

Alternatively, if isometric contractions are used for PFMT, a

woman is asked to rapidly contract and relax the levators Th ese

“quick fl icks” of the pelvic fl oor muscles may prove

advanta-geous if waves of urinary urgency strike Of note, there is a

mis-conception about the value of stopping urination midstream

Women should be counseled that this practice often worsens

voiding dysfunction

To augment exercise effi cacy, weighted vaginal cones or

obturators may be placed into the vaginal during Kegel exercises

Th ese provide resistance against which pelvic fl oor muscles can work

Reviewers of the Cochrane database have assessed the eff ects

of PFMT for women with urinary incontinence compared with

no treatment, placebo or sham treatments, or other inactive control treatments Although interventions varied considerably, women who performed PFMT were more likely to report cure

or improved incontinence and improved continence-specifi c quality of life than women who did not use PFMT Th e exer-cising women also objectively demonstrated less leakage during offi ce-based pad testing (Dumoulin, 2010) Prognostic indica-tors that may predict a poor response to PFMT for the treatment

of SUI include severe baseline incontinence, prolapse beyond the hymenal ring, prior failed physiotherapy, a history of prolonged second stage of labor, BMI 30 kg/m2, high psychological dis-tress, and poor overall physical health (Hendriks, 2010)

fl oor contraction, a vaginal probe may be used to deliver frequency electrical stimulation to the levator ani muscles

low-Although the mechanism is unclear, electrical stimulation may

be used to improve either SUI or urge urinary incontinence (Indrekvam, 2001; Wang, 2004) With urge urinary incon-tinence, traditionally a low frequency is applied, whereas for SUI, higher frequencies are used Electrical stimulation may

be used alone or more commonly in combination with PFMT

considered together as biofeedback therapy, measure physiologic

signals such as muscle tension and then display them to a patient

in real time In general, visual, auditory, and/or verbal feedback cues are directed to the patient during these therapy sessions

Specifi cally, during biofeedback for PFMT, a sterile vaginal probe that measures pressure changes within the vagina during levator ani muscle contraction is typically used Visual readings refl ect an estimate of muscle contraction strength Treatment sessions are individualized, dictated by the underlying dysfunc-tion, and modifi ed based on response to therapy In many cases, reinforcing sessions at various subsequent intervals may also prove advantageous

car-In addition, certain dietary supplements such as calcium erophosphate (Prelief) have been shown to decrease urgency and frequency symptoms (Bologna, 2001) Th is is a phosphate-based product and is thought to buff er urine acidity

glyc-Scheduled Voiding

Women with urge urinary incontinence may feel voiding urges

as frequently as every 10 to 15 minutes Initial goals extend ings to half-hour intervals Tools used to achieve this include Kegel exercises during waves of urgency or mental distraction

void-CHAPTER 23

techniques during these times Scheduled voiding, although

used primarily for urge urinary incontinence, may also be

help-ful for those with SUI For these patients, regularly scheduled

urination leads to an empty bladder during a greater percentage

of the day Because some women will leak urine only if

blad-der volumes surpass specifi c volumes, frequent emptying can

signifi cantly decrease incontinence episodes

Estrogen Replacement

Estrogen has been shown to increase urethral blood fl ow and

increase -adrenergic receptor sensitivity, thereby increasing

ure-thral coaptation and ureure-thral closure pressure Hypothetically,

estrogen may also increase collagen deposition and increase

vas-cularity of the periurethral capillary plexus Th ese are purported

to improve urethral coaptation Th us, for incontinent women

who are atrophic, administration of exogenous estrogen is

rea-sonable

Estrogen is commonly administered topically, and many

diff erent regimens are appropriate At our institution, we use

conjugated equine estrogen cream (Premarin cream)

adminis-tered daily for 2 weeks, then twice weekly thereafter Although

no data are available to address the duration of treatment,

women may be treated chronically with topical estrogen cream

Alternatively, oral estrogen may be prescribed if other

meno-pausal symptoms for which estrogen would be benefi cial coexist

(Chap 22, p 584)

However, despite these suggested benefi ts, a consensus

regarding estrogen’s benefi cial eff ects on the lower urinary tract

has not been reached Specifi cally, some studies have shown

worsening or development of urinary incontinence with

sys-temic estrogen administration (Grady, 2001; Grodstein, 2004;

Hendrix, 2005; Jackson, 2006)

■ Treatment of Stress Urinary Incontinence

Medications

Pharmaceutical treatment plays a minor role in the treatment

of women with SUI However, for women with mixed urinary

incontinence, a trial of imipramine is reasonable to aid urethral

contraction and closure As discussed earlier, this tricyclic

anti-depressant has -adrenergic eff ects, and the urethra contains a

high content of these receptors

Duloxetine (Cymbalta), a selective serotonin- and

norepine-phrine-reuptake inhibitor (SSRI), has been evaluated for SUI

treatment In animal studies, serotonergic agonists suppress

parasympathetic activity and enhance sympathetic and somatic

activity Th e sum eff ect promotes urine storage by relaxing the

bladder and increasing outlet resistance Although considered

investigational, in randomized studies, this SSRI has improved

symptoms in women with SUI (Dmochowski, 2003a; Millard,

2004; Norton, 2002) Moreover, Ghoniem and coworkers

(2005), in a randomized controlled trial, evaluated the

ben-efi ts of duloxetine, PFMT, and placebo combinations Pad and

quality-of-life data found the combination of duloxetine and

PFMT to be more eff ective than either alone

Previously, phenylpropanolamine (PPA) was used to treat

SUI However, in 2005, the Food and Drug Administration

(FDA) (2009) reclassifi ed PPA as Category II and considered it

not generally safe or eff ective Specifi cally, the FDA’s decision was prompted by an increased rate of hemorrhagic strokes suf-fered by womentaking this medication

Pessary and Urethral Inserts

Certain pessaries have been designed to treat incontinence as well as pelvic organ prolapse Incontinence pessaries are designed

to reduce downward excursion or funneling of the cal junction (Fig 24-17, p 648) Th is provides bladder neck support and thereby helps to reduce incontinence episodes

urethrovesi-Dependent on the amount of prolapse present, pessary effi cacy for urinary incontinence is variable Not all women are appro-priate candidates for pessaries, nor will all desire long-term management of incontinence or prolapse with these devices

A large prospective trial comparing incontinence pessaries and behavioral therapy for women with SUI demonstrated that

40 and 49 percent of patients were either much or very much improved at 3 months, respectively Th e women randomized

to behavioral therapy reported greater treatment satisfaction, and a greater percentage reported no bothersome incontinence symptoms (Richter, 2010b)

As an alternative to pessaries, a urethral insert may also be used for SUI control Th e only currently commercially available

device is the FemSoft Insert As the device is inserted, its sleeve

slides into and conforms to the urethra and creates a seal at the bladder neck to prevent accidental urine leakage During routine bathroom visits, the insert is removed, discarded, and replaced with a fresh insert Data are limited on the eff ective-ness of this insert However, in an observational study of 150 women, Sirls and associates (2002) found signifi cantly reduced rates of incontinence episodes

Surgical Treatment of Intrinsic Sphincteric Deficiency

been traditionally indicated for women who have stress nence associated with intrinsic sphincteric defi ciency However, the FDA has broadened the criteria for use of bulking agents

inconti-to include patients with less severe leak point pressures As a result, those with leak point pressures 100 cm H2O may also be suitable candidates (McGuire, 2006) Additionally, this offi ce procedure is a useful alternative for women with SUI who have multiple medical problems and are thus poor surgi-cal candidates

Agents are injected into the urethral submucosa to “bulk up” the mucosa and improve coaptation Ideally, these inject-able bulking agents should be easy to place, eff ective, durable, safe, and nonimmunogenic Since few agents satisfy all of these characteristics, newer agents are constantly being developed

Th e injection location around and along the length of the thra can vary Some recommend two locations on either side of the urethra, whereas others advocate injections in three or four quadrants At our institution, we usually inject at the level of the urethrovesical junction at sites of apparent urethral muco-sal defects However, if a global defect is noted or if a discrete defect is absent, then a two- to four-quadrant approach is used

ure-Th e specifi c steps of injection and types of products used are described in Section 43-6 (p 1198)

626 Female Pelvic Medicine and Reconstructive Surgery

Urethral Injection Bulking agent into urethral

submucosa

ISD Also for SUI in poor surgical candidates; may

require a number of repeated injectionsNeedle suspension Proximal urethra suspended by

anterior abdominal wall

SUI Low long-term success rates; no longer

recommended for SUIParavaginal defect

Pubocervical fascia attached to:

Cooper ligament (Burch) or

to symphysis pubis (MMK)

SUI Effective long-term treatment; requires

surgeon experience; less reproducible benefits than midurethral sling procedure Pubovaginal slings Bladder neck supported by

fascial strip attached to anterior abdominal wall

ISD; failed SUI procedure

Effective long-term treatment; may be useful

in patients in whom synthetic material is not desirable; requires isolation of graft from anterior abdominal wall or from leg fascia lata

Midurethral slings:

TVT

TOT

Midurethra supported by mesh placed :

by retropubic approach or

by transobturator approach

SUI; ISD SUI

Effective short-term treatment, rapid postoperative recovery; TVT with long-term efficacy data; further study required to determine effectiveness of TOT in patients with ISD

ATFP  arcus tendineus fascia pelvis; ISD  intrinsic sphincteric deficiency; MMK  Marshall-Marchetti-Krantz procedure;

SUI  stress urinary incontinence; TOT  transobturator tape; TVT  tension-free vaginal tape

Surgical Treatment of Anatomic

Stress Incontinence

For those who are not adequately improved with or do not

desire conservative management, surgery may be an

appropri-ate next step for successful treatment of stress incontinence As

noted earlier, urethral support is integral to continence Th us,

surgical procedures that recreate this support often diminish or

cure incontinence More than 200 procedures have been

devel-oped for the surgical correction of SUI, although the complete

physiology underlying their success is not entirely clear In

gen-eral, these surgical procedures are believed to prevent bladder

neck and proximal urethra descent during increases in

intra-abdominal pressure (Table 23-5)

Transvaginal Needle Procedures and Paravaginal Defect

theo-rized to prevent bladder neck and proximal urethra descent

dur-ing increases in intraabdominal pressure In the 1960s through

1980s, needle suspension procedures such as the Raz, Pereyra,

and Stamey techniques were popular surgical treatments for SUI

but have now largely been replaced by other methods In brief,

these surgeries used specially designed ligature carriers to place

sutures through the anterior vaginal wall and/or periurethral

tis-sues and suspend them to various levels of the anterior abdominal

wall Th ese relied on the strength and integrity of the periurethral

tissue and abdominal wall strength for successful suspension

Although initial cure rates were satisfactory, the durability of

these procedures decreased with time Success rates range from

50 to 60 percent, well below rates found with other current

antiincontinence procedures (Moser, 2006) Failure stemmed largely from “pull-through” of sutures at the level of the anterior vaginal wall

In addition, abdominal paravaginal defect repair (PVDR) is

a surgical procedure that corrects lateral support defects of the anterior vaginal wall Th e technique involves suture attachment

of the lateral vaginal wall to the arcus tendineus fascia pelvis

Currently, PVDR is primarily a prolapse-correcting operation

Although previously used to correct SUI, long-term data have shown this to no longer be a superior method for primary treat-ment of SUI (Colombo, 1996; Mallipeddi, 2001)

includes the Burch and Marshall-Marchetti-Krantz (MMK) colposuspension procedures, which involve suspension and anchorage of the pubocervical fascia to the musculoskeletal framework of the pelvis (Section 43-2, p 1189) Long con-sidered the gold standard for surgical treatment of SUI, the Burch technique uses the strength of the iliopectineal liga-ment (Cooper ligament) to lift the anterior vaginal wall and the periurethral and perivesicular fi bromuscular tissue In contrast, during MMK surgery, the periosteum of the sym-physis pubis is used to suspend these tissues

Th e retropubic urethropexy is an eff ective surgical treatment

of SUI, with 1-year overall continence rates between 85  and

90 percent and with a 5-year continence rate of approximately

70 percent (Lapitan, 2009) Complications commonly associated with these procedures can include de novo detrusor overactivity, urinary retention, and in the case of the MMK, osteitis pubis In

CHAPTER 23

addition, data suggest that performing a Burch retropubic

ure-thropexy concurrently with abdominal sacrocolpopexy for

vagi-nal vault prolapse may signifi cantly reduce rates of symptomatic

postoperative SUI (Chap 24, p 655) (Brubaker, 2008a)

for SUI It has traditionally been used for SUI stemming from

intrinsic sphincteric defi ciency In addition, this procedure may

also be indicated for patients with prior failed antiincontinence

operations

With this surgery, a strip of either rectus fascia or fascia lata

is placed under the bladder neck and through the retropubic

space Th e ends are secured at the level of the rectus

abdomi-nis fascia (Section 43-5, p 1196) Previously, cadaveric fascia

was used as the suspension material However, this tissue is

eventually degraded and found not to be durable over time

(FitzGerald, 1999; Howden, 2006) Currently, autologous

fas-cia is preferred and is obtained from the patient’s rectus sheath,

although fascia lata from the thigh is an alternative

the late 1990s, and their therapeutic mechanism is based on the

integral theory hypothesized by Petros and Ulmsten (1993) In

brief, control of urethral closure involves the interplay of three

structures: the pubourethral ligaments, the suburethral vaginal

hammock, and the pubococcygeus muscle Loss of these

sup-port structures is believed to result in urinary incontinence and

pelvic fl oor dysfunction Th ese slings are believed to reproduce

the support provided by these ligamentous support structures

Th ere are many diff erent variations of these procedures,

but all involve midurethral placement of synthetic mesh

Simplistically, they are classifi ed according to the route of

place-ment and can be subdivided into those using a retropubic or a

transobturator approach Of these, popular procedures include:

(1) tension-free vaginal tape (TVT), a retropubic method; and

(2) transobturator tape (TOT), a transobturator method

Midurethral slings provide several advantages First, these

techniques are eff ective, and short-term cure rates approximate

90 percent (Lim, 2006) Of the two, retropubic and

transobtu-rator approaches appear to off er comparable short-term

conti-nence results (de Tayrac, 2004; Morey, 2006) Laurikainen and

coworkers (2007) randomly assigned 267 women to undergo

either type and found equal rates of subjective and objective cure

Despite favorable comparisons, abundant long-term data

regarding the effi cacy of transobturator approaches are lacking

However, data obtained 17 months postoperatively showed an

incontinence improvement rate of 89 percent for those with

preoperative SUI (Juma, 2007) In contrast, long-term

conti-nence rates are known with the retropubic technique, and these

approximate 80 percent (Nilsson, 2004)

In addition to their effi cacy, recovery from midurethral

sling placement is rapid, and many gynecologists provide

this surgery on an outpatient basis However, as with other

anti incontinence surgeries, general risks for midurethral sling

procedures include urinary retention, lower urinary tract and

vascular injuries, and creation of de novo voiding dysfunction

such as urgency and retention

Retropubic Approach Th ere are several commercial kits

avail-able for this procedure, and one commonly used technique is

the tension-free vaginal tape (TVT) Completed bilaterally, one trocar is placed through a vaginal suburethral incision lateral

to the urethra and brought out suprapubically through a skin incision (Section 43-3, p 1191) Alternatively, needles may be placed through the retropubic space and into the vagina, in a

“top-down” approach

A prospective observational study conducted at three centers

in Sweden and Finland confi rmed the long-term safety and effi cacy of the TVT device, with a 77-percent cure rate at 11.5 years (Nilsson, 2008) Complications vary depending on institution and surgeon expertise and include: urgency, mesh erosion, uri-nary retention, de novo urge urinary incontinence, and vascular, bowel, and lower urinary tract injury Of these, bladder perfora-tion is one of the most common, and associated rates range from

-3 to 9 percent (Agostini, 2006; Tamussino, 2001; Ward, 2004)

Transobturator Approach Th e transobturator (TOT) approach to midurethral sling placement was introduced with the intent to reduce the risks of vascular and lower urinary tract injury that can be associated with traversing the retro-pubic space Various kits for this approach are available Each contains variations in needle and mesh design, but in general,

a permanent sling material, usually polypropylene, is placed

Sling material is directed bilaterally through the obturator men and underneath the midurethra Th e entry point overlies the proximal tendon of the adductor longus muscle

fora-Th e two major types of TOT procedures are defi ned by whether needle placement begins inside the vagina and is

directed outward, termed an in-to-out approach, or tively starts outside and is directed inward, called an out-to-

alterna-in approach (Section 43-4, p 1194) Initially, this procedure

was developed with an out-to-in approach However, with this direction, bladder and urethral injury were potential compli-cations In a retrospective study, Abdel-Fattah and colleagues (2006) compared these two approaches Injury to the bladder

or ureter complicated 1 percent of nearly 400 procedures, and all followed the out-to-in technique

As a result, the in-to-out approach was created and marketed with the assertion of decreased lower urinary tract injury rates

However, with the in-to-out technique, the trocar tip travels closer to the obturator neurovascular bundle (Achtari, 2006;

Zahn, 2007) Th us, although each method has its theoretical advantages, the possibility of injury is not entirely eliminated

Th e transobturator approach provides an eff ective surgery technique with potentially lower rates of bladder injury

day-However, some retrospective studies have suggested that it may have limited eff ectiveness for patients who demonstrate urody-namic criteria for intrinsic sphincteric defi ciency (Miller, 2006;

O’Connor, 2006) Prospective randomized comparative studies are needed to clarify the effi cacy of each transobturator midure-thral sling and to confi rm the relative safety of each technique

A multicenter randomized study of 597 women compared the retropubic and transobturator techniques for treatment of SUI

No signifi cant diff erences in objective and subjective success rates at 12 months were found between the retropubic (80.8 and 62.2 percent) and the transobturator (77.7 and 55.8 per-cent) routes of surgery Th e retropubic route had a signifi cantly higher rate of postoperative voiding dysfunction requiring reoperation, whereas the transobturator route resulted in more

628 Female Pelvic Medicine and Reconstructive Surgery

Other techniques that have been introduced include wave ablation of the periurethral tissues However, current data

micro-do not support the effi cacy or safety of this method

■ Treatment of Urge Urinary Incontinence

Anticholinergic Medications

Th ese medications appear to work at the level of the detrusor muscle by competitively inhibiting acetylcholine at muscarinic receptors (M2 and M3) (Miller, 2005) Th ese agents thereby blunt detrusor contractions to reduce the number of inconti-nence episodes and volume lost with each Th ese medications are signifi cantly better than placebo at improving symptoms of urge urinary incontinence and overactive bladder However, in a Cochrane database review, Nabi and colleagues (2006) reported that the reduction in baseline urgency incontinence episodes per day refl ects only a modest margin of benefi t

com-monly used drugs competitively bind to cholinergic receptors (Table 23-6) As discussed earlier, muscarinic receptors are

neurologic symptoms Overall quality of life and satisfaction

with the two procedures were similar (Richter, 2010a)

TOT procedure is seen with the minimally invasive slings,

some-times called “microslings” or “minislings.” With this technique,

an 8-cm-long strip of polypropylene synthetic mesh is placed

across and beneath the midurethra through a small vaginal

inci-sion Mesh is not threaded through the retropubic space and

avoids the potential for vascular injury Currently, the only

mini-mally invasive sling with published data is the TVT-Secur Initial

results have suggested high objective and subjective cure rates

(Neuman, 2008) Unfortunately, most of these studies have been

case series without comparison or control groups Additionally,

some studies have reported complications such as recurrent UTI

(10 percent), de novo urge urinary incontinence (10 percent),

and voiding diffi culty (8 percent) (Meschia, 2009) Moreover,

lower urinary tract injury is not completely averted with this

method As with most technology, data from well-conducted,

long-term comparative studies on effi cacy and safety should be

obtained before complete adoption of any new technique

Oxybutynin (short-acting) Ditropan Antimuscarinic 2.5–5 mg PO tid 5-mg tablet,

5 mg/mL syrupOxybutynin (long-acting) Ditropan XL See above 5–30 mg PO daily 5-, 10-, 15-mg tablet

Oxybutynin (transdermal) Oxytrol See above 3.9 mg/d; patch changed

twice weekly

36-mg patch,

8 per cartonOxybutynin (transdermal)

10% gel

Gelnique See above Gel applied 1 g daily 1-g packet,

30 per carton 1-g pump dose,

30 doses per bottleTolterodine (short-acting) Detrol See above 1–2 mg PO bid 1-, 2-mg tablet

Tolterodine (long-acting) Detrol LA See above 2–4 mg PO daily 2-, 4-mg capsule

Trospium chloride Sanctura Antimuscarinic

quaternary amine

10–25 mg PO qd-qid 10-, 25-, 50-mg

tablets

bid  twice daily; PO  orally; qd  daily; qid  four times daily; tid  three times daily

CHAPTER 23

not limited to the bladder Th us, side eff ects with these drugs

may be signifi cant Of these, dry mouth, constipation, and

blurry vision are the most common (Table 23-7) Patients

frequently report that dry mouth is a primary reason for

drug discontinuation Importantly, anticholinergics are

con-traindicated in those with narrow-angle glaucoma Because

of these eff ects, the therapeutic goal of bladder M3 blockade

with these antimuscarinic agents is often limited by their

anti-cholinergic side eff ects Accordingly, drug selection should

be tailored, and effi cacy is balanced against tolerability For

example, Diokno and associates (2003) found oxybutynin to

be more eff ective than tolterodine However, tolterodine was

associated with lower side eff ect rates Tolterodine and

fes-oterodine have also been compared in a randomized study of

1135 patients Fesoterodine was found to perform above

tolt-erodine, although once again, side eff ects were lowest in the

tolterodine group (Chapple, 2008) A population-based study

reported that only 56 percent of women felt their overactive

bladder medication was eff ective, and half stopped taking the

medication (Diokno, 2006)

Most side eff ects attributed to oxybutynin stem from its

sec-ondary metabolite that follows liver metabolism Th erefore, to

minimize oral oxybutynin side eff ects, a transdermal patch was

designed to decrease the “fi rst-pass” eff ect of this drug Th is

leads to decreased liver metabolism and fewer systemic

cholin-ergic side eff ects Dmochowski and coworkers (2003b) found

fewer anticholinergic side eff ects with transdermal oxybutynin

compared with long-acting oral tolterodine

Transdermal oxybutynin (Oxytrol) is supplied as a 7.6

5.7 cm patch that is applied twice weekly to the abdomen,

hip, or buttock Each patch contains 36 mg of oxybutynin and

delivers approximately 3.9 mg each day Application-site

pruri-tus is the most common side eff ect, and varying the application

site may minimize skin reactions (Sand, 2007) A newer

Side Effect Potential Clinical Consequence

Increased pupil size Photophobia

Decreased visual

accommodation

Blurred visionDecreased salivation Gingival and buccal ulceration

dermal 10-percent oxybutynin gel (Gelnique) is applied daily

to skin of the abdomen, upper arms/shoulders, or thigh, and application sites should be rotated Each sachet contains a 1-g dose of oxybutynin chloride gel, which delivers approximately

4 mg of oxybutynin daily (Staskin, 2009)

and oxybutynin but displays -adrenergic and gic characteristics Th erefore, it is occasionally prescribe for those with mixed urinary incontinence Importantly, doses of imipramine used to treat incontinence are signifi cantly lower than those used to treat depression or chronic pain In our experience, this minimizes the theoretical risk of drug-related side eff ects

anti-cholinergic medications have been introduced that aim to reduce side eff ects Th e agents are all M3-receptor selective antago-nists and include solifenacin (VESIcare), trospium chloride (Santura), and darifenacin (Enablex) Advantages of increased urgency warning time and decreased muscarinic side eff ects have been shown in randomized controlled studies (Cardozo, 2004;

Chapple, 2005; Haab, 2006; Zinner, 2004) However, although the side-eff ect profi les of these drugs are attractive, they have not been proved superior to nonselective muscarinic-receptor drugs

in randomized controlled trials (Nabi, 2006)

Sacral Neuromodulation

Urine storage and bladder emptying requires a complex dinated interaction of spinal cord and higher brain centers, peripheral nerves, urethral and pelvic fl oor muscles, and the detrusor muscle If any of these levels are altered, normal mic-turition is lost To overcome these problems, electrical nerve stimulation, also called neuromodulation, has been used

coor-InterStim is the only implantable neuromodulation system approved by the FDA for treatment of refractory urge urinary incontinence It is also approved for treatment of anal incon-tinence It may be also considered for those with pelvic pain, interstitial cystitis, and defecatory dysfunction, although it is not FDA-approved for these indications Sacral neuromodula-tion is not considered primary therapy and is generally off ered

to women who have typically exhausted pharmacologic and conservative options

Th is outpatient surgically implanted device contains a pulse generator and electrical leads that are placed into the sacral foramina to modulate bladder and pelvic fl oor innervation Its mode of action is incompletely understood, but may be related

to an inhibition of somatic aff erents that interrupts abnormal refl ex arcs in the sacral spinal cord involved in the fi lling and evacuation phases of micturition (Leng, 2005)

Implantation is typically a two-stage process Initially, leads are placed and attached to an externally worn genera-tor (Section 43-12, p 1212) After placement, frequency and amplitude of electrical impulses can be adjusted and tailored to maximize eff ectiveness If a 50-percent or greater improvement

in symptoms is noted, then internal implantation of a nent pulse generator is planned Th is procedure is minimally invasive and is typically completed in a day-surgery setting

perma-630 Female Pelvic Medicine and Reconstructive Surgery

is at risk? Study of Osteoporotic Fractures Research Group Obstet Gynecol 87(5 Pt 1):715, 1996

Brubaker L, Nygaard I, Richter HE, et al: Two-year outcomes after pexy with and without Burch to prevent stress urinary incontinence Obstet Gynecol 112:49, 2008a

sacrocolpo-Brubaker L, Richter HE, Visco AG, et al: Refractory idiopathic urge nence and botulinum A injection J Urol 180:217, 2008b

inconti-Bump RC: Racial comparisons and contrasts in urinary incontinence and vic organ prolapse Obstet Gynecol 81:421, 1993

pel-Bump RC, McClish DK: Cigarette smoking and urinary incontinence in women Am J Obstet Gynecol 167:1213, 1992

Bump RC, Norton PA: Epidemiology and natural history of pelvic fl oor function Obstet Gynecol Clin North Am 25:723, 1998

dys-Burgio KL, Richter HE, Clements RH, et al: Changes in urinary and fecal incontinence symptoms with weight loss surgery in morbidly obese women

Obstet Gynecol 110(5):1034, 2007 Cardozo L, Lisec M, Millard R, et al: Randomized, double-blind placebo con- trolled trial of the once daily antimuscarinic agent solifenacin succinate in patients with overactive bladder J Urol 172(5, Part 1):1919, 2004 Carlile A, Davies I, Rigby A, et al: Age changes in the human female urethra: a morphometric study J Urol 139:532, 1988

Chapple CR, Martinez-Garcia R, Selvaggi L, et al: A comparison of the effi cacy and tolerability of solifenacin succinate and extended release tolterodine at treating overactive bladder syndrome: results of the STAR Trial Eur Urol 48:464, 2005

Chapple CR, Van Kerrebroeck PE, Jünemann KP, et al: Comparison of odine and tolterodine in patients with overactive bladder BJU Int 102(9):

fesoter-1128, 2008 Cody JD, Richardson K, Moehrer, et al: Oestrogen therapy for urinary incontinence in post-menopausal women Cochrane Database Syst Rev 4:CD001405, 2009

Colombo M, Milani R, Vitobello D, et al: A randomized comparison of Burch colposuspension and abdominal paravaginal defect repair for female stress urinary incontinence Am J Obstet Gynecol 175:78, 1996

Dallosso HM, McGrother CW, Matthews RJ, et al: Th e association of diet and other lifestyle factors with overactive bladder and stress incontinence: a longitudinal study in women BJU Int 92:69, 2003

de Tayrac R, Deffi eux X, Droupy S, et al: A prospective randomized trial comparing tension-free vaginal tape and transobturator suburethral tape for surgical treatment of stress urinary incontinence Am J Obstet Gynecol 190:602, 2004

Deitel M, Stone E, Kassam HA, et al: Gynecologic-obstetric changes after loss of massive excess weight following bariatric surgery J Am Coll Nutr 7:147, 1988 Diokno AC, Appell RA, Sand PK, et al: Prospective, randomized, double-blind study of the effi cacy and tolerability of the extended-release formulations of oxybutynin and tolterodine for overactive bladder: results of the OPERA trial Mayo Clin Proc 78:687, 2003

Diokno AC, Brock BM, Herzog AR, et al: Medical correlates of urinary tinence in the elderly Urology 36:129, 1990

incon-Diokno AC, Sand PK, Macdiarmid S et al: Perceptions and behaviors of women with bladder control problems Fam Prac 23 (5):568, 2006 Dmochowski RR, Miklos JR, Norton PA, et al: Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence

J Urol 170(4 Pt 1):1259, 2003a Dmochowski RR, Sand PK, Zinner NR, et al: Comparative effi cacy and safety

of transdermal oxybutynin and oral tolterodine versus placebo in previously treated patients with urge and mixed urinary incontinence Urology 62:237, 2003b

Dumoulin C, Hay-Smith J: Pelvic fl oor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women Cochrane Database Syst Rev 1:CD005654, 2010

Fantl JA, Bump RC, Robinson D, et al: Effi cacy of estrogen supplementation

in the treatment of urinary incontinence Obstet Gynecol 88:745, 1996 Fantl JA, Cardozo L, McClish DK: Estrogen therapy in the management of uri- nary incontinence in postmenopausal women: a meta-analysis First report of the Hormones and Urogenital Th erapy Committee Obstet Gynecol 83:12, 1994

FitzGerald MP, Mollenhauer J, Bitterman P, et al: Functional failure of fascia lata allografts Am J Obstet Gynecol 181:1339, 1999

Surgical complications are rare but may include pain or

infec-tion at the generator inserinfec-tion site

Although its use is often reserved for those who have been

unsuccessfully treated with behavioral or pharmacologic

ther-apy, this modality has been shown to be eff ective for treatment

of urinary symptoms Studies have found improvement rates

ranging from 60 to 75 percent, and cure rates approximating

45 percent (Janknegt, 2001; Schmidt, 1999; Siegel, 2000)

Sustained improvement from baseline incontinence

param-eters has been shown at long-term follow-up One 3-year study

reported a 57-percent reduction in incontinence episodes per

day, and similar fi ndings were found in a separate 5-year study

(Kerrebroeck, 2007; Siegel, 2000) A systematic review of 17

case series at follow-up periods of 3 to 5 years similarly reported

39 percent of patients cured and 67 percent with greater than

50-percent improvement in incontinence symptoms (Brazzelli,

2006)

Bot ulinum Toxin A

Injection of botulinum toxin A into the bladder wall may

be used as a treatment for idiopathic detrusor overactivity

Th ree placebo-controlled studies showed the eff ectiveness

of this treatment (Anger, 2010) All three used cystoscopic

injection of 200 units of botulinum toxin A toxin versus

placebo, and each demonstrated signifi cant improvement

in incontinence Improvement occurred as early as 4 weeks

after injection (Brubaker, 2008b; Flynn, 2009; Khan, 2010;

Sahai, 2007) Urinary retention—defi ned as a 200-mL

postvoid residual—is a common side eff ect and developed in

27 to 43 percent of patients in these randomized trials Most

patients are asymptomatic, but patients receiving botulinum

toxin A for overactive bladder or urge urinary incontinence

should understand that temporary self-catheterization may be

required after injection

A patient can expect the eff ects of the toxin to wane over

time In a small study describing the need for repeat injections,

20 patients from a cohort of 34 received a second injection, and

9 patients received up to four injections Th ese repeat injections

appear to be equally eff ective as the primary injection Median

time between injections is approximately 377 days (Sahai, 2010)

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CHAPTER 23

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ROLE OF LEVATOR ANI 637

ROLE OF CONNECTIVE TISSUE 639

ROLE OF THE VAGINAL WALL 639

LEVELS OF VAGINAL SUPPORT 640

SYMPTOMS ASSOCIATED WITH PELVIC

Pelvic organ prolapse is a condition of specifi c signs and

symp-toms that lead to impairment of normal function and

dimin-ished quality of life Signs include descent of one or more of the

following: the anterior vaginal wall, posterior vaginal wall, uterus

and cervix, the apex of the vagina after hysterectomy, or the

perineum (Haylen, 2010) Symptoms include vaginal bulging,

pelvic pressure, and splinting or digitation Splinting is manual bolstering of the prolapse to improve symptoms, whereas digita-tion aids stool evacuation For pelvic organ prolapse to be con-sidered a disease state in a given individual, symptoms should

be attributable to pelvic organ descent such that surgical or surgical reduction relieves the symptoms, restores function, and improves quality of life

non-EPIDEMIOLOGY

Pelvic organ prolapse (POP) is a health concern aff ecting lions of women worldwide In the United States, it is the third most common indication for hysterectomy Moreover, a woman has an estimated lifetime risk of 11 percent to undergo surgery for prolapse or incontinence (Olsen, 1997)

mil-Estimation of disease prevalence has been hampered by lack of a consistent defi nition of pelvic organ prolapse If the validated Pelvic Organ Prolapse Quantifi cation (POP-Q) examination alone is used to describe pelvic organ support, 30

to 65  percent of women presenting for routine gynecologic care have stage 2 prolapse (Bland, 1999; Swift, 2000, 2005;

Trowbridge, 2008) In contrast, studies that defi ne prolapse solely based on patient symptoms show a prevalence ranging from 2.9 to 5.7  percent in the United States (Bradley, 2005;

Nygaard, 2008; Rortveit, 2007)

Although data are limited, studies show that the prevalence

of pelvic organ prolapse increases steadily with age (Olsen, 1997; Swift, 2005) Given the condition’s link to age and the changing demographics in the United States, the prevalence of pelvic organ prolapse will undoubtedly grow

RISK FACTORS

Table 24-1 summarizes predisposing factors for pelvic organ

prolapse Researchers agree that its etiology is multifactorial and develops gradually over a span of years Th e relative impor-tance, however, of each factor is not known

634 Female Pelvic Medicine and Reconstructive Surgery

als comparing elective and selective episiotomy have shown no proven benefi t, but have shown an association with anal sphinc-ter laceration, postpartum anal incontinence, and postpartum pain (Carroli, 2000)

Elective Cesarean Delivery

Controversy has arisen over the topic of elective ean delivery to prevent pelvic fl oor disorders such as pelvic organ prolapse and urinary incontinence Th eoretically, if all women underwent cesarean delivery, there would be fewer women with pelvic fl oor disorders Keeping in mind that

cesar-most women do not develop pelvic fl oor disorders, elective

cesarean delivery would subject many women to a potentially dangerous intervention who would otherwise not develop the problem Specifi cally, given the 11-percent lifetime risk of undergoing surgery for incontinence or prolapse, for every one woman who would avoid pelvic fl oor surgery later in life by undergoing primary elective cesarean delivery, nine women would gain no benefi t yet would nevertheless assume the potential risks of the cesarean Most researchers agree that defi nitive recommendations will require further clinical stud-ies to defi ne the potential risks and benefi ts of elective cesar-ean delivery for primary prevention of pelvic fl oor dysfunction (American College of Obstetricians and Gynecologists, 2007;

Patel, 2006) At this point in time, recommendations ing elective cesarean delivery to prevent pelvic fl oor disorders must be individualized

of connective tissues and the extracellular matrix necessary for pelvic organ support Estrogen and progesterone recep-tors have been identifi ed in the nuclei of connective tissue and smooth muscle cells of both the levator ani stroma and utero-sacral ligaments (Smith, 1990, 1993) Separating the eff ects

of estrogen deprivation from the eff ects of the aging process

is problematic

■ Connective Tissue Disease

Women with connective tissue disorders may be more likely

to develop POP Histologic studies have shown that in women with POP, the ratio of collagen I to collagen III and IV is decreased (Moalli, 2004) Th is relative decrease in well-orga-nized dense collagen is believed to contribute to weakening

of vaginal wall tensile strength and an increased ity to vaginal wall prolapse In a small case series study, one third of women with Marfan syndrome and three fourths of women with Ehlers-Danlos syndrome reported a history of POP (Carley, 2000)

susceptibil-■ Obstetric-Related Risks

Multiparity

Vaginal childbirth is the most frequently cited risk factor

Although there is some evidence that pregnancy itself

predis-poses to pelvic organ prolapse, numerous studies have clearly

shown that vaginal delivery increases a woman’s propensity for

developing POP For example, in the Pelvic Organ Support

Study (POSST), increasing parity was associated with advancing

prolapse (Swift, 2005) Specifi cally, the risk of POP increased

1.2 times with each vaginal delivery In the Reproductive Risks

for Incontinence Study at Kaiser (RRISK) study, Rortveit and

colleagues (2007) found that the risk of prolapse increased

sig-nifi cantly in woman with one vaginal delivery (odds ratio [OR]

2.8), two (OR 4.1), or three or more (OR 5.3) deliveries

com-pared with nulliparas

Other Obstetric-related Risks

Although vaginal delivery is implicated in a woman’s lifetime

risk for POP, specifi c obstetric risk factors remain

controver-sial Th ese include macrosomia, prolonged second-stage labor,

episiotomy, anal sphincter laceration, epidural analgesia,

for-ceps use, and oxytocin stimulation of labor Each is a proposed

risk factor, although not defi nitively proven As we await

fur-ther studies, we can anticipate that although each may have an

important eff ect, it is the cumulative sum of all events

occur-ring as the fetus traverses the birth canal that predisposes to

POP

Currently, two obstetric interventions—elective forceps

delivery to shorten second-stage labor and elective

episi-otomy—are not advocated because of a lack of evidence of

benefi t and their potential for maternal and fetal harm First,

forceps delivery is directly implicated in pelvic fl oor injury

through its known association with anal sphincter laceration

Secondly, evidence of pelvic fl oor benefi ts from shortening

the second stage of labor is lacking For these reasons, elective

forceps delivery is not recommended for prevention of pelvic

fl oor disorders Likewise, at least six randomized controlled

Organ ProlapsePregnancy

Vaginal childbirth

Menopause

Aging

Hypoestrogenism

Chronically increased intraabdominal pressure

Chronic obstructive pulmonary disease (COPD)

CHAPTER 24

■ Race

Racial diff erences in POP prevalence have been demonstrated in

several studies (Schaff er, 2005) Black and Asian women show

the lowest risk, whereas Hispanic and white women appear to

have the highest risk (Hendrix, 2002; Kim, 2005; Whitcomb,

2009) Although diff erences in collagen content have been

demonstrated between races, racial diff erences in the bony

pel-vis may also play a role For instance, black women more

com-monly have a narrow pubic arch and an android or anthropoid

pelvis Th ese shapes are protective against POP compared with

the gynecoid pelvis typical of most white women

■ Increased Abdominal Pressure

Chronically elevated intraabdominal pressure is believed to play a

role in POP pathogenesis Th is condition is present with obesity,

chronic constipation, chronic coughing, and repetitive heavy

lift-ing Higher body mass index (BMI) has been associated with

POP In the Women’s Health Initiative (WHI) trial, being

over-weight (BMI 25–30 kg/m2) was associated with an increase in

POP of 31 to 39 percent, and obesity (BMI 30 kg/m2) with

an increase of 40 to 75 percent (Hendrix, 2002) With regard

to lifting, a Danish study demonstrated that nursing assistants

who were involved with repetitive heavy lifting were at increased

risk to undergo surgical intervention for prolapse, with an odds

ratio of 1.6 (Jorgensen, 1994) In addition, cigarette smoking

and chronic obstructive pulmonary disease (COPD) have also

been implicated in the development of POP (Gilpin, 1989;

Olsen, 1997) In a matched case-control study, it was found that

chronic pulmonary disease was associated with an increased risk

of future pelvic fl oor repair after hysterectomy (Blandon, 2009)

Th e repetitive increases in intraabdominal pressure resulting

from chronic coughing may predispose to POP Some believe

that the inhaled chemical compounds in tobacco may cause

tis-sue changes that lead to POP rather than the chronic cough itself

(Wieslander, 2005)

DESCRIPTION AND CLASSIFICATION

■ Visual Descriptors

Pelvic organ prolapse is descent of the anterior vaginal wall,

posterior vaginal wall, uterus (cervix), the apex of the vagina

after hysterectomy, or the perineum, alone or in combination

Th e terms cystocele, cystourethrocele, uterine prolapse, uterine

procidentia, rectocele, and enterocele have traditionally been used

to describe the structures behind the vaginal wall thought to be

prolapsed (Fig 24-1) However, these terms are imprecise and

misleading, as they focus on what is presumed to be prolapsed

rather than what is actually seen

Although these terms are deeply entrenched in the

litera-ture, it is more clinically useful to describe prolapse in terms

of what one actually sees: anterior vaginal wall prolapse,

api-cal vaginal wall prolapse, cerviapi-cal prolapse, posterior vaginal

wall prolapse, perineal descent, and rectal prolapse Th ese

descriptors do not presuppose what is behind the vaginal

wall, but rather describe the tissues that are objectively noted

to be prolapsed

Anterior vaginal wall prolapse

Distal posterior wall prolapse

Apical posterior wall prolapse

A

Normal female pelvic anatomy

Uterus Bladder Urethra Vagina

Rectum

Prolapse of small bowel

636 Female Pelvic Medicine and Reconstructive Surgery

■ Pelvic Organ Prolapse

Quantification (POP-Q)

In 1996, the International Continence Society defi ned a

sys-tem of Pelvic Organ Prolapse Quantifi cation (POP-Q) (Bump,

1996) Demonstrating high intra- and interexaminer

reliabil-ity, the POP-Q system is a major advance in studying prolapse

It allows researchers to report fi ndings in a standardized, easily

reproducible fashion Th is system contains a series of

site-spe-cifi c measurements of a woman’s pelvic organ support Prolapse

in each segment is measured relative to the hymen, which is a

anatomic landmark that can be identifi ed consistently Six

points are located with reference to the plane of the hymen:

two on the anterior vaginal wall (points Aa and Ba), two in

the apical vagina (points C and D), and two on the posterior

vaginal wall (points Ap and Bp) (Fig 24-2) Th e genital

hia-tus (Gh), perineal body (Pb), and total vaginal length (TVL)

are also measured All POP-Q points, except TVL, are

mea-sured during patient Valsalva and should refl ect maximum

protrusion

Anterior Vaginal Wall Points

the anterior vaginal wall and is 3 cm proximal to the external

urethral meatus Th is corresponds to the proximal location of

the urethrovesical crease In relation to the hymen, this point’s

position ranges, by defi nition, from 3 (normal support) to

3 cm (maximum prolapse of point Aa)

any part of the upper anterior vaginal wall, that is, the segment

of vagina that normally would extend cephalad from point Aa

It is 3 cm in the absence of prolapse In a woman with total

vaginal eversion posthysterectomy, Ba would have a positive

value equal to the position of the cuff from the hymen

TVLBa

Aa

CD

Bp Ap

GhPb

FIGURE 24-2 Drawing displays the anatomic landmarks used

dur-ing pelvic organ prolapse quantification (POP-Q)

Apical Vaginal Points

the proximal vagina, represent the most proximal locations of a normally positioned lower reproductive tract Point C defi nes

a point that is at either the most distal edge of the cervix or the leading edge of the vaginal cuff after total hysterectomy

of the posterior fornix in a woman who still has a cervix It is omitted in the absence of a cervix Th is point represents the level of uterosacral ligament attachment to the proximal poste-rior cervix and thus diff erentiates uterosacral-cardinal ligament support failure from cervical elongation Th e total vaginal length

(TVL) is the greatest depth of the vagina in centimeters when point C or D is reduced to its fullest position

Posterior Vaginal Wall Points

poste-rior vaginal wall that lies 3 cm proximal to the hymen Relative

to the hymen, this point’s range of position is by defi nition 3 (normal support) to 3 cm (maximum prolapse of point Ap)

any part of the upper posterior vaginal wall By defi nition, this point is at 3 cm in the absence of prolapse In a woman with total vaginal eversion posthysterectomy, Bp would have a posi-tive value equal to the position of the cuff from the hymen

hymen, remaining measurements include those of the genital hiatus (Gh) and the perineal body (Pb) (see Fig 24-2) Th e genital hiatus is measured from the middle of the external ure-thral meatus to the midline of the posterior hymenal ring Th e perineal body is measured from the posterior margin of the genital hiatus to the midanal opening

Assessment with POP-Q

With the hymenal plane defi ned as zero, the anatomic position

of these points from the hymen is measured in centimeters

Points above or proximal to the hymen are described with a negative number Positions below or distal to the hymen are noted using a positive number Th e point measurements can be organized using a three-by-three grid as shown in Figure 24-3

Figures 24-4 and 24-5 illustrate the use of POP-Q in evaluating

diff erent examples of POP

Th e degree of prolapse can also be quantifi ed using a fi stage ordinal system as summarized in Table 24-2 (Bump, 1996) Stages are assigned according to the most severe portion

ve-of the prolapse

■ Baden-Walker Halfway System

Th is descriptive tool is also used to classify prolapse during ical examination and is in widespread clinical use Although not

phys-as informative phys-as the POP-Q, it is adequate for clinical use if each compartment (anterior, apical, and posterior) is evaluated (Table 24-3) (Baden, 1972)

CHAPTER 24

PATHOPHYSIOLOGY

Pelvic organ support is maintained by complex interactions among the pelvic fl oor muscles, pelvic fl oor connective tissue, and vaginal wall Th ese work in concert to provide support and also maintain normal physiologic function of the vagina, urethra, bladder, and rectum Several factors are believed to be involved in pelvic organ support failure Th ese include genetic predisposition, loss of pelvic fl oor striated muscle support, vaginal wall weakness, and loss of connective attachments between the vaginal wall and the pelvic fl oor muscles and pel-vic viscera

Although multiple mechanisms have been hypothesized as contributors to the development of prolapse, none fully explain the origin and natural history of this process Epidemiologic stud-ies indicate that vaginal birth and aging are two major risk fac-tors for the development of pelvic organ prolapse (Mant, 1997)

Th e loss of support that evolves decades after vaginal delivery may stem from an initial insult compounded by aging and other factors

■ Role of Levator Ani Muscle

Th e levator ani muscle is a pair of striated muscles comprised of three regions Th e iliococcygeal portion forms a fl at horizontal shelf spanning from one pelvic sidewall to the other (Figs 38-7 and 38-8, p 1178) Th e pubococcygeus muscle arises from the pubic bone on either side; is attached to the walls of the vagina, urethra, anus, and perineal body; and inserts on the coccyx Th e pubococcygeus muscle thereby is important in suspending the vaginal wall to the pelvis Th e third portion of the levator ani muscle, the puborectalis muscle, forms a sling that originates from the pubic bone Th is wraps around and behind the rec-tum extending to the external anal sphincter Connective tissue covers the superior and inferior fascia of the levator muscles

In the healthy state, baseline resting contractile activity of the levator ani muscles elevates the pelvic fl oor and compresses the vagina, urethra, and rectum toward the pubic bone (Fig 38-10,

p 926) Th is narrows the genital hiatus and prevents prolapse

of the pelvic organs

perineal body

anterior wall

cervix or cuff

total vaginal length

posterior fornix

Bp

Ba C

a A

B A

FIGURE 24-5 Grid and drawing of an anterior support defect

(A) and posterior support defect (B) in patients with prior

hysterectomy (From Bump, 1996, with permission.)

Bp

Bp

Ap

BaAa

Hymeneal ringSymphysis pubis

FIGURE 24-4 POP-Q depiction of varying degrees of uterine

prolapse (A–C)

638 Female Pelvic Medicine and Reconstructive Surgery

tial denervation of the levator ani Denervated muscle loses tone and the genital hiatus opens, thereby leading to pelvic vis-cera prolapse (DeLancey, 1993; Harris, 1990; Peschers, 1997;

Shafi k, 2000)

Experimental evidence for the relationship between vation-induced injury of the levator ani and pelvic organ pro-lapse has been diffi cult to obtain Investigations using direct assessment of levator ani muscles are not in agreement regard-ing neuromuscular damage in women with pelvic organ pro-lapse Whereas some studies demonstrate histomorphologic abnormalities in the levator ani muscle from women with pro-lapse and stress incontinence, other studies fail to fi nd histo-logic evidence of levator ani muscle denervation (Gilpin, 1989;

dener-Hanzal, 1993; Heit, 1996; Koelbl, 1989) In addition, tor ani muscle biopsies obtained from parous and nulliparous cadavers failed to fi nd evidence of atrophy or other important muscle changes (Boreham, 2009) Th is suggests that pregnancy and parturition have little or no eff ect on levator ani muscle histomorphology

leva-Additionally, experimental denervation of the levator ani muscle in the squirrel monkey led to signifi cant muscular atro-phy but did not aff ect pelvic organ support Taken together, experimental evidence does not support a role for denervation-induced injury in the pathophysiology of pelvic organ prolapse

Importantly, however, loss of skeletal muscle volume and function occurs in virtually all striated muscles during aging

Results obtained from young and older women with pelvic organ prolapse indicate that the levator ani muscle undergoes substantial morphologic and biochemical changes during aging

Th us, loss of levator tone with age may contribute to pelvic organ support failure in older women, possibly those with pre-existing defects in connective tissue support As striated muscles lose tone, ligamentous and connective tissue support of the pel-vic organs must sustain more forces conferred by abdominal

When the levator ani muscle has normal tone and the vagina

has adequate depth, the upper vagina lies nearly horizontal in

the standing female Th is creates a “fl ap-valve” eff ect in which

the upper vagina is compressed against the levator plate during

periods of increased intraabdominal pressure It is theorized that

when the levator ani muscle loses tone, the vagina drops from a

horizontal to a semivertical position (Fig 38-11, p 926) Th is

widens or opens the genital hiatus and predisposes pelvic viscera

to prolapse Without adequate levator ani support, the visceral

fascial attachments of the pelvic contents are placed on tension

and are thought to stretch and eventually fail

Changes to the Levator Ani Muscle

It is widely believed that the levator ani muscles sustain either

direct muscle or denervation injury during childbirth and that

these injuries are involved in the pathogenesis of pelvic organ

prolapse It is hypothesized that during second-stage labor,

nerve injury from stretch or compression or both leads to

Stage 0: No prolapse is demonstrated Points Aa, Ap, Ba, and Bp are all at 3 cm, and either point C or D is

between TVL (total vaginal length) cm and (TVL−2) cm (i.e., the quantitation value for point C or

D is [TVL−2] cm) Figure 24–2 represents stage 0Stage I: The criteria for stage 0 are not met, but the most distal portion of the prolapse is 1 cm above the level of

the hymen (i.e., its quantitation value is 1 cm) Stage II: The most distal portion of the prolapse is 1 cm proximal to or distal to the plane of the hymen (i.e., its

quantitation value is 1 cm but 1 cm)Stage III: The most distal portion of the prolapse is 1 cm below the plane of the hymen but protrudes no further

than 2 cm less than the total vaginal length in centimeters (i.e., its quantitation value is 1 cm but [TVL−2] cm) Figure 24–5A represents stage III Ba and Figure 24–5B represents stage III Bp prolapse

Stage IV: Essentially, complete eversion of the total length of the lower genital tract is demonstrated The distal

portion of the prolapse protrudes to at least (TVL−2) cm (i.e., its quantitation value is [TVL−2] cm) In most instances, the leading edge of stage IV prolapse will be the cervix or vaginal cuff scar Figure 24–4C represents stage IV prolapse

From Bump, 1996, with permission

Evaluation of Pelvic Organ Prolapse During Physical Examinationa

Grade

Grade 0 Normal position for each respective site

Grade 1 Descent halfway to the hymen

Grade 2 Descent to the hymen

Grade 3 Descent halfway past the hymen

Grade 4 Maximum possible descent for each site

aDescent of the anterior vaginal wall, posterior vaginal

wall, or apical prolapse can be graded with this system

From Baden, 1992, with permission

CHAPTER 24

abundant elastic fi bers, and neurovascular bundles (Fig 24-6)

Th e muscularis and adventitial layers together form the fi muscular layer, which was previously referred to as “endopelvic fascia.” Th e fi bromuscular layer coalesces laterally and attaches

bro-to the arcus tendineus fascia pelvis and superior fascia of the levator ani muscle In the lower third of the vagina, the vagi-nal wall is attached directly to the perineal membrane and the perineal body Th is suspensory system, together with the utero-sacral ligaments, prevents the vagina and uterus from descent when the genital hiatus is open

Abnormalities in the anatomy, physiology, and cellular ogy of vaginal wall smooth muscle may contribute to POP

biol-Specifi cally, in fi bromuscular tissue taken at the vaginal apex from both the anterior and posterior vaginal walls, vaginal prolapse is associated with loss of smooth muscle, myofi broblast activation, abnormal smooth muscle phenotype, and increased protease activity (Boreham, 2001, 2002a,b; Moalli, 2005; Phillips, 2006)

Additionally, abnormal synthesis or degradation of vaginal wall collagen and elastin fi bers appears to contribute to prolapse

■ The Defect Theory of Pelvic Organ Prolapse

Th is theory states that tears in diff erent sites of the “endopelvic fascia” surrounding the vaginal wall allow herniation of the pelvic organs Th e association of POP with vaginal delivery is consis-tent with this theory However, the microscopic anatomy of the vaginal wall illustrates that endopelvic fascia does not exist as a specifi c anatomic tissue, but rather represents the fi bromuscular layer of the vaginal wall, that is, vaginal muscularis and adventitia (Boreham, 2001)

Most researchers agree that vaginal delivery predisposes women to POP However, there is less agreement regarding changes in the pelvic musculature and vaginal wall that result in prolapse Nichols and Randall (1989) proposed an attenuation

of the vaginal wall without loss of fascial attachments Th ey

pressure As connective tissues bear these loads for long periods,

they stretch and may eventually fail, resulting in prolapse

■ Role of Connective Tissue

A continuous interdependent system of connective tissues and

ligaments surrounds the pelvic organs and attaches them to the

levator ani muscle and bony pelvis Th e connective tissue of

the pelvis is comprised of collagen, elastin, smooth muscle, and

microfi bers, which are anchored in an extracellular matrix of

polysaccharides Th e connective tissue that invests the pelvic

viscera provides substantial pelvic organ support

Th e arcus tendineus fascia pelvis is a condensation of the

pari-etal fascia covering the medial aspects of the obturator internus

and levator ani muscles (Fig 38-7, p 924) It provides the

lat-eral and apical anchor sites for the anterior and posterior vagina

Th e arcus tendineus fascia pelvis is therefore poised to withstand

descent of the anterior vaginal wall, vaginal apex, and proximal

urethra. Experts now believe that a major inciting factor for

pro-lapse is loss of connective tissue support at the vaginal apex

lead-ing to stretchlead-ing or tearlead-ing of the arcus tendineus fascia pelvis

Th e result is apical and anterior vaginal wall prolapse

Th e uterosacral ligaments contribute to apical support by

sus-pending and stabilizing the uterus, cervix, and upper vagina Th e

ligament is comprised of approximately 20 percent smooth

mus-cle Several studies have shown a decrease in the fractional area

and distribution of smooth muscle in the uterosacral ligaments of

women with prolapse (Reisenauer, 2008; Takacs, 2009) Th ese

studies suggest that abnormalities in uterosacral ligament support

of the pelvic organs contribute to the development of prolapse

Abnormalities of connective tissue and connective tissue

repair may predispose women to prolapse (Norton, 1995;

Smith, 1989) As noted, women with connective tissue

dis-orders such as Ehlers-Danlos or Marfan syndrome are more

likely to develop POP and urinary incontinence (Carley, 2000;

Norton, 1995)

Th e fascia and connective tissues of the pelvic fl oor may also

lose strength consequent to aging and loss of neuroendocrine

signaling in pelvic tissues (Smith, 1989) Estrogen defi ciency

can aff ect the biomedical composition, quality, and quantity

of collagen Estrogen infl uences collagen content by increasing

synthesis or decreasing degradation Exogenous estrogen

supple-mentation has been found to increase the skin collagen content

in postmenopausal women who are estrogen defi cient (Brincat,

1983) Moreover, estrogen supplementation prior to prolapse

surgery and/or postoperatively is considered essential by many

pelvic reconstruction surgeons Although this practice may seem

logical and empirically sound, no evidence supports improved

surgical outcomes with this use of adjuvant estrogen

■ Role of the Vaginal Wall

Abnormalities in the vaginal wall and its attachments to the

pelvic fl oor muscles may be involved in the pathogenesis of

pelvic organ prolapse Th e vaginal wall is comprised of mucosa

(epithelium and lamina propria), a fi broelastic muscularis layer,

and an adventitial layer that is composed of loose areolar tissue,

Epithelium Mucosa

Muscularis

Lamina propria

FIGURE 24-6 Photomicrograph shows a cross section of the vaginal wall Mucosal and muscularis layers are shown here

The adventitia, which is typically seen deep to muscularis, is not shown in this section The fibromuscular layer is comprised of

muscularis and adventitial layers (Photograph contributed by

Dr Ann Word.)

640 Female Pelvic Medicine and Reconstructive Surgery

Level II Support

Th is support consists of the paravaginal attachments that are contiguous with the cardinal/uterosacral complex at the ischial spine Th ese are the connective tissue attachments of the lateral vagina anteriorly to the arcus tendineus fascia pelvis and poste-riorly to the arcus tendineus rectovaginalis Detachment of this connective tissue from the arcus tendineus fascia pelvis leads to lateral or paravaginal anterior vaginal wall prolapse

Level III Support

Th e perineal body, superfi cial and deep perineal muscles, and

fi bromuscular connective tissue comprise level III Collectively, these support the distal one third of the vagina and introitus

Th e perineal body is essential for distal vaginal support and proper function of the anal canal Damage to level III support contributes to anterior and posterior vaginal wall prolapse, gaping introitus, and perineal descent

term prolapse of this type as distension cystocele or rectocele

(Fig 24-7) In contrast, anterior and posterior wall defects due

to loss of the connective tissue attachment of the lateral vaginal

wall to the pelvic side wall are described as displacement

(para-vaginal) cystocele or rectocele (Fig 24-8) With

distension-type prolapse, the vaginal wall appears smooth and without

rugae, due to attenuation With displacement-type prolapse,

vaginal rugae are visible Both defect types could result from

the stretching or tearing of support tissues during second-stage

labor

Many experts now believe the primary “defect” leading to

prolapse is often loss of support at the vaginal apex Although

this results in descent of the apical portions of the anterior and

posterior vaginal walls, resuspension of the vaginal apex will

restore support to both the anterior and posterior walls

■ Levels of Vaginal Support

Th e vagina consists of a fi bromuscular, fl attened, cylindrical tube

with three levels of support, as described by DeLancey (1992)

Level I support suspends the upper or proximal vagina Level

II support attaches the midvagina along its length to the arcus

tendineus fascia pelvis Level III support results from fusion of

the distal vagina to adjacent structures Defects in each level

of support result in identifi able vaginal wall prolapse: apical,

anterior, and posterior

Level I Support

Th is level consists of the cardinal and uterosacral ligaments

attachment to the cervix and upper vagina (Fig 38-15, p 931)

Th e cardinal ligaments fan out laterally and attach to the parietal

FIGURE 24-7 Photograph shows midline or distension cystocele

Note the characteristic loss of vaginal wall rugae

FIGURE 24-8 Photograph shows a lateral cystocele, also termed paravaginal or displacement cystocele Rugae are present, which indicates that loss of support is lateral rather than central

CHAPTER 24

symptoms—pelvic pressure, the feeling of sitting on a ball, or heaviness in the vagina—are most likely to correlate with pro-lapse Other symptoms, such as back pain, constipation, and abdominal discomfort, may exist in conjunction with prolapse but not result from it A thorough history and physical exami-nation will often help delineate the relationship between POP and symptoms

During symptom inventory, several tools may be useful in assessing severity Two commonly used questionnaires are the Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ) (Barber, 2005b) Th e PFDI assesses urinary, colorectal, and prolapse symptoms, whereas the PFIQ assesses the impact of prolapse on quality of life (Tables 24-5 and 24-6)

EVALUATION OF THE PATIENT WITH PELVIC

ORGAN PROLAPSE

■ Symptoms Associated with Pelvic

Organ Prolapse

Pelvic organ prolapse involves multiple anatomic and

func-tional systems Th us, POP is commonly associated with

genito-urinary, gastrointestinal, and musculoskeletal symptoms (Table

24-4) Prolapse rarely results in severe morbidity or mortality,

however, it can greatly diminish quality of life Th erefore, initial

evaluation must include a careful assessment of prolapse-related

symptoms and their eff ect on activities of daily living

Symptoms should be carefully reviewed to determine if

they are caused by the prolapse or by other etiologies “Bulge”

Bulge symptoms

Sensation of vaginal bulging or protrusion

Seeing or feeling a vaginal or perineal bulge

Pelvic or vaginal pressure

Heaviness in pelvis or vagina

Rectal prolapseVulvar or vaginal cyst/massPelvic mass

Hernia (inguinal or femoral)Urinary symptoms

Feeling of incomplete emptying

Manual reduction of prolapse to start or complete voiding

Position change to start or complete voiding

Urethral sphincter incompetenceDetrusor overactivity

Hypoactive detrusor functionBladder outlet obstruction (i.e., postsurgical)Excessive fluid intake

Interstitial cystitisUrinary tract infection

Bowel symptoms

Incontinence of flatus or liquid/solid stool

Feeling of incomplete emptying

Hard straining to defecate

Urgency to defecate

Digital evacuation to complete defecation

Splinting vagina or perineum to start or complete defecation

Feeling of blockage or obstruction during defecation

Anal sphincter disruption or neuropathyDiarrheal disorder

Rectal prolapseIrritable bowel syndromeRectal inertia

Pelvic floor dyssynergiaHemorrhoids

Anorectal neoplasmSexual symptoms

Other female sexual disorderPain

Pain in vagina, bladder, or rectum

Pelvic pain

Low back pain

Interstitial cystitisLevator ani syndromeVulvodynia

Lumbar disc diseaseMusculoskeletal painOther causes of chronic pelvic pain (Table 11-2, p 309)

Adapted from Barber, 2005a, with permission

SECTION 3

Please select the best answer to each question below

Name

Has your prolapse affected your:

1 Ability to do household chores (cooking, house cleaning, laundry)?

2 Physical recreation such as walking, swimming, or other exercises?

3 Entertainment activities (movies, church)?

4 Ability to travel by car or bus more than 30 minutes from home?

5 Participation in social activities outside your home?

6 Emotional health (nervousness, depression)?

7 Feeling frustrated?

From Flynn, 2006, with permission

POPDI—6

Do you usually , and if so how much are you bothered by:

1 experience pressure in the lower abdomen

2 experience heaviness or dullness in the abdomen or genital area

3 have a bulge or something falling out that you can see or feel in the vaginal area

4 have to push on the vagina or around the rectum to have or complete a bowel movement

5 experience a feeling of incomplete bladder emptying

6 have to push up on a bulge in the vaginal area with your fingers to start or complete urination

CRADI—8

, and if so how much are you bothered by it?

1 Do you usually feel you need to strain too hard to have a bowel movement

2 Do you usually feel you have not completely emptied your bowels at the end of bowel movement

3 Do you usually lose stool beyond your control if your stool is well formed

4 Do you usually lose stool beyond your control if your stool is loose or liquid

5 Do you usually lose gas from the rectum beyond your control

6 Do you usually have pain when you pass your stool

7 Do you usually experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement

8 Does part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement

UDI—8

Do you usually have , and if so, how much are you bothered by:

1 frequent urination

2 leakage related to feeling of urgency

3 leaking related to activity, coughing, or sneezing

4 leakage when you go from sitting to standing

5 small amounts of urine leakage (i.e., drops)

6 difficulty emptying the bladder

7 pain or discomfort in the lower abdomen or genital area

8 pain in the middle of your abdomen as your bladder fills

aFor each question, patients fill in the blank with each phrase underneath the question The same multiple choice

responses (not at all, mildly, moderately, and severely) used for the PFIQ-7 are used for the PFDI-22

From Flynn, 2006, with permission

CHAPTER 24

Th e need for digital decompression of the posterior vaginal wall, the perineal body, or the distal rectum to evacuate the rectum is the most common defecatory symptom associated with posterior vaginal wall prolapse (Barber, 2003; Burrows, 2004; Ellerkmann, 2001) Surgical approaches to this problem result in variable success, with symptom resolution rates as low

as 36 percent (Kenton, 1999)

Anal incontinence of fl atus, liquid, or solid stool may also

be seen in conjunction with POP On occasion, prolapse may lead to stool trapping in the distal rectum with subsequent leak-age of liquid stool around retained feces If symptoms are pres-ent, a full anorectal evaluation should be performed (Chap 25,

p 662) Most types of anal incontinence would not be expected

to improve with surgical repair of prolapse However, if tion reveals an anal sphincter defect as the cause of anal incon-tinence, anal sphincteroplasty may be performed concurrently with prolapse repair

evalua-Female Sexual Dysfunction

Female sexual dysfunction is present in women with reunia, low libido, problems with arousal, and inability to achieve orgasm Th e etiology is frequently multifactorial and includes psychosocial factors, urogenital atrophy, aging, and male sexual dysfunction (Chap 13, p 377) Sexual dysfunc-tion is often also seen in women with POP However, fi nd-ings from studies evaluating sexual function in women with prolapse are inconsistent In one study, a validated sexual function questionnaire was used to compare frequency

dyspa-of intercourse, libido, dyspareunia, orgasmic function, and vaginal dryness in women with and without prolapse (Weber, 1995) No diff erences were seen between the two groups In another cross-sectional study of 301 women seeking gyneco-logic care, pelvic fl oor symptoms were associated with dys-pareunia, reduced arousal, and infrequent orgasm (Handa, 2008) In addition, sexual dysfunction was worse in women with symptomatic prolapse versus those with asymptomatic prolapse

Accordingly, women with an obstructing bulge as a cause of sexual dysfunction may benefi t from therapy to reduce the pro-lapse Unfortunately, some prolapse procedures such as poste-rior repair with levator plication and vaginal placement of mesh may contribute to postoperative dyspareunia Th erefore, care should be taken in planning appropriate surgical procedures for women with concomitant sexual dysfunction

Pelvic and Back Pain

Many patients with pelvic organ prolapse complain of pelvic and low back pain, but little evidence supports a direct associa-tion A cross-sectional study of 152 consecutive patients with POP did not fi nd an association between pelvic or low back pain and prolapse after controlling for age and prior surgery (Heit, 2002) Swift and colleagues (2003) found that back and pelvic pain were common among 477 women presenting for routine annual gynecologic examination and had no relation-ship to POP

Some suggest that low back pain in a patient with prolapse may be caused by altered body mechanics However, if pain is

Treatment is symptom-directed, and in the absence of

symp-toms, prolapse generally does not require therapy However, for

those with complaints, treatment may include both nonsurgical

and surgical therapy

Bulge Symptoms

Th e complaints most strongly associated with prolapse are the

sensation or visualization of a vaginal or perineal protrusion,

and the sensation of pelvic pressure Women may comment

on feeling a ball in the vagina, sitting on a weight, or noting

a bulge rubbing against their clothes Th ese symptoms worsen

with prolapse progression (Ellerkmann, 2001) Specifi cally,

women with prolapse beyond the hymen are more likely to

report a vaginal bulge and have more symptoms than those

with prolapse above the hymen (Barber, 2005a; Bradley, 2005;

Swift, 2000; Tan, 2005; Weber, 2001a) If bulge symptoms are

the primary complaint, successful replacement of the prolapse

with nonsurgical or surgical therapy will usually provide

ade-quate treatment

Urinary Symptoms

Patients with POP often have concurrent urinary symptoms

Th ese may include stress urinary incontinence (SUI), urge

uri-nary incontinence, frequency, urgency, uriuri-nary retention,

recur-rent urinary tract infection, or voiding dysfunction Although

these symptoms may be caused or exacerbated by prolapse, it

should not be assumed that surgical or nonsurgical correction of

prolapse will be curative For example, irritative bladder

symp-toms (frequency, urgency, and urge urinary incontinence) do

not reliably improve with replacement of prolapse and

some-times worsen after surgical management Moreover, they may

be unrelated to the prolapse and require alternative therapy

In contrast, urinary retention has been found to improve with

prolapse treatment if the symptom is due to an obstructed

ure-thra (FitzGerald, 2000)

For these reasons, urodynamic testing is a valuable adjunct

in women with urinary symptoms who are undergoing

treat-ment of prolapse (Chap 23, p 621) Th is testing attempts

to determine the relationship between urinary symptoms and

POP and will help guide therapy Additionally,

consider-ation may also be given to temporarily placing a pessary prior

to surgery to determine if urinary symptoms improve Th is

may predict whether surgical reduction of prolapse will be

benefi cial

Gastrointestinal Symptoms

Constipation is often present in women with pelvic organ

pro-lapse, although it is generally not caused by POP Th us, surgical

repair or treatment with a pessary will not usually cure

con-stipation and may actually worsen it In one study of

defect-directed posterior repair, constipation resolved postoperatively

in only 43 percent of patients (Kenton, 1999) Th erefore, if a

patient’s primary symptom is constipation, treatment of

pro-lapse may not be indicated Constipation should be viewed

as a problem distinct from prolapse and evaluated separately

(Chap. 25, p 669)

644 Female Pelvic Medicine and Reconstructive Surgery

■ Physical Examination

Physical examination begins with a full body systems evaluation

to identify pathology outside the pelvis Systemic conditions such as cardiovascular, pulmonary, renal, or endocrinologic disease may aff ect treatment choices and should be identifi ed early

Perineal Examination

Initial pelvic examination is performed with a woman in lithotomy position Th e vulva and perineum are examined for signs of vulvar or vaginal atrophy, lesions, or other abnormali-ties A neurologic examination of sacral refl exes is performed

using a cotton swab First, the bulbocavernosus refl ex is elicited

by tapping or stroking lateral to the clitoris and observing traction of the bulbocavernosus muscle bilaterally Secondly, evaluation of anal sphincter innervation is completed by strok-ing lateral to the anus and observing a refl exive contraction of

con-the anus, known as con-the anal wink refl ex Intact refl exes

sug-gest normal sacral pathways However, they may be absent in women who are neurologically intact, due to false-negative testing

Pelvic organ prolapse examination begins by asking a woman to attempt Valsalva maneuver prior to placing a spec-ulum in the vagina (Fig 24-9) Patients who are unable to adequately complete a Valsalva maneuver are asked to cough

Th is “hands-off ” approach more accurately displays true omy With speculum examination, structures are artifi cially lifted, supported, or displaced Importantly, this assessment helps answer three questions: (1) Does the protrusion come beyond the hymen? (2) What is the presenting part of the prolapse (anterior, posterior, or apical)? (3) Does the geni-tal hiatus signifi cantly widen with increased intraabdominal pressure?

anat-a primanat-ary symptom, other sources should be sought (Chanat-ap 11,

p 309) In the absence of an identifi able etiology, temporary

pessary placement is often benefi cial to determine whether

prolapse reduction will improve pain symptoms Referral to a

physical therapist may also shed light on a connection among

prolapse, altered body mechanics, and pain

Asymptomatic Women

Many women with mild to advanced prolapse lack bothersome

symptoms Because the natural history of prolapse is unknown,

it is diffi cult to predict if prolapse will worsen or if symptoms

will develop In this situation, benefi ts of treatment should be

balanced against risk Th erefore, in the absence of other

fac-tors, invasive therapy is typically not selected for asymptomatic

women Pelvic fl oor muscle rehabilitation may be off ered to a

patient seeking to prevent prolapse progression However, no

data support the eff ectiveness of this practice (Adams, 2004;

Hagen, 2004)

Comparing Symptoms to Degree and

Location of Prolapse

Although POP has been associated with several diff erent types

of symptoms, the presence and severity of symptoms does not

always correlate well with advancing stages of prolapse In

addi-tion, many common symptoms do not diff erentiate between

compartments Several studies have shown a poor

predic-tive value among symptoms, the degree of their severity, and

the degree of prolapse in a particular vaginal compartment

(Ellerkmann, 2001; Jelovsek, 2005; Kahn, 2005; Weber, 1998)

Th us, when planning surgical or nonsurgical therapy, realistic

expectations should be set with regard to relief of symptoms A

patient should be informed that some symptoms cannot

pre-dictably be improved

FIGURE 24-9 Photographs of vaginal wall prolapse A. Stage 2 This stage is defined by the most distal edge of the prolapse lying within

1 cm of the hymenal ring B. Stage 3 This stage is defined by the most distal portion of the prolapse being 1 cm below the plane of

the hymen, but protruding no farther than 2 cm less than the total vaginal length in centimeters C. Stage 4 This stage is defined as

complete or near complete eversion of the vaginal wall

Sahai, 20 07) Urinary retention—defi ned as a 20 0-mL

postvoid residual—is a common side eff ect and developed in

27 to 43 percent... 113:1377, 20 06

Abrams P, Artibani W, Cardozo L, et al: Reviewing the ICS 20 02 terminology

report: the ongoing debate Neurourol Urodyn 28 (4) :28 7, 20 09... incontinence J Reprod Med 47:559, 20 02< /small>

CHAPTER 23

Laurikainen