DELA ROSA, KAE CEE WHITE E.
ANATOMIC DEFECT OF THE ABDOMINAL WALL AND PELVIC FLOOR
● The abdominal wall is made up of the following structures
beginning externally: skin; subcutaneous connective tissue;
external oblique, internal oblique, and transversus abdominis
muscles with their investing fascia; and parietal peritoneum.
● The rectus abdominis muscles run longitudinally in the midline
from the xiphoid to the pubic symphysis.
● The investing fasciae of the external oblique, internal oblique,
and transversus abdominis muscles completely encase the
rectus abdominis muscles cephalad to the semilunar line.
● Caudally from the semilunar line the muscle is completely
behind the aponeurosis of the fasciae of these muscles and
lies directly on the peritoneum
● Normally the investing fasciae join in the midline after
surrounding the rectus abdominis muscles.
● In the male the descent of the testes from their original retro-
peritoneal site to the scrotum necessitates passing through the
abdominal wall to the inguinal region.
● At the level of the transversalis fascia where the descent
begins, the internal inguinal ring is formed.
● The medial margin of this ring is defined by the inferior
epigastric artery as it courses from the external iliac artery
medially and superiorly into the rectus sheath. The ingui- nal
canal runs from the internal inguinal ring obliquely down- ward,
emerging through the external inguinal ring and opening in the
external oblique aponeurosis just above the pubic spine and
then continuing into the scrotum. This allows for passage of the
testes and for the presence of part of the spermatic cord.
● In the female the round ligament courses in the same direction
but ends short of the labia.
● An inguinal hernia, that is, a bulge of peritoneum through the
internal inguinal ring and into the inguinal canal, is less
common in the female than in the male and is frequently
identified after stretching of the abdominal wall during or after
pregnancy. It may be related to a congenital weakness of this
area.
● Femoral-type groin hernia
the defect in the transversalis fascia occurs in Hesselbach’s
triangle, which is an area bounded laterally by the inferior
epigastric artery, inferiorly by the inguinal ligament, and
medially by the lateral margin of the rectus sheath (Fig. 20-2).
○ The hernia sac passes under the inguinal ligament
into the femoral triangle rather than coursing
through the inguinal canal.
○ Femoral hernias are more common in females than
in males.
● The hernia is said to be reducible if the contents can be
returned to the abdominal cavity. If the contents cannot be
reduced, the hernia is said to be incarcerated. An incarcerated
hernia may be acute, accompanied by pain, or may be long-
standing and asymptomatic.
● If the blood supply to the incarcerated structure is
compromised, the hernia is said to be strangulated. Because
the hernia sac is primarily prolapsed peritoneum, the hernia
itself is not strangulated but only its contents.
● sliding hernia
○ portion of the wall of the hernia sac is composed of
an organ such as the sigmoid colon or the cecum.
● A ventral hernia occurs in the abdominal wall away from the
groin. Examples include umbilical hernias, which are caused by
congenital relaxation of the umbilical ring, and incisional
hernias, which are herniations through separation of fascial
planes after operative incision. Two special ventral hernias
include the epi- gastric hernia, which occurs in a defect of the
linea alba above the umbilicus, and the rare spigelian hernia,
which is a hernia- tion at a point where the vertical linea
semilunaris joins the lateral border of the rectus muscle.
● Incisional hernias generally involve the separation of the fascia
of the abdominal wall with the hernia sac palpated beneath the
skin and subcutaneous tissue. The sac wall is composed of
peritoneum.
● Because the umbilicus consists of a fusion of skin, fascia, and
peritoneum, an umbilical hernia generally occurs because the
fascial ring is grossly separated, allowing the hernia sac to pro-
trude. This occurs most frequently in obese women. The hernia
sac itself is made up of peritoneum and subcutaneous tissue
 beneath the skin (Fig. 20-3).
Etiology
● Hernias may be the result of a congenital malformation. The
umbilical hernia is the best example.
● Before 10 weeks’ gestation the abdominal contents are partially
herniated through the umbilicus into the extra embryonic
coelomic cavity. However, after 10 weeks the viscera normally
return to the abdominal cavity, and the defect in the abdominal
wall closes during subsequent fetal growth. Generally at birth
only the space occupied by the umbilical cord remains patent.
After the cutting of the cord the area heals so that the skin in
the area of the umbilicus fuses above the closed fascial layer.
Some infants at birth will show a small umbilical hernia, but in
most instances the fascial defect closes during the first 3 years
of life.
● If it does not close, an umbilical hernia will form. In rare cases
the abdominal wall closure process is less complete, leading to
an omphalocele, which is a hernia sac at the umbilicus covered
only by peritoneum and including bowel and other abdominal
contents.
● Omphaloceles are usually seen in infants with other
malformations and possibly chromosome anomalies, such as
trisomy 13.
● Black infants have umbilical hernias more often than do white
infants.
● umbilical hernias occur in adults after the distention of the
abdominal cavity with pregnancy or with ascites.
● Inguinal hernias are more common in males than in females.
● Femoral hernias occur primarily in females.
● Hernias that occur in adults are often associated with trauma or
injury.
● In many instances the hernia bulge develops slowly after years
of heavy labor.
● It is likely that a congenital anatomic defect was always present
but became exaggerated over time, leading to the development
of a hernia. Such lesions resulted from inadequate muscle
support at the lower area of the inguinal canal, primarily caused
by a defect in the internal oblique muscle. Stretching of this
area in pregnancy may initiate a hernia, but other factors, such
as chronic cough caused by smoking or chronic respiratory
disease, may be responsible.
● Incisional hernias generally occur because of poor healing of
the fascia. This may be secondary to poor nutrition, infection,
or necrosis of the fascia secondary to suturing. It may also
occur because absorbable suture loses its tensile strength
before healing is complete. Stress and strain secondary to
chronic cough or retching in the postoperative period may
contribute to the pro- cess. Emergency surgery increases the
risk of incisional hernia. Other conditions that inhibit wound
healing include obesity, smoking, connective tissue disorders,
and immunosuppressant medications.
Symptoms and Signs
● Bulges in the abdominal wall lead to the discovery of most
ventral or groin hernias in women, either by a physician at the
time of physical examination or by the patient. These hernias
are generally symptom free. Occasionally, excessive straining
or trauma will be implicated, and the patient may experience a
feeling of tearing of tissue.
● Frequently the bulges are noted during an increase in
intraabdominal pressure, such as with pregnancy or ascites.
● Most hernias are asymptomatic, but in some cases, particularly
with larger ones, there may be aching or discomfort. Should
intraabdominal organs move into the sac, the patient may
experience some discomfort. Organs that strangulate within the
sac cause acute pain and discomfort. Incarcerated organs may
give nonspecific visceral pain, which is most likely the result of
mesenteric stretching.
● In cases where a hernia exists but no contents are within the
sac, physical examination reveals a weakening at the site of
the hernia. It is often possible to feel the “ring” of the hernia as
one palpates the defect through the skin and subcutaneous
tissue. The patient’s straining will generally accentuate the
hernia, making it more palpable and visible. In the case of
inguinal and femoral hernias it may be necessary for the
patient to be standing for one to palpate the hernia.
● When there are intraabdominal contents within the hernia sac,
the hernia is more easily palpated. The physician should then
decide, based on his or her attempts to gently milk the contents
from the sac back through the defect ring, whether the contents
are reducible. For a hernia that does not reduce easily but in
which there is no evidence of vascular compromise it is
sometimes useful to apply ice packs to the abdomen in the
area of the incarcerated hernia before additional attempts are
made to reduce it. In cases of strangulated hernia, evidence of
devitalization of an organ, such as fever, leukocytosis, and
evidence for an acute abdomen, may be noted.
DISORDERS OF PELVIC SUPPORT
● Pelvic organ prolapse (POP) is a condition characterized by the
failure of various anatomic structures to support the pelvic
viscera.
● POP is common in parous women
● Pelvic support structures are often weakened by childbirth,
other pelvic trauma, stress and strain, and the aging process.
● Abnormalities that result from these relaxation problems
include urethrocele, cystocele, rectocele, enterocele, and
uterine prolapse (descensus of the cervix and uterus).
● If a hysterectomy has been performed, prolapse of the vagina
may also
● be a problem. It is unusual to have only one of these
conditions. In most cases the relaxation affects all the support
structures of the pelvis.
● Frequently, relaxation of the urethra, the bladder neck, and the
bladder (urethrocele, cystocele) is associated with urinary
incontinence,
Pathophysiology
● The pathophysiology of POP is probably multifactorial. (Fig. 20-
5).
● magnetic resonance imaging (MRI) for evaluat- ing healthy
female pelvic anatomy and anatomic variations to compare to
women with pelvic floor dysfunction.
● three-dimensional color thickness mapping
○ muscle atrophy from denervation from childbirth
injuries or muscle wasting from muscle insertion
 detachment also from childbirth, and possibly age
and hormonal status (Fig. 20-6).
● Imaging is not usually necessary in women with prolapse,
Urethrocele and Cystocele
● Attenuation or rupture of the pubovesicle cervical fascia for any
reason may allow the descent of the urethra (urethrocele),
bladder neck, or bladder (cystocele) into the vaginal canal.
Often only a cystocele is present (Fig. 20-7), and generally in
these cases the patient is continent. When a urethrocele is
present as well, the woman usually suffers from stress
incontinence. Urethroceles seem to be more common in
women with wide subpubic arches (gynecoid type), which allow
the full force of the fetal head against this area during descent
in labor. Narrower arches, such as those associated with the
android or anthropoid pelvic types, seem to protect this region
from the descent of the fetal head.
Symptoms and Signs
● Symptoms of POP are often not specific to the area that is
prolapsing.
● sensation of fullness, pressure or vaginal bulge and at times a
feeling that organs are falling out, occasional urgency, and
often a feeling of incomplete emptying with voiding. The patient
and the physician note a soft, bulging mass of the anterior
vaginal wall.
● In some patients this mass must be replaced manually before
the patient can void. Strain or cough accentuates the bulge.
The mass may descend to or beyond the introitus.
● Although urethroceles and cystoceles almost always occur in
parous women, they have been noted in nulliparous women
who have poor structural supports. This is particularly true in
women who have congenital malformations or weaknesses of
the endopelvic connective tissue and muscula- ture of the
pelvic floor. Most parous women demonstrate some degree of
cystocele, and when asymptomatic, they do not require
therapy.
● Women with prolapse often have other urinary symptoms.
Some women have stress incontinence due to urethral
hypermobility. Others are continent despite lack of urethral
support. Another group of women may have occult or latent
stress incontinence because their continence depends on
urethral kinking or obstruction from severe prolapse.
Diagnosis
● The urethrocele and the cystocele are best demonstrated with
a patient in the lithotomy position. A retractor or posterior wall
blade of a Graves speculum is used to depress the posterior
wall. The patient is then asked to strain, and the degree of the
cysto- cele or urethrocele is noted. The physician should
palpate the bladder neck and note whether it is well supported.
● Generally, if the supports of the bladder neck are adequate, the
urethra is adequately supported. If a cystocele and a
urethrocele are present, it invariably follows that the bladder
neck is not supported.
● The examination for cystocele and urethrocele is best
performed with the bladder at least partially filled (100–250
mL).
● Urethroceles must be differentiated from inflamed and enlarged
Skene’s glands and urethral diverticula.
● Cystoceles must be differentiated from bladder tumors and
bladder diverticula, both of which are rare but may occur.
● Urethroceles and cystoceles are generally soft, pliable, and
nontender. Although diverticula may be reducible, a sensation
of a mass is usually present.
● Inflamed Skene’s glands are generally tender, and it may be
possible to express pus from the urethra when they are
palpated. Pus may be expressed also in the presence of a
diverticulum of the urethra. In such cases gonococcal and
chlamydial infections should be considered.
Management
● Treatment of urethroceles and cystoceles may be nonoperative
or operative.
● Nonoperative treatment consists of supporting the herniation of
the bladder into the vagina with the use of the Smith-Hodge,
ring, or inflatable pessary (see Fig. 20-15) or even with the
intermittent use of a large tampon.
● Kegel exercises help to strengthen the pelvic floor musculature
and thereby may relieve some of the pressure symptoms
produced by the cystocele. While there is no direct evidence
that pelvic floor muscle training prevents or treats POP, it may
be beneficial and it is effective for concomitant symptoms of
urinary and fecal incontinence.
● Women who have performed Kegel exercises on their own and
have not improved, may still benefit from working with a
physical therapist. In an older woman the use of estrogen
vaginal cream may improve vaginal atrophy and patient
comfort if the prolapsed vaginal mucosa is irritated or ulcerated.
● A younger woman with a large cystocele should be encouraged
to avoid operative repair until she has completed her family.
Occasionally the abnormality is so uncomfortable that repair
must be performed before childbearing is complete. If this is the
case, cesarean delivery should be considered for subsequent
pregnancies.
● Operative repair of a cystocele is generally performed in con-
junction with the repair of all other pelvic support defects. It is
unusual for anterior supports of the vagina to relax without an
accompanying relaxation of the posterior wall.
● Repair therefore usually consists of an anterior and posterior
colporrhaphy.
● If uterine descensus is noted, this must also be treated.
● Frequently an enterocele accompanies a cystocele and
rectocele and where present must be excised and repaired.
These problems are discussed later in this chapter.
● Anterior wall repair (colporrhaphy) is performed by incising the
vaginal epithelium transversally just above the anterior lip of
the cervix in the region of the bladder reflection (Fig. 20-8).
● If the woman has undergone a hysterectomy in the past, the
incision may be made approximately 1 to 1.5 cm anterior to the
vaginal scar. The vagina is then incised longitudinally from the
transverse incision to the level of the bladder neck. If no
urethrocele is present, this incision is sufficient. If a urethrocele
is present, the incision must be continued under the urethra as
well.
● The longitudinal incision is made by separating the vaginal wall
from the underlying tissue progressively, using Metzenbaum
scissors. When the longitudinal incision is complete, the cut
edge of the vagina is held under tension and the pubocervical
fascia that is attached is separated from it by blunt and sharp
dissection. This is repeated on each side. At this point the
bladder is free of the pubocervical fascia, which is itself free of
the vaginal wall. The surgeon then places a suture over the
bladder neck (Kelly stitch), bringing together the pubocervical
fasciae on either side. The stitch should be placed in such a
fashion that the pubocervical fascia is sutured as far away from
the cut edge as possible and parallel to the previous incision. A
similar stitch is taken on the opposite side, and the suture tied.
Most appro- priate for this closure is 0 or 2-0 polyglycol suture.
With the bladder neck well identified and supported, the
 pubocervical fascia is then closed with progressive similar
stitches to com- pletely imbricate the fascia over the bladder. If
the urethrocele is present, similar sutures are also placed over
the urethra. After the imbrication of the pubocervical fascia is
completed, the vaginal edges are trimmed and the vagina
closed with a row of interrupted 2-0 polyglycol or catgut
sutures. Addition of graft materials to the repair has been
studied, and small randomized trials of polyglactin mesh
(Vicryl) suggest modest improvements in success rates.
● Postoperatively the bladder should be drained for about 2 to 3
days. There are several ways to accomplish this. The first is to
leave a No. 16 Foley catheter in place for 2 to 3 days, remove
the catheter on the second to third day, and allow the patient to
try to void.
● After voiding of at least 200 mL the patient should be
catheterized for the presence of residual urine or alternatively,
a bladder ultrasound can estimate residual volume.
● If residual urine is found in a quantity of more than 150 mL on
two succes- sive voidings or if the amount voided is less than
200 mL, the physician should consider replacing the catheter
for 24 to 48 hours. If residual urine amounts are less than 150
mL on two consecutive voidings, no further steps are
necessary.
● Occasionally, after an anterior repair, voiding does not occur
after 5 days of bladder drainage. At that point the patient may
require catheterization for 24 to 48 hours longer, or she may be
treated with a Foley catheter in place for continuous drainage
for a week, to be rechecked for voiding and residual urine as
an outpatient in 1 week. It is rarely necessary to treat the
patient with antibiotics during this period; however, lower
urinary tract infections are common and should be treated as
they occur. In some patients who have had chronic urinary tract
infections, prophylactic antibiotics, such as a sulfa preparation
or nitro- furantoin can be administered.
● Alternatives to the above-mentioned regimen include supra-
pubic catheter drainage or teaching the patient clean inter-
mittent self-catheterization (CISC). With a suprapubic catheter,
the drainage tube can be clamped, allowing the patient to void
when she can and allowing residual urine measurements to be
taken. The suprapubic technique is simple to use and seems to
have a lower incidence of infection than does transurethral
catheterization, but patients may complain of extravasation of
urine around the site and occasionally of hematoma formation.
CISC can be threatening for patients to learn, but once learned,
many patients prefer not having an indwelling catheter and can
measure their own postvoid residual urine volumes. CISC is
generally not necessary if short periods of catheterization are
anticipated. The surgeon should decide which method is best
suited to the needs of his or her institution and develop a
system that the surgeon and nursing team understand and can
follow.
● Postoperatively it is important to emphasize to the patient that
heavy lifting, straining, or prolonged periods of standing should
be avoided for 3 months. The healing process is slow, and the
tissue is generally weak initially. Complete healing should be
ensured before the tissue is stressed by normal activities.
● They speculated that the increased recurrency rate was due to
the retropubic dissection necessary for the needle suspension.
It is possible that the incontinent patients in the latter group
suffered from a different pathologic problem such as nerve
damage, collagen defect, and so on, and that this may have
been responsible for the poorer outcome.
● Certainly, recurrent anterior vaginal wall prolapse remains as
the most frustrating problem for the gynecologic surgeon and
patients.
Rectocele
Symptoms and Signs
● The patient with a rectocele often complains of a heavy or
“falling out” feeling in the vagina.
● She may complain of constipation and occasionally may need
to splint the vagina with her fingers to effect a bowel
movement.
● She may also have a feeling of incomplete emptying of the
rectum at the time of the bowel movement.
Diagnosis
● A rectocele may be identified by retracting the anterior vaginal
wall upward with one-half of a Graves or Pederson speculum
and again having the patient strain.
● The rectum will bulge into the vagina, and this bulge may
protrude through the introitus (Fig. 20-9). The physician should
then place one finger in the rectum and one in the vagina and
palpate the hernia. Often the rectovaginal septum is paper-thin,
and the rectocele can be palpated to its upper margin. If an
enterocele is present, it may be possible to differentiate it from
the rectocele by having the patient strain. Frequently, however,
the diagnosis of a small enterocele is established only at the
time of operation.
Management
● Nonoperative management of a rectocele is similar to that
mentioned for a cystocele. Pessaries, Kegel exercises, and
estrogen may be useful in the appropriate situations.
● Gastrointestinal symptoms must be thoroughly evaluated
including screening for colorectal cancer if appropriate.
● If constipation and straining are issues, a dietary fiber and fluid
intake review should be obtained. At least 20 g of fiber, six to
eight glasses of fluid, regular exercise, and allowing time for
defecation after meals can be recommended to regulate bowel
habits as first-line therapy.
● Operative management of a rectocele (posterior colporrhaphy)
is generally performed at the time of an anterior colporrhaphy
with or without enterocele repair or operation for descensus.
Most women with rectoceles also have gaping vaginas and
weakness in their perineal body. Therefore as part of a
rectocele repair a perineorrhaphy is performed as well. The
surgeon should estimate at the time of starting the posterior
repair what degree of perineorrhaphy he or she wishes to
perform.
● The margins of the perineum to be narrowed are generally
marked by placing Allis clamps at their extreme at the introital
opening (Fig. 20-10). The tissue of the introitus is then incised
between these clamps, and the vaginal wall is separated from
the underlying tissue and rectum in a progressive manner
longitudinally in the midline, beginning at the introital incision
and being carried forward to the apex of the vagina above the
limit of the rectocele. This is done by progressive separation
and incision using the Metzenbaum scissors in a fashion similar
to that described for cystocele repair.
● When the vaginal wall is completely incised, the edges are
grasped and placed under tension, and the perirectal
connective tissue is separated from the vaginal mucosa by
blunt and sharp (if necessary) dissection. This is carried out
bilaterally until it is possible for the operator to palpate the
perirectal space on each side. The operator then places a
finger of his or her non- dominant hand into the rectum using a
double-gloved technique while an assistant picks up perirectal
 tissue on either side. The operator then places a delayed
absorbable suture into the perirectal tissue on either side.
Approximately three to five of these stitches are placed, and
these are held without tying. The operator should use his or her
finger in the rectum to ensure that no suture is placed into the
rectum. The perirectal tissue usually includes portions of the
levator ani muscles. When the sutures are tied, these tissues
are interposed between rectum and vagina, thereby reducing
the rectocele. These sutures also serve to tack the vagina to
the levator ani area, thereby, it is hoped, avoiding future
vaginal prolapse if a hysterectomy has also been performed.
However, if vaginal vault prolapse is also present, a separate
repair is indicated for support of the vaginal apex and this is
discussed later. The vaginal edges are then trimmed and the
vagina closed with a row of either continuous or interrupted
absorbable suture.
● Attention is then turned to the perineorrhaphy when there is
perineal muscle separation, which is closed in the following
fashion. Polyglycol sutures are placed in the lateral margins of
the transverse incision, essentially bringing bulbocavernosal
and superficial perineal muscles together from either side to
the midline. The operator should be sure that the
bulbocavernosal muscle insertions are included in the sutures
by pulling on the suture and noting whether the tension
identifies the muscle bundles. The remainder of the perineal
incision is then closed with a row of 2-0 polyglycol sutures to
the deep tissue, and the skin of the perineum is closed with
either interrupted or con- tinuous subcuticular suture of 3-0
chromic catgut or polyglycol.
● Although anatomic position is often corrected by a posterior
colporrhaphy, function may not. Defecatory problems may
remain, so patients should be forewarned. Furthermore, dys-
pareunia can be a problem postoperatively, especially if levator
ani plication is done. Levator ani plication may best be indi-
cated in nonsexually active women because of possible vaginal
narrowing and band formation, which may lead to dyspareunia.
Enterocele
● Enteroceles frequently occur after an abdominal or vaginal
hysterectomy and generally are the result of a weakened
support for the pouch of Douglas.
● In the prevention of enteroceles, the uterosacral and cardinal
ligaments are the most important support structures and should
be incorporated into the vault repair at the time of a
hysterectomy and the ligaments from each side joined
together.
Diagnosis
● An enterocele is not always easy to diagnose. It is a true hernia
of the peritoneal cavity emanating from the pouch of Douglas
between the uterosacral ligaments and into the rectovaginal
septum (Fig. 20-11).
● It may be noticed as a separate bulge above the rectocele, and
at times it may be large enough to prolapse through the vagina
(Fig. 20-12).
● If such is the case, it may be possible to make the specific
diagnosis of enterocele by trans- illuminating the bulge and
seeing small bowel shadows within the sac. It may also be
possible to differentiate the enterocele from a rectocele by
rectovaginal examination.
● The contents of an enterocele are always small bowel and may
also include omentum. The contents may be easily reducible or
may be fixed to the peritoneum of the sac by adhesions.
Management
● Enteroceles may be reduced transabdominally as a primary
proce- dure or at the time of other abdominal procedures. In
the primary procedure the sac should be reduced upward if
possi- ble, and if the uterosacral ligaments are present, these
may be brought together in the midline. If the uterosacral
ligaments cannot be identified, as with large enteroceles after
previously performed hysterectomy, the cul-de-sac may be
obliterated by concentric purse-string sutures in the endopelvic
fascia. Care must be taken to avoid damaging the ureters,
rectum, and sigmoid colon. It is best to perform this procedure
with perma- nent sutures. The enterocele has probably
occurred because of weakening of pelvic floor structures.
Therefore, for optimum results, repair of the lower pelvis using
a vaginal approach is probably indicated, even though the
enterocele is obliterated abdominally.
● Repair of the enterocele can be carried out at the time of the
posterior colporrhaphy. The sac will be visualized as the vagina
is separated from the rectum. The sac must then be dissected
● Figure 20-12. Elderly patient with vaginal prolapse who proved
to have large enterocele with ulcers on the vagina.
● free of underlying tissue and isolated at its neck. It should be
opened to ensure that all contents are replaced. The neck of
the hernia is then sutured with a purse-string 0 chromic or
polyglycol suture ligature and the sac excised (Fig. 20-13).
● It is important to support the neck of the enterocele sac as
much as possible. Approximating the anterior and posterior
vaginal connective tissue may be beneficial. Usually with an
enterocele, support of the vaginal apex is indicated. If utero-
sacral ligaments can be identified or if they are present when a
vaginal hysterectomy has been performed in association with
an enterocele repair, they can be used in the repair. This can
be accomplished by fixing the uterosacral ligaments to the
perito- neum of the sac and the vaginal vault connective tissue
using a suture of 0 polyglycol, beginning on one side of the
vagina and continuing through the uterosacral ligament of that
side, the peritoneum of the sac, and the uterosacral ligament
and vagina of the opposite side. Multiple sutures can be placed
if space allows. This technique was described by McCall and is
often called the McCall stitch. It effectively shortens the cul- de-
sac and supports the enterocele neck. If uterosacral ligaments
cannot be identified, as is often the case if the uterus has been
previously removed, the rectocele repair should be continued
to the area of the enterocele sac neck to reinforce this area and
support the cul-de-sac as high as possible. This usually
involves the joining of the levator ani muscles up to the area of
the enterocele sac.
● Correctly repaired enteroceles usually will not recur. Entero-
celes repaired without proper attention to ligation of the neck of
the sac, closure of the anterior and posterior vaginal connec-
tive tissue, and without appropriate rectocele repair may recur.
In such cases a subsequent operation with special attention to
these surgical principles is indicated.
Uterine Prolapse (Descensus, Procidentia)
● Descensus of the uterus and cervix into or through the barrel of
the vagina is associated with injuries of the endopelvic fascia,
including the cardinal and uterosacral ligaments, as well as
injury to the neuromuscular unit with relaxation of the pelvic
floor muscles, particularly the levator ani muscles.
● prolapse is the result of increased intraabdominal pressure,
such as with ascites or large pelvic or intraabdominal tumors
super- imposed on poor pelvic supports.
● In some instances, sacral nerve disorders, especially injuries to
S1 to S4, or diabetic neuropathy may be responsible.
● larger transverse inlet diameters, but not anterior–posterior
diameters than do women without prolapse, suggesting an
anatomic predisposition.
● Associated factors that increase tension on pelvic floor
musculature, such as chronic respiratory disease including
chronic bronchitis, asthma, and bronchiectasis, or severe
obesity, may be associated.
● Congenitally damaged or relaxed pelvic floor supports may
cause prolapse in young, nulliparous women.
● Most of the time, however, the patients are multiparous, with
the prolapse being at least in part a result of childbirth trauma.
● Descensus is almost always associated with rectocele and
cystocele and, at times, enterocele, supporting the concept of
overall relaxation of the pelvic support structures.
● A prolapse into the upper barrel of the vagina is called first
degree.
● If the prolapse is through the vaginal barrel to the region of the
introitus, it is second degree.
● If the cervix and uterus pro- lapse out through the introitus, it is
called third degree or total.
● In total prolapse the vagina is everted around the uterus and
cervix and completely exteriorized. When this occurs, the
patient is in danger of developing dryness, thickening, and
chronic inflammation of the vaginal epithelium. Stasis ulcers
may result as edema and interference with blood supply to the
vaginal wall occur. These ulcers rarely become cancerous, but
biopsies should always be taken to ensure that they are not. In
almost every case of acquired prolapse, the perineal supports
are poor and the perineal body is damaged.
● When the examination is recorded according to the anatomic
points just cited, staging may be performed (listed in Table 20-
1). These organizations hope that by using this system, a
clearer understanding of a patient’s prolapse will be achieved,
and the transmittal of this information to others will be made
more accurate. They also expect that this system will make it
possible to standardize research information.
Symptoms and Signs
● Major symptoms: feeling of heaviness, fullness, or “falling out”
in the perineal area.
● In cases where the cervix and uterus are low in the vaginal
canal, the cervix may be seen protruding from the introitus,
giving the patient the impression that a tumor is bulging out of
her vagina.
● Where total descensus has occurred, the patient is aware that
a mass has actually prolapsed out of the introitus. Because
pro- lapse almost always is related to anterior and posterior
vaginal wall relaxation, symptoms that were reported earlier for
cystocele and rectocele may be present as well.
● It is not uncommon for the cervix or vaginal epithelium to
become damaged or ulcerated, in which case the patient may
report pain or vaginal bleeding. There is often discharge from
the cervix and vagina when secondary infection occurs.
Management
● Minimum prolapse does not require therapy unless the patient
is very uncomfortable. Degrees of prolapse that place the
cervix at or through the introitus probably cause greater dis-
comfort and are usually more bothersome to the patient.
Medical management of such conditions involves the use of a
pessary, usually of the Smith-Hodge, donut, cube, or inflatable
variety (Fig. 20-15). These require the replacement of the
uterus and cervix to their usual position in the pelvis and then
the institu- tion of support using one of these devices.
Pessaries are available in varying sizes and should be properly
fitted to the patient. In general the perineum must be capable of
holding the pessary in place, or the pessary will frequently fall
out. There is currently no evidence from randomized controlled
trials on pessary use to direct the selection of the device or to
compare pessaries with other treatments or surgery.
● The pessary reduced symptoms of POP including general
symptoms of a vaginal bulge. It also relieved urinary symptoms
such as voiding problems in 40% of women, urinary urgency in
38%, and urge incontinence in 29%. There was no
improvement in stress urinary incontinence. Bowel symptoms
improved as well.
● Complications from vaginal pessaries are rare with proper use.
This includes regular removal, cleaning, and replacement, as
well
● as use of vaginal estrogen cream for postmenopausal women
with vaginal atrophy. Complications include vaginal infections,
bleeding, discomfort, vaginal erosion and ulceration, and
impac- tion..
● If the patient is a young woman and pregnant, it is important to
replace the uterus before it enlarges and becomes trapped in
the lower pelvis or vagina. If this happens, edema may cause
incarceration and even loss of blood supply to the uterus. In a
postmenopausal woman, estrogen replacement for at least 30
days with vaginal estrogen cream may help improve the vitality
of the vaginal epithelium, the cervix, and the vasculature of
these organs, making fitting of a pessary or the operative
procedure and the healing process more efficient. The patient
should not undergo operation until all ulcers of the vagina and
cervix are healed, because to do otherwise is to risk infection
and breakdown of the repair.
● Operative repair for prolapse of the uterus and cervix gen-
erally involves a vaginal hysterectomy with a vaginal vault sus-
pension. The hysterectomy is performed carefully, isolating the
uterosacral and cardinal ligaments so that they may be used in
the support of the vaginal vault. The uterosacral ligaments
should be sutured together so that the cul-de-sac is shortened
or obliterated and the risk of a subsequent enterocele is
lessened. Other vaginal vault suspension procedures can be
used instead of the McCall type.
● In some cases a vaginal hysterectomy is not advisable. These
circumstances include previous intraabdominal operation for an
inflammatory process, such as endometriosis or pelvic
inflammatory disease. Where such is the case an abdominal
hysterectomy may be performed, followed by a vaginal anterior
and posterior colporrhaphy, if needed. Under these
circumstances the cardinal and uterosacral ligaments should
be treated as noted earlier. As an alternative, a
laparoscopically assisted vaginal hysterectomy may be
performed in such situations.
● In some women the cervix is hypertrophied and elongated to
the area of the introitus, but the supports of the uterus itself are
good. A cystocele and rectocele may be present, and opera-
tive repair can consist of a Manchester (Donald or Fothergill)
● operation. This operation combines an anterior and posterior
colporrhaphy with the amputation of the cervix and the use of
the cardinal ligaments to support the anterior vaginal wall and
bladder. Although it was suggested for repair in young women
who wish to maintain their reproductive abilities, the loss of the
cervix may interfere with fertility or lead to incompetence of the
internal cervical os. The operation has value in elderly women
with comorbid medical conditions who have an elongated
cervix and well-supported uterus because it is technically
easier and has a shorter operative time than the vaginal
hysterectomy in such cases, and the entering of the peritoneal
cavity is avoided.
● In elderly women who are no longer sexually active a simple
procedure for reducing prolapse is a partial colpocleisis. The
classic procedure was described by Le Fort (Fig. 20-16) and
involves the removal of a strip of anterior and posterior vaginal
wall, with closure of the margins of the anterior and posterior
wall to each other. This procedure may be performed with or
without the presence of a uterus and cervix, and when it is
completed, a small vaginal canal exists on either side of the
septum, which is produced by the suturing of the lateral
margins of the excision. The line of dissection of the vaginal
wall is carried to the level of the bladder neck anteriorly and to
the reflection of bladder onto the cervix at the upper margin of
the vagina. Posteriorly the dissection is carried from just inside
the introitus to a position just posterior to the cervix. If a hyster-
ectomy has been previously performed, the dissection may
begin approximately 1 cm on either side of the vaginal scar.
When the procedure is completed, the bladder neck is spared
from any scarring, and urinary incontinence is generally
avoided. Bladder neck plication may be carried out if the
patient is incontinent. After healing of the plication a small
introital area is noted; this has cosmetic benefits in older
women. In addition, narrow canals are noted on each lateral
vaginal wall. If the cervix and uterus are still present and
intrauterine pathology occurs, bleeding along these canals
could take place, alerting the physician to a potential problem..
● When a colpocleisis is performed, if an enterocele is found
when the vaginal wall is stripped away, the sac must be iden
tified, its neck ligated, and the peritoneum of the sac excised to
prevent recurrence of the enterocele behind the colpocleisis.
● In most cases a perineorrhaphy is performed with a colpocleisis
to reinforce the introitus.
● Prognosis for a colpocleisis procedure to reduce the prolapse
and prevent recurrence is generally excellent.
● A special circumstance involves the treatment of women who
wish to maintain their fertility despite the fact that they have a
total uterine prolapse. Kovac and Cruikshank have demon-
strated that uterosacral ligaments bilaterally could be sutured to
the sacrospinus ligaments, thereby reversing the prolapse. In
19 such patients treated, 5 delivered a total of 6 babies (1
delivered twice).g
Vaginal Apex Prolapse
● remote to either abdominal or vaginal hysterectomy
● The prolapse may be total and may be accompanied by a
cystocele, a rectocele, an enterocele, or some combination
thereof.
● It is probably the result of continuing pelvic support weakness
and failure of the vaginal support structures, namely, the
cardinal and uterosacral ligaments, to maintain their tone or
attachment to the vagina.
Symptoms and Signs
● similar to those delineated for descensus of the uterus.
● They include pelvic heaviness, backache, and a mass
protruding through the introitus.
● At times, stress incontinence, urgency, frequency, dribbling,
vaginal bleeding or discharge (if there is an ulcer), and,
depend- ing on the size of the mass, difficulty with sitting or
walking may occur.
Diagnosis
● Examination may help determine the contents of the herniation
depending on where the vaginal scar is located in relation to
the protruding mass and the extent to which the supports of the
pelvis are lost. Rectovaginal examination is often helpful in
delineating an enterocele from a rectocele.
Management
● Although the management of descensus with the uterus
present is uniformly agreed to be vaginal hysterectomy with
vaginal vault suspension and if indicated, anterior and posterior
col- porrhaphy, there is much controversy over the appropriate
proce- dure for vaginal apex prolapse. Nevertheless, certain
principles and facts are important. The first is that the normal
position of the vagina in the standing position is against the
rectum and no more than 30° from the horizontal (Fig. 20-18).
The second principle is that pelvic relaxation is a part of the
problem and dictates that an existing cystocele, rectocele, or
 enterocele must be repaired as part of the procedure. The third
principle ac- knowledges that the perineal body is almost
always severely weakened in such patients and must therefore
be reconstructed as well. Nonsurgical management, such as
the use of pessaries, estrogen, and the healing of ulcers,
should be used as appro- priate. Pessaries, however, are
rarely retained in such patients, and attempts to treat these
patients nonsurgically are generally met with frustration.
● The choices of operative procedures are many. These include
those that use the abdominal route, the vaginal route, or some
combination thereof. For the abdominal approach a variety of
procedures have been tried. These include fixation of the
vaginal vault to the anterior abdominal wall, to the lumbar
spine, to the sacral promontory, to various tendonous lines in
the muscula- ture of the true pelvis, and to the sacrospinous
ligament. The anterior abdominal wall fixation increases the
diameters of the pouch of Douglas and frequently adds to the
risk of subsequent enterocele development, often creating a
recurrence in short order. Fixation to the lumbar spine or the
sacral promontory is often difficult to achieve directly and
requires the interposition of a different material. In the past, ox
fascia lata, fascial aponeurosis from the patient, or inert
materials such as Mersilene have been used. In such
procedures it is important to cover the stent with peritoneum,
thereby rendering it retroeritoneal to avoid troublesome
adhesions and internal hernias at a future date. After such
procedures the pouch of Douglas may still be large enough to
allow an enterocele to develop. Fixation to various aspects of
the pelvic wall or to the sacrospinous ligament has had
encouraging degrees of success, the latter being the most
successful. Using the sacrospinous ligament can frequently be
accomplished vaginally.
● For operative procedures that fix the vaginal vault to an anterior
structure (i.e., the anterior abdominal wall) an obliteration of the
cul-de-sac must be carried out as part of the operative
procedure to prevent enteroceles from forming.
● An equally good technique (and possibly better than vaginal
techniques) for suspending the vaginal vault is the fixation of
the vault to the sacrum. This generally requires the use of a
stent, which can be a fascial strip taken from the patient or an
inert mesh such as Mersilene. The stent is sutured to the
anterior and posterior upper vaginal vault and the opposite end
to the ligamentum flavum of the sacral promontory or the
anterior longitudinal ligament of the sacrum. Care must be
taken to avoid the middle sacral artery and the plexus of veins
in its vicinity. The stent should be made retroperitoneal by
bringing the peritoneum in front of it. The procedure should
also include an obliteration of the cul-de-sac.
● If an abdominal sacrocolpopexy (ASC) is to be performed for
treatment of POP, urinary continence must be considered.
● Burch colposus- pension significantly reduced postoperative
stress incontinence when performed at the time of ASC,
without an increase in other urinary problems.
● In elderly women who are no longer sexually active, and
particularly in those who have medical reasons to avoid a
longer procedure, a Le Fort-type colpocleisis operation may be
performed with excellent results. It is extremely important to
identify and repair enteroceles in such women, but this can
readily be done as part of the procedure. Perineorrhaphy
should always be performed as part of any procedure to repair
a vaginal apex prolapse.
● The question of continuing sexual activity after vaginal vault
repairs is obviously an important one. With an adequate
vaginal operation (with the exception of colpocleisis),
intercourse is achievable in most patients who wish to maintain
this activity.
● Weber and coworkers studied sexual function in 81 women
who were sexually active before undergoing surgery for pelvic
prolapse or urinary incontinence or both. All remained sexually
active after surgery, but dyspareunia was likely to occur if a
combination of the Burch procedure and posterior colporrhaphy
was performed.
FECAL INCONTINENCE
Cor
onal section of the anal canal and lower rectum. ARR, level of anorectal
ring; CLM, conjoined longitudinal muscle; IRN, inferior rectal nerve; LA,
levator ani muscles; PRD, puborectalis/deep external sphincter complex;
SC, subcutaneous external sphincter.
● Estimates range from 2% to 16% of community-dwelling
women older than 64 years of age. Prevalence increases with
age. Over 30% of women reporting urinary incontinence also
report fecal incontinence, known as dual incontinence.
● Anal incontinence is the inability to defer the elimination of stool
or gas until there is a socially acceptable time and place to do
so.
● Fecal incontinence is the inability to defer the elimination of
stool.
● it is important for the physician to understand the patient’s
symptoms, type of loss (i.e., flatus or stool), frequency of
incontinence, and effect on the quality of her life.
● Evaluation and treatment should be directed by the severity of
the patient’s symptoms and the expected goals of therapy.
Physiology of Fecal Continence
● Fecal continence requires
○ normal stool consistency and volume
○ normal colonic transit time
○ a compliant rectum
○ innervation of the pelvic floor and anal sphincter,
and
○ interplay between the puborectalis muscle, rectum,
and anal sphincters.
○ Loss of one or more of these abilities can lead to
fecal incontinence.
● As a bolus of stool or gas passes from the sigmoid colon to the
rectal canal, receptors within the wall of the puborectalis sense
the distention of the rectum.
● As long as the pressure in the anal canal is maintained at a
higher level than the rectal pressure, continence is maintained.
● Anal canal pressure depends on a functional
 ○ internal anal sphincter (IAS)
○ external anal sphincter (EAS)
● IAS
○ thickened continuation of the circular muscle of the
colon
○ provides 75% to 85% of the resting tone of the anal
canal.
○ under autonomic control, maintains the high-
pressure zone or continence zone and along with
the EAS keeps the anal canal closed.
● The shape of the combined IAS and EAS is nearly cylindrical
as it encircles the anal canal.
● sphincter complex averages 18.3 mm in thick- ness and 2.8 cm
in length in the midline anteriorly.
● Fifty-four percent of the anterior thickness is attributable to the
IAS and the remainder to the EAS.
● EAS
○ provides the voluntary squeeze pressure that
prevents incontinence with increasing rectal or
abdominal pressure.
○ innervated by the hemorrhoidal branch of the
pudendal nerve from the S2 through the S4 nerve
roots.
○ Contraction of the EAS, either voluntarily or through
a spinal reflex, doubles the anal canal pressure.
● The third muscular component of the sphincter complex is the
puborectalis muscle (Fig. 20-21).
○ The puborectalis, part of the levator ani muscle
complex, originates from the pubic bone on either
side of the midline, passes beside the vagina and
rectum, and fuses posteriorly behind the anorectal
junction to form the U-shaped sling that cradles the
rectum while sending some fibers onto the walls of
the anal canal.
○ Unlike most other striated muscles, the puborectalis,
like the EAS, maintains a constant muscle tone that
is directly proportional to the volume of the rectal
content and pressure, and relaxes at the time of
defecation.
○ puborectalis and EAS
■ contain a majority of type I, or slow
twitch, muscle fibers - maintains a
constant contraction or tone.
■ also contains a small proportion of type
II, or fast twitch, fibers that allow for quick
responses to rapid increases in intra-
abdominal pressure.
○ innervated by direct branches from S3 and S4 and,
to a lesser degree, from the pudendal nerve.
○ anorectal angle
■ 90° angle between the rectum and anal
canal due to the constant contraction of
the puborectalis
■ Important in maintenance of continence
■ this angle creates a flap-valve effect that
presses the anterior rectal wall down
onto the upper anal canal and thereby
prevents rectal contents from entering
the anal canal when intraabdominal
pressure is applied.
○ The anterior rectal wall therefore acts as a plug.
○ anal sphincter was maximally stressed and the
rectum was visualized radiographi- cally, there was
no contact between the rectal wall and anal canal. In
addition, surgeries that try to recreate this angle in
hopes of restoring continence have not proven
effective.
● When a bolus of stool or gas is sensed in the rectum, the IAS
has a reflex relaxation that allows for colonic contents to be
sampled by the anal canal to distinguish solid, liquid, and gas
forms of fecal material.
● After the sampling, the IAS contracts and the fecal material is
pushed back into the rectum. The reflex, known as the
rectoanal inhibitory reflex, or RAIR, is absent in patients with
Hirschprung’s disease. This reflex can also be inhibited by
chronic dilation of the anus with fecal impaction and lead to
incontinence. If the impaction is cured, the reflex and anal tone
can return to normal.
● If the rectum has normal compliance and the person chooses
to defer defecation, the IAS and EAS sphincters and the
puborectalis remain contracted until the appropriate time to
eliminate.
Etiology and Pathophysiology
● There are many causes of fecal incontinence as seen in Table
20-3.
● One way to categorize the reasons for fecal incontinence is to
separate the initial cause into those that start outside the pelvis
with a normal pelvic floor from those that start with an abnormal
pelvic floor. Causes that start outside the pelvis in- clude all of
the pathologies that cause diarrhea or increased intestinal
motility, overflow incontinence from fecal impaction, and rectal
neoplasms. Known or diagnosable neurologic condi- tions such
as multiple sclerosis, diabetic neuropathy, trauma, or
neoplasms in the spinal cord or cauda equina initially begin as
pathologies outside of the pelvis and the pelvic floor is
presumed normal. As these neuropathies progress, there is
damage to the pelvic floor musculature or in rectal sensation,
resulting in fecal incontinence.
● Fecal incontinence secondary to an abnormal pelvic floor is
due to congenital anorectal malformations, surgery, obstetric
injury, aging, or pelvic floor denervation without a known
neurologic disease. Historically, incontinence secondary to de-
nervation has been designated as idiopathic and represents
80% of patients with fecal incontinence. Pelvic floor
denervation has been studied extensively in the last 15 years in
women with urinary and fecal incontinence as well as pelvic
organ prolapse. Denervation may be secondary to vaginal
delivery, chronic straining with constipation, rectal prolapse, or
descending peri- neal syndrome. Histologic studies of the EAS
and puborectalis show fibrosis, scarring, and fiber-type
grouping consistent with nerve damage and reinnervation in
women with idiopathic fecal incontinence. Electromyographic
(EMG) studies have demon- strated reinnervation of the pelvic
floor with increased fiber density and prolongation of nerve
conduction on pudendal nerve terminal motor latency (PNTML)
studies.
● In healthy women, the most common cause of fecal incon-
tinence is damage to the anal sphincters at the time of vaginal
delivery with or without neuronal injury. This type of incon-
tinence is often referred to as anal incontinence. Damage can
occur by mechanical disruption or separation of the IAS or EAS
(or both) or by damage to the muscle innervation by stretching
or crushing the pudendal and pelvic nerves. Sultan and
coworkers showed that 13% of primiparas and 23% of
multiparas devel- oped fecal incontinence or fecal urgency 6
weeks postpartum. By anal ultrasound, all but one of the
 women had evidence of anal sphincter disruption. The
incidence of occult external anal sphincter disruption after
vaginal delivery determined by endoanal ultrasound ranges
from 11% to 35%. The chance of muscular injury is increased
with midline episiotomy, instru- mented delivery, and vaginal
delivery of larger infants. Other risk factors include increasing
maternal age, prolonged second stage (greater than 2 hours),
and clinically diagnosed sphincter laceration at the time of
delivery. The first vaginal delivery appears to have the greatest
effect on pelvic floor function and risk of EAS disruption, but
subsequent deliveries can increase the risk of permanent
damage, especially in women with transient symptoms of fecal
incontinence after their first delivery. Not all risk factors are
known, and not all women are susceptible to pelvic floor and
sphincter damage with vaginal delivery.
Detection of Fecal Incontinence
● “How often do you leak gas, liquid, or solid stool?” should be
placed on the standard office intake questionnaire.
○ patients complain of fecal or flatal incontinence
when given written questionnaires rather than
answering verbal questioning.
● fecal incontinence or fecal urgency after one vaginal delivery -
incorporate open-ended questions concerning flatal or fecal
incontinence as part of the 6-week postpartum visit.
● as women age, the chances of developing fecal incontinence
increase, - target older women for questioning.
Physical Examination
● Undergarments or pads should be inspected for stool, mucus,
blood, or pus. If material is found, the patient should be asked if
this is her normal leakage.
● Physical examination begins with inspection of the perineum
and anal region.
● Pruritus ani, or dis- coloration and irritation of the perianal skin,
is commonly seen with fecal incontinence of liquid stool and
chronic diarrhea.
● Perianal skin creases or folds should completely encircle the
anus.
● Note the presence of protruding tissue around or from the anus
and determine if there are external hemorrhoids or mucosal or
full-thickness rectal wall prolapse.
● The dovetail sign or loss of anterior perineal folds indicates a
defect in the EAS or chronic third-degree laceration (Fig. 20-
22).
● Previous episiotomy, laceration, or surgical scars should be
noted. The size of the genital hiatus and the presence of
genital prolapse should be assessed as an indicator of pelvic
floor neuromuscular func- tion. The innervation of the EAS can
be grossly tested by eliciting the clitoral–anal or
bulbocavernosus reflex. Using a cotton swab, a gentle, quick
touch beside the clitoris or over the bulbocaver- nosus muscle
should elicit a contraction of the EAS. If intact, the reflex
implies that the pudendal nerve afferents and the rectal or
external hemorrhoidal branch of the pudendal efferent nerves
are functional. Unlike males, who should always exhibit this
reflex, about 10% of women lack this reflex naturally. However,
if absent, and in the presence of fecal incontinence, further
neurologic testing is indicated. Sensation in the S2 through S4
dermatomes should be screened by dull and pinprick
discrimination when touching the perineum. Loss of sensation
Figure 20-22. Perineum with chronic laceration of external anal
sphincter (EAS). Inspection of the perineum shows the classic
“dovetail” sign with loss of the anal skin creases anteriorly due
to a chronic third-degree laceration of the EAS. Normally, with
an intact sphincter, the skin creases are arranged radially
around the anus. (From Stenchever MA, Benson JT [eds]: Atlas
of Clinical Gynecology. New York, McGraw-Hill, 2000.) should
direct the clinician to further neurologic or radiologic
assessment of the nervous system.
● Next, the patient should be asked to squeeze as if trying to not
pass gas. Inspection of the perianal folds should be eval- uated
for a concentric contraction and some upward movement of the
perineal body as she contracts the EAS and levator ani.
Substitution with contraction of the buttocks, upper thighs, or
abdomen should be noted. The patient should then be asked to
bear down as if trying to have a bowel movement. She should
be reassured that it is expected she may pass flatus during this
part of the examination. The degree of perineal descent and
any prolapse of the vagina, pelvic viscera, or rectum should be
noted. If there appears to be any pelvic organ prolapse, the
examination should be performed in the standing position or
after straining on a commode to maximize the prolapse.
● Rectal examination is used to assess both resting and squeeze
tone of the anal canal. The resting tone of the anal canal is an
indicator of IAS function. When asked to squeeze, a circum-
ferential contraction and tightening should be felt. An upward
movement of the rectum and posterior compartment of the
pelvis should be seen as the levator ani muscles contract. As
these muscles also play an important role in anal continence,
palpation of the levators for strength and symmetry should be
performed by palpating the muscles on each side of the vagina
at the introitus.
● In addition to assessing rectal tone, the anal canal and rectum
should be palpated for masses and a dilated rectum or the
pres- ence of stool in the rectal vault. A chronically distended
rectum, either with stool, a tumor, or an intussuscepting bowel,
will disrupt the normal rectoanal inhibitory reflex that allows the
highly sensitive anal canal to sample the stool contents by
relaxing the IAS while time contracting the EAS to prevent in-
continence. If this reflex is suppressed, the anal canal remains
dilated, the EAS fatigues, and incontinence will occur.
● While doing the rectal examination, the patient is also asked to
strain to diagnose the presence of a rectocele, enterocele,
rectal prolapse, or bowel intussusception. With a finger in the
rectum the integrity of the rectovaginal septum, posterior
vaginal wall, and perineal body can be assessed by palpating
through the vagina via bimanual examination.
Testing

Diagnostic Procedures
● Colonoscopy.- chronic diarrhea to evaluate for inflammatory
bowel disease and infectious diarrhea.
● Transanal Ultrasoun - delineate defects of both the IAS and
EAS. The integrity, thickness, and length of the IAS and EAS
can be determined. The IAS is visible as a hypoechoic circle,
and the EAS is seen as a hyperechoic circle .
● Anal Manomet - used test that objectively assesses the
resistance to spontaneous def- ecation provided by the
anorectal sphincter mechanism and the sensory capabilities of
the rectum to provide a imminent defecation.
● Electromyography. EMG is used for mapping of the EAS defect
and for determining the presence and degree of neu- ropathy
and denervation and reinnervation..
● Treatment
● Treatment of fecal incontinence includes medications, biofeed-
back, electrical stimulation, and surgery. Obstructive devices,
including transanal plugs, have been marketed but are not
widely used.
RECTOVAGINAL FISTULAS
● Although not a true source of fecal incontinence by definition,
rectovaginal fistulas (RVF) are common enough complications
of vaginal birth and gynecologic surgeries to be addressed
under this heading. Any time a patient presents complaining of
fecal or flatal incontinence, an RVF should be included in the
differential diagnosis.
● The causes of RVF, as seen in Table 20-9, include traumatic,
inflammatory, and neoplastic origins, but obstetric injuries are,
by far, the most common cause. It is estimated that 0.1% of
vaginal births will result in an RVF.
● A fistula occurring caudad or adjacent to the EAS is termed an
anovaginal fistula and is managed differently from an RVF.
Fistulas that occur more than 3 cm above the anal verge are
true RVFs.
● Most RVFs secondary to obstetric injury occur in the lower third
of the vagina and may be associated with a sphincter
● defect in the EAS. It is important to evaluate the EAS as
outlined earlier with either a transanal ultrasound or EMG to
map any defects prior to surgical treatment.
● Fistulas secondary to surgical trauma, malignancy, or inflam-
matory process may occur anywhere along the vaginal wall,
including the apex. If a fistula develops after a difficult surgery,
such as following pelvic inflammatory disease, or after radia-
tion, it is important to check for more than one fistula prior to
repair. If the patient has a history of malignancy, examination
with biopsy specimens should be performed to rule out cancer
as the cause of the fistula.
● Depending on the size and location of the fistula, the patient
may be nearly asymptomatic or complain of a small amount of
flatus passing into her vagina with a low, small fistula. With a
large fistula, she may have formed stool coming through the
vagina with every bowel movement, causing significant distress
and hygiene problems.
● Evaluation of a patient includes history and physical exami-
nation to determine cause. If there is suspicion of inflammatory
bowel disease, a colonoscopy is warranted. A rectal
examination is important to determine the integrity of the anal
sphincters, the quality of the tissues surrounding the fistula,
and to palpate for abscesses and other masses. Methylene
blue mixed in lubri- cant can help identify the fistula. If still not
identified, a dilute methylene blue enema with a tampon in the
vagina may help in isolating the fistula. If the vaginal orifice is
found, but not the rectal opening, insertion of an angiocath with
a squirting of hydrogen peroxide can show bubbling on the
rectal side.
● An office anoscopy or proctoscopy may also help to evaluate
the surrounding tissues. In general, a mature epithelialized
fistula that is not infected is not painful on digital examination. If
the exam in the office is not successful in locating the fistula or
is too painful for the patient, she should be taken to the
operating room for exam under anesthesia. If the fistula has still
not been identified, filling the vagina with water and insufflating
the rectum should produce bubbling in the vagina that can be
traced to the opening. A barium enema may also be helpful for
iden- tifying high fistulas. A vaginogram using dilute barium
solution may also help identify a fistula.
● Surgical management of an anovaginal or anoperineal fistula is
accomplished by opening of the fistula tract, curetting the tract,
and leaving the tract open to heal secondarily. Excision of the
tract and primary closure will result in recurrent fistula formation
in most cases.
● Many surgical procedures have been described for manage-
ment of RVF. Regardless of the procedure chosen, basic
surgical principles must be followed. The tissue must be
healthy, well vascularized, and free of infection and induration.
This may require waiting for up to 3 months following the
original trauma or surgery for complete healing. If there is
significant fecal contamination, prior radiation, or persistent
abscess, a diverting colostomy should be considered. After a
colostomy, a delay of 8 to 12 weeks is generally required for
the inflammation and cellulites around the fistula to heal. At the
time of repair, a Martius fat pad graft can be used to increase
the vascular supply to the area. Preoperatively, the patient
should have a complete mechanical bowel prep starting
several days before the surgery to prevent liquid stool from
contaminating the field. Some surgeons may place the patient
on a liquid diet several days before surgery with no mechanical
bowel prep except enemas until clear the night before surgery.
The goal is to have no liquid stool in the rectum and to have
her first postoperative bowel movement, several days after
 surgery, be soft, but formed. Antibiotic bowel prophylaxis is
warranted.
● Other surgical principles include excision of the entire fistulous
tract, wide mobilization of the rectal tissue, and broad tissue-to-
tissue closure without tension. The rectal side is the high-
pressure side and requires the attention to repair. The vaginal
side may be closed or left open to drain if indicated and should
close spontaneously. A delayed-absorbable suture, such as a
3-0 Polysorb, is used on all layers. Permanent suture is not
used.
● Both transvaginal and transrectal repairs have been described,
but gynecologists, generally, prefer the transvaginal approach.
Depending on the location and the need to repair the anal
sphincters, an uncomplicated fistula can be repaired similar to
a fourth-degree laceration as a perineoproctotomy with layer
closure. After cutting from the perineal body, through the
sphincters and to the fistulous tract, care must be taken to
excise the tract and any surrounding scar tissue. A two-layered
closure of the rectum and anal canal is then performed as in a
fourth- degree closure. Care should be given to closing the
EAS.
● To preserve an intact sphincter, the RVF can be cored out by
placing a pediatric Foley transvaginally and filling the balloon
on the rectal side and then using the Foley for traction by
pulling upward. After excision, depending on the size, a small
fistula can be closed with two-layer purse-string sutures or with
an interrupted two-layer closure.
● Transrectal repairs, preferred by many colorectal surgeons,
generally involve the development of rectal mucosal flaps,
mobi- lized and brought down or lateral to cover the excised
fistula site. In 23 patients treated at the Cleveland Clinic with
rectal advancement flaps, fistulas were successfully cured in
77% of the patients with obstetric or surgical injury and 60% of
the patients with Crohn’s disease.
● Postoperatively, the patient’s diet and medications should be
managed to keep her bowel movements soft, but formed. In
most cases, a clear liquid diet is continued for the first 3 days
● after surgery followed by a low-residue diet. Broad-spectrum
antibiotics should be continued for 2 weeks.
● Sitz baths, two or three times a day, followed by the use of a
blow dryer or heat lamp, keeps the area clean and dry.

DELA ROSA, KAE CEE WHITE E.
LOWER URINARY TRACT FUNCTION AND DISORDERS
PHYSIOLOGY OF MICTURITION
● The normal lower urinary tract has two functions: the stor- age
of urine at low bladder pressures without leakage; and the
voluntary and complete emptying of urine from the blad- der.
These functions are achieved through complex anatomic,
physiologic, and neurologic interactions.
Neurophysiology
● The somatic system regulates structures that are under
voluntary control, such as the striated external urethral
sphincter and levator ani muscles. The auto- nomic system
regulates visceral functions such as detrusor (bladder muscle)
contraction and relaxation.
● The autonomic system consists of the parasympathetic system
(cranial and sacral segments of the spinal cord) and the
sympathetic system (thoracic and lumbar segments
● Voiding depends on the coordinated activity of the blad- der
outlet (external sphincter, proximal urethra/bladder base) and
detrusor muscle.
● Bladder contraction is mediated via mus- carinic receptors in
the bladder wall.
● In light of the complexity and extensive involvement of the
nervous system, a host of systemic disease processes,
including neurologic disease, and direct trauma, in addition to
medica- tions, can affect lower urinary tract function.
● In summary, normal bladder function requires the blad- der to
accommodate increasing volumes of urine at low pressure with
appropriate sensation and no involuntary con- tractions. The
bladder outlet has to be closed at rest and stay closed with
increase in intraabdominal pressures. The blad- der must then
contract in a coordinated manner of adequate strength as the
bladder outlet resistance at the level of the smooth muscle
sphincter and striated sphincter lowers. This requires intact
local and spinal reflexes and an intact CNS.
Lower Urinary Tract Anatomy and Physiology (Female Continence)
● The bladder consists of the bladder body—the bladder above
the ureteral orifices—and a bladder base consisting of the
trigone and bladder neck. The bladder neck, urethra, and pel-
vic floor musculature make up the bladder outlet
● The continence mechanism in women centers on the proxi- mal
urethra and urethrovesical junction. Continence is main- tained
by multiple structural and physiologic mechanisms that
promote a low-pressure reservoir and higher than storage
pressure outlet, regulate closure of the urethra, and support of
the bladder and urethrovesical junction. Actual closure of the
urethra is produced by the involuntary internal sphincter at the
bladder neck, the voluntary external sphincter muscles of the
urethra, and mucosal coaptation produced by the urethral
submucosal vascular plexus and anatomic attachments of the
urethra and anterior vagina (hammock hypothesis).
● Musculofascial support for the urethra is also important for
continence. Attachment of the midurethra anteriorly to the
symphysis by the pubourethral ligaments and laterally to the
arcus tendineus by the urethropelvic ligaments helps pre- vent
transmission of intraabdominal pressure to the remain- der of
the urethra. The anterior vaginal wall, when intact, provides
posterior support and compression of the midure- thra,
particularly with increased intraabdominal pressure.
● The zone with the highest pressure in the urethra is ap-
proximately at the midpoint of the functional urethral length.
DIAGNOSTIC PROCEDURES
● The clinical history is very useful in the diagnosis of urinary
incontinence.
Urinalysis and Culture
A simple urinalysis and urine culture may provide much in- formation.
● A formal microscopic urinalysis should be carried out to confirm
screening results because urine dip- stick tests can often yield
a false-positive result (such as a urine dipstick test positive for
occult blood), and actual RBCs need to be identified
microscopically before proceeding with a hematuria workup or
urologic referral.
Test for Residual Urine/Postvoid Residual
● Postvoid residual (PVR) testing is a simple procedure can be
extremely helpful in the evaluation of a woman with inconti-
nence with pelvic organ prolapse, voiding symptoms such as
frequency or incomplete bladder emptying, or recurrent UTIs.
● A large PVR suggests urinary retention resulting from inade-
quate bladder emptying as a result of detrusor underactivity,
bladder outlet obstruction, or a combination of the two.
LOWER URINARY TRACT PAIN: ACUTE BACTERIAL CYSTITIS,
BLADDER PAIN SYNDROME/ INTERSTITIAL CYSTITIS, URETHRAL
DIVERTICULUM
Acute Bacterial Cystitis
● Although the term urinary tract infection formally includes both
upper tract (i.e., pyelonephritis) and lower urinary tract infec-
tions, it is most commonly used for bacterial infections of the
bladder and will be used in this section to refer to only bacterial
infections of the bladder. Other commonly used terms are
acute, uncomplicated cystitis (AUC) and acute bacterial cystitis.
UTI is the most common bacterial infection seen in an
outpatient setting.
● Lower urinary tract infections are almost always associated
with some combination of the following: frequency, urgency,
dysuria, suprapubic pain, pyuria, and hematuria. Dysuria is a
highly specific symptom with more than 90% accuracy for UTI
in young women without vaginal discharge and irrita- tion and
no risk of sexually transmitted infection. Symptoms of flank
pain, rigors, nausea and vomiting, and fever should raise
concern for pyelonephritis. In older women, symptoms of UTI
may be less clear. At times, urinary incontinence is associated
with acute and recurrent infections. Although Escherichia coli is
the cause of most UTIs (80% to 85%), myriad organisms,
includ- ing Staphylococcus saprophyticus (5% to 15%),
Enterobacter, Klebsi- ella, Pseudomonas, Proteus,
Streptococcus faecalis, Enterococcus, and Chlamydia, can be
found.
● The presence of bacteria in the urine (bacteriuria) does not
necessarily prove clinical infection. Bacteriuria is fairly common
in women, especially older women. Asymptomatic bacteriuria is
defined as organisms present in the urine that are not causing
symptoms or illness. Cumulative data from several studies
have suggested that 20% of women older than 65 years will
 dem- onstrate bacteriuria, but the percentage increases from
approxi- mately 15% in the 65- to 70-year group to 20% to 50%
for women older than 80 years. Bacteriuria is present in women
who perform chronic catheterization and common in women in
nursing homes who are chronically incontinent. Treatment for
asymptomatic bacteriuria is not recommended, even in older
women or people with diabetes, with no change in their
morbidity or mortality (Mody, 2014). Exceptions exist to this
recommendation if the woman is undergoing an invasive
genitourinary procedure, is pregnant, has a renal transplant, or
is incontinent and her inconti- nence resolves with treatment. If
a woman with asymptomatic bacteriuria becomes symptomatic,
treatment is appropriate.
● After menopause, the vaginal pH rises and may alter vaginal
flora, allowing for the loss of the protective species
Lactobacillus crispatus and the colonization of uropathogenic
species, especially E. coli
● Nitrites indicate that certain gram-negative bacteria have
converted nitrate to nitrite and is highly specific but not
sensitive because it only occurs with gram-negative bac- teria
present.
● Nitrofurantoin monohydrate/macrocrystals twice a day for 5
days (resistance rates of E. coli to nitrofurantoin have remained
low).
● • Trimethoprim-sulfamethoxazole (TMP-SMX) double strength,
● twice a day for 3-day therapy (if local E. coli bacterial
resistance rates are less than 20%). Short-course (3-day)
therapy improves patient tolerability and compliance. This
treatment strategy results in more than a 90% cure rate.
● • Fosfomycin trometamol, 3 g given as a single dose. This may
have slightly lower efficacy than the other two options.
● Fluoroquinolones, although highly efficacious, should be
avoided in AUC because resistance is rising and more con-
cerning side effects have occurred.
Bladder Pain Syndrome (Interstitial Cystitis)
● Bladder pain syndrome, originally called interstitial cystitis
(IC/BPS), is a poorly understood chronic pain syndrome of
unknown cause characterized by genitourinary pain and void-
ing symptoms. IC/BPS is a clinical diagnosis—one of exclu-
sion. Once thought of primarily as a disease of the bladder and
of women, IC/BPS and its association with other chronic pain
syn- dromes suggest that its cause in at least a subset of
patients extends well beyond the bladder. The prevalence in
men has approached that of women in some studies (Suskind,
2013). The diagnosis of IC/BPS should be considered in
patients with chronic pelvic pain.
● persistent or recurrent chronic pelvic pain, pressure or dis-
comfort perceived to be related to the urinary bladder accom-
panied by at least one other urinary symptom such as an ur-
gent need to void or urinary frequency, diagnosed in the
absence of any identifiable pathology which could explain
these symptoms. Interstitial cystitis/Hunner lesion is used when
cystoscopic findings identify a Hunner lesion in con- junction
with the same symptoms as IC/BPS.”
● Society for Urodynamics and Female Urology (SUFU)
(2011)/AUA (2014) IC/PBS Guidelines: “ICPBS is an un-
pleasant sensation (pain, pressure, discomfort) perceived to be
related to the urinary bladder, associated with lower urinary
tract symptoms of more than 6 weeks duration in the absence
of infection or other identifiable causes.”
Diagnosis
● The diagnosis of IC/BPS can be difficult, often resulting in
misdiagnosis and delayed diagnosis. It is a diagnosis of ex-
clusion, and many conditions present with similar symp- toms,
as outlined in Table 21.4. The current definition from the AUA
guidelines, as stated earlier, is typically used as the criteria for
diagnosis.
Treatment
● Because IC/BPS is a chronic pain syndrome with no clear
cause, there is no cure. The goal of patient management is
symptomatic relief and improvement in patient’s quality of life
and functionality. Some patients have to void every 30 to 60
minutes, keeping them from participating in family life, main-
taining a job, and getting adequate sleep. There are multiple
ap- proaches to management of IC/BPS but no one best
approach. Generally an approach should involve working
together with the patient, taking into account her most
bothersome symptoms, limitations (e.g., too much urethral pain
with catheterizations excludes bladder instillations as an
option), and primary goals, works best. Often multimodal
therapy—directing therapy to limiting urothelial irritation,
neuropathic pain (Fig. 21.11), associated pelvic floor
dysfunction, and stress of a chronic illness—has a greater
chance of symptom improvemen
Urethral Diverticulum
● A urethral diverticulum (UD) is a periurethral cystic struc- ture
filled with urine connected to the urethra. UD can be difficult to
diagnose without a high level of suspicion because of the many
ways it can present, from an asymptomatic anterior vaginal wall
mass incidentally noted on pelvic examination to a history of
years of poorly defined pelvic pain, incontinence, and
dyspareunia. True UD prevalence is unknown, but series have
reported occurrence ranging from 1% to 6% of women. There
have been reports of congenital UD in young children, but UD
is more commonly found in patients between ages 20 and 60
years. Some data suggest that UD may occur more often in
African American women than in Caucasian women.
● A variety of causes for UD have been suggested, including
congenital, traumatic, and inflammatory. The exact cause of
UD is still unknown, but most are thought to be acquired from
infection, inflammation, and obstruction of the periurethral
glands. Evidence for this comes from anatomic observations
not- ing that the periurethral glands are located primarily
dorsolateral to the urethra with their ducts located in the distal
one-third of the urethra; periductal and interductal inflammation
is common. In more than 90% of UD cases the ostium is
located posterolat- erally in the mid- or distal urethra, which
corresponds to the anatomic location of the periurethral glands.
Several authors have suggested that gonococcus is the cause
of this condition, but E. coli and other organisms have been
found in such processes. Reinfection, inflammation, and
recurrent obstruction of the gland ostia are thought to result in
patient symptoms and en- largement of the gland sac with
eventual rupture of the now ab- scessed cavity into the urethral
lumen and UD formation. UD can be fairly small and simple or
markedly complex, multiple, and large, extending up to the
bladder neck dorsally or wrapped around the entire urethra with
the urethral connection, tiny, tortuous, and difficult to find.
Because of the location and size of the UD (i.e., near or
involving urinary sphincter), varying de- grees of urinary
sphincteric compromise may occur, which needs to be
considered before surgical repair.
Symptoms and Signs
● Historically the classic patient with UD has been said to present
with the “three Ds,” dribbling (postvoid), dysuria, and dyspareu-
nia; however, the most common symptoms associated with UD
 are bladder or urethral pain, urinary frequency, urgency, and
infection. One-third of patients present with recurrent cys- titis;
thus the presence of a urethral diverticulum should be con-
sidered in those patients with recurrent cystitis. Hematuria,
vagi- nal mass, vaginal discharge, urinary incontinence (often
without activity or urge to void), slow urinary stream, and even
urinary retention may be presenting complaints. As many as
20% of pa-tients with UD may be asymptomatic, with the UD
found inci- dentally on examination or on imaging. On occasion
stones may be found in the diverticulum from urinary stasis,
and there have been rare reports of cancer involving a UD.
Diagnosis
● With its wide range of presenting symptoms, UD diagnosis is
often not suspected until a physical examination is performed,
when, with careful palpation of the anterior vaginal wall, ten-
derness or a mass is found. UD is most often found at the mid-
and proximal portions of the urethra. More distal cystic masses,
often distorting the urethral meatus, are more likely Skene
gland cysts or abscesses. Purulent material, blood, or cloudy
urine may be expressed as the urethra and mass are mas-
saged. Imaging for UD includes the double-balloon positive
pressure urethrogram (more historic, rarely used because of
the availability of specialized catheters and because of patient
dis- comfort), voiding cystourethrogram (VCUG), transvaginal
ultra- sound, and magnetic resonance imaging (MRI) (Fig.
21.12, A). MRI is typically the preferred study for UD because it
is rela- tively noninvasive, does not require the patient to void,
and, with cross-sectional imaging, offers the most detailed
anatomic study of the diverticulum, urethra, and surrounding
anatomy. Other tests that can aid in diagnosis and treatment
planning include urine analysis and culture; cystourethroscopy,
which can elimi- nate other causes of urinary symptoms and at
times allow visual- ization of the UD ostium; and urodynamics
because 35% to 50% of patients have urinary incontinence.
Treatment
● Asymptomatic UDs do not require treatment, although lit- tle is
known about the natural history of untreated UD. Carcinoma
arising in UD has been reported, so patients should be
counseled appropriately. Mild symptoms of frequency and
urgency can be treated with anticholinergics and infections with
antibiotics. A variety of procedures have been described for the
management of UDs, including transurethral and open
marsupi- alization, fulguration, and, most commonly, excision
of the diver- ticulum with reconstruction. An open
marsupialization tech- nique, in which the diverticulum is
opened and sutured to the vaginal epithelial surface, generally
leads to a fistula, making this technique useful only in rare
circumstances such as a grossly in- fected diverticulum with
possible need to return for secondary closure of the fistula or
with a distal diverticulum, where vaginal voiding is not a
significant issue.
● Transvaginal diverticulectomy is the more common pro-
cedure. An incision is made in the anterior vaginal wall; many
surgeons prefer an inverted U-shaped incision (with the apex of
the U at the distal urethra), which prevents overlapping suture
lines and can be extended proximally as needed. A transverse
inci- sion is made in the periurethral fascia, preserving it to be
an in- tervening layer between the urethra and vaginal wall.
The diver- ticular sac is dissected free from the periurethral
fascia. Dissection is carried to the diverticular neck, which is
then excised. Often the Foley catheter is seen through the
defect in the urethra. The urethra is closed with absorbable
suture, usually in a longitudinal direction. The periurethral
fascia is then closed transversely, of- ten overlapping edges to
take up redundancy and close dead space. Next the vaginal
incision is closed (Fig. 21.12, B). The bladder is drained with a
urethral Foley catheter. Some surgeons place a suprapubic
tube for drainage as well, but this should be placed at the start
of the case to prevent disruption of the re- paired urethra.
● Postoperative bladder spasms are common and treated ag-
gressively with antispasmodics. Catheters are usually left in
place
Complications
● Complications from urethral diverticulectomy include re- current
UTIs, urinary incontinence, urethral stricture, ure- throvaginal
fistula, and recurrent UD.
URINARY INCONTINENCE
● Urinary incontinence (UI) is simply the involuntary loss of urine.
● There are several types of incontinence, in- cluding stress
incontinence, urgency UI, mixed UI, overflow in- continence,
continuous incontinence, and nocturnal enuresis. Identifying
patients with UI and determining their type of incon- tinence
and their treatment goals allows for appropriate patient and
provider discussion of available treatment options.
Treatment
● Conservative Management: Pelvic Floor Muscle Strengthening
● Conservative measures should be discussed and offered to all
women with stress incontinence (Box 21.4). The first-line
treatment is pelvic floor muscle training (PFMT) directed toward
the strengthening of the levator ani and pubococcygeal
muscles, which affect the urethral closure mechanism.
● Patients, however, must be able to localize their pelvic floor
muscles and exercise them correctly and regularly to see ben-
efit.
Conservative Management: Devices
● An incontinence pessary (Fig. 21.15, A) is a silicone ring de-
vice with a knob placed in the vagina, with the goal of stabi-
lizing the urethra to eliminate hypermobility and increase
urethral pressure during increases in intraabdominal pres-
sure.
● Conservative Management: Weight Loss
● Weight loss in women who are overweight or obese signifi-
cantly reduces urinary leakage, as shown in a randomized
controlled trial
Surgical Management
● Surgery is thought to be the most effective and durable long-
term therapy for SUI; however, it is associated with significant
potential complications. Treatment for SUI is elective, and often
the patient’s goal is to be better but not perfect
Surgical Management: Midurethral Slings
● Minimally invasive midurethral synthetic slings have become
the surgical procedure of choice for most women with SUI and
their surgeons as a result of their excellent cure rates, overall
low complication rates, minimal recovery time, and high patient
satisfaction
● Postoperative Voiding Trial
● It is usual postoperatively to check a woman for residual urine
after she voids because she has a 24% chance of need- ing a
catheter for temporary urinary retention after surgery
URGENCY URINARY INCONTINENCE/OVERACTIVE BLADDER
● Overactive bladder is a syndrome defined by the symptoms of
urinary urgency, with or without urge incontinence, usually with
frequency and nocturia in the absence of UTI or other
pathologic condition. Urgency is the complaint of a sudden
compelling desire to pass urine, which is difficult to defer,
 ● usually because of a fear of leakage if not actual leakage.
Urgency UI (UUI, or simply urge incontinence) is the complaint
of invol- untary leakage of urine accompanied by or
immediately preceded by urgency. OAB is generally chronic,
and symptoms may wax and wane. OAB is often slowly
progressive and associated with an urgency-frequency problem
that is usually accompanied by pain- less, involuntary, large-
volume urine loss. Rarely an event usually associated with
stress incontinence, such as coughing, triggers this urge
incontinence, but it is generally delayed until seconds after the
increase in abdominal pressure has occurred. Large-volume
urine loss is more characteristic of urge incontinence compared
with stress incontinence. Stress incontinence often disappears
when the woman is recumbent, but urge incontinence
continues, often with nocturia. Table 21.5 summarizes the
differences in symptoms. OAB occurs in approximately 17% of
the popula- tion, and the incidence increases with age. OAB
patients have a lower quality of life than women with stress
incontinence. Differential diagnoses include pathologic
conditions of the urinary tract, IC/BPS, polydipsia, polyuria,
nocturnal polyuria syndrome, diabetes insipidus, atrophic
vaginitis, and medical conditions that are associated with
nocturia (e.g., vascular or sleep disorders).
● Detrusor overactivity is a urodynamic observation; it is the
result of sudden, spontaneous (involuntary) detrusor
contraction and has previously been termed detrusor
hyperreflexia, unstable bladder, and detrusor instability. The
term idiopathic detrusor overac- tivity is used as a urodynamic
definition when there is no defined cause of the condition. If a
neurologic disorder, such as stroke, Parkinson disease,
multiple sclerosis, spinal cord injury, or an- other CNS
pathologic condition is present, the term neurogenic detrusor
overactivity is appropriate. In older women, urgency and
incomplete bladder emptying can coexist. Dribbling often re-
sults. This condition is termed detrusor hyperactivity with
impaired contractile function (DHIC), and these two conditions
may have different causative factors.
Etiology
● The increased bladder sensation in OAB is likely increased
sensory activity in the afferent nerve endings in the bladder
wall. The involuntary loss of urine with UUI/OAB explained by
the neurogenic hypothesis is a result emergence of
inappropriate excitation of bladder muscle during storage,
which implies a loss of inhibition from the CNS, reemergence of
primitive spinal reflexes, acquisition of new reflexes, or
sensitization of sensory afferent nerves (de Groat, 1997). The
integrative hypothesis sug- gests that a range of triggers can
generate localized detrusor contractions (“micromotions”) that
spread in the bladder wall and, if they become coordinated, can
result in involuntary blad- der contractions.
● Aging, neurologic disease, female gender, bladder outlet
obstruction, and metabolic diseases are associated with a
higher prevalence of OAB and thus potential influences on
OAB etiology. OAB prevalence has been reported as 11.8%,
with UUI prevalence estimated at 1.7% to 36.4% in U.S.
populations (Milsom, 2014). In women the prevalence of UUI
rose from 2% in those aged 18 to 24 to 19.1% in those aged 65
to 74 years.
● Diagnosis
● The AUA/SUFU 2019 guidelines for OAB recommend that clini-
cians engage in a diagnostic process to document symptoms
and signs that characterize OAB and exclude other disorders
that could be the cause of the patient’s symptoms. Minimum
requirements in- clude a careful history, physical examination,
and urinalysis. Other procedures and workups could include a
urine culture, PVR urine measurement, and home, patient
collected. Urodynamics, cystos- copy, and ultrasound imaging
should not be used in the initial workup of a patient with an
uncomplicated situation. A bladder diary such as that shown in
Fig. 21.7 can be useful in diagnosing OAB because it can
document frequency (more than eight daytime voids), nocturia
(more than one nighttime void), and episodes of inconti- nence
preceded by urgency. Additional information can be obtained
about incontinence related to activity (stress incontinence), fluid
intake, types of fluids ingested, pad usage, and voided volumes
(a measure of bladder capacity). The ideal diary duration has
yet to be established, but 1 to 3 days is generally
recommended. Urody- namic testing is not recommended for
the uncomplicated patient suspected of having OAB because
30% to 40% of these studies will be negative in patients with
known idiopathic OAB, possibly as a result of increased
inhibition in the test situation. History is the most sensitive
indicator for UUI/OAB in these patients.
Treatment: Behavioral—First Line
● Behavioral therapy is first-line treatment. Behavioral manage-
ment includes fluid management, avoidance of bladder irritants
(caffeine, carbonated beverages, diet beverages, and alcohol),
weight loss, smoking cessation, PFMT, and bladder training.
● Although women with urge incontinence may experience less
benefit from PFMT than women with stress inconti- nence,
there did appear to be improvement and few adverse effects.
● Treatment: Pharmacologic—Second Line
● Anticholinergic (antimuscarinic) or beta3-adrenergic recep- tor
agonist drugs may be useful; Table 21.6 shows currently
available drugs.
● ement but not health-related quality of life (Burgio, 2000).
● Overall, in clinical studies, antimuscarinic drugs reduce
incontinence episodes by 60% to 75%, but only 20% to 40% of
patients have no incontinent episodes. Although efficacy has
been proven in many randomized trials, poor patient compli-
ance is often found with these medications because of contin-
ued incontinence, expense without cure, and anticholinergic
side effects.
● The newer beta3-adrenergic agonist drug mirabegron has
similar efficacy
● Low-dose vaginal estrogens are approved for vaginal at- rophy,
and studies do suggest improvement of urinary fre- quency,
urgency, and possibly urge incontinence. Systemic estrogens
may worsen incontinence.
Mixed Urinary Incontinence
● As the term implies, mixed urinary incontinence means that a
woman complains of both stress and urge incontinence—
involuntary loss of urine with urgency and with physical exer-
tion, sneezing or coughing. Mixed incontinence may be urge
predominant, stress predominant, or equal. The pathophysiol-
ogy and treatment of mixed incontinence have not been well
studied despite the fact that it accounts for one-third of incon-
tinence complaints. Pelvic floor muscle exercises and
behavioral training are appropriate first-line therapies for both
types of incontinence (see the stress and urge incontinence
sections presented earlier). Usually women can articulate
which problem is worse, and treatment can begin for their more
bothersome symptom, stress or urgency. The literature
supports trying anti- muscarinic drugs in urge-predominant
mixed incontinence, which in one trial significantly reduced
incontinence episodes similar to those with pure urgency
incontinence. A systematic review and meta-analysis of
 midurethral slings in women with mixed UI showed an overall
subjective incontinence cure rate of 56% among women, with a
follow-up of 3 years.
● The patient with mixed incontinence who undergoes surgery for
her incontinence is often disappointed to still be leaking
because the urge compo- nent has not improved. The risk of
having persistent detrusor overactivity after surgery must be
discussed and emphasized during preoperative counseling.

Other Types of Urinary Incontinence

● Nocturnal enuresis is the complaint of loss of urine during
sleep. The term continuous urinary incontinence is the
complaint of continu- ous urine loss, day and night. This type of
incontinence is typically seen with fistula of the lower urinary
tract. Insensible UI is the com- plaint of urine loss when the
patient is unaware of how or precisely when the urine loss
occurred. Postural UI occurs with change in body position,
such as going from sitting to standing or getting out of bed from
being supine. Coital UI can occur with penetration or
intromission and/or at orgasm. Extraurethral incontinence is a
sign rather than a symptom and is defined as the observation
of urine leakage through channels other than the urethra, such
as the vagina or colon, and may be seen with urinary fistulas or
ectopic ureters.
● Overflow incontinence is the complaint of UI in the symptomatic
presence of an excessively full bladder with no cause
identified. Overflow incontinence usually occurs in the face of
chronic (typi- cally not painful) retention rather than acute
retention, because these latter patients are typically in pain and
are unable to void at all. Overflow incontinence occurs when a
bladder does not empty well either because the bladder is not
contracting (detrusor under- activity) or the bladder outlet is
obstructed or some combination of both, resulting in a full
bladder. The problem may be caused by a neurologic disorder
that interferes with normal bladder reflexes, neuropathy,
myogenic failure, or obstruction of the urethra. Typi- cally a
woman with overflow incontinence complains of small, poorly
defined leakage episodes and small voids, possibly with
increased frequency, a slow stream, and still feeling that there
is urine in her bladder. The bladder usually is not painful and
may be palpable after the woman has voided. The diagnosis is
made when there is persistence of a significant amount of urine
left in the bladder after voiding (PVR), as confirmed with
ultrasound bladder scanning or catheterization.
● In women this is most often seen after incontinence surgery;
the patient’s outlet resistance now too great for her detrusor
muscle action, resulting in bladder outlet obstruction and thus
retention. This can also be seen in female patients with a
neuro- logic disease such as multiple sclerosis, diabetes, with
certain medications, and trauma or tumors of the CNS and
PNS. A complete general medical and urologic workup is
necessary to clarify the patient’s condition. Therapy directed at
the primary cause may be beneficial, such releasing a
suburethral sling that is obstructive. If the cause is unclear or
irreversible, the patient will need bladder drainage, which can
be achieved by mechanical drainage with ei- ther intermittent
self-catheterization or an indwelling catheter— preferably a
suprapubic tube if it will be chronic, to prevent the risk of
urethral erosion with urethral catheters. Sacral neuro-
modulation is FDA approved for women with idiopathic urinary
retention. Alpha-blockers used for men with prostatic hypertro-
phy are not FDA approved for women and rarely work