MBBS IV O&G Case 4

Theme IV - Urinary incontinence & pelvic organ prolapse

Human Biology in Health & Disease

 Describe the typical symptom & sign of urodynamic stress incontinence (see footnote
at end of paper) & pelvic organ prolapse & their common association in a woman
 List the predisposing factors for pelvic floor dysfunction
 Describe the basic investigations for urinary incontinence & pelvic organ prolapse

Professional Skills: Diagnostic, Problem Solving, Effective Communication & clinical

Management

 Elicit clinical histories & conduct examination in an organized manner in women with
pelvic floor dysfunction
 Discuss the usual indication for surgical & non-surgical management for pelvic organ
prolapse & stress incontinence
 Counsel patients & discuss the importance of their family’s support in the clinical
management

Population Health, Health Services, Economics & Policy

 Aware that genital prolapse & incontinence are important primary health problems of
women
 Provide information & educate women to promote pelvic floor function

Medical Ethics, Professional Attitudes & Behavior

 Aware that although genital prolapse & urinary incontinence are NOT life-threatening
condition, they can affect the quality of life of a woman
 Liaise with other allied health professionals in the provision of care

Suggested readings:

Gynaecology by Ten Teachers

Stuart Campbell & Ash Monga
18th Edition, Arnold
MBBS IV O&G Case 4

Case presentation
Mrs. Wong was a 66 years old post-menopausal lady who presented to the gynaecological ward with
urinary retention. Her past health included chronic obstructive airway disease & DM with mild renal
impairment.

She noticed a mass coming out through the introitus for 2 years & recently it had got bigger. She also
had urinary frequency & sensation of incomplete emptying. She needed to strain when passing
urine & sometimes required manual reduction of the mass in order to void.

Problems: 1. Mass complaint, 2. Urinary symptoms (if have urinary symptoms – more likely to
involve the anterior compartment)

(1) What is your differential diagnosis of Mrs Wong’s gynaecological problems?

 1. Genital prolapse (mass, urinary symptoms)
o Uterine prolapse
o Vaginal prolapse
 2. Cystocele (descend of bladder base) -> urinary retention
o result of weakening of the pelvic floor muscles
 3. Rectocele
 4. Weakening of the pelvic floor (etiology = difficult to diagnose)
 5. Large cervical polyp (usually premenopausal)
 6. Fibroid polyp (leiomyoma) (can get very large, usually in premenopausal; fibroids usually
estrogen sensitive; during pregnancy – lots of estrogen  thus result in enlarged fibroid) (in
post-menopausal state, no estrogen – hormonal shutdown; thus fibroids are usually smaller)
o Quite uncommon for protrusion; more common in pedunculated submucosal type
o Location: 1. Submucosal (mucosal lining), 2. Subserosal (serosa), 3. Intra-mural
 7. Leiomyosarcoma (sarcomatous changes  malignancy; rare)
 8. Endometrial polyp (less likely, usually very small)
 9. Rectal prolapse (from the anus, in surgery)
 10. Femoral hernia (to vulva area; would be reducible; may develop into strangulation)
 11. Malignancy: vulva cancer, vaginal cancer (correlate with history) (usually ulcerated,
bleeding)
 12. Urinary symptoms: need to exclude urinary tract infection (common, easy to exclude) (can
be co-existing since risk factors)
 *Types of genital prolapse (pelvic soft tissue - muscles and ligaments – holds organ in place
= pelvic floor (muscles); weakened in trauma/ageing  result in prolapse)
o Anterior compartment
 Cystocele
o Central compartment
 Uterine prolapse
 Vaginal prolapse
o Posterior compartment
 Rectocele
*POP-Q: standardize the extent, involvement of prolapse
MBBS IV O&G Case 4

2) What other questions would you like to include in the history taking? What particular
examinations would you like to perform?
History:
 History of present illness: constipation (chronically increased intra-abdominal pressure)
 Obstetric Hx – parity & mode of delivery, instrumental delivery, macrosomia, perineal
laceration (4th degree – involve rectum and rectal mucosa → need surgical repair to prevent
fistula formation)
o Vaginal delivery: laceration of perineal muscles
o Instrumental delivery: traumatic, severe perineal tear (3rd degree, 4th degree (to anal
muscle and including pelvic floor muscle)

o Caesarean delivery
 Past medical history: Gynecological Hx – hysterectomy; chronic cough (COPD) – optimize
medical disease (smoking habits, compliance); surgical history (fit surgical candidate?);
recurrent prolapse (30% are recurrent)
 Bowel symptoms: involves posterior compartment? constipation?
 Urinary symptoms (eg. stress urge incontinence)
 Effect on daily activities: weight bearing activities (treatment aim – improve QoL)
 Post-menopausal bleeding – decubitus ulcer, abrasion in pelvic organ prolapse (very severe)
 Social Hx – occupational (need of heavy lifting)  lifestyle modification, alcohol, smoking,
drink preferences (tea, coffee – diuretic effects), sexual history
 Drug hx: diuretics (urinary frequency)
 Types of incontinence
 1. Stress incontinence: increase intra-abdominal pressure (pelvic floor weakened, sphincter
falls below; cannot protect increase intra-abdominal pressure)

 2. Urge incontinence (unstable or overactive bladder, or detrusor instability): urinary

frequency, (detrusor is the bladder muscle – problem with storage; detrusor should NOT be
actively contracting when storing urine) (function of bladder: 1. Storage, 2. Voiding)
 3. Overflow incontinence: rarer, more common in males  obstruction and cannot pee out
MBBS IV O&G Case 4

Physical Examination:
 General examination
o BMI (body weight, height, blood pressure, urinary dipstick)
o Blood pressure: hypertension (potentially taking diuretic drugs)
o Body weight and height: obesity is a risk factor (increase abdominal pressure)
o Urinary dipstick: urinary tract infection, protein, nitrate
 Abdominal examination: check for pelvic mass (extremely large abdominal mass may result
in increased intra-abdominal pressure  enlarged uterus), scars (past surgical history),
distension, bladder distension
 Vaginal examination – Sims speculum (insert into anterior compartment to observe posterior
compartment; insert anterior and posterior to observe central compartment and see if the
uterus drops) and bivalve speculum (modified Sims position instead of lithotomy position)
 Demonstrate urinary incontinence

She had 2 children & both were delivered vaginally. She suffered from chronic constipation which
she only opened her bowel every five days with help of laxatives. Apart from the above-mentioned
urinary symptoms, she occasionally leaked urine when she sneezed & walked fast. Because of the
urinary symptoms & the dragging discomfort, she had restricted herself from going out. She had to
go to toilet every 30 minutes & had to wear sanitary pad for protection for fear of leaking urine.

Her BMI was 35. The abdomen was obese & no mass was felt. Vaginal examination on straining
revealed a moderately big cystocoele beyond the introitus. The cervix descended to 1cm beyond
the introitus. There was evidence of urine leakage upon straining (stress incontinence). The uterus
was small & the adnexae were clear. The bladder was full & palpable in the suprapubic region.
Typically mass disappear in the morning after assuming supine position throughout the night

(3) List risk factors for her problems.

 Age (elastin degeneration)
 Menopausal (lack of estrogen -> weakening of pelvic floor)
 Multiparity (vaginal delivery, weaken pelvic floor)
 Obesity (intra-abdominal pressure)
 Chronic cough (intra-abdominal pressure)
 Chronic constipation (intra-abdominal pressure)
Pathophysiology: 1. Weakened floor, 2. Increased intra-abdominal pressure

(4) What is a cystocoele (膀胱膨出)? Is it responsible for her urinary retention?

 Cystocele: any abnormal descent of the anterior vaginal wall & bladder base at
rest or on straining is considered a cystocele.
o Urinary bladder pulled downwards; but urethra is fixed  “kinked” 
difficulty voiding (pressed upwards may relieve and make it easier to pee)
o Once restore anatomy, may result in stress incontinence because after
“kinked”/ “stretched” – disturbed anatomy
 A very big cystocele causes symptoms suggestive of urinary outflow obstruction &
voiding difficulty because of possible kinking (扭結) of the urethra. That is why
some women with big cystocele need to digitally reduce the mass in order to initiate
voiding.
 Any kind of POP can cause urinary retention by kinking of urethra.
 =Urgency and frequency (due to difficulty voiding)
MBBS IV O&G Case 4

(5) What is the likely clinical diagnosis for her urine leakage (stress incontinence) & what can
be the underlying pathophysiology for this condition?

 History is suggestive of urodynamic stress incontinence (USI).

The underlying etiology is usually related to an:

(1) increased bladder neck mobility as a result of decreased pelvic floor support and/or
(2) intrinsic sphincter deficiency as a result of poor urethral closure mechanism.

The typical symptom is involuntary leakage of urine during coughing, sneezing, laughing, heavy
lifting & running-activities during which the intra-abdominal pressure increases.

The patient may also have other urinary symptoms like frequency, urgency & occasionally urge
incontinence although the latter is a more typical symptom in detrusor overactivity.
Urodynamic stress incontinence is now the preferred term to “genuine stress incontinence”.
Idiopathic detrusor overactiviry is preferred to “detrusor instability”.

(6) What will be your immediate action?

1. Because this patient has a big cystocele & urinary retention (normal genital prolapse do
not need to be admitted), Foley’s catheter (or suprapublic catherization) should be inserted
to empty the bladder & catheterized urine should be sent for culture & sensitivity to look
for occult urinary tract infection. Chronic retention of urine may lead to increased
susceptibility to UTI.
2. The cystocele should be reduced manually & a ring pessary (環子宮托) should be inserted
as a temporary measure to lend support the pelvic structures (Diagram C). the patient
should try voiding with the ring pessary in-situ & the post-void residual urine volume
should be checked to exclude any significant amount of urine retention. This can be
checked by bladder USG.
o Can have sex with ring pessary on but the husband may NOT like it as it feels like
something is blocking the vagina.
o Types of ring pessary
 1. Supportive
 2. Space occupying
o Advantages: no surgery, no surgical complications
o Disadvantages: changed every 6 months, vaginal discharge, infection, ulceration
o Indications:
 Lack of perineal body, resulting in less “tight” vagina  pessary may fall out
easier (vagina elasticity  can expand as support;)  may use space
occupying pessary (cube pessary)
MBBS IV O&G Case 4

(7) What will be your discharge plan?

1. Advise Mrs Wong to complete a frequency-volume chart/ voiding diary for at least 2-3
consecutive days (Diagram D). This is informative for the doctor & the patient & may
indicate excessive fluid intake as a cause for the urinary complaints. It also provides
information on the functional bladder capacity if the volume of urine is measured, the
severity of the incontinence in terms of frequency of leakage accidents & the severity of the
incontinence in terms of frequency of leakage accidents & the severity of leakage, & the
type of fluid (eg. tea/ alcohol/ caffine in take which may cause dieresis & aggravate the Sx
of frequency), that the patient drinks in a day.

2. Discuss with Mrs. Wong the options of treatment, Ring pessary needs to be changed every
6 months. It is NOT a curative treatment & has the risks of falling out, ulceration and/ or
infection. Surgery is a definitive treatment but there is a small chance of recurrence &
surgical risks (vaginal hysterectomy and pelvic floor repair).

3. Arrange urodynamic study (specifically cystometry) if surgery is planned for the genital
prolapse. Cystometry (膀胱測壓) is recommended before surgery in the presence of urinary
incontinence if:
o There is clinical suspicion of detrusor overactivity (Sx of urinary frequency,
urgency); or
o There are symptoms suggestive of voiding dysfunction; as these urinary symptoms
may worsen after operation.
 Also advise lifestyle modifications
o Avoid weight bearing exercises
o Control COPD: better cough control
o Smoking cessation
o Weight reduction (dietician)
o Drinking habit (coffee/tea, frequency of drinking)
 Pregnancy is the only circumstances in which POP may be reversed

Mrs. Wong opted for ring pessary as she noted significant improvement in her urinary symptoms &
dragging discomfort with the conservative treatment. She was discharged home the next day & was
scheduled to be seen in 1 month time to review her symptoms & the frequency-volume chart.

(8) What are the common indications for non-surgical management of genital prolapse &
stress incontinence?

In general, conservative non-surgical treatment is indicated when:

MBBS IV O&G Case 4

(a) the symptoms of prolapse & incontinence are NOT bothering the woman
(b) patient is medically unfit for surgery
(c) patient does NOT wish to undergo surgery
(d) patient is keen for non-surgical treatment
(e) during pregnancy

Conservative measure for prolapse usually involves the insertion of a ring-like plastic pessary
diagram D); & for SI, pelvic floor muscle exercise (Kegel’s exercise).

Mrs. Wong came back 2 days following discharge because the ring pessary fell out when she opened
her bowel. A new ring pessary was inserted, but it fell out shortly afterwards. She now decided to
undergo surgery & a cystometry has been arranged in our unit.

(9) What is cystometry? – storage function

 Patient will be in a room: connected to several catheter (rectal catheter – intra-abdominal pressure,
vaginal pressure cathether; bladder pressure catheter)
 Bladder pressure – abdominal pressure = detrusor pressure (observe if the detrusor muscle
contracts  overactive bladder) (when the bladder is full  will ask to cough – presence of
leakage) (detrusor muscle is flat without contraction = stress incontinence)

 Collection of urine

Cystometry provides measurement of the pressure-volume relationship within the bladder

during the filling phase or the voiding phase. It is usually undertaken in conjunction with
uroflowmetry (another simple urodynamic test usually performed before cystometry) = should
be bell shaped (smoothless of the curve, length of curve to see if there is any obstruction)

Method: The bladder is filled with physiological saline / water via a transurethral catheter at a
rate of between 20-100 ml/min. The patient can be in the supine, sitting or standing position. The
MBBS IV O&G Case 4

intravesical (total bladder) pressure is measured via narrow fluid-filled catheter which is
connected to an external pressure transducer. The intraabdominal pressure is measured via
another fine fluid-filled catheter placed in the rectum, similarly connected to another transducer.

The detrusor pressure (the pressure generated by detrusor muscle contraction) is derived by
subtracting the intraabdominal pressure from the intravesical pressure (i.e. Pdet = Pves – Pabd).
Normally, the intravesical pressure should NOT rise during bladder filling & detrusor
contraction should NOT occur even if the bladder is provoked by various triggers e.g. cough,
or body movement.

The patient will be instructed to cough maximally (a few times) when the bladder is full (usually
in the standing position) in order to demonstrate visually the presence of leakage from the urethra
simultaneously at the time of cough. If this is positive & there is no detrusor contraction noted
in the tracing, the diagnosis of urethral sphincter incompetence is confirmed urodynamically
(hence the term urodynamic SI).

Cystometry is important to diagnose & differentiate leakage due to detrusor overactivity or

USI (urinary stress incontinence). Other useful information that can be obtained from cystometry
during filling include bladder sensation, capacity & compliance. If the patient is asked to void
into a special commode (with the bladder & rectal catheters in-situ); the voiding pressure can be
obtained during voiding.

(10) What is the diagnosis from the filling phase cystometrogram (refer to diagram C)?
USI (as leakage of urine is visualized & denoted on the tracing at the time of the coughing effort
& there was no detrusor contraction at time of leakage).

(11) Would you support Mrs. Wong’s decision of undergoing operation in view of her multiple
medical problems?

Adequate pre-operative counseling is important so that Mrs. Wong can make an informed
consent. It is a good practice to involve her family members during the discussion if the patient
agrees.
These include detailed discussion on the indication, nature & risks associated with the surgery &
anesthesia, esp. in view of her increased surgical & anesthetic risks related to her medical illness,
& increased recurrence rate due to chronic cough & constipation.
The genital prolapse & urinary incontinence are NOT life-threatening conditions, but the degree
of impact on her quality of life could be huge.
Hence she needs to strike a balance between the risks & benefits of surgery.

Sufficient time should be provided for the patient to think about the operation.

Adverse factors for pelvic floor dysfunction in this patient have to be modified, if possible
(e.g. avoid constipation, optimize her control of COPD, reduce weight). Vaginal estrogen cream
in a postmenopausal woman is recommended by many gynecologists before pelvic surgery to
improve vaginal atrophy & postoperative tissue bleeding.

Mesh repair available, no need hysterectomy, push organ back inside pelvic floor
MBBS IV O&G Case 4

Hysterectomy considered if uterine prolapse

Also tell pt that not all of her symptoms may go away, esp stress incontinence may require
another surgery (eg. urethral sling)

Benign condition  impact on QoL

MBBS IV O&G Case 4
MBBS IV O&G Case 4

Diagram E

urine
L= Leak
MBBS IV O&G Case 4
MBBS IV O&G Case 4

Sim’s Speculum used (easier to see prolapse):

Prolapse object ddx:
Uterine prolapse (can see cervix too because content fall anteriorly down)
- Have a hole in the fallen content
- Most common
Cystocele (common too but uterine prolapse more common)
- Causes kincking/ twising of the urethra
Rectocele (PR can feel your finger from the vagina) - rare

Hx:
1. ? Bleeding (erosion/ rupture)
2. ? urinary symptoms (urinary retention: because blocked urethra)
a. Can give manual reduction
3. ? bowel symptoms (too big mass effect -> can’t poop)
4. Effect to daily living

Stress incontinence (咳/ 追巴士/跳 -> 滲尿)

Urge incontinence (忍唔忍到)
Nocturia

P/E:
1. BMI
2. Abdom: mass?
3. Prolapsed mass any bleeding?
4. Demonstrate stress incontinence

General Stress Incontinence

Detrusor instability (constant contraction so feel urge to urinate)
Urge incontinence (
Urofometry used to differentiate between stress & urge urinary incontinence

Surgery:
 Hysterectomy
 Pelvic floor repair: push bladder/ fallen down mass back up -> sew together & keep it there.

Vaginal wall prolapse;

 Put ring pessary (first line)
 Laparoscopic Sacrocolpopexy

Different degree of vaginal prolapse:

MBBS IV O&G Case 4

4th Degree when cannot retract/ push the vagina back

Uroflometry: measure the voiding volume to see if have any obstruction = should be bell
shaped

Oestrogen cream: symptomatic treatment only (not definitive)

 Type of hormonal replacement therapy (HRT)
 Risk: thromboembolism, CA breast

GSI (general stress incontinence) treatment:

 1st line: Pelvic floor exercise (忍尿)
 2ns line: surgical Tx
o Tension free vaginal tape (can be placed in different method)
o If bind too type -> urine retention -> OT again
o Risk: perforation

USI operation

Detrusor over activity:

 OT never definitive, can only reduce the severity.
 Medical treatment- anti-cholinergic (oxybutanin)
 Oxybutynin reduces muscle spasms of the bladder & urinary tract.
 Oxybutynin is used to treat symptoms of overactive bladder, such as frequent or urgent urination,
incontinence (urine leakage), & increased night-time urination.