UROGYNECOLOGY

ANN MARGRETTE A. MADRID, MD

 TOPICS

• Pelvic anatomy
• Pelvic organ prolapse
• Urinary incontinence
 INTRODUCTION

• Downward displacement of central pelvic organs that are normally located at the
level of or adjacent to the vaginal wall
• Failure of the suspensory and supportive structures of the pelvic organs
• “pelvic hernia”
• Common condition; affects women as age advances (postmenopausal)
• Low mortality, but high morbidity
• Progressive disease (until menopause)
• Prolapse increased and regressed by 2cm in 11% of women respectively

Te Linde’s Operative Gynecology

UptoDate 2021
 ANATOMY

• BONY PELVIS
- Provides the surfaces
attachment for the muscles
and the ligaments
 ANATOMY

• PELVIC DIAPHRAGM
- The dynamic floor of the pelvis
that contracts tonically and
reflexly to support the pelvic
organs as well as maintain urinary
and fecal continence
 ANATOMY

• PELVIC DIAPHRAGM
- Levator plate
- Innervated by the
branches of the S1-S3
nerves and pudendal
nerve
 ANATOMY

• ENDOPELVIC FASCIA
- Fibromuscular sheath composed of collagen,
elastin and smooth muscles that is continuous
with the vagina, cervix and lower portion of
the uterus
- It envelops these organs and attaches and
suspends them to the pelvic walls
DELANCEY’S THREE LEVELS OF
SUPPORT

LEVEL I: PARAMETRIUM
- CARDINAL UTEROSACRAL
LIGAMENT COMPLEX
(PROXIMAL OR APICAL
VAGINAL)
DELANCEY’S THREE LEVELS OF
SUPPORT

LEVEL II: PARACOLPIUM

- PUBO- CERVICAL AND RECTO-
VAGINAL FASCIA (MIDVAGINAL)
- ATTACHES THE ANTERIOR AD
POSTERIOR VAGINAL WALLS TO
THE LATERAL PELVIC SIDEWALL
DELANCEY’S THREE LEVELS OF
SUPPORT

LEVEL III:
- PUBO-URETHRAL LIGAMENTS
ANTERIORLY & THE PERINEAL BODY
POSTERIORLY (DISTAL)
- FUSION OF THE ENDOPELVIC
FASCIA OF THE VAGINAL WALLS WITH
THE SURROUNDING STRUCTURES
 ANATOMY
MECHANISM OF PELVIC SUPPORT

• ENDOPELVIC FASCIA
- Stabilizes the pelvic organs above the levator
plate, preventing herniation into the vagina
• PELVIC DIAPHRAGM
- Maintains the levator plate, a horizontal shallow
basin, at the most dependent portion of the
pelvis and consequently prevents the herniation
of the vagina and its adjacent structures through
the genital hiatus

UptoDate 2021
 PATHOPHYSIOLOGY

WEAKNESS OF PELVIC DIAPHRAGM

(neurologic compromise, tissue damage

Downward rotation of the levator plate from its

horizontal position

STRESS ON THE ENDOPELVIC FASCIA

Pelvic organs no longer supported by th elevator
plate

DESCENT OF PELVIC ORGANS

Childbirth places damaging pressure on all segments of the suspension
and support during the various phases of labor and delivery
 SYMPTOMS

Symptoms are often related to position

● Often less noticeable in the morning or while supine and worsen as the day
progresses

Symptoms are usually related to site of prolapse

● Anterior: urinary symptoms
● Posterior: defecatory symptoms
● Apical: low back pain is associated with uterosacral strain (most common
in the evening and relieved by rest)

VAGINAL BULGE
Symptoms of “a bulge or that
something is falling out of
the vagina”
• With a large prolapse. with
external swelling and
inflammation, the patient
may have difficulty walking
/ carrying out daily
activities
SYMPTOMS
URINARY SYMPTOMS DEFECATORY SYMPTOMS
Loss of support of the Loss of support of the
anterior vaginal wall or posterior vaginal wall
vaginal apex affects affects rectal function
bladder and urethral
function
• Advanced anterior
compartment prolapse will
kink the urethra and cause
obstructed voiding
 SYMPTOMS

VAGINAL DISCHARGE COITAL DIFFICULTY

Chronic discharge May prevent penetration

Bleeding from and orgasm due to a
ulcerations lax outlet
 PHYSICAL EXAMINATION

● dorsal lithotomy position

● Inspect vulva for lesions
● supine cough stress test
● Ask patient to strain (Valsalva maneuver) or cough
● Inspect and palpate vaginal walls for lesions, ulcers, masses etc.
Anterior compartment
prolapse

– Hernia of anterior
vaginal wall associated
with descent of the
bladder (cystocele)
Posterior compartment
prolapse
– Hernia of the posterior
vaginal segment
associated with descent of
the rectum (rectocele)
Apical compartment prolapse
(uterine prolapse, vaginal
vault prolapse)

- Descent of the apex of the

vagina into the lower vagina,
to the hymen, or beyond the
vaginal introitus
- The apex can be either the
uterus and cervix, cervix
alone, or vaginal vault
- Apical prolapse is often
associated with enterocele
 DIFFERENTIAL DIAGNOSIS

• Vulvar masses
• Anterior vaginal wall masses
• Cervical masses
• Prolapsed uterine masses
• Chronic uterine inversion
 APICAL
Aa Ba C
Fixed point 3cm proximal Most distal point of POP-Q SYSTEM
Most distal edge of cervix
to hymen remaining upper anterior or vaginal cuff
vaginal wall
ANTERIOR

Gh Pb TVL
Middle of external Posterior midline hymen Depth of vagina
urethral meatus to to middle of anal opening
posterior midline hymen

Ap Bp D
Fixed point 3cm proximal Most distal point of Posterior fornix (NOT
POSTERIOR to the hymen remaining upper posterior applicable if post
vaginal wall hysterectomy)
POP-Q SYSTEM

Aa
ANTERIOR Fixed point 3cm
proximal to hymen
Ap
Fixed point 3cm
POSTERIOR proximal to the
hymen Aa
Ap
POP-Q SYSTEM
Ba
Most distal point of
ANTERIOR remaining upper
anterior vaginal wall

Bp Ba
Most distal point of Bp
POSTERIOR remaining upper
posterior vaginal wall
MIDDLE COMPARTMENT

C
Most distal edge of D
cervix or vaginal cuff
ANTERIOR
C

D
Posterior fornix (NOT
POSTERIOR applicable if post
hysterectomy)
 POP-Q SYSTEM
Gh Pb TVL
Middle of external urethral Posterior midline hymen to Depth of vagina
meatus to posterior midline middle of anal opening
hymen
 CHOICE OF TREATMENT
CONSERVATIVE VS SURGICAL

“Vaginal reconstructive surgery is concerned with the return of

abnormal organ relationships to a usual or normal state”

- Telindes
 CHOICE OF TREATMENT

• Highly individualized
• understand the patient’s symptoms, concerns, limitations related to her
prolapse
• ”good quality of life”
KEGEL’S EXERCISE

- After emptying the

bladder, patient is asked to
lean as far forward as her
stability allows
- Muscles are tighten until
they voluntarily relax and
it also aids the process of
bladder emptying
- Kegels exercise brings
about complete emptying
and strengthening the 8 – 12 X, for a count of 6-8
pelvic floor seconds, for 3 sets/day
 PESSARY CONSERVATIVE
Indications

A pessary is a prosthetic
or removable device • Significant co morbidities
inserted into the vagina • Patients preference
most commonly used for • Desire future fertility
pelvic organ prolapse • Delay surgery for
(POP) to maintain the treatment of vaginal
location of organs in the ulceration
pelvic region
 SUPPORT PESSARY
• Used to treat pelvic organ prolapse and
stress urinary incontinence
• Easy to remove and insert
• Sexual intercourse is possible with pessary
in place
SPACE FILLING PESSARY
• Supports severe pelvic organ prolapse
• Large base supports the vaginal Apex
• Difficult to remove and insert
• Sexual intercourse not possible with pessary
in place
 PESSARY SELECTION AND FITTING

• examiner places two fingers within the vagina

• bimanual examination to estimate the vaginal depth and

width to approximate the diameter of the pessary
 PESSARY SELECTION AND FITTING

• small amount of water-based lubricant to the leading edge

of the pessary

• apply pressure gently toward the posterior vagina and

place the pessary at an oblique angle

• ask the patient to increase intrabdominal pressure like

Valsalva while the pessary is in place (voiding and
defecation)
CONTRAINDICATIONS
• Severe genital atrophy or
narrowing
• Undiagnosed vaginal
bleeding and/or discharge
• Current vaginal or cervical
cancer
• Inability to comply with
follow-up
CONSERVATIVE
COMPLICATIONS
• Vaginal discharge or odor
• Vaginal bleeding
application
• Pain or discomfort
• Urinary and/or fecal
impaction
FOLLOW UP
• Evaluate 1 week or 1
month after placement
and every 1 to 3 months
after
• It depends whether the
patient is able to remove
or replace the pessary
 SURGICAL APPROACH

● SYMPTOMATIC POP
● FAILED OR DECLINED NON-SURGICAL MANAGEMENT
● COMPLETED FAMILY SIZE
 SURGICAL APPROACH

Aims of surgery

1. Reestablish the anatomic position and support of the pelvic

organs
2. Return of normal function of pelvic organs
3. Achieve patient satisfaction
4. Avoid complication or reoperation
 SURGICAL APPROACH
ABDOMINAL APPROACH VAGINAL APPROACH

ANTERIOR Burch colposuspension Anterior colporrhaphy

Cystocoele Paravaginal repair Paravaginal repair
Urethrocoele Sacrocolpopexy with anterior mesh Transvaginal mesh interposition
interposition

POSTERIOR Sacrocolpopexy with posterior mesh Posterior colporrhaphy

Rectocoele interposition (levator myorrphaphy, fascial repair)
Transvaginal mesh interposition

APICAL Sacrohysteropexy Iliococcygeus / prespinous fixation

Uterovaginal Sacrocolpopexy Sacrospinous ligament fixation
prolapse Uterosacral ligament (USL) fixation McCall culdoplasty
Enterocoele Halban/Moschowitz culdoplasty USL fixation or plication
Vaginal vault Obliterative: Le Fort Colpocleisis
prolapse
 APICAL COMPARTMENT PROLAPSE

• McCall culdoplasty
- Incorporates the uterosacral and cardinal
ligaments to the posterior peritoneum
- Prophylactic procedure to prevent
• enterocoele formation
 APICAL COMPARTMENT PROLAPSE

• Bilateral iliococcygeal fixation

- Involves suspending the vaginal
vault to the iliococcygeus fascia
 APICAL COMPARTMENT PROLAPSE

• Sacrospinous ligament fixation

- Involves suspending the vaginal vault to one sacrospinous
ligament through the rectovaginal space
 APICAL COMPARTMENT PROLAPSE

• Uterosacral ligament fixation

- Suspension of the vaginal vault to the
uterosacral ligament
 POST OPERATIVE COMPPLICATIONS

● Fistula
● Vault prolapse
● Urinary incontinence
● Perforation
● Bleeding and hematoma
● Nerve entrapment
● Infection
 POST OPERATIVE CARE AND HEALTH TEACHING

● Vaginal pack and foley catheter in place for 24 hours post op

● Voiding trial prior to discharge
● Sexual pelvic rest for 6 weeks
● Heavy lifting is restricted
 URINARY
INCONTINENCE
 TYPES

• STRESS URINARY INCONTINENCE

- Involuntary leakage of urine that occurs with increase in intra-abdominal pressure in the
absence of bladder contraction
- Incidence: 50% to 80% of incontinent women
• URGE URINARY INCONTINENCE

- Involuntary urine loss associated with a strong desire to void (urgency)

• URGENCY
- Complaint of a sudden, compelling desire to pass urine which is difficult to defer
• Results from detrusor overactivity, leading to uninhibited (involuntary) detrusor muscle
contractions during bladder filling

UptoDate 2021
 TYPES

• MIXED URINARY
INCONTINENCE
- Complaint of involuntary loss
of urine associated with urgency and
also with effort or physical exertion or
on sneezing or coughing

UptoDate 2021
 TYPES

OVERFLOW INCONTINENCE
• characterized by incomplete bladder emptying
• “water flows over dam”

CAUSES
- Detrusor underactivity
- Bladder outlet obstruction

UptoDate 2021
 TYPES

FUNCTIONAL INCONTINENCE
• Inability of patient to reach the restroom due to
factors unrelated to urinary tract
• Patient has intact urinary storage and emptying
functions but is physically unable to toilet herself
in a timely fashion
• May be reversible

UptoDate 2021
 EVALUATION

• Gynecologic
- 40% with urethral sphincter incompetence has anterior vaginal wall prolapse
• Neurologic
- S2-S4 most important to assess
- perineal sensation, anal wink, pelvic floor contraction, anal sphincter tone
 EVALUATION

• Urinalysis and urine culture

- urge incontinence and irritative symptoms
- infection, stones, urothelial disease
• Estimation of postvoid residual urine
- adequate bladder emptying <50 mL
- significant residual >200 mL
- overflow incontinence
• Voiding diary
- 3 day clinical record of input and output, urine volume and frequency, leak episodes and triggering
factors
 EVALUATION

• Office cystogram with CST

- Simple bladder filling test that provides presumptive
diagnosis of incontinence
- First sensation, first desire to void, strong desire to void,
and maximum cystometric capacity are recorded
- Cough stress test (CST) is performed when nearing
maximum capacity
 EVALUATION

• Q-tip Test
- A sterile cotton tip is placed with the urethra
and, upon straining or coughing, any
deflection greater than 30’ from the horizontal
is considered an indication of urethral
hypermobility
THANK YOU!