this is PPT based on utero vaginal prolapse and urinary incontinence

1. Pelvic organ prolapse & incontinence
Dr Bhaskar J Paul
Associate professor
Obstetrics and Gynaecology

2. Learning Objective
• Q1 Definition of prolapse
• Q3 what are the symptoms of pelvic floor disorders in women ? What are the
symptoms of abnormal function of the lower urinary tract associated with pelvic
floor problems in women and how can this condition be treated ?
• Q5 . What are the symptoms of abnormal function of the gastrointestinal tract in
women with pelvic floor problem ?
• Q6 . how does prolapse of the internal reproductive organs in women come about ?
• Q8. what are the findings on physical examination of women with a cystocele or
rectocele and what is the treatment ?
• What are the findings on physical examination of a prolapsed uterus ? What are the
three possible treatments for a patient with prolapsed complaints ?

3. A 64 years old multipara
presents with loss of small
amount of urine when she
coughs or laughs or lifts heavy
objects
On examination she has a
second degree uterovaginal
prolapse on standing position
an relieves on lying position.
She is mildly constipated and
some times needs digitalisation
to initiate defecation
Clinical
problem
What you can offer to this
woman ?
.
Your
solution

4. Outliner
• Definition
• Cause /path physiology
• Types
• Symptoms
• Evaluation and clinical findings
• Differential diagnosis
• Treatment

5. Definition LQ 1
• Pelvic organ prolapse is a disorder in which organs have lost
their support and descend through the urogenital hiatus

6. Normal support of the pelvic organs

7. Normal support of the pelvic organ
• PELVIC FLOOR
– Comprises
Pelvic diaphragm
Endopelvic fascia
Perineal membrane
Perineal body

8. Pelvic diaphragm

9. Level of support of uterus
• 3 levels of support

10. Level 1 support (Delency )
• Level 1 : uretero sacral and cardinal ligament complex

11. Level 2 support
• Level II- Pelvic fascias and paracolpos
– Fascial septae connects mid vagina to the pelvic sidewalls
– Anteriorly
• Pubocervical
– Posteriorly
• Rectovaginal facia
– which connects the vagina to the white line on the lateral pelvic wall
through arcus tendinous

12. Level 3 support
• Level III-Levator ani muscle
– supports the lower one-third of vagina.
– Anteriorly
• Urethra
• Urogenital diaphragm
• Pubis
– laterally
• Levator ani fascia
– Posteriorly
• Perineal body
Level II and III detail. In level III, the vagina is fused to the
medial surface of the levator ani muscles, urethra, and
perineal body. The anterior surface of the vagina at its
attachment to the arcus tendineus fascia pelvis forms the
pubocervical fascia, while the posterior surface forms the
rectovaginal fascia

13. Causes and pathophysiology LQ 6
• Menopause
• birth injury
• Prolonged bearing down in the second stage
• Delivery of a big baby
• Rapid succession of pregnancies
• Lack of rest in peurperium
• Peripheral nerve injury
• raised intra-abdominal pressure
• Surgeries
• Congenital

14. Pathophysiology
• Menopause
– prolapse are of menopausal age when the pelvic floor muscles
– d/t oestrogen deficiency and decreased collagen content in fascias
atonicity and asthenia that follow menopause

15. Cause related to child birth
excessive stretching
of the pelvic floor
muscles and
ligaments
overstretching causes
atonicity
Perineal tear is less
harmful than
overstretching
whereas torn
muscle could be
stitched or toned up

16. Cause related to raised abdominal pressure
• chronic bronchitis,
• large abdominal tumours or
• obesity
• Smoking,
• chronic cough and
• constipation

17. Types
Upper two-
third-Cystocele
Lower one-third-
Urethrocele
Anterior
vaginal
wall(anterior
compartment)
Uterine descent
Middle
compartment
Upper one-third-
Enterocele
(pouch of
Douglas hernia)
Lower two-third-
Rectocele
Posterior
compartment

18. Symptoms LQ 3 & 5
• General symptoms
• Backache
– uterosacral strain
• Towards evening
relieved by rest
• Decubitus ulcer
• benign and is present on dependant part.
• d/t venous stasis  tissue anoxia
• With third degree uterine prolapse and procidentia prevents
penetration and orgasm due to a lax outlet (coital difficulty )

19. Symptoms related to LUT LQ 3
• imperfect control of micturition
• Frequency of micturition
– (diurnal or nocturnal)
– (d/t chronic cystitis & incomplete emptying of the bladder)
• Manual reduction of the cystocele into the vagina with their fingers
• Straining to pass urine
• Stress incontinence
• Ureteric obstruction and hydronephrosis (severe massive prolapse)

20. Symptoms related to lower gastrointestinal tract
(Bowel symptoms )LQ 5
• Urgency
• Straining
• Feeling of incomplete emptying
• Pressure on vagina or perineum to start or complete
defaecation

21. Evaluation and Findings LQ 8 & 9
Anterior compartment
• Sim’s speculum retracting
posterior vaginal wall
• Look for cystocele
• Lateral cystocele or
paravaginal defect
• Urethrocele } stress
incontinence
Middle compartment
• Degree of descent
• Ulceration of cervix
• Vagina may show
keratinisation
• Vaginal examination –
length of cervix,position
and mobility of uterus,any
adnexal mass
• Cervical cytology
Posterior compartment
• Sim’s speculum retracting
anterior vaginal wall
• Enterocele – bulge
appears from above
downwards
• Rectal examination –
impulse on
• tip of finger- enterocele
• pulp - rectocele
• Bimanual examination-
r/o pelvic mass

22. Evaluation of the pelvic floor
• Pubococcygeus part of levator ani assessed at 4 and 8 o’clock
position
• Perineal body
• Rectal examination – tone of anal sphincter

23. Evaluation Baden walker classification

24. Pelvic organ prolapse quantification POPQ
Anterior wall
• A
• B
• C
Posterior wall
• A
• B
• c
Other 3
parameters
• gH
• PB
• TvL

25. Differential diagnosis
• Vulval cyst or tumour
• Cysts of anterior vaginal wall
• Urethral diverticula
• Congenital elongation of cervix
– vaginal portion of the cervix is elongated and
– no vaginal prolapse.
– deep fornices
• Cervical fibroid polyp
• Chronic inversion

26. Treatment : prophylaxis
 Antenatal physiotherapy ,relaxation exercises,due attention to weight gain
and anaemia
 Proper supervision and management of second stage of labour
 A generous episiotomy
 Low forceps delivery if there is delay in second stage
 Suture perineal tear
 Postnatal exercises and physiotherapy
 early postnatal ambulation
 Adequate spacing of births
 Avoid multiparity
 Prophylatic HRT in postmenopausal women

27. Treatment
• Surgical
– in women over 40
• Conservative management
– mechanical devices and
– pelvic floor muscle exercises ,abdominal massage,
• in mild degrees of prolapse,
• surgery not desired by patient ,
• in whom child bearing is not complete
• Should be advised 3 to 4 months following delivery
• Pregnancy – contraindication for surgery

28. Pessary (conservative treatment)
• Indications
A young woman planning a pregnancy
During early pregnancy (<18 weeks)
Puerperium
Temporary use while clearing infection and decubitus ulcer
A woman unfit for surgery
In case a woman refuses for surgery

29. Surgical approach
• Ward-Mayo’s operation-vaginal hysterectomy with pelvic floor
repair with or without:
sacrospinous colpopexy –vault suspended from sacrospinous
ligament
• Fothergill’s or Manchester operation –uterus preserved and part
of cervix is cut
• Shirodkar’s Extended Manchester operation-both cervix and
uterus preserved
• Le Fort’s operation –obliterative procedure of anterior and
posterior walls of vagina

30. Urinary incontinence
Section 2

31. Learning objectives
• LQ1 : definition of urinary incontinence : stress incontinence,
urge incontinence, mixed incontinence ,
• LQ 2 : incidence of urinary incidence : how does it changes
throughout
• LQ 7: what are the causes of urinary incontinence in women?
what are the treatment option for two types of incontinence ?

32. Outliners
• Definition and Types
• Incidence
• Characteristics
• Causes
• Evaluation
• Treatment

33. Definition
• Incontinence is defined as the complaints of any involuntary
leakage of urine which is a social and hygienic issue to the
patient

35. Incidence

36. Characteristics

37. Causes of incontinence

38. Causes of incontinence

39. Initial evaluation of incontinence

40. EVALUATION
HISTORY
• QUALITY OF LIFE MEASURES
PHYSICAL
EXAMINATION
• VOIDING DIARY

41. Evaluation
BASIC TEST
•URINALYSIS
•PVR
•COUGH
STRESS TEST
•PAD TEST
ADDITIONAL
TEST
• BLOOD TEST
•BUN , CR
GLUCOSE , Ca
ADVANCED
TEST
•URO
DYNAMICS
•ENDOSCOPIC
•IMAGING

42. Components of urodynamic study
• The following are the different component of urodynamic
study cystometry
• Uroflowmetry :
• Filling cystometry
• Video uro dynamics
• Ambulatory urodynamic monitoring
• Urethral pressure profile
• Electromyography

43. Treatment
Behavioural
• Modify bladder
function
• Vaginal and
urethral device
Pharmacologic
• Stress
incontinence
• Urge
incontinence
Surgical
• colposuspension
• Minimally
invasive sling

44. Fecal Incontinence
Section 3

45. Fecal incontinence : learning questions
• LQ 10 : what physical examination should be conducted on a
patient with fecal incontinence ? What are the treatment
options ?

46. Fecal continence :Causes
• Damage to anal sphincters
• Neurologic causes
• Decreased distensibility of the rectum
• Fecal impaction
• Diarrhoea
• Idiopathic

47. Fecal incontinence: Diagnosis
• Diagnostic test
• Direct examination
• Anorectal manometry
• Ultrasound or MRI
• Stool test

48. Fecal incontinence: treatment
• Bulking substance
• Medication that reduces stool frequency
• Anti cholinergic medications
• Defecation programs
• Biofeed back /sacral neuro modulation
Medical
Therapy
• Over lapping sphincteroplasty
• Muscle transfer surgery
• Synthetic anal cuff
Surgical
Therapy

49. References
Obstetrics and
Gynaecology
Beckmann 7th edition
Surgical practice
Bailey and love 25th
edition

50. Thank you