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pop andurinary incontinence

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pop andurinary incontinence

  1. 1. POP AND URINARY INCONTINENCE FENTA MD JULY 5 2018 GC
  2. 2. Objectives • difintion of POP & UI • risk factors for POP &UI • clinical presentations • management principle
  3. 3. ANATOMY OF PELVIC SUPPORT interaction between the muscles of the pelvic floor and connective tissue attachments to the bony pelvis • The levator ani muscle complex-consisting of the pubococcygeus, puborectalis and iliococcygeus muscles, • provide primary support • The endopelvic fascial attachments, • uterosacral and cardinal ligaments - condensations of the endopelvic fascia
  4. 4. Schematic diagram of the striated musculature of the pelvic floor. PR, puborectalis; PC, pubococcygeus; IC, iliococcygeus; O, obturator muscle; TA, tendinous arc of the obturator muscle
  5. 5. Levels of pelvic organ support • Level 1 – Uterosacral/cardinal ligament complex • Level 2 – Paravaginal attachments along the length of the vagina to the superior fascia of the levator ani muscle and the arcus tendineus fascia pelvis • Level 3 – Perineal body, perineal membrane, and superficial and deep perineal muscles
  6. 6. POP • pulvic organ prolapse is herination of pelvic organ to or beyond vaginal walls • what are pelvic organs? urinary blader,urethra ,uterus,rectum ,some parts of small intestine& omentum
  7. 7. commonly used terminologies to describe specific female genital prolapse Anterior compartment prolapse – Hernia of anterior vaginal wall often associated with descent of the bladder (cystocele) Posterior compartment prolapse – Hernia of the posterior vaginal segment often associated with descent of the rectum (rectocele) Enterocele – Hernia of the intestines to or through the vaginal wall. ''source upto date 2018GC''
  8. 8. 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 • Uterine procidentia — Hernia of all three compartments through the vaginal introitus.
  9. 9. Factors promoting prolapse • Erect posture causes increased stress on muscles, nerves and connective tissue(Evolution) • Acute and chronic trauma of vaginal delivery • Aging • Estrogen deprivation • Intrinsic collagen abnormalities • Chronic increase in intraabdominal pressure • heavy lifting • coughing • constipation
  10. 10. Clinical Evaluation Symptom: • Variable & not associated with degrees • Feeling of something coming down • Back ache or dragging sensation • Urinary symptoms like difficulty in passing urine, frequency, etc • Bowel symptoms like constipation • Excessive white or blood stained discharge
  11. 11. ON PHYSICAL EXAM • inspection for ulceration • speculum and bimanaul examination • rectovaginal examination- level of rectocele • neuromuscular examination
  12. 12. Apical defects • Uterine prolapse • Normal cervix located in upper third of vagina • Degree of prolapse measured by position of cervix at maximum intraabdominal pressure, without traction • Complete uterovaginal prolapse is called procidentia • Vault prolapse • Enterocele
  13. 13. Cystocele • Main support of urethra and bladder is the pubo-vesical-cervical fascia • Essentially a hernia in the anterior vaginal wall due to weakness or defect in this fascia • Midline weakness allows bladder to descend causing central cystocele • Tearing of endopelvic fascial connections from lateral sulci to arcus tendinii causes lateral or displacement cystocele • Detachment of pubocervical fascia from pericervical ring causes a transverse or apical cystocele • Symptoms include pelvic pressure and bulge or mass in the vagina
  14. 14. Enterocele • A true hernia of the rectouterine or cul-de-sac pouch (pouch of Douglas) into the rectovaginal septum • Descent of bowel in a peritoneum-lined sac between posterior vaginal apex and anterior rectum • Pulsion enterocele is filled with bowel and distended by abdominal pressure • Can occur anteriorly as well • Generally after a surgical change in vaginal axis • Symptoms of fullness and vaginal pressure or palpable mass • Bowel peristalsis confirms diagnosis
  15. 15. Posterior compartment defects • Rectocele • Perineal descent • Sagging and funneling of the levator ani around the perineum such that anus becomes most dependent • Difficulty with defecation
  16. 16. Rectocele • Chiefly a hernia in the posterior vaginal wall secondary to weakness or defect in the rectovaginal septum or fascia of Denonvilliers • Symptoms include difficulty evacuating stool, a vaginal mass, and fullness sensation • Rectovaginal exam confirms diagnosis
  17. 17. Simplified POPQ classification system • Stage 1: Prolapse where the given point remains at least 1 cm above the hymenal remnants. • ●Stage 2: Prolapse where the given point descends to the introitus, defined as an area extending from 1 cm above to 1 cm below the hymenal remnants. • ●Stage 3: Prolapse where the given point descends greater than 1 cm past the hymenal remnants, but does not represent complete vaginal vault eversion or complete uterine procidentia. This implies that at least some portion of the vaginal mucosa is not everted. • ●Stage 4: Complete vaginal vault eversion or complete uterine procidentia
  18. 18. Baden-Walker system • ●0 – Normal position for each respective site • ●1 – Descent halfway to the hymen • ●2 – Descent to the hymen • ●3 – Descent halfway past the hymen • ●4 – Maximum possible descent for each site
  19. 19. Complications 1.Vaginal mucosa: keratinization & decubitus ulcer 2.Cervix: hypertrophied & elongated 3.Urinary symptom: -Bladder: cystitis, trabeculation, incomplete evacuation -Ureters: hydroureter, pyelonephritis(water under the bridge) 4. Incarceration 5. Peritonitis 5. Carcinoma: rarely develops on decubitus ulcer
  20. 20. DDX • Cystocele versus Gartner’s cyst(wolffian remnant) • Congenital elongation of the cervix • Chronic uterine inversion • Fibroid or polyp • Tumors
  21. 21. Cervical elongation
  22. 22. Diagnosis • diagnosis is clinical • CBC ,U/A ,BG&RH, CXR , ECG RFT ,IVU MANAGEMENT • depends on wether paient symptomatic or asymptomatic • Indications for treatment-symptoms of prolapse or associated conditions urinary, bowel, or sexual dysfunction
  23. 23. Management options • Expectant management • Conservative management • Vaginal pessary • Pelvic floor muscle exercises • Estrogen therapy • Surgical treatment • reconstructive procedure • obliterative procedure -coldocleisis
  24. 24. URINARY INCONTINENCE • Definition: urinary incontinence (UI) is an involuntary loss of urine that is social and hygienic problem which is demonstrable objectively. • A common problem of women of all ages. • Affects women‘s social and sexual activity. • Only <50% of women with UI seeks help.
  25. 25. • UI is 2-4x common in women than men. • UI increases with aging. • Prevalence :(11-57)%.
  26. 26. Negative impact on quality of life. • Social embarrassment. • Avoids physical activity. • low self esteem. • Sexual dysfunction. • Anxiety. • Depression in 80%.
  27. 27. Risk Factors • Enuresis • Obesity • Pregnancy • ↑ed parity • Vaginal delivery • ↓estrogen • Pelvic surgery (hysterectomy) • CHF • COPD • Smoking • DM • TIA • Stroke • Impaired mobility
  28. 28. Pathogenesis • Continence depends on integrity of LUT, pelvic support and neurological system, plus • Intact functional ability to toilet oneself: - Ready access to toilet facilities - Motivation to maintain dryness - Cognitive ability to recognize and react appropriately to sensations of bladder filling - Impairment of one of these leads to UI
  29. 29. Classification of UI • Extra urethral: • Congenital • Ectopic ureter • Bladder extrophy • Aquired (fistulas) • Uretero-vaginal • Vesico-vaginal(VVF) • Urthero-vaginal • complex combinations. • Transurethral • Stress urinary incontinence (SUI) • Urge urinary incontinence (UUI) • Mixed urinary incontinence (MUI) • Overflow incontinence • Urethral diverticulum • Urethral instability (UI) • functional incontinence.
  30. 30. Clinical evaluation of urinary incontinence • History: • Urgency (a strong desire to void), Dysuria, Frequency, Nocturia • Leakage with ↑ed intraabdominal pressure. • Dribbling. • Frequency >7-8x/day, Nocturia >2x/day, hesitancy, poor streaming, interrupted voiding. Precipitants • Coital incontinence. • Giggle incontinence. (nervous laugh) • running water, opening the door. • Exercise.
  31. 31. Evaluation…  Physical examinations:  Mental status  Spina bifida  Bladder distention.  Rectal mass/fecal impaction.  Gynecologic evaluation – Evaluation of urethral support (pt standing, full bladder).  Neurological evaluation  Perianal sensation.  Anal sphincter tone
  32. 32. Evaluation…  Laboratory evaluation  Urinalysis/culture.  Serum glucose level.  Cystoscopy .  Urine cytology (age > 50, hematuria)  RFT  Videocystography  Trans-vaginal endosonography
  33. 33. Urodynamic tests 1) Bladder filling test: - Urinate, catheterize (measure post void volume), fill the bladder with N/S at a rate of 60-75 ml/min till functional capacity. 2) Cystometry – 2 types A – Filling Cystometry --- measures bladder pressure while filling. B – Voiding Cystometry (pressure flow study)
  34. 34. Evaluation… Normal Cystometry values: • Residual volume <50 ml. • First desire to void is b/n 150-250 ml. • Strong desire to void be after 250 ml. • Bladder capacity 400ml- 600 ml. • No detrusor contraction on filling phase. • No leakage on coughing. • No provoked detrusor contraction. • Maximum detrusor pressure < 50 cmH2O. • Maximum flow rate >15 ml/sec.
  35. 35. Stress urinary incontinence (SUI) Definition: • is leakage of urine that occurs when intravesical pressure exceeds mean urethral closure pressure in the absence of detrusor contraction (sneezing, coughing, exercise). • Causes: • Urethral hyper mobility. • Intrinsic sphincter deficiency (ISD).
  36. 36. DO… • Treatment: 1. Bladder training • Is to reestablish cortical control over detrusor. • Patient will have scheduled voiding. • Cure rate 47-90%. 2. Pelvic floor exercise .
  37. 37. SUI… 2) Surgical treatment a) Anterior colporrhaphy – long term success rate 35-65%. b) Operation for urethral hyper mobility b.1 - Retro pubic urethropexy - Para Vaginal repair
  38. 38. Detrusor Over activity (DO) Definition by ICS: • Spontaneous or provoked detrusor contraction during filling phase of bladder. • Characterized by urge incontinence. • Dribbling or leakage when they see toilets, when they put the key in the door upon returning home
  39. 39. DO… • Treatment: 1. Bladder training • Is to reestablish cortical control over detrusor. • Patient will have scheduled voiding. • Cure rate 47-90%. 2. Pelvic floor exercise .
  40. 40. Mixed incontinence (MUI) • The predominant feature guides the line of management i.e. SUI/UUI. • Generally safer management is to treat DO first medically and then surgery for failed cases.
  41. 41. Overflow incontinence (Incomplete Emptying) • Is a result of detrusor weakness or bladder out let obstruction. • Typically the leakage is small in volume. • ↑ed post void residual urine. • Poor streaming, dribbling, hesitancy. • Causes of obstruction; • Anti incontinence surgery. • Cystocele (kinking of urethra) • Spinal cord injury
  42. 42. • treatment • treat the underlining cause
  43. 43. •QUESTIONS?
  44. 44. THANK YOU

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