Genital Prolapse & Urinary Incontinence

What is it?

- A prolapse is the protrusion of an organ or a structure beyond its normal anatomical site. - Genital prolapse involves weakness of the supporting structures of the pelvic organs so that they descend from their normal positions. - In the female genital tract, the type of pro- lapse depends on the organ involved and its position in relation to the anterior or posterior vaginal wall lecture def "descent of one or more of the genital organ (urethra, bladder, uterus, rectum or Pouch of Douglas) through the fasciomuscular pelvic floor below their normal level."

Managing stress UI

- First-line treatment for stress or mixed UI should be pelvic floor muscle training (PFMT) lasting at least 3 months - PFMT should consist of at least eight contractions, three times a day - If PFMT is beneficial, continue an exercise programme During PFMT, do not routinely use: - electrical stimulation; consider it and/or biofeedback in women who cannot actively contract their pelvic floor muscles - biofeedback using perineometry or pelvic floor electromyography Discuss the risks and benefits of surgical and non-surgical options. Consider the woman's child-bearing wishes during the discussion. If conservative management for SUI has failed, offer: - synthetic mid-urethral tape - open colposuspension - autologous rectus fascial sling Intramural bulking agents (glutaraldehyde crosslinked collagen, silicone, carbon-coated zirconium beads, hyaluronic acid/dextran co-polymer). Explain that: - the technique is less effective than retropubic suspension or sling - repeat injections may be needed - the effect decreases over time An artificial urinary sphincter if previous surgery has failed ( long term follow up is necessary)

Review: pathophysiology of urinary incontinence

- In USI the factors which maintain positive urethral closure pressure at rest may be inadequate ( weakness of urethral sphincter mechanism) when there is increase in the intra abdominal pressure - Particularly if the bladder neck and proximal urethra are poorly supported or have descended through the pelvic floor as in case of concomitant cystourethrocele - An abnormaly high detrusor pressure may occur in detrusor overactivity when there is inability to inhibit the detrusor contractions - In case of low compliance incontinence may occur when there is failure of bladder to accommodate a large volume of urine for a small rise in pressure

Presentation of incontinence

- Incontinence, Stress incontinence is the most common complaint. It may be symptom or a sign - Overactive bladder symptoms presents as urgency with or without incontinence, with or without frequency (>8times/day) and nocturia (once or more at night) in the absence of another identifiable metabolic or pathological process affecting the lower urinary tract - Women may complain of dribble or giggle incontinence or incontinence during sexual intercourse - Voiding difficulties, hesitancy, a poor stream, straining to void and incomplete bladder emptying - Nocturnal enuresis (bed wetting)

Lecture info on pessary

- Majority - silicone - Different shapes and sizes - Temporary - Elderly, medical comorbidities - Trial size - 4-6 months follow up - Vaginal discharge - Ulceration - Vaginal oestrogens

Pelvic floor testing

- Palpation through the vagina or rectum helps in assessing pelvic floor squeeze strength and levator muscle thickness. - The tone and strength of the pelvic floor muscles can be assessed by asking the patient to contract the pelvic floor muscles around the examining fingers. - Women with poor pelvic floor muscle function may benefit from pelvic physical therapy

Surgical treatment of prolapse

- Surgery should be considered with a severe degree of prolapse or if conservative management fails. - Prior to surgery it is important to know whether a woman is sexually active, because the vagina might be narrowed and shortened, potentially causing dyspareunia. - Surgery is not recommended in a woman who has not yet completed her family. - In pregnancy, after pelvic floor repair, caesarean section is indicated to reduce soft tissue trauma and the risk of recurrent prolapse. Anterior colporrhaphy This operation, also known as an anterior repair, is indi- cated for the repair of a cystocoele or a cystourethro- coele. A portion of redundant anterior vaginal wall mucosa is excised and the exposed fascia is plicated to support the bladder. Postoperatively, there is a risk of worsening urinary symptoms. Posterior colporrhaphy Also known as a posterior repair, this operation is used to repair a rectocoele or a rectocoele combined with an enterocoele. Using a similar technique to the operation described above, a triangle of posterior vaginal wall mucosa - its apex behind the cervix and the base at the introitus - is removed. The underlying levator ani muscles are plicated to support the perineum. If an enterocoele is present, the pouch of Douglas is opened and the enterocoele sac of redundant peritoneum is excised. Obliterative procedures (eg, colpocleisis) are reserved for women who cannot tolerate more extensive surgery or who are not planning future vaginal intercourse Vaginal hysterectomy This operation is performed for uterine prolapse, as well as for other gynaecological pathology. It can be com- bined with one or both of the operations above. Manchester repair (Fothergill procedure) This operation is rarely performed for uterine prolapse nowadays. It consists of amputation of the cervix and then apposing the cardinal ligaments to lift the uterus, followed by anterior and posterior colporrhaphy if nec- essary. It may be offered to a woman who wants to pre- serve the uterus. Sacrospinous fixation To treat the prolapsed vaginal vault, the apex is fixed to sacrospinous ligament using a transvaginal approach. This ligament runs from the ischial spine to the lower lateral aspect of the sacrum. Care must be taken to avoid the pudendal nerve and vessels, as well as the sacral plexus and the sciatic nerve. Sacral colpopexy This abdominal procedure involves suspending the vag- inal vault from the sacrum or from the sacral promon- tory, using either strips of fascia or synthetic mesh. The main complications are intraoperative haemorrhage and infection of the mesh. New procedures are currently being developed using synthetic mesh to relieve prolapsed vaginal walls or the vaginal vault. At present, follow-up data regarding suc- cess rates are limited.

Complications of prolapse

- Ulcers - Pelvic incarceration - Infection of the paravaginal and cervical tissues makes the entire prolapsed mass odematous and congested and as a result the mass is irreducible

How to assess symptoms of incontinence?

- Women should be encouraged to complete a minimum of 3 days of bladder diary, covering variations in their usual activities such as working and leisure days - Diaries can yield considerable information on voiding habit; for instance number of voids during the day and night, volume voided and episode of urgency and incontinence - The effect on the quality of life should be assessed for all women with urinary incontinence using validated measure of symptoms and quality of life forms (ICIQ UISF) Ask about... - Prolapse or menstrual disturbances - Obstetric history is important - Recurrent UTI, episode of acute urinary retention or childhood enuresis - Urinary incontinence is sometimes the 1st manifestation of a neurological problem eg multiple sclerosis - Endocrine disorders eg diabetes - Drug history such as diuretics, tricyclic antidepressants, major tranquilizers and alpha adrenergic blockers

Baden Walker staging

0 - No prolapse 1 - Leading edge of prolapsed structure descends halfway to vaginal introitus (hymen) 2 - Leading edge of prolapsed structure descends to the vaginal introitus 3 - Leading edge of prolapsed structure(s) protrudes up to halfway outside the vagina 4 - Leading edge of prolapsed structure(s) protrudes more than halfway outside the vagina, procidentia + POPQ scoring

Predisposing factors to incontinence

1) Age - elderly women have been found to have a higher filling pressure,reduced bladder capacity and lower maximum voiding pressure 2) Race - Lower incidence of both stress urinary incontinence and urogenital prolapse in black as compared to white women 3) Pregnancy - Detrusal overactivity, stress incontinence and low bladder compliance have been reported be increased. - High progestrogen level and pressure from the gravid uterus are the probable causes 4) Child birth - This is due to the damage to the pelvic floor musculature as well as injury to pelvic and pudendal nerves. - There is a linear relationship with the parity, instrumental deliveries and fetal macrosomia 5) Menopause - prevalence rises with increasing years of estrogen deficiency

Complementary therapies

Absorbent products, hand held urinals and toileting aids should not be considered as a treatment for UI. They should be used only as: - a coping strategy pending definitive treatment - an adjunct to ongoing therapy - long-term management of UI only after treatment options have been explored Bladder catheterisation (intermittent or indwelling urethral or suprapubic) should be considered for women in whom persistent urinary retention is causing incontinence, symptomatic infections, or renal dysfunction

Other risk factors

Africans lower prevalence than other ethnic groups Risk of white women is four to five fold higher than Africans

Acquired causes of prolapse

Although most women with genital prolapse have a degree of congenital predisposition, the following fac- tors are also important: • Obstetric factors • Postmenopausal atrophy • Chronically raised intra-abdominal pressure • Iatrogenic. In terms of aetiology, obstetric factors are particularly important, and if prolapse is to be prevented, good intrapartum management of the patient is essential.

Prolapse terminolgoy

Anterior compartment prolapse (cystocele and urethrocoele) - Hernia of anterior vaginal wall often associated with descent of the bladder or urethra - Prolapse of the upper part of the anterior vaginal wall with the base of the bladder is called cystocele - Prolapse of the lower part of the anterior vaginal wall with the urethra is called urethrocele - Complete anterior vaginal wall prolapse is called cysto-urethrocele Posterior compartment prolapse (Rectocele and enterocoele) = involves posterior vaginal wal - Hernia of the posterior vaginal segment often associated with descent of the rectum or small intestine - Rectocele - The anterior wall of the rectum is prolapsed with the lower two third of the posterior vaginal wall - Enterocele - (hernia of the pouch of Douglas) The upper third of the posterior vaginal wall descends lined by the peritoneum of the Douglas pouch and containing loops of the intestine 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

Chronically raised IAP

Any factors that raise intra-abdominal pressure in the long term can predispose to prolapse, including: • intra-abdominal or pelvic tumour • chronic cough • constipation.

Prevention of prolapse

Because obstetric factors are most commonly involved in the development of a genital prolapse, it is important that damage to the supporting structures of the pelvis is minimized. Appropriate management of labour should include: - avoiding prolonged first and second stages - postnatal pelvic floor exercises. The current decline in parity, as well as the increasing use of caesarean section may influence the incidence of prolapse.

Vault prolapse

Descent of the vaginal vault, where the top of the vagina descends or inversion of the vagina after hysterectomy. Vault prolapse can happen after an abdominal or a vaginal hysterectomy

OAB with or without UI

Discuss the risks and benefits of surgical and non-surgical options. Consider the woman's child-bearing wishes during the discussion If conservative treatments have failed, consider: - Botulinum toxin A to treat idiopathic detrusor overactivity in those willing and able to self-catheterise; explain the lack of long-term data; special arrangements for audit or research should be in place - Sacral nerve stimulation for UI due to detrusor overactivity; select patients on basis of response to preliminary peripheral nerve evaluation - Augmentation cystoplasty in those willing and able to self-catheterise; explain common and serious complications and the small risk of malignancy in the augmented bladder - Urinary diversion only if sacral nerve stimulation and augmentation cystoplasty are not appropriate or unacceptable

Examination

Following abdominal palpation to exclude a mass, the patient should be examined in the left lateral posi- tion using a Sims' speculum in order to exclude a vagi- nal wall prolapse. With the posterior vaginal wall retracted, any anterior wall prolapse will be demon- strated if the patient is asked to bear down. Conversely, if the anterior vaginal wall is retracted, then an entero- coele or rectocoele will be seen. Abdominal palpation and bimanual pelvic examination are mandatory to exclude a pelvic mass. Uterine descent is assessed by examining the position of the cervix within the vagina, again usually in the left lateral position with the Sims' speculum. If the patient has a full bladder, stress incontinence can be demonstrated by asking the patient to cough.

Incidence of genital prolapse

Genital prolapse is common. A cystourethrocoele is the most common type, next uterine descent and then rec- tocoele. The incidence increases with increasing age. Prolapse is seen less commonly in Afro-Caribbean women than in Caucasian women.

Iatrogenic

Hysterectomy predisposes to future prolapse of the vaginal vault. In order to remove the uterus, the transverse cervical and uterosacral ligaments have to be divided and the upper vaginal supports are weakened. Colposuspension predisposes to development of an enterocoele because the anterior vaginal wall is lifted anteriorly, which in turn pulls the upper posterior vaginal wall forwards.

Conservative measures for managing prolapse

Improvement in general health should aim to treat the underlying cause of chronically raised intra-abdominal pressure, including: • weight loss • stopping smoking to reduce cough • treating constipation. 1) Pelvic floor exercises Pelvic floor exercises can improve symptoms with minor degrees of genital prolapse, sufficiently to avoid surgery. However, their use is probably more important in prevention. 2) HRT In the presence of atrophic pelvic tissues, HRT can help minor degrees of prolapse by increasing skin collagen content. Preopera- tive use of HRT reduces the friability of atrophic tissues; making tissue handling easier during surgery. 3) Vaginal pessaries

Delancey's 3 levels of support

Level 1: The cardinal-uterosacral ligament complex provides apical attachment of the uterus and vaginal vault to the bony sacrum. Uterine prolapse occurs when the cardinal-uterosacral ligament complex breaks or is attenuated. Level 2: The arcus tendineous fascia pelvis and the fascia overlying the levator ani muscles provide support to the middle part of the vagina. Level 3: The urogenital diaphragm and the perineal body provide support to the lower part of the vagina

Conservative management of OAB

Life style interventions - Trial of caffeine reduction in women with OAB - Modification of high fluid intake - Weight loss particularly in those with BMI of >30 Physio - Bladder training for 6 weeks - In women with cognitive impairment, prompted and timed voiding programmes are recommended as strategies for reducing leakage episode

History

Local discomfort or a feeling of 'something coming down' is a common symptom. This is usually worse with standing or straining (cough, defecation) and relieved by lying down. It may interfere with sexual function. Remember that your history should exclude symp- toms related to the urinary and bowel systems. Uterine descent Can give symptoms of backache. However, other causes of backache must be excluded, especially in the older patient. A procidentia causes discomfort as it rubs on the patient's clothing and can cause a bloody, some- times purulent, discharge. Other symptoms depend on the organ/organs involved. Urinary symptoms These occur with a cystocoele or a cystourethrocoele, such as frequency of micturition. The patient might notice incomplete emptying of the bladder, which pre- disposes her to urinary infection and even possibly over- flow incontinence. Stress incontinence may be present if there is descent of the urethrovesical junction (bladder neck) associated with a cystocoele. Bowel symptoms A rectocoele can cause incomplete bowel emptying. This can be relieved if the patient pushes back the prolapse digitally.

Urinary symptoms

Loss of support of the anterior vaginal wall or vaginal apex may affect bladder and/or urethral function. Symptoms of stress urinary incontinence often coexist with stage I or II prolapse Advanced anterior or apical prolapse may "kink" the urethra and result in symptoms of obstructed voiding such as - slow urine stream need to change position - manually reduce (splint) the prolapse to urinate - sensation of incomplete emptying - complete urinary retention Women with POP have a two- to five-fold risk of overactive bladder symptoms (urgency, urge urinary incontinence, frequency) 13% to 65% of continent women develop symptoms of stress incontinence after surgical correction of prolapse

Urodynamics

Multi-channel cystometry, ambulatory urodynamics or video-urodynamics is not recommended - Before starting conservative treatment - For the small group of women with a clearly defined clinical diagnosis of pure stress urinary incontinence These investigations are recommended before surgery for stress urinary incontinence in women with the following; - Clinical suspicion of detrusor over activity - History of previous surgery for stress incontinence - Concomitant anterior compartment prolapse - Symptoms suggestive of voiding dysfunction

Medical management of OAB or mixed UI

Offer one of the following choices first: - oxybutynin (immediate release), or - tolterodine (immediate release), or - darifenacin (once daily preparation). If the first treatment for OAB or mixed UI is not effective or well-tolerated, offer another drug with the lowest acquisition cost Offer a transdermal OAB drug to women unable to tolerate oral medication. Merabegron has been approved for use in the treatment of overactive bladder where other treatments are contraindicated, ineffective, or have unacceptable side effects. Other - Consider desmopressin to reduce troublesome nocturia - The following are not recommended: propiverine for the treatment of UI flavoxate, imipramine and propantheline

Investigating urinary incontinence

Pelvic floor assessment - Assessment of the patient ability to contract and relax the pelvic floor muscle (squeezing without abdominal muscle contraction and valsalva manoeuvre) Urine testing - Urine dipstick should be undertaken in all the women presenting with urinary incontinence to detect the presence of blood, glucose, protein, leucocytes and nitrites in the urine Post void residual volume measurement - It is an important investigation especially in women with the H/O voiding dysfunction and repeated lower urinary tract infection - Bladder scan is preferable over catheterisation - Patients with a palpable bladder on pelvic examination after voiding should be referred to appropriate specialist

Symptoms

Severity of symptoms does not correlate well with the stage of prolapse Symptoms related specifically to the prolapsed structures - bulge or vaginal pressure or with associated symptoms including urinary, defecatory or sexual dysfunction Symptoms such as low back or pelvic pain have often been attributed to POP, but this association is not supported by well-designed studies Protrusion from the vagina may cause chronic discharge and/or bleeding from ulceration Symptoms are often related to position; they are often less noticeable in the morning or while supine and worsen as the day progresses Many women with prolapse are asymptomatic, treatment is generally not indicated in these women

Congenital causes of prolapse

Some women are born with a predisposition to genital prolapse, which is probably secondary to abnormal collagen production. Conditions associated with prolapse include: • spina bifida • connective tissue disorder.

Types of incontinence

Stress urinary incontinence is the complaint of involuntary leakage on effort or exertion or sneezing or coughing Urge urinary incontinence is the complaint of involuntary leakage accompanied by or immediately preceded by urgency Mixed urinary incontinence is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing

Obstetric factors

Stuff that can cause prolapse secondary to denervation and muscular trauma of the pelvic floor.

Post-menopausal atrophy

The incidence of prolapse increases with age. This is due to atrophy of the connective tissues secondary to the hypo-oestrogenic state following the menopause.

More about vaginal pessaries

The more commonly used pessary is the ring pessary, made of inert white plastic. The diameter is measured in millimetres and the appropriate size is assessed by vaginal examination. The pessary is passed into the vagina so that it sits behind the pubic bone anteriorly and in the posterior fornix of the vagina posteriorly, enclosing the cervix. The other type of pessary is the shelf pessary, used for larger prolapses. The indications for the use of a vaginal pessary include the following: - The patient has not completed her family. - The patient prefers conservative management. - The patient is medically unfit for surgery. With major degrees of prolapse, especially where the introitus is lax and the perineal body deficient, the pes- sary may not be supported enough to stay in situ. It can also fall out if too small a size is fitted. The main complications of a pessary are vaginal discharge or bleeding, particularly if the pessary is not replaced every 6 months. Granulation tissue may develop, incarce- rating the pessary, if it is not changed regularly. If the pessary is too large it will cause discomfort and may ulcerate the vaginal walls

Review pelvic floor muscles

The pelvic floor consists of a muscular, gutter-shaped, forward sloping diaphragm formed by the: • levator ani muscles • internal obturator and piriform muscles • superficial and deep perineal muscles. The levator ani consists of two parts, the pubococcygeal part anteriorly and the iliococcygeal part posteriorly and is covered by pelvic fascia. The vagina and urethra pass through the urogenital aperture formed by the medial border of the levator ani. The rectum passes posteriorly with muscle fibres from the pubic bone uniting behind the anorectal junction. Thus, the muscles provide an indirect support for these structures.

Review: uterine position

The uterus is normally anteverted,anteflexed Version: is the angle between the longitudinal axis of cervix, and that of the vagina. Flexion: is the angle between the longitudinal axis of the uterus, and that of the cervix.

Investigating prolapse

This is a clinical diagnosis so there are few relevant investigations. If the patient has urinary symptoms the following would be appropriate: • Mid-stream urine specimen • Urodynamics: only used in special circumstances, e.g. if surgical intervention contemplated, a mixed incontinence picture or failed medical management