37. Pelvic Floor Disorders

A 67-year-old G3P3 woman presents with severe pelvic protrusion several years following an abdominal hysterectomy. She denies any incontinence. She failed conservative management with a pessary. As a result, she underwent a vaginal surgical repair where the pubocervical fascia was plicated in the midline, as well as laterally to the arcus tendineus fascia (white line). What defect was repaired in this patient? A. Cystocele B. Rectocele C. Uterine prolapse D. Enterocele E. Urethral diverticulum

*A* Central and lateral cystoceles are repaired by fixing defects in the pubocervical fascia or reattaching it to the sidewall, if separated from the white line. Defects in the rectovaginal fascia are repaired in rectoceles. Uterine prolapse is surgically treated by a vaginal hysterectomy, but this patient already had a hysterectomy. Enteroceles are repaired by either vaginal or abdominal enterocele repairs. Vaginal vault prolapse is treated either by supporting the vaginal cuff to the uterosacral or sacrospinous ligaments, or by sacrocolpopexy. Urethral diverticulum does not present with severe pelvic protrusion.

A 60-year-old G4P4 woman presents with a two-year history of urine leakage with activity such as coughing, sneezing and lifting. Her past medical history is significant for vaginal deliveries of infants over 9 pounds. She had a previous abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine fibroids. She is on vaginal estrogen for atrophic vaginitis. Physical examination reveals no anterior, apical or posterior wall vaginal prolapse. The vagina is well-estrogenized. Post-void residual is normal. Q-tip test shows a straining angle of 60 degrees from the horizontal. Cough stress test shows leakage of urine synchronous with the cough. Cystometrogram reveals the absence of detrusor instability. The patient failed pelvic muscle exercises and is not interested in an incontinence pessary. Which of the following is the best surgical option for this patient? A. Retropubic urethropexy B. Needle suspension C. Anterior repair D. Urethral bulking procedure E. Colpocleisis

*A* Genuine stress incontinence (GSI) is the loss of urine due to increased intra-abdominal pressure in the absence of a detrusor contraction. The majority of GSI is due to urethral hypermobility (straining Q-tip angle >30 degrees from horizon). Some (<10%) of GSI is due to intrinsic sphincteric deficiency (ISD) of the urethra. Patients can have both hypermobility and ISD. Retropubic urethropexy such as tension-free vaginal tape and other sling procedures have the best five-year success rates for patients with GSI due to hypermobility. Needle suspensions and anterior repairs have lower five-year success rates for GSI. Urethral bulking procedures are best for patients with ISD, but with little to no mobility of the urethra. Colpocleisis is one option to treat uterine prolapse, and is not indicated for urinary incontinence.

A 48-year-old G0 woman presents to the office for preoperative counseling. She has severe endometriosis that has failed medical management, and she is planning to undergo a robotic total hysterectomy and salpingo-oophorectomy. She is concerned about developing a "dropped bladder" following her surgery, since both her mother and aunt have undergone surgery for this condition. She reports no urinary incontinence or other urinary or bowel symptoms. She is in good health and exercises with running and weight lifting. Pelvic examination reveals a well-estrogenized vagina, a normal nulliparous cervix, anteverted uterus, and mildly tender adnexa without masses. Which of the following is likely to increase her risk of subsequent development of pelvic organ prolapse? A. Age B. Family History C. Endometriosis D. Exercising E. Hysterectomy

*B* Risk factors for the development of pelvic organ prolapse are increasing parity, increasing age, obesity, some connective tissue disorders (Ehlers-Danlos syndrome), and chronic constipation. Vaginal delivery is associated with a higher risk of POP than Cesarean delivery. It is unclear whether occupations that require heavy lifting increase the risk of POP. Women with a family history of POP have up to a 2.5 fold increase in prolapse. Although hysterectomy is associated with an increased risk of apical prolapse, studies show mixed results on the role of hysterectomy in the development of prolapse. The risk of future prolapse may be highest when hysterectomy is performed in women with existing prolapse, while the risk in women with normal pelvic support is less clear.

A 60-year-old G2P2 woman presents with complaints of urinary frequency and urge incontinence. Past medical history is unremarkable. She is on no medications. Pelvic examination reveals no evidence of pelvic relaxation. Post void residual is normal. Urine analysis is negative. A cystometrogram reveals uninhibited detrusor contractions upon filling. Which of the following is the best treatment for this patient? A. Amitriptyline B. Oxybutynin C. Topical (vaginal) estrogen D. Pseudoephedrine E. Kegel exercises

*B* The patient has the diagnosis of detrusor instability. The parasympathetic system is involved in bladder emptying and acetylcholine is the transmitter that stimulates the bladder to contract through muscarinic receptors. Thus, anticholinergics are the mainstay of pharmacologic treatment. Oxybutynin is one example. Although the tricyclic antidepressant, amitriptyline, has anticholinergic properties, its side effects do not make it an ideal choice. Vaginal estrogen has been shown to help with urgency, but not urge incontinence. Pseudoephedrine has been shown to have alpha-adrenergic properties and may improve urethral tone in the treatment of stress incontinence. Kegel exercises or pelvic muscle training are used to strengthen the pelvic floor and decrease urethral hypermobility for the treatment of stress urinary incontinence.

A 57-year-old G2P2 woman presents with a six-month history of urinary incontinence, urgency, and nocturia. She describes the amount of urine loss as large and lasting for several seconds. The urine loss occurs when she is standing or sitting and is not associated with any specific activity. A post-void residual is 50cc. What is the most likely cause of this patient's symptoms? A. Stress incontinence B. Overflow incontinence C. Urge incontinence D. Mixed incontinence E. Vesicovaginal fistula

*C* This patient has urge incontinence, which is caused by overactivity of the detrusor muscle resulting in uninhibited contractions, which cause an increase in the bladder pressure over urethral pressure resulting in urine leakage. Stress incontinence is caused by an increase in intra-abdominal pressure (coughing, sneezing) when the patient is in the upright position. This increase in pressure is transmitted to the bladder that then rises above the intra-urethral pressure causing urine loss. Associated structural defects are cystocele or urethrocele. Overflow incontinence is associated with symptoms of pressure, fullness, and frequency, and is usually a small amount of continuous leaking. It is not associated with any positional changes or associated events. Mixed incontinence occurs when increased intra-abdominal pressure causes the urethral-vesical junction to descend causing the detrusor muscle to contract. A vesicovaginal fistula typically results in continuous loss of urine.

A 90-year-old G7P7 woman presents with severe vaginal prolapse. The entire apex, anterior and posterior wall are prolapsed beyond the introitus. She cannot urinate without reduction of the prolapse. Hydronephrosis is noted on ultrasound of the kidneys and thought to be related to the prolapse. She has a long-standing history of diabetes and cardiac disease. She has failed a trial of pessaries. Which of the following is the next best step in the management of this patient? A. Do nothing and observe B. Anterior and posterior repair C. Colpocleisis D. Sacrospinous fixation E. Sacrocolpopexy

*C* Because of the hydronephrosis due to obstruction, intervention is required. Colpocleisis is a procedure where the vagina is surgically obliterated and can be performed quickly without the need for general anesthesia. Anterior and posterior repairs provide no apical support of the vagina. She will be at high risk of recurrent prolapse. The sacrospinous fixation (cuff to sacrospinous-coccygeus complex) or sacrocolpopexy (cuff to sacral promontory using interposed mesh) require regional or general anesthesia and is not the best option for this patient with high surgical morbidity.

A 76-year-old G3P3 woman presents to your office with worsening urinary incontinence for the past three months. She reports increased urinary frequency, urgency and nocturia. On examination, she has a mild cystocele and rectocele. A urine culture is negative. A post-void residual is 400 cc. Which of the following is the most likely diagnosis in this patient? A. Genuine stress incontinence B. Detrusor instability C. Overflow incontinence D. Functional incontinence E. Mixed incontinence

*C* Overflow incontinence is characterized by failure to empty the bladder adequately. This is due to an underactive detrusor muscle (neurologic disorders, diabetes or multiple sclerosis) or obstruction (postoperative or severe prolapse). A normal post-void residual (PVR) is 50-60 cc. An elevated PVR, usually >300 cc, is found in overflow incontinence. Stress incontinence occurs when the bladder pressure is greater than the intraurethral pressure. Overactive detrusor contractions can override the urethral pressure resulting in urine leakage. The mixed variety includes symptoms related to stress incontinence and urge incontinence.

A 65-year-old G3P3 woman presents with symptoms of vaginal pressure and heaviness, which seem to worsen towards the end of the day. She has a history of three vaginal deliveries. Her surgical history is significant for hysterectomy for abnormal vaginal bleeding at age 45. On exam, she is found to have a large pelvic prolapse. Which of the following is the most appropriate initial treatment of this patient's prolapse? A. Sacrospinous ligament suspension B. Transvaginal tape C. Pessary fitting D. Anterior repair E. Topical vaginal estrogen

*C* Pessary fitting is the least invasive intervention for this patient's symptomatic prolapse. Although a sacrospinous ligament suspension would be an appropriate procedure for this patient, it is invasive and not an appropriate first step. Transvaginal tape is used for urinary incontinence and has no role in the management of this patient. An anterior repair can potentially help with her symptoms, depending on what is contributing most to her prolapse but, again, it is invasive. Topical estrogen is unlikely to properly treat her prolapse and related symptoms.

A 70-year-old G3P3 woman presents with a four-year history of constant leakage of urine. Her history is significant for abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She had two anterior repairs in the past for recurrent cystocele. The leakage started six months after her last anterior repair. Pelvic examination reveals no evidence of pelvic relaxation. The vagina is well-estrogenized. Q-tip test reveals a fixed, immobile urethra. Cystometrogram shows no evidence of detrusor instability. Cystourethroscopy showed no evidence of any fistula and reveals a "drain pipe" urethra. Which of the following is the best first treatment for this patient? A. Retropubic urethropexy B. Needle suspension C. Artificial urethral sphincter D. Urethral bulking procedure E. Sling procedure

*D* This is a classic example of intrinsic sphincteric deficiency. Urethral bulking procedures are minimally invasive and have a success rate of 80% in these specific patients. The success rates for retropubic urethropexies, needle suspension and slings are less than 50%. An "obstructive or tight" sling can be performed to increase the success rate, but the voiding difficulties are significant, even requiring prolonged or lifelong self-catheterization. Artificial sphincters should be used in patients as a last resort.

A 56-year-old G3P3 woman presents to the office for her annual health maintenance examination. She is in good health and is not taking any medications. She has been postmenopausal for three years. She had an abnormal Pap test 10 years ago, but results have been normal every year since. She is sexually active with her husband. On examination, her cervix is 1 cm above the vaginal introitus and there is moderate bladder prolapse. Her uterus is normal in size and she has no adnexal masses or tenderness. In addition to recommending a mammogram, what is the most appropriate next step in the management of this patient? A. Cystocele repair B. Pelvic ultrasound C. Total hysterectomy D. Observation E. Topical estrogen

*D* This patient is asymptomatic from her prolapse; therefore, no intervention is necessary at this point. Cystocele repairs and hysterectomies are invasive procedures which are not indicated in this asymptomatic patient. It is not necessary to obtain a pelvic ultrasound, as her uterus is normal in size and she has no adnexal masses. Topical estrogen would not help improve the prolapse, although it might help with her vaginal dryness. She seems to be doing well with the lubricants and it is not necessary to expose her to estrogen.