Pelvic Organ Prolapse

Plummer XD, Liang A

Clinical Case Applicability: urinary incontinence, pelvic organ prolapse

Learning Objectives:

1. Describe the normal anatomy of the pelvic floor

2. Understand the pathophysiology of pelvic organ prolapse (POP)

3. Understand the different management options for POP

Clinical Presentation: A sensation of bulging in the vagina that can be accompanied by urinary/fecal incontinence, incomplete bladder emptying, constipation, dyspareunia; NOT typically painful

What are different types of prolapse? (figure 1)

Cystocele (bladder, anterior vaginal wall)

Rectocele (rectum, posterior vaginal wall)

Uterine prolapse (uterus)

Vaginal vault prolapse (vagina after hysterectomy)

What are the risk factors for POP?

– Major risk factors: vaginal birth (Risk ↑ 1.2 times with each vaginal delivery) & aging

– Other risk factors include: menopause, chronically increased intra-abdominal pressure, constipation, increased BMI, pelvic floor trauma and connective tissue disorders

What is the anatomy of the normal pelvic floor?

Delancey’s 3 levels of support for the vagina (figure 2):

1) Apical: cardinal-uterosacral ligament complex provides apical attachment of the uterus and vaginal vault to the sacrum (defect: uterovaginal prolapse)

2) Mid vagina: arcus tendineous fascia pelvis & the fascia overlying the levator ani muscles (defect: cystocele)

3) Distal vagina: urogenital diaphragm and the perineal body (defect: distal rectocele, perineal descent)

1° support: Levator ani: group of 3 paired muscles: iliococcygeus, pubococcygeus, puborectalis (figure 3)

– works as a “sling”, provides the foundation of support

– Innervated by sacral plexus/pudendal nerve

2° support: endopelvic fascia: fibromuscular sheath

What is the pathophysiology behind POP?

Proposed mechanisms include:

1. Levator ani defects: Injury/avulsion during childbirth higher rates of prolapse associated with increasing severity of these muscle defects

2. Age-related change: incidence doubles between age 20-59; may be secondary to physiological changes in aging, degenerative processes & decreased estrogen; ↓ collagen content, collagen stiffer/more fragile

3. Connective tissue dysfunction: increased incidence in women with connective tissue disorders (Ehlers-Danlos); injury (i.e. during delivery)abnormal tissue repairinstability & prolapse

How is prolapse diagnosed?

History & pelvic exam; use of POP-Q – objective classification system for describing/staging prolapse; quantitative measurements of various points at rest and with Valsalva (anterior, apical, posterior)

What are the treatment options available for POP?

– Expectant management

– Pelvic floor physical therapy: may limit progression and alleviate prolapse symptoms

– Vaginal pessaries fitted into the vagina and include support & space-filling pessaries

– Surgery: includes hysterectomy and reconstructive options Plummer XD, Liang A

Figure 1

Figure 2

Figure 3

Figures 1 & 2: Aki Yao, Learning Design & Publishing, Medical School Information Services, University of Michigan

References:

-Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM (2016). Williams Gynecology. 3e. McGraw-Hill Education.

-Patel PD, Amrute KV, Badlani GH. Pelvic organ prolapse and stress urinary inconteinence: a review of etiological factors. Indian J Urol. 2007 Apr;23(2):135-141.

-Rortveit G, Brown JS, Thom DH, Van Den Eeden Sk, Creasman JM, Subak LL. Symptomatic pelvic organ prolapse: prevalence and risk factors in a population-based, racially diverse cohort. Obstet Gynecol. 2007 Jun;109(6):1396-403.

-Word RA, Pathi S, Schaffer JI. Pathophysiology of Pelvic Organ Prolapse. Obstet Gynecol Clin North Am. 2009 Sep;36(3):521-39.

-Rogers, RG, Fashokun, TB. Pelvic organ prolapse in women: Epidemiology, risk factors, clinical manifestations, and management. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (2018)

-Fashokun, TB, Rogers, RG. Pelvic organ prolapse in women: Diagnostic Evaluation. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (2017)

Urinary Incontinence

Liang A

Clinical Cases Applicability: Urinary incontinence, urinary retention

Learning Objectives:

1) Describe the anatomy of the bladder

2) Understand the physiology of normal bladder filling, emptying and continence

3) Understand the autonomic control of the bladder

4) Understand the pathophysiology of urinary incontinence

5) Describe the pharmacology of medications for urge incontinence

Describe the layers of the bladder wall:

1)Mucosa – consists of transitional cell epithelium and lamina propria 2)Submucosa 3)Muscularis – detrusor composed of 3 smooth-muscle “plexiform” layers  allow for rapid expansion 4)Adventita

What is unique about the transitional cell epithelium? “Umbrella” cell layer – stretches & thins with bladder filling; impermeable to provide urine-plasma barrier; covering the lining is a glycosaminoglycan (GAG) layer prohibits bacterial adherence and acts as a protective barrier

What are the components of the peripheral nervous system?

Somatic: innervates striated muscle, VOLUNTARY movements

Autonomic: innervates smooth muscle, INVOLUNTARY movements

Sympathetic “fight or flight”: acts through epinephrine & norepinephrine on α and β adrenergic receptors

Parasympathetic “rest and digest”: acts through acetycholine (Ach) binding to muscarinic or nicotinic receptors

What is the innervation of the bladder and urethra? Sympathetic: T10-L2, terminates into R & L hypogastric nerves; parasympathetic: S2-S4, pelvic nerves (figure 1)

Bladder dome: parasympathetic muscarinic receptors (contraction, voiding) & sympathetic β receptors (relaxation, storage)

Bladder neck: greater density of sympathetic α receptors (contraction, aids in continence)

Urethral sphincter: composed of striated muscle, somatic innervation through the pudendal N (S2-S4)

What happens in normal storage (figure 2)? ↑ Sympathetic, ↓parasympathetic

Contraction of striated urethral sphincter muscles

Sympathetic stimulation w/ NE on (α) contraction of bladder neck; on (β) relaxation of dome

Inhibited parasympathetic transmissiondecreased detrusor contraction

What happens in normal voiding (figure 2)? ↓Sympathetic, ↑parasympathetic

sensation of bladder stretching efferent impulses from pontine micturition center 

Voluntary relaxation of striated urethral sphincter

Inhibition of sympathetic system  (α) relaxation of bladder neck, (β) decreased relaxation of dome

Stimulation of parasympathetic system w/ Ach release detrusor muscarinic contraction

What are the different types of urinary incontinence? Treatment?

(all types may benefit from weight loss, normalize fluid intake, ↓bladder irritants (alcohol, carbonation, caffeine), minimize constipation, smoking cessation)

Stress – occurs with increases in intra-abdominal pressure; mechanism: urethral hypermobility from insufficient support tissue vs intrinsic sphincter deficiency; Treatment: Kegel, PT, pessary, urethral bulking agent, midurethral sling

Urge – urge to urinate followed by involuntary leakage, overactive bladder; detrusor overactivity; Treatment: Bladder

training, anti-muscarinic agents & β adrenergic agents (relaxes detrusor muscle)

Overflow: continuous leakage or dribbling in the setting of incomplete bladder emptying; Treatment: treat

underlying impairment, possible intermittent straight catheterization (i.e. spinal cord injury)

What are side effects of anti-muscarinic agents? Urinary retention, dry mouth, constipation, blurred vision, tachycardia, drowsiness, decreased cognitive function; contraindicated in myasthenia gravis & narrow angle-closure glaucoma Urinary Incontinence

Liang A

Figure 1:

Figure 2:

References

– Rickey, LM. Chronic urinary retention in women. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (2017)

– Hoffman, BL, Schorge, JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM. Chapter 23 Urinary Incontinence. Williams Gynecology, 3e New York, NY: McGraw-Hill; 2016.

– Lukacz ES. Treatment of urinary incontinence in women. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (2018)

– Urinary Incontinence in Women. Practice Bulletin 155. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015; 126:e66-81.

00:01
my name is Ashley and I had a complete
00:05
hysterectomy and flashlight about a
00:07
decade ago I started having pain kind of
00:12
ignored it for a long time and then I
00:15
had weekend where I was doubled over in
00:18
pain in the bathroom for the entire
00:20
weekend and what we think happened
00:22
probably is that assist first but that
00:24
really started me kind of on this
00:26
journey to figure out what is going on
00:28
inside my body that’s that’s causing all
00:30
of this probably half my life I have had
00:34
on and off issues with incontinence so
00:37
when I would jump for sneeze or laugh or
00:39
cough or all of those things that we do
00:43
sometimes there I just couldn’t control
00:46
it and really over the last four or five
00:49
years it’s got it had gotten to the
00:51
point where it was really impacting what
00:54
I was able to do with my family and
00:57
really creating a situation that
00:59
sometimes I wouldn’t do things in public
01:00
because of it I remember a time at
01:03
soccer practice when I generally ran
01:06
with the girls and I remember making the
01:08
first lap and having an accident I just
01:12
could not I couldn’t not and I I
01:16
remember thinking myself I’m so glad I
01:17
have a long-sleeve shirt on today so I
01:19
could take it off and tie it around my
01:20
waist when my child says mom come jump
01:24
on the trampoline with me and let me run
01:26
to the restroom and so I do and I go out
01:29
there and I jump for five minutes and
01:31
I’m like I gotta stop baby she was
01:35
understanding about it but it was really
01:37
upsetting that I couldn’t share that
01:40
moment with her because of this stupid
01:42
issue kind of coupling both of those
01:45
things really when it was time for me to
01:47
have a conversation with my doctor and
01:50
my annual appointment I really brought
01:52
up the possibility of trying to take
01:56
care of both of these things I just
01:57
needed to feel like I could be normal
02:00
and so with her support got connected to
02:04
urologist and they both agreed to do
02:07
both surgeries at one time
02:08
so it’s all gone now I am just a few
02:13
days over a month out of surgery and
02:16
it’ll never be a day that I regret doing
02:18
it I wish I would have known that there
02:20
were things I could have done earlier
02:21
you know everybody just makes the
02:23
assumption that that’s gonna happen when
02:25
you have kids but now that I’ve I’ve
02:27
talked to people and know that there are
02:30
exercises and treatments and different
02:32
things that that can come before doing
02:35
surgery I absolutely would have done
02:38
those things and and asked about him and
02:40
explore those options you don’t have to
02:43
just accept this as a part of life like
02:44
this does not have to be something that
02:48
you deal with I’m glad that now my
02:50
problems are taken care of but it’s also
02:54
one of those things to you that I know
02:56
that I will have to make sure that I
02:58
keep all of my muscles strong so that it
03:00
doesn’t get to a point where it was
03:02
before there’s no doubt I would have
03:05
sought treatment had a noon that there
03:06
were some things that were available
03:08
before