{"id":432,"date":"2020-08-13T20:37:41","date_gmt":"2020-08-13T20:37:41","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=432"},"modified":"2022-09-08T16:52:37","modified_gmt":"2022-09-08T16:52:37","slug":"urinary-tract-problems","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/basic_obgyn\/advanced-training\/urinary-tract-problems\/","title":{"rendered":"Urinary Incontinence and Prolapse"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/30TiM72_8GA\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 8:06<\/p>\n<input type='hidden' bg_collapse_expand='69e9c89a773692045825384' value='69e9c89a773692045825384'><input type='hidden' id='bg-show-more-text-69e9c89a773692045825384' value='Show Teaching Transcript'><input type='hidden' id='bg-show-less-text-69e9c89a773692045825384' value='Hide Teaching Transcript'><button id='bg-showmore-action-69e9c89a773692045825384' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Teaching Transcript<\/button><div id='bg-showmore-hidden-69e9c89a773692045825384' ><\/p>\n<p class=\"p2\">Pelvic Organ Prolapse<\/p>\n<p class=\"p3\">Plummer XD, Liang A<\/p>\n<p class=\"p4\"><b>Clinical Case Applicability: <\/b>urinary incontinence, pelvic organ prolapse<\/p>\n<p class=\"p4\"><b>Learning Objectives: <\/b><\/p>\n<p class=\"p4\">1. Describe the normal anatomy of the pelvic floor<\/p>\n<p class=\"p4\">2. Understand the pathophysiology of pelvic organ prolapse (POP)<\/p>\n<p class=\"p4\">3. Understand the different management options for POP<\/p>\n<p class=\"p4\"><b>Clinical Presentation: <\/b>A sensation of bulging in the vagina that can be accompanied by urinary\/fecal incontinence, incomplete bladder emptying, constipation, dyspareunia; NOT typically painful<\/p>\n<p class=\"p4\"><b>What are different types of prolapse? (figure 1) <\/b><\/p>\n<p class=\"p4\">Cystocele (bladder, anterior vaginal wall)<\/p>\n<p class=\"p4\">Rectocele (rectum, posterior vaginal wall)<\/p>\n<p class=\"p4\">Uterine prolapse (uterus)<\/p>\n<p class=\"p4\">Vaginal vault prolapse (vagina after hysterectomy)<\/p>\n<p class=\"p4\"><b>What are the risk factors for POP? <\/b><\/p>\n<p class=\"p4\">&#8211; Major risk factors: vaginal birth (Risk \u2191 1.2 times with each vaginal delivery) &amp; aging<\/p>\n<p class=\"p4\">&#8211; Other risk factors include: menopause, chronically increased intra-abdominal pressure, constipation, increased BMI, pelvic floor trauma and connective tissue disorders<\/p>\n<p class=\"p4\"><b>What is the anatomy of the normal pelvic floor? <\/b><\/p>\n<p class=\"p4\">Delancey\u2019s 3 levels of support for the vagina <b>(figure 2)<\/b>:<\/p>\n<p class=\"p4\">1) Apical: cardinal-uterosacral ligament complex provides apical attachment of the uterus and vaginal vault to the sacrum (defect: uterovaginal prolapse)<\/p>\n<p class=\"p4\">2) Mid vagina: arcus tendineous fascia pelvis &amp; the fascia overlying the levator ani muscles (defect: cystocele)<\/p>\n<p class=\"p4\">3) Distal vagina: urogenital diaphragm and the perineal body (defect: distal rectocele, perineal descent)<\/p>\n<p class=\"p4\">1\u00b0 support: Levator ani: group of 3 paired muscles: iliococcygeus, pubococcygeus, puborectalis <b>(figure 3) <\/b><\/p>\n<p class=\"p4\">&#8211; works as a \u201csling\u201d, provides the foundation of support<\/p>\n<p class=\"p4\">&#8211; Innervated by sacral plexus\/pudendal nerve<\/p>\n<p class=\"p4\">2\u00b0 support: endopelvic fascia: fibromuscular sheath<\/p>\n<p class=\"p4\"><b>What is the pathophysiology behind POP? <\/b><\/p>\n<p class=\"p4\">Proposed mechanisms include:<\/p>\n<p class=\"p4\">1. Levator ani defects: Injury\/avulsion during childbirth <span class=\"s2\">\uf0e0<\/span>higher rates of prolapse associated with increasing severity of these muscle defects<\/p>\n<p class=\"p4\">2. Age-related change: incidence doubles between age 20-59; may be secondary to physiological changes in aging, degenerative processes &amp; decreased estrogen; \u2193 collagen content, collagen stiffer\/more fragile<\/p>\n<p class=\"p4\">3. Connective tissue dysfunction: increased incidence in women with connective tissue disorders (Ehlers-Danlos); injury (i.e. during delivery)<span class=\"s2\">\uf0e0<\/span>abnormal tissue repair<span class=\"s2\">\uf0e0<\/span>instability &amp; prolapse<\/p>\n<p class=\"p4\"><b>How is prolapse diagnosed? <\/b><\/p>\n<p class=\"p4\">History &amp; pelvic exam; use of <b>POP-Q <\/b>\u2013 objective classification system for describing\/staging prolapse; quantitative measurements of various points at rest and with Valsalva (anterior, apical, posterior)<\/p>\n<p class=\"p4\"><b>What are the treatment options available for POP? <\/b><\/p>\n<p class=\"p4\">&#8211; Expectant management<\/p>\n<p class=\"p4\">&#8211; Pelvic floor physical therapy: may limit progression and alleviate prolapse symptoms<\/p>\n<p class=\"p4\">&#8211; Vaginal pessaries fitted into the vagina and include support &amp; space-filling pessaries<\/p>\n<p class=\"p4\">&#8211; Surgery: includes hysterectomy and reconstructive options <span class=\"s3\">Plummer XD, Liang A <\/span><\/p>\n<p class=\"p4\"><b>Figure 1 <\/b><\/p>\n<p class=\"p4\"><b>Figure 2 <\/b><\/p>\n<p class=\"p4\"><b>Figure 3 <\/b><\/p>\n<p class=\"p3\"><b>Figures 1 &amp; 2: Aki Yao, Learning Design &amp; Publishing, Medical School Information Services, University of Michigan <\/b><\/p>\n<p class=\"p4\"><b>References: <\/b><\/p>\n<p class=\"p5\">-Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM (2016). <i>Williams Gynecology<\/i>. 3e. McGraw-Hill Education.<\/p>\n<p class=\"p5\">-Patel PD, Amrute KV, Badlani GH. Pelvic organ prolapse and stress urinary inconteinence: a review of etiological factors. <i>Indian J Urol<\/i>. 2007 Apr;23(2):135-141.<\/p>\n<p class=\"p5\">-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. <i>Obstet Gynecol. <\/i>2007 Jun;109(6):1396-403.<\/p>\n<p class=\"p5\">-Word RA, Pathi S, Schaffer JI. Pathophysiology of Pelvic Organ Prolapse. <i>Obstet Gynecol Clin North Am. <\/i>2009 Sep;36(3):521-39.<\/p>\n<p class=\"p5\">-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)<\/p>\n<p class=\"p5\">-Fashokun, TB, Rogers, RG. Pelvic organ prolapse in women: Diagnostic Evaluation. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (2017)<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/YgYtgnKhK9I\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 9:46<\/p>\n<input type='hidden' bg_collapse_expand='69e9c89a779741047671306' value='69e9c89a779741047671306'><input type='hidden' id='bg-show-more-text-69e9c89a779741047671306' value='Show Teaching Script'><input type='hidden' id='bg-show-less-text-69e9c89a779741047671306' value='Hide Teaching Script'><button id='bg-showmore-action-69e9c89a779741047671306' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Teaching Script<\/button><div id='bg-showmore-hidden-69e9c89a779741047671306' ><\/p>\n<p class=\"p2\">Urinary Incontinence<\/p>\n<p class=\"p3\">Liang A<\/p>\n<p class=\"p4\"><b>Clinical Cases Applicability: <\/b>Urinary incontinence, urinary retention<\/p>\n<p class=\"p4\"><b>Learning Objectives: <\/b><\/p>\n<p class=\"p5\">1) Describe the anatomy of the bladder<\/p>\n<p class=\"p5\">2) Understand the physiology of normal bladder filling, emptying and continence<\/p>\n<p class=\"p5\">3) Understand the autonomic control of the bladder<\/p>\n<p class=\"p5\">4) Understand the pathophysiology of urinary incontinence<\/p>\n<p class=\"p6\">5) Describe the pharmacology of medications for urge incontinence<\/p>\n<p class=\"p6\"><b>Describe the layers of the bladder wall: <\/b><\/p>\n<p class=\"p6\">1)Mucosa \u2013 consists of transitional cell epithelium and lamina propria 2)Submucosa 3)Muscularis \u2013 detrusor composed of 3 smooth-muscle \u201cplexiform\u201d layers <span class=\"s2\">\uf0e0 <\/span>allow for rapid expansion 4)Adventita<\/p>\n<p class=\"p6\"><b>What is unique about the transitional cell epithelium? <\/b>\u201cUmbrella\u201d cell layer \u2013 stretches &amp; thins with bladder filling; impermeable to provide urine-plasma barrier; covering the lining is a glycosaminoglycan (GAG) layer <span class=\"s2\">\uf0e0<\/span>prohibits bacterial adherence and acts as a protective barrier<\/p>\n<p class=\"p6\"><b>What are the components of the peripheral nervous system? <\/b><\/p>\n<p class=\"p6\">Somatic: innervates striated muscle, VOLUNTARY movements<\/p>\n<p class=\"p6\">Autonomic: innervates smooth muscle, INVOLUNTARY movements<\/p>\n<p class=\"p6\">Sympathetic \u201cfight or flight\u201d: acts through epinephrine &amp; norepinephrine on \u03b1 and \u03b2 adrenergic receptors<\/p>\n<p class=\"p6\">Parasympathetic \u201crest and digest\u201d: acts through acetycholine (Ach) binding to muscarinic or nicotinic receptors<\/p>\n<p class=\"p6\"><b>What is the innervation of the bladder and urethra? Sympathetic: T10-L2, terminates into R &amp; L hypogastric nerves; parasympathetic: S2-S4, pelvic nerves (figure 1) <\/b><\/p>\n<p class=\"p6\">Bladder dome: parasympathetic muscarinic receptors (contraction, voiding) &amp; sympathetic \u03b2 receptors (relaxation, storage)<\/p>\n<p class=\"p6\">Bladder neck: greater density of sympathetic \u03b1 receptors (contraction, aids in continence)<\/p>\n<p class=\"p6\">Urethral sphincter: composed of striated muscle, somatic innervation through the pudendal N (S2-S4)<\/p>\n<p class=\"p6\"><b>What happens in normal storage (figure 2)? <\/b>\u2191 Sympathetic, \u2193parasympathetic<\/p>\n<p class=\"p6\">Contraction of striated urethral sphincter muscles<\/p>\n<p class=\"p6\">Sympathetic stimulation w\/ NE on <b>(\u03b1) <\/b>contraction of bladder neck; on <b>(\u03b2) <\/b>relaxation of dome<\/p>\n<p class=\"p6\">Inhibited parasympathetic transmission<span class=\"s2\">\uf0e0<\/span>decreased detrusor contraction<\/p>\n<p class=\"p6\"><b>What happens in normal voiding (figure 2)? <\/b>\u2193Sympathetic, \u2191parasympathetic<\/p>\n<p class=\"p6\">sensation of bladder stretching<span class=\"s2\">\uf0e0 <\/span>efferent impulses from <b>pontine micturition center <\/b><span class=\"s2\">\uf0e0 <\/span><\/p>\n<p class=\"p6\">Voluntary relaxation of striated urethral sphincter<\/p>\n<p class=\"p6\">Inhibition of sympathetic system <span class=\"s2\">\uf0e0 <\/span>(<b>\u03b1<\/b>) relaxation of bladder neck, (<b>\u03b2) <\/b>decreased relaxation of dome<\/p>\n<p class=\"p6\">Stimulation of parasympathetic system w\/ Ach release <span class=\"s2\">\uf0e0<\/span>detrusor muscarinic contraction<\/p>\n<p class=\"p6\"><b>What are the different types of urinary incontinence? Treatment? <\/b><\/p>\n<p class=\"p6\">(all types may benefit from weight loss, normalize fluid intake, \u2193bladder irritants (alcohol, carbonation, caffeine), minimize constipation, smoking cessation)<\/p>\n<p class=\"p6\"><b>Stress <\/b>\u2013 occurs with increases in intra-abdominal pressure; mechanism: urethral hypermobility from insufficient support tissue vs intrinsic sphincter deficiency; <i>Treatment<\/i>: Kegel, PT, pessary, urethral bulking agent, midurethral sling<\/p>\n<p class=\"p6\"><b>Urge <\/b>\u2013 urge to urinate followed by involuntary leakage, overactive bladder; detrusor overactivity<i>; Treatment: <\/i>Bladder<\/p>\n<p class=\"p6\">training, anti-muscarinic agents &amp; \u03b2 adrenergic agents (relaxes detrusor muscle)<\/p>\n<p class=\"p6\"><b>Overflow: <\/b>continuous leakage or dribbling in the setting of incomplete bladder emptying; <i>Treatment<\/i>: treat<\/p>\n<p class=\"p6\">underlying impairment, possible intermittent straight catheterization (i.e. spinal cord injury)<\/p>\n<p class=\"p6\"><b>What are side effects of anti-muscarinic agents? <\/b>Urinary retention, dry mouth, constipation, blurred vision, tachycardia, drowsiness, decreased cognitive function; contraindicated in myasthenia gravis &amp; narrow angle-closure glaucoma <span class=\"s3\">Urinary Incontinence <\/span><\/p>\n<p class=\"p3\">Liang A<\/p>\n<p class=\"p6\">Figure 1:<\/p>\n<p class=\"p6\">Figure 2:<\/p>\n<p class=\"p6\">References<\/p>\n<p class=\"p5\">&#8211; Rickey, LM. Chronic urinary retention in women. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (2017)<\/p>\n<p class=\"p5\">&#8211; Hoffman, BL, Schorge, JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM. Chapter 23 Urinary Incontinence. <i>Williams Gynecology, 3e <\/i>New York, NY: McGraw-Hill; 2016.<\/p>\n<p class=\"p5\">&#8211; Lukacz ES. Treatment of urinary incontinence in women. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (2018)<\/p>\n<p class=\"p6\"><span class=\"s4\">&#8211; <\/span>Urinary Incontinence in Women. Practice Bulletin 155. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015; 126:e66-81.<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/3aEv7ssVMwQ\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 3:13<\/p>\n<input type='hidden' bg_collapse_expand='69e9c89a77e345093343377' value='69e9c89a77e345093343377'><input type='hidden' id='bg-show-more-text-69e9c89a77e345093343377' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9c89a77e345093343377' value='Hide Transcript'><button id='bg-showmore-action-69e9c89a77e345093343377' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fafafa;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9c89a77e345093343377' ><\/p>\n<p>00:01<br \/>\nmy name is Ashley and I had a complete<br \/>\n00:05<br \/>\nhysterectomy and flashlight about a<br \/>\n00:07<br \/>\ndecade ago I started having pain kind of<br \/>\n00:12<br \/>\nignored it for a long time and then I<br \/>\n00:15<br \/>\nhad weekend where I was doubled over in<br \/>\n00:18<br \/>\npain in the bathroom for the entire<br \/>\n00:20<br \/>\nweekend and what we think happened<br \/>\n00:22<br \/>\nprobably is that assist first but that<br \/>\n00:24<br \/>\nreally started me kind of on this<br \/>\n00:26<br \/>\njourney to figure out what is going on<br \/>\n00:28<br \/>\ninside my body that&#8217;s that&#8217;s causing all<br \/>\n00:30<br \/>\nof this probably half my life I have had<br \/>\n00:34<br \/>\non and off issues with incontinence so<br \/>\n00:37<br \/>\nwhen I would jump for sneeze or laugh or<br \/>\n00:39<br \/>\ncough or all of those things that we do<br \/>\n00:43<br \/>\nsometimes there I just couldn&#8217;t control<br \/>\n00:46<br \/>\nit and really over the last four or five<br \/>\n00:49<br \/>\nyears it&#8217;s got it had gotten to the<br \/>\n00:51<br \/>\npoint where it was really impacting what<br \/>\n00:54<br \/>\nI was able to do with my family and<br \/>\n00:57<br \/>\nreally creating a situation that<br \/>\n00:59<br \/>\nsometimes I wouldn&#8217;t do things in public<br \/>\n01:00<br \/>\nbecause of it I remember a time at<br \/>\n01:03<br \/>\nsoccer practice when I generally ran<br \/>\n01:06<br \/>\nwith the girls and I remember making the<br \/>\n01:08<br \/>\nfirst lap and having an accident I just<br \/>\n01:12<br \/>\ncould not I couldn&#8217;t not and I I<br \/>\n01:16<br \/>\nremember thinking myself I&#8217;m so glad I<br \/>\n01:17<br \/>\nhave a long-sleeve shirt on today so I<br \/>\n01:19<br \/>\ncould take it off and tie it around my<br \/>\n01:20<br \/>\nwaist when my child says mom come jump<br \/>\n01:24<br \/>\non the trampoline with me and let me run<br \/>\n01:26<br \/>\nto the restroom and so I do and I go out<br \/>\n01:29<br \/>\nthere and I jump for five minutes and<br \/>\n01:31<br \/>\nI&#8217;m like I gotta stop baby she was<br \/>\n01:35<br \/>\nunderstanding about it but it was really<br \/>\n01:37<br \/>\nupsetting that I couldn&#8217;t share that<br \/>\n01:40<br \/>\nmoment with her because of this stupid<br \/>\n01:42<br \/>\nissue kind of coupling both of those<br \/>\n01:45<br \/>\nthings really when it was time for me to<br \/>\n01:47<br \/>\nhave a conversation with my doctor and<br \/>\n01:50<br \/>\nmy annual appointment I really brought<br \/>\n01:52<br \/>\nup the possibility of trying to take<br \/>\n01:56<br \/>\ncare of both of these things I just<br \/>\n01:57<br \/>\nneeded to feel like I could be normal<br \/>\n02:00<br \/>\nand so with her support got connected to<br \/>\n02:04<br \/>\nurologist and they both agreed to do<br \/>\n02:07<br \/>\nboth surgeries at one time<br \/>\n02:08<br \/>\nso it&#8217;s all gone now I am just a few<br \/>\n02:13<br \/>\ndays over a month out of surgery and<br \/>\n02:16<br \/>\nit&#8217;ll never be a day that I regret doing<br \/>\n02:18<br \/>\nit I wish I would have known that there<br \/>\n02:20<br \/>\nwere things I could have done earlier<br \/>\n02:21<br \/>\nyou know everybody just makes the<br \/>\n02:23<br \/>\nassumption that that&#8217;s gonna happen when<br \/>\n02:25<br \/>\nyou have kids but now that I&#8217;ve I&#8217;ve<br \/>\n02:27<br \/>\ntalked to people and know that there are<br \/>\n02:30<br \/>\nexercises and treatments and different<br \/>\n02:32<br \/>\nthings that that can come before doing<br \/>\n02:35<br \/>\nsurgery I absolutely would have done<br \/>\n02:38<br \/>\nthose things and and asked about him and<br \/>\n02:40<br \/>\nexplore those options you don&#8217;t have to<br \/>\n02:43<br \/>\njust accept this as a part of life like<br \/>\n02:44<br \/>\nthis does not have to be something that<br \/>\n02:48<br \/>\nyou deal with I&#8217;m glad that now my<br \/>\n02:50<br \/>\nproblems are taken care of but it&#8217;s also<br \/>\n02:54<br \/>\none of those things to you that I know<br \/>\n02:56<br \/>\nthat I will have to make sure that I<br \/>\n02:58<br \/>\nkeep all of my muscles strong so that it<br \/>\n03:00<br \/>\ndoesn&#8217;t get to a point where it was<br \/>\n03:02<br \/>\nbefore there&#8217;s no doubt I would have<br \/>\n03:05<br \/>\nsought treatment had a noon that there<br \/>\n03:06<br \/>\nwere some things that were available<br \/>\n03:08<br \/>\nbefore<\/p>\n<p><\/div>\n<hr \/>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Duration 8:06 Duration 9:46 Duration 3:13 &nbsp;<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":160,"menu_order":12,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-432","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/432","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/comments?post=432"}],"version-history":[{"count":4,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/432\/revisions"}],"predecessor-version":[{"id":1220,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/432\/revisions\/1220"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/160"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/media?parent=432"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}