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7/31/2019 Gyne Report
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Kathleen S. Chua, M.D.
Jose R. Reyes Memorial Medical Center
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Levator ani +connectivetissue
Spans anteriorlyfrom symphysispubis to thecoccyx, laterallyattaches to the
pelvis via thearcus tendinusfascia
Pelvic Diaphragm
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Diaphragmatic
Ileococcygeus
Coccygeus
Pubovisceral
Pubococcygeus
Puborectalis
Levator ani
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Triangular sheet of
dense fibromuscular
tissue Covers the anterior
half of the pelvicoutlet
Urogenitaldiaphragm
Supports the vaginaand urethra
Perineal membrane
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Space through which the urethra, vagina, and
rectum pass
Genital hiatus
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The Continence
Mechanism
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Urethra lies on the anterior vaginal wall
Anterior vaginal wall supports the urethra and
bladder neck Filling phase: Inhibition of the parasymphathetic mechanism
Urine flows down from the kidney, ureter, to bladderNo increase in intravesical pressure due to
accomodation (elasticity of bladder) There is stimulation of the sympathetic mechanism by
alpha-adrenergic receptors of bladder neck andurethra and additional stimulation by the striatedmuscle of the sphincter urethra
Continence mechanism
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Voiding phase (bladder
is full)
There is mild contractionof the detrussor musclethus urge to urinate
Pelvic floor relaxesBladder neck opensfunnelling of bladder
neck to facilitate flow ofurine from bladder tourethra simultaneouscontraction of detrussors
Continence mechanism
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Involuntary loss of urine through an increase in
intraabdominal pressure (coughing, sneezing,
laughing, etc)May be provoked by detrusor contraction
genuine stress incontinence involuntary urethralloss of urine when the intravesical pressure exceeds
the maximum urethral pressure in the absence ofdetrusor activity
STRESS INCONTINENCE due to urethral sphincterincontinence
Urinary Stress
Incontinence
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Occurs when the intravesical pressure exceeds the closing
pressure on the urethra
Childbirth is the most common causative factordenervation of the pelvic wall during trauma of delivery
Other causes: congenital weakness of the bladder neck,trauma from other causes, estrogen deficiency, s/p pelvicsurgery or radiotherapy
Signs & symptoms: leakage of urine when patient coughs,sneezes, runs, jumps, carry
Incidence higher in multiparous, older patients
Stress Incontinence
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Tests: Midstream urine to exclude infection or glycosuria
Uroflowmetry simple non-invasive test that will excludevoiding difficulties. Patient is asked to urinate into a toiletwith flow-measuring device in the pan. Normal flow rate =15ml/second
Bladder outflow obstruction is rare in women
Cystometry and videocystourethrography used to assess
leakage and exclude detrusor instability. Bladder is filledwith radioopaque fluid with urethral catheter and pressureis measured by subtracting rectal pressure from bladderpressure
Stress Incontinence
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Bladder storage or filling for complains of
frequency, urgency, and urge incontinence
Bladder / voiding diary record for at least 3 days
Records amount of urine using toilet cup withgradiations
Records leaking urine associated with activity
Strong urge
Amount of water input
Tests for Lower Urinary
Tract Dysfunction
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Pad test Evaluate incontinence intervention Quantifies urine loss Weigh the pad before using, weigh again after use May not be accurate
Simple office bladder filling Screen detrussor overactivity
Qualitative, not quantitative Ordinary catheter connected to IV tubing (water runs
through into the bladder) Patient tells first sensation ofbladder filling Patient tells she has to urinate but able tohold it Patient says she could no longer hold urine
Stress test done in between
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Residual Urine Volume < 50 mL
1st sensation to void 150-250 mL
2nd desire to void 400 600 mL
Normal cystometric
values
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Treatment of:
Obesity
Chronic cough Chronic constipation
Urogenital estrogen deficiency
Pelvic floor muscle exercises
Conservative treatment of
Urinary Stress Incontinence
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Anterior colporrhaphy women with combined stress incontinence
and vaginal prolapse
Endoscopic bladder neck suspension suture done on either side of
the bladder neck, anchoring it to the pubocervical fascia and tying theupper end on the rectus sheath
Tension-free vaginal tape proline mesh inserted on either side of theurethra
Burch colposuspension 2 or 3 sutures placed in the vaginal tissueand fascia on each side of the bladder neck and tied to each side of thebladder neck.
Marshal-Marchetti-Krantz sutures inserted between the periurethraltissues along the proximal half of the urethra
Sling procedure
Periurethral injections collagen injected to act as cushion to tissue
reduce caliber of the bladder neck.
Surgical treatment of
urinary stress incontinence
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I. Superior and lateral connective tissue attachments
(cardinal and uterosacral ligaments)
II. The paracolpium attaches the vagina laterally andmore directly to pelvic wall (midportion)
Pubocervical fascia
Rectovaginal fascia
III. Vaginal wall is directly attached to thesurrounding structures (distal part)
Levels of vaginal
support
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Stage 0 No prolapse demonstrated
Stage I Most distal portion of the prolapse is > 1cm
above the level of the hymen Stage II Most distal portion of the prolapse is < 1 cm
proximal or distal to the plane of the hymen
Stage III Most distal portion of the prolapse is > 1 cmbelow the plane of the hymen but no further than 2cm
less than the total vaginal length Stage IV Complete to nearly complete eversion of the
vagina; Most distal portion of prolapse protrudes morethan 2cm of the total vaginal length
Stages of Pelvic Organ
Prolapse
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Urethrocele Prolapse of the lower anterior vaginal wallinvolving the urethra only.
Cystocele Prolapse of the upper anterior vaginal wallinvolving downward displacement of bladder.Generally, prolapse of the urethra is alsoassociated and hence the term cystourethrocele isoften used.
UterovaginalProlapse
This term is used to describe prolapse of theuterus, cervix and upper vagina.
Enterocele Prolapse of the upper posterior wall of the vaginausually containing loops of small bowel.
Rectocele Prolapse of the lower posterior wall of the vaginainvolving the rectum bulging forwards into the
posterior vaginal lumen
Female genital prolapse
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Cystocele
occurs when the pubocervical fascia between awoman's bladder and her vagina is torn by
childbirth, allowing the bladder to herniate into thevagina
Most Gr 1 and 2 cystoceles are asymptomatic
High grade cystoceles are associated with vaginalbuldging, vaginal pressure, dyspareunia, UTI,
obstructive voiding, urinary retentionA high grade cystocele may mask urethral
hypermobility and stress incontinence
h l f
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Physical examination ofCystocele
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MRI of Cystocele
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Enterocele
protrusion of the small intestines and peritoneuminto the vaginal canal
Simple enterocele Complex enterocele- associated with vault prolapse
and anterior or posterior vaginal prolapse
Cause vaginal pressure, dyspareunia, low back pain,
constipation, symptoms of bowel obstruction
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MRI of Enterocele
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Rectocele
Defect of prerectal and pararectal fascia,andrectovaginal septum Rectal tissue bulges through
this tear and into the vagina as a hernia Present in 80% asymptomatic patients
Vaginal mass, vaginal pressure, dyspareunia,constipation
Ph i l i i f
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Physical examination ofRectocele
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MRI of Rectocele
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Uterine Prolapse
Laxity of uterosacral ligaments
May present with vaginal mass, dyspareunia,
urinary retention, back painGrade 4 prolapse is associated with ureteral
obstruction
Ph i l i ti f
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Physical examination ofUterine Prolapse
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MRI of Uterine Prolapse
C l t E i f
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Complete Eversion ofVaginal Vault
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Physiotherapy
Pelvic floor exercises
Vaginal cones or pessary
Hormone replacement therapy
Functional electrical stimulation
Non-surgical treatment
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Anticholinergics
Smooth muscle relaxants, cholinergics, local
anesthetics
Medical Treatment
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Obliterative
Colpocleisis obliterate the vagina
For those not fit for surgery for those with no desire for sexual function,
Restorative
Colporrhaphy anterior/posterior vaginal repair Abdominal sacral colpopexy
Sacrospinous ligament fixation
Surgical Treatment
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Compensatory
Repair with mesh
Paravaginal repair
Surgical Treatment
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Thank you
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