Gyne Report

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

Gyne Report

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