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Toronto Notes 2019
Urogynecology
Gynecology GY37
Table 19. Pelvic Prolapse
Type
Cystocele
(protrusion of bladder into the anterior vaginal wall)
Enterocele
(prolapse of small bowel in upper posterior vaginal wall)
Rectocele
(protrusion of
rectum into
posterior vaginal wall)
Uterine Prolapse
(protrusion of cervix and uterus into vagina)
Vault Prolapse
(protrusion of
apex of vaginal vault into vagina, post- hysterectomy)
Clinical Features
Frequency, urgency, nocturia
Stress incontinence
Incomplete bladder emptying ± associated increased incidence of UTIs – may lead to renal impairment
Straining/digitation to evacuate stool Constipation
Groin/back pain (stretching of uterosacral ligaments)
Feeling of heaviness/pressure in the pelvis Worse with standing, lifting
Worse at the end of the day Relieved by lying down Ulceration/bleeding (particularly if hypoestrogenic)
± urinary incontinence
Treatment
See above
Anterior colporrhaphy (“anterior repair”)
Consider additional/alternative surgical procedure if documented urinary stress incontinence
Similar to hernia repair
Contents reduced, neck of peritoneal sac ligated, uterosacral ligaments, and levator ani muscles approximated
See above
Also laxatives and stool softeners
Posterior colporrhaphy (“posterior repair”), plication of endopelvic fascia and perineal muscles approximated in midline to support rectum and perineum (can result in dyspareunia)
The only true hernia of the pelvis is an ENTEROCELE because peritoneum herniates with the small bowel
See above
Vaginal hysterectomy ± surgical prevention of vault prolapse
Consider additional surgical procedures if urinary incontinence, cystocele, rectocele, and/or enterocele are present
See above
Sacralcolpopexy (vaginal vault suspension), sacrospinous fixation, or uterosacral ligament suspension
• involuntarylossofurinewithincreasedintra-abdominalpressure(cough,laugh,sneeze,walk,run)
Urinary Incontinence
• seeUrology,U6
STRESS INCONTINENCE
Definition
Risk Factors for Stress Incontinence in Women
• pelvicprolapse
• pelvicsurgery
• vaginaldelivery
• hypoestrogenicstate(post-menopause) • age
• smoking
• neurological/pulmonarydisease
Treatment
• seeProlapse,GY36 • surgical
■ tension-free vaginal tape (TVT), tension-free obturator tape (TOT), prosthetic/fascial slings or retropubic bladder suspension (Burch or Marshall-Marchetti-Krantz procedures)
URGE INCONTINENCE
Definition
• urinelossassociatedwithanabrupt,suddenurgetovoid • “overactivebladder”
• diagnosedbasedonsymptoms
• idiopathic(90%)
• detrusormuscleoveractivity(“detrusorinstability”)
Urge Incontinence
Urine loss associated with an abrupt, sudden urge to void
Rule Out Neurological Causes of Urge Incontinence
• MS
• Herniated disc
• DM
Etiology
Associated Symptoms
• frequency, urgency, nocturia, leakage
Treatment
• behaviourmodification(reducecaffeine/liquid,smokingcessation,regularvoidingschedule) • Kegelexercises
• medications
■ anticholinergics: oxybutinin (Ditropan®), tolterodine (Detrol®), solifenacin (VESIcare®) ■ tricyclic antidepressants: imipramine