Pelvic Prolapse and Lower Urinary Tract Symptoms

1
Pelvic Prolapse and Lower Urinary Tract Symptoms

• Hann-Chorng Kuo
• Department of Urology
• Buddhist Tzu Chi General Hospital

2
Vaginal Prolapse

• Anterior vaginal prolapse cystocele, urethral
  hypermobility, cystourethrocele
• Middle vaginal prolapse apical prolapse,
  enterocele (bowel herniation), uterine prolpase,
  vault prolapse
• Posterior vaginal prolapse rectocele (rectal
  herniation)

3
Anatomical classification of Pelvic prolapse
4
Prevalence of pelvic prolapse

• 11.1 of all women by age 80 years
• Comprise 16.3 of the indications for
  hysterectomy
• Patients often initially present to urologists
  with complaint of stress urinary incontinence

5
Vaginal support

• Vaginal vault supported by cardinal and
  uterosacral ligaments
• Uterine support broad ligaments attached to
  lateral pelvic wall
• Mid vagina supported by lateral attachments to
  pubococcygeal muscles
• Distal vagina embedded in connective tissue of
  perineal membrane and attached to urogenital
  diaphragm structures

6
The vaginal support
7
(No Transcript)
8
retroverted uterus 1st sign
attenuation, stretching or Breakage ??
9
ut
cx
130o
b
LP
sp
u
r
v
10
(No Transcript)
11
Sagittal view
Coronal view
12
Pathophysiology of cystocele

• Weakened pubocervical fascia at the medial edge
  of the levator muscle
• Detachment of lateral vaginal wall from the
  pelvic side wall at the white line of arcus
  tendineus fascia

13
Pelvic organ support prolapse
14
(No Transcript)
15
Classification of cystocele

• Anatomical grade Gr I Bladder descent toward
  introitus with straining
• Gr II Bladder to introitus with straining
• Gr III Bladder outside of introitus with
  straining Gr IV Bladder outside of introitus at
  rest
• VCUG grade GrI Just below inferior ramus
• Gr II 2-5 cm below inferior ramus
• Gr III Outside introitus and exterior

16
Cystocele
17
Cystocele

• Central defect 5-15, result from attenuation of
  the levator hiatus fascia
• Lateral defect 70-80, disruption of lateral
  attachments to vesicopelvic or pelvic side wall
• Combined central and lateral defects

18
Symptomatology of Anterior Vaginal prolapse

• Gr I and Gr 2 cystocele asymptomatic or stress
  urinary incontinence
• Gr III and Gr IV cystocele vaginal mass, lower
  abdominal fullness, frequency urgency, stress
  urinary incontinence, dysuria, leaning forward to
  void, residual urine sensation, frequent
  cystitis, dyspareunia, ureteral obstruction

19
Physical examination of vaginal prolapse

• Pelvic examination in supine and standing
  position
• Evaluate concomitant types of prolapse rectocele
  and uterine prolapse
• Ask the patient to strain and relax with blade
  retraction of rectum or finger pushing the cervix
  upward
• Reduce cystocele to test stress incontinence

20
Differential diagnosis of cystocele

• Urethral diverticulum
• Ectopic ureterocele
• Cystourethrgraphy identified descent of bladder
  base and evaluate the urethrovesical angle
• MRI diagnosis of cystocele with or without
  combination of enterocele or rectocele

21
Cystourethrography of Cystocele
22
Urodynamic study

• Multichannel pressure flow studyevaluate
  detrusor dysfunction, stress urinary
  incontinence, and voiding efficiency
• Provocative maneuvers coughing, walking,
  jumping, straining to demonstrate SUI
• Detecting detrusor overactivity in patients with
  symptom of urge incontinence
• Residual urine volume determination

23
Uterine prolapse and cystocele causing bladder
outlet obstruction
24
Reduction of prolapse relieves BOO in patient
with SUI
25
Cystocele and Stress urinary incontinence

• High grade cystocele masks intrinsic sphincteric
  deficiency in 50-80 women
• Correction of cystocele without concomitant
  anti-incontinence surgery may unmask ISD and
  cause SUI
• Use of pessary test or vaginal pack for prolapse
  reduction and detecting genuine stress urinary
  incontinence

26
Cystourethroscopy and Lower urinary tract
ultrasound

• Examination of bladder and urethral pathology,
  such as stone, tumor, stricture
• Bladder neck incompetence and intrinsic sphincter
  deficiency should be suspected
• Measurement of striated urethral sphincter
  component and bladder neck hypermobility by
  transrectal sonography of bladder urethra

27
Female Urethral Incompetence

• Bladder neck incompetence
• Urethral incompetence

28
Urethral Ultrasound in ISD and Cystocele
29
Surgical procedure for cystocele

• Gr I observation in asymptomatic women or
  bladder neck suspension when treating SUI
• High grade cystocele with SUI anterior
  colporrhaphy with pubovaginal sling
• Correct uterine prolapse or rectocele
  concomitantly to prevent exacerbation of vaginal
  prolapse after colporrhaphy

30
Techniques of cystocele repair

• Raz 4 corner suspension
• Vaginal sling procedure
• Pubovaginal sling procedure with colporrhaphy
• Fascial patch repair to levator ani muscles and
  vaginal cuff or pubocervical fascia
• Burch colposuspension

31
Technique of Anterior colporrhaphy
32
Urodynamic point-of-view in cystocele repair

• Correct cystocele with adequate increased
  urethral resistance but not obstructing bladder
  outlet
• Patient with large cystocele may have detrusor
  underactivity and void by abdominal straining
• Accurate assessment of detrusor and urethral
  function during urodynamic study

33
Detrusor underactivity in Cystocele
34
Complications of cystocele repair

• Bladder injury during vaginal wall dissection
• Ureteral injury during placing plication sutures
• Urethral injury during dissection or suture
  passage
• Infection and fascia rejection
• Ureteral obstruction
• Stress urinary incontinence becomes prominent
  after cystocele repair

35
Postoperative Care

• Foley catheter and vaginal pack removed at day 1
  or 2
• Check residual urine after voiding till volume is
  less than 100ml
• Keep on antibiotics for 3 weeks to prevent
  synthetic material infection or abscess
• Laxatives and avoid abdominal straining

36
Postoperative urinary incontinence

• Intrinsic sphincteric deficiency is unmasked
  after cystocele correction
• De novo detrusor overactivity
• Urethral kinking due to improper placement of
  pubovaginal sling
• Videourodynamic study and transrectal sonography
  are indicated and a second sling can be applied
  at distal urethra for ISD
• Urethrolysis to relieve urethral obstruction

37
Transrectal sonography of ISD after repair of
cystocele
38
Apical Vaginal prolapse (Enterocele)

• Peritoneal herniation at vaginal apex
• Sometimes difficult to differentiate from large
  cystocele or high rectocele
• Acquired enterocele (5-27) after Burch
  culposuspension and leave a wide open cul-de-sac,
  or after hysterectomy and a weakened vaginal apex
• Can be prevented during pelvic surgery

39
Apical Enterocele
40
Symptomatology of Enterocele

• Mass at or beyond introitus
• Perineal pressure, vaginal mucosal erosion
• Mass will reduce spontaneously at supine

41
Physical examination of Enterocele

• Examined in supine and standing positions
• Ask patient to cough and strain, with finger or
  blade retraction of bladder or rectum
• Posterior vaginal wall length is normal in
  enterocele,but shortened in vault prolapse
• Check rectocele to find the presence of apical
  vaginal prolapse

42
Physical examination of Vaginal Cuff Prolapse
43
Treatment of Enterocele

• High peritonealization and approximation of
  uterosacral ligaments, obliteration of hernial
  sac and cul-de-sac
• When vaginal ulceration, vaginal surgery, or
  pelvic prolapse surgery is planned
• Abdominal approach or transvaginal approach is
  feasible

44
Transabdominal repair of Enterocele
45
Transvaginal Repair of Enterocele

• More direct and less morbid
• All component of vaginal prolapse should be
  repaired concomitantly
• Dyspareunia due to vaginal shortening should be
  addressed
• Approximation of levator ani at posterior vaginal
  wall can preserve vaginal depth

46
Transvaginal repair of Enterocele
47
Complication of Enterocele repair

• Small intestine injury adhesion of small bowel
  after previous pelvic surgery or irradiation
• Rectal injury careful vaginal wall dissection
  can prevent it
• Bladder perforation in combined cystocele with
  enterocele
• Ureteral injury during applying purse-string
  suture at herniac sac

48
Vaginal vault prolapse

• Due to vaginal apex weakness after previous
  hysterectomy
• Patients often have sensation of mass protruding
  from vagina
• Perineal pressure
• Dyspareunia
• Difficult urination and vaginal reduction to
  facilitate voiding

49
Pelvic examination of Vault Prolapse

• Posterior vaginal wall foreshortening
• Careful differential diagnosis from enterocele,
  surgical procedure is similar
• Nonsurgical procedure a pessary
• Urodynamic study to investigate detrusor function
  and stress urinary incontinence

50
Pessary
51
BL
vagina
rectum
52
bl
cx
r
USL
53
Uterosacral Ligament
54
AC Richardson Breaks, not attenuation or
stretching Site-specific defects Clin Obstet
Gynecol 1993 J Pelvic Surg 1995
55
(No Transcript)
56
(No Transcript)
57
Surgical procedures for Vaginal Vault Prolapse

• Abdominal sacraocolpopexy securing vaginal
  vault to sacrum using autologous, allogenic,or
  synthetic material to bridge the gap
• Transvaginal levator myorrhaphy high
  approximation of levator uterosacral ligament
  complex at midline
• Sacrospinous ligament fixation
• Colpocleisis closure of vagina in sexually
  inactive women

58
Transabdominal Sacrocolpopexy
59
Transvaginal Levator myorrhaphy
60
Sacrospinous fixation
61
Uterosacral ligament suspension
62
Uterosacral ligament suspension
63
Uterine prolapse

• Perineal pressure
• Dyspareunia
• Mass at introitus
• Urinary incontinence
• Difficult urination
• Constipation

64
Examination of uterine prolapse

• Evaluated in supine and standing position
• Voiding cystourethrography for cystocele and
  urethrovesical angle
• MRI to detect concomitant enterocele or rectocele
• Urodynamic study in supine (after reduction) and
  sitting position for voiding function and
  presence of ISD

65
Uterine prolapse
66
Surgical treatment

• Abdominal or vaginal hysterectomy with apical
  vaginal fixation to prevent postoperative vaginal
  vault prolapse
• Transvaginal levator myorrhaphy
• Repair other component of pelvic prolapse
  including cystocele, enterocele, rectocele by
  myorrhaphy or synthetic mesh or cadaveric fascia

67
Posterior vaginal wall prolapse

• Rectocele results from a weakened rectovaginal
  septum and perineal body
• Stool becoming stuck during defecation
• Chronic constipation
• Perineal pressure
• Backache
• Fecal incontinence

68
Rectocele
69
Grading of Rectocele

• Gr I (A) Protrusion with straining
• (B) Protrusion does not reach
  introitus
• Gr II Protrusion to introitus
• Gr III Protrusion outside introitus

70
Surgical repair of Rectocele

• To restore rectovaginal septum and perineal body
• Risk of rectal injury and dyspareunia secondary
  to vaginal tightening
• Repair the transverse perineal muscles by sutures
  at superficial and deep perineal muscles
• Not to close vagina too tightly

71
Technique of Rectocele repair
72
(No Transcript)