Female Urinary Incontinence and Pelvic Floor Dysfunction: A

Female Urinary Incontinence and
Pelvic Floor Dysfunction:
A Gynecologists’ perspective
Hisham Khalil BSc, MD, FRCSC
Urogynecology and Pelvic Reconstructive Surgery
The Ottawa Hospital
Assistant Professor, University of Ottawa
Disclosures
• Provided consulting services to Ethicon Inc
Acknowledgements
• Urology Nurses of Canada
• AUGS (American Urogynecology Society)
Agenda
• What are pelvic floor disorders?
– Epidemiology and definitions
– Approach to the evaluation and treatment of stress
urinary incontinence and pelvic organ prolapse
– Case Presentations
– Resource list
Patient Presentation
• 59 year old female
with 3 prior vaginal
deliveries
• Seen in emergency
department with
urinary retention
• Bilateral
hydronephrosis
• Pelvic and lower
abdominal pain
4
What is the Pelvic Floor ?
• The pelvic floor is a set of
muscles, ligaments and
connective tissue in the
lowest part of the pelvis
that provides support for a
woman’s internal organs:
• Bowel
• Bladder
• Uterus
• Vagina and rectum
What is the pelvic floor ?
Barber MD. Contemporary views on female pelvic anatomy. Cleve Clin J Med 2005; Suppl 4: S3.
• Level I:
Uterosacral
ligament complex
• Level II:
paravaginal
attachments to
the levatorani
and
arcustendineus
fascia pelvis
• Level III: perineal
body, perineal
membrane,
superficial and
deep perineal
muscles
Historic Paradigm
What are Pelvic Floor disorders
(PFD’s)?
• Pelvic Organ Prolapse
• Urinary Incontinence (stress,
urge, mixed)
• Voiding dysfunction
(incomplete bladder emptying)
• Defecatory disorders
• Anal incontinence
Pelvic Floor Disorders
One in three women will
experience a PFD in her lifetime
 Lawrence, JM, et al. Prevalence and Co-Occurrence of Pelvic Floor Disorders in Community-Dwelling Women. Obstetrics & Gynecology. 111(3).
 Nygaard I, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA, 300(11), Sept. 2008.
 Tahereh E., et al. The Frequency of Pelvic Floor Dysfunctions and their Risk Factors in Women aged 40‐55. Journal of Family and
Reproductive Health 6(2), June 2012.
Pelvic Floor Disorders
• Age and life stage:
– 1 in 3 women—risk increases with age.
– Pregnancy and childbirth.
– 1 in 4 younger women (20 to 39 years).
• Lifestyle and behaviors:
– Obesity and limited physical activity.
– Smoking.
 Nygaard I, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA, 300(11), Sept. 2008.
 Tahereh E., et al. The Frequency of Pelvic Floor Dysfunctions and their Risk Factors in Women aged 40‐55. Journal of Family and
Reproductive Health 6(2), June 2012.
Urinary Incontinence in women
Responsible for 10% of nursing home admissions
$ 6 Billion US cost annually
Morrison A, Levy R. Fraction of nursing home admissions attributable to urinary incontinence.
Value Health. 2006 Jul-Aug;9(4):272-4.
Health Care Utilization
Minassian VA et al. The iceberg of health care utilization in women with urinary incontinence. In Urogynecol J. 2012:
23 ; 1087-1093.
• 41% prevalence of urinary incontinence
• 72% reported moderate to severe symptoms
• 25% sought care, 23% received it
• 12% received subspecialty care
Definition of Stress Urinary
Incontinence
• ICS: Involuntary leakage of urine with effort or
exertion or on sneezing or coughing
• Due to either urethrovesical hypermobility or
instrinsic sphincter deficiency (MUCP < 20 cm
H2O )
Definitions
• Urgency incontinence / OAB:
– Involuntary urine lose immediately preceded by
sudden compelling need to void
– If urodynamic finding of involuntary contraction of
detrusor muscle: detrusor overactivity
– If neurological cause for detrusor dysfunction
known: neurogenic detrusor overactivity
– If unknown: idiopathic detrusor overactivity
Distribution of Incontinence Types
Epidemiology and Scope
Ogah J, Cody JD, Rogerson L. Cochrane Database of Systematic Reviews 2009,
Issue 4. Art. No.: CD006375. DOI: 10.1002/14651858.CD006375.pub2.
• Prevalence of SUI : 10-40% of community
dwelling women
• Annual incidence of 2-11%
• Annual cost : $20 billion per year in the U.S.
• 50%–75% of these costs attributable to routine
care from incontinence pads, diapers, laundry,
dry cleaning, odor control, bed pads, and skin
care products
EPINCOT Study
Y.S. Hannestad et al. Journal of Clinical Epidemiology. 2000; 53: 1150–1157
Epidemiology and Scope
Jonsson M, Levin P, Wu J. Obstetrics & Gynecology. 119(4):845-851, April 2012.
Canada in Context
“Canadians in Context - Aging Population: Human Resources and Skills Development Canada”
http://www4.hrsdc.gc.ca/.3ndic.1t.4r@-eng.jsp?iid=33#foot_1
19
Urethral Sphincters
Coordination between urethral sphincters and detrusor musculature
Rahn DD et al. Obstet Gynecol Clin N Am. 2009; 36: 463–474
Vaginal delivery vs C/S ?
Rortveit G et al. Urinary Incontinence after Vaginal Delivery or Cesarean Section (Norwegian EPINCONT Study)
N Engl J Med 2003;348:900-7.
Nulliparous
C/S
OR C/S
Vs Nulliparity
Vaginal
Delivery
OR Vag Delivery
vs C/S
Any incontinence
10.1
15.9
1.5 (1.2-1.9)
21.0
1.7 (1.3-2.1)
Severe incontinence
3.7
6.2
1.4 (1.0-2.1)
8.7
2.2 (1.5-3.1)
SUI
4.7
6.9
1.4 (1.0-2.1)
12.2
2.4 (1.7-3.2)
Mixed UI
3.1
5.3
1.7 (1.2-2.5)
6.1
1.3 (0.9-1.9)
Risk factors for SUI
Stothers L, Friedman B. Risk factors for the development of stress urinary
incontinence in women. Curr Urol Rep (2011) 12:363–369
•
•
•
•
•
•
•
•
•
Age
Hypoestrogenism
Obesity (2x)
Pregnancy
Vaginal delivery
Diabetes mellitus
Pelvic surgery
Genetic factors
Others: Medications, smoking, high-impact exercise
A 62 year old G3P3 presents to your office with
a complaint of stress urinary incontinence,
progressively worsening x 5 years.
The Index Patient : Simplified Protocol
Evaluation of SUI
Farrell SA et al. The evaluation of stress incontinence prior to primary surgery. J
Obstet Gynaecol Can 2003;25(4):313–8.
• Complete history and physical
examination
• Cough test
• Post-void residual volume
• Urine Culture
• Urinalysis
• Bimanual Examination
• Assessment of urethral mobility
– Q-tip test > 30o
General Inspection
• Vulva:
– Lichen sclerosis / lichen planus
– Atrophy / lesions / cysts
• Urethra:
– Urethral caruncle
– urethral mucosal prolapse
– urethral diverticulum
• Vagina:
– Atrophy / estrogenization
– Scarring / pain
Value of the cough stress test
McLennan M, Bent AE. Supine Empty Stress Test as a Predictor of Low Valsalva
Leak Point Pressure. Neurourol Urodyn. 1998: 17; 121-127
• Cough test (provocative cough test) confirms
presence of SUI.
• Ideally, bladder filled with 300 cc or to a sense of
fullness
• Significant relationship between low leak point
pressure and positive supine empty stress test
(79% sensitivity, 62.5% specificity)
• Negative Predictive value of 90%
What about Urodynamic Testing ?
Indications for Urodynamic Testing
Farrell SA et al. SOGC Committee Opinion on Urodynamics Testing. J Obstet
Gynaecol Can 2008;30(8):717–721
• No definitive criteria
• 2008 SOGC Committee opinion (III-C):
– when the diagnosis remains uncertain after an
initial history and physical examination
– when patient symptoms do not correlate with
objective physical findings
– if the patient fails to improve with treatment
– in a clinical trial setting
Randomized Trials of Urodynamics
prior to Surgery for SUI
Nager C et al. A randomized trial of urodynamic testing before stressincontinence surgery. NEJM. 2012 May 24;366(21):1987-97
• 630 women with demonstrable SUI
randomized to undergo urodynamic testing or
office evaluation only (n=315 each)
• Successful treatment :
– 76.9% in UDS group
– 77.2% in evaluation only group
QUID Questionnaire
Farrell S, Bent A et al. Women’s ability to assess their urinary incontinence type using
the QUID as an educational tool. Int Urogynecol J. 2013 : 24; 759-762.
• Patients referred to urogynecology clinic for UI
asked to complete QUID questionnaire
• Physicians blinded to QUID results
• n = 338 pts
• High degree of agreement between patient
self-assessment of UI type can physician
assessment
Urolog
Information you get
• Urinary frequency
• Volumes voided
• Incontinence episodes
• Precipitating factors
• Fluid intake
Occult Stress Incontinence
Haessler AL et al. Reevaluating occult incontinence.CurrOpinObstetGynecol 2005; 17: 535-40
• Urinary incontinence with valsalva maneuvers after reduction of
prolapse [in the absence of detrusor contractions]
• Patients with POP have distorted anatomy and risk factors for both POP
and SUI
• Severe uterovaginal prolapse can prevent urinary leakage and produce
obstructive symptoms by elevating urethral resistance.
• 11-22% of continent patients with POP > 3 stage will develop postoperative SUI after correction of apical or anterior prolapse
• Source of much patient and clinician frustration
Occult Stress Incontinence
Haessler AL et al. Reevaluating occult incontinence.CurrOpinObstetGynecol 2005; 17: 535-40
• Methods to reduce prolapse:
• Pessary
• Rectal swabs
• Gauze
• Speculum blades
• Poorly studied in the literature
• Relationship between occult SUI and postoperative stress incontinence ?
Relationship between OSUI and postoperative SUI ?
Liang CC et al. Pessary Test to Predict Postoperative Urinary Incontinence in Women Undergoing
Hysterectomy for Prolapse. Obstet Gynecol. 2004; 104(4): 795-800.
• 79 patients evaluated for POP stage > 3
• 49 patients had + pessary test
Vaginal hysterectomy, anterior and
posterior repair and TVT
Vaginal hysterectomy, anterior and
posterior repair
Objective Postoperative SUI : 0%
Subjective Postoperative SUI: 10%
Objective Postoperative SUI: 53 %
Subjective Postoperative SUI: 64.7%
Canadian Urological Association (CUA)
Treatment Algorithm
Corcos J, et al. http://www.cua.org/guidelines_e.asp : accessed Aug 29, 2013.
Kegel Exercises
Dumoulin C, Hay-Smith J. Pelvic Floor muscle training versus no treatment, or
inactive control treatments, for urinary incontinence in women. Cochrane
Database Syst Rev. 2010 Jan 20;(1):CD005654.
• 14 trials (836 women)
– 435 PFMT, 401 controls
• Mean difference in number of SUI episodes
per day -1.29 (95% CI -2.24, -0.34)
• Mean difference in number of mixed UI
episodes per day -0.77 (95% CI -1.22,-0.32)
Simplified Kegel’s Protocol
• Do two sets of exercises each day
• Do 15 exercises for each set
• Each exercise consists of two parts:
– Part 1- Squeeze the pelvic muscles as strongly as
you can and try to hold for a count of 5. Relax.
– Part 2- Do 4 quick contractions one after the other.
• Do a total of 30 exercises each day.
• Each exercise session should take no more than 10
minutes.
What is the value of Pelvic Floor Exercises ?
Bo K, Nygaard I. Lower urinary tract symptoms and pelvic floor muscle
exercise adherence after 15 years. Obstet Gynecol. 2005; 105: 999-1005
• 52 women with urodynamic stress urinary incontinence
• 26 randomized to intensive pelvic floor physiotherapy
• 26 randomized to home with instructions on Kegel exercises
• 15 year follow-up with 90.4% response rate
• 50% of patients in each group ultimately underwent surgery
• 28% of patients continue to do pelvic floor exercises.
Weighted vaginal cones
Herbison GP, Dean N. Weighted vaginal cones for urinary incontinence.
Cochrane Database Syst Rev. 2013 Feb 28;2:CD009407.
• 23 trials involving 1806
women
– 717 randomized to vaginal
cones
– Superior to no active
treatment
– Not superior to pelvic floor
muscle retraining
Incontinence Pessaries
Robert M et a. J Obstet Gynaecol Can 2013;35(7 eSuppl):S1–S11
• Pessaries should be considered in all women
presenting with urinary stress incontinence
• Made of medical grade silicone
• Incontinence pessaries elevate and slightly constrict
the urethra.
• If a woman develops stress incontinence after being
fitted with a prolapse pessary, switching to an
incontinence pessary may be beneficial.
Current Incontinence Pessaries
Ring with support and knob
(SAK)
Ring with knob
Incontinence Pessaries
Ring with support and
knob (SAK)
Uresta Pessary
Pessaries ?
Nager CW et al. Incontinence pessaries: size, POPQ measures, and successful
fitting. Int Urogynecol J Pelvic Floor Dysfunct 2009;20(9):1023–8
• Initial successful fitting varies from 60-92%
• At 1 year, overall continuation rates may be as
low as 16%
Farrell SA, et al. Continence pessaries in the management of urinary
incontinence in women. J Obstet Gynaecol Can 2004;26(2):113–7
• 59% continence rate at 11 months
• Reasons for discontinuing: persistent
incontinence, pessary falling out, pain, bleeding
Weight Loss ?
Wing RR, et al. Improving Urinary Incontinence in Overweight and Obese women
through modest weight loss. Obstet Gynecol. 2010; 116: 284-292.
• 5-10% weight
loss associated
with significant
improvments in
frequency of UI
Barriers to care ?
Hagglund D et al. Reasons why women with long-term urinary incontinence do not seek professional help: a
cross-sectional population-based cohort study. Int Urogynecol J. 2003: 14; 296-304.
• Survey of 95 women aged 23-51 years with UI
• Reasons for not seeking care:
• Disorder is a minor problem
• Coping on their own
• Embarrassment
• Reasons for seeking care:
• afraid of the odor of urine
• perceived the leakage as shameful and embarrassing.
• Pelvic floor exercises were the most commonly used
management methods for all participants.
Female Pelvic Medicine and
Reconstructive Surgery
• Board Certification in U.S. since 2012
• 6 fellowship programs in Canada1
– 22 Canadians have completed these programs
• 5 Canadian trainees moved to U.S.
– 28 externally sponsored
• Professional society guidelines recognize need
for specialized training
1Cundiff
G. On the Brink: The Future of Female Pelvic Medicine and Reconstructive Surgery in Canada. J Obstet Gynaecol
Can. 2011; 33(12): 1253-1255
Subspecialty care ?
48
Stepwise continence Care Model
Farrell S et al. Two models for delivery of women’s continence care: the step-wise continence team versus the
traditional medical model. J Obstet Gynaecol Can 2009;31(3):247–253
• 154 patients in step-wise arm, and 78 in medical model
arm.
• Both groups showed significant improvement in all
measures of urinary incontinence after treatment.
• Step wise arm: education sessions and conservative
therapies led by nurse continence advisor:
– More rapid resolution of stress incontinence and irritative
bladder symptoms.
– Improved quality of life scores and treatment satisfaction.
Nurse Continence Advisors
Moore KH et al. Randomised controlled trial of nurse continence advisor therapy compared with standard urogynaecology
regimen for conservative incontinence treatment: efficacy, costs and two year follow-up . BJOG. 2003; 110: 649-657.
• 157 women with stress or urge incontinence
undergoing conservative therapy with
urogynecologist or NCA
• No significant differences between groups in
terms of pad tests, incontinence scores or
quality of life scores
• Longer duration of consultation with NCA
• Labour costs lower
•
•
•
•
Urologists, Urogynecologists
Physiotherapists
Nurses
Family Physicians
• Male and Female incontinence
• Rationale:
– Common Health Problems
– Great impact on quality of life
– Patients are not seeking help for their condition
Trends in Management of SUI
Jonsson F, et al. Obstet Gynecol. 2012 ; 119(4):845-851
Midurethral Slings
Retropubic tape
Trans-obturator tape
Retropubic Midurethral Slings
• Developed by Ulmsten and Petros in 1995
• “integral theory” of placing a sling distally
• Based on theory that pubourethral ligaments
support the midurethra and attach to pubis,
acting as a “backboard”
• Strip of polypropylene mesh to be left loose or
“tension-less” to avoid direct compression of
the urethra.
Long-term cure ? 17 year data-TVT
Nilsson et al. Seventeens years’ follow-up of the tension-free vaginal tape procedure
for female stress urinary incontinence. Int Urogynecol J. 2013. 24:1265-9.
• 90% objective continence rate
• 87% subjective cure rate
Pelvic Organ Prolapse
• Pelvic Organ Prolapse disorders affecting quality of
life : 30% of the population (lifetime incidence of
surgery 11.1%)1
• 45% increase in demand for treatments for Pelvic
Floor disorders over next 30 yrs2
1Olsen,
AL et al.ObstetGynecol 1997;89:501.
et al. Am J Obstet Gynecol. 2001; 184(7): 1496-1503
2Luber KM,
Surgical Management of POP
Olsen, AL et al. Epidemiology of Surgically Managed Pelvic Organ Prolapse and Urinary
Incontinence. Obstet Gynecol 1997;89:501.
29 % reoperation rate
44-54% anatomic failure
Symptoms of Pelvic Organ Prolapse
• Pelvic organ prolapse occurs with descent of
one or more pelvic structures
• Symptoms may affect a wide range of
activities including sexual function, exercise,
and have a detrimental impact on body image
• Vaginal support defects occur with and
without symptoms
1Lowder
JL et al. Am J ObstetGynecol 2011; 204: 441.e1.
ICS Definition of Pelvic Organ Prolapse
An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the
Terminology for Female Pelvic Floor Dysfunction. Neurourol Urodynam29:4–20 (2010)
• Descent of one or more of the:
–
–
–
–
anterior vaginal wall (central, paravaginal, or combination cystocele)
posterior vaginal wall (rectocele)
the uterus (cervix)
the apex of the vagina (vaginal vault or cuff scar) after hysterectomy.
• The presence of any such sign should correlate with relevant POP
symptoms.
• Diagnostic Criteria: symptoms and clinical examination, assisted
by any relevant imaging
Definitions
• A definition of of clinically significant prolapse
remains elusive.
• ½ of parous women can be demonstrated to have
prolapse by physical examination, most are
asymptomatic.
• Pelvic examination findings do not correlate well
with specific pelvic symptoms.
1ACOG
2
Practice Bulletin No 85. ACOG 2007.
Prolapse Definitions
• Anterior
compartment
prolapse:
cystocele
• Apical
compartment
prolapse:
uterine prolapse
or vaginal vault
prolapse
Prolapse Definitions
• Posterior
compartment:
hernia of posterior
vaginal wall
(rectocele)
• Enterocele: hernia
of the intestines
through the
vaginal wall.
Terminology
• Anterior prolapse vs cystocele ?
• Posterior prolapse vs rectocele ?
• Vaginal topography does not reliably predict
location of the associated viscera.
• Half of anterior prolapse can be attributed to
apical descent
Bump RC et al. Am J ObstetGynecol 1996; 175: 10.
Summers A et al. Am J ObstetGynecol 2006; 194: 1438.
What are the symptoms and clinical
presentation of Pelvic Organ Prolapse ?
Symptoms of Pelvic Organ Prolapse
Bowel:
-Incontinence of flatus or solid stool
-incomplete emptying
-straining during defecation
-Urgency to defecate
-Digital evacuation
-Splinting to start or complete defecation
-Feeling of blockage or obstruction during
defecation
Vaginal:
-Sensation of bulge or protrusion
-seeing or feeling bulge or protrusion
-pressure
-heaviness
Urinary:
-Incontinence
-Frequency
-Urgency
-Weak or prolonged urinary
stream
-hesitancy
-incomplete emptying
-manual reduction of
prolapse to start voiding
-position change to start or
complete voiding
Sexual:
-dyspareunia
-abstaining from intercourse
Take home: Severity of prolapse symptoms does not correlate
well with stage of prolapse
Splinting ?
Jelovsek JE et al. Pelvic Organ Prolapse. Lancet. 2007; 369: 1027-1038.
• Splinting:
reporting of either
a need to splint or
push on or around
the vagina to
urinate, defecate
or a feeling of a
vaginal bulge
• Suggests more
advanced POP
Does POP-Q stage correlate with
symptoms ?
Gutman RE et al. Is there a pelvic organ prolapse threshold that predicts pelvic floor symptoms ?
Am J Obstet Gynecol. 2008; 199(6): 683.e1-7
• POP-Q > 2: noted among 37% of women presenting
for annual gynecologic examinations.
• The only symptom predicted by anatomic prolapse
severity was bulging or protrusion symptoms
(vaginal descent > 0.5 cm beyond the hymen).
Tan JS et al. Predictive value of prolapse symptoms: a large database study. IntUrogynecol J
Pelvic Floor Dysfunct 2005; 16: 203.
• Vaginal bulge symptoms:sensitivity 67%,
specificity 87%, for POP at or past the hymen
What are risk factors for Pelvic Organ
Prolapse ?
History: Risk Factors for POP
Hendrix SL et al. Pelvic Organ Prolapse in the Women’s Health Initiative: gravity and gravidity.
Am J Obstet Gynecol. 2002 ; 186(6): 1160-6
• n= 27,342women (16,616 had uterus)
Risk Factors
OR (95% CI)
No Increased Risk
Age 60-69
1.16 (1.03 – 1.30)
Education
Age 70-79
1.36 (1.19 – 1.56)
Occupation
Hispanic
1.24 (1.01 – 1.54)
Hormone Therapy
BMI 25-30
1.31 (1.15-1.48)
Time since Menopause
BMI> 30
1.40 (1.24-1.59)
Breastfeeding
Waist circumference> 88 cm
1.17 (1.06-1.29)
Hysterectomy
Parity
2.13 (1.67-2.72)
Past Smoking
Additional Parity> 1
1.10 (1.05-1.16)
Coffee consumption
Constipation
1.10 (1.03 – 1.16)
EtOH Consumption
Connective Tissue Disorders
Carley ME et al. Urinary Incontinence and pelvic organ prolapse in women with Marfan or
Ehlers Danlos Syndrome. Am J Obstet Gynecol. 200; 182(5): 1021-1023.
• Marfan Syndrome: 33% prevalence POP
• Ehlers Danlos Syndrome: 75% prevalence POP
Hundley AF et a. Gene expression in the rectursabdominus muscle of patients with and
without pelvic organ prolapse. Am J ObstetGynecol 2008; 198: 220e1-220e7
• Differential gene expression of MYH3 myosin
related protein among patients with POP
Symptoms of Pelvic Organ Prolapse:
Take Home
• Prolapse severity does not correlate well with symptoms
• Vaginal topography does not correlate well with location
of associated viscera
• Asymptomatic women with pelvic organ prolapse do not
require treatment
• History may help clarify cases of severe prolapse
– Splinting, bulge symptoms
• Be alert to associated urinary and GI symptoms
Physical Examination: What are the
essential elements ?
Physical Examination
• Inspection
• Bimanual examination
– Pelvic masses
• Assessment of pelvic organ prolapse
– Location
– Severity (grading)
•
•
•
•
Rectovaginal examination
Assessment of associated incontinence
Neurological examination
Supplementary testing ?
Quantifying Pelvic Organ Prolapse:
Baden Walker System
• Grade 0 : No prolapse
• Grade 1: Descent halfway to
hymen
• Grade 2: Descent to hymen
• Grade 3: Descent halfway past
hymen
• Grade 4: Maximal possible
descent for each site
POP-Q
Bump RC et al. The standardization of terminology of female pelvic organ prolapse
and pelvic floor dysfunction. Am J Obstet Gynecol. 1996; 175:10-17
Treszezamsky AD et al. Female Pelvic Med Reconstr Surg. 2012 ; 18(1): 37-40.
• 9 parameters
• Useful in research
studies or for
post-surgical
follow-up
• Used by 59% of
gynecologists in
U.S.
Kegel Strength
Strength Grading / 5
0
No contraction
1
Contraction< 1 s
2
Weak contraction 1-3 s
3
Moderate contraction 4-6 s
4
Strong contraction 7-9 s repeated 3 times
5
Unmistakably strong
Physical Examination
• Sim’s speculum or lower
blade of grave’s speculum
retracting posterior
vaginal wall
Staging based on POP-Q
• Stage 0: no prolapse demonstrated
• Stage 1: most distal prolapse > 1 cm above the
hymen
• Stage 2: most distal portion of prolapse < 1 cm
above or below hymen
• Stage 3: most distal portion of prolapse > 1 cm
below the hymen but no further than tvl – 2 cm
• Stage 4: complete eversion of the total length of
the lower genital tract
U/S of upper urinary tract ?
Hui SYA et al. A prospective study on the prevalence of hydronephrosis in
women with pelvic organ prolapse and their outcomes after treatment.
IntUrogynecol J. 2011; 22: 1529-1534
• Prospective evaluation of 233 patients with with
stage 3 or 4 apical or anterior prolapse
• Hydronephrosis in 10.3 %(95% CI 6-14%)
• Resolved in 95% of patients after treatment
• Value in setting of normal renal function
uncertain
Pelvic Floor U/S and MRI in patients
with POP
Tubaro A et al. Ultrasound Imaging of the Pelvic Floor: Where are we going ?
NeurourolUrodynam. 2011; 30: 729-734.
• Interesting correlations
have been identified
such as between
childbirth, dimension of
levator hiatus, avulsion
of levatorani and risk of
prolapse
• Clinical benefit of pelvic
floor imaging has yet to
be demonstrated.
Treatments
• Symptom Based Approach:
─ POP is not life-threatening.
─ Treatments can help improve quality of life and sexual health.
• Conservative approach:
─ Pelvic floor muscle exercises.
─ Pelvic floor physical therapy.
• Pessary:
─ Support bladder, uterus and vagina.
 Food and Drug Administration. Information for Patients for POP,
www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh.
 PFD Alliance. www.voicesforpfd.org.
Introduction
Surgery
Obliterative
-Colpocleisis
Compensatory
-Use of graft
Bradley CS et al. Obstet, Gynecol. 2007; 109(4): 848-854
Reconstructive
-Apex
-Anterior
-Posterior
Goals of Surgery
• Restore normal anatomy
• No single operation is right
for every patient
• Desire to retain sexual
function ?
• Experience and training
• Emerging controversies
FDA Public Health Notification: Serious Complications Associated with Transvaginal
Placement of Surgical Mesh in Repair of Pelvic Organ Prolapse and Stress Urinary
Incontinence
Issued: October 20, 2008
• > 1000 reports of complications to 2008
– (9 manufacturers)
• “FDA identified surgical mesh for transvaginal repair of POP
as an area of continuing serious concern.”
• Jan 2008 – Dec 2010: 2,874 additional reports of
complications
– 1,503 associated with POP repairs
– 1,371 associated with SUI repairs
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm262435.htm: accessed Jan 4th
2012
SGS Guidelines for use of Vaginal
Grafts
Murphy, M. Clinical Practice Guidelines on Vaginal Graft use from the Society of Gynecologic
Surgeons. Obstet Gynecol 2008; 112: 1123.
• Native tissue repair remains the default or
standard of care
• Nonabsorbable synthetic mesh:
– may improve anatomic outcomes of anterior
vaginal wall repair, but there are significant tradeoffs in regard to the risk of adverse events (3
studies included)
Summary
• POP is a common entity affecting QOL
• Asymptomatic women do not require treatment
• Diagnosis and decision making based on clinical
exam and history
• Role of ancillary testing is minimal in routine
practice
• Be alert to urinary incontinence / latent SUI
Let’s Meet Some Patients…
• 43 YO G2P2 healthy:
– dairy farmer, smoker
– procidentia & SUI
– what are surgical options?
91
92
93
94
Take Home
• Pelvic Floor disorders are common:
– ask about them
• Evaluation and treatment of pelvic floor disorders
require a multi-disciplinary approach
• Not a normal part of aging: can be treated
successfully
• Nurses and Nurse Continence Advisors constitute
essential first line care
Resources
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www.voicesforpfd.org
www.facebook.com/TaketheFloorPFD
www.iuga.org/?patientinfo
www.SOGC.org
www.CUA.org