Anatomy review

Abdominal anatomy
Rectus abdominus
External Oblique
Internal oblique
Transverse
Know the blood vessels and where they come from
- Ilioinguinal nerve:
- iliohypogastric nerves
Don't go past lateral border of rectus with c-sections because risk injurying the nerves
Median umbilical fold- urachus
Medial umbilical fold- umbilical artery - there are two of them (two arteries one vein in the chord)
Lateral umbilical fold - has the epigastrics
Folds are important because when we put our ports in - can be preperitoneum or intraabdominal bleeding
Low transverse incision and long midline one are most common
Innervation
-

Anterior vagina: Ilioinguinal, genital branch of genital femoral nerve

Posteriori vagina: Perineal nerve and posterior cutaneous nerves of the thigh

Important nerves:
Ilioinguinal - anterior vagina
Iliohypogastric
Femoral - can be injured by open retractor during open surgery, or if hyperflexed at the hip. Flexes at
the hip and extends at the knee, lose some sensation
Common peroneal - pressure in the boots where it comes over the head of the fibula. Causes foot
drop and dorsal foot numbess
Ulnar - When arms are tucked at sides during surgery
Brachial plexus
Should be abducted < 90 degrees during surgery
Abdominal c-section
- The iliohypogastric nerve provides
cutaneous sensation to the groin and the skin
overlying the pubis. The ilioinguinal nerve
follows a similar, although slightly lower,
course as the iliohypogastric nerve where it
provides cutaneous sensation to the groin,
symphysis, labium and upper inner thigh.
These nerves may become susceptible to
injury when a low transverse incision is
extended beyond the lateral border of the
rectus abdominus muscle, into the internal
oblique muscle.
Pelvic Anatomy

Muscles
Blood vessels
-

Levator ani: from medial to lateral, includes puborectalis, pubococcygeus, iliococcygeus

Branches of the internal iliac:

- Posterior: Superior gluteal
- Anterior: obdurato
- Anterior: uterine artery may branch to superior vesical arteries, or they
may come off on their own
- Anterior: vaginal artery inferior vesical arteries
- Posterior: Inferior gluteal
- Posterior: Internal pudendal vuvla (along with external pudendal)

Uterine Anatomy

Vagina
-

Blood supply:
Nerves:

internal iliac artery anastamotic network

vaginal branch of uterine artery, from ilioinguinal artery
Middle rectal and inferior vaginal branches of ilioinguinal artery

UROGYNECOLOGY
Prolapse
50% of women have mild asymptomatic prolapse. 3-7% have symptomatic prolapse. Approximately 1 in 9 will require
surgery for vaginal prolapse or related disorder.
Vaginal support: from levator ani, endopelvic fascia, and horizontal orientation of upper of vagina
Three levels of fascial support to vagina
1) Level 1: upper third = cardinal uterosacral complex
- Loss = cervical, uterine, or vault prolapse
2) Level 2: middle third = arcus tendineus fascia pelvis
- Cystocele or rectocele
3) Level 3: Distal third = anterior: pubo urethral structures and arcus tendineus fascia pelvis, posterior =
arcus tendineus fascia rectovaginalis
- low rectocele and/or deficient perineum
Etiology
- Usually initial injury, most often during labor or childbirth, in susceptible women.
- Susceptibility increases with
- age, menopause
- pregnancy regardless of mode of delivery, forceps delivery, young age at first
delivery, prolonged 2nd stage, infant birth > 4500 grams, vaginal parity,
- obesity,
occupations with lots of heavy lifting, conditions with repetitive bearing down,
- hysterectomy,
- collagen disorders (decreased type 1, increased type 3)
- Bony pelvis with more horizontal inlet
- Less common in African Americans
- NOT diabetes, running
Symptoms of prolapse:
- pelvic heaviness, pelvic pressure or bulge, sensation of sitting on a mass such as an egg. Pain is not
a usual complaint!
- Can be associated with urinary incontinence or fecal incontinence, constipation, need to splint

Types of prolapse:
- Cystocele: anterior vaginal prolapse - loss of level 2 support
- Rectocele: posterior vaginal prolapse - loss of level 2 support
- Apical or uterine: uterus slides down - loss of level 1 support
- Procidentia: complete descent - uterus falls out!
- Enterocele: Prolapse of any area of the vagina when the prolapsing wall is a sac filled with small
bowel - especially common in women who have undergone
hysterectomy
POP Quantification exam (POP-Q):
Examine 6 points on the vaginal wall (Aa, Ba, C, D, Ap, Bp) along with the length
of the vaginal opening/genital hiatus (gh), perineal body (pb), and total vaginal
length (tvl).

Maximum prolapse of the 6 points is recorded relative to the hymen during maximal straining
- Stage 0: None
- Stage 1: Within vagina, more than 1 cm above hymen
- Stage 2: Prolapse to the hymen (< 1cm inside or outside)
- Stage 3: External prolapse > 1cm outside hymen
- Stage 4: Complete prolapse = beyond tvl - 2 cm. TVL is usually around 9 cm.
Treatment
- Watchful observation is indicated if patient is asymptomatic.
- Pessary: require fitting and surveillance to manage urinary incontinence, pessary falling out, or
pressure ulcers
- Surgery:
- Anterior repair/anterior colporrhaphy: open anterior vaginal epithelium and plicate
the deeper redundant tissues
- Support the anterior wall with biologic or synthetic grafts
- Retach the sides of the vagina if prolapse due to loss of lateral vaginal support
- Colpocleisis is indicated if the patient isnt a good surgical candidate. Just obliterate
the vagina, can be done quickly and w/out general anesthesia.e
- Topical estrogen wont do anything for prolapse, only vaginal dryness - and remember that its
contraindicated if the patient has a uterus!
Urinary System
Physiology of micturition and storage
Detrusor contraction = cholinergic from the pelvic parasympathetic plexus, from S2S4.
Distal ureters, trigone, bladder neck = sympathetic adrenergic fibers originating at the T10L2
Voluntary sphincter contraction = pudendal nerve, from the S2S4 nerve roots.
Generally sympathetic makes you store, parasympathetic makes you pee
Three layers of muscle for urethra
striated urogenital sphincter
vaginal wall is behind the urethra - presses against the urethra
Levator ani
Highest pressure is at midurethra level
Storage: When bladder distends,
Afferent sympathetic input to hypogastric nerve inhibit the parasympathetic input to the
detrusor and increase tone at the bladder neck continence
Afferent pelvic nerve sends info to efferent pudendal nerve, which contracts the external urethral
sphincter
Voiding: Afferent pelvic nerves ascend in spinal cord and synapse in the pontine micturition center, which coordinates
voiding with descending pathways:
Inhibit pudendal firing to relax external sphincter
Inhibit sympathetic firing to open bladder neck, permit parasympathetic input to detrusor
Parasympathetic input to detrusor contraction
Stopping voiding voluntarily: Descending corticospinal pathways from pudendal nucleus contract
external sphincter, so urethral pressure increases above detrusor pressure and stream is interrupted
Painful Bladder
Primary UTI
-

Can treat based on symptoms alone! If not complicated, treat for 3 days. Test of cure not needed.

Recurrent urinary tract infections

- Definition: 3+ UTIs in one year. > 50% of women will have this happen at least once.
- Risk factors:
- Genetics - easy for bugs to adhere to bladder.
- Anatomic - short distance from urethra to anus
- Physiologic - immunosuppression, urinary retention, menopause
- Personal - hygeine
- Sex - UTI often 24-48 hours
- Diagnosis:
- Nitrites are more specific (87%) than leukocyte esterase (54%). If both are present,
sensitivity of 94%. But can still have UTI even if they are absence.
- Culture is gold standard!
- Infection confirmed w/ 100k colony forming units on clean catch
culture. But less severe UTI can be associated with lower colony counts and may be
significant - especially if obtained w/ transurethral catheter.
- If many epithelial cells contamination. Get a catheterized
culture.
- Management
- Obtain urine culture before starting empiric abx! This confirms abx coverage and
distinguishes from interstitial cystitis.
- Treat for 3 days
- Consider prophy
- 1 dose abx after sex
- Postmenopausal with genital atrophy: vaginal estrogen prevents
recurrent UTIs
- Cranberry juice is helpful! Tablets unknown
- Not helpful - wiping front to back, voiding after sex.
Recurrent pyelonephritis
- Get an U/S of the kidneys to look for stones or anatomic problems
Overactive bladder syndrome
- Definition: Urgency, frequency, and nocturia (> 1 void per night) +/- urge incontinence. Cuased by
uninhibited bladder contractions. Often leak with orgasm..
- 15-17% of women
- Risk factors:
- Aging - bigget risk factor!
- Neuro disease or spinal cord injury
- UTI
- Anatomic - prior incontinence surgery, pelvic surgery, radiation
- Prolapse does not cause OAB, but often coexist in older women
- Diagnosis
- Imaging not necessary!
- Treatment
- NO SURGERY FOR URGE INCONTINENCE!
- Lifestyle: Decrease/eliminate caffeine, stop smoking, limit alcohol, control fluid intake,
kegels for stress AND urge incontinence
- Meds:
- Anticholinergics (oxybutinin, terodine).
- CIed if urinary retention, narrow angle glaucoma
- SE: dry mouth, blurred vision, dry eyes, tachycardia,
upset stomach, constipation, confusion in old people
Painful bladder syndrome/Interstitial Cystitis

- Definition: Pain with bladder filling - classically relieved when bladder is empty (contrast UTI),
urinary frequency (> 8 voids while awake), no infection or obvious pathology.
- Common cause of pelvic pain.
- Specific cause unknown! More of a syndrome than a disease. Maybe neuronal cross
sensitization by inflammatory mediators from other diseased organs. Maybe disruption of protective
GAG layer.
- Associated with IBS, dyspareunia
- Management
- Initially: diet modification - avoid bladder irritants
- Cystoscopy - can be normal. Bx can also be normal. Not required for dx.
- Look for decreased capacity,
- Glomerulations = petechial hemorrhages (but nonspecific, found in
45% of healthy people!)
- Hunners ulcers. Do hydrodistention for diagnosis and treatment
- Meds:
- Elmiron
- TCAs like amitryptiline
- Bladder instilations
- Refractory sacral neurostimulation
Evaluation of patients with urinary urgency-frequency disorders
- History:
- How many times do you urinate in the day? At night?
- How many UTIs? Proven by culture?
- Dysuria?
- Pain when bladder is full?
- Trouble controlling bladder?
- Urge, stress, or mixed?
- Do you have to wear a pad?
- Always looking for bathroom?
- Sensation that bladder is not empty?
- Change or limiting activities? Avoid public places or social activites?
- Constipation? Accidents with stool or flatus?
- PMH: diabetes, neuro diseases, spinal injury
- PSH: back/spine surgery, pelvic surgery
- Meds: Diuretics, cholinergics, anticholinergics
- Allergies
- Social History: Smoking, drugs, alcohol
- Exam:
- Suprapubic/urethral tenderness, CVA tenderness, PVR, cough stress test for stress
incontinence, atrophic vaginitis can be associated with frequency, vulvar hypersensitivity to Q-tip
- Labs: urinalysis and culture.
- Other: voiding diary, imaging
Urinary incontinence
Approx. of adult women have urinary incontinence - 50% stress. 11% of women will have surgery for UI or
proloapse. will require follow up operation
- Increased frequency with low estrogen (but supplementing doesnt treat), obesity, FH, pelvic surgery,
forceps vaginal delivery, smoking,
- Risk factors for incontinence:
- Predisposition: women more than men until age 70
- Inciting factors: childbirth - even more important for prolapse, hysterectomy, vaginal
surgery, radical surgery, radiation, injury
- Promoting: constipation, occupation, recreation, obesity, lung disease, smoking,
infection, meds (beta blockers - can't relax the bladder!), menopause

Decompensating: aging, dementia, debility, disease, environment, meds

Define incontinence when it happens > 1x per month

Reversible vs. treatable
Reversible: meds, uti, stool impaction (bowel spasms --> bladder spasms), hypercalcinuria,
hyperglycemia, volume overload, delirium, decreased mobility, psychological
Treatable: detrusor overactivity, stress incontinence, mixed incontinence, fistula
Nocturia: voiding > once per night
In older people, can be a marker for a cardiovascular disease! If have mild CHF, then lay down at
night and not pumping against gravity - get increased return of fluids
How much should we drink per day? At least 1500 cc per day
Normal threshholds
First sensation: > 75 ccs (above normal PVR of < 50 ccs).
First urge: 150 ccs (3x PVR)
Bladder capacity: 300 ccs while awake, 1L under anesthesia
1) Stress incontinence
- Caused by urethral hypermobility (aging, childbirth) or by intrinsic sphincter deficiency
(congenital, trauma, radiation, spinal cord injury, surgery)
- Q-tip test: Normal is < 30 degrees of movement with straining - more = hypermobility
- Dx with filling cystometry
- Treatment:
- First try lifestyle changes (quit smoking, lose weight), kegels and biofeedback, and
pelvic floor muscle physiotherapy
- Second, surgery:
- If urethral hypermobility + ISD
- Tension free urethral support system = tension
free tape at mid-urethra
- Risks include bleeding (hematoma,
external iliac, femoral, obturator, inferior epigastric), de novo urgency and
voiding dysfunction, and tape erosion and bladder perforation. Also bowel
injury
- TVT is better than burch for
continence
- Burch retropubic urethropexy
- Pubovaginal sling at bladder neck
- Efficacy similar to TVT
- If only intrinsic sphincter deficiency
- Urethral injections of bulking agents (myoblast,
fibroblast)
- Post op care: May have urinary retention after surgery. If able to void a bit, can place a catheter and
send home with follow up in several days. It should improve with time. If cant void at all, loosen the sling prior
to hospital discharge.
2) Urge incontinence and overactive bladder

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- Overactive bladder syndrome (OAB) includes urinary urgency with or without incontinence.
Associated with increased frequency and nighttime voiding. Everyone has bladder spasms to some extent,
but usually urethra is strong enough to inhibit release of urine
- Lifestyle modifications: Start thinking about what she is drinking, how much she is drinking. decrease
caffeine, 2L fluid limit, void by schedule, bladder retraining - waiting to void 3-4 hours, follow up in 6 weeks
- Second line: antimuscarinics (M1-M5, M3 most important), have roughly equal efficacy
- Trospium and Tolterodine: nonselective
- Solifenacin and oxybutynin: moderate selectivity for M3
- Darifenacin: highly selective for M3 subtype
- Third line: sacral neuromodulation: stimulates sacral plexus, usually S3. Exact mechanism poorly
understood. Reversible. Do only if failed meds.
3) Detrusor Instability
4) Genitourinary fistulas
Number one cause is pelvic surgery - especially abdominal hysterectomy, followed by vaginal hysterectomy.Childbirth
is 8% of cases. Has a delayed presentation of days to weeks.
5) Overflow incontinence
Caused by decreased bladder wall compliance (radiation, IC, recurrent uti) or obstruction. PVR > 100, increased risk
of UTIs. Look for anticholinergics, calcium channel blockers, alpha adrenergics, and beta agonists
Treatment: Generally ISC is best. Can also consider bethanecol, a cholinergic med that selectively activates bladder
muscarinic receptions. Retention may resolve with correction of prolapse if > Stage II, but may not.

6) Functional and transient

Transient - delirium, infection, atrophic vaginitis, alpha blockers, antipsychotics, antidepressants, benzos, psych,
uncontrolled DM, stool impaction
Evaluation
- PVR - above 200 is abnormal, below 50 is reassuring
- UA - do culture if blood, nitrates, or leukocytes
- Q tip test measures the mobility of the urethra and bladder from the horizontal axis - normal is < 30
degrees
- Lack of hypermobility with stress incontinence - may be intrinsic sphincter deficiency
- Single channel office cystometry: fill bladder with saline- estimates bladder capacity and detrusor
contractions.
- Standing stress test: remove catheter and ask patient to cough - see if leakage occurs
- Multichannel urodynamic testing: do if dx is unclear or if at risk of treatment failure or complications
Evaluation

history - when did it start, what was her largest baby

physical exam, voiding diary
sacral reflexes, estrogen status
PVR
urine culture
stress test
Note if bladder is full or empty, the position of the patient,
single channel cystometrogram

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measures detrusor activity, sensation, capacity, compliance, DI vs. GSI, leak points
q-tip test for hypermobility, but biggest factor for urge and stress is urethral strength
advanced testing

START WITH PADS: PVR, urinalysis, diary, stress test

diary: frequency of urination, en route loss, stress incontinence, nocturia, insensible loss, intake
Therapy:
Behavioral therapy - fluid (1 cc per kcal), management, voiding frequency, scheduled toileting,
bladder retraining (wait 15 minutes after urge to go), pelvic floor exercises (don't do while urinating - maybe
just once to know that it's the right muscles, because don't want to disrupt the relaxation), biofeedback (probe
or sensor to tell you that you're doing the right thing)
Defecation
Normal physiology
- Rectosigmoid distention rectorectal reflex = bowel before bolus contracts and bowel after
bolus relaxes.
- Stool in rectum triggers rectaanal inhibitory reflex - internal anal sphincter relaxes to enable rectum
to accommodate feces (urge to go) and increase in external sphincter tone. Sensory nerves in upper anal
canal perform sampling to distinguish solid/liquid/gas.
- Defer:
- Muscles of continence:
- Internal anal sphincter - smooth muscle inner layer, responsible for
majority of resting tone and passive continence
- Sympathetic input from L5 via hypogastric plexus
and parasympathetic branches from S2-S4.
- External anal sphincter - striated muscle, encircles anal canal and
IAS. Plays a maor role in maintaining continence under stress - increased pressure, urgency.
- Inferior branch of pudendal nerve (S2-S4)
- Puborectalis (part of levator ani, muscular sling from pubis around
anorectal junction, see atlas p. 166)
- Volitionally contraction puborectalis and external anal sphincter. Internal anal
sphincter relaxation reflex will fade in 15 seconds, urge resolves until triggered again.
- External sphincter also tenses in response to small colonic contractions via spinal
cord reflex modulated by higher centers
- Increased colonic time disrupts the normal pressure gradient - the rapid transport of
large volumes produces urgency & incontinence even in healthy people
- Volitional defecation:
- Contract levator ani relaxes external sphincter and puborectalis to allow
straighter anorectal passage
Bristol stool chart
- Type 1 = separate hard lumps, type 4 = ideal, smooth, soft; type 7 = entirely liquid
Anal Incontinence
Anal incontinence = uncontrolled loss of liquid, solid, or gas from rectum > 1 month
- Minor incontinence: Flatus, a little feces
- Major incontinence: Normal consistency
- Urge incontinence: Involuntary passage of gas. solid, or liquid in spite of attempt to stop
- Passive incontinence: Unrecognoized leakage

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Causes of incontinence
- Systemic

- Metabolic/endocrine: DM, thyroid

- Neuro: CNS and PNS
- Infectious: Bacteria, virus, parasite
- Idiopathic/Autoimmune: Inflammatory bowel, food allergy
- Meds: Prescription, OTC
Anatomic/structural
- Pelvic outlet obstruction (POP, rectal prolapse, neoplasia, hemorrhoids)
- Anal sphincter disruption/fistula: Obstetrics, surgical, trauma, radiation
- Obstetrics is #1 cause! 30-40% of women with anal tear during
delivery report anal incontinence.
- Tear the internal and external sphincters
early onset of incontinence. Risk in first delivery, large baby, forceps,
episiotomy
- Dennervate the pelvic floor (pudendal
neuropathy) late onset of incontinence. Risk with lots of babies, big
babies, forceps, prolonged active labor, third degree tears
Functional causes
- Functional limits
- Motility

Detailed history is important!

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Anorectal studies:
- Manometry, rectal compliance, EMG studies - EAS and pelvic neuropathy, motor nerve conduction
studies
- Endoanal ultrasound - can see defects in EAS, IAS, and puborectalis.Especially good for obstetric or
surgical injuries
Treatment
- Diet: Increase fiber, avoid irritants that cause diarrhea in some people - pepper, lactose, citrus, beer,
coffee
- Meds: Reduce frequency, improve consistency, enhance sphincter tone
- Bulking agents = metamucil
- Constipating agents = loperimide, diphenoxylate hydrochloride, codeine
- Laxatives and enemas if constipated with overflow incontinence
- Enhance tone of sphincter - phenylephrine (research only)
- Biofeedback: strengthen EAS, coordinate distention and contraction, improve sensation of stool in
rectum. Very successful in short term, unclear in long term
- Pelvic floor exercises = kegels: minimal data
- Surgery
- Anal spincteroplasty: Often after obstetric trauma or surgical procedures. Even if
good initial results, poor long term results - repairs deteriorate, maybe due to aging, stretching scar,
nerve degeneration
- Postanal pelvic floor repair - Rarely done. Used with patients with intact but poorly
functioning sphincters and pelvic floor. Reestablish the anorectal angle, tighten the canal. Best if
incontinent from loss of angleor from stretch of canal. Poor long term improvement
- Encirclement procedures: muscle transpositions (sartorius, gracilis, gluteus max).
Option if cant repair the sphincter. Lots of morbidity.
- Colostomy and ileostomy: For very difficult cases
- Emerging options - sacral neuromodulation, injectable bulking agents, artificial
sphincter
- Prevention: Manage labor, appropriate use of episiotomy and assisted vaginal delivery
Sexual function
Sexual sensations
Afferents from the pudendal nerve
Bulbocavernosus reflex: pudendal nerve stimulation S2-4 contract pelvic floor muscles

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 Vaginal and clitoral cavernosal autonomic nerve stimulation: clitoral, labial, and vaginal
engorgement

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