Académique Documents
Professionnel Documents
Culture Documents
UROGYNECOLOGY
UPCM Interns Refresher Course
15 June 2015
OUTLINE
I. Pelvic Organ Prolapse
II. Urinary Incontinence
copyright_joanneaguinaldomd_manilaphilippines_june2015
Definition
Pathophysiology
Risk Factors
Diagnosis
i.
ii.
iii.
Presentation
Scoring and Staging
Ancillary tests
E. Management
copyright_joanneaguinaldomd_manilaphilippines_june2015
copyright_joanneaguinaldomd_manilaphilippines_june2015
copyright_joanneaguinaldomd_manilaphilippines_june2015
copyright_joanneaguinaldomd_manilaphilippines_june2015
copyright_joanneaguinaldomd_manilaphilippines_june2015
copyright_joanneaguinaldomd_manilaphilippines_june2015
copyright_joanneaguinaldomd_manilaphilippines_june2015
10
copyright_joanneaguinaldomd_manilaphilippines_june2015
11
copyright_joanneaguinaldomd_manilaphilippines_june2015
12
copyright_joanneaguinaldomd_manilaphilippines_june2015
13
copyright_joanneaguinaldomd_manilaphilippines_june2015
14
copyright_joanneaguinaldomd_manilaphilippines_june2015
15
copyright_joanneaguinaldomd_manilaphilippines_june2015
16
Inciting
Promoting
Decompensating
copyright_joanneaguinaldomd_manilaphilippines_june2015
17
Stress incontinence
Frequency
Urgency
Urge incontinence
Hesitancy
Weak or prolonged stream
Feeling of incomplete emptying
Manual reduction to start or complete bladder emptying
Positional changes to start or complete bladder emptying
copyright_joanneaguinaldomd_manilaphilippines_june2015
18
Sexual
copyright_joanneaguinaldomd_manilaphilippines_june2015
19
Definition
Pathophysiology
Risk Factors
Diagnosis
i.
ii.
iii.
Presentation
Scoring and Staging
Ancillary tests
E. Management
copyright_joanneaguinaldomd_manilaphilippines_june2015
20
copyright_joanneaguinaldomd_manilaphilippines_june2015
21
copyright_joanneaguinaldomd_manilaphilippines_june2015
22
(-)
0
(+)
copyright_joanneaguinaldomd_manilaphilippines_june2015
23
Point Aa
Point Ba
Point D
Posterior compartment
Located in the midline of the posterior vaginal wall 3 -3 to +3
cms proximal to the hymen
Represents the most distal or dependent position of Middle to proximal third of the
Point Bp
the posterior vaginal wall from the posterior fornix or posterior vaginal wall
the cuff to point Ap
24
copyright_joanneaguinaldomd_manilaphilippines_june2015
Point Ap
copyright_joanneaguinaldomd_manilaphilippines_june2015
25
copyright_joanneaguinaldomd_manilaphilippines_june2015
26
No prolapse demonstrated
A, B points are at -3 cm
C,D points are at TVL cm or (TVL-2) cm
Stage I
Criteria for Stage 0 are not met but the most distal or dependent portion
of the prolapse is more than 1 cm above the hymen (< -1 cm)
Stage II
The most distal or dependent portion of the prolapse is less than or equal
to 1 cm above or below the hymen (> -1 cm or < +1 cm)
Stage III
Stage IV
copyright_joanneaguinaldomd_manilaphilippines_june2015
27
1. Supplemental PE
- Vaginal inspection:
- Loss of rugae
- Atrophy : loss of labial fullness, pallor of vagina
and urethra, minimal vaginal moisture
copyright_joanneaguinaldomd_manilaphilippines_june2015
28
1. Supplemental PE
- Vaginal examination:
- Check pelvic floor muscle strength
- Modified Oxford Scale
- 0 : no contraction
- 1 : flicker
- 2 : weak squeeze, no lift
- 3 : fair squeeze, definite lift
- 4 : good squeeze, with lift
- 5 : strong squeeze with a lift
copyright_joanneaguinaldomd_manilaphilippines_june2015
29
1. Supplemental PE
- Rectovaginal examination (enterocoele,
rectocoele)
copyright_joanneaguinaldomd_manilaphilippines_june2015
30
2. Bladder testing
Screen for infection urinalysis, urine culture
Determine post void residual urine
Assess bladder function
Cystometry with Cough stress test (with prolapse
reduced) : 15-80% occult stress incontinence
copyright_joanneaguinaldomd_manilaphilippines_june2015
31
copyright_joanneaguinaldomd_manilaphilippines_june2015
32
5. Endoscopy/ Cystoscopy
- Bladder symptoms/ conditions : hematuria,
urolithiases
- Bowel symptoms/ conditions: obstipation,
painful defecation, rectal prolapse
copyright_joanneaguinaldomd_manilaphilippines_june2015
33
CASE
60 G4P4 (4004) presents with sensation of
Aa
something coming out of her vagina. She
reports a palpable bulge at the introitus on
occasion. All her pregnancies were delivered
GH
vaginally except for the last, for which she
underwent a CS-hysterectomy for placenta
accreta. On physical examination, the vagina
Ap
was pale and smooth and measured 6 cms
long. The vaginal cuff most dependent, noted 1
cm above the hymen. The urethrovesical
crease was 2 cms above the hymen and there
was no displacement of the posterior vaginal
wall.
Ba
PB
TVL
Bp
34
CASE
60 G4P4 (4004) presents with sensation of
something coming out of her vagina. She
reports a palpable mass at the introitus on
occasion. All her pregnancies were delivered
vaginally except for the last, for which she
underwent a CS-hysterectomy for placenta
accreta. On physical examination, the vagina
was pale and smooth and measure 6 cms long.
The vaginal cuff most dependent, noted 1 cm
above the hymen. The urethrovesical crease
was 2 cms above the hymen and there was no
displacement of the posterior vaginal wall.
Aa
-2
Ba
-1
C
-1
GH
PB
TVL
6
Ap
-3
Bp
-3
D
N/A
35
CASE
What level of support is
most compromised in
this case?
A.
B.
C.
D.
Level 1
Level 2
Level 3
Level 4
- Parametrium
(uterosacral/cardinal
ligament complex)
copyright_joanneaguinaldomd_manilaphilippines_june2015
Aa
-2
Ba
-1
C
-1
GH
PB
TVL
6
Ap
-3
Bp
-3
D
N/A
36
Definition
Pathophysiology
Risk Factors
Diagnosis
i.
ii.
iii.
Presentation
Scoring and Staging
Ancillary tests
E. Management
copyright_joanneaguinaldomd_manilaphilippines_june2015
37
copyright_joanneaguinaldomd_manilaphilippines_june2015
38
VAGINAL ROUTE
ABDOMINAL ROUTE
ANTERIOR Compartment
Cystocele/
Cystourethrocele
Anterior Colporrhaphy
Paravaginal Repair
Burch Colposuspension
Paravaginal Repair
Sacrocolpopexy
Posterior Colporrhaphy
(fascial repair;
levator myorrhaphy;
site-specific repair;
post-anal repair)
Sacrocolpopexy
(Vaginal Hysterectomy)
Le Fort Colpocleisis
Sacrospinous Ligament Fixation
(SSLF) /
Prespinous / Iliococcygeal Fixation
USL Suspension/Plication
McCalls Culdoplasty
Sacrohysteropexy
Sacrocolpopexy
USL Fixation /
Moschowitz Procedure / Halbans
Procedure
POSTERIOR Compartment
Rectocele
MIDDLE/APICAL
Uterovaginal Prolapse
Vault Prolapse
Enterocele
copyright_joanneaguinaldomd_manilaphilippines_june2015
39
Definition
Mechanism of continence
Micturition cycle
Classification
Basic evaluation
Specific conditions
Genuine Stress Incontinence
Overactive Bladder
copyright_joanneaguinaldomd_manilaphilippines_june2015
40
copyright_joanneaguinaldomd_manilaphilippines_june2015
41
copyright_joanneaguinaldomd_manilaphilippines_june2015
42
copyright_joanneaguinaldomd_manilaphilippines_june2015
43
copyright_joanneaguinaldomd_manilaphilippines_june2015
44
copyright_joanneaguinaldomd_manilaphilippines_june2015
45
copyright_joanneaguinaldomd_manilaphilippines_june2015
46
Urethral
Incontinence
Extra-urethral
Fistula
copyright_joanneaguinaldomd_manilaphilippines_june2015
47
Definition
Mechanism of continence
Micturition cycle
Classification
Basic evaluation
Specific conditions
Urodynamic Stress Incontinence
Overactive Bladder
copyright_joanneaguinaldomd_manilaphilippines_june2015
48
Evaluation
Gynecologic
40% with urethral sphincter incompetence has anterior
vaginal wall prolapse
Fistulas may be observed with speculum exam
Neurologic
S2-S4 most important to assess
- perineal sensation, anal wink, pelvic floor contraction,
anal sphincter tone
copyright_joanneaguinaldomd_manilaphilippines_june2015
49
Voiding diary
- 3 day clinical record of input and output, urine volume and frequency,
leak episodes and triggering factors
copyright_joanneaguinaldomd_manilaphilippines_june2015
50
copyright_joanneaguinaldomd_manilaphilippines_june2015
51
copyright_joanneaguinaldomd_manilaphilippines_june2015
52
copyright_joanneaguinaldomd_manilaphilippines_june2015
53
copyright_joanneaguinaldomd_manilaphilippines_june2015
54
copyright_joanneaguinaldomd_manilaphilippines_june2015
55
copyright_joanneaguinaldomd_manilaphilippines_june2015
56
copyright_joanneaguinaldomd_manilaphilippines_june2015
57
58
copyright_joanneaguinaldomd_manilaphilippines_june2015
59
copyright_joanneaguinaldomd_manilaphilippines_june2015
60
61
Drug
Propantheline Br
Dosage
7.5-60 mg
Frequency
3-5 times/day
Oxybutynin
2.5-10 mg
2-3 times/day
Tolterodine
Trospium Cl
1-4 mg
20 mg
2 times/day
2 times/day
Propiverine
15 mg
2-4 times/day
Dicyclomine HCl
10-20 mg
3 times/day
Imipramine HCl
25-75 mg
1-3 times/day
DDAVP (synthetic
vasopressin)
100-200 mg
Once At bedtime
Antimuscarinic, calcium
channel antagonist
Tricyclic antidepressant,
antimuscarinic, alphaadrenergic agonist,
antihistaminic
Antidiuretic
copyright_joanneaguinaldomd_manilaphilippines_june2015
62
REFERENCES
Pelvic organ prolapse
1. The standardization of terminology of female pelvic organ prolapse and
pelvic floor dysfunction. http://www.ajog.org/pb/assets/raw/Health%
20Advance/journals/ymob/12_Bump.pdf
2. Pelvic organ prolapse (ICS committee report) http://www.ics.
org/Publications/ICI_2/chapters/Chap05.pdf
Urinary incontinence
1. The neural control of micturition. http://www.ncbi.nlm.nih.
gov/pmc/articles/PMC2897743/
2. The standardisation of terminology of lower urinary tract function. http:
//www.ics.org/Publications/ICI_3/v2.pdf/abram.pdf
Others
1. Evaluation and treatment of Urinary Incontinence, Pelvic organ Prolapse
and Faecal Incontinence. http://www.ics.org/Publications/ICI_4/filesbook/recommendation.pdf
63
A Review of
UROGYNECOLOGY
UPCM Interns Refresher Course
15 June 2015
Good Luck!