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

8. retroverted uterus: 1st sign attenuation, stretching or Breakage ??

9. ut cx 130o b LP sp u r v

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

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 study:evaluate 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