Npmc Disotrders Of Pelvic Floor & Uv Prolapse Final 2

Disorders of pelvic floor & UV prolapse BY DR. J.U.E. ONAKEWHOR,

MBBS, M.SC, FWACS, FICS

(Consultant Ob-Gyn and Coordinator, PMTCT Program, UBTH, Benin City)

Presentation made at the Revision Course organised by the National Post Graduate Meidcal College of Nigeria at the University of Benin Teaching Hospital ,Benin City, Nigeria September 510 ,2005.

Pelvic floor disorders : Background Many women will spend hours each week exercising their legs and abdomen muscles in order to "keep in shape." Unfortunately, one of the most important sets of muscles is overlooked and ignored leading to pelvic floor problems. A report from the Temple University researcher found 72 percent of women reported suffering from one or more pelvic floor disorders 70 percent had not sought medical help.

Background contd. •Onset of incontinence compel them to see the doctor; multiple urogynecological problems are seen. Of all pelvic floor disorders, it is incontinence that brings most women to the doctor. "They cannot tolerate leaking urine and the disruption to their daily lives. But incontinence is usually just the tip of the iceberg. Many also sufferifrom such pelvic floor disorders as uterine or rectal prolapse." (Women's Health NewsPublished: Tuesday, 28-Jun2005) More than 50% of women age 55 and older suffer one or more of the problems caused by pelvic floor dysfunction.

Background contd. 1 in every 9 women will undergo surgery for a pelvic floor disorder. Women who suffer from pelvic floor disorders underreport their condition due to embarrassment. 1 in every 3 women will suffer sphincter muscle damage due to vaginal childbirth; a damage that may lead to loss of bowel control. 30% of women with overactive bladder or urinary incontinence also suffer from loss of bowel control. 20% of patients suffer from vaginal organ prolapse also experience loss of bowel control. Most women suffer from pelvic floor disorders (PFD), the majority don't seek help until they are incontinent 60% of nursing home occupants suffer from loss of bowel control and/or urinary incontinence.

The pelvic floor structures Made up of muscles & ligaments: Pelvic diaphragm - Mucsular: -Levator ani -Coccygeus •Ligaments -Transverse cervical lig.(Mackenrodt) -Utero-sacral lig. -Others - Broad lig., round lig. of the uterus, Pubocervical lig.

PELVIC FLOOR- "pelvic floor" muscles The pelvic floor (pelvic diaphragm ) is composed of a group of muscles, which span the inferior, or underlying surface of the bony pelvis. The muscle group, originate at the pubis anteriorly, at the frontal portion of the pelvis, just above the genitals. The pelvic floor muscles extend back to the coccyx,(tailbone) This thick sheath muscular floor is pierced by -the urethra- the sphincter mechanism of the lower urinary tract, -the vagina,-the upper and lower vaginal supports, and -the anal canal-the internal and external anal sphincters. and gives off fibers that connect it to these organ structures. Ligaments- Transverse

Female Pelvis Showing the Position of the Pelvic Organs and Pelvic Floor Muscles

Fig. 3: Vagina & Perinreal pouches in coronal section

Fig. 2: Female perineum

Fig. 4: Urogenital & Anal triangles

Functions of pelvic floor muscles 1) support of the organ systems (Uterus , Bladder and rectum&

colon) within the pelvis and lower abdomen;

2) closure of the urethra and anal canal to maintain continence; 3) signaling to the bladder, rectum and colon when voiding or defecation is desired; and 4) opening of the urethra and anal canal by total relaxation to allow for complete and effortless defecation and urination. If any of the above functions are disturbed, normal bowel and bladder control will be disrupted 5). The pelvic floor muscles play an important role in bladder and bowel control and sexual sensation. • The pelvic floor muscles are normally under voluntary control, When torn or weakens, the organs may shift, bulge and push

Factors associated with weakness of the pelvic floor muscles Pregnancy and childbirth; esp multiparity & big babies - those who experienced tears in the perineum and pelvic floor during childbirth, are at higher risk for pelvic floor disorders. Continual straining to empty bowels; constipation Persistent heavy lifting; Chronic cough (such as smoker’s cough or chronic bronchitis and asthma);

Obesity / overweight- Excessive body weight adds extra strain to the

pelvic floor resulting in pelvic organ prolapse, incontinence, and sexual dysfunction

changes in hormone levels at menopause (change of life); lack of general fitness. connective tissue disorders, degenerative neurologic conditions, and prior pelvic surgery

Pelvic floor disorders include Incontinence - bowel control -urinary incontinence constipation Rectal pain Utero-vaginal and/or rectal prolapse Pelvic pain/trauma Sexual dysfunction (Dyspareunia, Apareunia) Others- Disorders of elevated levels of pelvic muscle activity

Others: Disorders of elevated levels of pelvic muscle activity

considerable overlap in symptoms; same underlying cause. Proctalgia Fugax - severe and sudden attacks of sharp pain in the rectum and anal canal -stabbing, burning, or grinding pain localized in the anal canal or rectum. Attacks often follow defecation, sexual activity or stress, but may occur spontaneously as well. Levator Ani Syndrome - continual discomfort in portions of the anal canal and can extend throughout the pelvic region and into the vagina. -syndrome as having the anal canal pulled in knots, or feeling there is a hard object, like a golf ball, in the anal canal. Dyspareunia -pain or muscle spasm that extends across the buttocks, down the legs and up into the lower back.

Others: Disorders of elevated levels of pelvic muscle activity Coccydinia - pain around the coccyx ; C/o coccyx "on fire.“ Pelvic Floor Tension Myalgia - pain and discomfort associated with the three syndromes described above. Anismus - failure to relax or, a paradoxical contraction of the pelvic floor muscles with defecation. - abnormal increase of pelvic floor muscle activity with defecation rather than the normal decrease in muscle activity. -leads to constipation, incomplete evacuation and straining with stool. Voiding Dysfunction- - associated with bladder disorders, which include symptoms of voiding hesitancy, interrupted stream, urinary urge and painful urination.

Problems caused by vaginal birth & advancing age 1.Pelvic Organ Prolapse 2. Incontinence -occurs when women have trouble controlling their urine or their bowels; urinary incontinence or of fecal incontinence. 3. Both Incontinence + 1.Pelvic Organ Prolapse ; - May require multidisciplinary approach; urogynecology & colorectal surgery. Functional problems of pubococcygeal muscles -urinary and fecal incontinence, - cystocele, rectocele, enterocele, interstitial cystitis,

Significant risks for PFD older age, high body mass index- obesity Minor incontinence and other PFDs. Uterine or rectal prolapse and incontinence. multiple vaginal births giving birth to large babies (more than 9 pounds) difficult instrumented deliveries (forceps, vacuum) presence of a pelvic tumor Diabetes Asthma Chronic bronchitis

Utero-Vaginal Prolapse – Definition – Downward displacement of the uterus &/Vagina towards or through the intoitus - The bladder, ,urethra, rectum & bowel may be secondary involvement Degrees 1st- degree-descent of the cervix to the introitus 2nd degree- descent of the cervix and part of , but not the whole uterus through the introitus 3rd degree- Descent of the cervix and the whole uterus through the introitus- Procidentia, UV prolapse complicated by bladder ± rectal ± enterocele

The signs and symptoms of the condition Mild prolapse may not cause any symptoms With more severe prolapse, a woman may have: -a falling out sensation -a feeling like she's sitting on a ball -sensation of pelvic heaviness -low backache - lower abdominal discomfort -increased vaginal discharge -increased urinary tract infections -increased desire to urinate or more frequent urination -stress incontinence, or leakage of urine that is worsened by coughing, sneezing, or lifting objects -a feeling of not having completely emptied the bladder -Dyspareunia (pain with intercourse) -Apareunia (no sexual intercourse). -painful bowel movements - constipation - rectal and/or vaginal heaviness or pain, constipation,

Urinary Incontinence Is Involuntary loss of urine that is socially unacceptable to the patient -It impacts a woman’s self-esteem, affecting both her emotional well being as well as her independence. - 20-30% of women 65years or older have significant degree of incontinence; it could be more!! -Many women suffer in silence either because they are too embarrassed to discuss this issue with their physician or are fearful that surgery is the only treatment option. -Good news : After a comprehensive evaluation nearly 60% of women with incontinence can be successfully treated using non-surgical techniques.

Types of Urinary incontinence contd. 1.Stress incontinence - loss of small amount of urine during exercise, coughing, sneezing, or straining. Occurs when intravesical Pressure (IVP)> MUP (Maximum Uretrhal Pressure) without detrusor activity. 2. Urge Incontinence - involuntary loss of urine in the presence of strong desire to mictuirate 3. Motor urgency- due to uninhibited detrusor contractions 4. Sensory incontinence -due to irritative lesion (Cystitis, calculus, tumors, etc) 5. Reflex Incontinence - abnormal spinal reflex 6. Overflow Incontinence - when intravesical Pressure (IVP)> MUP (Maximum Uretrhal Pressure) with bladder distension without detrusor activity 7. True Incontinence - due to anatomical abnormality of the urinary tract.

Types of Incontinence. • Genuine Stress Incontinence- due to alteration in position of the bladder neck to pelvic flow Detrusor Instability- present in 60-70% of women - cause unknown, - Seen naturally in children • Genitourinary fistulae

Diagnosis 1.History & Clinical examination 2. Investigations a) Routine ; MSU→ MCS, b) Special - IVU - Cystoscopy Cystometry (CMG) - test the reservoir function of the bladder -Filling Cysytometrogram – assess derusor activity & leakage during the filling phase. - Voiding CMG-to assess urinary flow ; differentiate obstruction from under active bladder - Urehtral pressure profile- assess urethral closure pressure

Special investigation contd • Video-cystourethrography -assesses anatomical relationship of urethra urethrovesical junction and bladder base; bladder press is measured , urine flow and volume- useful in complex or failed surgical cases fluoroscopic urodynamics endoanal manometry pudendal nerve testing

Treatment of Uterine Prolapse for uterine prolapse depends on many things, including: the severity of the prolapse the severity of the symptoms the presence of other signs and symptoms a woman's wishes to preserve her fertility the woman's age It may be medical, conservative surgery of definitive surgery

Treatment contd. • Conservative method b) medicine to treat the incontinence - imipramine, an anti-depressant that stimulates the

closure of the bladder neck. - Other adrenergic drugs (anticholinergic not effective in GSI)

-b) Kegel exercises to strengthen the muscles around the bladder and sphincter. c. . Biofeedback is one learning procedure that uses sensitive electronic instruments to measure.

The responses are displayed on a computer screen in a way which helps the patient differentiate and practice those responses that are associated with better physiological function.

Conservative Treatment contd. Because pelvic floor muscles are controlled voluntarily, their function can be improved through various learning procedures Biofeedback treatment for bowel or bladder dysfunction -a small EMG sensor is placed in the anal canal or vagina that measures and then displays the electrical activity of the muscles being recorded. d) Injection of a bulking agent (Collagen) into the bladder neckusually pretty effective.

Other, conservative treatments for disorders related to excessive pelvic floor muscle activity e). various physiotherapy modalities including rectal diathermy, hydrotherapy, massage,& postural adjustments. Electrical stimulation to the pelvic floor muscles is sometimes used to fatigue or normalize muscle activity to augment their relaxation. All these techniques can be used independently or in conjunction with biofeedback.

Conservative management Contd. Pessary, a plastic doughnut-shaped device placed into the vagina to push up the uterus eg Hodge pessary Double vaginal rings Non-surgical treatment of uterovaginal prolapse using Estrogen therapy given directly into the vagina with creams – HRT in menopausal women

2. surgical approach: a) Conservative surgery when all else has failed, a sling is surgically inserted to hold up the bladder neck, suspension of the uterus and bladder without a hysterectomy Laparoscopic suspensions but the best results still seem to be with the more major procedures. - Pelviscopic uterine suspension using Webster-Baldy and Franke's method. Round ligament suspension procedure, an operation to provide muscle support to the uterus

When multiple PFDs are involved, it's important for a multidisciplinary team of experts to work together on solutions.

Surgical approach Sacrocervicopexy and combined operations in the treatment of uterovaginal prolapse in women with desire to preserving. Surgical support and suspension of genital prolapse, including preservation of the uterus, using the GoreTex soft tissue patch -Abdominal-retroperitoneal sacral genito-colpopexy using the expanded polytetrafluoroethylene (ePTFE) soft tissue patch has been found to be highly effective for repair of genitovaginal prolapse

Surgical approach contd. A new technique of uterine suspension to pectineal ligaments in the management of uterovaginal prolapse ; -Through a Cherney incision, the uterus is suspended to the pectineal ligaments on both sides with mersilene tape. . A simultaneous Burch colposuspension can be useful in selected cases Anterolateral hysteropexy via abdominal approach. -abdominal suspension is reserved for young patients in whom retention of sexual function is desirable. -Fixation to the sacral promontory is the reference method but has some contraindications. -Anterolateral suspension of the uterine isthmus to the anterior superior iliac spines by a strip of non-absorbable mesh, as described by Kapandji, is then a good alternative.

Surgical approach contd Uterine preservation in the surgical management of genuine stress urinary incontinence associated with uterovaginal prolapse. -Retropubic ventral suspension of both the uterine isthmus and the vesical neck ; designed to correct uterovaginal prolapse as well as genuine stress urinary incontinence while preserving the uterus.

b) Definitive Surgery Hysterectomy and pelvic floor repair vaginal route abdominal route Sacrospinous Fixation for - Vault Prolapse and at the Time of Vaginal Hysterectomy for Marked Uterovaginal Prolapse

The side effects of the treatments?

The side effects depend on the treatment. Hormone replacement therapy may cause nausea, weight gain, abdominal bloating, increased vaginal discharge, and breast tenderness. After a hysterectomy a woman will need 6 to 8 weeks to recuperate. possible side effects with any surgery..

Advice after treatment for the condition After surgical treatment of a prolapsed uterus, Avoid all necessary risk factors: avoid lifting heavy objects prevent constipation by drinking plenty of fluids, using stool softeners for a short time, and increasing her fiber intake perform Kegel exercises daily during pregnancy and after giving birth to strengthen pelvic muscles avoid smoking lose weight through diet and exercise, if she is overweight continue with hormone replacement therapy, if she was using it before surgery for a long time ; during and after menopause to maintain the tone of the pelvic muscles ? For Africans avoid wearing tight girdles or other garments that put pressure on the abdomen

Surgical vs. nonsurgical repair of prolapse in elderly woman A Case Senarioo A grandmother has a prolapsed uterus and bladder and I am trying to help her decide on the best option for an 85 year old woman. She is in fairly good health but I'm concerned about the anesthesia at her age. Are there any non-invasive procedures? What are the benefits/risks to a stitch vs. removal of the uterus? The only nons-urgical treatment would be a pessary Surgically, the stitch of sewing the vagina shut (colpocleisis) is about 85% successful and carries less risk of surgical complications than a hysterectomy. If either a vaginal hysterectomy or colpocleisis is done, it can be performed under spinal or epidural rather than general anesthesia. This is safer for the heart in an elderly woman.

Summary of surgery Condition

Intervention

1.Urinary Stress -Burch colposuspension Incontinence (GSI) -urethropexy (Marshal – Marchetti & Kranz technic) -Endoscpic bladder neck susupension ( Stamey procedure) -Artificial Sphincter implant – in failed repeated surgeries -Urinary diversion- ileal conduit When all methods fail

Summary of surgery Condition

Intervention

2.Detrusor instability (DI)

Difficult to Treat •Bladder training • Drug RX - anticholinergic drugs ± beneficial -Oxybutalin intravesical in refractory cases. • Surgery ; not usually indicated; -Clam csystoplasty -Detrusor myomectomy

3. Refractory idiopathic /hyperreflexic DI

Summary of surgery Condition Intervention 4. Uterine Prolapse Hysterectomy + anterior/ posterior colpoperineorrhaphy/ Colposuspension Watkins Interposition operation Reserved for the woman who has completed her family. Amputation of the Cx, the ligs. Sturmdorf (absorbable) -The posterior lip of the lower uterine suture segment is covered by post vaginal epithelium by bringing the stitch thro the post vaginal mucosa x2 to the into the endocanal of the LUS covered at ant stump by the ant vag mucosa

5. Pelvic prolapse

Summary of surgery Type of PFD

Operation

Remark/ Purpose

Cystourethrocele

Anterior Repair Colposuspension Burch technic Anterior Repair + Kelly Plication of urethra

↓cystourethrocele; reinforce PVF support of bladder &urethra

↑es intra urethra

intravesical press in the resting & stress state i.e with valsava maneuver

Cystourethrocele + Stress incontinen. Physiological changes (Kelly’s Operation)

Pressure to level >

Vaginal Prolapse Sacrospinous lig suspension

± vaginal Hysterectomy; ↓urethra diameter

Ideal for sexually active women with complete prolapse

Summary of surgery Condition

Intervention

2nd or 3rd degree UV Manchester (Futhergill) Prolase + operation/ repair Csystourtethrocele Advantage– no entry into the peritoneal cavity; -Op time is reduced; low morbidity 2nd or 3rd degree UV Manchester operation + Kelly plication of the urethrovesical Prolase + Csystourtethrocele+ sphincter Stress incontinence

Complete prolapse in the elderly woman with no desire for sex in the future

RX: Le Fort Operation- advantage - failure /recurrence extremely rare; Complication: overflow /stress incontinence - To avoid this remove upper 2/3 of vagina wall & leave lower 1/3 behind

Thank you All