Prolapse and Urogynaecology

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Chapter 12 Prolapse and Urogynaecology

Retroversion of the Uterus 214

Symptoms and Treatment of Displacement 215

Uterovaginal Prolapse 216

Vaginal Prolapse 218

Anterior Prolapse 218

Prolapse of the Posterior Wall 219

Clinical Features of Prolapse 220

Differential Diagnosis of Prolapse 221

Pessary Treatment 222

Alternative-Shaped Pessaries 222

Indications for Pessary Treatment 222

Anterior Colporrhaphy (and Repair of Cystocele) 223

Anterior Repair 223

Manchester Repair 225

Posterior Colpoperineorrhaphy (Including Repair of Rectocele) 227

Repair of Enterocele 228

Vaginal Hysterectomy 229

Indications 229

Operative and Postoperative Complications 230

Late Complications 230

Urogynaecology 231

The Anatomy of the Urinary Tract 231

Blood Supply of the Ureter 233

Histology of the Ureter 233

Physiology of Micturition 234

Intravesical Pressure 234

Intraurethral Pressure 234

Innervation of Bladder and Urethra 235

Mechanism of Voiding 236

Detrusor Instability 237

Symptoms 237

Genuine Stress Incontinence 238

Symptoms 238

Genuine Stress Incontinence 238

Other Incontinence Mechanisms 239

Overflow Incontinence 239

Neurological Disease 239

Other Symptoms and Signs Associated with Incontinence 239

The Urethral Syndrome 240

Investigation of Incontinence 241

Examination 241

Demonstrations of Stress Incontinence 241

Urodynamic Investigation of Bladder Function 242

Cystometry 242

Abnormal Cystometry 242

Indications for Urodynamic Assessment 243

Other Investigations 243

Treatment of Stress Incontinence 244

Conservative Treatment of Stress Incontinence 244

New Surgical Developments in the Treatment of Stress Incontinence 244

Surgical Treatment of Stress Incontinence 245

Marshall–Marchetti–Krantz Urethropexy 246

Burch’s Colposuspension Operation 247

Stamey Needle Suspension Procedure 247

Sling Procedures 248

Treatment of Detrusor Instability 249

Bladder Retraining 249

Drug Treatment 249

Retroversion of the uterus

An alteration from the usual anteverted position of the uterus often with a change in the curve of the uterine axis. Most of the so-called displacements are merely variations of the normal and are of little clinical significance.

Symptoms and treatment of displacement

Consequences of Uncomplicated Displacement

Usually none. However, if there is pelvic pathology present, the woman may complain of deep dyspareunia. If such pain occurs, it can easily be reproduced by pressing with the examining fingers. It is quite possible for the patient to present with a complaint of dyspareunia and to have a retroverted uterus which has nothing to do with her complaint.

Uterovaginal prolapse

Herniation of the genital tract through the pelvic diaphragm.

The uterus and vagina are held in the pelvis by the cardinal and uterosacral ligaments and by the pelvic floor musculature, mainly the levatores ani.

When these ligaments and muscles become ineffective, the uterus and vagina descend (prolapse) through the gap between the muscles.

The causes of prolapse are the following:

• The stretching of muscle and fibrous tissue which occurs with childbirth and damage to the innervation of the pelvic floor.

• Age and menopausal changes lead to changes in connective tissue support.

• Increased intra-abdominal pressure, for example, chronic cough, heavy manual work; congenital predisposition to stretch the ligaments.

• Distortion of pelvic anatomy by previous surgery, for example, vault prolapse after hysterectomy or entercoele after colposuspension.

The incidence of this condition in the United Kingdom has been greatly reduced because of smaller families and higher caesarean section rates.

Uterovaginal prolapse

The uterus gradually descends in the axis of the vagina taking the vaginal wall with it. It may present clinically at any level, but is usually classified as one of three degrees.

First degree: cervix still inside vagina.

Second degree: the cervix appears at the level of the introitus.

Third degree: complete prolapse. In the picture, the uterus is retroflexed and the outline of bladder can be seen. There may be a rectal prolapse as well. This is sometimes called complete procidentia. The vaginal mucosa is non-keratinised and the tissues can become very dry and ulcerated with a 3rd degree uterine prolapse. Bleeding and infection can also occur.

Vaginal prolapse

The prolapse involves the vaginal walls and the related viscera. Prolapse of several sites may co-exist and a uterine prolapse may also be present.

Anterior prolapse

When the upper part of the anterior wall prolapses, there is an underlying failure of the investing fascia, and the bladder base also descends. This is called a cystocele.

Sometimes the lower part of the vaginal wall prolapses and the urethra also descends. This is called a urethrocele.

Vaginal prolapse

Prolapse of the posterior wall

If the prolapse is at the level of the middle third of the vagina, the rectovaginal septum is often involved and rectum prolapses with vaginal wall. This is called a rectocele. If the lowest part of the vagina prolapses, the perineal body is involved rather than the rectum.

If the upper part of the posterior vaginal wall prolapses, the Pouch of Douglas is elongated and small bowel or omentum may descend. This is called an enterocele. Enterocele is often associated with uterine prolapse, as in the picture.

Where the uterus has been removed, prolapse of this region is known as a vault prolapse. This is a difficult condition to treat. The technique depends on suspending the vaginal vault from fixed ligaments within the pelvic and often requires insertion of a non-absorbable mesh.

Clinical features of prolapse

• Asymptomatic. It is not uncommon for women to palpate a prolapse, for example, during washing or attempting to insert a tampon. For some women, simple reassurance that there is no sinister cause is all that is required. It can also be identified during routine smear, etc., and if asymptomatic no treatment is required.

• ‘Something coming down’ within the vagina is the commonest symptom. It tends to be worse when the woman has been on her feet and it disappears when she lies down.

• Backache. Some women will experience a dragging feeling or bearing down sensation. This is sometimes resolved with treatment of the prolapse, but mechanical back pain is very common and it may be unrelated to prolapse.

• Coital problems. This is relatively unusual but the woman may admit to difficulties with intercourse, only on direct questioning.

• Increased frequency of micturition. This can be due to anatomical changes that make it difficult to empty the bladder fully. Detrusor instability is also common in older women and may co-exist. A careful urinary history should be taken including fluid and caffeine intake.

• Stress incontinence. This is by no means always present. Sometimes, it is found that reduction of the prolapse causes stress incontinence.

• Difficulty in voiding urine and defecating. The patient may find that it is impossible to initiate micturition except by pushing up the cystocele with her finger. In the same way, the rectocele must be pushed back to allow emptying of the rectum.

The onset may be gradual or quite sudden and is commoner after the menopause when the genital tract tissues begin to atrophy.

Differential diagnosis of prolapse

Prolapse should be confirmed by vaginal examination. The following conditions resemble prolapse on superficial examination; however, careful examination will detect the difference.

Pessary treatment

There are a number of different shapes of vaginal pessaries, the simplest to insert is a ring pessary. This is usually made of semi-rigid plastic and is inserted into the vagina so that the vaginal walls are stretched and they cannot prolapse through the introitus.

The pessary is compressed into a long ovoid shape, lubricated and gently pushed into the vagina, where it resumes its circular shape and takes up a position in the coronal plane. It must not be too tight; and correct fitting is learnt by experience. To an extent, pessary fitting is trial and error and the woman should be warned that the pessary may dislodge. A point of contact should be given so that she can be seen again without delay if this is the case.

Alternative-shaped pessaries

The ‘shelf’ pessary can be particularly useful for uterine prolapse but it is slightly less malleable and insertion can be more difficult.

Indications for pessary treatment

• The patient prefers a pessary. Pelvic surgery with its unavoidable risks should only be applied to a willing patient.

• The prolapse is amenable to pessary support. If the perineal muscles are very deficient they will not hold a pessary and the pessary will fall out. If too big a ring is required, the vaginal wall or cervix will prolapse through it. Posterior vaginal wall prolapses are poorly supported by pessaries.

• The patient is not fit for surgery.

• The patient wishes to delay operation temporarily (e.g., another pregnancy is anticipated).

Plastic rings should be changed once or twice a year, and if it has been properly fitted, the patient will be unaware of its presence in her vagina even during coitus. An ill-fitting pessary is ineffective and may cause dyspareunia and discomfort. If it is too tight or left too long, ulceration of the vaginal wall will occur, and malignant change has been reported. Vaginal oestriol cream or vaginal oestradiol tablets (0.025 mg) help prevent atrophic vaginitis.

Anterior colporrhaphy (and repair of cystocele)

Surgical restoration of the normal anatomy is the purpose of treatment. Reconstitution of the fibrous ‘scaffolding’ of the pelvic organs aims to allow the musculature to function efficiently

Cystocele and rectocele are dealt with by anterior and posterior colporrhaphy. Uterine prolapse may require vaginal hysterectomy. Cervical amputation or Manchester repair may be adequate if the cervix is hypertrophied and the uterus is well supported. Each ‘repair’ must be adapted to the extent of the prolapse and this may often be fully appreciated only at examination under anaesthesia. Women should be counselled regarding the possible surgical consequences prior to surgery and consent should reflect this.

Manchester repair

This involves at the least some shortening of the transverse cervical ligaments and usually amputation of the elongated supravaginal cervix. It is often done in conjunction with anterior and posterior repairs.

1. The cystocele has been repaired. The cervix is being stripped of vaginal wall.

2. Posterior vaginal wall being stripped back.

3. Elongated transverse cervical and uterosacral ligaments are sutured and divided.

4. Amputation of cervix.

5. Covering the posterior stump with vaginal wall.

6. Tying the transverse cervical ligaments in front of the cervix and so shortening them and raising the uterus. (This is the so-called Fothergill suture: sometimes two are put in.)

7. Covering cervical stump and closing the vaginal wall. On release of the cervical stump, the uterus returns to the pelvis.

Vaginal hysterectomy

Indications

• When the uterine prolapse is significant.

• When hysterectomy is required for a non-malignant uterine condition – menorrhagia.

It may be difficult to remove the ovaries by the vaginal route and laparoscopically assisted vaginal hysterectomy may facilitate this.

Appropriate access is required to the remove the uterus. The blood supply has to be divided from the uterus and the pedicles secured. The bladder has to be mobilised so that it is not injured during the procedure. Access may be limited by a number of factors, for example, an enlarged fibroid uterus or if there is pelvic adhesion related to endometriosis. This procedure is always easier in women who have had vaginal deliveries.

1. The bladder has been mobilised. The uterine ligaments are put on the stretch and divided.

2. Uterovesical pouch has been entered. Broad ligament structures are put on the stretch and divided. The uterus is then removed.

3. The lateral pedicles are sutured together to support the Pouch of Douglas. The vaginal vault is closed.

Operative and postoperative complications

Selection of Patients

• Neither youth nor age is a contraindication, but the patient must be reasonably fit, with adequate cardiorespiratory and renal function. Oestradiol vaginal cream may be used to treat atrophic vaginitis prior to surgery.

• The prolapse should be symptomatic.

Perioperatively

• Bleeding pedicles are more difficult to control than during abdominal surgery. The parametric structures should be clamped, divided and ligated in small rather than large bites.

• With the uterus gone, there is a risk of distorting the ureters if the bladder fascia is tightened too much during repair of the cystocele.

Postoperatively

If uncomplicated, the recovery following vaginal surgery is usually associated with less pain and more rapid mobilisation than with abdominal surgery. There is a higher risk of vault haematoma with vaginal hysterectomy when compared to abdominal hysterectomy. This may become infected; however, this usually responds to antibiotics and usually discharges per vaginam. Insertion of a vaginal pack at the end of the procedure is often performed to provide local pressure and reduce the risk of haematoma. A urinary catheter is required when a pack is used.

Late complications

Recurrence of prolapse

This is a relatively common problem. The prolapse that returns within the first months of a repair may be due to a break down or herniation within the primary repair. There may have been a history of postoperative infection. In the long term, women who have undergone pelvic floor repair are at an increased risk of prolapse. It is likely that the fundamental weakness of the fibrous supports of the pelvic floor continues but it may also be that a repair in one area of the pelvic floor transits pressure to another area of the pelvis.

Urinary incontinence

Urinary symptom can appear for the first time after a pelvic floor repair. This is often due to an underlying problem when the anatomy returns to normal.

Dyspareunia

The surgeon must enquire before the operation about the patient’s sexual activity and must be careful to leave a functional vagina where this is required (although this may make support of the prolapse more difficult). Occasionally, dyspareunia may be caused by vaginal adhesions.

Urogynaecology

The anatomy of the urinary tract

The Ureters

The ureter enters the pelvis retroperitoneally by crossing over or near the bifurcation of the common iliac artery.

The ureter is itself crossed by the ovarian vessels and is near the fold of peritoneum which forms the infundibulo-pelvic ligament.

It passes down and medially behind the ovarian fossa and is in close relation to the internal iliac artery. In the healthy subject, its shape can be made out beneath the peritoneum and peristatic movements can be observed (vermiculation).

The ureter then passes beneath the base of the broad ligament, through the transverse uterine ligament and into the bladder. In this parametrial part of its course, it lies alongside the vaginal fornix and passes under the uterine artery.

This picture shows the parametrial part of the ureter with the connective tissue removed. Note that the asymmetry of the uterus and vagina makes the left ureter have a much closer relationship with the vaginal fornix than the right.

Relationship of bladder base to vagina

Blood supply of the ureter

The ureter is supplied by branches from the main arteries with which it is in relation, principally the renal and ovarian arteries. The pelvic vessels are variable and because the blood enters mostly at the upper and lower ends, the peri-ureteric anastomoses are important.

Histology of the ureter

The adventitia is a fibrous sheath containing the peri-ureteral arterial network, the autonomic nerves and the lymphatics.

The muscularis consists of two or three layers of smooth muscle irregularly arranged.

The lumen is lined by plicated transitional epithelium on a loose areolar stroma. This arrangement allows for distension of the ureter as required (cf. the fallopian tube).

Physiology of micturition

Incontinence of urine is very common in women. The assessment and treatment call for an understanding of bladder and urethral physiology.

Intravesical pressure

The bladder displays the phenomenon of adaptation to increased urinary volume. Pressure remains below 10 cm H₂O until over 500 ml of urine are contained.

Intraurethral pressure

Urethral pressure is maintained by the ‘internal sphincter’ made up of longitudinal and circular plain muscle and elastic tissue; and an ‘external sphincter’ which contributes striated muscle.

A ‘urethral pressure profile’ shows the changes in pressure along the length of the urethra. This is normally much greater than the intravesical pressure, thus ensuring continence.

Innervation of bladder and urethra

There is an intercommunicating sympathetic, parasympathetic and somatic supply. The parasympathetic stimulates detrusor contraction, and the sympathetic fibres (chiefly through the alpha receptors) stimulate contraction of the bladder neck and urethra.

The striated muscle has been shown to have a dual autonomic/somatic supply via the pelvic plexus. In normal urethral closure, all the components of the sphincter mechanism must function together and the striated muscle has more to do than merely contract voluntarily when the desire to micturate must be resisted.

Diagram of urethral closure mechanism

Mechanism of voiding

Cystometry recording demonstrates the timing of events.

1. Intra-abdominal pressure increase. (Measured with a vaginal or rectal probe.)

2. Detrusor contracts. (Intravesical pressure increase.)

3. Sphincter relaxes. (Electromyogram of anal sphincter.)

4. Urine flow begins.

The urethra and bladder neck are maintained in the closed state by the trigonal condensation of muscle (the base plate) and the urethral sphincter (plain and striated muscle).

When cortical inhibition is withdrawn, the detrusor contracts and the bladder neck relaxes (funnelling). The sphincter also relaxes and urine is voided. As the flow continues, the bladder neck moves downwards and backwards and the urethrovesical (UV) angle is obliterated.

Detrusor instability

For most women with this condition, it may be associated with neurological conditions, for example, multiple sclerosis and stroke.

The normal bladder does not contract unless voiding is desired. For reasons that are poorly understood, patients with detrusor instability experience detrusor contractions at other times. This can occur spontaneously but may also be provoked, for example, with coughing. The mechanism is altogether different from that of genuine stress incontinence, but some women will have both pathologies.

Symptoms

The patient experiences an irresistible and sudden desire to micturate (urgency). Detrusor instability is the commonest cause, but it may also be due to inflammatory disease of the bladder without detrusor contraction. All forms of bladder pathology must be considered including calculus and carcinoma. There is usually an associated complaint of frequency.

Genuine stress incontinence

Symptoms

When a sudden increase in intravesical pressure is caused by a contraction of the detrusor muscle or by an increase in intra-abdominal pressure as by coughing or straining, the stimulus is usually applied to the intra-abdominal urethra as well, and there is no leakage of urine. If urine does escape, the symptom is called stress incontinence.

Genuine stress incontinence

(alternatively named urethral sphincter incompetence)

Involuntary leakage occurring in the absence of a detrusor contraction. This leakage is attributed to weakness and displacement of the bladder neck so that it cannot respond normally to a sudden increase in intra-abdominal pressure. The cause is likely to be a pelvic floor weakness as a result of parturition and/or oestrogen deficiency.

Other incontinence mechanisms

Fistula incontinence is described in Chapter 14 Complications of Gynaecological Surgery.

Overflow incontinence

Retention of urine is relatively unusual in women; however, it can occur after surgery and is particularly common after regional anaesthesia. Spasmodic detrusor contractions force a little urine into the urethra and the stretched muscle takes several days to regain its tone.

When obstruction to outflow occurs gradually, as from pressure by a pelvic tumour or an incarcerated retroverted gravid uterus, the detrusor has time to hypertrophy and, for a time, forces urine out; but eventually the bladder becomes atonic and painless, and urine dribbles out only when the intra-abdominal pressure is raised.

Neurological disease

Failure of detrusor inhibition is the commonest symptom and is the cause of senile incontinence. It is also a symptom, although not usually the presenting one, of multiple sclerosis. Full sensation is present, but the incontinence is of the urgency type and cannot be resisted.

Failure of bladder sensation is a result of diseases which interrupt the posterior columns of the cord, for example, tabes, syringomyelia and occasionally multiple sclerosis. Chronic overdistension leads to an atonic bladder and overflow incontinence, and infection is a common complication.

Other symptoms and signs associated with incontinence

Frequency

Increased frequency of micturition may arise from any source of irritation including infection, detrusor instability, tumour or incomplete emptying. It is usually diurnal – during waking hours only – but in severe cases will awaken the patient from her sleep. It is one of the earliest symptoms of pregnancy.

Urgency

This is defined as a desire to void urine before the bladder contains 50 ml of urine. True urgency occurs in the absence of a detrusor contraction, and is often associated with infection. Severe urgency leads to ‘urge incontinence’.

Dysuria

This means pain associated with micturition and indicates an infection either of the bladder and urethra, or of the vulval and perineal epithelium which is irritated by the dribbling of urine.

Nocturia

Requiring to pass urine during the night.

The urethral syndrome

The urethral syndrome includes complaints of frequency, dysuria, urgency and a sensation of incomplete emptying in a patient in whose urine no evidence of infection can be demonstrated. The cause is not known and there are several views.

Urinary infection is strictly defined as being present only when 10⁴ or more typical urinary pathogens are grown per ml of freshly voided mid-stream urine and it may be that the urethral syndrome is simply a condition caused by fewer than the usual number of organisms, or by organisms which cannot be cultured in the media used for conventional organisms. Clinically, these patients must be regarded as suffering from a possible urinary tract infection and investigation should be persevered with. Even if no evidence of infection is obtained, empirical antibiotic treatment may be of benefit. In menopausal women, topical oestrogens will treat atrophic changes in the urethral epithelium which can predispose to infection.

Investigation of incontinence

It is useful to distinguish between genuine stress incontinence and detrusor instability as their treatment is different although it is important to remember that some women will have dual pathologies.

History and clinical examination are useful but investigation of bladder function may be required particularly where surgical intervention is being considered.

Incontinence may be due to the following:

1. Genuine stress incontinence

Usually occurs after one or more pregnancies.

Urine appears only after effort (stress) such as coughing, laughing or running for a bus.

Usually only small quantities of urine are passed, whether the bladder is full or not.

2. Detrusor instability

Complaints of urge incontinence and frequency, especially at night (nocturia).

May pass large volumes of urine when bladder muscle contracts.

Stress incontinence combined with urgency incontinence due to bladder infection or cystocele is quite common. Continuous incontinence suggests fistula (p. 292).

The social effects of urinary incontinence should be considered when planning treatment.

Examination

Signs of infection (urethritis) and scarring from previous surgery are looked for, and the usual bimanual and speculum examinations are performed (Chp. 5).

Demonstrations of stress incontinence

The patient is asked to strain and cough and, if stress incontinence is present, small amounts of urine will be observed escaping from the urethral meatus. Unfortunately, this test is really valid only in the erect position when observation of the meatus becomes almost impossible.

Urodynamic investigation of bladder function

This means an investigation of bladder movements and tensions during different levels of filling, and involves measurement of bladder activity (cystometry) and urethral flow (uroflowmetry).

Cystometry

The bladder pressures are continuously recorded as the bladder is filled. In twin channel cystometry, the intra-abdominal pressure is simultaneously recorded by a transducer in the rectum or vagina. The detrusor pressure is calculated by subtracting abdominal pressure from intravesical pressure.

Abnormal cystometry

If detrusor contractions are seen in the filling phase (up to 400 ml infused into bladder), a diagnosis of detrusor instability can be made.

In stress incontinence, leakage on acts such as coughing occurs in the absence of a rise in detrusor pressure.

Indications for urodynamic assessment

These investigations are invasive, but their application would be justified in the presence of the following indications:

1. Continuing difficulty in distinguishing genuine stress incontinence from detrusor instability.

2. After failure of surgery to relieve a complaint of incontinence.

3. Where there are other complicating factors such as neurological disease.

4. Where difficulty in voiding urine is complained of or is suspected. Such a condition may be met with after pelvic surgery and leads to incomplete emptying and perhaps retention overflow.

5. Some clinicians would advocate urodynamic assessment prior to surgical treatment for stress incontinence. The purpose of this is to assess for underlying detrusor instability which may be exacerbated by surgery.

Other investigations

Bacteriological Culture of Urine

This must be carried out in every case.

Fluid Balance Chart

The patient is asked to record the volume of oral fluid intake and urine output over the course of a week. Recordings of urine production should include the volume and the time of each micturition. Any episodes of incontinence should also be recorded. This procedure is useful for identifying the patient with an excessive oral intake. An estimate of the patient’s normal bladder capacity can also be made.

Neurological Disease

This possibility must always be borne in mind and the gynaecologist should test for reflexes in the usual manner. Where there is doubt, the patient must be referred to a neurologist.

Endocrine Diseases

Diseases such as diabetes mellitus and insipidus may present with frequency of micturition.

Treatment of stress incontinence

General measures:

The following should be treated if present:

1. Chronic urinary tract infection

2. Obesity

3. Chronic cough.

Conservative treatment of stress incontinence

1. Physiotherapy – pelvic floor exercises

Pelvic floor exercises may be of value, especially in the puerperium. The best results are achieved when the patient has input from a physiotherapist with an expertise in pelvic floor exercises. Repeated contraction of the pelvic floor will strengthen the muscle tone. A number of techniques are used to achieve this including vaginal cones and biofeedback. This is where the woman’s pelvic floor strength is measured to enable her to be aware of her own pelvic floor tone.

2. Mechanical devices to occlude urethra or support the bladder neck

These devices are usually placed within the vagina and efficacy is variable. Urinary tract infection, expulsion of the device and patient discomfort are reasonably common.

New surgical developments in the treatment of stress incontinence

1. Peri-urethral injections

Substances such as collagen or subcutaneous fat are injected around the urethra using a vaginal approach. This procedure is suitable for frail patients. Cure rates of up to 80% have been reported in the short term but this is reduced in longer follow-up.

2. Artificial urinary sphincters

Implantation of an artificial urinary sphincter may be considered as a last resort in the treatment of stress incontinence.

Surgical treatment of stress incontinence

All operations attempt to elevate the bladder neck above the pelvic floor and behind the symphysis so that increases in intra-abdominal pressure will compress the urethra and not force it downwards. There are three conventional methods, each with several variations.

1. Anterior colporrhaphy

This procedure may be useful in women with coexisting anterior vaginal wall prolapse, but the rate of objective cure for stress incontinence is less than 40%.

2. Urethropexy

The bladder neck is approached through a suprapubic incision and elevated by suturing the paraurethral tissues to adjacent structures such as the rectus sheath or the ilio-pectineal ligament.

These operations are more difficult than vaginal urethroplasty, especially in obese women. Some operators employ a laparoscopic technique.

3. Urethral sling operations

A sling of synthetic material, sutures or tendon is passed under the urethra and attached to the rectus muscles or adjacent ligaments. This requires a combined vaginal-suprapubic approach and is the most difficult of the three methods.

The urethropexy operations are probably most likely to be successful when the incontinence is due to urethral inadequacy and not detrusor instability.

Marshall–marchetti–krantz urethropexy

The urethrovesical junction is made to adhere firmly to the anterior vaginal wall by suturing the vaginal tissue to the back of the symphysis pubis.

1. The urethrovesical junction is exposed in the space of Retzius. Adhesions are divided and all bleeding points picked up. The urethra must be dissected to within 1 cm of the external meatus.

2. A Foley’s catheter in the bladder helps to identify the urethrovesical junction. Sutures pick up vaginal tissue on either side and suture it to the pubic periosteum.

Bleeding from paravesical blood vessels is common and a drain can be useful to reduce the risk of a pelvic collection.

Periosteitis is sometimes a late complication and the operation is difficult in the presence of excessive obesity. If too acute an angle is produced, the patient may have difficulty in emptying her bladder.

Burch’s colposuspension operation

This operation elevates the anterior vaginal wall, bringing the urethra up with it.

1. Through a suprapubic incision, the bladder neck area is mobilised from the paravaginal fascia. This procedure may be accompanied by a good deal of bleeding which can be controlled by tightening the sutures.

2. The paravaginal fascia (and some vaginal tissue as well) is sutured on each side to the inguino-pectineal ligaments, using four or five sutures.

The wound is closed with drainage as for the Marshall operation, and the possible complications are similar. Suprapubic operations can be difficult when the patient is very obese. This procedure may now be performed laparoscopically by appropriately trained surgeons.

Stamey needle suspension procedure

The Stamey procedure is one of a number of needle suspension procedures. They are less invasive than conventional colposuspension. A long Stamey needle is passed through a small incision above the pubis on each side, behind the pubic bones, into the vaginal lumen. A nylon suture is attached to the vaginal wall and tied to the rectus sheath, to elevate the vagina and bladder base.

A cystoscope is passed to ensure that the needle has not entered the bladder after each pass of the Stamey needle.

Sling procedures

Slings can be made from either the patient’s own tissues (abdominal fascia) or synthetic material. These materials are placed under the urethra to achieve compression when the intra-abdominal pressure increases.

The synthetic materials are meshes, which are non-absorbable and permanent. They are inserted vaginally either side of the urethra. They can be a source of infection and can occasionally erode through tissues.

TVT: retropubic approach

TVT: transobturator approach

Treatment of detrusor instability

Bladder retraining

Women with symptoms suggestive of detrusor instability should be advised to cut out bladder stimulants such as caffeine and alcohol.

This may be done as an inpatient or an outpatient, although inpatient treatment is more effective. The patient is instructed to void only at defined intervals (to start with, this is normally 1.5 h). When the patient can achieve continence between scheduled voiding, the interval is increased gradually. A normal fluid intake should be allowed. Support and enthusiasm from medical and nursing staff is required for this procedure to be effective.

Drug treatment

Antimuscarinic agents (oxybutynin, tolterodine). These agents act by blocking parasympathetic stimulation of the detrusor muscle. Improvement is seen in 70% of patients who can tolerate the drug.

Non-compliance is common, because of the anticholinergic side effects of dry mouth, blurred vision, tachycardia, drowsiness and constipation.

Tricyclic Antidepressants (Imipramine)

These drugs are useful if nocturia is a significant compliant. Anticholinergic side effects may be a problem.

Oestrogen

Although few trials have formally evaluated the efficacy of oestrogens, they appear to have a role in postmenopausal women.

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