Uterovaginal prolapse and urinary incontinence

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8 Uterovaginal prolapse and urinary incontinence

Chapter Contents

Uterovaginal prolapse

Definition
Incidence
Anatomy of the pelvic floor
Types of prolapse
Aetiology of prolapse
Clinical assessment
History
Examination
Urodynamics
Treatment

Urinary incontinence

Physiology of micturition
Bladder innervation
Assessment
Investigation of urinary incontinence

Overactive bladder

Management

Stress incontinence

Aetiology
Management
Causes
Management
Treatment

True incontinence

Assessment
Management

Summary

Uterovaginal prolapse

In the majority of women the uterus is said to be in a position of anteversion (the fundus directed forwards) and anteflexed (the body of the uterus bent forward over the cervix) – retroversion and retroflexion are the converse of these and occur in approximately 20% of cases. The main structures that hold the uterus in position are the uterosacral and transverse cervical ligaments. The normal uterus is mobile and is, therefore, able to adjust its position in the pelvis as a result of any pelvic mass or distension of the bladder or rectum. The secondary support of the uterus is the muscular pelvic floor.

Definition

Uterovaginal prolapse is defined as descent of a pelvic organ or structure into and sometimes outside the vagina. ‘Prolapse’ can be taken as meaning pelvic organ prolapse, urogenital prolapse, genital prolapse, rectocele/cystocele/urethrocystocele, vaginal vault prolapse and uterine descent (Fig. 8.1).

image

Figure 8.1 Areas of potential prolapse. (1) Urethrocele; (2) cystocele; (3) apical (uterus/vault); (4) enterocele; (5) rectocele.

Incidence

The incidence of prolapse in the female population is difficult to define as many women do not seek medical attention and clinical examination does not necessarily correlate with symptoms. It is estimated that a woman has an 11% lifetime risk of having an operation for prolapse by the age of 80 and that 30% of these patients will require further prolapse surgery.

Anatomy of the pelvic floor

Prolapse is caused by a failure of the supporting structures of the genital tract and it is, therefore, important to have an understanding of this anatomy. The pelvic floor consists of muscular and fascial structures that support the abdominopelvic cavity and the external openings of the vagina, urethra and rectum. The uterus and vagina are suspended from the pelvic side walls by endopelvic fascial attachments that support the vagina at three levels or anatomical sections:

• Level 1 (upper third of the vagina) support consists of endopelvic fascial tissue that condenses laterally as the cardinal (transverse cervical) ligaments and posteriorly as the uterosacral ligaments.

• Level 2 (middle third of vagina) support attaches the middle portion of the vagina to the arcus tendineus and fascia of the levator ani muscles.

• Level 3, the lower vagina, is supported predominantly by connections to fibres of the pelvic diaphragm and the perineal membrane.

Most of the endopelvic fascia fibres attach to the vaginal wall, but a few pass from one side to the other and are recognized as the rectovaginal septum separating the vagina and rectum. Damage at the different levels of vaginal support causes different types of prolapse. Level 1 support failure results in vaginal vault or uterine prolapse, whereas loss of level 2 support leads to development of cystocele and rectocele, and level 3 disruption results in any of the above (as it acts as an anchor for all the supports) and a deficient perineum.

Types of prolapse

Anterior vaginal wall prolapse may have bladder or urethra above it and this is known as a cystocele, urethrocele or a combination of the two. Posterior wall prolapse can contain a part of the rectum (rectocele) or higher up on the posterior wall when the pouch of Douglas containing small bowel can herniate through the posterior fornix (enterocele). An enterocele is usually associated with uterine prolapse, but is also known to be a late complication of previous colposuspension procedures.

Uterine prolapse is descent of the cervix and uterine body into the vagina and three types are recognized:

1. First-degree, in which there is descent of the cervix into the vagina but not as far as the introitus.

2. Second-degree, in which the cervix reaches the introitus.

3. Third-degree, in which the cervix and body of the uterus lie outside the introitus (this is also known as procidentia).

Vault prolapse is eversion of the vault of the vagina that can occur after hysterectomy.

Aetiology of prolapse

Congenital

The connective tissue is known to play an important role in pelvic organ support and collagen is the main provider of tensile strength. Deficiencies in collagen metabolism have been shown to be associated with stress urinary incontinence and prolapse.

Childbirth

Vaginal delivery and factors such as prolonged second stage, instrumental delivery and large birth weight of the infant have all been shown to be associated with disruption of the anatomical relations and possible denervation of the pelvic floor.

Menopause

The incidence of prolapse is known to increase with age and it is thought that this is due to the deterioration of collagenous connective tissue that occurs following oestrogen withdrawal.

Iatrogenic

Hysterectomy involves division of the uterosacral ligaments, which are important in level 1 support of the vagina. The cumulative risk of prolapse is 1% 3 years after hysterectomy, rising to 5% 15 years after.

Chronic predisposing factors

Prolapse is aggravated by any chronic increase in intra-abdominal pressure and, therefore, factors such as obesity, chronic cough secondary to smoking or respiratory tract conditions, heavy lifting at work or in the home and constipation.

Clinical assessment

Prolapse is often asymptomatic, but patients may complain of any or a combination of the symptoms outlined below.

There may be a dragging sensation in the pelvis or a feeling of ‘something coming down’ through the vagina. Patients may feel a swelling at the vagina that gets worse as the day progresses and describe difficulty with intercourse (dyspareunia).

Anterior wall prolapse can be associated with urinary symptoms, in particular leakage of urine with increased intra-abdominal pressure, e.g. on coughing or sneezing, or incomplete emptying of the bladder resulting in high residual volumes of urine that may lead to urinary tract infections. Patients may also complain of frequency, nocturia or urgency with or without incontinence, which could be due to cystitis or because of a coexisting overactive bladder.

Posterior wall prolapse may be associated with difficulty in defecation to the extent that many patients may need to attempt digital reduction of the prolapse to ease defecation. Procidentia may result in vaginal bleeding or discharge, as an erosion or decubitus ulcer may form on the exposed prolapsed uterus. Rarely, procidentia may result in ureteric obstruction causing chronic renal failure.

History

Ascertaining the degree of impairment of quality of life or daily activities will influence management. Specific questioning on urinary and bowel function as well as sexual function should be included. A full obstetric and gynaecological history as well as medical and surgical history will guide the practitioner as to the suitability of conservative or surgical management options. Specific instruments, for example, the King’s Health Questionnaire, are available and are routinely used to measure quality of life.

Examination

Abdominal examination should always be performed to exclude any masses or organomegaly. The woman should first be examined in the dorsal position when she is asked to bear down, strain or cough, during which inspection of the introitus should reveal any obvious second- or third-degree prolapse; stress incontinence may be demonstrated and atrophy may be apparent. Examination is then performed with the patient in the Sims’ position (patient in left lateral position with chest at 45°∞ to the examining couch, the left leg straight, the right hip extended and knee flexed) with a Sims’ speculum, which allows full inspection of the uterine prolapse and vaginal walls (Fig. 8.2

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