There has been a convergence of the subspecialties of female urology and urogynecology over the past few years. One of the prevailing undertones of our book speaks to the fact that there are many ways to treat any single disease.
INCONTINENCE Evaluation of Incontinence
PELVIC ORGAN PROLAPSE
OTHER
INTRODUCTION
Identification of the various components of pelvic floor dysfunction is aided by diagnostic tools such as video urodynamics and magnetic resonance imaging of the pelvis. This chapter will focus on normal female pelvic anatomy, including the supporting structures relevant to voiding dysfunction and incontinence, as well as the pathophysiology of pelvic floor relaxation, with a description of the various components of pelvic organ prolapse.
PELVIC SUPPORTING STRUCTURES A. Bone
The levator ani group consists of the pubococcygeus, ischiococcygeus, and iliococcygeus, named for their origin from the pelvic sidewall (4). The posterior muscle group consists of the posterior part of the levator ani and the coccygeus muscle.
ANTERIOR VAGINAL SUPPORT
The puburethral ligaments are a condensation of the levator fascia that connects the inner surface of the inferior pubis with the middle part of the urethra. The second layer of the urethropelvic ligament consists of the levator fascia, which covers the abdominal side of the urethra (endopelvic fascia), which fuses with the periurethral fascia.
UTERINE AND VAGINAL VAULT SUPPORT
POSTERIOR VAGINAL AND PERINEAL SUPPORT A. Rectovaginal Septum
PATHOPHYSIOLOGY OF PELVIC FLOOR DYSFUNCTION
Bladder outflow resistance is compromised, allowing the intravesical pressure to exceed the pressure in the urethra and bladder neck and leading to urinary incontinence. This anatomical repositioning of the urethra and bladder neck to a more dependent pelvic position eliminates the valvular effect.
ANTERIOR VAGINAL WALL PROLAPSE A. Bladder Neck and Urethra
Anterior vaginal wall support defects are further categorized according to the location of the primary anatomic defect. The fibers of the pubocervical fascia attach bilaterally to the anterior aspect of the cardinal.
VAGINAL VAULT PROLAPSE A. Uterus and Vaginal Vault
After hysterectomy, deficient sacrouterins and cardinal ligamentous support can lead to prolapse of the vaginal dome and cuff. An enterocele is defined as a herniation of peritoneum and its contents at the level of the vaginal apex.
POSTERIOR VAGINAL WALL PROLAPSE AND PERINEUM
There are several components of posterior vaginal wall support to consider: the presence of a rectocele; separation of the levator hiatus;. In type IV defects, a fistula is present in the lower third of the vaginal wall with an intact perineum.
CONCLUSIONS
Voiding dysfunction also occurs as a result of normal aging and is affected by changes in the viscoelastic properties of the bladder wall. As with other neurological systems, innervation of the lower urinary tract is not static; it changes in response to disease and aging.
PROPERTIES OF DETRUSOR MUSCLE AND BLADDER WALL A. Excitation-Contraction Coupling
The ability of the bladder to accommodate increasing volumes of urine at low pressure is called bladder compliance. They are also critical to compliance, and any change in the composition of the ECM can lead to reduced compliance.
LOWER URINARY TRACT INNERVATION
The second nerve bundle passes down to the junction of the urethra with the anterior wall of the vagina. However, Elbadawi and Atta (11) reported that there is evidence for a triple innervation (somatic plus cholinergic and adrenergic autonomic) of the intramural striated sphincter.
NEUROTRANSMISSION AND RECEPTORS A. General
The role of the sympathetic nervous system in the lower urinary tract is a matter of debate. However, the role of NANC mechanisms in contractile activation of the human bladder is still disputed.
SENSORY INNERVATION
In situ hybridization studies revealed high messenger RNA for AMPA receptor subunits GluR-A and GluR-B in sacral parasympathetic preganglionic neurons, but not NR2 NMDA receptor subunits. In contrast, high levels of messenger RNA for all four AMPA receptor subunits (GluR-A to D) as well as the NR1 NMDA subunit are expressed in EUS motor neurons (53).
PHYSIOLOGY OF THE EXTERNAL URETHRAL SPHINCTER (EUS)
They found that the fatigue-resistant slow-twitch fibers are only 35%, 20% fast-twitch resistant, and 45% of the intramural striated sphincter. The fast-twitch fibers (fatiguable) can be converted into slow-twitch fibers by physiotherapy (e.g. electrical stimulation).
CENTRAL NERVOUS CONNECTIONS OF THE LOWER URINARY TRACT
This loop consists of two components: (a) supraspinal and (b) segmental innervation of the peripheral striated muscle. Efferent impulses travel via the pelvic nerve, and the function is inhibition of the detrusor contraction.
SUMMARY
An analysis of the axon populations in the nerves to the pelvic viscera in the rat. The structure and innervation of smooth muscle in the wall of the bladder neck and proximal urethra.
RISK FACTORS A. Age
Mushkat and colleagues investigated the prevalence of stress urinary incontinence in first-degree relatives of 259 female probands (11). African American women had a significantly lower prevalence of stress urinary incontinence and higher prevalence of urge incontinence than Caucasian women.
PREVALENCE
The influence of age, parity, oral contraception, hysterectomy and menopause on the prevalence of urinary incontinence in women. The influence of age, parity, oral contraception, hysterectomy and menopause on the prevalence of urinary incontinence in women.
HEALTH-RELATED QUALITY-OF-LIFE RESEARCH
The goal of this chapter is to provide background on HRQOL research as it applies to urinary incontinence and to present an overview of the existing instruments available for patients with urinary incontinence. In addition, we will summarize the literature on the impact of urinary incontinence on quality of life.
DEVELOPMENT AND EVALUATION OF NEW INSTRUMENTS
Validity refers to how well the scale or instrument measures the trait it is intended to measure. It is a measure of how meaningful the scale or survey instrument is when in practical use.
HEALTH-RELATED QUALITY-OF-LIFE INSTRUMENTS AVAILABLE FOR USE IN URINARY INCONTINENCE
Although not as widely used in the general population as the SF-36, both the Nottingham Health Profile and the SIP have been used successfully to measure overall quality of life in women with incontinence (22,23). However, in clinical practice the questionnaires were difficult to complete, which limited their usefulness. addressed by the development of short versions of these questionnaires: the IIQ-7 and the UDI-6.
IMPACT OF URINARY INCONTINENCE ON GENERAL HEALTH-RELATED QUALITY OF LIFE
It is also notable that urinary incontinence can have a significant impact on psychological health, which in turn can affect the overall quality of life. In conclusion, urinary incontinence and lower urinary tract symptoms appear to significantly affect health-related quality of life and affect physical, psychological, and emotional domains to a greater extent than clinicians would expect.
THE IMPACT OF INCONTINENCE TREATMENT ON HRQOL
Medical therapy plays an important role in the treatment of urge incontinence and overactive bladder. Before the introduction of disease-specific QoL questionnaires over the past five years, little information was available on the impact of these medications on the quality of life of patients with these conditions.
CONCLUSIONS
The quality of life in women with urinary incontinence measured by the disease impact profile. Development and testing of a measure of health-related quality of life for men with urinary incontinence.
FEMALE SEXUAL RESPONSE CYCLE
Pelvic floor disorders include incontinence, cystocele, rectocele, enterocele, and vaginal and uterine prolapse. Studies have shown that urinary incontinence can be an important contributing factor to female sexual dysfunction (6,7).
NEUROGENIC MEDIATORS OF THE FEMALE SEXUAL RESPONSE
Using the same model, it was found that VIP caused dose-dependent relaxation of the clitoris and vaginal muscle (16). In preliminary organ chamber experiments using rabbit vaginal tissue, exogenous norepinephrine (alpha-1 and alpha-2 agonist) was found to cause dose-dependent contraction of vaginal smooth muscle.
HORMONAL INFLUENCE ON FEMALE SEXUAL FUNCTION AND RESPONSE
In animal models, aging and surgical castration are associated with reduced vaginal and clitoral NOS expression and apoptosis of vaginal smooth muscle and mucosal epithelium. These findings suggest that medications such as sildenafil (Viagra), which increase levels of NO, may play a role in the treatment of female sexual dysfunction, particularly sexual arousal disorder.
MEDICAL RISK FACTORS ASSOCIATED WITH SEXUAL DYSFUNCTION
Neurogenic sexual dysfunction can occur in both men and women with spinal cord injury (SCI) or central or peripheral nervous system disease. They also reported that only 17% of women with lower Table 1 Medical Risk Factors Associated with Sexual Dysfunction.
EVALUATION OF THE FEMALE SEXUAL RESPONSE A. Psychosocial/Psychosexual
Hypertonicity of the levator ani muscles can cause sexual pain disorders such as vaginismus leading to dyspareunia. Examination of the posterior forchette and hymenal ring can help recognize episiotomy scars and possible strictures.
TREATMENT
Decreased testosterone levels can be seen in women with premature ovarian failure and natural, surgical, or chemotherapy-induced menopause. Sexual response in women with spinal cord injury: neurological pathways and recommendations for the use of electrical stimulation.
ESTROGEN RECEPTORS AND HORMONAL FACTORS
In addition to estrogen receptors, both androgen and progesterone receptors are expressed in the lower urinary tract, although their role is less clear. Estrogen receptors were found to be consistently expressed in the squamous epithelium, although they were absent in the urothelial tissues of the lower urinary tract of all women, regardless of estrogen status.
HORMONAL INFLUENCES ON LOWER URINARY TRACT SYMPTOMS
In addition, α-receptors are located in the urethral sphincter and, when sensitized by estrogens, are thought to help maintain muscle tone (14). The role of estrogen replacement therapy in the prevention of ischemic heart disease has recently been assessed in a 4-year randomized trial, the Heart and Estrogen/Progestin Replacement Study (35).
HORMONAL INFLUENCES ON URINARY TRACT INFECTION
In the study, 55% of women reported at least one episode of urinary incontinence each week and were randomly assigned to receive oral conjugated estrogen plus medroxyprogesterone acetate or placebo daily. Finally, the role of estrogen therapy in the treatment of women with faecal incontinence has also been investigated in a prospective observational study using symptom questionnaires and anorectal physiological testing before and after 6 months of ERT.
HORMONAL INFLUENCES ON LOWER URINARY TRACT FUNCTION A. Neurological Control
Estrogen receptors have been demonstrated in the squamous epithelium of the proximal and distal urethra (10), and estrogen has been shown to improve the maturation index of urethral squamous epithelium (47). Estrogen is known to have an effect on collagen synthesis and has been shown to have a direct effect on collagen metabolism in the lower genital tract (57).
LOWER URINARY TRACT SYMPTOMS A. Urinary Incontinence
In addition, estrogens have been shown to cause vasodilation in the systemic and cerebral circulation, and these changes are also seen in the urethra ( 52 – 54 ). Overall, 8% of the total population in the developed world has been estimated to have urogenital symptoms (78), representing 200 million women in the United States alone.
MANAGEMENT OF LOWER URINARY DYSFUNCTION A. Estrogens in the Management of Incontinence
A recent review of estrogen therapy in the management of urogenital atrophy was conducted by the HUT committee (116). Meta-analysis of 10 placebo-controlled trials confirmed the significant effect of estrogen in the management of urogenital atrophy (Table 3).
CONCLUSIONS
Low does 17b-estradiol tablets in the treatment of atrophic vaginitis: a double-blind, placebo-controlled study. Estradiol-releasing vaginal ring versus estriol vaginal pessaries in the treatment of bothersome lower tract symptoms.
BACKGROUND
Compression and stretching of the pudendal during labor appears to be a major risk factor associated with reduced levator muscle function afterward. Some elements of pelvic floor connective tissue damage are inevitable during childbirth.
OBSTETRICAL CORRELATES OF URINARY INCONTINENCE
They also found that bladder neck descent during Valsalva was significantly increased after vaginal delivery compared with caesarean section in both primiparous and multiparous women (P,.001). Presumably, these changes may be responsible for persistent or new onset of actual stress incontinence in women after vaginal delivery.
PREVENTION OF OBSTETRICAL PELVIC FLOOR INJURY
Other, less common delivery positions can have a positive or negative impact on the pelvic floor. Fetal position may also have prognostic significance for the effects of labor and delivery on the pelvic floor.
ELECTIVE CESAREAN DELIVERY FOR PROTECTING THE PELVIC FLOOR
Others express concern that epidurals, by causing a sensory block, may increase the risk of stalled labor, leading to higher rates of forceps or cesarean sections and thus greater risks of pelvic floor injury. Other studies examining the effect of epidurals on pelvic floor injuries (137) have found no differences with regard to intrapartum trauma.
POSTPARTUM ISSUES
Studies that randomized women to a structured pelvic floor exercise program or routine postpartum care showed modest reductions in stress incontinence rates with structured treatment (149,150). When pelvic floor exercises are combined with biofeedback and electrostimulation, one study showed a reduction in stress incontinence for 19% of women, significantly.2% in the placebo group (p.
AFTER PELVIC FLOOR INJURY: MANAGING THE NEXT PREGNANCY
The role of partial pelvic floor denervation in the etiology of genitourinary prolapse and stress urinary incontinence. Faecal incontinence due to division of the external anal sphincter during childbirth is associated with damage to the innervation of the pelvic floor muscles; double pathology.
HISTORY
A consistent methodology for evaluating patients with urogenital tract symptoms is paramount in determining the underlying etiology of the patient's pelvic floor disorder. Effective treatment of pelvic floor disorders depends on an accurate diagnosis and an understanding of the patient's expectations of treatment.
SYMPTOMS
The most common symptom of pelvic floor dysfunction is urinary incontinence - the involuntary leakage of urine. Finally, it is critical for the clinician to assess the impact of the incontinence on a patient's quality of life and on her caregivers.
QUESTIONNAIRES
Visual inspection of the abdomen will reveal any surgical scars that are unexplained by the patient's history or unusual abdominal distension. Although limitations of the POP-Q system exist, it is a sensitive measure of change in pelvic prolapse in an individual patient.
POP-Q
- CONCLUSIONS
- TECHNIQUE
- DEFINITIONS
- AUGMENTED UCPP
- DYNAMIC UCPP
- MICTURITION UCPP
- ANCILLARY TESTS A. Bulbocavernosus Reflex
- DEFINITIONS
- ABDOMINAL LEAK POINT PRESSURE A. Technique
- CLINICAL APPLICATION
- DETRUSOR LEAK POINT PRESSURE A. Technique
- CONCLUSIONS
- CYSTOMETROGRAM
- VIDEOURODYNAMICS
The curve on the left shows good pressure transmission, with the space below the curve representing that patient's "margin to leak". The curve on the right flattens with each cough and the patient leaks urine. The reliability of the urethral closure pressure profile during stress in the diagnosis of true stress incontinence.