Pelvic Floor Disorders: Evaluation and Treatment

Pelvic Floor Disorders: Evaluation and Treatment
By:Elisa Rodriguez Trowbridge, MD
Departments OB/GYN and Urology
Division of Female Pelvic Medicine and Reconstructive Surgery



3 General Categories of Disorders

* Urinary Incontinence
* Pelvic Organ Prolapse
* Anal Incontinence

Urinary Incontinence
Types of Urinary Incontinence
* Stress Incontinence
* Urge Incontinence
* Mixed Incontinence
* Overflow Incontinence

Stress Urinary Incontinence (SUI)
* Generally occurs with sudden movements or increases in intra-abdominal pressure- coughing, laughing, sneezing, or running.
Urge Incontinence
* Typically preceded by an urge to void, and can involve a trigger such as running water, opening a door, removing undergarments.
* Mixed urinary incontinence: Involuntary leakage associated with urgency and also with exertion, sneezing, or coughing (SUI).

Overactive Bladder
* Urgency- DRY
* Frequency- DRY
* Urge Urinary Incontinence (UUI)- WET

Urinary Incontinence- Evaluation
* History
* Exam
Incontinence Physical Exam
* Standing or Supine Stress Test
Post Void Residual & Urine Dipstick
Voiding Diary
* Normal Voiding
Overflow incontinence
* Obstruction of urethra
* Poor contractile bladder muscle
* Must find out PVR !!
** Must stop anticholinergics!!
Simple Cystometry (Urodynamics)
Multichannel Urodynamics
Indications:
* Uncertain diagnosis
* Fail respond to treatment
* Prior failed surgery
* Complex

Risk factors of UI
* Sex: Women are more likely than men to have stress incontinence –pregnancy, childbirth, and menopause.
* Age: As you get older, the muscles in your bladder and urethra lose some of their strength. Changes with age reduce how much your bladder can hold and increase the chances of involuntary urine release. However, getting older doesn't necessarily mean that you'll have incontinence. Incontinence isn't normal at any age — except during infancy.
* Obesity: Being overweight increases the pressure on your bladder.
* Smoking: A chronic cough can cause episodes of incontinence or aggravate incontinence that has other causes. Smokers are also at risk of developing overactive bladder.
* Other diseases: Having kidney disease or diabetes may increase risk of urinary incontinence.

Treatment Urinary Incontinence
* Lifestyle modification
* Pads
* Physical Therapy- Kegels, biofeedback
* Pessary
* Medications- eg anticholinergics (Detrol)
* Botox (OAB)
* Surgery (many!!)

Pelvic Prolapse
3 Compartments of Prolapse

* Anterior
* Middle or Apical
* Posterior
3 Compartments: Normal Support
3 Compartments of Prolapse
Cystocele (Anterior)
Symptoms: bulging, pressure, “mass”, difficulty voiding, incomplete emptying, splinting vaginal wall, difficulty inserting tampon, pain with intercourse.
Vaginal vault prolapse/ Enterocele (Middle/Apical)
Symptoms: bulging, pressure, “mass”, difficulty voiding, incomplete emptying, splinting vaginal wall, difficulty inserting tampon, pain with intercourse.
Rectocele (Posterior)
Symptoms: bulging, pressure, “mass”, difficulty defecation, incomplete defecation, splinting vaginal wall or perineum, difficulty inserting tampon.
Complete eversion (All compartments)
* Uterine Procidentia
* Complete uterine prolapse

Pelvic Organ Prolapse Quantification System (POP-Q)
* Patient straining, 6 specific sites are evaluated, at rest 3 sites measured.
* Measure each site (cm) in relation to the hymenal ring, which is a “fixed”. The hymenal ring is the zero point of reference.
* If a site is above the hymen, assigned a negative number.
* If site prolapses below the hymen, the measurement is positive.

POP-Q: Normal
* What type of prolapse
* What compartment?
Prolapse treatment options
* Expectant Management
* Physiotherapy???
* Pessary
* Surgery (Many!!)
o Abdominal
o Vaginal
o Laparoscopic
o Robotic assisted Laparoscopy
o Mesh kits
Abdominal Sacralcolpopexy
Vaginal Hysterectomy
Mesh repairs
Anal Incontinence
Anal incontinence (AI)
* Anal Incontinence is the inability to control passage of gas, liquid or solid stool from the rectum.
* Affects two to 15 percent of adults in the United States.
* This condition affects men and women of all ages, but because people are embarrassed to talk about their symptoms, many people go untreated because they are unwilling to ask for help.

Types of Anal Incontinece
* Flatal incontinence:
* Double incontinence:
* Rectovaginal fistula:

Evaluation- AI
* History
* Pelvic exam
* Transanal ultrasound: Assess integrity of external and internal anal sphincter. A probe is about the size of a finger is place in the anorectum.
* MRI: Muscles of the pelvic floor, CNS or spinal cord lesions.
* Defecography: Barium paste is placed into your rectum and vagina and patient sits in the toilet simulationg defecation.
* Anal manometry: Assessment of muscles, capacity and sensation of the anorectum. A small air-filled balloon is inserted into your rectum.

Treatment of AI
* Lifestyles modifications
* Medications
* Physical Therapy
o Electrical Stimulation
o Biofeedback
Surgery for Separated Anal Sphincter
Anal sphincteroplasty
* Performed if involuntary loss of stool is caused by an injured/separated sphincter muscle.
* Opening made between the vagina and anus. Separated muscles are identified and approximated with sutures.
Treatment AI
* There are effective treatments that can help, or even cure, the problem. However, fecal incontinence has long been a neglected subject, and for some fecal incontinence problems, we do not yet have completely effective treatments.

Pelvic Floor Disorders: Evaluation and Treatment .ppt