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

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Sexual organs

Sexual organs
* Genitalia
* Reproductive tracts
* Glandular systems
* Nervous system

Women
* Genitalia
o Vulva
o Clitoris
o Vagina
* Reproductive tracts
o Ovaries
o Fallopian tubes
o Uterus
The vulva
* Mons pubis or mons veneris
* Labia majora
* Labia minora
* Prepuce or clitoral hood
* Bartholin’s glands
* Vaginal opening
* Skene’s glands
* Introitus or vestibule; vestibular bulbs
* Pubococcygeal muscles and Kegel exercises: close to 1 cm diameter
o Vaginismus and dyspareunia
* Perineum and episiotomy

The clitoris
* Glans
* Shaft
* Smegma
* Circumcision, clitoridectomy (excision), Pharaonic circumcision, and infibulation
* Urethra, between clitoris and vagina

The vagina
* Hymen or maidenhead
* Mucosal lining: Lubrication
* Nerve endings: Outer 1/3 of vagina
* Grafenberg spot

Vaginal health
* Self-examination with mirror, flashlight
* Do not douche or use vaginal deodorants
* Wash vulva daily, but do not scrub
o Insist that a sexual partner is also freshly clean
* Wear all-cotton panties
o Especially if taking antibiotics or perspiring
* Normal signs:
o A creamy discharge, clear to white in color
o Odor from sweet to musky, varies with hormones, medication, perspiration
* Limit tampon use: TSS, ulceration
o Avoid superabsorbent types
o Four-hour limit; no overnight use
* Change panty liners frequently
* Warning signs of vaginitis:
o Yellow or green discharge, clumps in discharge
o Foul odor
o Irritation, itching, or burning
o Urgent need to urinate

Reproductive tract
* Uterus
o Fundus and body: Perimetrium, myometrium, and endometrium: Endometriosis
o Cervix and Os
* Ovaries: Hormones and ova
o Ovarian ligaments
o Follicles and oocytes
* Fallopian tubes
* Hysterectomy

Fallopian tubes
* Fimbriae collect ova
* Infundibulum and ciliary movement
* Fertilization
* Ectopic pregnancy

Menstruation
* Menarche
* Dysmenorrhea
* Oligomenorrhea, amenorrhea, and menorrhagia
* Attitudes toward menstruation
* Sexual activity during menses: Safer sex
* PMS/PMDD: Does it exist?

The menstrual cycle
* 1. Menstrual phase, 5 days (variable)
* 2. Proliferative phase, 9- 11 days
o FSH --> Estrogen --> Endometrial growth
* 3. Ovulation, 14 days before menses
* 4. Secretory or luteal phase, 14 days
o LH --> Progesterone --> Preparation for implantation
Menopause
* Clemacteric, perimenopause, and menopause
* Decreased responsiveness of ovaries to pituitary hormones
* Perimenopausal symptoms
o Flashes, flushes, and sleep problems
o Dizziness, pains, and paresthesias
o Vaginal dryness, impaired cognition
* HRT/ERT
HRT/ERT: Increased risk of health problems counter obvious benefits
* Breast cancer:
o Estrogen alone: 15% increased risk; Estrogen + progestin: 58%; Estrogen + testosterone: 77% (all compared to no HRT) (Tamimi et al, 2006)
o The Women’s health Initiative study (2002) reported 26% increase in estrogen + progestin group—from 30/10,000 to 38/10,000

Other health risks of HRT
* Contrary to predictions, a 29% increased risk of heart attack (37/10,000 vs 30/10,000)
* 41% increased risk of stroke (29/10,000 vs. 21/10,000)
* Blood clot risk more than doubles (34/10,000 vs 16/10,000)
* Risk of ovarian cancer triples in women using estrogen for 20 or more years (NCI, 2002)
* Estrogen + progestin HRT impairs hearing (Frisina et al, 2006)

The gynecological examination
* Medical and sexual history
* External examination
* Speculum examination
* Pap smear
* Palpation
* Recto-vaginal examination
* Breast examination
o Breast self-examination
Breasts

* Secondary sex characteristics and self-esteem: Breasts vs. menstruation
* Mammary glands and ducts
* Adipose tissue
* Nipples and areolas
o Respond to stimulation: Temperature, arousal
o May be involuted
* Sensitivity varies with menstrual cycle

Sexual organs.ppt

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Cervical/Vulvar/Vaginal Cancer

Cervical/Vulvar/Vaginal Cancer
By:Steve Remmenga, M.D.
The McClure L Smith Professor of Gynecologic Oncology
Division of Gynecologic Oncology, Department of OB/GYN
University of Nebraska Medical Center

Cervical Cancer

Cervical CA
* International estimates
Pap Smear
* With the advent of the Pap smear, the incidence of cervical cancer has dramatically declined

Cervical CA Etiology
* Cervical cancer is a sexually transmitted disease.
* HPV DNA is present in virtually all cases of cervical cancer and precursors.
* Some strains of HPV have a predilection to the genital tract and transmission is usually through sexual contact (16, 18 High Risk).
* Little understanding of why small subset of women are affected by HPV.
* HPV may be latent for many years before inducing cervical neoplasia.

Cervical CA Risk Factors
* Early age of intercourse
* Number of sexual partners
* Smoking
* Lower socioeconomic status
* High-risk male partner
* Other sexually transmitted diseases
* Up to 70% of the U.S. population is infected with HPV

Prevention
* Educate all providers, men and women regarding HPV and the link to cervical cancer.
* Adolescents are an especially high-risk group due to behavior and cervical biology.
* Delay onset of sexual intercourse.
* Condoms may help prevent sexually transmitted disease.

Screening Guidelines for the Early Detection of Cervical Cancer, American Cancer Society 2003
* Screening should begin approximately three years after a women begins having vaginal intercourse, but no later than 21 years of age.
* Screening should be done every year with regular Pap tests or every two years using liquid-based tests.
* At or after age 30, women who have had three normal test results in a row may get screened every 2-3 years. However, doctors may suggest a woman get screened more if she has certain risk factors, such as HIV infection or a weakened immune system.
* Women 70 and older who have had three or more consecutive Pap tests in the last ten years may choose to stop cervical cancer screening.
* Screening after a total hysterectomy (with removal of the cervix) is not necessary unless the surgery was done as a treatment for cervical cancer.

Pap Smear
* Single Pap false negative rate is 20%.
* The latency period from dysplasia to cancer of the cervix is variable.
* 50% of women with cervical cancer have never had a Pap smear.
* 25% of cases and 41% of deaths occur in women 65 years of age or older.

Symptoms of Invasion
* May be silent until advanced disease develops
* Post-coital bleeding
* Foul vaginal discharge
* Abnormal bleeding
* Pelvic pain
* Unilateral leg swelling or pain
* Pelvic mass
* Gross cervical lesion

Cell Type
* Squamous Cell Carcinoma 80-85%
* AdenoCarcinoma 15%
* Adenosquamous
* Others

Staging
* Clinical Staged Disease
o Physical Exam
o Blood Work
o Cystoscopy
o Proctoscopy
o IVP

Staging Cervical Cancer
* Stage I Confined to Cervix
Microscopic Disease
* Squamous carcinoma of the cervix that has <3mm invasion from the basement membrane
* The diagnosis must be based on a cone or hysterectomy specimen.
* No lymph-vascular invasion
* May be successfully treated with fertility preservation in selected patients
* These patients should all be referred for consultation.





Staging

* Stage III Lower 1/3 Vagina, Sidewall or ureteral involvement
* IIIA Lower 1/3 of Vagina
* IIIB Sidewall or Ureteral Involvement
* Stage IV Bladder, Rectal or Distal Spread
* IVA Bladder or Rectal Involvement
* IVB Distal Spread

Treatment of Early Disease
* Conization or simple hysterectomy (removal of the uterus) - microinvasive cancer
* Radical hysterectomy - removal of the uterus with its associated connective tissues, the upper vagina, and pelvic lymph nodes. Ovarian preservation is possible.
* Chemoradiation therapy

Advanced Disease
* Chemoradiation is the mainstay of treatment

What is Standard Therapy for
Stage IB2 - IVA Cervical Carcinoma?
* External beam pelvic radiation (4,000 to 6,000 cGy)
* Brachytherapy (8,000 to 8,500 cGy to Point A)
* I.V. Cisplatin chemotherapy

Symptoms of Recurrence
* Weight loss, fatigue and anorexia
* Abnormal vaginal bleeding
* Pelvic pain
* Unilateral leg swelling or pain
* Foul discharge
* Signs of distant metastases
* NOTE: must distinguish radiation side effects from recurrent cancer

Management of Recurrence
* Chemoradiation may be curative or palliative, especially in women who have not received prior radiation therapy.
* Isolated soft tissue recurrence may occasionally be treated by resection with long-term survival.
Topotecan in Recurrent Cervical Cancer – Overview of Phase II Studies
Reference Regimen Evaluable Prior CT ORR Median OS
Survival
By Treatment Group
Proportion Surviving
Vulvar Cancer
Vulvar Cancer Etiology
* Chronic inflammatory conditions and vulvar dystrophies are implicated in older patients
* Syphilis and lymphogranuloma venereum and granuloma inguinal
* HPV in younger patients
* Tobacco
* Paget’s Disease of Vulva
Symptoms
* Most patients are treated for “other” conditions
* 12 month or greater time from symptoms to diagnosis
* Pruritus
* Mass
* Pain
* Bleeding
* Ulceration
* Dysuria
* Discharge
* Groin Mass
* May look like:
o Raised
o Erythematous
o Ulcerated
o Condylomatous
o Nodular
* IF IT LOOKS ABNORMAL ON THE VULVA
* BIOPSY!
Tumor Spread
* Very Specific nodal spread pattern
* Direct Spread
* Hematogenous

Treatment
* Primarily Surgical
o Wide Local Excision
o Radical Excision
o Radical Vulvectomy with Inguinal Node Dissection
+ Unilateral
+ Bilateral
+ Possible Node Mapping, still investigational

* Local advanced may be treated with Radiation plus Chemosensitizer
* Positive Nodal Status
* Special Tumor
o Verrucous Carcinoma

Vulva 5 year survival
* Stage I 90
* Stage II 77
* Stage III 51
* Stage IV 18

Recurrence
* Local Recurrence in Vulva
o Reexcision or radiation and good prognosis if not in original site of tumor
o Poor prognosis if in original site
Melanoma
Melanoma Treatment
Clear Cell Carcinoma
Treatment

Cervical/Vulvar/Vaginal Cancer.ppt

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