by

ANDREW L. SIEGEL, M.D.Board-Certified Urologist and Urological Surgeon

Director, Center for Continence Care

FEMALE PELVICRELAXATION

A Primer for Women with Pelvic Organ Prolapse

An educational service provided by:BERGEN UROLOGICAL ASSOCIATES

Hackensack University Medical Center Plaza

20 Prospect Avenue, Suite 715

hackensack, NJ 07601

(201) 342-6600

www.bergenurological.com

www.pelvicrelaxation.com

Table of Contents

INTRODUCTION.................................................................1

WHYAUROLOGIST?..........................................................2

PELVICANATOMY..............................................................4

PROLAPSE

URETHRA....................................................................7

BLADDER.....................................................................7

RECTUM......................................................................8

PERINEUM..................................................................9

SMALLINTESTINE.....................................................9

VAGINALVAULT.......................................................10

UTERUS.....................................................................11

EVALUATIONOFPROLAPSE............................................11

SURGICALREPAIROFPELVICPROLAPSE.....................15

STRESSINCONTINENCE.........................................16

CYSTOCELE..............................................................18

RECTOCELE/PERINEALLAXITY.............................19

ENTEROCELEANDVAULTPROLAPSE..................20

UTERINEPROLAPSE................................................21

January, 2010 Printing

IntroductionPelvicrelaxationisacommonconditioninwhichthereisweaknessofthesupportingstructuresofthefemalepelvis,therebyallowingdescent(prolapse)ofoneormoreofthepelvicorgansthroughthe“potentialspace”of thevagina.Theseorgans include the following:urethra,bladder,rectum,smallintestine,uterus,andthevagina(vaginalvault)itself.Theurethraandbladderareanatomicallysituatedabovethe“roof”’ortopwallofthevagina,thecervixanduterusattheverydeepestpartofthevagina(theapex),andtherectumbelowthe“floor”orbottomwallofthevagina.Thus,whenprolapsedevelops,oneormoreofthefollowingmayoccur:theurethraandbladdermaydescendintothevaginalroof,thecervixanduterusmaydescendintothevaginalcanal,andtherectummayascendintothevaginalfloor.Pelvicrelaxationcanvaryfromminimaldescent—causingfew,ifany,symptoms—tomajordescent—inwhichoneormoreofthepelvicorgansliterallyprolapseoutsidethevaginaatalltimesandcausesignificantsymptoms.Thedegreeofdescentoftenvarieswithpositionandactivitylevel,increasingwith theassumptionof theuprightpositionandwithexertional activities, anddecreasingwith lyingdownand resting.

Pelvicrelaxationusuallyresultsfromacombinationoffactorsincludingmultiplepregnanciesandvaginaldeliveries(especiallydeliveriesoflargebabies),menopause,hysterectomy,aging,weightgain,andanyconditionassociatedwithchronicincreasesinabdominalpressure,suchasasthmaandbronchitis(chronicwheezingandcoughing),seasonalallergies(chronicsneezing),orconstipation(chronicstraining).Vaginalbirthisprobablythesinglemostimportantfactorinthedevelopmentofprolapse.Passageof the largehumanhead through the femalepelviscauses tissue trauma, separationorweaknessofconnectivetissueattachments,andalterationsinthegeometryofthepelvis.Itisunusualforwomenwhohavenothadchildrenorwhohavedeliveredbyelectivecaesariansectiontodevelopsignificantpelvicrelaxation.

Becausethefemalegenitaltractandurinarytractareintimatelyrelated(duetotheiranatomicproximityaswellasacommonembryologicalorigin),pelvic relaxationcancause significantchanges innormalurinary function.These range fromstressurinary incontinence(aspurt-likeleakageofurinefromtheurethraassociatedwithanincreaseinabdominalpressuresuchasoccurswithsneezing,coughing,etc.),to

-1-

aninabilitytoemptythebladderunlessonemanuallypushesbacktheprolapsedbladder.Itisimportanttoknowthatsuchsymptomaticpelvicrelaxationcanbesurgicallycorrected.Thegoalofthispelvicreconstructivesurgeryistorestorenormalanatomyandfunction.Non-operativetreatmentofpelvicrelaxationisusedwhensymptomsareminimalorwhensurgerycannotbeperformedbecauseofinfirmityandfrailty.Suchconservativetreatmentoptionsincludechangeofactivities,managementof constipation andother circumstancesthatincreaseabdominalpressure,pelvicfloorexercises,hormonereplacement,andpessaries.Pessariesaremechanicaldevicesthatareinsertedintothevaginatoactasa“strut”tohelpprovidepelvicsupport.Thesideeffectsofpessariesarevaginitis(vaginalinfectionanddischarge),extrusion(theinabilitytoretainthepessaryinproperposition),andthe“unmasking”ofstressincontinence.

Why a Urologist?You may wonder why a urologist is interested in female pelvicrelaxation,sinceformanyyearsurologywastraditionallyconsideredtobeamalefield.Inthelate1970’s,femaleurologyemergedasaspecialtybranchofurologymuchaspediatricurologyhaddonepreviously.ThepersonlargelyresponsibleforthisemergencewasDr.ShlomoRaz,directoroffemaleurologyattheU.C.L.A.SchoolofMedicine.Dr.Raz, aworld-renownedphysician and surgeon,developedthefieldoffemaleurologyintoacomprehensivesurgicaldiscipline.InadditiontowritingthetextbookAtlas of Transvaginal Surgery and editing the textbook Female Urology, Dr. Raz isresponsibleforredefiningthepreviouslyconfusingnomenclatureoffemalepelvicanatomy.Forthepastfourdecades,Dr.RazhashostedafellowshipatU.C.L.A.inwhichtwosurgeonsperyeararetrainedwithhiminallaspectsoffemaleurology.IwasfortunatetobeselectedforoneofthesepositionsandafterthecompletionofmyurologyresidencyattheUniversityofPennsylvaniaSchoolofMedicine,spenttheyears1987–1988operatingwithDr.Raz,focusingonprolapse,incontinence,andvoidingdysfunction.Obviously,prolapse isanexclusivelyfemalefield,butincontinenceandvoidingdysfunctionencompassbothfemalesandmales.Mypracticeis,infact,almostequallydividedbetweenwomenandmen,andIfindthatIenjoythisbalance.

-2-

For years, the urologist’s role infemalepelvicrelaxationwaslimitedtosurgeryforurinaryincontinence,andotheraspectsofpelvicrelaxationwere largely ignored. Similarly,the gynecologist’s role in femalepelvic relaxationwas focusedonprolapseofthebladder,uterus,andrectum,but ignored theurethralprolapse that isoften responsiblefor stress urinary incontinence.Thustherewasadivisionoflabor,a“territoriality”withintherealmoffemalepelvicsurgery,asillustratedinthiscartoondemonstratingtherolesoftheurologist,gynecologist,aswellasthecolon/rectalsurgeon.(Figure 1).Dr.Razespousedtheconceptofapelvicsurgeon,onecapableofdealingwithanyandallaspectsoffemalepelvicrelaxation,withathoroughknowledgeofpelvicanatomyandplasticsurgicalreconstructiveprinciples.TheultimategoalofthefemaleurologyfellowshipthatDr.RazestablishedbecametotrainaccomplishedpelvicsurgeonswhocouldthenobtainacademicpositionsatUniversitymedicalcentersthroughouttheUnitedStates,theappropriatevenueforfurtherdisseminationoftheartandscienceoffemaleurologyandpelvicreconstructivesurgerytomedicalstudentsandresidents in training.Thus,atHackensackUniversityMedicalCenter,oneofmyrolesistoinstructurologyresidentsandmedicalstudentsfromtheUniversityofMedicineandDentistryofNewJerseyintheprinciplesandsurgicaltechniquesofDr.Raz.

Femalepelvicreconstructivesurgeryincorporatesprinciplesofbothurological,gynecological,andplasticsurgery.Apelvicreconstructionforpelvicprolapseisnotdissimilartocosmeticfacialsurgicalproceduresperformedbyplasticsurgeonsforagingandsaggingeyelidsandjowels.Bothpelvic reconstructiveandplastic facial reconstructivesurgeryrequiresomedegreeofcreativityandartistictalentinadditiontotherequisite scientificknowledgeof anatomyandsurgicalprinciples.Ipersonallyfind female reconstructive surgery tobeparticularlygratifyingbecauseofboththeinstantabilitytoassesstheresultsbeforeleavingtheoperatingroomaswellasthegreatpotentialtoimprovethelifestyleandfunctionofthepersonsufferingwithprolapse.Unlikefacialcosmeticsurgery,pelvicreconstruction,inadditiontoimproving

Figure 1

-3-

cosmetic appearance, will result in functional improvement intermsofalleviationofincontinence,voidingdysfunction,sexualdysfunction,boweldysfunction,andothersymptomsassociatedwithpelvicprolapse.

Anatomy of The Female PelvisAbasicknowledgeofpelvicanatomywillallowyoutounderstandwhyprolapseoccursandhowitcanbecorrected. (Figure 2).

Thebonypelvisistheframeworktowhichthesupportstructures

Uterus

Bladder

PubicBone

Urethra

Vagina

Sacrum

Rectum

LevatorAni

ofthepelvisareattached.Thepelvisisdefinedasthecup-shapedringofboneatthelowerendofthetrunk,formedbythehipbone(comprisedofthepubicbone,ilium,andischium)oneithersideandinfront,andthesacrumandcoccyxinback.Locatedwithinthis “scaffolding” are the urinary structures (bladder, urethra),genitalstructures(vagina,cervix,uterus,fallopiantubes,ovaries),andtherectum.

Thefailureofthepelvicsupportsystemallowsfordescentofoneormoreofthepelvicorgansintothepotentialspaceofthevagina,andatitsmostseveredegree,outsidethevaginalopening.

Figure 2

-4-

Thelevatoranimuscle is themajor muscle that providessupporttotheurethra,vagina,and rectum. (Figure 3).Thelevatoraniarisesfromthepubicbone,theischialspine,andthetendinousarc.Thetendinous arc isavery importantanatomicsupport in thepelvisbecauseitformsthecommoninsertionpointforasetofpelvicmusclesincluding the levator animuscles.Thelevatoranimuscleextendsfromthelefttendinousarctotherighttendinousarc,

creatingahammock-likestructure.Thislevator“hammock”hasopeningsthroughwhichthevagina,rectum,andurethratraverse.

Thereareseveralfasciasthatare important inprovidingpelvic support. Fascia isthe tough, fibrous tissuethat envelopes muscles.The levator fascia coversbothsidesofthelevatoranimuscle. The “pelvic leaf”fuseswiththe“vaginalleaf”toinsertintothetendinousarc.Thepelvicleafiscalledtheendopelvic fascia.(Figure 4).

Figure 4

Endopelvic Fascia Overlying Levators

Figure 5

Vaginal View of Bladder Support

Abdominal View of The Bladder

Thevaginalleafiscalledtheperi-urethral fascia (at the leveloftheurethra),andtheperivesical fascia(atthelevelofthebladder).(Figure 5). Containedwithinthetwoleavesofthelevatorfasciaarethepelvicorganstowhichitprovidessupport:theurethra,bladder,vagina,anduterus.

Specialized regions of thelevatorfasciaformcritical

Perivesicalfascia

-5-

Figure 3

ligamentory supports tomaintain the relationshipsbetween theurethra,bladder,vagina,anduteruswithinthebonypelvis.Thesespecializedregionsarethepubourethral ligaments, theurethropelvic ligaments, thevesicopelvic fascia, and the cardinal ligaments.Thepubourethralligamentsanchortheurethratotheundersurfaceofthe

pubic bone, providingmidurethralsupport.Theurethropelvic ligamentsare composed of theleaves of levator fascia(endopelvic and peri-urethral fascia) thatattachtheurethratothe

tendinousarc.(Figure 6). Thisattachmentprovidessupporttotheurethraattimesofincreasedabdominalpressure.Weaknessoftheurethropelvic ligaments ispresent in femaleswith stressurinaryincontinence.Thevesicopelvic fascia iscomposedof the leavesoflevatorfasciaatthelevelofthebladder(endopelvicandperivesicalfascia),whichanchorthebladdertothetendinousarcandpelvicsidewallsandprovidebladdersupport.Weaknessinvesicopelvicfasciaispresentinfemaleswithcystoceles.Theprerectalandpararectal fasciaareanatomicallysituatedbetweentherectumandbottomwallofthevagina.Whenthesefasciasbecomeweakened,arectoceleresults.Thecardinalligamentscontaintheuterinearteriesandprovideattachmentof theuterus to thepelvicsidewalls.Thesacro-uterine ligamentsprovideattachmentofthecervixtothebonysacrum.Weaknessorseparationofthecardinalandsacro-uterineligamentsgivesriseto

uterineprolapse,enterocele,andvaginalvaultprolapse.

The levator ani muscles andurogenitaldiaphragmprovidesupport to the rectum andperineum.Theperineumistheanatomical regionbetweenthe vagina and anus. Theurogenitaldiaphragmconsistsofthebulbocavernosus muscle, transverse perineal muscle,

external anal sphincter, andcentral tendon. (Figure 7).

Thevaginacanbedividedintoproximal(deep),middle,anddistal(superficial)thirds.Thecardinalligamentssupporttheproximalthird,

Figure 7

The Female Perineum

Figure 6

Schematic of Urethropelvic Ligament

-6-

thetendinousarcattachmentthe middle third, and thelevatorsandperinealmusclesthedistalthird.Whenpelvicfloor relaxationoccurs, thelevator muscles and theurogenitaldiaphragmmusclesbecomeflaccid,allowingtheopenings for the urethra,vagina,andrectumtobecome

enlargedandthenormalangleofthevaginatobecomealtered.(Figure 8).Thiscreateswideningof thevaginalopeningandshorteningof thedistancebetweenthevaginaandanus,asituationcalledperineallaxity.

Types of ProlapseURETHROCELE (urethralhypermobility)Greek“ourethra”=urethra&“kele”=hernia

Theurethra,thetubethatconveysurinefromthebladder,isabout11/2inchesinlengthandisfusedtothedistalthirdofthevagina.Descentof theurethra into theroofof thevaginaoccurswhen its supportstructuresbecomelax.Detachmentof theurethro-pelvic ligamentsfromthetendinousarcallowssuchdescent.Thiscausesstressurinaryincontinence,aspurt-like leakageofurinethatcanoccurwithanyactivitythatincreasesabdominalpressure,typicallysneezing,coughing,lifting,laughing,running,dancing,aerobics,etc.

CYSTOCELE (bladderprolapse)(Figure 9)Greek“kystis”=bladder&“kele”=hernia

Descent of the bladder througha weakness in its supportingtissues gives rise to a cystocele,a.k.a.“droppedbladder,”“prolapsedbladder,” or “bladder hernia.” Acentral-defectcystoceleoccurswhenthebladderfallsintotheroofofthevaginaasaresultofaweaknessintheperivesicalfascia

Figure 9

Perineal View of Normal Levators (left) and Damaged Levators After Childbirth (right)

Figure 8

-7-

betweenthetopwallof thevaginaandthebladder.A lateral-defect cystoceleoccurswhen theattachmentof thebladder to thepelvicsidewallweakens(thevesicopelvicfasciabecomesdetachedfromthetendinousarc).Themostcommondefectisacombinedcentralandlateraldefectfollowedbyalateraldefectalone,followedbyacentraldefectalone.Asacystoceleprogresses, theamountofdescent intotheroofofthevaginaincreases.Cystocelesaregradedasfollows: GRADE1=mild GRADE2=bladdertovaginalopening(introitus)withstrain GRADE3=bladderoutsidevaginalopeningwithstrain GRADE4=bladderoutsidevaginalopeningatalltimes

The symptoms of a cystocele are typically one or more of thefollowing:

•abulgeorlumpprotrudingfromthevagina•kinkingoftheurethracausingobstructionandhence: ■theneedfor“manualreduction”(pushingback)ofthe

cystoceleinordertourinate ■obstructiveurinarysymptoms(aslow,weakstreamthatstops

andstarts) ■irritativeurinarysymptoms(frequentandurgenturinating) ■urinarytractinfectionsduetoincompletebladderemptying•vaginalpainorpainfulintercourse

RECTOCELE(rectalprolapse)(Figure 10)Greek“rectum”=straight&“kele”=hernia

Ascentoftherectumthroughaweakness in itssupportingtissuesgivesrisetoarectocele,a.k.a. “dropped rectum,”“prolapsedrectum,”or“rectalhernia.”Therectumprotrudesthroughthefloorofthevaginabecause the levatormuscles,prerectalfascia,andpararectalfascia have become lax.As a rectocele progresses,the amount of ascent intothevaginalfloorincreasesEssentially,arectoceleisanupside-downcystocele.

Figure 10

-8-

Rectocelesaregradedasfollows: GRADE1=mild GRADE2=rectumtovaginalopeningwithstrain GRADE3=rectumoutsidevaginalopeningwithstrain GRADE4=rectumoutsidevaginalopeningatalltimes

Thesymptomsofarectocelearetypicallyoneormoreofthefollowing:•abulgeorlumpprotrudingfromthevagina,especially

noticeableduringbowelmovements•kinkingofthenormallystraightrectumcreatingarelative

obstructionandthus: ■difficultywithbowelmovements ■theneedfor“splinting”(holdingtherectoceledownwith

yourfingers)toemptythebowels ■fecalsoiling ■incompleteemptyingoftherectum•vaginalpainorpainfulintercourse

PERINEAL FLOOR RELAXATION

Usuallyaccompanyingarectoceleisperineal muscle laxity,aconditioninwhichthemusclesoftheperineum(theanatomicalregionbetweenthevaginaandanus)becomelax.Weaknessinthelevatormuscles,thebulbocavernosusmuscle,thetransverseperinealmuscles,andthecentraltendonoccurcausingthefollowinganatomicalchanges:

•awideandlaxvaginalopening•decreaseddistancebetweenthevaginaandanus•changeinthevaginalanglesuchthatthevaginaassumesamore

verticalaxisasopposedtoitsnormalposterior(downwards)angulation

Womenwithperinealrelaxationwhoaresexuallyactivemaycomplainofaverylooseorgapingvagina,makingintercourselesssatisfyingforthemselvesandtheirpartners.

ENTEROCELE(smallintestinalprolapse)(Figure 11)Greek“enteron”=intestine&“kele”=hernia

Theperitoneumisthethinsacthatcontainstheabdominalorgans,includingthesmallintestine.Descentoftheperitonealcontentsthrough aweakness in the supportingtissuesattheapexofthevaginagivesrisetoanenterocele,a.k.a.

Figure 11

Enterocele

-9-

“droppedsmallintestine,”“smallintestineprolapse,”or“smallintestinehernia.”Enterocelesarecausedbyaweaknessorseparationofthecardinalandsacro-uterineligaments.Asanenteroceleprogresses,theamountofdescentintothevaginaincreases.

Enterocelesaregradedasfollows: GRADE1=mild GRADE2=peritonealsactovaginalopeningwithstrain GRADE3=peritonealsacoutsidevaginalopeningwithstrain GRADE4=peritonealsacoutsidevaginalopeningatalltimes

The symptomsof anenterocele are typicallyoneormoreof thefollowing:

•abulgeorlumpprotrudingthroughthevagina•intestinalcrampingduetosmall intestine trappedwithinthe

enterocele•vaginalpainorpainfulintercourse

Thereareseveraltypesofenteroceles:•“pulsion”:fromchronicallyincreasedabdominalpressure•“traction”:whenotherpelvicorgans,suchastheuterus,bladder

or rectum,causeapull (traction)on thevaginalvaultand peritoneum

•“iatrogenic”:followingasurgicalproceduresuchashysterectomy

“Simple”enterocelesexistwhenthere isnovaginalvaultprolapse;“complex”enterocelesareassociatedwithvaginalvaultanduterineprolapse.

VAGINAL VAULT PROLAPSE

Themostadvancedstageofpelvicrelaxationoccurswhenthesupportstructuresofthevagina(cardinalanduterosacralligaments)aredamagedbyhysterectomyorotherpelvicsurgerysuchthatthevaginalvaulteverts.Vaultprolapse,a.k.a.“droppedvaginalvault,”“prolapsedvaginalvault,”or“vaginalvaulthernia”israrelyanisolatedevent,butratheroccursinassociationwithenterocele,cystocele,anduterineprolapse.Forillustrativepurposes,ifthevaginacanbethoughtofasa“sock,”vaginalvaultprolapseisaconditioninwhichthesockisturnedinsideout.

-10-

UTERINE PROLAPSE(Figure 12)

Descentoftheuterusandcervixbecauseofweaknessoftheirsupportingstructures(utero-sacral and cardinal ligaments)resultsinuterineprolapse,a.k.a.“droppeduterus,”“prolapseduterus,”or“uterinehernia.”Normally, thecervix is locatedin thedeepest thirdof thevagina.Asuterineprolapseprogresses,theamountofdescent into thevaginal canalwillincrease.Uterineprolapse isgradedasfollows: GRADE1=descentofthecervixtowardsthevaginal openingwithstrain GRADE2=cervixtovaginalopeningwithstrain GRADE3=cervixoutsidevaginalopeningwithstrain GRADE4=“procidentia,”completeprolapseinwhichthe cervixanduterusareoutsidethevaginal openingatalltimes

Thesymptomsofuterineprolapseare typicallyoneormoreof thefollowing:

•bulgeorlumpprotrudingfromthevagina•asenseof“droppingout”andlackofpelvicsupport•urinarysymptoms:obstructivevoidingsymptoms,theneedto

“manuallyreduce”(pushback) theuterus inorder to initiatevoiding,irritativevoidingsymptoms,incontinence,urinarytractinfections

•kidneyobstructionbecauseofdescentofbladderandureters(tubesthatdrainurinefromthekidneytothebladder)

•vaginalpainwithsittingandwalking•painfulintercourse•spottingorbloodyvaginaldischarge

Figure 12

Uterine Prolapse

-11-

Evaluation of Pelvic RelaxationEvaluationofpelvicprolapsebeginswithathoroughhistoryandphysicalexamination.Thefollowingquestionsneedtobeanswered:

•Doyouhaveanintroital(vaginal)bulge?Whatactivitiespromoteanincreaseinthesizeofthebulge?Doyouneedto“reduce”thebulgetourinateordefecate?Howmuchistheintroitalbulgedisturbingyou?Haveyouhadanypriortreatmentsforthebulge?

•Doyouhaveurinaryincontinence,andifso,whattype,towhatextent,whatmeansarenecessaryforprotection,andhowbothersomeisit?Whatactivities,ifany,promotetheincontinence?

•Doyouhaveobstructivevoidingsymptomsincluding:hesitancy,decreaseinforceofthestream,decreaseincaliberofthestream,intermittency,theneedtostraintovoid,thefeelingthatyouarenotemptyingcompletely,theneedtodoublevoid?

•Doyouhave irritativevoidingsymptoms including:urgency,precipitancy,frequency,nocturia?

•Doyouhaveurinarytractinfections?•Doyouhavevaginalpain?Areyousexuallyactive,andifso,doyou

havepainfulintercourse?•Doyouhaveawideandlaxvaginalopeningthathasmadesexual

relationslesssatisfying?•Doyouhaveobstructiverectalsymptomsincludingconstipation,

incompleteemptying,fecalsoiling?•Doyouhaveflankandbackpainwhentheprolapseoccurs?•Whatmedicalproblemsdoyouhave?Doyouhaveanymedical

problemsthatmaycontributetopelvicrelaxationsuchas:obesity,chroniccoughing,sneezingorwheezingfrombronchitis,allergiesorasthma,orchronicstrainingduetoconstipation?Whatmedicationsdoyoutake?Whatallergiesdoyouhavetomedications?Whatsurgerieshaveyouhad,particularlyhysterectomy,orpriorsurgeryforpelvicprolapseandincontinence?

•Howmanypregnancieshaveyouhad?Howmanyvaginaldeliveries?Howlargewereyourbabiesatbirth?Waslaboranddeliveryprolongedordifficult?Wastheresignificantvaginaltearingrequiringrepair?Doyouanticipatehavingmorechildren?

•Ifmenopausal,atwhatagedidyouexperiencemenopause?Areyouonreplacementfemalehormonetherapy?

•Haveyoueverfracturedyourpelvicbonesorsustainedasignificantpelvicinjury?

•Isthereatendencyforpelvicrelaxationand/orincontinencetoruninyourfamily,i.e.,mother,grandmother,sisters,aunts?

-12-

Theprecisediagnosisofpelvicprolapseismadeonthebasisofacarefulphysicalexam.Theexaminationmustbeperformedwiththepatientstrainingforcefullyenoughtodemonstratetheprolapseatitslargestextent.Eachregionofpotentialprolapsemustbeexaminedindependently,i.e.,vaginalroof,vaginalapex,vaginalfloor.

Athoroughpelvicexaminationinvolvesvisualobservation,asinglebladespeculumexam,passageofasmallfemalecatheterintothebladder,andabimanualpelvicexam.Initialinspectionwilldeterminethepresenceofurogenitalatrophy(lossoftissueintegrityofthegenitalarea,includingthinningofthevaginalskin,redness,irritation,etc.),commonlyseenaftermenopause.

Asmallcalibercatheterispassedaftervoidingforseveralpurposes:todeterminetheresidualurinaryvolume,tosubmitaurinecultureintheeventthattheurinalysissuggestsaurinaryinfection,andtodeterminethechangeinurethralangulationthatoccurswithstraining.Urethralangulationwithstrainingisasignoflossofsupportoftheurethra,whichgivesrisetohypermobilityandthesymptomofstressurinaryincontinence.

Inordertoobservethetopwallofthevaginaforthepresenceofaurethroceleorcystocele,itisimportanttoretractthebottomwallofthevaginadownwithaspeculum.Toobservethebottomwallofthevaginaforthepresenceofarectoceleandperineallaxity,thetopwallofthevaginamustberetractedupwithaspeculum.Toobservethevaginalapexforuterineprolapseandenterocele,bothtopandbottomwallsmustberetractedupanddownrespectively.Oncethespeculumisplaced,thepatientisaskedtostrainvigorously.Thisspeculumexaminationwilldeterminewhatspecificstructureisprolapsedandgradethedegreeofprolapse.

Finally,abimanualexaminationisperformedtocheckforpelvicmasses.Thisisacombinedinternalandexternalexaminwhichthepelvicorgansarefeltbetweenaninternalexaminingfingerwithinthevaginaandanexternalexaminingfingeronthelowerabdomen.Thelimitationofthephysicalexaminthelying-downpositionisthatthisisNOTthepositioninwhichprolapsetypicallymanifestsitself.Theidealpositiontoexamineprolapseisthestandingposition,butthisobviouslyisaverydifficultandawkwardpositioninwhichtoperformanexam.For this reason a standing x-ray of the contrast filled bladder at rest and with straining is a useful means of determining the degree and type of bladder prolapse.

-13-

Urodynamicsareanofficeprocedurehelpful in theevaluationofpelvicrelaxation.Thepreparationgenerally involvesonlytakinganoralantibioticpriortotheprocedure.Usingsteriletechnique,asmallcatheterisplacedintheurinarybladder.Anadditionalcatheterisplacedintherectumandpatchelectrodesareplacedadjacenttotheanalarea.Theindividualcatheterswillbeconnectedtothecomputer-assistedurodynamicunit.Duringtheprocedure,thepressureinthebladderandtherectumwillbemonitoredaswellastheactivityofthepelvicfloormuscles.Whenthetestbegins,fluidatacontrolledratewillfilltheurinarybladder.Youwillbeaskedwhenyouhaveaninitialdesiretourinate,whenitbecomesurgent,andwhenyoufeelfull.Atseveraltimesduringtheprocedureyouwillbeaskedtostrainorcough.Everyeffortwillbemadetoreplicateyoursymptomsduringthecourseofthestudysothatthepressuresandpelvicflooractivitycanbemeasuredatthatparticulartime.Oncethebladderisfilledtocapacity,youwillbeaskedtovoidintothecommodeatwhichtimetheurinaryflowrateaswellasthepressurewithinthebladderwillbemeasured.Attheendoftheurodynamicevaluation,allofthecatheterswillberemoved.Thefinalelementoftheevaluationisacystoscopy.Duringthisprocedure,theurethraisnumbedwithanestheticjellyafterwhichatinylightedopticalinstrumentisusedtoviewtheurethra,bladderneck,andbladderonamonitorthatyouwillbeabletosee.

Aftertheurodynamicevaluationhasbeencompletedandallthedatastoredinthecomputerhasbeenexamined,Iwillreviewindetailwithyou(andafamilymemberorsignificantother,ifyousodesire)theresultsoftheurodynamicstudy.Thisstudywillprovidethenecessaryquantitativeanatomicandfunctional informationtomakeaprecisediagnosissothatmanagementoptionscanbediscussedandtreatmentplansinitiated.

-14-

Surgical Repair of Pelvic ProlapseSymptomaticpelvic relaxation canbe surgically corrected,withexcellent results.Thegoal ofpelvic reconstructive surgery is torestorenormal anatomyand function. In addition to improvingcosmeticappearance,pelvicreconstructionstrivestocureincontinenceandvoidingdysfunction,and improvebowelandsexual function.Thesurgicalrepairofpelvicrelaxationisreferredtoaspelvic reconstruction. Thismayinvolveoneormoreofthevaginalcompartments.Anteriorcompartmentpelvicreconstructionisforrepairingaprolapsedbladder; posteriorcompartmentpelvicreconstructionisforrepairingaprolapsedrectum;apical compartmentpelvic reconstruction is for repairingprolapsedsmallintestine.Thepelvicreconstructionmayormaynotbeaugmentedwithapieceofnettingknowasmesh.Meshrepairsareusedmorecommonlywhenone’snativetissuesaredefective.

Surgicalrepairofprolapsecanoftenbeperformedonanoutpatientbasis.Theprocedureisperformedundereithergeneralorregionalanesthesia.Theanesthesiologistwilldiscusstheseoptionswithyoutohelpyoudeterminewhattypeofanesthesiaisbestforyou.Theentireprocedureisperformedwithyourlegsinpaddedstirrupsandisdonethroughthevagina.Aftercompletionofthesurgery,thevaginawillbepackedwithantibioticgauzeforseveralhours.

Yournormaldietandmedicationscanberesumedimmediately.Youcanresumemostofyournormalactivitiesassoonaspossible.Infact,walkingandstairclimbingaredesirableasrapidreturntoactivitiesfacilitates recovery.Youmaybatheor shower.Anynon-strenuousactivityispermissibleaslongaspainisnotexperienced.Avoidheavylifting,strenuousexercise,strainingatbowelmovements,andsexualintercourse.Theoperativesitemayhurtmorewithexcessactivities.Thisshouldbeasignalforyoutoeaseupabit.Vaginal,pubic,andpelvicsorenessarenormalforseveralweeks.Vaginaldischarge(oftenbloody),isalsotypicalforseveralweeksfollowingsurgeryanditisthereforerecommendedthatyouwearapad.

Priortobeingdischarged,youwillbegiventypedinstructionsandaprescriptionforantibioticsandapainmedication.Itisimportanttocompletetheprescriptionforantibioticstohelpavoidaurinarytractorpelvicinfection.

-15-

-16-

Surgical Repair of Stress Urinary Incontinence (SUI)Sub-urethral Sling. Stressurinaryincontinence(SUI)isaninvoluntaryspurt-likelossofurineduetoasuddenincreaseinabdominalpressure.Itisoftenprovokedbysneezing,coughing,laughing,exercising,changingpositions,etc.Underlyingcontributingfactorsincludechildbirth(inparticular, traumaticvaginaldeliveriesof largebabies),menopause,hysterectomy,agingandanyconditioncausingachronicincreaseinabdominalpressuresuchascough,asthma,andconstipation.SUIisusuallyduetoacombinationof intrinsicandextrinsiccauses.Theintrinsic factor, intrinsicsphincteric deficiency, isaweaknessof theurethralsphinctermuscles.Theextrinsicfactor,urethral hypermobility,isanacquiredlaxityinthetissuesupportoftheurethrathatallowsurethraldescentwithincreasesinabdominalpressure.

ThegoalofsurgicalmanagementofSUIistoprovidesupporttotheurethra inorder tocorrect the intrinsicandextrinsicdeficiencies.Therearemanyvariationsonsurgical techniques toprovidesub-urethralsupporttosureSUI.ThesurgicaltreatmentofSUIhasevolvedsignificantlyover thepast severaldecades.Thecurrentprocedurerepresentsanevolutionofsurgicaltechniquethathasmeritbecauseofitseffectiveness,durability,relativesimplicity,andneedforonlytinyincisions.

AcommonlyusedsurgicalprocedureforrepairofSUIisasub-urethral sling.ItspurposeistocureSUI.Itisalsoperformedinconjunctionwithcystocele(bladderprolapse)repairtopreventtheoccurrenceofSUIthatmaybeunmaskedasaresultofthecystocelerepair.Theslingprocedureworksbyprovidingsupportanda“backboard”totheurethrasuchthatwith“stress”maneuverssuchascoughingandsneezing,theurethracanbecompressedagainsttheslingtoprovidecontinence.

Onlyasmallvaginalincisionandatinypubicorgroinincisionisneeded.Thestitchesusedtorepairthevaginaandpubicorgroinregionwilldissolveontheirownanddonotrequireremoval.

Sub-urethralreferstotheplacementoftheslingbeneaththeurethra,thetubularchannelthatleadsfromthebladdertotheurinaryopening.Theslingplacedunderneaththeurethrarecreatesthe“backboardeffect”.

Slingreferstothe“hammock”thatprovidesurethralsupportandthatallowscompressionoftheurethrawithstressmaneuvers.

-17-

Benefits and Potential Risks of the Sling ProcedureBenefits: • 90%cureofstressurinaryincontinence• 65%ofpatientswithpre-existingurgencyincontinencethat accompaniesthestressurinaryincontinencewillhave resolutionoftheurgencyincontinence

Potential Adverse Effects: • FailureoftheproceduretocuretheSUIin10%• Newonsetofurgencyincontinencein5-10%.Urgency incontinenceisasuddenurgetourinatewiththeinabilityto makeittothebathroomontime.Ifthisoccurs,itcanbetreated withabladderrelaxantmedication.• Prolongedtimebeforeresumptionofspontaneousvoidingin2.5%• Inabilitytourinateinlessthan1%requiringself-catherizationor takedown/revisionofthesling• Injurytotheurethra,bladder,bowel,orvascularstructures: extremelyrare.• Protrusionofslingmaterial:extremelyrare

Surgical Repair of Cystocele (Classic Repair)

Mesh-Augmented Cystocele Repair

Incision in anterior vaginal wall

Exposure of hardy perivesical fascia

Perivesical fascia sewn together in midline to obliterate cystocele

Completion of cystocele repair

-18-

Wedge of perineal skin removed

Rectocele dissected off posterior vaginal wall

Perirectal & pararectal fascia sewn together in midline

Levator muscle sewn together

Perineal muscles repaired Completed rectocele and perineal repair

Surgical Repair of Rectocele

Perineal Repair

-19-

Surgical Repair of Enterocele and Vault Prolapse

Vaginal incision over enterocele

Enterocele sac is opened

Contents of enterocele are exposed

Intestines retracted in order to repair

enterocele

Neck of enterocele is now closed Completion of enterocele repair

-20-

Surgical Repair of Uterine ProlapseIftheuterineprolapseislowtomoderategrade,considerationforuterinesuspensioncanbemade,aprocedureinwhichtheuterusissecuredtothepelvisinordertopreventitsdescent.Essentially,apieceofsurgicalmeshissuturedtotheuterinecervix,andtheotherendofthemeshisattachedtooneofthehardypelvicligaments.Thisresultsinthere-establishmentofuterinesupportandareturnoftheuterustoitsnormalanatomicalposition.However, if theuterineprolapseishighgrade,hysterectomyistheoptionofchoice.Hysterectomyisthesurgicalremovaloftheuterus,aprocedurethatcanoftenbeperformedvaginallybyyourgynecologist.Ifhighgradeuterineprolapsecoexistswithbladderandurethralprolapse,thegynecologistandurologistwillcollaboratetorepairallaspectsoftheprolapse.

At completion of enterocele repair, intestines are back in their proper position

-21-

About the AuthorDr.AndrewL.SiegelearnedabachelorofsciencedegreemagnacumlaudefromSyracuseUniversity,Syracuse,NewYork,in1977,andamedicaldegree fromtheChicagoMedicalSchool,Chicago, Illinois, in1981,wherehewaselectedtotheAlphaOmegaAlphaHonorMedicalSociety.

Hecompletedatwo-yearresidencyingeneralsurgeryattheNorthShoreUniversityHospital,Manhasset,NewYork,anaffiliateofCornellUniversitySchoolofMedicine.Dr.SiegelthenwentontoundertakeresidencytraininginurologyattheUniversityofPennsylvaniaSchoolof Medicine, Philadelphia, Pennsylvania, from 1983 to 1987. Dr.Siegel completed a fellowship in incontinence, urodynamics, andreconstructive and female urology at the University of CaliforniaSchoolofMedicine,LosAngeles,California,underthedirectionofDr.Shlomo Raz, the world-renowned expert in incontinence andfemaleurology.In1988,Dr.SiegeljoinedBergenUrologicalAssociates.

Dr. Siegel is a diplomate of the American Board of Urology andthe National Board of Medical Examiners. He is a member of theAmerican Urological Association, the New York section of theAmericanUrologicalAssociation,theAmericanMedicalAssociation,theSocietyforUrodynamicsandFemaleUrology,theAmericanUro-GynecologicalSociety,andtheInternationalContinenceSociety.

Dr. Siegel has authored chapters in urology textbooks includingCurrent Operative Urology and Interstitial Cystitis,andhaspublishedarticlesinnumerousprofessionaljournalsincludingUrology, Journal of Urology, Urologic Clinics of North America, Postgraduate Medicine, Neuro-Urology and Urodynamics, and International Urogynecology Journal.Hehaspresentedpapersatprofessionalmeetingsformanymedical societies including the Philadelphia Urological Society,theAmericanAcademyofPediatrics,andtheAmericanUrologicalAssociation,bothnationallyandinternationally.

Dr. Siegel is a urological surgeon at Hackensack UniversityMedicalCenter,andistheDirectorofTheCenterforContinenceCare. He is very involved in the training of urology residentsat the University of Medicine and Dentistry of New Jerseywhere he is a Clinical Assistant Professor of Urology. He is theauthor of Finding Your Own Fountain of Youth – The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity.Seewww.findingyourfountainofyouth.comformoreinformation.