Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Surgical treatment of vaginal apex prolapse

Introduction Although anterior vaginal prolapse is most common, loss of apical support is usually present in women with prolapse that extends beyond the hymen. There is growing recognition that adequate support for the vaginal apex is an essential component of a durable surgical repair for women with advanced prolapse ( ; ). At least half of the observed variation in anterior compartment support may be explained…

Surgical treatment of posterior vaginal wall prolapse

One-third to one-half of all surgeries for pelvic organ prolapse involve the posterior vaginal wall. Although rectocele repair has been commonly performed for over a century, the long-term functional and anatomic outcomes and ideal surgical technique have not been determined. This chapter will review the anatomy, pathophysiology, evaluation techniques, and surgical management of posterior vaginal wall prolapse and perineal body defects. Anatomy and pathophysiology The histology…

Surgical treatment of anterior vaginal wall prolapse

Introduction Anterior vaginal prolapse occurs commonly and may coexist with disorders of micturition. Mild anterior vaginal prolapse often occurs in parous women, but usually presents few problems. As the prolapse progresses, symptoms may develop and worsen, and treatment becomes indicated. The anterior vaginal wall is the most common segment of the vagina to prolapse and the segment that is most likely to fail long-term after surgical…

Urethral injection of bulking agents for intrinsic sphincter deficiency

Introduction In 1938 Murless reported the use of morrhuate sodium for injection management of urinary incontinence. In the early 1990s, transurethral and periurethral injection of bovine collagen was introduced for the treatment of stress urinary incontinence and was the gold standard with which all later studies have been compared, although production of this material ceased in 2011. Since the 1990s, several urethral bulking agents have been…

Synthetic midurethral slings for stress urinary incontinence

Introduction Synthetic midurethral slings (MUSs) have become the most popular surgical procedures performed for the treatment of stress urinary incontinence (SUI) in the twenty-first century. Few operations in gynecology or urology have been as well studied or have gained such wide acceptance. These procedures generally have been shown to be minimally invasive, and have high efficacy, low morbidity, and a relatively quick recovery. This chapter discusses…

Biologic bladder neck slings for stress urinary incontinence

Introduction The concept of using a patient’s own tissue as a “sling” to provide support under the urethra to treat urinary incontinence dates to the beginning of the twentieth century; however, it was not until the last quarter of the century that the procedure gained widespread appreciation and evolved into its current identity. Initially, the procedure was described as using a strip of mobilized abdominal muscle…

Retropubic operations for stress urinary incontinence

Introduction Since 1949, when Marshall et al. first described retropubic urethrovesical suspension for the treatment of stress urinary incontinence (SUI), retropubic procedures have proved to be consistently curative. Although numerous terminologies and variations of retropubic repairs have been described, the basic goal remains the same: to suspend and stabilize the anterior vaginal wall, and thus the bladder neck and proximal urethra, in a retropubic position. This…

Stress urinary incontinence and pelvic organ prolapse: Nonsurgical management

Introduction Stress urinary incontinence (SUI) is an involuntary loss of urine on effort, physical exertion, or with an increase in the intraabdominal pressure upon sneezing or coughing ( ). Pelvic organ prolapse (POP) is clinically defined as “the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix) or the apex of the vagina (vaginal vault or cuff scar after…

Radiologic studies of the lower urinary tract and pelvic floor

Introduction Pelvic floor disorders (PFDs), including urinary incontinence (UI), pelvic organ prolapse (POP), and anorectal disorders, are prevalent conditions that have a significant negative impact on women’s quality of life. The main approach to evaluating these conditions starts with a detailed history and physical examination, along with evaluation of pelvic muscle function, strength, and integrity. The pelvic floor anatomy may be described as comprising an anterior,…

Endoscopic assessment of the lower urinary tract

Historical perspective The first endoscopic technique for evaluating the female urethra and bladder was described by Bozzini in 1805 and used candlelight reflected through a funnel in the urethra. Nineteenth-century refinements to this crude instrument included a surrounding cannula and, later, a lens system to provide magnification of the field of view. Despite efforts to improve illumination using reflective mirrors, an alcohol lamp, a platinum wire…

Urodynamics: Indications, techniques, interpretation, and clinical utility

Introduction to urodynamics The term urodynamics means observation of the changing function of the lower urinary tract (LUT) over time. Specifically, urodynamic studies are a number of interactive diagnostic tests that can be used to obtain functional information about bladder filling, urine storage, and voiding. To understand the fundamental value of urodynamics, one should realize that the female bladder responds similarly to a variety of pathologies.…

Female sexual function and dysfunction: Assessment and treatment

Introduction Sexual health is an important component of a woman’s well-being. Evidence suggests that healthy sexual functioning is a fundamental component of a woman’s sense of self and quality of life. Diminished sexual function has been found to correlate with advancing age, menopause, and economic and health problems ( ; ). Sexual dysfunction is associated with poorer mental health and reduced vitality and social function, as…

Evaluation of pelvic floor disorders: History, physical examination, and diagnostic testing

Introduction The term pelvic floor disorders includes urinary and fecal incontinence, pelvic organ prolapse, and sensory and emptying abnormalities of the lower urinary and gastrointestinal tracts. Pelvic floor disorders are common in women and often coexist, so it is important for providers to inquire about each of these conditions. Urinary incontinence can be a symptom of which patients complain, a sign demonstrated on examination, or a…

Description and classification of lower urinary tract dysfunction and pelvic organ prolapse

Introduction The purposes of any classification system are to facilitate understanding of disease etiology and pathophysiology, to help establish and standardize treatment and research guidelines, and to avoid confusion among those who are concerned with the problem. Classification systems for voiding disorders and pelvic organ prolapse have been based on various symptoms, as well as anatomic, radiographic, and urodynamic findings. This chapter reviews the classification of…

Synthetic mesh and biologic grafts: Properties and biomechanics

Introduction The female pelvis is comprised of a complex, interconnected network of connective tissues and muscles that collectively work together to provide support to the pelvic organs. The vagina also provides support to the pelvic organs by supporting the urethra and bladder anteriorly, the uterus apically, and the rectum posteriorly. In the event that support to the pelvic organs is lost, via damage to or abnormalities…

Epidemiology and psychosocial impact of female pelvic floor disorders

Epidemiology Female pelvic floor disorders include urinary incontinence, pelvic organ prolapse, and anal incontinence, as well as emptying disorders of the lower urinary and gastrointestinal tracts. These conditions can have a significant impact on a woman’s functioning and quality of life, and are associated with limitations that can negatively impact a woman’s wellness and health. With the aging population, female pelvic floor disorders are a significant…

Pathophysiology of pelvic floor disorders

Introduction This chapter addresses the pathophysiology of stress urinary incontinence, pelvic organ prolapse, and fecal incontinence (FI). As Fig. 5.1 depicts, overlap of pelvic floor disorders in women suggests that there may be common risk factors or a common pathophysiology to these disorders. Pathophysiologic pathways involved in urgency urinary incontinence and overactive bladder are described in Chapter 31 . Stress urinary incontinence Urinary incontinence is defined…

Physiology of the pelvic muscles, vagina, and anorectum

Pelvic floor Anatomy and composition The pelvic floor is a highly complex, heterogeneous structure that supports the pelvic organs. In certain cases, such as childbirth, substantial stretch and accommodation of the pelvic floor must occur. Although the precise physiology by which the pelvic floor provides support to the vagina is not understood, it is known to comprise a combination of striated muscles, connective tissues, and bones.…

Neurophysiology and pharmacology of the lower urinary tract

Introduction The two functions of the lower urinary tract are the storage of urine within the bladder and the timely expulsion of urine from the urethra. The precise neurologic pathways and neurophysiologic mechanisms that control these functions of storage and micturition are complex and not completely understood, with our understanding of many of these pathways adapted from animal models. Understanding the interaction of the autonomic nervous…

Embryology and congenital anomalies of the urinary tract, rectum, and female genital system

Embryology Formation of the mesoderm The period of organogenesis, also called the embryonic period, spans the third to the eighth week of development. At approximately 15 days after fertilization, invagination and lateral migration of mesodermal cells occur between the ectodermal and endodermal layers of the embryo. At about the sixteenth day of development, the posterior wall of the yolk sac forms a small diverticulum, the allantois,…