Prolapse and disorders of the urinary tract

Learning Outcomes

After studying this chapter you should be able to:

Knowledge criteria

Describe the normal supports of the uterus and vagina.
Describe the normal mechanisms that maintain urinary continence and the physiology of normal micturition.
Describe the epidemiology, aetiology and clinical features associated with urinary incontinence, urinary frequency, urinary tract infections and genitourinary prolapse.
Evaluate the common surgical and non-surgical treatments used in the management of urinary incontinence and genital prolapse, including catheterization, bladder retraining, pelvic floor exercises, medical therapies, vaginal repair with or without hysterectomy, sling procedures and colposuspension.

Clinical competencies

Take a history from a woman presenting with bowel, bladder and sexual symptoms.
Perform a pelvic examination to assess genitourinary prolapse and pelvic floor tone.
Explain the investigations employed in the assessment of incontinence and prolapse, including microbiology, urodynamics, cystoscopy and imaging.

Professional skills and attitudes

Consider the impact of urinary incontinence on women and the community.

Uterovaginal prolapse

The position of the vagina and uterus depends on various fascial supports and ligaments derived from specific thickening of areas of the fascial support ( Figs 21.1–21.4 ). There has been a paradigm shift in our understanding of the anatomy of pelvic floor supports and with it the pathophysiology of development of pelvic organ prolapse. Three levels of pelvic organ support are clinically relevant and conceptually easier to grasp. The uterosacral ligaments responsible for providing level I support to the upper vagina and the cervix (and by extension to the uterus) have a broad attachment over the second, third and fourth sacral vertebrae arising posteriorly from the junction of the cervix and the upper vagina running on each side lateral to the rectum towards the sacral attachments. The other important structure is the arcus tendineus fasciae pelvis (ATFP; see Figs 21.3 and 21.5 ), also known as the white line – a condensation of pelvic cellular tissue on the pelvic aspect of the obturator internus muscle. The ATFP runs from the ischial spines to the pubic tubercle, and its terminal medial end is known as the iliopectineal ligament (Cooper’s ligament), well known to general surgeons who operate on inguinal and femoral hernias. Extending medially from the white lines are condensed sheets of pelvic cellular tissue suspending the anterior and posterior vaginal walls and the organs underlying these, namely the urinary bladder and the rectum providing level II support. The anterior support to the bladder was previously referred to as the pubovesicocervical fascia or bladder pillars , whereas the posterior support to the rectum was termed the rectovaginal fascia .

Fig. 21.1, The pelvic diaphragm viewed from below.

Fig. 21.2, Muscles of the pelvic floor, lateral view.

Fig. 21.3, The lateral attachments of the pubocervical fascia (PCF) and the rectovaginal fascia (RVF) to the pelvic sidewall. Also shown are the arcus tendineus fascia pelvis (ATFP), arcus tendineus fasciae rectovaginalis (ATFRV) and ischial spine (IS).

Fig. 21.4, Three-dimensional view of the endopelvic fascia. Notice the location of the cervix in the proximal anterior vaginal segment.

Fig. 21.5, The endopelvic fascia of a post-hysterectomy patient divided into DeLancey’s biomechanical levels: level I, proximal suspension; level II, lateral attachment; level III, distal fusion.

Level III support is provided by the perineal body posteriorly and the pubourethral ligaments anteriorly. The perineal body is a complex fibromuscular mass into which several structures insert. It is bordered cephalad by the rectovaginal septum (Dennonviller’s fascia), caudal by the perineal skin, anteriorly by the wall of the anorectum and laterally by the ischial rami. The three-dimensional form has been likened to the cone of the red pine ( Pinus resinosa ), and it forms the keystone of the pelvic floor, a 4cm × 4cm fibromuscular structure providing support not just to the lower third of the vaginal wall (part of the genital hiatus) anteriorly but also to the external anal sphincter posteriorly. Attaching laterally to the perineal body are the superficial and deep perineal muscles.

The anterior vaginal wall is supported by the pubovesicocervical fascia, which extends from the ATFP on one side to the ATFP of the other, providing a hammock-like level II support. The posterior vaginal wall is supported by the fibrous tissue of the rectovaginal septum that is well defined only in the midline; laterally the hammock-like supports arise from the ATFP.

The uterus is supported indirectly by the supports of the vaginal walls but directly by the uterosacral ligaments. The round and broad ligaments provide weak, if any, support to the vagina and uterus. Indirect support of the lower third of the vagina and uterus is provided by the intact levator ani (pelvic floor). The role of the latter has always been in doubt, but the puborectalis portion of the levator ani plays a significant role in the distension of the genital hiatus in labour and delivery, making it very prone to injury. Injury to this muscle has been postulated to be the cause for vaginal prolapse later in life.

Definitions

Vaginal prolapse

Prolapse of the anterior vaginal wall may affect the urethra ( urethrocele ) and the bladder ( cystocele, Fig. 21.6 ). On examination, the urethra and bladder can be seen to descend and bulge into the anterior vaginal wall and, in severe cases, will be visible at or beyond the introitus of the vagina. A urethrocele is the result of damage to level III (anterior) support, i.e. the pubourethral ligaments. Cystoceles usually result due to a loss of level II support and usually due to a midline defect in pubovesicocervical fascia. However, nearly half of anterior prolapses have apical defects as well. A rectocele is formed by a combination of factors: a herniation of the rectum through a defect in the rectovaginal fascia, as well as a lateral detachment of the level II support from the ATFP. This can usually be seen as a visible bulge of the rectum through the posterior vaginal wall. It is often associated with a deficiency and laxity of the perineum. This is the classical level III defect (posterior) affecting the perineal body.

An enterocele is formed by a prolapse of the small bowel through the rectouterine pouch, i.e. the pouch of Douglas, through the upper part of the vaginal vault (see Fig. 21.6 ). The condition may occur in isolation but usually occurs in association with uterine prolapse. An enterocele may also occur following hysterectomy when there is inadequate support of the vaginal vault. This represents damage to level I support.

Uterine prolapse

Descent of the uterus, which occurs when level I support is deficient, may occur in isolation from vaginal wall prolapse but more commonly occurs in conjunction with it. First-degree prolapse of the uterus often occurs in association with retroversion of the uterus and descent of the cervix within the vagina. If the cervix descends to the vaginal introitus, the prolapse is defined as second degree. The term procidentia is applied to where the cervix and the body of the uterus and the vagina walls protrude through the introitus. The word actually means ‘prolapse’ or ‘falling’ but is generally reserved for the description of total or third-degree prolapse ( Fig. 21.7 ).

Fig. 21.7, Procidentia: a third-degree prolapse of the uterus and vaginal walls.

Symptoms and signs

Symptoms generally depend on the severity and site of the prolapse ( Table 21.1 ).

Mild degrees of prolapse are common in parous women and may be asymptomatic.

Table 21.1

Levels of supports with diagnosis and co-relation with symptoms

Level of pelvic organ support	Organ affected	Type of prolapse	Symptoms
Level I – uterosacral ligaments	Uterus/vaginal vault (post-hysterectomy)	Uterocervical/vault prolapse/enterocele	Vaginal pressure, sacral backache, ‘something coming down’, dyspareunia, vaginal discharge
Level II – arcus tendineus fascia pelvis (ATFP)	Urinary bladder	Cystocele	‘Something coming down’, double voiding, occult stress incontinence, recurrent urinary tract infection
Level II – arcus tendineus fascia pelvis (ATFP)	Rectum	Rectocele	‘Something coming down’, difficult defecation, manual digitation
Level III – anterior (pubourethral ligaments)	Urethra	Urethrocele	‘Something coming down’, stress incontinence
Level III – posterior (perineal body)	Lower third of the vagina/vaginal introitus/anal canal	Enlarged genital hiatus	Vaginal looseness, sexual dysfunction, vaginal flatus, needing to apply pressure to the perineum to evacuate faeces

Table 21.2

Primary and secondary symptoms at each site used in the Baden–Walker halfway system

Reproduced with permission from Baden WF, Walker T (1992) Surgical repair of vaginal defects. Lippincott, Williams & Wilkins, Philadelphia, p. 12.

Anatomical site	Primary symptoms	Secondary symptoms
Urethral	Urinary incontinence	Falling out
Vesical	Voiding difficulties	Falling out
Uterine	Falling out, heaviness, etc.
Cul-de-sac	Pelvic pressure (standing)	Falling out
Rectal	True bowel pocket	Falling out
Perineal	Anal incontinence	Too loose (gas/faeces)

Some symptoms are common to all forms of prolapse; these include:

A sense of fullness in the vagina associated with dragging discomfort
Visible protrusion of the cervix and vaginal walls
Lower backache is usually relieved on lying down

Symptoms are often multiple and related to the nature of prolapse. It is important to note that the symptoms (and signs) of prolapse are worse at the end of the day. It is therefore of some value to schedule examination of patients who have typical symptoms of prolapse without its obvious signs a little later in the day.

Urethrocele and cystocele

Typically patients complain of ‘something coming down’ per vaginam. At times there may be incomplete emptying of the bladder, and this will be associated with double micturition, the desire to repeat micturition immediately after apparent completion of voiding. The patient may give a history of having to manually replace the prolapse into the vagina to void. Some patients may get recurrent urinary tract infections as a result of incomplete emptying of the bladder. Occasionally the patient may complain of occult stress incontinence, i.e. the involuntary loss of urine following raised intra-abdominal pressure that is not readily demonstrable on coughing but appears on reducing the prolapse.

The diagnosis is established by examination in the dorsal position. A single-bladed Sims’ speculum can be used to visualize the anterior vaginal wall. When the patient is asked to strain, the bulge in the anterior vaginal wall can be seen and often appears at the introitus. It is important to culture a specimen of urine to exclude the presence of infection. The differential diagnosis is limited to cysts or tumours of the anterior vaginal wall and diverticulum of the urethra or bladder.

Rectocele

The prolapse of the rectum through the posterior vaginal wall is commonly associated with a deficient pelvic floor, disruption of the perineal body and separation of the levator ani. It is predominantly a problem that results from over-distension of the introitus and pelvic floor during parturition.

The symptoms of a rectocele include difficulty with evacuation of faeces with an occasional need to ‘manually digitate’. Needless to say, the awareness of a reducible mass bulging into the vagina and through the introitus is often the presenting symptom.

Examination of the vulva usually shows a deficient perineum (measuring less than 3cm in length) bringing the posterior fourchette in close apposition with the anterior anal verge. Patients can complain of vaginal looseness and sexual dysfunction as a result of this. Not uncommonly the symptom of vaginal ‘flatus’ can be uncovered on direct questioning.

Enterocele

Herniation of the pouch of Douglas usually occurs through the vaginal vault if the uterus has been removed. It is often difficult to distinguish between a high rectocele and an enterocele, as the symptoms of vaginal pressure are identical. Occasionally an examination in the standing position or a bidigital examination may reveal an enterocele in a woman with no obvious signs of prolapse but complaints of a dragging sensation in the pelvis or a low backache. Uncommonly the enterocele occurs anterior to the vaginal vault and may mimic a cystocele.

A large enterocele may contain bowel and may be associated with incarceration and obstruction of the bowel.

Uterine prolapse

Descent of the uterus is initially associated with elongation of the cervix and descent of the body of the uterus. Mostly the affected portion of the cervix is supravaginal, i.e. above the level of the vaginal fornices. The symptoms are those of pressure in the vagina and, ultimately, complete protrusion of the uterus through the introitus. At this stage, the prolapsed uterus may produce discomfort on sitting, and decubitus ulceration may result in bleeding. Sometimes patients with minor degrees of prolapse or with congenital prolapse may have infravaginal cervical elongation that often leads to confusion in staging the degree of prolapse, as it may appear to be in a more advanced stage than it actually is.

Urinary tract infection may occur because of compression of the ureters and consequent hydronephrosis due to incomplete emptying of the bladder. Not unusually, patients experience dyspareunia but are not very forthcoming with this symptom.

Staging/grading of prolapse

Baden–Walker halfway system ( Fig. 21.8 and Table 21.2 )

This system was developed in an effort to introduce more objectivity into the quantification of pelvic organ prolapse. For example, measurements in centimetres are used instead of subjective grades. Nine specific measurements are recorded, as indicated in Figure 21.9 .

Fig. 21.8, Guidelines on how to assign grades in the Baden–Walker halfway system.

Fig. 21.9, Pelvic organ prolapse quantification system (POP-Q).

Pathogenesis

Prolapse may be:

Congenital: Uterine prolapse in young or nulliparous women is due to weakness of the supports of the uterus and vaginal vault. There is a minimal degree of vaginal wall prolapse.
Acquired: The commonest form of prolapse is acquired under the influence of multiple factors. This type of prolapse is both uterine and vaginal, but it must also be remembered that vaginal wall prolapse can also occur without any uterine descent. Predisposing factors include:
- High parity: Uterovaginal prolapse is a condition of parous women. The pelvic floor provides direct and indirect support for the vaginal walls, and when this support is disrupted by laceration or over-distension, it predisposes to vaginal wall prolapse. Instrumental delivery employing forceps/ventouse, especially mid-cavity rotational forceps delivery, may play a contributory role in the causation of urinary incontinence and prolapse in later life.
- Raised intra-abdominal pressure: Tumours or ascites may result in raised intra-abdominal pressure, but a more common cause is a chronic cough and chronic constipation.
- Hormonal changes: The symptoms of prolapse often worsen rapidly at the time of menopause. Cessation of oestrogen production leads to thinning of the vaginal walls and the supports of the uterus. Although the prolapse is generally present before menopause, it is at this time that the symptoms become noticeable and the degree of descent visibly worsens. The age at first vaginal childbirth affects the incidence of prolapse and urinary incontinence in later life. It has been postulated that increased maternal age predisposes to levator trauma, making these women more prone to developing pelvic floor disorders.

Management

The management of prolapse can be conservative or surgical.

Prevention

Good surgical technique in supporting the vaginal vault at the time of hysterectomy reduces the incidence of later vault prolapse. Avoiding a prolonged second stage of labour and inappropriate or premature bearing-down efforts, encouraging pelvic floor exercises after delivery and the judicious use of instrumental delivery with appropriately individualized episiotomies may all help reduce the risk of prolapse in later life.

Conservative treatment

Many women have minor degrees of uterovaginal prolapse, which are asymptomatic. If the recognition of the prolapse is a coincidental finding, the woman should be advised against any surgical treatment.

Minor degrees of prolapse are common after childbirth and should be treated by pelvic floor exercises or the use of a pessary. Operative intervention is deferred for at least 6 months after delivery, as the tissues remain vascular and may undergo further spontaneous improvement.

Hormone replacement therapy may be used preoperatively to prepare the tissues but by itself is of limited benefit in alleviating symptoms.

Where short-term support is required or the general health of the woman makes operative treatment potentially dangerous, both vaginal wall and uterine prolapse can be treated by using vaginal pessaries. It is, however, necessary to have some pelvic floor support if a pessary is to be retained.

The most widely used pessaries ( Fig. 21.10 ) are:

Ring pessary: This pessary consists of a malleable plastic ring, which may vary in diameter from 60 to 105mm. The pessary is inserted in the posterior fornix and behind the pubic symphysis. Distension of the vaginal walls tends to support the vaginal wall prolapse.
Hodge pessary: This is a rigid, elongated, curved ovoid which is inserted in a similar way to the ring pessary and is principally useful in uterine retroversion.
Gelhorn pessary: This pessary is shaped like a collar stud and is used in the treatment of severe degrees of prolapse.
Shelf pessary: This is shaped like a coat hook and is used mainly in the treatment of uterine or vaginal vault prolapse.

Fig. 21.10, Various types of vaginal pessaries used in the conservative management of uterovaginal prolapse.

The main problem with long-term use of pessaries is ulceration of the vaginal vault, and rarely a fistula may form, usually between the bladder and the vagina, if the pessary is ‘neglected’ or ‘forgotten’. Pessaries should be replaced every 4–6 months, and the vagina should be examined for any signs of ulceration. In postmenopausal women it is considered good practice to prescribe vaginal oestrogen creams/tablets to prevent ulceration.

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