Urinary incontinence and genital

prolapse

Urinary incontinence

ICS: involuntary loss of urine that represents a

hygienic or social nproblem to the individual.
Types of incontinence:
- Stress incontinence
- Urge incontinence
- Mixed incontionence
- Reflex incontinence
- Overflow incontinence

Stress incontinence

Occurs coincident with increase intraabdominal

pressure in the absence of uninhibited detrusor
contraction.
The bladder outley has poor resistance to urinary
flow.
Etiology: urethral hypermobility secxondary to
poor anatomic pelvic support
Less common cause: intrinsec sphincter
deficiency.

Urge incontinence

Is due to detrusor overactivity.

Etiology: detrusor miopathy or neuropathy or a
combination of both.
Overactive detrusor in the absence of a neurologic
identifiable cause detrusor instability

Mixed incontinence

Results from a combination of stress and urge

incontinence (the bladder outlet is weak and the
detrusor is overactive)

Reflex incontinence

A result of neurologic impairment of the central

nervous system (stroke, Parkinson disease, brain
tumours, spinal cord injuries and multiple
sclerosis).
Signs of urge incontinence in patients with
suprasacral spinal cord lesions detrusor
hyperreflexia.

Overflow incontinence

Occurs because of overdistension of the detrusor

muscle.
Etiology: bladder outlet obstruction (BPH,
antiincontinence surgery), detrusor atony, or
neurologic impairment of the urinary bladder
(herniated lumbar disc, diabetic cistopathy).

Frequency

UI affects 13 milion people in the US

Underdiagnosed - 50-70% of women with UI fail
to seek medical evaluation because of social
stigma.
SUI affects 15 60% of women
> of nulliparous young athletes experience SUI
when participating in sports.

Morbidity

Prolonged hospital admission

UTIs
Contact dermatitis
Colonization of the indwelling catheter, recurrent
bladder infections, bladder stones, ascending
pielonephritis, urethral erosions

Clinical - history

SUI a variable amount of urine escapes suddenly

with an increase in intraabdominal pressure. The
urinary loss is very predictible and irritative
voiding symptoms and nocturia are usually absent.

History

Urge incontinence the urine loss is associated

with a strong desire to void. It is not preventable
and usually the entire content of bladder is lost.
The symptoms are: urgency, urge incontinence,
urinary frequency, and nocturia.
Situations that precipitate urge incontinence:
washing dishes, hearing running water, drinking
too much water or alcohol.

History

Mixed incontinence the symptoms of stress

incontinence and urge incontinence coexist.
Reflex incontinence the same as those of urge
incontinence, but are particular to women with
neurologic disorders.
Overflow incontinence incomplete emptying,
slow-flowing urine and urinary dribbling.

Lab studies/tests/procedures

Urinalysis and urine culture

Urine cytology
Imaging studies: cystogram , MRI
Other test: voiding diary, clinical tests (pad test,
cough stress test, standing pelvic examination)
Procedures: PVR volume, uroflowmetry,
cistoscopy, e.a.

Treatment - SUI

Surgery in SUI, procedures that increase urethral

outlet resistance
nonsurgical means in all types of incontinence

Diet

Food to avoid: spices, citrus fruits, chocolatecontaining sweets, caffeine

Fluids 6-8 glasses of fluids
To avoid caffeinated drinks, carbonated beverages,
citrus fruits drinks, acidic juices, artificial
sweeteners.

Anti-incontinence exercises

Emphasize rehabilitating and strengthening the

pelvic floor muscle
Pelvic floor exercise (SUI, urge incontinence,
mixed) Kegel exercises
Vaginal weights
Biofeedback
Electrical stimulation
Bladder training

Medication

SUI agonists of alpha adrenergic receptors

(sympathomimetics), estrogens, tricyclic agents
Urge incontinence anticholinergic drugs,
antispasmodics and tricyclic antidepressant agents.

Treatment for the other types of

incontinence

Absorbent products
Uretrhal occlussive devices
Catheters (indwelling, suprapubic, intermitent
catheterization)

 Uterine

Uterine
Prolapse

prolapse, or dropped womb, is a condition in

which the uterus drops downward in the pelvis below its
normal position.
Grade 1 - The uterus may drop slightly and remain
above the introitus (vaginal opening).
Grade 2 - drop further so that the cervix or lower portion
of the uterus reaches the region of the introitus .
Grade 3 - In the most severe form, the cervix or even the
entire uterus bulges out of the introitus
Uterine prolapse is one of the most frequent indication
for hysterectomy in the U.S.

Genital Prolapse
Genital prolapse is a more general term that includes several
conditions, which may occur separately or in combination.
These include:

Uterine prolapse (dropped womb)

Vaginal prolapse,
Cystocele (dropped bladder),
Rectocele(dropped rectum)
Enterocele (herniation of the small bowel into the space between
the rectum and vagina).

Genital prolapse

Is due to pelvic relaxation

Etiology is complex:

constitutional factors - congenital (inherited) weakness

of the pelvic floor (muscles, ligaments, fascias that
support the pelvic floor and prevent pelvic organs from
dropping down).
More commonly, genital prolapse is caused by trauma
during vaginal delivery (especially those with protracted
labor) to supporting structures (muscular pelvic
floor),connective tissue and the endopelvic fascia;
instrumental deliveries (forceps, vacuum extraction), and
vaginal delivery of large babies.
conditions associated with an elevated intra-abdominal
pressure (physical labor, obesity, chronic bronchitis) and
postmenopausal atrophy.

Causes of genital prolapse

Aging and menopause can weaken the pelvic floor

in part because of diminished estrogen levels as well as by aging

itself.
The tissues comprising the pelvic floor are weakened in the absence
of sufficient estrogen levels.

Increased intra-abdominal pressure on a long-term

basis

can contribute to genital prolapse, for example: heavy manual labor,

heavy lifting, use of a tight abdominal girdle.

Chronic coughing and straining during bowel

movements

because of chronic constipation are also important contributing

factors in genital prolapse.

Causes of genital prolapse

Following hysterectomy
The strength of support ligaments may be reduced or
Their central attachment to the vaginal dome may be weakened and
Vaginal prolapse may result.

The pubo cervical fascia extends laterally like a hammock that is

attached to the pelvic sidewall along a horizontal line called the
"white line". This fascia supports the bladder base and urethra from
prolapsing.
Damage to the pubo cervical fascia (such as tearing or stretching during a
traumatic labor) can be centrally located and result in bulging of the bladder and
vagina into the anterior vagina, which is called central cystocele.
Also, the hammock (pubo cervical facia) may be detached laterally from the
white line, which also results in dropped bladder (cystocele).

Pelvic Floor Ligaments

Prevention of genital prolapse.

The physical and neurologic integrity of the pelvic floor

muscles and the integrity of the pelvic floor ligaments are
vital for the prevention
Damage to the nerves of the pelvic floor muscles
will prevent them from effectively contracting to
counteract downward push of the pelvic organs by a
sudden increase in abdominal pressure (such as the
pressure caused by coughing).
Damage to Ligament System
The ligament system may be damaged by traumatic and
instrumental delivery, or by the delivery of a big baby

Pelvic Floor Ligaments

Drop in Estrogen Levels
Since the pelvic ligaments are also estrogen dependent, the
drop in estrogen levels as during menopause may lead to
weakness and stretching of these ligaments.

Aging
- Process of aging may also lead to weakness and stretching
of these
ligaments
Stretching of Pelvic Ligament
This may lead to further weakening of the pelvic floor.
This is why prolapse may develop or deteriorate after the
menopause (aging and estrogen deficiency)

Symptoms of pelvic relaxation

Very variable and by no means parallel to the

severity of the condition.
Include pressure, fullness, the feeling of a mass,
and traction in the lower abdomen and the lumbar
area.
Discomfort increase during the course of the day
and during physical activity and resolves with
lying down or when prolapse is reduced.
The complaints are non-specific not always caused
by pelvic relaxation.

Symptoms

Mild degrees of uterine prolapse, cystocele, or

rectocele may not cause
any discomfort.
Enteroceles are associated with more pain because
traction is exerted on the peritoneum and mesentery.
May also interfere with sexual function.
There may pain or a feeling of something blocking
penetration.
Sex may also be less fulfilling because of loss of
vaginal tone

Specific symptoms

Cystocele may cause

Pelvic discomfort
Sexual dysfunction
May involve urinary stress incontinence .
Rectocele can cause
Rectal pressure
Constipation.
Prolapse which results in a protrusion of the uterus and/or vagina out of the
vaginal introitus may lead to
Irritation
Ulceration
Infection
Enterocele may cause
Low back pain
Painful defecation.

Pathogenic associations

Pelvic relaxation usually involves descent of both

the genital organs and the neighboring orgens but
one element can predominate
Urinary incontinence
Urinary retention
Fecal incontinence or retention (more rarely).

Uterine descensus

Usually associated with retroversion and

retroflexion of the uterus and with elongation and
hypertrophy of the cervix
Conveniently graded as
- grade I the cervix descend to the introitus
- grade II the cervix descend below the vulva
- grade III total procidentia, uterus completely
below the introitus with inversion of the vagina
Can occur in isolation (nulliparas or virgins) but
more often is associated with descent of other
organs)

Descent of the anterior vaginal wall

- cystocele

Along with the bladder urethtra or both: cystocele,

urethrocele.
Two types of cystocele:
- pulsion (distention) cystocele stretching of the
anterior vaginal wall
- traction (displacement) cystocele relaxation of
the lateral support of the vagina
Symptoms 1/3 - of the patients are incontinent
of urine.

Cystocele
Assessment-History
Difficulty in emptying bladder
Urinary frequency & urgency
UTI
Stress urinary incontinence

Loss of urine during activities that increase intraabdominal pressure

such as
Laughing
Coughing
Sneezing
Lift heavy objects

Cystocele (continued)

Assessment Physical
Pelvic exam reveals a large bulge of the anterior vaginal wall when
the women is asked to bear down.
Diagnostic tests
Cystography-shows presence of bladder herniation
Measurement of residual urine by catheterization or bladder
ultrasound
Urine C&S

Cystocele (continued)
Determining the degree of cystocele
(1) Radiographic imaging of the urinary tract or Intravenous
Urogram (IUV)
shows urinary anatomy

(2) Voiding cystourethrography-(VCUG)

Degree of cystole in standing position
Amount of postvoid residual
Urethral abnormalities

(3)Cystometrogram
Measures bladder storage
(4)Uroflowmetry
Evaluates characteristics of voiding pattern
Failure to empty bladder because of poor bladder contraction

Cystocele - Management

Mild Symptoms-Conservative Management

(A) Pessary support bladder
(B) Estrogen therapy-post menopausal to prevent atrophy and
weakening of vaginal walls
Kegel exercises-help strengthen perineal muscles
Instruct pt to tighten & relax perineal muscles
Pt presses buttocks together and hold the position for at least 5 seconds
Instruct pt to repeat the exercise often throughout the day

(D) An alternative exercise is to try to stop the flow of urine after

urinatoin has started and then hold the position for a few seconds
before letting the urine flow again

Cystocele - Management

Severe Symptoms Surgery

Anterior Colporrhaphy (Anterior Repair)
Tightens the pelvic muscles for better bladder support
Vaginal surgical approach is used

Modern - meshes
Nursing care similar to vaginal hysterectomy
After surgery

Instruct pt to limit activities

Not life anything heavier than 5 pounds
Avoid strenous exercies
Avoid sex for 6 weeks

Notify MD for signs of infection

Fever
Persistent Pain
Purulent, foul smelling discharge

Descent of posterior vaginal wall rectocele

Rectocele Protrusion of the rectum through a

weakened vaginal wall.
It is usually combined with the relaxation of the
perineum.
Usually results from pressure of an infants head during
difficile delivery
Traumatic forceps delivery
Congenital defect of supporting tissues
Symptoms do not typically appear until the women is
older than 35 yr

Rectocele

Management of Rectocele

Promoting bowel elimination

High fiber diet
Stool softeners
Laxatives

Surgical procedure
(1) Posterior Colporraphy (posterior repair)
Strengthens pelvis support and reduces bulging

(2) Anterior and Posterior Colporrhaphy

(Anterior and Posterior [A&P] Colporrhaphy repair
If BOTH a Cystocele AND a Rectocele are present

Rectocele postoperative
management
Nursing Care Posterior Repair
Similar to that of any rectal surgery
Low residue low fiber dietTo prevent bowel movements
Allow time for incision to heal

Instruct pt not to strain when having a bowel

movement to avoid pressure on suture line
Bowel Movement often painful
Pain medication
Sitz Baths to relieve discomfort
Posterior repair instructions similar to Anterior repair

Rectocele - symptoms

Symptoms relatively few, usually feelling of

rectal or vaginal fullness
If severe constipation, stool retention
(dyschezia) rsulting in straining that encourages
the rectocele.
If the anal sphincter is damaged incontinence of
stool and flatus.
Association hemorrhoids, less often anal or
rectal prolapse.

Enterocele

True hernia with a peritoneal sac and a hernial

orifice.
The most common type of enterocele extends into
the rectovaginal septum
Ethiology partly congenital, partly acquired
(obstetric trauma, chronically increase
intraabdominal pressure, post surgery)
The main symtom is low back pain especially in
the standing position

Treatment

Conservative pesary
Surgery. Its goal is to restore the normal
topographic anatomy and to normalize the
function of the involved organs.
Usually the uterus is removed
Most surgery for pelvic relaxation is performed
vaginally

Prophylaxis of the genital prolapse

Kegel exercises ante- and postnatally.

Perineotomy effect still not clear.
HRT during menopause contributes to tone
maintaining in pelvic muscles

Treatment

Mild degrees of cystocele, rectocele, or uterine prolapse may

not require any intervention, especially if the patient has no
discomfort.
Obesity optimal weight.
Avoiding hard physical activity.
Conservative - pesary
Kegel Exercise
- Special exercises to strengthen pelvic floor muscles-Kegel
Can improve symptoms, urinary stress incontinence,
sexual function, and pelvic discomfort.
Reduction of the size of a cystocele can be documented

Kegel exercises
Pelvic muscle (Kegel) exercises
Goal: to improve urethral resistance and urinary control
through the
active exercise of the pubococcygenus muscle
Components:
Proper identification of muscle (if able to stop urine
midstream)
Planned active exercise (hold for 10 seconds then relax)
30-80 times per day for a minimum of 8 weeks

Non-Surgical Treatment Options

Changes in lifestyle can halt the progression of genital
prolapse

Changes such as
Eliminating heavy lifting
Avoiding use of a tight girdle
Treatment and suppression of a chronic cough,
Treatment of chronic constipation

Other Treatment Options

Medications
Estrogen replacement therapy (combined with a
progestin)

Can improve the strength of the pelvic floor ligaments

and muscles
Bringing an improvement in symptoms
Increases the effectiveness of Kegel exercises.

Other Treatment Options

Devices-Pessary
Pessaries are special prostheses of different shapes and
sizes that are fitted into the vagina and can effectively
prevent the prolapse.
The pessary must be fitted according to the type and
degree of prolapse.
Specialized pessaries can also effectively prevent urinary
stress incontinence.
However, pessaries require some vaginal tone to stay
in place and may be ineffective in the more advanced
cases of genital prolapse

Surgical Treatment Options

Surgery is designed to

Repair and reconstruct the

weakened pelvic floor
Restore normal function.

It is indicated only when

Prolapse is causing significant

symptoms
When conservative non-surgical
measures have failed.

Surgery is also
indicated when

Conservative measures are

not
desired by the patient
Patient is requesting relief by

means of surgery.
Surgery is rarely
indicated
for mild degrees of
prolapse

Surgical treatment

Objective restauration of normal anatomy and

normalization of function.
Usually implies hysterectomy
Most of the surgical techniques adressed to pelvic
relaxation implies hysterectomy.