After studying this chapter you should be able to:
Knowledge criteria
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Describe the normal supports of the uterus and vagina
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Describe the normal mechanisms that maintain urinary continence and the physiology of normal micturition
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Describe the epidemiology, aetiology and clinical features associated with urinary incontinence, urinary frequency, urinary tract infections and genitourinary prolapse
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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 tapes and colposuspension
Clinical competencies
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Take a history from a woman presenting with urinary tract symptoms or symptoms of prolapse
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Perform a pelvic examination to assess genitourinary prolapse and pelvic floor tone
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Explain the investigations employed in the assessment of incontinence and prolapse including: microbiology, urodynamics, cystoscopy and imaging
Professional skills and attitudes
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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. There are three levels of pelvic organ support that 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 that 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.
Level III support is provided by the perineal body posteriorly and the pubourethral ligaments anteriorly. The perineal body is a complex fibromuscular mass in to which several structures insert. It is bordered cephalad by the rectovaginal septum (Dennonviller’s fascia), caudad 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 4 cm × 4 cm 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. An 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. 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 ( 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 ).
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.
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A sense of fullness in the vagina associated with dragging discomfort.
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Visible protrusion of the cervix and vaginal walls.
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Sacral backache is usually relieved on lying down.
| 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 |
| 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 |
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 that 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 vaginum. 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 Sim’s 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 3 cm 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 complains 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 .
| Anatomic 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) |
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