Urogyn CREOG Review 12/15/2010 Barbara L. Robinson

1. Urogyn CREOG Review12/15/2010Barbara L. Robinson

2. Objectives • Pelvic Organ Prolapse • Urinary Incontinence • Videourodynamics

3. What is Pelvic Organ Prolapse?

4. Pelvic Organ Prolapse

5. Risk Factors for Prolapse • Parity – direct trauma • Nerve injury/ neuropathy – pudendal nerve • Obesity • Race – Nonwhite protective • Chronic cough • Constipation • Menopause • Age – increase prevalence with age • Large birth weight • Previous Hysterectomy • Connective tissue disorder

6. Anatomy

8. Paravaginal Repair

9. A 52 year old woman, para 4, reports a “vaginal bulge and vaginal pressure.” Her first delivery was a forceps-assisted delivery of a 4,200g baby over a midline episiotomy. Her following deliveries were SVDs of 3,600 g. She is 1 year postmenopausal, is healthy and on no medications. She smokes a pack of cigarettes per day and does step aerobics 3 days per week. On PE, cervix is 2cm beyond the hymen. The most likely reason for her prolapse is • Forceps • Parity • Smoking • >50 years old • Fetus > 4,000g

10. A 40 yo G5P5 comes to your office and reports a vaginal bulge worsening over the past year. Exam reveals normal rugae and anterior vaginal wall descent that protrudes 1 cm beyond the hymen with Valsalva. The anterior vaginal wall descent can be reduced by placing your fingers in the lateral fornices of the vagina. The uterus and posterior vaginal wall are well supported. The cause of this type of cystocele is detachment of the pubocervical fascia from the • Pubic arch • vaginal muscularis • arcus tendineus • Cardinal ligaments • Perineal membrane

11. 62 yo G5P5 with no medical problems reports a vaginal bulge that interferes with intercourse and is more prominent when she plays golf. She reports problems with defecation; she places her fingers in her vagina to evacuate stool. She also has discomfort with intercourse. On exam, she has a central defect cystocele, a well-supported small uterus, and a rectocele that can be brought to the hymen on digital exam. POP-Q Aa 0; Ba 0, C -6, D -8, Ap 0; Bp 0; Gh 6; Pb 3; TVL 9. UDS showed no SUI and a low compliance bladder. She chooses surgery instead of pessary. In addition to a posterior repair, you perform • Paravaginal defect repair • Anterior colporrhaphy • TVH • Colpocleisis

12. POP-Q

14. Anterior Repair

15. Anterior Repair

16. Posterior Repair

17. 50 yoP4 with vaginal pressure and “stool getting stuck” with bowel movements. Exam reveals stage 2 rectocele. Vaginal reconstructive surgery is planned. She asks if there is a way to strengthen the repair and prevent recurrence. You discuss with her the use of augmentation of the PR with either a porcine dermal or small intestinal graft versus performing the traditional posterior repair. The best information that you can give her is that when using graft compared with the traditional standard approach there is • Lower incidence of dyspareunia • Improved anatomic outcome • Improved ability to defecate • Decreased incidence of postop infection • No demonstrable benefit

18. Utero-vaginal prolapse

19. 84 yo P6 with prior TAH/BSO presents with increasing pelvic discomfort and difficulty sitting, along with the findings seen on the previous slide. She is not sexually active, and her medical history is significant for chronic afib, htn, copd, and oa. She is not able to retain a pessary. The best surgical option would be • a/p repair with sacrospinous ligament fixation • Perineoplasty • Laparoscopic USLS • colpocleisis

20. Colpocleisis

21. 74 yo p3 presents with symptomatic uterovaginal prolapse. You plan a vaginal hysterectomy and a/p repair with uterosacral ligament suspension. The most common complication of uterosacral ligament suspension is • Hemorrhage • Rectal injury • Bowel obstruction • Ureteral obstruction • Vaginal cuff abscess

23. 42 yo p2 has symptoms of pelvic pressure, menorrhagia, and dysmenorrhea refractory to medical therapy. She also notices a bulge in the vagina that is bigger toward the end of the day. Exam reveals a mobile, bulbous but smooth uterus, approx 10 weeks in size with no adnexal masses. Her cervix and anterior vaginal wall are at the hymen. A pregnancy test was negative. She desires definitive surgery for the problem but needs to recover quickly. She is concerned about the future risk of developing urinary incontinence and pelvic prolapse. You counsel her that the best surgical procedure for her would be • Laparoscopic supracervical hysterectomy • vaginal hysterectomy, anterior repair • LAVH, anterior repair • TAH, Burch

24. You are performing a sacrocolpopexy on a 58 yo g4p4 with complete vaginal vault eversion and an enterocele. She previously had a TAH/BSO. You have dissected out the presacral space and are placing a permanent suture through the midsacral promontory by sewing from the patients right to left. As you needle exits the tissue, a large amount of blood begins pooling in the field. The vessel you most likely lacerated is the • Left common iliac vein • Left common iliac artery • Left lateral sacral vein • Middle sacral artery • Middle sacral vein

27. Urinary Incontinence • SUI – 40% in post-menopausal women • Leaking with cough, laugh, sneeze, etc • Bladder pressure exceeds urethral resistance • Risk factors: • White race • Obesity • Pregnancy & Childbirth

28. 68 yo P2 has symptoms of daily SUI. She reports leakage when running to the bathroom. She previously had a TOT mid-urethral sling 1 year ago. There is no demonstrated prolapse on exam, but leakage of urine is observed from the urethra when she bears down. The diagnostic test that will provide the most information regarding her condition would be • Cystourethroscopy • Cotton-swab test • Cystogram • Multichannel cystometrogram • Cough stress test

29. Multichannel UDS • Assess: • Sensation • Capacity • Compliance • Detrusor function • Overactive • Underactive • Ability to empty

30. UDS

31. UDS

33. Cotton swab test “Q-tip Test”

34. 65 yo with 2 year history of urinary frequency both day and night and loss of urine when she stands up. She underwent a retropubic urethropexy for incontinence 10 years ago. Her medical history is significant for well-controlled dmII for the past 5 years and depression since her husband died 2 years ago. Her medications are duloxitene hydrochloride (Cymbalta) and metformin hydrochloride (Glucophage). On examination, her vagina is well estrogenized, and she has good support of the anterior and posterior vaginal walls as well as the uterus. A cotton swab test shows a resting angle of -10 and a straining angle of 0. A cough stress test with a comfortably full bladder is negative. Your next step is to • prescribe an anticholinergic • Perform urodynamics • Stop her duloxitene • Recommend a sling procedure • Obtain a PVR

35. 46 yo undergoes an outpatient TVT procedure for stress urinary incontinence. She call you the following morning stating that she cannot void and feels very uncomfortable. On examining her in the office, you notice a 3cm x 4cm hematoma in the right labium majus. You insert a red rubber catheter into the bladder with production of 800ml of urine. Your best next step is to • Instruct patient in Intermittent self-cath • Insert Foley cath • Surgically remove the TVT • Instruct the patient to double void • Prescribe an alpha blocker

36. 24 yo woman calls your office for the third time in 5 months reporting lower abdominal discomfort, urgency, and dysuria. Both times previously, she was given empiric treatment for an acute UTI and the symptoms resolved. The best next step in her care would be • 7 days of quinolone therapy • Acidify her urine • Renal U/S • A urine culture • Dipstick urinalysis

37. 56 yo who had a previous retropubic urethropexy undergoes an anterior repair and sling for a cystocele and recurrent SUI. Intraoperative cysto is negative. She does well until postop day 14 when she calls you to report severe urinary incontinence associated with daytime activity as well as nocturnal enuresis. She is wearing adult diapers that are soaked when she changes them. She states that she has no urge to void, but find she leaks on the way to the toilet. She denies dysuria or frequency. On exam you see an intact suture in the anterior wall. Your most appropriate course of action would be to • Prescribe an anticholinergic • Check for a pvr • Instill dye into the bladder • Obtain a urine culture • Perform UDS

39. TVT-O

40. TVT

41. SPARC