Gynecology_Novak

Gynecology_Novak. Urologists often use ﬂexible cystoscopy in men; however, women tolerate a rigid cystoscope well, given their short urethras and absence of prostate glands. The view afforded by a rigid cystoscope is clearer than that obtained with a ﬂexible scope, and less technical skill is required to view the entire bladder using a rigid scope. However, with advancement in technology, the efficacy divide between rigid and ﬂexible cystoscopes continues to narrow. Cystoscopes are available with several viewing angles: 0 degree (straight), 30 degrees (forward-oblique), 70 degrees (lateral), and 120 degrees (retroview). The last scope is rarely used in women. Zero-degree lenses are essential for viewing the urethra, whereas a 30-degree lens provides the best view of the bladder base and posterior wall, and the 70-degree lens generally provides the best view of the anterior and lateral walls. For diagnostic cystoscopy, sterile water is an ideal medium because it is readily available and inexpensive.


Gynecology_Novak

Gynecology_Novak. To evaluate the urethra, the cystoscope, typically with a 0-degree or 30-degree lens, should be advanced with distension medium ﬂowing, keeping the center of the urethral lumen in the center of the visual field. The mucosa is normally pink and smooth and the urethral folds close. After insertion of the cystoscope into the bladder with a 70-degree lens, an air bubble will be present at the bladder dome, which may assist in proper orientation. Then the remainder of the bladder is examined systematically by making a series of sweeps, slowly rotating the cystoscope between the dome and urethrovesical junction. To view the trigone, the light cord should be oriented toward the ceiling (keeping the camera in an upright position). The scope is pulled back until it is almost in the urethra and the base of the bladder is viewed. Because the trigone is a zone of metaplasia, it looks different from the rest of the urothelium (Fig. 26.15).


Gynecology_Novak

Gynecology_Novak. Vaginal and abdominal hysterectomies are associated with a 0.02% to 0.85% incidence of ureteral injury (137). The injury rate increases in reconstructive pelvic surgeries, reaching as high as 11% after uterosacral ligament suspension (138). In a study of 46 women who underwent proximal uterosacral ligament vaginal vault suspension, three of the five women with cystoscopic evidence of obstruction were treated successfully by removing and replacing the sutures. This finding emphasizes the importance of confirming ureteral integrity at surgery. The value of cystoscopy to evaluate ureteral injury after minimally invasive hysterectomy is unknown because this injury is often thought to occur in association with thermal injury, and it is unclear whether obstruction or decreased ﬂow will be apparent intraoperatively.


Gynecology_Novak

Gynecology_Novak. Administering indigo carmine dye intravenously 5 minutes before cystoscopy aides in the assessment of ureteral patency. Quick efﬂux of stained urine should be seen bilaterally. Sluggish efﬂux should prompt further investigation. However, preexisting ureteral obstruction may be responsible for lack of ﬂow. In 157 women who underwent complex urogynecologic procedures, 5 cases (3.2%) of unsuspected ureteral obstruction were identified with intraoperative cystoscopy (139). One was caused by ureteral ligation, and the remaining four represented chronic ureteral obstruction resulting from pelvic organ prolapse (two cases), ureteropelvic junction obstruction (one case), and ureterovesical junction stenosis after prior transurethral resection of bladder cancer (one case).


Gynecology_Novak

Gynecology_Novak. Figure 26.14 Repair of apical vesicovaginal fistula. A: The fistula at the vaginal apex is exposed with adequate retraction. A pediatric foley can be placed into the fistula tract to aid in traction and dissection. B: The vaginal epithelium is dissected from the fistula to mobilize the tissue to allow for tension-free closure. In the classic Latzko procedure, the vaginal epithelium 2 cm around the opening of the fistula is removed. C: The fistula tract may either be completely excised, or in the Latzko procedure, the fistula edge may freshened up slightly but is not excised. D: Interrupted absorbable sutures are placed in an extramucosal location in an interrupted fashion. An additional layer of interrupted sutures is often placed to invert the initial suture line. The vaginal epithelium is then closed over the repair. In the classic Latzko procedure, the initial layer involves closure of the vagina over the fistula tract, then two additional layers with the vaginal epithelium result


Gynecology_Novak

Gynecology_Novak. is then closed over the repair. In the classic Latzko procedure, the initial layer involves closure of the vagina over the fistula tract, then two additional layers with the vaginal epithelium result in an apical colpocleisis. (Redrawn from original by Jasmine Tan.)


Gynecology_Novak

Gynecology_Novak. Figure 26.15 Cystoscopic view of normal-appearing trigone with left ureteral orifice visible.


Gynecology_Novak

Gynecology_Novak. Voiding Dysfunction Women are afﬂicted less commonly than men with voiding difficulties, but these disorders do occur in women and can be defined as emptying dysfunction resulting from relaxation of the pelvic ﬂoor musculature or failure of the detrusor muscle to contract appropriately. True outﬂow obstruction (defined as a detrusor pressure of more than 50 cm H2O in association with a urine ﬂow rate of less than 15 mL/sec) is rare in women and, when seen, is usually found in those who underwent obstructive bladder neck surgery for stress incontinence (140,141). For normal voiding to occur, the pelvic ﬂoor and urethral sphincter must relax, which should happen in conjunction with a coordinated contraction of the detrusor muscle that leads to complete bladder emptying. The bladder may be emptied by other mechanisms, such as by abdominal straining in the absence of a detrusor contraction or simply by relaxation of the pelvic ﬂoor. Complete bladder emptying is not the same as normal


Gynecology_Novak

Gynecology_Novak. be emptied by other mechanisms, such as by abdominal straining in the absence of a detrusor contraction or simply by relaxation of the pelvic ﬂoor. Complete bladder emptying is not the same as normal voiding. Some women may empty their bladders completely but only by expending great effort over several minutes. In such cases, voiding is clearly abnormal, even though the bladder is empty when voiding ceases. In the worst cases, voiding is both difficult and incomplete.


Gynecology_Novak

Gynecology_Novak. Causes Neurologic diseases, such as multiple sclerosis, may cause voiding difficulty as a result of detrusor-sphincter dyssynergia, in which the urethral sphincter contracts at the same time as the detrusor (143). Great effort is required to overcome urethral resistance; the patient voids with an interrupted stop-and-start stream and usually has a significant amount of residual urine.


Gynecology_Novak

Gynecology_Novak. Other causes of voiding difficulty include medications (such as antihistamines and anticholinergic agents), infections (in particular, herpes simplex virus, and urinary tract infections), obstruction (following bladder neck surgery, or in women with advanced pelvic organ prolapse), overdistension, severe constipation (particularly in the elderly), and, rarely, psychogenic factors. Fowler’s syndrome refers to unexplained urinary retention occurring as an isolated phenomenon (144). Such women usually are between 20 and 35 years of age. Commonly the first retention episode will be triggered by an event such as surgery or childbirth. Retention rarely resolves but is not associated with the development of other disorders.


Gynecology_Novak

Gynecology_Novak. Evaluation Evaluation of a woman with voiding difficulty begins with a careful physical examination. Advanced pelvic organ prolapse may contribute to urinary retention, but it is unlikely that prolapse above the level of the vaginal introitus will be the sole cause of retention. When in doubt, the woman can wear a pessary for a week to see whether elevating the prolapse reduces the voiding difficulty. Occasionally pelvic masses—in particular, low anterior myomas—may cause urinary retention. Abnormal findings detected during neurologic examination of the perineum and lower extremities may suggest the need to focus on the spine. Urodynamic evaluation will help determine whether the woman has an obstruction (manifested by high detrusor pressures during voiding or by no urethral relaxation during voiding) or whether the detrusor muscle is not contracting. The latter is not necessarily indicative of a neurogenic disorder in women, because a large minority of normal healthy women void by


Gynecology_Novak

Gynecology_Novak. during voiding) or whether the detrusor muscle is not contracting. The latter is not necessarily indicative of a neurogenic disorder in women, because a large minority of normal healthy women void by urethral and pelvic ﬂoor muscle relaxation alone, with no detrusor contraction. Cystourethroscopy may reveal an obstructing lesion, such as a polyp, tumor, ureterocele, or ball-valve stone. Usually, the evaluation reveals no obvious source, and treatment can commence.


Gynecology_Novak

Gynecology_Novak. Treatment The mainstay in the treatment of voiding difficulty is clean, intermittent self-catheterization (145). The most important protection against urinary tract infection is frequent and complete bladder emptying rather than avoiding the introduction of a foreign body into the bladder. Selfcatheterization allows the patient to accomplish this task using a small (14-Fr) plastic catheter that she inserts through the urethra into the bladder, draining its contents. The catheter is then removed, washed with soap and water, dried, and stored in a clean, dry place. Elaborate sterile procedures are not necessary. Bacteria are introduced into the bladder in this process, and the urine of women after self-catheterization regimens will always be colonized with bacteria; however, this condition should not be treated unless symptomatic infection occurs.


Gynecology_Novak

Gynecology_Novak. In addition to decreasing urinary urgency and incontinence caused by detrusor overactivity, neuromodulation of the sacral nerve roots may help women with nonobstructive urinary retention (122). In a trial of 177 patients with idiopathic urinary retention, those who had greater than 50% improvement in baseline voiding symptoms during a test stimulation period qualified for surgical implantation of InterStim. Of these, 37 were randomly assigned to early implantation, whereas 31 in the control group delayed implantation for 6 months. Improved voiding occurred in 83% of the implant group compared with 9% of the control group at 6 months (146). It appears that the long-term success rates of InterStim for urinary retention remain high. In a trial following patients for 5-years after implantation, 71% of the patients with urinary retention had successful outcomes (147). Although this technology requires a surgical procedure, many women favor this therapy over lifelong self-catheterization.


Gynecology_Novak

Gynecology_Novak. Mild sedatives are sometimes helpful in this process, as are α-blockers (e.g., prazosin, phenoxybenzamine, tamsulosin), which reduce urethral tone. Although cholinergic medications such as bethanechol chloride are successful in making strips of bladder muscle contract in a laboratory, there is little evidence that such drugs are helpful clinically (148). Most patients with disorders of bladder sensation experience pain rather than lack of bladder sensation. As with the treatment of most chronic pain disorders, the cause of most painful bladder conditions is unknown, and the therapies used are only partially successful. As a result, disorders of bladder sensation are among the most frustrating urogynecologic conditions to manage.


Gynecology_Novak

Gynecology_Novak. Bladder pain syndrome, often termed interstitial cystitis, is a poorly defined heterogeneous syndrome, and diagnostic criteria are changing continuously. The International Continence Society standardization report recommends adapting the term bladder pain syndrome, rather than interstitial cystitis, and defines painful bladder syndrome as “an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder associated with lower urinary tract symptom(s) of more than 6 weeks duration, in the absence of infection or other identifiable causes” (15). Urgency and pain are the defining characteristics of bladder pain syndrome (149). Several factors have inhibited advances in the understanding of interstitial cystitis, including the lack of specific diagnostic criteria, the lack of specific histopathologic changes, the unpredictable ﬂuctuation in symptoms, and the marked variability among patients in terms of symptoms, objective findings, and treatment


Gynecology_Novak

Gynecology_Novak. criteria, the lack of specific histopathologic changes, the unpredictable ﬂuctuation in symptoms, and the marked variability among patients in terms of symptoms, objective findings, and treatment responses (150).


Gynecology_Novak

Gynecology_Novak. The National Institute of Diabetes, Digestive, and Kidney Diseases (NIDDK) developed a research definition for interstitial cystitis that requires objective findings of glomerulations or a classic Hunner’s ulcer during hydrodistention of the bladder and subjective symptoms of bladder pain or urinary urgency in the absence of other urogenital pathology (151). Strict application of NIDDK criteria in one study would have misdiagnosed more than 60% of patients thought to definitely or possibly have interstitial cystitis (152). Many clinicians have challenged the clinical utility of the NIDDK research criteria, and most conceptualize interstitial cystitis as the end point on the spectrum of painful bladder disorders (153).


Gynecology_Novak

Gynecology_Novak. The prevalence of bladder pain syndrome varies widely depending on the diagnostic criteria utilized. When mild and moderately severe cases are considered, the syndrome is not rare (154). Estimates of prevalence in the United States range from 52 per 100,000 women in the population-based Nurses Health Study to as high as 1 in 4.5 women “with accurate diagnostic records” (155,156). The prevalence appears to be 6 to 15 times more common among women than men (155,157). The identification of risk factors for bladder pain syndrome is particularly challenging because of the typically long delay in diagnosis (154). The Interstitial Cystitis Database study confirms many of the previous epidemiologic observations: affected individuals are predominately female (92%), white (91%), and report an average age of symptom onset of 32.2 years (150,155).


Gynecology_Novak

Gynecology_Novak. Diagnosis A careful history should be obtained, along with a sterile urine specimen for analysis and culture. Many women treated repetitively for chronic cystitis take multiple courses of antibiotics on the basis of symptoms without ever having the presence of an infection confirmed by cultures. Detrusor overactivity may be the cause of frequency, urgency, and urge incontinence, but that is not usually a factor in dysuria or painful urination. Women older than 50 years (particularly those who smoke or are exposed to chemicals at work) are at risk for bladder cancer, and this possibility must be considered, especially if hematuria is present. Urinary cytologic assessment is sometimes helpful in detecting early tumors of the urinary tract, and cystoscopy and intravenous urography are mandatory in the evaluation of patients with hematuria.


Gynecology_Novak

Gynecology_Novak. Other possible causes for painful voiding must be considered in the differential diagnosis, including urethral diverticula; vulvar disease; endometriosis; chemical irritation from soaps, bubble bath, or feminine hygiene products; urinary stones; urogenital atrophy from estrogen deprivation; and sexually transmitted disease. The diagnosis of bladder pain syndrome or interstitial cystitis is largely one of exclusion. The ideal diagnostic test for interstitial cystitis is not determined, and there are myriad proposed tests. Treatment Typically, the evaluation of bladder pain syndrome results in no definitive diagnosis, and management focuses on the treatment of symptoms. Frequency–urgency syndromes should be managed with a careful voiding regimen (similar to that used in the treatment of urgency urinary incontinence) and local care.


Gynecology_Novak

Gynecology_Novak. Frequency–urgency syndromes should be managed with a careful voiding regimen (similar to that used in the treatment of urgency urinary incontinence) and local care. The use of urinary tract analgesics such as Prosed DS may be helpful in reducing urethral irritation. Prosed DS is a polypharmaceutical agent containing a mixture of methenamine, methylene blue, phenyl salicylate, benzoic acid, and hyoscyamine that has a soothing effect on many irritative urinary tract symptoms.


Gynecology_Novak

Gynecology_Novak. There is no scientific evidence linking diet to painful bladder syndrome, but many doctors and patients find that alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, and high-acid foods may contribute to bladder irritation and inﬂammation. Some patients note that their symptoms worsen after eating or drinking products containing artificial sweeteners. Patients may try eliminating various items from their diet and reintroducing them one at a time to determine which, if any, affect their symptoms. Instruction in the basics of vulvar and perineal hygiene is important (thorough drying; avoidance of most body powders, perfumes, or colored irritating soaps; avoidance of tight-fitting undergarments) to avoid other factors that may contribute to painful voiding.


Gynecology_Novak

Gynecology_Novak. Hydrodistention of the bladder (usually under anesthesia) is recommended as a treatment option and can result in clinical improvement in some patients. Likewise, bladder installations are commonly used for acute treatment of bladder pain syndrome. The medications used range from local anesthetics to bladder specific medications including resiniferatoxin, dimethyl sulfoxide, BCG, pentosan polysulfate, and oxybutynin. Some patients benefit from the instillation into the bladder of 50 mL of a 50% solution of dimethylsulfoxide (DMSO) for 20 to 30 minutes every other week for four or five sessions. A recent Cochran review found that evidence is limited and randomized controlled trials are needed to adequately assess outcomes. Intravesical installations of BCG and oxybutynin are reasonably well tolerated, and evidence is the most promising for these agents (157).


Gynecology_Novak

Gynecology_Novak. Tricyclic antidepressants are commonly used in patients with pain. A trial by the Interstitial Cystitis Collaborative Research Network found that amitriptyline plus education and behavioral modification did not significantly improve symptoms in the treatment of naive patients with bladder pain syndrome, but the network did suggest that it may be beneficial in those patients who could tolerate a daily dose of 50 mg or greater (158). Pentosan polysulfate (Elmiron) is an FDA-approved oral agent with heparin-like activity that attempts to replace the glycosaminoglycan sulfate layer that is believed deficient in these patients. The FDA-recommended oral dosage of pentosan polysulfate is 100 mg, three times a day. Patients may not feel relief from pain for the first 2 to 4 months, and it may take up to 6 months for a decrease in urinary frequency to occur.


Gynecology_Novak

Gynecology_Novak. It is theorized that bladder pain may result from increased histamine release, and some patients benefit from medications that block these inﬂammatory mediators, such as diphenhydramine hydrochloride, 25 to 50 mg orally three times per day, in combination with 300 mg of cimetidine three times per day. Tricyclic antidepressants help some women by modulating sensory nerve pain. Transcutaneous electrical nerve stimulation (TENS), through wires placed on the lower back or just above the symphysis, may help some women, though the mechanism of action is unclear. Ongoing preliminary research suggests that some women with severe bladder pain syndrome may find relief following sacral neuromodulation (InterStim), acupuncture, or intravesical Botox injection associated with hydrodistension. 1. DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994;170:1713–1723. 2.


Gynecology_Novak

Gynecology_Novak. 1. DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994;170:1713–1723. 2. Wall LL, Helms M, Peattie AB, et al. Bladder neck mobility and the outcome of surgery for genuine stress urinary incontinence: a logistic regression analysis of lateral bead-chain cystourethrograms. J Reprod Med 1994;39:429–435. 3. Sand PK, Bowen LD, Panganiban R, et al. The low pressure urethra as a factor in failed retropubic urethropexy. Obstet Gynecol 1987; 69:399–402. 4. Stay K, Dwyer PL, Rosamilia L, et al. Risk factors of treatment failure of midurethral sling procedures for women with urinary stress incontinence. Urogynecol J Pelvic Floor Dysfunct 2010;21:149–155. 5. Burnstock G. Nervous control of smooth muscle by transmitters, cotransmitters and modulators. Experientia 1985;41:869–874. 6. Burnstock G. The changing face of autonomic neurotransmission. Acta Physiol Scand 1986;126:67–91. 7.


Gynecology_Novak

Gynecology_Novak. 6. Burnstock G. The changing face of autonomic neurotransmission. Acta Physiol Scand 1986;126:67–91. 7. Daniel EE, Cowan W, Daniel VP. Structural bases of neural and myogenic control of human detrusor muscle. Can J Physiol Pharmacol 1983;61:67–91. 8. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic ﬂoor dysfunction. Neurourol Urodyn 2010;29:4–20. 9. U.S. Department of Health and Human Services. Urinary incontinence in adults: acute and chronic management. In: U.S. Public Health Service. Agency for Health Care Policy and Research. No. 96–0682. AHCPR Publications, 1996. 10. Frazer MI, Haylen BT, Sutherst JR. The severity of urinary incontinence in women: comparison of subjective and objective tests. Br JUrol 1989;63:14–15. 11. Nygaard I, DeLancey JO, Arnsdorf L, et al. Exercise and incontinence. Obstet Gynecol 1990;75:848–851. 12.


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Gynecology_Novak. 11. Nygaard I, DeLancey JO, Arnsdorf L, et al. Exercise and incontinence. Obstet Gynecol 1990;75:848–851. 12. Wall LL. Diagnosis and management of urinary incontinence due to detrusor instability. Obstet Gynecol Surv 1990;45:1S–47S. 13. Larrson G, Victor A. Micturition patterns in a healthy female population, studies with a frequency/volume chart. Scand J Urol Nephrol Suppl 1998;114:53–57. 14. Fitzgerald MP, Stablein U, Brubaker L. Urinary habits among asymptomatic women. Am J Obstet Gynecol 2002;187:1384– 1388. 15. Abrams P, Andersson KE, Birder L, et al. Fourth international consultation on incontinence recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn 2010;29:213–240. 16.


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Gynecology_Novak. 16. Hunskaar S, Burgio K, Diokno A, et al. Epidemiology and natural history of urinary incontinence. In: Abrams P, Cardozo L, Khoury S, et al., eds. Incontinence. Plymouth, UK: Plymbridge Distributors Ltd, 2002:165–201. 17. Resnick NM, Yalla SV. Management of urinary incontinence in the elderly. N Engl J Med 1985;313:800–805. 18. Resnick NM, Yalla SV, Laurine E. An algorithmic approach to urinary incontinence in the elderly. Clin Res 1986;34:832–837. 19. Stanton SL. Gynecologic complications of epispadias and bladder exstrophy. Am J Obstet Gynecol 1974;119:749–754. 20. Mitchell RJ. An ectopic vaginal ureter. J Obstet Gynaecol Br Commw 1961;68:299–302. 21. Ibeanu OA, Chesson RR, Echols KT, et al. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol 2009;113:6–10. 22. Tamussino KF, Lang PF, Breini E. Ureteral complication with operative gynecologic laparoscopy. Am J Obstet Gynecol 1998;178: 967–970. 23.


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Gynecology_Novak. 22. Tamussino KF, Lang PF, Breini E. Ureteral complication with operative gynecologic laparoscopy. Am J Obstet Gynecol 1998;178: 967–970. 23. Porcaro AB, Zicari M, Zecchini Antoniolli S, et al. Vesicouterine fistulas following cesarean section: report on a case, review and update of the literature. Int Urol Nephrol 2002;34:335–344. 24. Viktrup L, Lose G, Rolff M, et al. The symptom of stress incontinence caused by pregnancy or delivery in primiparas. Obstet Gynecol 1992;79:945–949. 25. Peschers UM, Schaer GN, DeLancey JO, et al. Levator ani function before and after childbirth. BJOG 1997;104:1004–1008. 26. DeLancey JO, Kearney R, Chou Q, et al. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 2003;101:46–53. 27. Snooks SJ, Swash M, Mathers SE, et al. Effect of vaginal delivery on the pelvic ﬂoor: a 5-year follow-up. Br J Surg 1990;77:1358–1360. 28.


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Gynecology_Novak. 27. Snooks SJ, Swash M, Mathers SE, et al. Effect of vaginal delivery on the pelvic ﬂoor: a 5-year follow-up. Br J Surg 1990;77:1358–1360. 28. Chiarelli P, Brown W, McElduff P. Leaking urine: prevalence and associated factors in Australian women. Neurourol Urodyn 1999;18:567–571. 29. Brown JS, Grady D, Ouslander JG, et al. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Heart and Estrogen/Progestin Replacement Study (HERS) Research Group. Obstet Gynecol 1999;94:66–70. 30. Hannestad YS, Rortveit G, Dalveit AK, et al. Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPICONT study. Br J Obstet Gynaecol 2003;110:247–254. 31. Subak LL, Wing R, Smith West D. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med 2009; 360:481–490. 32. Bissada NK, Finkbeiner AE. Urologic manifestations of drug therapy. Urol Clin North Am 1988;15:725–736. 33.


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Gynecology_Novak. 32. Bissada NK, Finkbeiner AE. Urologic manifestations of drug therapy. Urol Clin North Am 1988;15:725–736. 33. Ostergard DR. The effects of drugs on the lower urinary tract. Obstet Gynecol Surv 1979;34:424–432. 34. Wall LL, Addison WA. Prazosin-induced stress incontinence. Obstet Gynecol 1990;75:558–560. 35. Menefee SA, Chesson R, Wall LL. Stress urinary incontinence due to prescription medications: alpha-blockers and angiotensin converting enzyme inhibitors. Obstet Gynecol 1998;91:853–854. 36. Walters MD, Diaz K. Q-tip test: a study of continent and incontinent women. Obstet Gynecol 1987;70:208–211. 37. Artibani W, Andersen JT, Gajewski JB, et al. Imaging and other investigations. Plymouth, UK: Plymbridge Distributors Ltd, 2002. 38. Wall LL, Norton PA, DeLancey JOL. Practical urodynamics. Baltimore, MD: Williams & Wilkins, 1993. 39.


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Gynecology_Novak. 38. Wall LL, Norton PA, DeLancey JOL. Practical urodynamics. Baltimore, MD: Williams & Wilkins, 1993. 39. Richardson DA, Ramahi A, Chalas E. Surgical management of stress incontinence in patients with low urethral pressure. Obstet Gynecol Invest 1991;150:106–109. 40. Hilton P, Stanton SL. Urethral pressure measurement by microtransducer: the results in symptom-free women and in those with genuine stress incontinence. Br J Obstet Gynaecol 1983;90:919–933. 41. Weber AM. Is urethral pressure profilometry a useful diagnostic test for stress urinary incontinence? Obstet Gynecol Surv 2001;56:720– 735. 42. Culligan PJ, Goldberg RP, Blackhurst DW, et al. Comparison of microtransducer and fiberoptic catheters for urodynamic studies. Obstet Gynecol 2001;98:253–257. 43. Versi E, Cardozo LD, Studd JW, et al. Internal urinary sphincter in maintenance of female continence. BMJ 1986;292:166–167. 44.


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Gynecology_Novak. 43. Versi E, Cardozo LD, Studd JW, et al. Internal urinary sphincter in maintenance of female continence. BMJ 1986;292:166–167. 44. Neitlich JD, Foster HE Jr, Glickman MG, et al. Detection of urethral diverticula in women: comparison of a high resolution fast spin echo technique with double balloon urethrography. JUrol 1998;159:408–410. 45. Hay Smith J, Berghman B, Burgio K, et al. Adult conservative management. In: Abrams P CL, Khoury S, Wein A, eds. Incontinence. 4th ed. Paris, France: Health Publications, 2009:1025– 1120 46. Dumoulin C, Hay-Smith J. Pelvic ﬂoor muscle training versus no treatment, or inactive control treatment, for urinary incontinence in women for urinary incontinence in women. Cochrane Database Syst Rev 2010;1:CD005654. 47. Luber KM, Wolde-Tsadik G. Efficacy of functional electrical stimulation in treating genuine stress urinary incontinence: a randomized clinical trial. Neurourol Urodyn 1997;16:543–551. 48.


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Gynecology_Novak. 47. Luber KM, Wolde-Tsadik G. Efficacy of functional electrical stimulation in treating genuine stress urinary incontinence: a randomized clinical trial. Neurourol Urodyn 1997;16:543–551. 48. Sand PK, Richardson DA, Staskin DR, et al. Pelvic ﬂoor electrical stimulation in the treatment of genuine stress urinary incontinence: a multicenter, placebo-controlled trial. Am J Obstet Gynecol 1995;173:72–79. 49. Brubaker L, Benson JT, Bent AE, et al. Transvaginal electrical stimulation for female urinary incontinence. Am J Obstet Gynecol 1997;177:536–540. 50. Yamanishi T, Yasuda K, Sakakibara R, et al. Randomized, double-blind study of electrical stimulation for urinary incontinence due to detrusor overactivity. Urology 2000;55:353–357. 51. Burgio K. Current perspectives on management of urgency using bladder and behavioral training. J Am Acad Nurse Pract 2004;16: 4–9. 52.


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Gynecology_Novak. 51. Burgio K. Current perspectives on management of urgency using bladder and behavioral training. J Am Acad Nurse Pract 2004;16: 4–9. 52. Burgio KL, Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA 1998;280:1995–2000. 53. Goode PS, Burgio KL, Locher JL, et al. Effect of behavioral training with or without pelvic ﬂoor electrical stimulation on stress incontinence in women: a randomized controlled trial. JAMA 2003; 290:345–352. 54. Donnelly MJ, Powell-Morgan S, Olsen AL, et al. Vaginal pessaries for the management of stress and mixed urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2004;15:302–307. 55. Richter HE, Burgio KL, Brubaker L, et al. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol 2010;115:609–617. 56.


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Gynecology_Novak. 56. Sirls LT, Foote JE, Kaufman JM, et al. Long-term results of the FemSoft urethral insert for the management of female stress urinary incontinence. Intern Urogynecol J Pelv Floor Dys 2002;13:88–95. 57. Kernan WN, Viscoli CM, Brass LM, et al. Phenylpropanolamine and risk of hemorrhagic stroke. N Engl J Med 2000;343:1826–1832. 58. Nygaard I, Kreder KJ. Pharmacologic therapy of lower urinary tract dysfunction. Clin Obstet Gynecol 2004;47:83–92. 59. Grady D, Brown JS, Vittinghoff E, et al. The HERS Research Group. Postmenopausal hormones and incontinence: the Heart and Estrogen/Progestin Replacement Study. Obstet Gynecol 2001;97: 116–120. 60. Hendrix SL, Cochrane BB, Nygaard IE, et al. Effects of estrogen with and without progestin on urinary incontinence. JAMA 2005;293: 935–948. 61. Hartmann KE, McPheeters ML, Biller DH, et al. Treatment of overactive bladder in women. Evid Rep Technol Assess (Full Rep) 2009:1–120 62.


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Gynecology_Novak. 61. Hartmann KE, McPheeters ML, Biller DH, et al. Treatment of overactive bladder in women. Evid Rep Technol Assess (Full Rep) 2009:1–120 62. Janknegt RA, Zweers HM, Delaere KP, et al. Oral desmopressin as a new treatment modality for primary nocturnal enuresis in adolescents and adults: a double-blind, randomized, multicenter study. Dutch Enuresis Study Group. JUrol 1997;157:513–517. 63. Valiquette G, Abrams GM, Herbert J. DDAVP in the management of nocturia in multiple sclerosis. Ann Neurol 1992;31:577. 64. Ray WA, Griffin MR, Schaffner W, et al. Psychotropic drug use and the risk of hip fracture. N Engl J Med 1987;316:363–369. 65. Pedersen PA, Johansen PB. Prophylactic treatment of adult nocturia with bumetanide. BrJUrol 1988;62:145–147. 66. Black NA, Downs SH. The effectiveness of surgery for stress incontinence in women: a systematic review. Br J Urol 1996;78:497–510. 67.


Gynecology_Novak

Gynecology_Novak. 66. Black NA, Downs SH. The effectiveness of surgery for stress incontinence in women: a systematic review. Br J Urol 1996;78:497–510. 67. Leach GE, Dmochowski RR, Appell RA, et al. Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association. JUrol 1997;158:875–880. 68. Kelly HA, Dumm WM. Urinary incontinence in women without manifest injury to the bladder. Surg Gynecol Obstet 1914;18:444– 450. 69. Stanton SL, Cardozo LD. A comparison of vaginal and suprapubic surgery in the correction of incontinence due to urethral sphincter incompetence. BrJUrol 1979;51:497–499. 70. Bailey KV. A clinical investigation into uterine prolapse with stress incontinence treatment by modified Manchester colporrhaphy. I. J Obstet Gynaecol Br Emp 1954;61:291–301. 71.


Gynecology_Novak

Gynecology_Novak. 70. Bailey KV. A clinical investigation into uterine prolapse with stress incontinence treatment by modified Manchester colporrhaphy. I. J Obstet Gynaecol Br Emp 1954;61:291–301. 71. Colombo M, Vitobello D, Proietti F, et al. Randomised comparison of Burch colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and anterior vaginal wall prolapse. Br J Obstet Gynaecol 2000;107:544–551. 72. Beck RP, McCormick S. Treatment of urinary stress incontinence with anterior colporrhaphy. Obstet Gynecol 1982;59:269–274. 73. Beck RP, McCormick S. A 25-year experience with 519 anterior colporrhaphy procedures. Obstet Gynecol 1991;78:1011–1018. 74. Bergman A, Elia G. Three surgical procedures for genuine stress incontinence: five-year follow-up of a prospective randomized study. Am J Obstet Gynecol 1995;173:66–71. 75.


Gynecology_Novak

Gynecology_Novak. 74. Bergman A, Elia G. Three surgical procedures for genuine stress incontinence: five-year follow-up of a prospective randomized study. Am J Obstet Gynecol 1995;173:66–71. 75. O’Sullivan DC, Chilton CP, Munson KW. Should Stamey colposuspension be our primary surgery for stress incontinence? Br J Urol 1995;75:457–460. 76. Trockman BA, Leach GE, Hamilton J, et al. Modified Pereyra bladder neck suspension: 10-year mean follow-up using outcomes analysis in 125 patients. JUrol 1995;154:1841–1847. 77. Tebyani N, Patel H, Yamaguchi R, et al. Percutaneous needle bladder neck suspension for the treatment of stress urinary incontinence in women: long-term results. JUrol 2000;163:1510–1512. 78. Marshall VF, Marchetti AA, Krantz KE. The correction of stress incontinence by simple vesicourethral suspension. Surg Gynecol Obstet 1949;88:509–518. 79.


Gynecology_Novak

Gynecology_Novak. 78. Marshall VF, Marchetti AA, Krantz KE. The correction of stress incontinence by simple vesicourethral suspension. Surg Gynecol Obstet 1949;88:509–518. 79. Burch J. Urethrovaginal fixation to Cooper’s ligament for correction of stress incontinence, cystocele and prolapse. Am J Obstet Gynecol 1961;81:281–290. 80. Burch J. Cooper’s ligament urethrovesical suspension for stress incontinence: a nine-year experience—results, complications, technique. Am J Obstet Gynecol 1968;100:764–774. 81. Richardson AC, Lyon JB, Williams NL. Treatment of stress urinary incontinence due to paravaginal fascial defect. Obstet Gynecol 1981;57:357–362. 82. Shull BL, Baden WF. A six-year experience with paravaginal defect repair for stress urinary incontinence. Am J Obstet Gynecol 1989;160:1432–1440. 83. Turner-Warwick R. Turner-Warwick vagino-obturator shelf urethral repositioning procedure. New York: Springer-Verlag, 1988. 84.


Gynecology_Novak

Gynecology_Novak. 83. Turner-Warwick R. Turner-Warwick vagino-obturator shelf urethral repositioning procedure. New York: Springer-Verlag, 1988. 84. German KA, Kynaston H, Weight S, et al. A prospective randomized trial comparing a modified needle suspension procedure with the vagina/obturator shelf procedure for genuine stress incontinence. BrJUrol 1994;74:188–190. 85. Lapitan MC, Cody JD, Grant A. Open retropubic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev 2009;2:CD002912. 86. Moehrer B, Ellis G, Carey M, et al. Laparoscopic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev 2002;1:CD002239. 87. Parker RT, Addison WA, Wilson CJ. Fascia lata urethrovesical suspension for recurrent stress urinary incontinence. Am J Obstet Gynecol 1979;135:843–852. 88. Beck RP, McCormick S, Nordstrom L. The fascia lata sling procedure for treating recurrent genuine stress incontinence of urine. Obstet Gynecol 1988;72:699–703. 89.


Gynecology_Novak

Gynecology_Novak. 88. Beck RP, McCormick S, Nordstrom L. The fascia lata sling procedure for treating recurrent genuine stress incontinence of urine. Obstet Gynecol 1988;72:699–703. 89. Beck RP, Lai AR. Results in treating 88 cases of recurrent urinary stress incontinence with the Oxford fascia lata sling procedure. Am J Obstet Gynecol 1982;142:649–651. 90. Chaikin DC, Rosenthal J, Blaivas JG. Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis. JUrol 1998;160:1312–1316. 91. Cross CA, Cespedes RD, McGuire EJ. Our experience with pubovaginal slings in patients with stress urinary incontinence. JUrol 1998;159:1195–1198. 92. Breen JM, Geer BE, May GE. The fascia lata suburethral sling for treating recurrent urinary stress incontinence. Am J Obstet Gynecol 1997;92:747–750. 93. Stanton SL, Brindley GS, Holmes DM. Silastic sling for urethral sphincter incompetence. Br J Obstet Gynaecol 1985;92:747–750. 94.


Gynecology_Novak

Gynecology_Novak. 93. Stanton SL, Brindley GS, Holmes DM. Silastic sling for urethral sphincter incompetence. Br J Obstet Gynaecol 1985;92:747–750. 94. Horbach NS, Blanco JS, Ostergard DR, et al. A suburethral sling procedure with polytetraﬂuoroethylene for the treatment of genuine stress incontinence in patients with low urethral closure pressure. Obstet Gynecol 1988;71:648–652. 95. Rottenberg RD, Weil A, Brioschi PA, et al. Urodynamic and clinical assessment of the Lyodura sling operation for urinary stress incontinence. Br J Obstet Gynaecol 1985;92:829–834. 96. Wright EJ, Iselin CE, Carr LK, et al. Pubovaginal sling using cadaveric allograft for the treatment of intrinsic sphincter deficiency. JUrol 1998;160:759–762. 97. Amundsen CL, Visco AG, Ruiz H, et al. Outcome in 104 pubovaginal slings using freeze-dried allograft fascia lata from a single tissue bank. Urology 2000;56:2–8. 98. Kobashi KC, Dmochowski R, Mee S. Erosion of polyester pubovaginal sling. JUrol 1999;162:2070–2072. 99.


Gynecology_Novak

Gynecology_Novak. 98. Kobashi KC, Dmochowski R, Mee S. Erosion of polyester pubovaginal sling. JUrol 1999;162:2070–2072. 99. Clemons JQ, DeLancey JO, Faerber GJ, et al. Urinary tract erosions after synthetic pubovaginal slings: diagnosis and management strategy. Urology 2000;56:589–595. 100. Albo ME, Richter HE, Brubaker L, et al. Burch coloposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med 2007;356:2143–2155. 101. Heit M. What is the scientific evidence for bone anchor use during bladder neck suspension? Int Urogynecol J Pelvic Floor Dysfunct 2002;13:143–144. 102. Falconer C, Ekman-Ordeberg G, Malmstrom A, et al. Clinical outcome and changes in connective tissue metabolism after intravaginal slingplasty in stress incontinent women. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:133–137. 103.


Gynecology_Novak

Gynecology_Novak. 103. Ward KL, Hilton P. A prospective multicenter randomized trial of tension-free vaginal tape and colposuspension for primary urodynamic stress incontinence: two-year follow-up. Am J Obstet Gynecol 2004;190:324–331. 104. Dargent D, Bretones S, George P, et al. [Insertion of a sub-urethral sling through the obturating membrane for treatment of female urinary incontinence.] Gynecol Obstet Fertil 2002;30:576–582. 105. Delorme E, Droupy S, de Tayrac R, et al. Transobturator tape (Uratape): a new minimally-invasive procedure to treat female urinary incontinence. Eur Urol 2004;45:203–207. 106. Costa P, Gris P, Droupy S, et al. Surgical treatment of female stress urinary incontinence with a trans-obturator-tape (TOT): short term results of a prospective multicentric study. Eur Urol 2004;46:102– 106. 107. Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic sub-urethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev 2009;4:CD006375.


Gynecology_Novak

Gynecology_Novak. 107. Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic sub-urethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev 2009;4:CD006375. 108. Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versus transobturator midurethral slings for stress incontinence. N Engl J Med 2010;362:2066–2076. 109. De Ridder D, Berkers J, Deprest J, et al. Single incision mini-sling versus a transobutaror sling: a comparative study on MiniArc and Monarc slings. Int Urogynecol J Pelvic Floor Dysfunct 2010;21:773– 778. 110. Basu M, Duckett J. A randomised trial of a retropubic tension-free vaginal tape versus a mini-sling for stress incontinence. BJOG 2010;117:730–735. 111. Murless BC. The injection treatment of stress incontinence. J Obstet Gynaecol Br Emp 1938;45:67–73. 112.


Gynecology_Novak

Gynecology_Novak. 111. Murless BC. The injection treatment of stress incontinence. J Obstet Gynaecol Br Emp 1938;45:67–73. 112. Lightner D, Calvosa C, Andersen R, et al. A new injectable bulking agent for treatment of stress urinary incontinence: results of a multicenter, randomized, controlled, double-blind study of Durasphere. Urology 2001;58:12–15. 113. Ghoniem G, Corcos J, Comiter C, et al. Cross-linked polydimethylsiloxane injection for female stress urinary incontinence: results of a multicenter, randomized, controlled, single-blind study. JUrol 2009;204–210. 114. Ghoniem G, Corcos J, Comiter, et al. Durability of urethral bulking agent injection for female stress urinary incontinence: 2-year multicenter study results. JUrol 2010;183:1444–1449. 115. Mayer RD, Domochowski RR, Appell RA, et al. Multicenter prospective randomized 52-week trial of calcium hydroxlapatite versus bovine dermal collagen for treatment of stress urinary incontinence. Urology 2007;69:876–880. 116.


Gynecology_Novak

Gynecology_Novak. 116. Lightner D, Diokno A, Synder J. Study of Durasphere in the treatment of stress urinary incontinence: a multicenter, double blind randomized, comparative study. JUrol 2000;163:166. 117. Smith ARB, Daneshgari F, Dmochowski R. Surgical treatment of incontinence in women. In: Abrams P, Cardozo L, Khoury J, et al., eds. Incontinence. Plymouth, UK: Plymbridge Distributors, 2002. 118. Ward K, Hilton P. Prospective multicentre randomised trial of tension-free vaginal tape and colposuspension as primary treatment for stress incontinence. BMJ 2002;325:67. 119. Deng DY, Rutman M, RAz S, et al. Presentations ad management of major complications of midurethral slings: are complication underreported. Neurourol Urodyn 2007;26:46–52. 120. Kuuva N, Nilsson CG. A nationwide analysis of complications associated with the tension-free vaginal tape (TVT) procedure. Acta Obstet Gynecol Scand 2002;81:72–77. 121.


Gynecology_Novak

Gynecology_Novak. 120. Kuuva N, Nilsson CG. A nationwide analysis of complications associated with the tension-free vaginal tape (TVT) procedure. Acta Obstet Gynecol Scand 2002;81:72–77. 121. Schmidt RA, Jonas U, Oleson KA, et al. Sacral nerve stimulation for treatment of refractory urinary urge incontinence. Sacral Nerve Stimulation Study Group. JUrol 1999;162:352–357. 122. Siegel SW, Catanzaro F, Dijkema HE, et al. Long-term results of a multicenter study on sacral nerve stimulation for treatment of urinary urge incontinence, urgency-frequency, and retention. Urology 2000;56:87–91. 123. Janknegt RA, Hassouna MM, Siegel SW, et al. Long-term effectiveness of sacral nerve stimulation for refractory urge incontinence. Eur Urol 2001;39:101–106. 124. Herbison GP, Arnold EP. Sacral neuromodulation with implanted devices for urinary storage and voiding dysfunction. Cochrane Database Syst Rev 2009;2:CD004202. 125.


Gynecology_Novak

Gynecology_Novak. 124. Herbison GP, Arnold EP. Sacral neuromodulation with implanted devices for urinary storage and voiding dysfunction. Cochrane Database Syst Rev 2009;2:CD004202. 125. Peters KM, Carrico DJ, Perez-Marrero RA, et al. Randomized trial of percutaneous tibial nerve stimulation versus sham efficacy in the treatment of overactive bladder syndrome: results of the SUmiT trial. JUrol 2010;183:1438–1443. 127. Peters KM, MacDiarmid SA, Wooldridge, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the Overactive Bladder Innovative Therapy trial. JUrol 2009;182:1055–1061. 128. MacDiarmid SA, Peters K, Shobeiri SA, et al. Long-term durability of percutaneous tibial nerve stimulation for the treatment of overactive bladder. JUrol 2010;183:234–240. 129.


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Gynecology_Novak. 128. MacDiarmid SA, Peters K, Shobeiri SA, et al. Long-term durability of percutaneous tibial nerve stimulation for the treatment of overactive bladder. JUrol 2010;183:234–240. 129. Reitz A, Stohrer M, Kramer G, et al. European experience of 200 cases treated with botulinum-A toxin injections into the detrusor muscle for urinary incontinence due to neurogenic detrusor overactivity. Eur Urol 2004;45:510–515. 130. Brubaker L, Richter HE, Visco A, et al. Refractory idiopathic urge incontinence and botulinum A injection. JUrol 2008;180:217–222. 131. Greenwell TJ, Venn SN, Mundy AR. Augmentation cystoplasty. BJU Int 2001;88:511–525. 132. Yong SM, Dublin N, Pickard R, et al. Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy. Cochrane Database Syst Rev 2003;1:CD003306. 133.


Gynecology_Novak

Gynecology_Novak. 133. Fitzpatrick C, Elkins TE. Plastic surgical techniques in the repair of vesicovaginal fistulas: a review. Int Urogynecol J Pelvic Floor Dysfunct 1993;4:403–406. 134. Arrowsmith SD. Genitourinary reconstruction in obstetric fistula. JUrol 1994;152:287–295. 135. Menefee SA, Elkins T. Urinary fistula. Curr Opin Obstet Gynecol 1996;8:380–383. 136. Andersen JT, Gajewski JB, Ostergard DR. Imaging and other investigations. Plymouth, UK: Plymbridge Distributors, 2002. 137. Gilmour DT, Dwyer PL, Carey MP. Lower urinary tract injury during gynecologic surgery and its detection by intraoperative cystoscopy. Obstet Gynecol 1999;94:883–889. 138. Barber MD, Visco AG, Weidner AC, et al. Bilateral uterosacral ligament vaginal vault suspension with site-specific endopelvic fascia defect repair for treatment of pelvic organ prolapse. Am J Obstet Gynecol 2000;183:1402–1411. 139.


Gynecology_Novak

Gynecology_Novak. 139. Handa VL, Maddox MD. Diagnosis of ureteral obstruction during complex urogynecologic surgery. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:345–348. 140. Lose G, Jorgensen L, Mortensen SO, et al. Voiding difficulties after colposuspension. Obstet Gynecol 1987;69:33–38. 141. Carlson KV, Rome S, Nitti VW. Dysfunctional voiding in women. JUrol 2001;165:143–148. 142. Leng WW, Davies BJ, Tarin T, et al. Delayed treatment of bladder outlet obstruction after sling surgery: association with irreversible bladder dysfunction. JUrol 2004;172:1379–1381. 143. Rackley RR, Appell RA. Evaluation and management of lower urinary tract disorders in women with multiple sclerosis. Int Urogynecol J Pelvic Floor Dysfunct 1999;10:139–143. 144. Swinn MJ, Fowler CJ. Isolated urinary retention in young women, or Fowler’s syndrome. Clin Auton Res 2001;11:309–311. 145.


Gynecology_Novak

Gynecology_Novak. 144. Swinn MJ, Fowler CJ. Isolated urinary retention in young women, or Fowler’s syndrome. Clin Auton Res 2001;11:309–311. 145. Lapides J, Diokno AC, Silber SJ, et al. Clean, intermittent selfcatheterization in the treatment of urinary tract disease. JUrol 1972;107:458–461. 146. Jonas U, Fowler CJ, Chancellor MB, et al. Efficacy of sacral nerve stimulation for urinary retention: results 18 months after implantation. JUrol 2001;165:15–19. 147. van Kerrebroeck PE, van Voskuilen AC, Heesakkers JP, et al. Results of sacral neuromodulation for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. JUrol 2007;178:2029–2034. 148. Finkbeiner AE. Is bethanechol chloride clinically effective in promoting bladder emptying? A literature review. JUrol 1985;134:443– 449. 149. O’Leary MP, Sant GR, Fowler FJ Jr, et al. The interstitial cystitis symptom index and problem index. Urology 1997;49:58–63. 150.


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Gynecology_Novak. 149. O’Leary MP, Sant GR, Fowler FJ Jr, et al. The interstitial cystitis symptom index and problem index. Urology 1997;49:58–63. 150. Simon LJ, Landis JR, Erickson DR, et al. The Interstitial Cystitis Data Base Study: concepts and preliminary baseline descriptive statistics. Urology 1997;49:64–75. 151. Gillenwater JY, Wein AJ. Summary of the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases Workshop on Interstitial Cystitis, National Institutes of Health, Bethesda, Maryland, August 28–29, 1987. JUrol 1988;140:203–206. 152. Hanno PM, Landis JR, Matthews-Cook Y, et al. The diagnosis of interstitial cystitis revisited: lessons learned from the National Institutes of Health Interstitial Cystitis Database study. JUrol 1999; 161:553–557. 153. Clemons JL, Arya LA, Myers DL. Diagnosing interstitial cystitis in women with chronic pelvic pain. Obstet Gynecol 2002;100:337–341. 154.


Gynecology_Novak

Gynecology_Novak. 153. Clemons JL, Arya LA, Myers DL. Diagnosing interstitial cystitis in women with chronic pelvic pain. Obstet Gynecol 2002;100:337–341. 154. Oravisto KJ. Epidemiology of interstitial cystitis. Ann Chir Gynaecol Fenn 1975;64:75–77. 155. Curhan GC, Speizer FE, Hunter DJ, et al. Epidemiology of interstitial cystitis: a population based study. JUrol 1999;161:549– 552. 156. Parsons CL, Dell J, Stanford EJ, et al. Increased prevalence of interstitial cystitis: previously unrecognized urologic and gynecologic cases identified using a new symptom questionnaire and intravesical potassium sensitivity. Urology 2002;60:573–578. 157. Dawson TE, Jamison J. Intravesical treatment for painful bladder syndrome/interstitial cystitis. Cochrane Database Syst Rev 2007;4:CD006113. 158. Foster HE, Hanno PM, Nickel JC, et al. Effects of amitriptyline on symptoms in treatment naive patients with interstitial cystitis/painful bladder syndrome. JUrol 2010;183:1853–1858. R. Edward Varner


Gynecology_Novak

Gynecology_Novak. R. Edward Varner Jonathan L. Gleason Holly E. Richter Pelvic organ prolapse is an increasingly common condition seen in women with the aging of the population. Causes of pelvic organ prolapse are multifactorial and contribute to the weakening of the pelvic support connective tissue and muscles as well as nerve damage. Patients may be asymptomatic or have significant symptoms such as those related to the lower urinary tract, pelvic pain, defecatory problems, fecal incontinence, back pain, and dyspareunia. Physical examination includes thoughtful attention to all parts of the vagina, including the anterior, apical, and posterior compartments, levator muscle, and anal sphincter complex. Nonsurgical treatment options include pelvic ﬂoor muscle training and the use of intravaginal devices. Surgical treatment involves an individualized, multicompartmental approach consistent with the patient’s previous treatment attempts, activity level, and health status.


Gynecology_Novak

Gynecology_Novak. Surgical treatment involves an individualized, multicompartmental approach consistent with the patient’s previous treatment attempts, activity level, and health status. Studies are needed to determine the characteristics of those patients who would derive long-term benefit from vaginal versus abdominal approaches to the surgical repair of pelvic organ prolapse.


Gynecology_Novak

Gynecology_Novak. Pelvic organ prolapse (POP) is a bulge or protrusion of pelvic organs and their associated vaginal segments into or through the vagina (1). It is a common and costly afﬂiction of older women (2,3). It has been estimated that over the next 30 years, the demand for treatment of POP will increase 45%, commensurate with an increase in the population of women older than 50 years of age (4,5). As this problem grows in significance, it becomes increasingly important to comprehend the pathophysiology and risk factors associated with pelvic organ prolapse and try to prevent its occurrence. Furthermore, continued efforts are needed to understand factors that result in long-lasting, robust repair of pelvic organ prolapse for those patients undergoing surgical management. Despite extensive anecdotal experience, the optimal surgical approach to apical and other compartment prolapse remains elusive (6).


Gynecology_Novak

Gynecology_Novak. In the United States, 11% of women up to the age of 80 years have surgery for pelvic organ prolapse or urinary incontinence, and nearly one-third of procedures are repeat surgery (3). Data from the Women’s Health Initiative revealed anterior pelvic organ prolapse in 34.3%, posterior wall prolapse in 18.6%, and uterine prolapse in 14.3% of women in the study (7). In this study, a significant risk factor associated with prolapse was vaginal delivery. After adjusting for age, ethnicity, and body mass index, women with at least one vaginal delivery were twice as likely as nulliparous women to have pelvic organ prolapse. Causes of pelvic support disorders are most likely multifactorial, however; factors other than vaginal delivery also are associated with the development of these disorders. One study found that the incidence of prolapse doubled with each decade of life between the ages of 20 and 59 years (8). In another study, each year of increasing age was associated with a 12% increase


Gynecology_Novak

Gynecology_Novak. study found that the incidence of prolapse doubled with each decade of life between the ages of 20 and 59 years (8). In another study, each year of increasing age was associated with a 12% increase in the risk of developing prolapse (9). Other associated risk factors for the development of POP include history of hysterectomy (8), obesity (7,10,11), history of previous prolapse operations, and race (11).


Gynecology_Novak

Gynecology_Novak. Pelvic organ prolapse results from attenuation of the supportive structures, whether by actual tears or “breaks” or by neuromuscular dysfunction or both. Support of the vaginal canal is provided by the enveloping endopelvic connective tissue and its condensations at the vaginal apex, which form the cardinal uterosacral ligament complex. The endopelvic connective tissue is the first line of support, buttressed intimately with the pelvic diaphragm, composed of the levator ani and coccygeus muscles. These muscles provide a supportive diaphragm through which the urethra, vagina, and rectum egress (Fig. 27.1). The muscular support provides basal tonicity and support of the pelvic structures; when contracted, as in the setting of increased abdominal pressure, the rectum, vagina, and urethra are pulled anteriorly toward the pubis. The support system for the uterus and vagina has been described as consisting of three levels (12).


Gynecology_Novak

Gynecology_Novak. The support system for the uterus and vagina has been described as consisting of three levels (12). Level I refers to the uterosacral/cardinal ligament complex, which serve to maintain the vaginal length and axis. Level II support consists of the paravaginal attachments of the lateral vagina and endopelvic fascia to the arcus tendineus that maintain the midline position of the vagina. Level III support pertains to the distal vagina and is made up of the muscles and connective tissue surrounding the distal vagina and perineum. Definitions The more common pelvic support disorders include rectoceles and cystoceles (Fig. 27.2), enteroceles (Fig. 27.3), and uterine prolapse (Fig. 27.4); reﬂecting displacement of the rectum, small bowel, bladder, and uterus, respectively; resulting from failure of the endopelvic connective tissue, levator ani muscular support, or both (12).


Gynecology_Novak

Gynecology_Novak. A rectocele is a protrusion of the rectum into the vaginal lumen resulting from weakness in the muscular wall of the rectum and the paravaginal musculoconnective tissue, which holds the rectum in place posteriorly. An enterocele is a herniation of the peritoneum and small bowel and is the only true hernia among the pelvic support disorders. Most enteroceles occur downward between the uterosacral ligaments and the rectovaginal space, but they may also occur primarily apically, especially in the setting of a previous hysterectomy. A cystocele is descent of the urinary bladder with the anterior vaginal wall. Cystoceles usually occur when the pubocervical musculoconnective tissue weakens midline or detaches from its lateral or superior connecting points. Uterine prolapse is generally the result of poor cardinal or uterosacral ligament apical support, which allows downward protrusion of the cervix and uterus toward the introitus.


Gynecology_Novak

Gynecology_Novak. Uterine prolapse is generally the result of poor cardinal or uterosacral ligament apical support, which allows downward protrusion of the cervix and uterus toward the introitus. Procidentia, which involves prolapse of the uterus and vagina, and total vaginal vault prolapse, which can occur after hysterectomy, represent eversion of the entire vagina (Fig. 27.5). Figure 27.1 A sagittal view of the female pelvis with bladder and uterus removed (ureters, trigone, and cervix intact) illustrating anterior and posterior vaginal fibromuscular planes, their endopelvic fascial attachments, and a functional pelvic ﬂoor. (Redrawn by J. Taylor from Skandalakis JE, ed. Hernia: surgical anatomy and technique. New York: McGraw-Hill: 244–250.)


Gynecology_Novak

Gynecology_Novak. These descriptive terms are somewhat inaccurate and misleading, focusing on the bladder, rectum, small bowel, or uterus rather than the specific defects responsible for the alterations in vaginal support. Specific defect support issues will be discussed in the setting of the surgical management section. Pelvic support structures include: 1. The muscles and connective tissue of the pelvic ﬂoor 2. The fibromuscular tissue of the vaginal wall 3. The endopelvic connective tissue Figure 27.2 A: Sagittal section of the pelvis showing normal anatomy. B: Cystocele and rectocele. Figure 27.3 A: Posterior enterocele without eversion. B: Enterocele with eversion. Figure 27.4 Uterine prolapse with apical detachment from the uterosacral ligament complex and lateral wall detachment from the endopelvic connective tissue. Figure 27.5 Procidentia of the uterus and vagina. Endopelvic connective tissue includes: 1.


Gynecology_Novak

Gynecology_Novak. Figure 27.5 Procidentia of the uterus and vagina. Endopelvic connective tissue includes: 1. The cardinal/uterosacral complex, which attaches the upper vagina and cervix posteriorly 2. Lateral connective tissue attachments of the anterior vaginal wall to the arcus tendineus pelvis and of the posterior vaginal wall to the fascia of the levator ani and to the posterior arcus tendineus near the ischial spine 3. Less dense areolar connective tissue surrounding retroperineal portion of the pelvic organs


Gynecology_Novak

Gynecology_Novak. Less dense areolar connective tissue surrounding retroperineal portion of the pelvic organs The orientation of these structures is noted in Figure 27.1. In general, an intact pelvic ﬂoor, including a functional puborectalis muscle and an intact cardinal/uterosacral complex, should prevent pelvic organ prolapse by allowing posterior deﬂection of the rectum and vagina and compression of these structures against the pelvic ﬂoor in the upright position (Fig. 27.6). The fibromuscular layer of the vaginal wall and the other endopelvic connective tissue attachments augment the support structure and are particularly important when pelvic ﬂoor function is compromised.


Gynecology_Novak

Gynecology_Novak. Apical Compartment Normal apical support includes the integrity of the cardinal/uterosacral ligaments, the upper paravaginal fibromuscular connective tissue, and, when the uterus is present, the paracervical fascia. The fibromuscular tissue of the upper vagina blends in with the paracervical fascia. Both of these are attached laterally and posterior laterally to the cardinal ligaments and uterosacral ligaments (Fig. 27.1). The vaginal fibromuscular tissue is also


Gynecology_Novak

Gynecology_Novak. Figure 27.6 Vaginograms from the same patient at rest (A) and during Valsalva maneuver (B). Illustrates posterior vaginal deﬂection maintained by apical cardinal/uterosacral posterior suspension and the anterior sling effect of the puborectalis muscle and more distal perineal structures. (From Nichols DH, Randall CL. Vaginal surgery. 4th ed. Baltimore, MD: Williams & Wilkins, 1996:4–5, with permission.) attached to the upper anterior rectum at its sigmoid junction and forms the inferior border of the cul-de-sac of Douglas. The cardinal and uterosacral ligaments are condensations of areolar connective tissue and they contribute level I support for the vagina. Their origin is at the lateral borders of sacral vertebra 2 to 4, and they travel retroperitoneally to their insertion at the upper vagina and cervix (Fig. 27.1). They serve as the anterior and lateral borders of the cul-de-sac and cross at or just anterior to the ischial spines. The ureter is closest to the uterosacral ligament


Gynecology_Novak

Gynecology_Novak. vagina and cervix (Fig. 27.1). They serve as the anterior and lateral borders of the cul-de-sac and cross at or just anterior to the ischial spines. The ureter is closest to the uterosacral ligament at or just posterior to its insertion on the posterior lateral cervix. If anterior cephalad traction is placed on the ureter or cervix, frequently the cardinal uterosacral ligaments will stand out as ridges lateral to the cul-de-sac; however, peritoneal folds may have similar appearance. Therefore, placement of sutures in such structures based on visual appearance may not be reliable.


Gynecology_Novak

Gynecology_Novak. Defects in apical support include: 1. The loss of cardinal/uterosacral support with resultant cervical/uterine or vaginal cuff descent 2. The detachment of the fibromuscular vagina from the anterior rectum with resultant enterocele or, at times, sigmoidocele into the rectovaginal space 3. Tears or attenuation of the upper fibromuscular tissue, usually after hysterectomy, leading to a central apical descent that frequently presents as a ballooning defect Often, these defects occur concurrently. Defects in cardinal/uterosacral attachment are at sites close to their insertion into the cervix and upper vagina where breaks or tears occur; in those with apical descent, condensations of cardinal/uterosacral tissue can be found adjacent to the peritoneum just cephalad to the ischial spines (13).


Gynecology_Novak

Gynecology_Novak. Anterior Compartment The anterior vaginal compartment includes the anterior vaginal wall, its attachments, the urethra, and the bladder. The support structure for the bladder is the rhomboid-shaped anterior vaginal wall (specifically its fibromuscular layer), which is attached laterally to the arcus tendineus fascia (Fig. 27.7). Inferiorly, the fibromuscular layer blends in with the connective tissue, which spans the two bands of puborectalis and pubococcygeus muscles Figure 27.7 View of the pelvic cavity with bladder, upper vagina, and sigmoid colon removed. The fibromuscular wall of the anterior vagina is attached to the arcus tendineus fascia pelvis by endopelvic connective tissue and supports the bladder. The pararectal fascia (Denonvillier’s fascia) includes the fibromuscular tissue of the posterior vagina and its lateral attachment to the fascia levator ani.


Gynecology_Novak

Gynecology_Novak. and the pubic rami. The urethra appears to be preferentially supported by these connective tissues as well as by the pubourethral ligaments. In the apical area, the vaginal fibromuscular layer blends in with the precervical fascia and the connective tissue of the cardinal ligament complex. In the upright position, the rhomboid-shaped anterior vaginal wall is oriented approximately 30 degrees from the horizon (from pubis to ischial spines). There is some downward bulge of the central area of the rhomboid plate, which should be minimized by the back-stop effect of the posterior vagina and rectum if the pelvic ﬂoor anatomy and function are normal. Defects of this support structure may include tears or attenuation of the vaginal fibromuscular wall, or detachment from the pelvic sidewalls, the cervix or cardinal ligament complex, or from the pubis. Specific sites of fibromuscular tears are frequently difficult to recognize. Physical examination may reveal the following findings: 1.


Gynecology_Novak

Gynecology_Novak. Physical examination may reveal the following findings: 1. The presence of a central ballooning-type defect 2. Descent of the area of the vaginal wall below the bladder neck 3. Descent of the cervix or apical vaginal area 4. The presence or absence of sulci extending lateroanteriorly, which would indicate that lateral detachment to the arcus is maintained or lost. Posterior Compartment The support of the rectum and posterior vagina includes the pelvic ﬂoor musculature and connective tissue posteriorly and Denonvillier’s (pararectal) fascia, which is the fibromuscular layer of the posterior vaginal wall and its lateral attachments to the lateral pelvic ﬂoor (levator) musculature and its fascia (Fig. 27.8). This lateral attachment site, the fascia levator ani, fuses with the arcus tendineus fascia pelvis at the middle to upper level of the vagina


Gynecology_Novak

Gynecology_Novak. Figure 27.8 Sagittal oblique view of the distal midvagina illustrating lateral connection of the posterior musculoconnective tissue wall to the fascia levator ani and anterior wall to the arcus tendineus pelvis. The attachment sites fuse together at a point closer to the ischial spine where the vagina assumes a more oval shape. (Modified by J. Taylor from illustration by Lianne Krueger Sullivan. From Cundiff GW, Fenner D. Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction. Obstet Gynecol 2004;104:1403– 1421, erratum in Obstet Gynecol 2005;105:222, with permission.) and continues to the level of the ischial spine. Less dense, areolar, connective tissue surrounds the rectum and vagina and may supply some support to these structures as well.


Gynecology_Novak

Gynecology_Novak. The fibromuscular layer at the upper vagina fuses with the paracervical fascia and the fan-shaped cardinal ligament structure. The integrity of the attachment of this posterior vaginal layer to the anterior rectal wall just below the rectal sigmoid junction prevents enterocele formation. In the distal vagina, the fibromuscular layer fuses laterally with the fascia of the puborectalis and then the bulbocavernous muscle and centrally with the perineal connective tissue. Thus, normal posterior support includes a plate of connective tissue that is attached laterally as noted, posteriorly toward sacral segments 2 to 4, and inferiorly to the perineum. This fibromuscular plane not only holds the rectum in place posteriorly, but also aids in preventing perineal descent by suspending the perineum to the sacrum. The constant resting tone of the pelvic ﬂoor muscles, particularly the puborectalis, serve to close the genital hiatus, pulling the distal vagina and anorectal junction toward the pubic


Gynecology_Novak

Gynecology_Novak. the sacrum. The constant resting tone of the pelvic ﬂoor muscles, particularly the puborectalis, serve to close the genital hiatus, pulling the distal vagina and anorectal junction toward the pubic symphysis and creating an anorectal angle and a posterior deﬂection of the rectum, vagina, and bladder base.


Gynecology_Novak

Gynecology_Novak. It has been hypothesized, based on careful cadaveric dissections, that most rectoceles were due to discrete tears in the Denonvillier’s fascia at its lateral, apical, and perineal attachments and centrally within the fascia itself (14). Perineal detachment, along with a defect in the perineal membrane, has been described as a perineal rectocele, which is most commonly associated with reports of difficulty with defecation. Apical attachment defects are generally associated with enteroceles and occasionally sigmoidoceles.


Gynecology_Novak

Gynecology_Novak. Although as many as 50% of women older than age 50 have some degree of pelvic organ prolapse (15), fewer than 20% seek treatment (16). This may result from a number of causes, including lack of symptoms, embarrassment, or misperceptions about available treatment options. Although pelvic organ prolapse is not life threatening, it can impose a significant burden of social and physical restrictions of activities, impact on psychological well-being, and overall quality of life.


Gynecology_Novak

Gynecology_Novak. Symptoms Pelvic organ prolapse often is accompanied by symptoms of voiding dysfunction, including urinary incontinence, obstructive voiding symptoms, urinary urgency and frequency, and, at the extreme, urinary retention and upper renal compromise with resultant pain or anuria. Other symptoms often associated with POP include pelvic pain, defecatory problems (e.g., constipation, diarrhea, tenesmus, fecal incontinence), back and ﬂank pain, overall pelvic discomfort, and dyspareunia. Patients seeking care for prolapse may have one or several of these symptoms involving the lower pelvic ﬂoor. Choice of treatment usually depends on severity of the symptoms and the degree of prolapse consistent with the patient’s general health and level of activity (16).


Gynecology_Novak

Gynecology_Novak. Data relating pelvic ﬂoor symptoms to the extent and location of prolapse are weak (17–19). Any symptoms associated with physical findings of lower stage prolapse require careful evaluation, especially if surgery is being considered. A recent retrospective study of 330 patients reported that women with more advanced prolapse were less likely to have symptoms of stress incontinence and more likely to use manual reduction of the prolapse to void. Therefore, careful consideration of lower urinary tract symptoms is important. Prolapse severity was not associated with bowel or sexual problems in this study (20).


Gynecology_Novak

Gynecology_Novak. Physical Examination In evaluating patients with pelvic organ prolapse, it is particularly useful to divide the pelvis into compartments, each of which may exhibit specific defects. The use of a Graves speculum or Baden retractor can help to evaluate the apical compartment of the vagina. The anterior and posterior compartments are best examined with the use of a univalve or Sims speculum. The speculum is placed posteriorly to retract the posterior wall downward when examining the anterior compartment and placed anteriorly to retract the anterior wall upward when examining the posterior compartment. A rectovaginal examination may be useful in evaluating the posterior compartment to distinguish a posterior vaginal wall defect from a dissecting apical enterocele or a combination of both.


Gynecology_Novak

Gynecology_Novak. If an anterior lateral detachment defect is suspected, an open ring forceps (or a Baden retractor) may be placed in the vagina at a 45-degree angle posteriorly cephalad to hold the lateral fornices adjacent to the pelvic sidewall. During the evaluation of each compartment, the patient is encouraged to perform Valsalva so the full extent of the prolapse can be ascertained. If the findings determined with Valsalva are inconsistent with the patient’s description of her symptoms, it may be helpful to perform a standing straining examination with the bladder empty (20,21).


Gynecology_Novak

Gynecology_Novak. Many systems for staging prolapse have been described. Typically it is graded on a scale of 0 to 3 or 0 to 4, with the grade increasing with the severity of prolapse (22). Currently the system approved by the International Continence Society is the Pelvic Organ Prolapse Quantification system, or POP-Q (23). This standardized quantification system facilitates communication between physicians in practice and research and enables progression of these conditions to be followed accurately. In this system, anatomic descriptions of specific sites in the vagina are used in place of traditional terms. The system identifies nine locations in the vagina and vulva in centimeters relative to the hymen, which are used to assign a stage (from 0 to IV) of prolapse at its most advanced site (Fig. 27.9). Although probably more detailed than necessary for general practice, clinicians should be familiar with the POP-Q system because most published studies use it to describe research results. Its two most


Gynecology_Novak

Gynecology_Novak. probably more detailed than necessary for general practice, clinicians should be familiar with the POP-Q system because most published studies use it to describe research results. Its two most important advantages over previous grading systems are (i) it allows the use of a standardized technique with quantitative measurements at straining relative to a constant reference point (i.e., the hymen), and (ii) its ability to assess prolapse at multiple vaginal sites.


Gynecology_Novak

Gynecology_Novak. The classification uses six points along the vagina (two points on the anterior, middle, and posterior compartments) measured in relation to the hymen. The anatomic position of the six defined points should be measured in centimeters proximal to the hymen (negative number) or distal to the hymen (positive number), with the plane of the hymen representing zero. Three other measurements in the POP-Q examination include the genital hiatus, perineal body, and the total vaginal length (23).


Gynecology_Novak

Gynecology_Novak. Figure 27.9 Standardization of terminology for female pelvic organ prolapse (POP-Q) classification. This diagram demonstrates the anatomic position of the POP-Q sites, including six sites involving the anterior (Aa, Ba), middle (C, D), and posterior (Ap, Bp) compartments with the genital hiatus (gh), perineal body (pb), and total vaginal length (tvl). (From Bump RC, Mattiason A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic ﬂoor dysfunction. Am J Obstet Gynecol 1996;175:12, with permission.) The genital hiatus is measured from the middle of the external urethral meatus to the posterior midline hymen. The perineal body is measured from the posterior margin of the genital hiatus to the midanal opening. The total vaginal length is the greatest depth of the vagina in centimeters when the vaginal apex is reduced to its full normal position. All measurements except the total vaginal length are measured during maximal straining.


Gynecology_Novak

Gynecology_Novak. The anterior vaginal wall measurements are termed Aa and Ba, with the Ba point moving depending on the amount of anterior compartment prolapse. Point Aa represents a point on the anterior vagina 3 cm proximal to the external urethral meatus, which corresponds to the bladder neck. By definition, the range of position of this point is −3to +3. Point Ba represents the most distal or dependent point of any portion of the anterior vaginal wall from point Aa to just anterior to the vaginal cuff or anterior lip of the cervix. This point can vary depending on the nature of the patient’s support defect. For example, point Ba is −3 in the absence of any prolapse (it is never less than −3) to a positive value equal to the total vaginal length in a patient with total eversion of the vagina.


Gynecology_Novak

Gynecology_Novak. The middle compartment consists of points C and D. Point C represents the most dependant edge of the cervix or vaginal cuff after hysterectomy. Point D is the location of the posterior fornix; it is omitted if the cervix is absent. This point represents the level of the attachment of the uterosacral ligament to the posterior cervix. It is intended to differentiate suspensory failure from cervical elongation. The posterior compartment is measured similarly to the anterior compartment: the corresponding terms are Ap and Bp. The nine measurements can be recorded as a simple line of numbers (i.e., −3, −3, −8, −10, −3, −3, 11, 4, 3 for points Aa, Ba, C, D, Ap, Bp, total vagina length, genital hiatus, and perineal body, respectively). The six vaginal sites have possible ranges that depend on the total vaginal length (Table 27.1). After collection of the site-specific measurements, stages are assigned according to the most dependent portion of the prolapse (Table 27.2).


Gynecology_Novak

Gynecology_Novak. The POP-Q examination often appears confusing on initial review; however, a measuring device (i.e., a marked ring forceps or marked cotton-tip applicator) can assist in instructing those unfamiliar with this staging system. The POP-Q examination provides a standardized measurement system to allow for more accurate assessments of postoperative outcome and to ensure uniform, reliable, and site-specific descriptions of pelvic organ prolapse. There is interest in using the POP-Q examination to measure prolapse as a continuous variable rather than in stages because it would provide greater statistical power in clinical research (24). The American Urogynecology Society provides a video (25) that describes the POP-Q exam and demonstrates its use. In a clinical setting, at least three measurements should be obtained: the most advanced extent of the prolapse in centimeters relative to the hymen that affects the anterior vagina, the posterior vagina, and the cervix or vaginal apex.


Gynecology_Novak

Gynecology_Novak. As noted previously, whether the older staging systems or the POP-Q system is used, it is important to document the most pertinent findings on examination. This will help in documenting the baseline extent of prolapse and the results of treatment. Table 27.1 Possible Ranges of the Six Site-Specific Pelvic Organ Prolapse Quantitative Examination Measurements TVL, total vaginal length. Adapted from Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic ﬂoor dysfunction. Am J Obstet Gynecol 1996;175:11–12, with permission. Table 27.2 Stages of Pelvic Organ Prolapse From Bump RC, Mattiassion A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic ﬂoor dysfunction. Am J Obstet Gynecol 1996;175:13, with permission.


Gynecology_Novak

Gynecology_Novak. From Bump RC, Mattiassion A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic ﬂoor dysfunction. Am J Obstet Gynecol 1996;175:13, with permission. Pelvic muscle function should be assessed during the pelvic examination. Following bimanual examination with the patient in the lithotomy position, the examiner can palpate the puborectalis and pubococcygeus muscles inside the hymen along the pelvic sidewalls at approximately the 4 and 8 o’clock positions. One can appreciate basal muscle tone and whether there is increased tone with contraction as well as strength, duration, and symmetry of contraction (26). A recto-vaginal examination should also be performed to assess basal and contraction muscle tone of the anal sphincter complex.


Gynecology_Novak

Gynecology_Novak. As a part of the pelvic organ prolapse examination, urethral mobility often is measured. Many women with prolapse will have urethral hypermobility (defined as a resting urethral angle greater than 30 degrees or a maximal strain angle greater than 30 degrees). The presence of urethral mobility in combination with symptoms of stress incontinence may help determine whether an incontinence procedure should be performed. However, studies have shown that nearly all women with stage II to IV prolapse have urethral hypermobility, and asymptomatic parous women have an average maximum straining angle of 54 degrees (27,28). During pelvic examination, the urethra is typically swabbed with Betadine, and lidocaine jelly is placed in the urethra or on a cotton tip swab. The swab is placed in the urethra at the urethrovesical junction and, with the use of a goniometer (Fig. 27.10), the baseline urethral angle from the horizontal and maximal strain angles is measured.


Gynecology_Novak

Gynecology_Novak. Figure 27.10 Goniometer, which is used to measure baseline urethral angle and maximal strain angle of the urethra with a cotton tip swab in place.


Gynecology_Novak

Gynecology_Novak. Patients with prolapse exhibit the full range of lower urinary tract symptoms. Despite the fact that some patients may not have significant symptoms, it is important to obtain objective information about bladder and urethral function. With severe POP, the urethral kinking effect of the prolapse may mask a potential urine leakage problem; therefore, basic office bladder testing with prolapse reduction should be performed to mimic bladder and urethral function if the prolapse were treated. At a minimum, the following assessments should be performed: a clean catch or catheterized urine sample to test for infection, a postvoid residual (PVR) volume, and assessment of bladder sensation, which can be performed as a part of office cystometrics. Although there is no consensus as to what constitutes an abnormal PVR volume, provided the patient has voided 150 mL or more, a PVR less than or equal to 100 mL is acceptable (27). Reduction stress testing at the time of simple office cystometrics can


Gynecology_Novak

Gynecology_Novak. an abnormal PVR volume, provided the patient has voided 150 mL or more, a PVR less than or equal to 100 mL is acceptable (27). Reduction stress testing at the time of simple office cystometrics can be performed with the use of a pessary, large cotton swab, ring forceps, or the posterior blade of a speculum. Care should be taken that the urethra not be overly straightened (with a resultant false-positive test result) or obstructed (with a resultant false-negative test result), or that tension is not placed on the puborectalis muscles by excessive posterior retraction. These risks can be minimized by orienting the vaginal apex toward the sacrum.


Gynecology_Novak

Gynecology_Novak. Once a decision is made to perform surgical repair of the posterior compartment based on symptoms, type, and location of defects, an appropriate approach should be determined and the patient should be made aware of the expected outcomes and potential adverse effects such as pain and sexual dysfunction. If the patient has defecatory dysfunction with a rectocele and symptoms of constipation, pain with defecation, fecal or ﬂatal incontinence, or any signs of levator spasm or anal sphincter spasm, appropriate evaluation and conservative management of concurrent conditions could be initiated before repair of the rectocele and continued postoperatively (28).


Gynecology_Novak

Gynecology_Novak. Imaging Diagnostic imaging of the pelvis in women with pelvic organ prolapse is not routinely performed. However, if clinically indicated, tests that may be performed include ﬂuoroscopic evaluation of bladder function, ultrasound of the pelvis, and defecography for patients in whom intussusception or rectal mucosal prolapse are suspected. Magnetic resonance imaging is increasingly being used for the evaluation of pelvic pathology such as mullerian anomalies and pelvic pain; however, generalized use in women with prolapse is not currently clinically indicated and is used primarily for research purposes. Nonsurgical Therapy Nonsurgical therapy of pelvic organ prolapse includes conservative behavioral management and the use of mechanical devices. A nonsurgical treatment approach usually is considered in women with mild to moderate prolapse, those who desire preservation of future childbearing, those in whom surgery may not be an option, or those who do not desire surgical intervention.


Gynecology_Novak

Gynecology_Novak. Conservative Management Conservative management approaches include alteration of lifestyle or physical intervention such as pelvic ﬂoor muscle training (PFMT). These approaches are used mainly in cases of mild to moderate prolapse; however, their true role in managing prolapse and associated symptoms is unclear (29,30). The goals of a conservative therapy approach to the treatment of prolapse are as follows (31): Decrease the severity of symptoms Increase the strength, endurance, and support of the pelvic ﬂoor musculature Lifestyle intervention includes such activities as weight loss and reduction of those activities that increase intra-abdominal pressure. This interaction is typically anecdotal in practice. No case series, prospective studies, or randomized control trials exist that have examined the effectiveness of this approach to the treatment of prolapse.


Gynecology_Novak

Gynecology_Novak. Pelvic ﬂoor muscle exercises may limit the progression of mild prolapse and related symptoms (32,33); however, a lower response rate has been noted when prolapse extends beyond the vaginal introitus (34).


Gynecology_Novak

Gynecology_Novak. The efficacy of biofeedback therapy in the treatment of impaired defecation associated with a rectocele has been determined (35). Thirty-two female patients, median age 52 years (range, 34–77 years), experiencing impaired rectal evacuation with a rectocele greater than 2 cm at proctography underwent a structured behavioral retraining. Immediate and medium-term follow-up results were reported (median 10 months; range 2–30 months). Fifty-six percent of patients (n = 14) felt a little and 16% (n = 4) felt major improvement in symptoms, including 3 (12%) with complete symptom relief. Immediately after biofeedback there was a modest reduction in need to strain (67; 50%), feeling of incomplete evacuation (73; 59%), and need to assist defecation digitally (79; 63%) that was maintained at follow-up. Bowel movement frequency was significantly normalized at follow-up (p = .02). These investigators concluded that behavioral retraining, including biofeedback therapy, may be an effective primary


Gynecology_Novak

Gynecology_Novak. Bowel movement frequency was significantly normalized at follow-up (p = .02). These investigators concluded that behavioral retraining, including biofeedback therapy, may be an effective primary therapy for some patients with a rectocele associated with impaired defecation.


Gynecology_Novak

Gynecology_Novak. Mechanical Devices The use of mechanical devices such as pessaries is usually considered for women who cannot undergo surgery for medical reasons, desire to avoid surgery, or have a significant degree of prolapse that makes other nonsurgical approaches unfeasible. Some practitioners extend indications to include pregnancy-related prolapse as well as prolapse and incontinence in elderly women. Reports have shown that age older than 65 years, the presence of severe medical comorbidity, and sexual activity were associated with successful pessary user (36,37). Unsuccessful use or a preference for surgery has been associated with a shortened vaginal length (≤6 cm), a wide vaginal introitus, sexual activity, stress incontinence, stage III or IV posterior compartment prolapse, and desire for surgery at a first office visit (38). Few literature-based reviews and reports recommend pessaries as first-line treatment for women with POP, and there is little consensus regarding choice of pessary


Gynecology_Novak

Gynecology_Novak. at a first office visit (38). Few literature-based reviews and reports recommend pessaries as first-line treatment for women with POP, and there is little consensus regarding choice of pessary and management of pessary usage (39). Most of the information on pessary use is derived primarily from descriptive and retrospective studies, relatively small prospective series, manufacturer’s recommendations, and anecdotal experience.


Gynecology_Novak

Gynecology_Novak. Pessaries provide pelvic organ support within the vaginal vault. Two categories of pessaries— support and space filling—exist for prolapse (39). The ring pessary (with diaphragm) is a commonly used support pessary, and the Gelhorn pessary is a commonly used space-filling pessary. The ring and other support pessaries are recommended for stage I and II prolapse, whereas the space-filling pessaries are used for stage III and IV prolapse (40). It is unclear whether pessaries can prevent the progression of POP with regular use. A prospective cohort study addressed this issue in a series of 56 women who were fitted with a pessary, of which 33.9% (n = 19) continued use for at least 1 year (41). Baseline and follow-up pelvic examinations were performed using the POP-Q system (23). The women removed the pessary 48 hours before one visit, but there was no information to ascertain adherence to pessary use. No woman had worsening of the prolapse, and four women (21.1%; 95% confidence interval


Gynecology_Novak

Gynecology_Novak. the pessary 48 hours before one visit, but there was no information to ascertain adherence to pessary use. No woman had worsening of the prolapse, and four women (21.1%; 95% confidence interval [CI], 0.2%–43.7%) had an improvement. Improvement overall was noted in women with anterior compartment prolapse.


Gynecology_Novak

Gynecology_Novak. In women with stages I and II prolapse with stress urinary incontinence, a continence pessary may be considered and has been shown to produce patient satisfaction above 50% at 12 months (42). There are no randomized controlled trials of pessary use in women with POP (43). Likewise, there are no consensus guidelines on the care of pessaries (i.e., intervals between changes), the role of local estrogens, or the type of pessary indicated for specific types of POP (43). Manufacturers recommendations and different pessary types can be seen in Figure 27.11. Effective and satisfactory outcomes have been reported for stage II or greater prolapse using the Gelhorn and ring diaphragm pessary (36). After 2 to 6 months, 77% to 92% of women with a successful pessary fitting were satisfied and, using intention-to-treat analysis, 44% to 67% of all women who were treated initially with a pessary for prolapse were satisfied. There are few other series describing pessary use for prolapse with greater


Gynecology_Novak

Gynecology_Novak. intention-to-treat analysis, 44% to 67% of all women who were treated initially with a pessary for prolapse were satisfied. There are few other series describing pessary use for prolapse with greater than 4 weeks follow-up (36,38,44,45).


Gynecology_Novak

Gynecology_Novak. Possible complications associated with pessary use include vaginal discharge and odor. Failure to retain the pessary may occur or, conversely, the pessary may be too large, which could lead to excoriation or irritation. With reduction of vaginal prolapse, de novo or Figure 27.11 Pessaries used to treat the various degrees of prolapse. (Milex Company, a Division of Cooper Surgical.) increased stress incontinence may occur, and in rare instances, more severe complications, including vesicovaginal or rectovaginal fistula, small bowel entrapment, hydronephrosis, and urosepsis, have been described (46–48).


Gynecology_Novak

Gynecology_Novak. Pessary placement involves consideration of a number of issues, primarily the patient’s desire and motivation to use this type of device. Typically, if she has had previous surgery or strongly desires to avoid surgery, she may be motivated enough for a primary attempt at pessary placement. Other issues include current sexual function status, type and duration of exercise in which the patient engages, and the status of the vaginal walls and cervix. In hypoestrogenic women, treatment of the vagina with estrogen and maintenance of intravaginal estrogen treatment is recommended. The patient should be examined in the lithotomy position after emptying her bladder.


Gynecology_Novak

Gynecology_Novak. The patient should be examined in the lithotomy position after emptying her bladder. The clinician should use a dry glove to better grasp the pessary and water-soluble lubricants as needed. The size of the pessary is estimated after a digital examination and use of ring forceps to reduce the prolapse or bladder neck. Once the approximate size is determined, the appropriate type is selected based on the patient’s needs and activity level. When fitted, the patient is asked to stand, perform Valsalva, and cough to ensure the pessary is retained. The pessary should be assessed to ensure it is providing the desired support and leakage control. The patient should be able to void with the pessary in place before leaving the office. Proper size is ensured by the ability to sweep the index finger between the pessary and the vaginal wall. The patient should feel comfortable with the pessary in place.


Gynecology_Novak

Gynecology_Novak. Insertion of the pessary is eased by using a water-soluble lubricant for insertion, folding or collapsing the pessary to reduce its size, and when it is inside the vagina, pushing it high to an area behind the symphysis pubis and inserting the device more posteriorly to avoid the urethra. Instructing the patient how to insert and remove the pessary may be done with the patient in a standing or supine position, depending on her dexterity (49).


Gynecology_Novak

Gynecology_Novak. Ring pessaries, with or without support, are the most commonly used type. They are the easiest to fold, insert, and remove. Gellhorn and cube pessaries are typically more difficult to insert and remove by the patient. They are held in place by significant space occupation and suction and offer strong support. The suction of the cube pessary needs to be broken, facilitating removal. Cube pessaries should be removed daily; Gelhorns can stay in longer (up to 6–8 weeks). Donut pessaries, which are very popular, are considered a space-fitting pessary for large vaginal vault prolapse, complete procidentia with decreased perineal support, and good introital integrity. The patient should be questioned about a latex allergy and instructed to remove and clean the device every 2 to 3 days. Continence pessaries, rings, and dishes with support typically also are easy to fold, insert, and remove (50).


Gynecology_Novak

Gynecology_Novak. After the initial fitting, the patient should return in 1 to 2 weeks and then at 4 to 6 weeks, depending on her independence with the pessary, her proficiency in placement and removal, and her cognitive and motor abilities (44). After this initial follow-up, follow-up should continue at 6-to 12-month intervals at the discretion of the provider and depending on the patient’s ability to insert and remove the pessary effectively. If the patient needs to return to the provider for removal and cleaning of the pessary, 4-to 12-week intervals are more appropriate. On follow-up visits, proper placement of the pessary and support of the prolapse as well as continence efficacy should be ensured. Because pessaries are fitted through a process of trial and error, it is not uncommon to change the size or type at least once after the initial fitting. The pessary’s integrity should be checked, and the tissues should be evaluated for irritation, pressure sores, ulceration, and lubrication (44).


Gynecology_Novak

Gynecology_Novak. Surgical Management The primary aims of surgery are to relieve symptoms, which may be caused by prolapse, and, in most cases, to restore vaginal anatomy so that sexual function may be maintained or improved without significant adverse effects or complications. Occasionally, when sexual function is not desired, obliterative or constrictive surgery is more appropriate and also may relieve symptoms. There is no steadfast rule as to when surgery is indicated. Many patients with more advanced prolapse have few or no symptoms, whereas some with lesser degrees of prolapse have what they describe as severe symptoms. This is confounded by the observation that many of the “symptoms” may not be specifically related to the anatomic defect or may be worsened by anxiety. In general, surgery should be offered to patients who have tried conservative therapy and were not satisfied with the results or who do not desire conservative therapy. The prolapse should be symptomatic or should be greater than


Gynecology_Novak

Gynecology_Novak. offered to patients who have tried conservative therapy and were not satisfied with the results or who do not desire conservative therapy. The prolapse should be symptomatic or should be greater than or equal to stage II with apparent progression. All patients should be given the alternative of trying conservative treatments when applicable (51).


Gynecology_Novak

Gynecology_Novak. Approaches to surgery include vaginal, abdominal, and laparoscopic routes, or a combination of approaches. Depending on the extent and location of prolapse, surgery may involve a combination of repairs directed to the anterior vagina, vaginal apex, posterior vagina, and perineum. Concomitant surgery may be planned for urinary or fecal incontinence. The surgical route is chosen based on the type and severity of prolapse, the surgeon’s training and experience, the patient’s preference, and the expected or desired surgical outcome. Procedures for prolapse can be broadly categorized into three groups: (i) restorative, which use the patient’s endogenous support structures; (ii) compensatory, which attempt to replace deficient support with permanent graft material; and (iii) obliterative, which close or partially close the vagina (51).