Urogynecology

The field of Urogynecology is a subspecialty within Obstetrics and Gynecology and is dedicated to the study and treatment of pelvic floor disorders in women, in all the various ways that it can present itself. Urogynecology involves the diagnosis and treatment of urinary incontinence and female Pelvic Relaxation or Pelvic Organ Prolapse.

Incontinence and pelvic floor problems are remarkably common but many women are reluctant to receive help because of the stigma associated with these conditions.

Pelvic floor conditions are more common than hypertension, depression, or diabetes. One in three adult women have hypertension; one in twenty adult women have depression; one in ten adult women have diabetes; and more than one in two adult women suffer from pelvic floor dysfunction.

Pelvic Relaxation or Pelvic Organ Prolapse occurs when the female pelvic organs fall from their normal position, into or through the vagina. Occurring in women of all ages, it is more common as women age, particularly in those who have delivered large babies or had exceedingly long pushing phases of labor. Smoking, obesity, connective tissue disorders, upper respiratory disorders‚ and repetitive strain injuries can all increase prolapse risk.

Minor prolapse can be treated with exercises to strengthen the pelvic floor muscles; more serious prolapse, e.g., complete procidentia, requires pessary use or reconstructive surgical treatment. Reconstructive pelvic prolapse surgery may be done without resorting to complete hysterectomy by hysteropexy, the resuspension of the prolapsed uterus.

Traditional gynecologic practice favors removal of the uterus or ovaries (or both) at the time of prolapse surgery, and one estimate states that of the 600,000 hysterectomies performed in the United States every year, 13 percent are for prolapse. However, there is concern that many of these hysterectomies may be unnecessary and that hysteropexy would suffice as a treatment instead.

The rectum or urinary bladder may also prolapse as a result of changes in the integrity of connective tissue in the posterior or anterior vaginal walls, respectively. Symptoms may include a feeling of pressure in the pelvis, or the visible protrusion of organs from the vagina. This is known as severe pelvic organ prolapse POP-Q grade 3-4.

Most of the patients do not receive treatment because the symptoms are not noticeable or not severe. Anyway, there are some people who do not go through a treatment course because of their shyness or because they do not know that pelvic organ prolapse can be treated. Although some studies found that there are a large number of people having pelvic organ prolapse in the world, not many people actually seek for their medical treatment. The reason of this situation can possibly be the thought that pelvic organ prolapse is just only a natural cause and cultural customs which are different in each country.

The cause of pelvic organ prolapse is pelvic area muscle degeneration. Its factors are:

Heredity
Age, especially when reaching menopausal age which estrogen is not produced sufficiently.
Pregnancy and vaginal delivery, especially in difficult birth and instrumental vaginal delivery
Circumstances where there are increase of abdominal pressure such as coughing, chronic sneezing, constipation, lifting heavy objects and obesity

Pelvic organ prolapse can be categorized as:

Uterine prolapse
Anterior vaginal wall prolapse
Posterior vaginal wall prolapse
Occurrence of all mentioned above at a time

The symptoms of pelvic organ prolapse are divided into 3 groups:

1) General symptoms directly associated with pelvic organ prolapse:

A woman complains she feels ‘full’ or ‘heavier’ than normal.
Difficulty in walking or running associated with severe uterine prolapse.
Enlarged, wide, and gaping vaginal opening, this is a common symptom of a vaginal vault prolapse.
Protrusion of tissue at the back wall of the vagina, this is a common symptom of a rectocele.
Protrusion of tissue at the front wall of the vagina, this is a common symptom of a cystocele or urethrocele.
Pain that increases during long periods of standing, this may be indicative of an enterocele, vaginal vault prolapse, or prolapsed uterus.

2) Symptoms of Pelvic Organ Prolapse associated with sexual intercourse:

Pain
No gratification or orgasm
Infrequent sexual intercourse
Urinary incontinence while having the sexual intercourse

3) Symptoms associated with bowel and urinary symptoms of pelvic organ prolapse:

Chronic constipation
Pressure on the vagina
Frequent bladder infection
Difficulty in completely emptying the bladder and bowel
Frequent urination and constantly being impelled to urinate
Urinary incontinence while coughing, sneezing, or from heavy lifting

There are 4 stages of pelvic organs prolapse:

1^st stage – The relaxation of the birth canal.
2nd stage – There is occurrence of relaxation of the birth canal and the tissues of the vaginal wall are coming outside.
3rd stage – There is occurrence of relaxation of the birth canal and some parts of the vaginal wall tissue prolapsed. It can be seen outside the vulva.
4th stage – Vaginal wall relaxation is severe. All the vaginal wall tissue prolapsed and is apparently visible outside the vulva.

Pelvic organ prolapse diagnostic options:

Diagnosis of pelvic organ prolapse begins with your history and a physical exam of your pelvic organs to help your doctor determine the type of prolapse.

There are many diagnostic tests that can be performed to determine what types of POP a woman may have. Some of the most common tests performed are:

Pelvic floor strength tests : Your doctor will test the strength of your pelvic floor and sphincter muscles at the time of your physical examination. This tests the strength of muscles and ligaments that support the vaginal walls, uterus, rectum, urethra and bladder.

Bladder function tests : Some tests are as simple as finding out whether your bladder leaks when it is put back into place at the time of your physical exam. Other tests might measure how well your bladder empties. Seeing these results can help you and your doctor determine the most appropriate type of management for prolapse.

Magnetic resonance imaging (MRI) : An MRI creates a detailed, 3-D image of your pelvis and is useful only in complex cases.

Ultrasound : An ultrasound helps your doctor view your kidneys, bladder and the muscles around your anus and is useful only in complex cases.

Urodynamic Study : Urodynamic testing can be considered to evaluate urinary incontinence and to rule out potential incontinence. completely painless computerized bladder and urethral function exam is conducted. This takes about 40-60 minutes to complete.

The different pelvic organ prolapse is the following.

Pelvic Support Defects (Categorized By Affected Organ (s)):

1. Cystocele (the bladder protrudes into the vagina)

A woman’s bladder ascends or falls from its regular position. With a Cystocele, you will find it extremely difficult to completely void your bladder. This affliction can potentially cause bladder infections.

Large Cystocele can actually overfill the bladder, thus you will notice urine trickling from your urethra. This leakage tends to occur when a woman is walking or having a coughing fit.

2. Urethrocele (prolapse of the urethra into the vagina)

A woman’s urethra prolapses into the vagina. A Urethrocele usually develops in conjunction with a Cystocele. Coupled, these conditions cause involuntary urine loss.

Urine leakage incidences are more frequent and intense when abdominal pressure rises (while walking, jumping, coughing, sneezing, laughing, making sudden movements, etc.).

3. Rectocele (the rectum protrudes into the vagina)

A woman’s rectum protrudes into or out of the vagina. Rectoceles usually result from injuries sustained during the birthing process. When the rectum is weakened or projected outwards, bowel movements become more difficult and less frequent.

4. Enterocele (a part of the small intestine prolapse into the vagina)

A section of a woman’s small intestine (small bowel) bulges into the posterior vaginal wall.

5. Uterine Prolapse (uterus protrudes downward into the vagina)

A woman’s uterus falls or drastically shifts from its normal position. There are ‘severity degree classifications’ applied during Uterine Prolapse diagnostic testing.

These varying degrees are essentially based the amount of organ descent. Women may feel as if their ‘uterus is falling out’. At the same time, it is not uncommon to have a persistent ‘heavy’ or ‘full’ sensation.