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• Common Complaints
• Differential Diagnosis
• Anatomy of Pelvic Support
• Physical Findings
• Treatment Plan
• Urinary Incontinence
• Handouts

Common Complaints:  "Something feels like it is following out."  I feel pressure in my vagina"  "I have trouble passing my stool and I have to put my fingers in my vagina so that I can have a bowel movement."

Differential Diagnoses:

Uterine Decenses
Cystocele.  SUI is not ordinarily related to cystocele.
Rectocele
Enterocele
Urethrocele
Vulva, vaginal, perineal, rectal mass

Anatomy of Pelvic Support

A.  Bony pelvis

The human pelvis has an exaggerated lumbar spinal curve and downward tilted pelvis.  The bladder rests on the symphysis and the posterior organs rest on the sacrum and coccyx.  The pelvis helps to hold the pelvic organs, however, the erect human posture causes a funneling effect and downward pressure to the pelvic organs.  

B.  Pelvic and perineal musculure

The muscles of the deep and superficial layers offer considerable support yet allows considerable temporary expansion for vaginal delivery and defecation.

C.  Ligaments and fascia

Uterosacral and round ligaments help support the uterus.  They do not actually hold the uterus up.  Broad ligament plays no role in support.  The "cardinal ligaments: are actually blood vessels and lymphatic channels traveling between the pelvic walls and the uterus at the level of the cervix.  They gain their strength from the condensation of fibrous tissue around them.

Support of the pelvic viscera and intra-abdominal contents present a significant anatomic engineering problem.  There are many forces and events during a woman's lifetime that may diminish the support and strength of the pelvic floor.  The main factor is vaginal delivery.  The tome and strength of the pelvic floor after pregnancy and delivery are rarely fully retained.  Other factors include obesity, lifting, chronic cough, laughing, withdrawal of estrogen, abdominal tumors, straining at stool.

Physical Findings:

Cervix has descended spontaneously during pelvic exam or with Valsalva or upright position.  Bulge anteriorally or posteriorally.

Degree of prolapse (of uterus):

1st.  Just a little
2nd  Introitus
3rd  Just beyond introitus
4th  Completely out

Treatment Plan:

Kegals
Behavioral changes.  Avoid heavy lifting;  lose weight; stop smoking to decrease chronic cough
Medication.  Estrogen, local or systemic
Pessaries
Surgery.  Repair usually with hysterectomy.

ICD-9-CM  Genital prolapse(fourth digits 1-9)

Genital relaxation
Uterine decensus
Procedentia
Dropped uterus

Urinary Incontinence

Chief complaint:  "I'm here because I'm loosing urine and it really embarrasses me.  I have to wear a pad because I leak so much."

Review the physiology and anatomy of the bladder and urethra.  In general continence is a relaxed bladder and a contracted sphincter.  The pubococycygeus muscle is central.

History Questions:

• Do you have problems with your bladder?
• Do you ever lose urine when you don't want to?
• Do you wear anything to protect your clothes from getting wet?
• Do you have trouble holding onto your urine until you get to the bathroom?
• Do you loose urine with physical activity (coughing, sneezing, exercise?
• Do you ever find that you have lost control of your urine, without any urge or specific activity?
• Do you lost just a few drops, or enough to soak a pad or soil your clothing?
• Do you have a chronic cough?  Do you smoke?
• Do you strain to have a bowel movement?
• How often do you normally urinate during the day?  Remember to use terms such as "pee" and "wet" and "pass your water"
• How often do you awaken during the night to urinate?
• What is your normal fluid intake, spicy foods?
• What activities have you given up because of your bladder problem?
• How much does your bladder problem bother you?

Physical:

• Assess perineal tone and rectal tone.
• Neruo exam.

Differential Diagnoses

• Neruological disorder such as Multiple Sclerosis.  May be one of the first symptoms.
• UTI
• Drugs such as alpha blockers (relaxes the bladder neck) Note:  this is a beneficial side effect or effect for men with BPH (benign prostatic hypertrophy).  Drugs are the "zozins".  Diuretics, anticholinergics.
• Diabetes,

Tests:

• UA
• Post voiding residual.  Should be less than 100cc

Work-up:

Voiding Diary

Types

Stress.  Loss of urine with increased intraabdominal pressure.  Caused by hypermobil or displacement of the urethrovesical junction. 

Urge.  Patient feels an abrupt strong desire to urinate but is unable to reach the bathroom.  Cause is detrusor muscle hyperactivity.  Some causes are multiple sclerosis, drugs, inflammation of the bladder.

Mixed. A combination of the above.

Overflow. Incomplete bladder emptying--when the bladder fills to capacity, urine leaks by overflow.  Causes are lo9ss of detrusor contractility and obstruction.

Treatment

• Eliminate caffeine intake for Urge and Mixed incontinence.  Caffeine is a bladder stimulant.
• Timed voiding for Urge and Mixed incontinence.
• Keegal exercises  ( use of graduated pelvic cones of increasing weight), biofeedback)
• Self catheterization for inability to void.
• Other bladder retraining
• Devices that increase the  posterior urethral vesicle angle such as Pessaries, continence ring, impress softpatch, reliance catheter, Fem Assist and Introl device. (Read about these in the April 1998, Women's Health in Primary Care.
• Surgery

Pharmacology. 

Drugs.

• Oxybutynin chloride (Ditropan). Antispasmotic. 5 mg BID to TID. (for urge incontinence or mixed)
• Estrogens for menopausal women  (for stress incontinence or mixed)
• Hyoscyamine sulfate (Levsin).  as sublingual or long acting.  (for urge and mixed incontinence)
• Pseudoephedrine and phenopropanolamine  (OTC cold meds).  (for stress incontinence)

New drugs.

• Tolterodine tartate (Detrol).  This is an muscarinic antagonist.  Usual dose 1-2 mg BID. 
• Oxybutynin chloride (Ditropan XL).  This is an Antispasmotic.  Usual dose not available yet.

Surgical procedures.  Effective for Stress Incontinence.  This surgery replaces the PUV (posterior urethral angle)

ICD-9  788.3  Incontinence of urine

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