Uterovaginal Prolapse

Today we sit down with Dr. Julia Shinnick, one of our co-residents at Brown University and future FPMRS specialist, to talk through prolapse!

The POP-Q tool from AUGS is a helpful web-based tool (also with iPhone/iPad apps!) that can help you understand prolapse, as well as illustrate prolapse to patients in your practice.

One common quiz question are the levels of support. These are:

  • Level I consists of the cardinal and uterosacral ligaments, and suspends the vaginal apex. Uterosacral/cardinal ligament complex, which suspends the uterus and upper vagina to the sacrum and lateral pelvic side wall. In a magnetic resonance imaging (MRI) study of asymptomatic women, the uterosacral ligaments were found to originate on the cervix in 33 percent, cervix and vagina in 63 percent, and vagina alone in 4 percent. Loss of level 1 support contributes to the prolapse of the uterus and/or vaginal apex.

  • Level II consists of the paravaginal attachments, are what create the H shape of the vagina. The anterior vaginal wall is suspended laterally to the arcus tendineus fascia pelvis (ATFP) or “white line,” which is a thickened condensation of fascia overlying the iliococcygeus muscle. The anterior Level II supports suspend the mid-portion of the anterior vaginal wall creating the anterior lateral vaginal sulci. Detachment of these lateral supports can lead to paravaginal defects and prolapse of the anterior vaginal wall. There are also more posterior lateral supports at Level II. The distal half of the posterior vaginal wall fuses with the aponeurosis of the levator ani muscle from the perineal body along a line referred to as the arcus tendineus rectovaginalis. It converges with the ATFP at a point approximately midway between the pubic symphysis and the ischial spine. Along the proximal half of the vagina, the anterior and posterior vaginal walls are both supported laterally to the ATFP. 

  • Level III consists of the perineal body and includes interlacing muscle fibers of the bulbospongiosus, transverse perinei, and external anal sphincter.  Loss of level 3 support can result in a distal rectocele or perineal descent.  

Remember — the treatments are generally conservative with pelvic floor PT; devices, such as pessaries; or surgeries.

Urinary Incontinence

On today’s episode, we visit with Dr. Kyle Wohlrab, who is an associate professor and urogynecologist at Brown University / Women and Infants Hospital of Rhode Island. He takes us through the basics of urinary incontinence.

Urinary incontinence is quite common: almost 1/3 of women in their lifetime. The Women’s Preventive Services Initiative even recommends annual standardized incontinence screening for women annually.

The mechanisms of incontinence include:
Stress - leakage with Valsalva (sneeze/laugh/cough/activity). Generally in small volumes.
Urge - aka overactive bladder; spasms or overactivity of bladder detrusor muscle that can prompt large volume leakage.
Mixed - a combination of the above; often one of the above types is “predominant.”

We review in the podcast many of the most important parts of a history and workup, but the most important aspect are the patient’s goals with respect to incontinence. This also will guide our therapy. Childbirth, obesity, and activities involving heavy weight bearing are some common risk factors.

One of the tests that can easily be performed, but many have limited experience with, is a simple cystometrogram. Essentially, one backfills the bladder. If during filling, one sees a rise in the meniscus, this is suggestive of detrusor overactivity. After filling with 200-300cc,, one can do a filled cough stress test to evaluate for stress incontinence.

Treatments vary by type of incontinence, but can be broken down into three categories for each type:
Stress - pelvic floor PT, vaginal inserts, and surgical therapy — midurethral sling, Burch urethropexy, urethral bulking.
Urge - pelvic floor PT and behavioral modification, medial therapies, and surgical therapies — neurostimulators.

For medical therapies for urge incontinence, antimuscarinic therapy is generally first line. Oxybutynin and trospium are the most commonly used medications in this class. Recall that antimuscarinic drugs have the “slow down” side effects of dry mouth/dry eyes, constipation, abdominal pain, and sedation. Newer medications in this class can have fewer side effects but can have difficulty with insurance coverage. Trospium is the newest medication that also doesn’t cross the blood-brain barrier, limiting neurologic side effects — especially useful in the elderly!

Beta agonists are another option for medical therapy with mirabegron. Rather than acting on muscarinic receptors, these act on beta agonists. These thus should be avoided in patients with uncontrolled hypertension.

When should someone refer to urogynecology? Dr. Wohlrab’s advice is to refer once someone has failed a line of therapy, or when patients begin looking for surgical therapy. Especially after listening today, we hope you’re comfortable with this workup and treatment!

Further reading from the OBG Project:
Urinary Incontinence – How to Make the Diagnosis in Your Office and When to Refer
Treating Urinary Incontinence Without Surgery: Options and Pearls
Prolapse and Stress Incontinence: Burch Procedure vs Midurethral Sling
Surgery for Urinary Incontinence – When the Sling’s the Thing