Urogynecology for the OB/GYN Generalist

Educational Objectives

The goal of this program is to improve management of pelvic floor disorders (PFDs). After hearing and assimilating this program, the clinician will be better able to:

1. Identify the presentation of various types of PFDs.
2. Select appropriate therapy for patients with PFD.

Summary

Pelvic floor disorder (PFD): a group of conditions that affect the pelvic floor muscles, ligaments, and connective tissue; includes urinary incontinence (UI; eg, stress, urge, mixed), pelvic organ prolapse (POP), bowel control issues (eg, fecal incontinence [FI], gas loss, constipation, difficulty evacuating, obstructive defecation), fistula (less common), and myofascial pelvic floor dysfunction (less common)

Epidemiology: per the National Health and Nutritional Examination survey, 25% of women have ≥1 PFD; individuals with POP may experience UI with or without FI; UI is most common (17%), followed by FI and POP (least common); Wu et al (2011) determined that the surgical rates for UI and POP will increase by 47.2% over the next 40 yr; Subak et al (2001) showed the rising annual direct costs of POP surgeries

Urinary incontinence

Stress UI: classic type; urine leaks while coughing, sneezing, laughing, or jumping; prevalence ranges from 25% to 45%, depending on the amount of leakage; an anatomic issue resulting from loss of urethral support from behind the pubic bone; treatment is similar to POP; baseline treatment is pelvic floor physical therapy (PFPT) or Kegel exercises; vaginal support devices (eg, pessary) and surgery are other options

Overactive bladder (OAB; ie, urge incontinence): impacts 1 in 6 women; incidence increases with age; the negative neural signal from the brain to the bladder is lost, allowing the bladder to contract without brain control; patients have urinary urgency, frequency, and OAB wet (UI and leakage associated with urinary urge; some patients may experience this without feeling an urge); treatment can be done at home and involves behavioral modifications (ie, training the bladder not to feel full at a smaller volume and reducing the frequency of bathroom visits)

Mixed UI: common; combines symptoms of OAB and stress UI; asking patients the appropriate questions is crucial; initially treat the predominant type of UI, but treat both types; focus treatment on the most bothersome symptoms (typically urgency and frequency)

Pelvic organ prolapse: involves loss of pelvic floor support with dropping pelvic organs; herniation through the pelvic floor is bothersome; Nygaard et al (2004) found that some degree of prolapse is nearly ubiquitous (97.7%) in elderly women, based on the POP Quantification System; staging of pelvic support may not necessarily correlate with symptoms; symptoms develop when the prolapse is ≤1 cm from the hymen, causing sensory and neurologic alterations (innervation is more autonomic above the level of the hymen and becomes more somatic at and below the hymen); symptoms include, eg, pressure, bulging, tissue protrusion, urinary symptoms (including difficulty emptying), bowel symptoms, sexual dysfunction, and significantly affect quality of life; ≤33% of patients are depressed or embarrassed and do not discuss POP with providers, family, or caregivers; POP is not physically painful

Meister et al (2019): 85% of women reported some degree of pelvic floor muscle pain on examination (10% reported mild pain, 25% reported severe symptoms, and the rest had moderate symptoms); the degree of reported pain did not correlate with POP symptoms; subjective symptoms included, eg, abdominal pressure, pelvic pressure, pain, sensation of incomplete emptying; objective symptoms included, eg, seeing and feeling a bulge, protrusion of tissue, need to replace the tissue to completely evacuate for urination and defecation; severe muscle pain correlated with subjective symptoms (especially pressure) but not with objective symptoms

Myofascial pelvic floor dysfunction: requires a multidisciplinary approach; hypertonic or hypotonic muscles cause dysfunction; short, tight, and tender pelvic floor muscles with myofascial trigger points cause local and referred pain; can alter physiologic function; obstructed defecation — surgical treatment of rectocele may not provide resolution; puborectalis muscle appears very tight, and relaxation is needed to allow stretching at the anorectal angle and complete defecation; gastrointestinal and colorectal consultation may help; not surgically managed; pelvic floor dyssynergia — performing the Valsalva maneuver during urination or defecation causes paradoxical muscle contraction; train patients to avoid straining; irritative voiding dysfunction — ie, lower urinary tract symptoms; patients report dysuria; cultures for, eg, Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, Mycoplasma hominis, are negative; patients usually have tight pelvic floor muscles (including the obturator internus); significantly improves with PFPT; associated with interstitial cystitis/painful bladder syndrome

Treatment: provide patient education through handouts and weblinks for POP and bladder retraining; counseling sessions are usually too time-consuming to be feasible

Pessary: vaginal support device that can help treat stress incontinence and POP; one study found that a diameter of 65 mm (size 4) is most commonly used; a fitting kit can be helpful

Pelvic floor physical therapy: a program of functional retraining to improve pelvic floor muscle strength, endurance, power, and relaxation in patients with pelvic floor dysfunction; modalities include myofascial release, strengthening exercises, and biofeedback with or without electrical stimulation; there is good evidence to support the effectiveness of PFPT, and it is noninvasive; Li et al (2016) showed improvement in objective POP stage and a greater number of women who reported prolapse improvement; Tu et al (2005) found that 60% to 80% of women reported reduction in pelvic pain following PFPT; Dumoulin et al (2017) found that patients receiving guided PFPT for stress UI were 8 times more likely to report a cure than patients receiving standard care (ie, Kegel exercises at home), likely secondary to adherence to PFPT; Wallace et al (2019) found strong evidence for benefit with hypertonic and hypotonic PFDs, but the evidence for perioperative PFPT was weak, compared with surgery alone

Questions and answers: a trial of 8 sessions of PFPT is recommended as initial treatment; pelvic pain and trauma — a high correlation exists between chronic pelvic pain, myofascial pelvic pain, and trauma; limited studies do not reveal significant improvement from vaginal pain suppositories (eg, gabapentin, baclofen, diazepam); use of electrical stimulation — studies do not reveal significant pelvic floor strengthening following biofeedback with electrical stimulation; in-office percutaneous tibial nerve stimulation and at-home transcutaneous electrical nerve stimulation successfully treat OAB

Readings

Alouini S, Memic S, Couillandre A. Pelvic floor muscle training for urinary incontinence with or without biofeedback or electrostimulation in women: a systematic review. Int J Environ Res Public Health. 2022;19(5):2789. doi:10.3390/ijerph19052789; Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;10(10):CD005654. doi: 10.1002/14651858.CD005654.pub4; Hicks CW, Weinstein M, Wakamatsu M, et al. In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort. Surgery. 2014;155(4):659-67. doi: 10.1016/j.surg.2013.11.013; Kenne KA, Wendt L, Jackson JB. Prevalence of pelvic floor disorders in adult women being seen in a primary care setting and associated risk factors. Scientific Reports. 2022;12(1):9878. doi:10.1038/s41598-022-13501-w; Li C, Gong Y, Wang B. The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis. Int Urogynecol J. 2016;27:981–992. doi:10.1007/s00192-015-2846-y; Meister MR, Sutcliffe S, Badu A, et al. Pelvic floor myofascial pain severity and pelvic floor disorder symptom bother: is there a correlation? Am J Obstet Gynecol. 2019;221(3):235.e1-235.e15. doi: 10.1016/j.ajog.2019.07.020; Nygaard I, Bradley C, Brandt D; Women's Health Initiative. Pelvic organ prolapse in older women: prevalence and risk factors. Obstet Gynecol. 2004;104(3):489-97. doi:10.1097/01.AOG.0000136100.10818.d8; Tu FF, As-Sanie S, Steege JF. Musculoskeletal causes of chronic pelvic pain: a systematic review of existing therapies: part II. Obstet Gynecol Surv. 2005;60:474–483. doi:10.1097/01.ogx.0000162246.06900.9f; van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, et al. Pelvic floor physical therapy for pelvic floor hypertonicity: a systematic review of treatment efficacy. Sex Med Rev. 2022;10(2):209-230. doi: 10.1016/j.sxmr.2021.03.002; Wallace SL, Miller LD, Mishra K. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. 2019;31(6):485-493. doi: 10.1097/GCO.0000000000000584; Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol. 2014;123(1):141–148. doi:10.1097/AOG.0000000000000057.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Painter was recorded at the Obstetrics and Gynecology Update: What Does the Evidence Tell Us?, held October 12-14, 2022, in San Francisco, CA, and presented by the University of California, San Francisco, School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences. For information on future CME activities from this presenter, please visit ObGynUpdate.ucsf.edu. Audio Digest thanks the speakers and University of California, San Francisco, School of Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.25 CE contact hours.

Lecture ID:

OB700102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.