Handbook> Selectives > OB > Female Pelvic Medicine/Urogynecology

Selectives - OB/GYN

Female Pelvic Medicine/Urogynecology Selective

Selective Number: (Oasis - S52m) 1914

Rotation Supervisor: Dr. Elisa Trowbridge

Available: TBA

Duration: 2 weeks

Report to: Dr. Hullfish

Time to Report: 8:00 am

Place to Report: Northridge Suite 305

Typical Day: 7:30 am - 5:00 or 6:00 pm

Suggested preparatory reading: Ostegards Urogynecology, and other selected articles to be given out by the attending

Number of students per rotation: 1

Course Description: Selective students will have the opportunity to evaluate ambulatory patients several days a week with attending physicians (Dr. Kathie Hullfish and Dr. Elisa Trowbridge) and the residents on service. Students will be responsible for taking a targeted history, with the ultimate goal of being able to demonstrate proficiency and independence in the performance and evaluation of a gynecologic examination, with particular emphasis on pelvic floor dysfunction. Written clinic notes will be completed by the student and co-signed by either the attending physician or the resident. Outpatient activities will alternate with the opportunity to assist and/or observe surgical procedures throughout the week. In the operating room, the student will scrub or observe on cases and assist the resident with all aspects of post-operative care, including orders, post-op notes and daily rounds. The student will be responsible for seeing all inpatients twice a day with two progress (SOAP) notes in the chart, co-signed by the resident and/or attending.


The student will be responsible for providing one 15 minute presentation on a gynecologic topic of their choice, agreed to by either Dr. Hullfish or Dr. Trowbridge. This will be presented to the team, using evidence-based research skills and PowerPoint, during one of the didactic sessions at the end of the rotation.


The student may be able to observe multi-channel urodynamics in the Urology suite, other Urologic or Colorectal Surgeries, and sessions of pelvic floor physical therapy as time and/or interest permits.


As this is the first selective offered by the Female Pelvic Medicine Division, feedback from the student will be encouraged. The student will meet with one of the supervising attendings at the end of the two week rotation for a feedback session.


Patients with pelvic floor disorders present in a variety of ways. The student should be familiar with the presenting symptoms and signs of pelvic organ prolapse, urinary incontinence, and anal incontinence, and understand the approach to management of these patients. The student will demonstrate knowledge of the following:

  • predisposing factors for pelvic organ prolapse (POP), urinary incontinence (UI) and anal incontinence (AI)
  • anatomic changes, fascial defects and neuromuscular pathophysiology
  • signs and symptoms of pelvic organ prolapse, UI & AI
  • physical exam
    • cystocele
    • rectocele
    • enterocele
    • vaginal vault or uterine prolapse

Risk factors:

  • vaginal delivery
    • large baby
    • prolonged 2nd stage labor
    • forceps
    • multiparous
  • increased abdominal pressure
    • obesity
    • chronic constipation
    • chronic lung disease
  • altered nerve function or tissue strength
    • diabetes
    • neurologic diseases
    • aging
    • collagen disorders
    • hypoestrogenism
    • pelvic surgery

Anatomy

  • basic
    • levator ani muscles
    • pubococcygeuas
    • puborectalis
    • iliococcygeus
    • endopelvic fascia - attaches uterus and vagina to pelvic wall
    • parametria - cardinal and uterosacral ligaments
  • fascial defects

Symptoms:

  • Pelvic organ prolapse (POP)
    • asymptomatic
    • vaginal pressure heaviness
    • vaginal pain
    • sensation of tissue protruding from the vagina
    • abdominal pain
    • dyspareunia/impaired coitus
    • vaginal dryness
    • ulceration/bleeding
  • Urinary incontinence - unexpected loss of urine which is bothersome
    • stress incontinence - involuntary loss of urine with increased abdominal pressure (valsalva, cough, laugh or sneeze)
    • urge incontinence (overactive bladder) – frequency, urgency with or without incontinence
    • incomplete emptying - hesitancy, straining, recurrent UTIs, overflow leakage
  • GI symptoms
  • constipation
    • incomplete evacuation/obstructed defecation
    • dyschezia
    • hematochezia
    • anal incontinence (gas, solid and/or liquid stool)
  • Sexual dysfunction symptoms
    • dyspareunia
    • bleeding
    • UI or GI symptoms
  • Impact on quality of life

Physical Exam (definitions)

  • cystocele (anterior)
    • defect where the bladder and anterior vaginal wall protrudes through the vaginal introitus
    • secondary to attenuation or rupture of the pubovesical cervical fascia
    • note anterior relaxation with urethral inclination
    • mobility of bladder base and urethra with valsalva maneuver
  • rectocele (posterior)
    • protrusion of posterior vaginal wall and anterior rectal wall
    • look for bulging of posterior vaginal wall with valsalva maneuver
    • insert finger in rectum and, if vaginal and rectal tissue are jauxtaposed = rectocele
    • enterocele (apical)
    • cerical/uterine prolapse, or vaginal apex/cuff prolapse
    • 50% are diagnosed intraoperatively
    • physical exam (patient standing) - palpate enterocele sac and small bowel
  • examination
    • screening neurological exam: perineal sensation and reflexes
    • degree of atrophy
    • pelvic exam and POP-Q, supine and standing
    • pelvic muscle strength
    • anal sphincter tone

Diagnostic points

  • urine culture and post void residual (PVR)
    • rule out retention (>150 cc); urinary tract infection (>10 organisms)
    • assess for hematuria: infectious or sterile
  • voiding diary
    • normal bladder capacity (up to 60 cc)
    • normal frequency (<8 void/day)
    • accidents/leaking with physical activity
    • amount and type of intake
  • standing or supine stress test - note urine loss with cough or valsalva
  • filling cystometrogram - examines the bladder during filling and storage
    • post-void residual <100cc
    • first urge - 100 - 200 mL
    • maximum capacity - 400 - 500 mL
      o resting bladder pressure <10 - 15 cm of water
  • cystoscopy
  • defecography


Nonsurgical treatments

  • pessary
    • conservative management
    • adjunctive treatment - estrogen
  • medications
    • stress incontinence - antagonist to increase smooth muscle tone (phenylpropanolamine)
    • urge incontinence - anticholinergics to decrease spasm of the detrusor muscle (oxybutynin, tolterodine)
    • estrogen for irritative urogenital atrophy symptoms
    • bulking agents for anal incontinence (fiber, lomotil)
  • pelvic floor muscle excercises
    • kegels - voluntary contraction of the pelvic floor
    • vaginal cones
    • electrical stimulation, pelvic floor physical therapy
    • anal biofeedback for anal incontinence

Surgery

  • for pelvic organ prolapse:
    • reconstructive or obliterative
    • for anterior wall prolapse (cystocele)
      • vaginal approach - anterior colporrhaphy (central defect) - paravaginal repair (lateral defect)
    • for apical defect
      • vaginal approach - sacrospinous ligament fixation - uterosacral colposuspension
      • abdominal approach - abdominal sacrocolpopexy - uterosacral colposuspension
    • for posterior defect - posterior colporraphy
    • obliterative - LeFort colposleisis (vaginal closure)
    • perineorraphy – reconstruction of the structures of the perineal body
  • for stress incontinence
    • suburethral slings (TVT: Tension free vaginal tape)
    • Burch colposuspension
    • Bulking injections (with collagen) to improve urethral coaptation (for patients without urethrovesical junction hypermobility)
  • for anal incontinence
    • anal sphincteroplasty
    • diversion