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Part II. Management of Abnormal Pap Results

Part II. Management of Abnormal Pap Results

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Chapter 13

Office Management

of Female Pelvic Floor

Dysfunction

Sara Kostant and Michael D. Moen



Introduction

Pelvic floor dysfunction, including urinary incontinence and

pelvic organ prolapse, affects millions of American women.

These problems are more common than most healthcare providers realize. About 24% of all women have at least one

symptom of pelvic floor dysfunction [1]. The lifetime risk of

undergoing surgery for pelvic organ prolapse or incontinence

is 20% [2], which does not take into account women who

undergo medical management of their symptoms or do not

seek treatment at all.

The prevalence of pelvic floor disorders is set to increase

significantly over the next few decades. One study estimates that

by 2050, the number of women with urinary incontinence will

increase 55% to 28.4 million, and the number of women with

pelvic organ prolapse will increase 46% to 4.9 million [3].



S. Kostant

Hackensack University Medical Center, Department of Obstetrics

and Gynecology, Hackensack, NJ, USA

M. D. Moen (*)

Rosalind Franklin University Chicago Medical School, Advocate

Lutheran General Hospital, Department of Obstetrics and

Gynecology, Park Ridge, IL, USA

e-mail: Michael.moen@advocatehealth.com

© Springer Science+Business Media, LLC, part of Springer

Nature 2018

J. V. Knaus et al. (eds.), Ambulatory Gynecology,

https://doi.org/10.1007/978-1-4939-7641-6_13



195



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Increasing age is a risk factor for pelvic floor dysfunction, and

the number of women over age 65 will have doubled between

2008 and 2050 [4].

A general gynecologist is often the first provider to see

patients with pelvic floor dysfunction, as most women do not

seek out a specialist when these symptoms initially occur.

General gynecologists can expect to see an increase in

women presenting with urinary incontinence, pelvic organ

prolapse, and voiding dysfunction to his or her office over the

next decades. Management of these issues might seem daunting to many gynecologists. Graduating OB/GYN residents

have less experience managing issues related to pelvic floor

dysfunction than obstetric and benign gynecological issues

common to the premenopausal patient.

The general gynecologist will have a growing responsibility to manage urinary incontinence, pelvic organ prolapse,

and voiding dysfunction. The purpose of this chapter is to

provide a framework for the evaluation and management of

these issues. Voiding dysfunction, for the purposes of this

chapter, refers to patient complaints of changes in her urine

flow and ability to empty her bladder.



Pelvic Floor Dysfunction Terminology

Standardized terminology for female pelvic floor dysfunction

eases communication between providers and patients. The

following definitions are taken from the most recent

International Urogynecological Association (IUGA)/

International Continence Society (ICS) guidelines [5].

Stress incontinence

The complaint of the involuntary loss of urine on effort or

physical exertion

Urgency

The complaint of a sudden, compelling desire to pass urine

which is difficult to defer



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Urgency incontinence

The complaint of the involuntary loss of urine associated with

urgency

Mixed incontinence

The complaint of involuntary loss of urine associated with

urgency and also with effort or physical exertion or on sneezing or coughing

Frequency

The complaint that urination occurs more frequently during

waking hours than previously deemed normal by the woman

Nocturia

The complaint of the interruption of sleep one or more times

because of the need to urinate

Overactive bladder (OAB, urgency) syndrome

Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the

absence of urinary tract infection or obvious pathology

Feeling of incomplete (bladder) emptying

The complaint that the bladder does not feel empty after

urination

This symptom may or may not actually correlate with an

elevated post-void residual on exam. Patients presenting with

this complaint may mention a need to strain or change position in order to feel like she is emptying her bladder.

Pelvic Organ Prolapse

The descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina

(vaginal vault or cuff scar after hysterectomy)



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A patient with this finding would likely be presenting with

a complaint of a “bulge” sensation in the vagina.



Evaluation

A complete medical, surgical, and gynecological history

should be obtained from the patient. The patient’s non-gynecological medical history may explain a patient’s symptoms.

Patients with neurologic disorders may experience both overactive bladder and incomplete emptying. Frequently used

medications for hypertension, such as diuretics and acetylcholinesterase inhibitors, can increase urinary frequency.

Sleep apnea can often be responsible for nocturia, and the

introduction of CPAP therapy may resolve the patient’s

symptoms. The patient’s medical history may also guide treatment. If a patient reports a history of closed-angle glaucoma

or bowel obstructions due to constipation, anticholinergic

medications will be contraindicated.

Increased gravidity and parity can predispose patients to

pelvic floor disorders. A history of a third- or fourth-degree

episiotomy should be noted as fecal incontinence is more common in these patients, but women are often embarrassed to

reveal this symptom. Prior pelvic surgery can contribute to

denervation injury, which may contribute to overactive bladder or incomplete emptying. Pelvic radiation for gynecological

cancer can lead to a loss of compliance of the bladder wall and

urethra. This can lead to stress incontinence due to the scarring

of the bladder neck and urethral sphincter muscles and urinary

urgency and frequency due to reduced bladder capacity.

The healthcare provider should thoroughly review the

patient’s current symptoms. The onset and duration of the

patient’s symptoms is important. If incontinence is the main

complaint, it is critical to differentiate between stress and urge

incontinence, recognizing that more than a third of women

will have components of both (mixed incontinence) [6].

The abdominal and pelvic examination is key to the assessment of women with pelvic floor dysfunction. The vulva and



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vagina should be examined for signs of urogenital atrophy.

Loss of rugations and thin, pale vaginal mucosa may be noted

in this circumstance. The patient is asked to cough, and the

mobility of the urethra and leakage of urine is noted. A

change in the angle of the urethra of more than 30 degrees

indicates a hypermobile urethra. The neuromuscular exam

includes an assessment of perineal and vulvar sensation, pelvic floor resting tone, and pelvic floor muscle strength.

Perineal sensation can be assessed with a q-tip or by direct

light palpation. The patient can then be instructed to contract

her pelvic floor muscles as if she is trying to stop the flow of

urine or trying to hold gas in the rectum. Pelvic floor contraction strength can be graded according to a modified Oxford

scale as shown in Table 13.1.

Prolapse of the anterior and posterior vaginal walls, uterus,

and vaginal apex are measured in the supine position with the

patient performing a Valsalva maneuver. A half speculum is

useful for examination of the anterior and posterior walls

separately.

Many providers are confused by the appropriate documentation of the stage of prolapse. The Pelvic Organ Prolapse

Quantification System (POP-Q), describes the measurement

of nine points of vaginal support. A newer, abbreviated system focuses on the evaluation of four points – the anterior

and posterior vaginal walls, the vaginal apex, and the cervix.

In women who have had a hysterectomy, the cervix is left out

and only three points are documented. This system has been

noted to have good inter-observer and inter-system reliability

[7]. Table 13.2 describes the points in the vagina that are used

for measurement of each compartment, and Table 13.3 shows

how each point corresponds to staging.

Multichannel urodynamic testing is not necessary in the

initial evaluation of most patients with incontinence. Simple

cystometry, or a “bladder fill”, is a quick, inexpensive tool for

bladder function assessment. After the urethral meatus is

swabbed with iodine, a red rubber catheter is placed in the

bladder using sterile technique. The end of the catheter is

connected to a 50–60 ml funnel syringe. The bladder is then



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Table 13.1 Modified

Oxford scale for pelvic

muscle contraction

strength



Grade

0



Definition

No contraction



1



Flicker



2



Weak



3



Moderate



4



Good (with lift)



5



Strong (with lift)



Laycock [26]

Table 13.2  Simplified pelvic organ prolapse quantification (POPQ) system

Vaginal

Area of measurement

compartment

Anterior wall

A point 3 cm proximal to the urethral meatus

Cervix



Most distal aspect of the cervix



Apex/cuff



Posterior fornix; if post-hysterectomy, then

most distal aspect of the cuff



Posterior wall



A point 3 cm proximal to the hymenal

remnants



Swift et al. [7]



filled with sterile water or saline. The patient is asked to

report when she feels the following sensations: first sensation

of fluid in the bladder, first urge to urinate, strong urge to

urinate, and her maximum bladder capacity. Sensations of

urgency during bladder filling may be indicative of an overactive bladder. After the maximum capacity is reached, the

catheter is removed, and a cough stress test can be performed.

The physician can also re-­catheterize the patient after she

voids to check a post-void residual if there is a concern for

incomplete emptying.



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Table 13.3  POP-Q staging system

Stage Location of area of measurement at Valsalva

I

More than 1 cm proximal to the hymenal remnants

II



Between 1 cm proximal and 1 cm distal to the hymenal

remnants



III



More than 1 cm distal to the hymenal remnants but

without complete vaginal eversion



IV



Vaginal mucosa is completely everted



Swift et al. [7]



Treatment

Therapies Useful for All Pelvic Floor Disorders

Fluid and Diet Management

Unless otherwise medically indicated, fluid restriction is not

recommended as a means to decrease urinary frequency.

Likewise, excessive hydration is not helpful or necessary.

Concentrated urine can further irritate the bladder, actually

increasing urgency and frequency. Women should be encouraged to drink enough to satisfy their thirst and counseled that

this may result in a transient exacerbation of their overactive

bladder symptoms.



Timed Voiding/Bladder Training

Timed voiding can help women manage both overactive

bladder symptoms and incomplete emptying. Women with

frequency are encouraged to slowly increase the intervals

between their voids. For example, if a woman normally feels

the urge to void every hour, she is encouraged to increase this

interval by an additional 15 min for 1 week. If she is able to

wait 1 h and 15 min between voids without leakage, she

should increase the interval the next week to an hour and a

half, and so forth. Each woman should be encouraged to pro-



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S. Kostant and M. D. Moen



ceed at her own pace; some women may need to wait 2 or

3 weeks before increasing their voiding intervals. Timed voiding can be used in conjunction with anticholinergic therapy in

women with frequent leakage.

Patients with incomplete bladder emptying are advised to

void every 3 h, whether or not they feel the urge to void at

that time. “Double voiding” – having the patient stand up

from the commode and then sit down again – may allow the

patient to begin or continue emptying her bladder. Running

water from a tap can also be useful cue to help a patient start

voiding. Emptying the bladder more frequently may increase

bladder sensitivity in women who have become accustomed

to waiting several hours between voids. For patients who continue to have elevated post-void residual volumes despite

timed voiding, intermittent self-catheterization may be

necessary.



Topical Estrogen

Postmenopausal women with urogenital atrophy may have

increased irritation of the urethra, leading to dysuria and

urgency, even in the absence of a urinary tract infection.

Topical estrogen may be a useful adjunct to timed voiding

and anticholinergic medication in these women, especially if

vaginal dryness, dyspareunia, and recurrent urinary tract

infections are also present.

Topical estrogen may be delivered by a vaginal cream

(Estrace or Premarin cream), ring (Estring 2 mg/3 months),

or tablet (Vagifem 10 mcg). All forms of topical estrogen are

equally effective in treating vaginal atrophy. A patient should

use the form of delivery that most appeals to her and will

increase her compliance. Use of the tablet, ring, or low dose

(1–2 g twice weekly) cream preparations do not raise systemic serum estradiol levels to premenopausal levels [8].

Traditionally, hormone replacement therapy, including topical estrogen, has been avoided in patients with a history of

breast cancer. There is evidence that breast cancer recurrence



13.  Office Management of Female Pelvic Floor…



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may not be associated with either oral or vaginal hormone

therapy use [9].

Supplemental progesterone is not routinely recommended

in women using topical estrogen who still have a uterus. The

endometrial safety of the estrogen ring and tablet have been

shown for use up to 12 months and for low doses of estrogen

cream for use up to 6 months [10]. As there is a lack of data

regarding topical estrogen use in these patients after

12 months of use, consideration may be given to providing

supplemental progesterone in women who have been using

topical estrogen for over a year; however, this is not routine

in our practice.

Pessary users with atrophy may have less vaginal abrasions

and therefore a greater likelihood of continuing pessary use,

if they use topical estrogen [11].



Pelvic Floor Exercises

Since Dr. Arnold Kegel first discussed the benefits of pelvic

floor exercises, [12] multiple studies have shown they can

improve symptoms of pelvic floor disorders.

Pelvic floor exercises, even when done correctly and regularly, will likely provide more of an improvement of incontinence and prolapse symptoms, rather than a cure.

Most women presenting to a gynecologist’s office with

pelvic floor dysfunction have heard of “Kegel exercises”

through the popular media. However, less than half of

patients have been taught how to properly perform pelvic

floor muscle contractions, and most patients who have been

taught received verbal training only [13]. Verbal training and

reading instructions on pelvic floor exercises do not seem to

be sufficient, as less than 25% of patients are able to perform

a pelvic floor contraction with a strength rating of 3, 4, or 5 on

the Oxford scale [14]. The ideal teaching of pelvic floor contractions occurs during the pelvic exam. The healthcare provider should demonstrate the pelvic floor muscles by

palpation and instruct the patient to contract these muscles

around the provider’s examining finger. The patient should



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S. Kostant and M. D. Moen



be counseled to avoid performing a Valsalva maneuver or

using her abdominal and gluteal muscles during the pelvic

floor contraction.



 reatment Options Specific to Different Types

T

of Pelvic Floor Dysfunction

Pelvic Organ Prolapse

Pessaries in general have been underutilized in recent years

due to misconceptions about the difficulties of pessary fitting

and management. Younger patients, in particular, may have a

misconception that pessaries are only an option for “elderly”

women or believe that they will not be able to be sexually

active if they wear a pessary. In fact, pessary use is an excellent option for women of all ages, especially premenopausal

women who desire future pregnancies. Most women can be

taught to remove, clean, and replace their pessaries so that

sexual activity is not precluded. All women presenting with

symptomatic pelvic organ prolapse should be offered a trial

of a pessary.

A properly fitted pessary is comfortable and is not felt at

all by the patient. Advanced stages of prolapse should not

discourage a physician from offering a pessary. Successful

continuation of pessary use has not been found to be related

to the severity of prolapse or location of the pelvic defect (i.e.,

cystocele vs rectocele) [15]. Pessaries come in a number of

different shapes and sizes, which may seem intimidating to

gynecologists unfamiliar with their use. However, most

patients can be fitted successfully with a ring with support pessary. Ring pessaries have the longest continuation rate due to

their ease of use and are the least likely to cause bothersome

vaginal abrasions and ­vaginal discharge [16]. In addition to

standard ring pessaries, there are also ring pessaries with

knobs, which can be used in patients with stress incontinence



13.  Office Management of Female Pelvic Floor…



205



(Fig.  13.1). Gellhorn pessaries and cube pessaries (Fig. 13.2)

are used when a ring pessary cannot stay in the vagina due to

the severity of the prolapse. The cube pessary is more likely to

cause vaginal abrasions and discharge if not removed on a

regular basis [17]. A patient who cannot be managed with a

ring pessary may benefit from a referral to a specialist.

After initial pessary placement, the patient returns within

1–2 weeks to assess the comfort and effect of the pessary. If

the patient can remove the pessary herself, she should be

encouraged to do so at least weekly and leave the pessary out

overnight after its cleaning. These women do not need any

additional special follow-up and can be seen again at the time

of their annual exams. Women who cannot or are not willing

to remove the pessary on their own should return at 2–3month intervals for pessary removal and cleaning. At these

follow-up visits, a speculum exam is performed to assess for

abrasions, ulcerations, foul-smelling vaginal discharge, and

granulation tissue. The vagina may be cleaned at this time

with hydrogen peroxide, but there is no evidence to support

that this prevents infections. The pessary can be replaced

after cleaning if only superficial, hemostatic abrasions are



Fig. 13.1  Ring with support, ring with knob, and incontinence dish

pessaries



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