Table II-2-1. Vaginal Prolapse
Anterior Cystocele
Posterior Rectocele
| Pouch of Douglas | Enterocele |
Diagnosis. The diagnosis of pelvic relaxation is mainly made through observation at the timeof pelvic examination. The prolapsed vagina, rectum, and uterus are easily visualized particu-larly as the patient increases intraabdominal pressure by straining.
Management. The management of pelvic relaxation includes non-surgical and surgical treatment.
• Non-surgical. Used when there is a minor degree of relaxation. Kegel exercises involvevoluntary contractions of the pubococcygeus muscle. Estrogen replacement may be useful in postmenopausal women. Pessaries are objects inserted into the vagina that elevate the pelvic structures into their more normal anatomic relationships.
156
GI
Chapter 2 l Pelvic Relaxation
• Surgical. Used when more conservative management has failed. The vaginal hyster-ectomy repairs the uterine prolapse, the anterior vaginal repair repairs the cystocele,and the posterior vaginal repair repairs the rectocele. The anterior and posterior col-porrhaphy uses the endopelvic fascia that supports the bladder and the rectum, and aplication of this fascia restores normal anatomy to the bladder and to the rectum.
Follow-Up. Strenuous activity should be limited for about 3 months postoperatively to avoidrecurrence of the relaxation.
URINARY INCONTINENCE
A 58-year-old woman complains of urinary leakage after exertion. She loses urine while coughing, sneezing, and playing golf. She underwent menopause 5 years ago and is not on estrogen therapy. On examination there is evidence of urethral detachment with a positive Q-tip test.
Definition. Urinary incontinence is the inability to hold urine, producing involuntary urinaryleakage.
Physiology of Continence. Continence and micturition involve a balance between urethralclosure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are normally both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence. Normal voiding is the result of changes in both of these pressure fac-tors: urethral pressure falls and bladder pressure rises. Spontaneous bladder muscle (detrusor) contractions are normally easily suppressed voluntarily.
|
|
|
Pharmacology of Incontinence
• a-adrenergic receptors. These are found primarily in the urethra and when stimu-lated cause contraction of urethral smooth muscle, preventing micturition. Drugs: ephedrine, imipramine (Tofranil), and estrogens. a-adrenergic blockers or antagonists relax the urethra, enhancing micturition. Drugs: phenoxybenzamine (Dibenzyline).
• b-adrenergic receptors. These are found primarily in the detrusor muscle and whenstimulated cause relaxation of the bladder wall, preventing micturition. Drugs: flavox-ate (Urispas) and progestins.
• Cholinergic receptors. These are found primarily in the detrusor muscle and whenstimulated cause contraction of the bladder wall, enhancing micturition. Drugs: bethanecol (Urecholine) and neostigmine (Prostigmine). Anticholinergic medications block the receptors, inhibiting micturition. Drugs: oxybutynin (Ditropan) and prop-antheline (Pro-Banthine).
157
| S2 OB-GYN.indb 157 | 7/8/13 6:35 PM | |||
USMLE Step 2 l Gynecology
Beta-adrenergic receptors (β)
• Bladder
• SNS
| • | Relaxation | β |
| • | Prevent micturition | |
| β |
Alpha-adrenergic receptors (α)
• Urethra
• SNS
• Contraction
• Prevent micturition
GI
| c | β c β | Cholinergic receptors (c) | ||
| • | Bladder | |||
| • PSNS | ||||
| β | • | Contraction | ||
| • | Voiding | |||
β
α
α
α
α
|
|
|
α α
α
Figure II-2-2. Continence and Micturition
Cystometric studies. Basic office cystometry begins with the patient emptying her bladder asmuch as possible. A urinary catheter is first used to empty the bladder and then left in place to infuse saline by gravity, with a syringe into the bladder retrograde assessing the following:
• Residual volume. How much is left in the bladder? Normal is <50 mL.
• Sensation-of-fullness volume. How much infusion (in mL) until the patient sensesfluid in her bladder? Normal is 200–225 mL.
• Urge-to-void volume. How much infusion (in mL) until the patient feels the need toempty her bladder? Normal is 400–500 mL.
Involuntary bladder contractions. By watching the saline level in the syringe rise or fall, involun-tary detrusor contractions can be detected. The absence of contractions is normal.
Дата добавления: 2018-11-24; просмотров: 291; Мы поможем в написании вашей работы! |
Мы поможем в написании ваших работ!