- •Preface and Acknowledgments
- •Contents
- •Contributors
- •1: Embryology for Urologists
- •Introduction
- •Renal Development
- •Pronephros
- •Mesonephros
- •Metanephros
- •Development of the Collecting System
- •Critical Steps in Further Development
- •Anomalies of the Kidney
- •Renal Agenesis
- •Renal Aplasia
- •Renal Hypoplasia
- •Renal Ectopia
- •Renal Fusion
- •Ureteral Development
- •Anomalies of Origin
- •Anomalies of Number
- •Incomplete Ureteral Duplication
- •Complete Ureteral Duplication
- •Ureteral Ectopia
- •Embryology of Ectopia
- •Clinical Correlation
- •Location of Ectopic Ureteral Orifices – Male (in Descending Order According to Incidence)
- •Symptoms
- •Ureteroceles
- •Congenital Ureteral Obstruction
- •Pipestem Ureter
- •Megaureter-Megacystis Syndrome
- •Prune Belly Syndrome
- •Vascular Ureteral Obstructions
- •Division of the Urogenital Sinus
- •Bladder Development
- •Urachal Anomalies
- •Cloacal Duct Anomalies
- •Other Bladder Anomalies
- •Bladder Diverticula
- •Bladder Extrophy
- •Gonadal Development
- •Testicular Differentiation
- •Ovarian Differentiation
- •Gonadal Anomalies
- •Genital Duct System
- •Disorders of Testicular Function
- •Female Ductal Development
- •Prostatic Urethral Valves
- •Gonadal Duct Anomalies
- •External Genital Development
- •Male External Genital Development
- •Female External Genital Development
- •Anomalies of the External Genitalia
- •References
- •2: Gross and Laparoscopic Anatomy of the Upper Urinary Tract and Retroperitoneum
- •Overview
- •The Kidneys
- •The Renal Vasculature
- •The Renal Collecting System
- •The Ureters
- •Retroperitoneal Lymphatics
- •Retroperitoneal Nerves
- •The Adrenal Glands
- •References
- •3: Gross and Laparoscopic Anatomy of the Lower Urinary Tract and Pelvis
- •Introduction
- •Female Pelvis
- •Male Pelvis
- •Pelvic Floor
- •Urinary Bladder
- •Urethra
- •Male Urethra
- •Female Urethra
- •Sphincter Mechanisms
- •The Bladder Neck Component
- •The Urethral Wall Component
- •The External Urethral Sphincter
- •Summary
- •References
- •4: Anatomy of the Male Reproductive System
- •Testis and Scrotum
- •Spermatogenesis
- •Hormonal Regulation of Spermatogenesis
- •Genetic Regulation of Spermatogenesis
- •Epididymis and Ductus Deferens
- •Accessory Sex Glands
- •Prostate
- •Seminal Vesicles
- •Bulbourethral Glands
- •Penis
- •Erection and Ejaculation
- •References
- •5: Imaging of the Upper Tracts
- •Anatomy of the Upper Tracts and Introduction to Imaging Modalities
- •Introduction
- •Renal Upper Tract Basic Anatomy
- •Modalities Used for Imaging the Upper Tracts
- •Ultrasound
- •Radiation Issues
- •Contrast Issues
- •Renal and Upper Tract Tumors
- •Benign Renal Tumors
- •Transitional Cell Carcinoma
- •Renal Mass Biopsy
- •Renal Stone Disease
- •Ultrasound
- •Plain Radiographs and IVU
- •Renal Cystic Disease
- •Benign Renal Cysts
- •Hereditary Renal Cystic Disease
- •Complex Renal Cysts
- •Renal Trauma
- •References
- •Introduction
- •Pathophysiology
- •Susceptibility and Resistance
- •Epidemiological Breakpoints
- •Clinical Breakpoints
- •Pharmacodynamic Parameters
- •Pharmacokinetic Parameters
- •Fosfomycin
- •Nitrofurantoin
- •Pivmecillinam
- •b-Lactam-Antibiotics
- •Penicillins
- •Cephalosporins
- •Carbapenems
- •Aminoglycosides
- •Fluoroquinolones
- •Trimethoprim, Cotrimoxazole
- •Glycopeptides
- •Linezolid
- •Conclusion
- •References
- •7: An Overview of Renal Physiology
- •Introduction
- •Body Fluid Compartments
- •Regulation of Potassium Balance
- •Regulation of Acid–Base Balance
- •Diuretics
- •Suggested Reading
- •8: Ureteral Physiology and Pharmacology
- •Ureteral Anatomy
- •Modulation of Peristalsis
- •Ureteral Pharmacology
- •Conclusion
- •References
- •Introduction
- •Afferent Signaling Pathways
- •Efferent Signaling
- •Parasympathetic Nerves
- •Sympathetic Nerves
- •Vesico-Spinal-Vesical Micturition Reflex
- •Peripheral Targets
- •Afferent Signaling Mechanisms
- •Urothelium
- •Myocytes
- •Cholinergic Receptors
- •Muscarinic Receptors
- •Nicotinic Receptors
- •Adrenergic Receptors (ARs)
- •a-Adrenoceptors
- •b-Adrenoceptors
- •Transient Receptor Potential (TRP) Receptors
- •Phosphodiesterases (PDEs)
- •CNS Targets
- •Opioid Receptors
- •Serotonin (5-HT) Mechanisms
- •g-Amino Butyric Acid (GABA) Mechanisms
- •Gabapentin
- •Neurokinin and Neurokinin Receptors
- •Summary
- •References
- •10: Pharmacology of Sexual Function
- •Introduction
- •Sexual Desire/Arousal
- •Endocrinology
- •Steroids in the Male
- •Steroids in the Female
- •Neurohormones
- •Neurotransmitters
- •Dopamine
- •Serotonin
- •Pharmacological Strategies
- •CNS Drugs
- •Enzyme-inducing Antiepileptic Drugs
- •Erectile Function
- •Ejaculatory Function
- •Premature Ejaculation
- •Abnormal Ejaculation
- •Conclusions
- •References
- •Epidemiology
- •Calcium-Based Urolithiasis
- •Uric Acid Urolithiasis
- •Infectious Urolithiasis
- •Cystine-Based Urolithiasis
- •Aims
- •Who Deserves Metabolic Evaluation?
- •Metabolic Workup for Stone Producers
- •Medical History and Physical Examination
- •Stone Analysis
- •Serum Chemistry
- •Urine Evaluation
- •Urine Cultures
- •Urinalysis
- •Twenty-Four Hour Urine Collections
- •Radiologic Imaging
- •Medical Management
- •Conservative Management
- •Increased Fluid Intake
- •Citrus Juices
- •Dietary Restrictions
- •Restricted Oxalate Diet
- •Conservative Measures
- •Selective Medical Therapy
- •Absorptive Hypercalciuria
- •Thiazide
- •Orthophosphate
- •Renal Hypercalciuria
- •Primary Hyperparathyroidism
- •Hyperuricosuric Calcium Oxalate Nephrolithiasis
- •Enteric Hyperoxaluria
- •Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Distal Renal Tubular Acidosis
- •Chronic Diarrheal States
- •Thiazide-Induced Hypocitraturia
- •Idiopathic Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Hypomagnesiuric Calcium Nephrolithiasis
- •Gouty Diathesis
- •Cystinuria
- •Infection Lithiasis
- •Summary
- •References
- •12: Molecular Biology for Urologists
- •Introduction
- •Inherited Changes in Cancer Cells
- •VEGR and Cell Signaling
- •Targeting mTOR
- •Conclusion
- •References
- •13: Chemotherapeutic Agents for Urologic Oncology
- •Introduction
- •Bladder Cancer
- •Muscle Invasive Bladder Cancer
- •Metastatic Bladder Cancer
- •Conclusion
- •Prostate Cancer
- •Other Chemotherapeutic Drugs or Combinations for Treating HRPC
- •Conclusion
- •Renal Cell Carcinoma
- •Chemotherapy
- •Immunotherapy
- •Angiogenesis Inhibitor Drugs
- •Conclusion
- •Testicular Cancer
- •Stage I Seminoma
- •Stage I non-seminomatous Germ Cell Tumours (NSGCT)
- •Metastatic Germ Cell Tumours
- •Low-Volume Metastatic Disease (Stage II A/B)
- •Advanced Metastatic Disease
- •Salvage Chemotherapy for Relapsed or Refractory Disease
- •Conclusion
- •Penile Cancer
- •Side Effects of Chemotherapy
- •Conclusion
- •References
- •14: Tumor and Transplant Immunology
- •Antibodies
- •Cytotoxic and T-helper Cells
- •Immunosuppression
- •Induction Therapy
- •Maintenance Therapy
- •Rejection
- •Posttransplant Lymphoproliferative Disease
- •Summary
- •References
- •15: Pathophysiology of Renal Obstruction
- •Causes of Renal Obstruction
- •Effects on Prenatal Development
- •Prenatal Hydronephrosis
- •Spectrum of Renal Abnormalities
- •Renal Functional Changes
- •Renal Growth/Counterbalance
- •Vascular Changes
- •Inflammatory Mediators
- •Glomerular Development Changes
- •Mechanical Stretch of Renal Tubules
- •Unilateral Versus Bilateral
- •Limitations of Animal Models
- •Future Research
- •Issues in Patient Management
- •Diagnostic Imaging
- •Ultrasound
- •Intravenous Urography
- •Antegrade Urography and the Whitaker Test
- •Nuclear Renography
- •Computed Tomography
- •Magnetic Resonance Urography
- •Hypertension
- •Postobstructive Diuresis
- •References
- •Introduction
- •The Normal Lower Urinary Tract
- •Anatomy
- •Storage Function
- •Voiding Function
- •Neural Control
- •Symptoms
- •Flow Rate and Post-void Residual
- •Voiding Cystometry
- •Male
- •Female
- •Neurourology
- •Conclusions
- •References
- •17: Urologic Endocrinology
- •The Testis
- •Normal Androgen Metabolism
- •Epidemiological Aspects
- •Prostate
- •Brain
- •Muscle Mass and Adipose Tissue
- •Bones
- •Ematopoiesis
- •Metabolism
- •Cardiovascular System
- •Clinical Assessment
- •Biochemical Assessment
- •Treatment Modalities
- •Oral Preparations
- •Parenteral Preparations
- •Transdermal Preparations
- •Side Effects and Treatment Monitoring
- •Body Composition
- •Cognitive Decline
- •Bone Metabolism
- •The Kidneys
- •Endocrine Functions of the Kidney
- •Erythropoietin
- •Calcitriol
- •Renin
- •Paraneoplastic Syndromes
- •Hypercalcemia
- •Hypertension
- •Polycythemia
- •Other Endocrine Abnormalities
- •References
- •General Physiology
- •Prostate Innervation
- •Summary
- •References
- •Wound Healing
- •Inflammation
- •Proliferation
- •Remodeling
- •Principles of Plastic Surgery
- •Tissue Characteristics
- •Grafts
- •Flap
- •References
- •Lower Urinary Tract Symptoms
- •Storage Phase
- •Voiding Phase
- •Return to Storage Phase
- •Urodynamic Parameters
- •Urodynamic Techniques
- •Volume Voided Charts
- •Pad Testing
- •Typical Test Schedule
- •Uroflowmetry
- •Post Voiding Residual
- •Further Diagnostic Evaluation of Patients
- •Cystometry with or Without Video
- •Cystometry
- •Videocystometrography (Cystometry + Cystourethrography)
- •Cystometric Findings
- •Comment:
- •Measurements During the Storage Phase:
- •Measurements During the Voiding Phase:
- •Abnormal Function
- •Disorders of Sensation
- •Causes of Hypersensitive Bladder Sensation
- •Causes of Hyposensitive Bladder Sensation
- •Disorders of Detrusor Motor Function
- •Bladder Outflow Tract Dysfunction
- •Detrusor–Urethral Dyssynergia
- •Detrusor–Bladder Neck Dyssynergia
- •Detrusor–Sphincter Dyssynergia
- •Complex Urodynamic Investigation
- •Urethral Pressure Measurement
- •Technique
- •Neurophysiological Evaluation
- •Conclusion
- •References
- •Endoscopy
- •Cystourethroscopy
- •Ureteroscopy and Ureteropyeloscopy
- •Nephroscopy
- •Virtual Reality Simulators
- •Lasers
- •Clinical Application of Lasers
- •Condylomata Acuminata
- •Urolithiasis
- •Benign Prostatic Hyperplasia
- •Ureteral and Urethral Strictures
- •Conclusion
- •References
- •Introduction
- •The Prostatitis Syndromes
- •The Scope of the Problem
- •Category III CP/CPPS
- •The Goal of Treatment
- •Conservative Management
- •Drug Therapy
- •Antibiotics
- •Anti-inflammatories
- •Alpha blockers
- •Hormone Therapies
- •Phytotherapies
- •Analgesics, muscle relaxants and neuromodulators
- •Surgery
- •A Practical Management Plan
- •References
- •Orchitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment of Infectious Orchitis
- •Epididymitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation of Epididymitis
- •Treatment of Acute Epididymitis
- •Treatment of Chronic Epididymitis
- •Treatment of Spermatic Cord Torsion
- •Fournier’s Gangrene
- •Definition and Etiology
- •Risk Factors
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment
- •References
- •Fungal Infections
- •Candidiasis
- •Aspergillosis
- •Cryptococcosis
- •Blastomycosis
- •Coccidioidomycosis
- •Histoplasmosis
- •Radiographic Findings
- •Treatment
- •Tuberculosis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Schistosomiasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Filariasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Onchocerciasis
- •References
- •25: Sexually Transmitted Infections
- •Introduction
- •STIs Associated with Genital Ulcers
- •Herpes Simplex Virus
- •Diagnosis
- •Treatment
- •Chancroid
- •Diagnosis
- •Treatment
- •Syphilis
- •Diagnosis
- •Treatment
- •Lymphogranuloma Venereum
- •Diagnosis
- •Treatment
- •Chlamydia
- •Diagnosis
- •Treatment
- •Gonorrhea
- •Diagnosis
- •Treatment
- •Trichomoniasis
- •Diagnosis
- •Treatment
- •Human Papilloma Virus
- •Diagnosis
- •Treatment
- •Scabies
- •Diagnosis
- •Treatment
- •References
- •26: Hematuria: Evaluation and Management
- •Introduction
- •Classification of Hematuria
- •Macroscopic Hematuria
- •Microscopic Hematuria
- •Dipstick Hematuria
- •Pseudohematuria
- •Factitious Hematuria
- •Menstruation
- •Aetiology
- •Malignancy
- •Urinary Calculi
- •Infection and Inflammation
- •Benign Prostatic Hyperplasia
- •Trauma
- •Drugs
- •Nephrological Causes
- •Assessment
- •History
- •Examination
- •Investigations
- •Dipstick Urinalysis
- •Cytology
- •Molecular Tests
- •Blood Tests
- •Flexible Cystoscopy
- •Upper Urinary Tract Evaluation
- •Renal USS
- •KUB Abdominal X-Ray
- •Intravenous Urography (IVU)
- •Computed Tomography (CT)
- •Retrograde Urogram Studies
- •Magnetic Resonance Imaging (MRI)
- •Additional Tests and Renal Biopsy
- •Intractable Hematuria
- •Loin Pain Hematuria Syndrome
- •References
- •27: Benign Prostatic Hyperplasia (BPH)
- •Historical Background
- •Pathophysiology
- •Patient Assessment
- •Treatment of BPH
- •Watchful Waiting
- •Drug Therapy
- •Interventional Therapies
- •Conclusions
- •References
- •28: Practical Guidelines for the Treatment of Erectile Dysfunction and Peyronie´s Disease
- •Erectile Dysfunction
- •Introduction
- •Diagnosis
- •Basic Evaluation
- •Cardiovascular System and Sexual Activity
- •Optional Tests
- •Treatment
- •Medical Treatment
- •Oral Agents
- •Phosphodiesterase Type 5 (PDE 5) Inhibitors
- •Nonresponders to PDE5 Inhibitors
- •Apomorphine SL
- •Yohimbine
- •Intracavernosal and Intraurethral Therapy
- •Intracavernosal Injection (ICI) Therapy
- •Intraurethral Therapy
- •Vacuum Constriction Devices
- •Surgical Therapy
- •Conclusion
- •Peyronie´s Disease (PD)
- •Introduction
- •Oral Drug Therapy
- •Intralesional Drug Therapy
- •Iontophoresis
- •Radiation Therapy
- •Surgical Therapy
- •References
- •29: Premature Ejaculation
- •Introduction
- •Epidemiology
- •Defining Premature Ejaculation
- •Voluntary Control
- •Sexual Satisfaction
- •Distress
- •Psychosexual Counseling
- •Pharmacological Treatment
- •On-Demand Treatment with Tramadol
- •Topical Anesthetics
- •Phosphodiesterase Inhibitors
- •Surgery
- •Conclusion
- •References
- •30: The Role of Interventional Management for Urinary Tract Calculi
- •Contraindications to ESWL
- •Complications of ESWL
- •PCNL Access
- •Instrumentation for PCNL
- •Nephrostomy Drains Post PCNL
- •Contraindications to PCNL
- •Complications of PCNL
- •Semirigid Ureteroscopy
- •Flexible Ureteroscopy
- •Electrohydraulic Lithotripsy (EHL)
- •Ultrasound
- •Ballistic Lithotripsy
- •Laser Lithotripsy
- •Ureteric Stents
- •Staghorn Calculi
- •Lower Pole Stones
- •Horseshoe Kidneys and Stones
- •Calyceal Diverticula Stones
- •Stones and PUJ Obstruction
- •Treatment of Ureteric Colic
- •Medical Expulsive Therapy (MET)
- •Intervention for Ureteric Stones
- •Stones in Pregnancy
- •Morbid Obesity
- •References
- •Anatomy and Function
- •Pathophysiology
- •Management
- •Optical Urethrotomy/Dilatation
- •Urethral Stents
- •Preoperative Assessment
- •Urethroplasty
- •Anastomotic Urethroplasty
- •Substitution Urethroplasty
- •Grafts Versus Flaps
- •Oral Mucosal Grafts
- •Tissue Engineering
- •Graft Position
- •Conclusion
- •References
- •32: Urinary Incontinence
- •Epidemiology and Risk Factors
- •Pathophysiology
- •Urge Incontinence
- •Conservative Treatments
- •Pharmacotherapy
- •Invasive/ Surgical Therapies
- •Stress Urinary Incontinence
- •Male SUI Therapies
- •Female SUI Therapies
- •Mixed Urinary Incontinence
- •Conclusions
- •References
- •33: Neurogenic Bladder
- •Introduction
- •Examination and Diagnostic Tests
- •History and Physical Examination
- •Imaging
- •Urodynamics (UDS)
- •Evoked Potentials
- •Classifications
- •Somatic Pathways
- •Brain Lesions
- •Cerebrovascular Accident (CVA)
- •Parkinson’s Disease (PD)
- •Multiple Sclerosis
- •Huntington’s Disease
- •Dementias
- •Normal Pressure Hydrocephalus (NPH)
- •Tumors
- •Psychiatric Disorders
- •Spinal Lesions and Pathology
- •Intervertebral Disk Prolapse
- •Spinal Cord Injury (SCI)
- •Transverse Myelitis
- •Peripheral Neuropathies
- •Metabolic Neuropathies
- •Pelvic Surgery
- •Treatment
- •Summary
- •References
- •34: Pelvic Prolapse
- •Introduction
- •Epidemiology
- •Anatomy and Pathophysiology
- •Evaluation and Diagnosis
- •Outcome Measures
- •Imaging
- •Urodynamics
- •Indications for Management
- •Biosynthetics
- •Surgical Management
- •Anterior Compartment Repair
- •Uterine/Apical Prolapse
- •Enterocele Repair
- •Conclusion
- •References
- •35: Urinary Tract Fistula
- •Introduction
- •Urogynecologic Fistula
- •Vesicovaginal Fistula
- •Etiology and Risk Factors
- •Clinical Factors
- •Evaluation and Diagnosis
- •Pelvic Examination
- •Cystoscopy
- •Imaging
- •Treatment
- •Conservative Management
- •Surgical Management
- •Urethrovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Ureterovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Vesicouterine Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Uro-Enteric Fistula
- •Vesicoenteric Fistula
- •Pyeloenteric Fistula
- •Urethrorectal Fistula
- •References
- •36: Urologic Trauma
- •Introduction
- •Kidney
- •Expectant Management
- •Endovascular Therapy
- •Operative Intervention
- •Operative Management: Follow-up
- •Reno-Vascular Injuries
- •Pediatric Renal Injuries
- •Adrenal
- •Ureter
- •Diagnosis
- •Treatment
- •Delayed Diagnosis
- •Bladder and Posterior Urethra
- •Bladder Injuries: Initial Management
- •Bladder Injuries: Formal Repair
- •Anterior Urethral Trauma
- •Fractured Penis
- •Penile Amputation
- •Scrotal and Testicular Trauma
- •Imaging
- •CT-IVP (CT with Delayed Images)
- •Technique
- •Cystogram
- •Technique
- •Retrograde Urethrogram (RUG)
- •Technique
- •Retrograde Pyelogram (RPG)
- •Technique
- •One-Shot IVP
- •Technique
- •References
- •37: Bladder Cancer
- •Who Should Be Investigated?
- •Epidemiology
- •Risk Factors
- •Role of Screening
- •Signs and Symptoms
- •Imaging
- •Cystoscopy
- •Urine Tests
- •PDD-Assisted TUR
- •Pathology
- •NMIBC and Risk Groups
- •Intravesical Chemotherapy
- •Intravesical Immunotherapy
- •Immediate Cystectomy and CIS
- •Radical Cystectomy with Pelvic Lymph Node Dissection
- •sexual function-preserving techniques
- •Bladder-Preservation Treatments
- •Neoadjuvant Chemotherapy
- •Adjuvant Chemotherapy
- •Preoperative Radiotherapy
- •Follow-up After TUR in NMIBC
- •References
- •38: Prostate Cancer
- •Introduction
- •Epidemiology
- •Race
- •Geographic Variation
- •Risk Factors and Prevention
- •Family History
- •Diet and Lifestyle
- •Prevention
- •Screening and Diagnosis
- •Current Screening Recommendations
- •Biopsy
- •Pathology
- •Prognosis
- •Treatment of Prostate Cancer
- •Treatment for Localized Prostate Cancer (T1, T2)
- •Radical Prostatectomy
- •EBRT
- •IMRT
- •Brachytherapy
- •Treatment for Locally Advanced Prostate Cancer (T3, T4)
- •EBRT with ADT
- •Radical Prostatectomy
- •Androgen-Deprivation Therapy
- •Summary
- •References
- •39: The Management of Testis Cancer
- •Presentation and Diagnosis
- •Serum Tumor Markers
- •Primary Surgery
- •Testis Preserving Surgery
- •Risk Stratification
- •Surveillance Versus Primary RPLND
- •Primary RPLND
- •Adjuvant Treatment for High Risk
- •Clinical Stage 1 Seminoma
- •Risk-Stratified Adjuvant Treatment
- •Adjuvant Radiotherapy
- •Adjuvant Low Dose Chemotherapy
- •Primary Combination Chemotherapy
- •Late Toxicity
- •Salvage Strategies
- •Conclusion
- •References
- •Index
469
PElvic ProlaPsE
The POP-Q also defines an ordinal staging sys- |
necessary to further evaluate for rectocele or |
tem for prolapse, which is based upon the maxi- |
posterior enterocele. |
mally protruding segment, and ranges from 0 (no |
Genital sensation should be assessed as part of |
prolapse) to 4 (vaginal eversion). All points must |
the neurological evaluation by touch or pinprick. |
be measured before assigning stage (Table 34.1). |
The bulbocavernosus and anal reflexes can be |
The physical exam should include many of |
tested by tapping on the clitoris or gently stroking |
the components of the general exam and should |
the inside of the thigh and inspecting the anus for |
include a thorough pelvic examination and |
subsequent contraction. Anal sphincter tone |
assessment of neurologic status. The pelvic |
should be evaluated at the time of rectal exam. |
exam is usually performed in dorsal lithotomy |
The external components of the POP-Q (geni- |
position with a full bladder, and may include a |
tal hiatus, perineal body, and total vaginal |
standing exam. A bivalved speculum or Sims’s |
length) are measured. Also, notation should be |
retractor is used during the exam to allow |
made of vaginal volume particularly if vaginal |
inspection of single compartments. Initial exam |
repairs are considered to avoid narrowing the |
should include an assessment of inguinal lymph |
vaginal vault. Additional assessments can be |
nodes, visual inspection of the external genita- |
made using a lubricated Q-tip to quantify ure- |
lia, assessment of the vaginal mucosa, and nota- |
thral hypermobility (degrees at rest and at |
tion of estrogen status. The urethral meatus |
strain) or by the use of a ring forceps to support |
should be inspected for evidence of prolapse or |
the lateral vaginal fornices in evaluating for cys- |
caruncle and the urethra palpated for presence |
tocele (lateral versus central cystocele). |
of diverticula or anterior vaginal wall cystic |
Further imaging or diagnostic testing can be |
structures. The urethra should also be assessed |
useful to supplement physical exam findings in |
for hypermobility and for the presence of con- |
formulating the diagnosis. Often, urodynamic |
comitant stress incontinence. The levator and |
testing,MRI or CT,fluoroscopic studies,or cystos- |
coccygeus muscles should be palpated for tone |
copy will be needed to complete the evaluation. |
and strength of kegel maneuvers evaluated. |
|
Examination of the anterior and posterior vagi- |
Outcome Measures |
nal walls and cervix/vaginal apex should be per- |
|
formed in a resting state. Each compartment |
|
must be examined individually, using the specu- |
Standardization in symptom assessment, physi- |
lum to reduce the other compartments. The |
cal examination,and outcome measures has been |
compartments are then re-examined individu- |
a challenge in the field of female pelvic recon- |
ally in a straining state, either during cough or |
struction. Despite much effort and attention, |
valsalva maneuvers. Sometimes, a rectal exam is |
there is no uniform system of preoperative or |
Table 34.1. states of pelvic organ prolapse. stages are assigned according to the most severe portion of the prolapsed when the full extent of the protrusion has been demonstrated. (reprinted from Bump et al.28 copyright 1996.With permission from Elsevier)
stage 0 |
no prolapse is demonstrated. Points aa, ap, Ba, and Bp are all at 3cm and either point c or d is between –tvl cm |
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and –(tvl2)cm. |
stage i |
the criteria for stage 0 are not met, but the most distal portion of the prolpase is >1cm above the level of the |
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hymen (i.e., its quantitation value is <1cm). |
stage ii |
the most distal portion of the prolapse is £1 cm proximal to or distal to the plane of the hymen (i.e., it |
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quantitation value is ³−1 cm but £+1 cm). |
stage iii |
the most distal portion of the prolapse is >1cm below the plane of the hymen but protrudes no further than |
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2cm less than the total vaginal length in cm (i.e., its qunatitation value is >+1cm but <+[tvl2]cm). |
stage iv |
Essentially, complete eversion of the total length of the lower genital tract is demonstrated. the distal portion |
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of the prolapse protrudes to at least (tvl2)cm ( i.e., its quantitation value is ³+[tvl2]cm). in most cases, |
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the leading edge of stage iv prolapsed will be the cervix or vaginal cuff scar. |
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Practical Urology: EssEntial PrinciPlEs and PracticE |
postoperative evaluation in the literature. |
In identifying objective measures of success, |
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Progress has been made in adopting the POP-Q |
the pad weight test and the voiding diary have |
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grading system for prolapse, but there are many |
often been incorporated as instruments in stud- |
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different validated bladder, bowel, and sexual |
ies and trials. Both of these measures can be |
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function symptom questionnaires widely in use. |
labor intensive and therefore are dependent |
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Because objective success is often vastly different |
upon patient compliance. The 3 day voiding |
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than patient perception of success, more atten- |
diary has been shown to have better patient |
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tion is now being focused on patient symptoms, |
compliance with more accurate information |
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patient centered goals, and quality of life. |
than the 5 or 7 day diary.31 |
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Numerous bladder and bowel specific symp- |
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tom questionnaires exist, including those which |
Imaging |
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aim to assess related quality of life perception. |
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Most of these questionnaires address voiding |
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symptoms, such as the Urogenital Distress |
A supplement to history and physical exam, pel- |
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Inventory (UDI) or the Incontinence Impact |
vic imaging by ultrasound, x-ray studies, or MRI |
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Questionnaire (IIQ); however, there are ques- |
may provide additional anatomic information |
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tionnaires that are prolapse specific. The |
in prolapse patients, particularly those who |
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Prolapse Quality of Life Questionnaire (P-QOL) |
have had prior pelvic surgery or prior failed |
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is constructed to address the impact of prolapse |
repairs. |
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on several quality of life domains. The Pelvic |
The standing cystourethrogram can provide |
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Floor Distress Inventory (PFDI) and Pelvic Floor |
dynamic information in changes in position of |
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Incontinence Questionnaire (PFIQ) incorporate |
the bladder and urethra between rest and |
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both assessments of prolapse and voiding symp- |
straining. It is a readily available modality |
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toms and resulting impact on quality of life. |
which requires catheterization with retrograde |
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An important part of the initial patient evalu- |
filling of the bladder with contrast material. |
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ation should be an assessment of patient expec- |
Precise measurements of urethal angle and |
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tations and goals. Lowenstein et al. evaluated |
degree/extent of bladder descent can be |
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patient goals at initial consultation and repeated |
obtained on lateral views, along with voiding |
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an assessment of goals in the same group of |
views32(Figs. 34.5–34.7). |
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patients at follow-up before surgical interven- |
Defecography or culpocystodefecography are |
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tion. The authors found that the “most impor- |
specialized imaging techniques requiring instil- |
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tant” goals changed after the initial visit in 56% |
lation of contrast material into the rectum, the |
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of patients from“symptoms,”“information,” and |
bladder, and the vagina. Fluoroscopic images are |
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“treatment” to “treatment” and “emotional” at |
obtained at rest, at straining, and during defeca- |
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subsequent visits.29 |
tion/voiding. Interpretation requires a special- |
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Sexual function is often negatively impacted |
ized radiologist. Physical examination is not |
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in patients with pelvic organ prolapse, either as |
accurate in the detection of rectocele or entero- |
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a direct result of the anatomic changes and |
cele, and defecography is used to enhance detec- |
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mechanical difficulties of intercourse or sec- |
tion beyond exam.33 Obstructive defecation |
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ondarily by coexisting depression. Patients with |
correlates well with presence of rectocele on |
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pelvic organ prolapse are more likely to feel |
preoperative clinical examination, but not on |
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physically and sexually unattractive, more self- |
postoperative exam, and is therefore limited for |
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conscious, and less confident than their normal |
use in follow-up.34 |
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counterparts.30 There are fewer validated sexual |
MRI has been recently employed to evaluate |
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function questionnaires, the most commonly |
the pelvic organs in cases of recurrent or com- |
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employed being the Female Sexual Function |
plex prolapse. No standardized technique has |
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Index (FSFI) and the Pelvic Organ Prolapse/ |
been used in performing the study or in mea- |
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Urinary Incontinence Sexual Questionnaire |
surements/assessment of prolapse; however, |
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(PISQ). The PISQ addresses bladder and bowel |
MRI has gained wide acceptance thus far |
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function in addition to sexual function,whereas |
(Fig. 34.8). Although the patient is supine and |
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the FSFI address sexual function alone, exam- |
bladder filling is usually not standardized, |
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ining the domains of desire, arousal, orgasm, |
images can be compared between static and |
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and pain. |
dynamic states and provide exquisite detail of |
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PElvic ProlaPsE
Figure 34.5. vcUg grading system. Based upon the distance of cystocele descent on lateral cystogram (measured from the inferior edge of the pubic symphysis to inferior edge of the cystocele). (a) stage 0 = inferior edge of cystocele above symphysis; (b) stage i = inferior edge <2 cm below inferior edge of symphysis; (c) stage ii = inferior edge of cystocele 2–5 cm below inferior edge of symphysis; (d) stage iii = inferior edge of cystocele >5 cm below inferior edge of symphysis.
Figure 34.6. voiding cystoure throgam (vcUg) for evaluation of prolapse. in addition to staging prolapse,vcUg can give a visual estimate of the size of the pelvic floor defect and resulting pelvic organ herniation.the position of the urethra can also be determined (left image is wellsupported, right image is hypermobile).
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472 |
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Practical Urology: EssEntial PrinciPlEs and PracticE |
Figure 34.7. vcUg outcome. |
a |
b |
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Preoperative and postoperative |
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voiding views in the same patient |
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documenting resolution of the |
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prolapse and wellsupported urethra |
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after repair. |
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Pelvic |
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Bone |
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Corrected |
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Cystocele |
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Urethra |
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Poorly |
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Supported |
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Pelvic Bone |
Large |
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Cystocele |
Well Supported |
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Urethra |
Figure 34.8. Mri of pelvic organ prolapse in a patient com plaining of recurrent vaginal bulge, suspected of having a cysto cele.the bladder was noted to be well supported by Mri and the bulge represented a large enterocele.
the pelvic organs. MRI is useful in distinguishing the presence of urethral diverticulum or cystic lesions of the urinary or reproductive tracts, as well as in detecting enteroceles, which can be
difficult at times to confirm by physical exam alone.
Urodynamics
Urodynamic evaluation in patients with pelvic organ prolapse is aimed at confirming or identifying stress incontinence, which can exist in up to 40% of patients.35 Stress incontinence is often masked by urethral kinking as a result of the prolapse and may not be detected unless the prolapse is reduced, either on cough stress test or during urodynamics. Obstructive symptoms can also be caused by severe prolapse, with urodynamic parameters demonstrating higher detrusor pressures at peak flow and higher maximum urethral closure pressures.36 Detrusor overactivity can also be assessed during the filling phase, though the presence of overactivity does not impact the surgical approach employed.
Urodynamic testing should be performed with and without prolapse reduction. Reduction can be effectively achieved using a pessary, ring forceps, a vaginal packing constructed of gauze or swab, or a speculum. The CARE trial demonstrated that the most effective methods of reduction were the forceps, swab, and speculum.37 Care must be taken to avoid overly aggressive prolapse reduction, which may compress the urethra and prevent demonstration of stress incontinence.