Clinical Cases - Pelvis & Pelvic Viscera
L.D., a 60-year-old mother of four, visited her family doctor complaining of back pain and the sensation of something "coming down" her vagina, especially when she was standing. In addition, L.D. was troubled by stress incontinence when she coughed, sneezed, or lifted a heavy object, and by the need to micturate about ten times per day and five times each night. Pelvic examination revealed a first degree uterine prolapse (the cervix was still inside the vagina) and prolapse of the bladder base. The physician referred L.D. to a gynecologist, who recommended surgery. A vaginal hysterectomy and an anterior colporrhaphy (a procedure to correct the cystocele and stress incontinence) were performed , and L.D. was subsequently relieved of her symptoms.
Questions to consider:
- What sphincter controls urinary flow and where is it located?Urinary flow is controlled voluntarily by the striated urethrovaginal sphincter muscle. This action is assisted by the pubococcygeus portion (levator prostate in the male) of the levator ani.
- What is stress incontinence and why might coughing, sneezing, or lifting cause it ?Stress incontinence is the involuntary loss of urine caused by an increase in the intra-abdominal pressure when the abdominal muscles contract, as in coughing, sneezing, lifting and the like. Compromised urethral sphincters and/or support are unable to resist this stress, resulting in leakage.
- How is the uterus ordinarily supported and what causes prolapse?The uterus is supported by the pelvic floor, the viscera surrounding it (i.e. the bladder, rectum, etc.), and connective tissue support structures. As the pelvic floor weakens due to aging or injury (like from multiple childbirths), the pelvic organs, including the uterus, will begin to sag if the pelvic diaphragm tone cannot be maintained. Several fascial ligaments, including the round ligament of the uterus and the rectouterine ligaments, and the cardinal ligaments help maintain the orientation of the uterus and cervix, and aid in supporting the pelvic viscera.
- What is a vaginal hysterectomy?A vaginal hysterectomy is a surgical procedure in which the uterus is excised and removed from the body via a vaginal route (rather than abdominal). This procedure is the preferred surgical treatment for prolapse in the United States.
- The cystocele caused a bulge in the anterior wall of the vagina. What structures could prolapse and cause a bulge in the posterior wall of the vagina?Loops of the small intestine in the rectouterine pouch may cause a bulge at the posterior fornix (enterocele) and the rectum may bulge into the lower vagina (rectocele).
You are in the middle of an international rotation in West Africa and consult with a surgeon on a 35-year old female patient who complains of irregular and painful menses, and an unexplained abdominal mass. The patient reports that she has six children. On physical exam you palpate a large (15 cm in diameter) mass in the lower abdomen. The patient denies pain on deep palpation, bowel sounds are present and normal. The surgeon decides to perform an exploratory laparotomy . She advises the patient that she may have to perform a hysterectomy and makes certain that the patient understands the consequences of the surgery. On beginning the surgery, she makes a midline incision up to the umbilicus, retracts the rectus muscles and fascia and notes that the patient has an enlarged uterus which is covered with large fibroid tumors. The surgeon then inspects the ovaries and observes that they are normal in size and morphology. She then proceeds to perform a hysterectomy. The excised uterus weighed in at six kilograms.
Questions and answers:
- OPTIONAL: What would be the indications for a hysterectomy?
Chronic pelvic pain/discomfort not due to other medical problems such as STD's, sexual abuse, heavy metal exposure, sickle cell disease, and psychiatric or psychosocial disorders. Obvious palpable masses in the abdomen with or without changes in bowel sounds would also suggest the need for an exploratory laparotomy.
Physical exam would also include inspection for hernias, scars or obvious deformities, in addition to assessment of the patient's gait and any restriction of movement while walking. It is also important to auscultate for bowel sounds and palpate the abdomen, flanks, epigastric, back and femoral regions. During palpation special attention should be placed on the character, duration, type of pain and the site at which the pain was elicited. Noting the site of pain may give indication of strictures (urethral, uterine), masses or nodal tenderness. The patient also should be examined for any infectious disease processes, pregnancy, kidney stones, biliary problems or bleeding.
Indications for a hysterectomy would also include treatment for leiomyomas, irregular and painful menses, and chronic pelvic pain. Unsuccessful antibiotic treatment of spontaneous abortion (septic abortion) with a subsequent abscess formation within the uterus would also necessitate a hysterectomy.
- To excise the uterus what ligaments would the surgeon have to cut?
The round ligament of the uterus, which connects to the uterus anterior and inferior to the uterine tube between the layers of the broad ligament.
The ligament of the ovary (proper ovarian ligament), which lies posterior and inferior to the uterine tube.
The anterior leaf of the broad ligament and the lateral attachments of the broad ligament.
In addition the surgeon would detach the uterus by cutting below the external os of the cervix and suturing the four corners of the vaginal wall.
- What blood vessels would she be concerned about as she performed the surgery?
The uterine artery is the most significant source of blood to the uterus and therefore requires careful dissection. It is generally a branch of the internal iliac artery which supplies the uterus and uterine tube.
The other major blood supply to the region is the ovarian artery which a direct branch off the aorta.
- What other vessel or tube would be of great concern?
The ureters pass under the uterine arteries on their way to the bladder - "yellow water" under "red bridge" is the term frequently used to describe their passage.
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