CASE STUDY

SPECIAL ISSUES( WOMEN HEALTH)

URGE AND STRESS
INCONTINENCE WITH GRADE 1 UV
PROLAPSE
BY:NURDINA AFINI BT IZAMUDIN
031390
UNISZA

ANATOMY OF
FEMALE
REPRODUCTIVE
SYSTEM

Mons pubis
The mons pubis is the rounded portion of the
vulva where sexual hair development occurs at the
time of puberty. This area may be described as
directly anterosuperior to the pubic symphysis.
Labia
The labia majora are 2 large, longitudinal folds of
adipose and fibrous tissue. They vary in size and
distribution from female to female, and the size is
dependent upon adipose content. They extend
from the mons anteriorly to the perineal body
posteriorly. The labia majora have hair follicles.

The labia minora, also known as nymphae, are

2 small cutaneous folds that are found between
the labia majora and the introitus or vaginal
vestibule. Anteriorly, the labia minora join to
form the frenulum of the clitoris.
Hymen
The hymen is a thin membrane found at the
entrance to the vaginal orifice. Often, this
membrane is perforated before the onset of
menstruation, allowing flow of menses. The
hymen varies greatly in shape.

Clitoris
The clitoris is an erectile structure found beneath
the anterior joining of the labia minora. Its width in
an adult female is approximately 1 cm, with an
average length of 1.52.0 cm. The clitoris is made
up of 2 crura, which attach to the periosteum of
the ischiopubic rami. It is a very sensitive
structure, analogous to the male penis. It is
innervated by the dorsal nerve of the clitoris, a
terminal branch of the pudendal nerve.

Vagina
The vagina extends from the vulva externally to
the uterine cervix internally. It is located within
the pelvis, anterior to the rectum and posterior to
the urinary bladder. The vagina lies at a 90
angle in relation to the uterus. The vagina is held
in place by endopelvic fascia and ligaments. The
vagina is lined by rugae, which are situated in
folds throughout. These allow easy distention,
especially during child bearing. The structure of
the vagina is a network of connective,
membranous, and erectile tissues.

Cervix
The cervix is the inferior portion of the uterus,
separating the body of the uterus from the
vagina. The cervix is cylindrical in shape, with an
endocervical canal located in the midline,
allowing passage of semen into the uterus. The
external opening into the vagina is termed the
external os , and the internal opening into the
endometrial cavity is termed the internal os. The
internal os is the portion of a female cervix that
dilates to allow delivery of the fetus during labor.
The average length of the cervix is 3-5 cm.

Uterine tubes
The uterine tubes (also referred to as oviducts or
fallopian tubes) are uterine appendages located
bilaterally at the superior portion of the cavity.
Their primary function is to transport sperm
toward the egg, which is released by the ovary,
and then to allow passage of the fertilized egg
back to the uterus for implantation.

Ovaries
The ovaries are paired organs located on either
side of the uterus within the mesovarium portion
of the broad ligament below the uterine tubes.
The ovaries are responsible for housing and
releasing the ova, or eggs, necessary for
reproduction. At birth, a female has
approximately 1-2 million eggs, but only 300 of
these eggs ever mature and are released for the
purpose of fertilization.

BLADDER
Urinary incontinence
means there is loss of
INCONTINENCE

bladder control which leads to unintentional

passing of urine
There are several types of bladder
incontinence which are:
1. Stress incontinence occurs during certain
activities like coughing, sneezing, laughing
2. Urge incontinence - leakage of urine which
involves a strong and sudden need to
urinate

3. Mixed incontinence combination of

both stress and urge incontinence
symptoms
4. Overflow incontinence loss of
small amounts of urine when the
bladder does not empty all the way
during voiding

AETIOLOGY
Stress incontinence
weakening of urethral sphincter and pelvic floor
muscles
pregnancy
Childbirth
age
obesity
menopause
surgical procedures, e.g. hysterectomy

Urge incontinence
-overactivity of the detrusor muscles
- cystitis (inflammation of bladder)
-central nervous system (CNS) problems
- an enlarged prostate

Overflow incontinence
-an obstruction or blockage to the bladder
-an enlarged prostate gland
-a tumor pressing against the bladder
-urinary stones
- constipation

PATHOLOGY
Incontinence of the bladder occurs when
those pelvic muscles that involves in urination
get traumatized, either overstretched or tear,
that leads to weakness of the muscles.
As time goes by, the muscles become
weaker until at certain point, they cannot
support the bladder anymore.
When there is high pressure from the
abdominal such as coughing, sneezing, lifting
or pushing heavy things, the bladder forces
urine past the urethral sphincter causing
incontinence to occur.

CLINICAL FEATURES
Stress incontinence
occur when:
Cough
Sneeze
Laughing
Lifting heavy objects
Vigorous exercise
Have sexual
intercourse
Standing in prolonged
time

URGE INCONTINENCE OCCURS :

Frequent urination, in a day and at nighttime
Loss of urine without meaning to urinate
Sudden and urinary urgency
OVERFLOW INCONTINENCE OCCURS:
Bladder never feels empty
Frequent urination, in a day and at nighttime
urinate
Inability to void when when the urge is felt
Urine dribbles even after voiding

DRS MANAGEMENT
Medication - Anticholinergics
(medication to calm an overactive
bladder)
- Topical estrogen.
- Anti depressant
- Imipramine
-Duloxetine
Medical device
Urethral insert (FemSoft insert)
Pessary

Surgery
- Sling procedures
-Bladder neck
suspension

UTERO-VAGINAL
PROLAPSE

DEFINITION
Uterine prolapse is
the condition of the
uterus collapsing,
falling down, or
downward
displacement of
the uterus through
the vagina.
It is also defined as
the bulging of the
uterus into the
vagina

AETIOLOGY
Pregnancy & Childbirth:
When there can be
excessive stretching of the
tissues
After menopause: When a
relative lack of female
hormones can lead to
thinning and weakening of
the tissues
Increase in the pressure in
the abdominal cavity (e.g.
chronic cough, constipation
or heavy lifting) can
aggravate the prolapse.

GRADES
Grade 1: Descent of the
uterus to above the
hymen
Grade 2: Descent of the
uterus to the hymen
Grade 3: Descent of the
uterus beyond the
hymen
Grade 4: Total prolapse.

PATHOPHYSIOLOGY
Due to birth through vaginal delivery or menopause

CLINICAL FEATURES
Mild degrees of uterine
prolapse are common and
usually asymptomatic
Feeling likely sitting on a ball
Vaginal bleeding or increased
discharge
Problems with sexual
intercourse
Seeing the uterus or cervix
coming out from the vagina
Pulling or heavy feeling in
pelvis
Constipation
Recurrent bladder infections

MEDICAL MANAGEMENTS
DIAGNOSIS
Doctor will perform
pelvic exam by
inserting a
speculum into the
vagina to examine
the vaginal canal
and uterus

TREATMENTS
Nonsurgical
Estrogen
replacement
therapy
Pessary (a device
inserted into the
vagina that fits
under the cervix
and helps push up
and stabilize the
uterus and cervix)

SURGICAL
Hysterectomy (the
uterus is removed from
the body)
Uterine suspension (the
uterus is placed back
into its original position
by reattaching pelvic
ligaments or using
surgical materials)

PHYSIOTHERAPIST AX.
Assessment of muscle strength and functions
Therapist preparation: wearing disposable
gloves
Patient position : crooked lying
Action : by using lubricant jelly, therapist gently
and slowly insert the index and middle fingers
into the vagina. Then palpates the posterior
vaginal wall with distal two phalanges. Asked the
patient to hold the fingers there.
Positive findings: strong muscle will squeeze
the fingers firmly
Graded: 4 very good
3 good
2 fair

Perionometer
It is an instrument for
measuring the strength of
voluntary contractions of the
pelvic floor muscles.
The instruction to patient is
same as digital evaluation of
vagina

PHYSIOTHERAPY TREATMENT

For medical condition such as incontinence

Pelvic floor exercises- slow and fast kegel exs
Interferential therapy:
Patient position : supine lying
Electrode placement : a bipolar technique is recommended
posterior pad places under ischial tuberosity
anterior pad on the perineum just below the
symphysis
pubis
Frequency : stress incontinece = 10 50 hz
urge incontinece = 5 10 hz

Bladder training : re-education of pelvic floor

muscle by delay the periods of micturation for a
few minutes.

CASE STUDY
Name: Mrs. SZ
Age: 62 y/o
Gender: Female
R/N:5208xxx
Date of Ax: 2 Dicember 2014
Date of referred: 24 November 2014
Dr. Diagnosis: -Urge and stress continence
- Grade 1 UV prolapse
Dr. Mx: Conservative and refer physio

Problem:
c/o vaginal heaviness
c/o something coming out from vagina when squatting
and when passing stool since 52 y/o.
Special question:
-General Health: Healthy
-PMHx: NIL
-Obstetric Hx:
Age

Gender

Mode of
delivery

Birth weight

Complication

1982

Male

SVD +
Vacuum

3.4 kg

-Prolonged 2nd
stage
-episiotomy grade
1

1990

Female

SVD

3.2 kg

-Episiotomy grade
1
-Baby died on 10th
month d/t biliary
atricia

01

02

Gynaecological surgery:NIL
Menopausal status:
Yes on 49 y/o, no HRT taken.
Medication: On detrusitol and calcium
Social Hx:
-Occ: Ex bank officer retired on 49 y/o
-Nature: Sedentary life style
-Marital status: Married
-Lifestyle: Currently h/w and working as rubber
tapper on age 52 y/o, lift heavy things and
pushing wheelbarrow.

Current Hx:
Bowel: Constipation, 2 day/once
Stress Incontinence:
NIL, improve after taking medication and limit water intake
Incontinence:
Frequency : NIL
Severity: Pad using when travelling as a precaution
Micturation frequency:
Day: 4x
Night: 1x
Max. vol. voided: 180 ml
Min. vol. voided: 150 ml

Measured by pt.

No. of drinks (type of drink)

500 ml ( 3 mug of tea and 2 mug of mineral water)

Urgency: NIL
Observation:
GO: A mesomorph body size of malay woman come to
department with normal but slow gait and normal posture.
LO: Clean and hygiene of external perineal area
Present of UV prolapse ( 2cm)
Palpation:
No tenderness around vaginal wall
Palpable sagging down of cysticole? at anterior of vaginal
wall
Palpable mass buldge of rectocele? At posterior of vaginal
wall
Palpable mass at superior vaginal wall. UV prolapse?

Provocation test: Coughng 5x

+ve 2 drops
Pelvic floor Ax.
Characteristics of PVM
-Displacement in plane: slight incline of fingers along total
length
-Duration: 5 sec hold
-Pressure: Weak, feel pressure on fingers but not all way
round.
Perineometer reading:
Peak: 8 cm
Gradient: 10/1.9 cm/sec
Area: 7 cm-sec
FTF strength: Fair
STF endurance: Fair
GPFM: Poor

Analysis
PTs Impression
-Cystocele,rectocele and UV prolapse d/t general PFM
strength is poor.
- Urge incontinence d/t STF endurance is poor
-Stress incontinence d/t FTF strength is poor
STG
-To improve STF,FTF and GPFM strength within 1/12
-To prevent worsening of prolapse and incontinence.
LTG
-To enable pt to return to normal functional activity and
recreation without feeling discomfort and heaviness of
vaginal.

Plan of treatment
-PFM exs.
-Abd exs.
-CBT exs.
-PFM during functional activites
-Education
-HEP

Intervention:
1) PFM dysfunction using adjunct 5th vaginal cone
i. STF: 5 sec hold, 5 reps, rest 10 sec.
ii. FTF: 10 reps, ratio 1:1 sec
2) Abdominal exs.,hold 5 sec.,10 reps.,rest 10 sec.
3) Functional activities
-Walking for 10 min. STF contraction for 5 sec.
-Sitt to stand.PFM contraction during motion for 5
sec,10 reps.
-Rolling on gymball. PFM contraction during motion
for 5 sec.,10 reps.
4)Advice pt to do regular PFM exercise for 3
sessions/day.
5)Advice to do CBT when perform functional
activities.

Evaluation:
Pt. give cooperation and able to do all exs.
Review:
Cont. same activities on next TCA.

Follow up
Date: 30 Dicember 2014
S:
c/o increase prolapse when squatting
Claim able to hold urinate when laughing and coughing.
O:
GO: A mesomorph body size of malay woman come to
department with normal but slow gait and normal posture.
LO: Clean and hygiene of external perineal area
Present of UV prolapse ( 2cm)

Palpation:
No tenderness around vaginal wall
Palpable sagging down of cysticole? at anterior of vaginal
wall
Palpable mass buldge of rectocele? At posterior of vaginal
wall
Palpable mass at superior vaginal wall. UV prolapse?
Pelvic floor Ax.
Characteristics of PVM
-Displacement in plane: slight incline of fingers along total
length
-Duration: 6 sec hold
-Pressure: Weak, feel pressure on fingers but not all way
round.

Analysis
PTs Impression
-Cystocele,rectocele and UV prolapse d/t general PFM
strength is poor.
- Imrpove of STF endurance
-Stress incontinence d/t FTF strength is poor

Plan of tx:
1) PFM dysfunction using adjunct 5th vaginal cone
i. STF: 6 sec hold, 5 reps, rest 10 sec.
ii. FTF: 10 reps, ratio 1:1 sec
2) Abdominal exs.,hold 56sec.,10 reps.,rest 10 sec.
3) Functional activities
-Walking for 10 min. STF contraction for 6 sec.
-Sitt to stand.PFM contraction during motion for 6
sec,10 reps.
-Rolling on gymball. PFM contraction during motion
for 6 sec.,10 reps. Dislodged when start to sitt on
gymball.
4) KIV for same tx on next TCA
5)Advice pt to do regular PFM exercise for 3
sessions/day.
6)Advice to do CBT when perform functional
activities.

References
http://www.nlm.nih.gov/medlineplus/ency/article
/001602.htm
http://www.coreconcepts.com.sg/physiotherapy/
diastasis-recti-abdominis/
http://www.zen104556.zen.co.uk/Medicine/ObsG
yn/Gynaecology/Surgery/UVProlapse.html