Author
Information
Parulekar
SV
(Professor
and Head, Department of Obstetrics and Gynecology, Seth GS Medical
College & KEM Hospital, Mumbai, India.)
Abstract
Urinary
stress incontinence can be caused by loss of urethral support due to
childbirth trauma, postmenopausal atrophy of connective tissue, and
chronic stress on the pelvic floor by lifting heavy weights, chronic
cough, constipation, or obesity. It may be due to pudendal neuropathy
caused by childbirth trauma or ageing. A vaginal wall cyst. has not yet been reported to
cause this condition. A first case of urinary stress incontinence
caused by an anterior vaginal wall cyst is presented here.
Introduction
Urinary
stress incontinence affects 4 to 35 percent of women.[1,2]
It is caused by a lack of support under the bladder neck and urethra,
such that the urethra is not compressed during Valsalva's maneuver.
It may be due to anatomical conditions like childbirth trauma,
postmenopausal atrophy of connective tissue, and chronic stress on
the pelvic floor by lifting heavy weights, chronic cough,
constipation, or obesity.[2,3] It may also be due to pudendal
neuropathy caused by childbirth trauma or ageing.[2,4] A case of
urinary stress incontinence caused by an anterior vaginal wall cyst
is presented here. It is the first case of its type in the world
literature.
Case
Report
A
28 year old woman, gravida 2 para 2, presented with a complaint of
something coming out per vaginum for two months. She had no history
of lifting heavy weights, chronic cough, constipation, or obesity.
She had no history of urinary
stress
incontinence in past. Her menstrual cycles were regular, every 28
days, painless, and with moderate flow. She had two full term normal
deliveries which had been uneventful. Her last menstrual period had
been one week ago. Her medical and surgical history was not
contributory. There were no bowel complaints. Her general and
systemic examination revealed no abnormality. A speculum examination
of the lower genital tract showed the presence of an anterior vaginal
wall cyst on the right side of the urethra and the bladder neck. It
was 5 cm in diameter, nontender, soft and cystic. The cervix and
vagina were normal. There was no genital prolapse or urinary stress
incontinence. Bimanual pelvic examination showed normal sized uterus
and no pelvic abnormality.
Surgical
removal of the mass was done under spinal anesthesia. A number 14
Foley's catheter was passed into the urinary bladder through the
urethra. A longitudinal incision was made on the anterior vagina over
the undersurface of the cyst. The cyst was dissected away from the
bladder and urethra, which were not traumatized in any way.
Hemostasis was achieved by electrocoagulation. Redundant part of the
vaginal walls was excised. The edges of the vagina were approximated
with interrupted sutures of No. 1-0 polyglactin, occluding the dead
space in the cavity left behind after excision of the cyst. The
urinary catheter was removed after 24 hours. The patient made an
uneventful recovery and was discharged after 3 days.
The
patient came for a follow up examination after 15 days. She
complained of urinary stress incontinence which had started two days
after the operation. There were no symptoms suggestive of urinary
tract infection. An examination showed the presence of urinary
stress incontinence which was confirmed by Bonney's test. Sensations
in the area of distribution of the pudendal nerve were normal.
Postvoid residual urine volume was 10 ml. Her urinalysis was normal
and microbiological test of urine showed no growth of any bacteria.
She was counseled on the treatment options. She chose to perform
Kegel's perineal exercise and not undergo any surgical treatment. She
was well six months after the operation. Her symptom had decreased
considerably, but not totally controlled. She opted to continue
Kegel's perineal exercise.
Figure 1. Vaginal wall cyst below and to the right of the bladder and the urethra.
Figure 2. The collapsed cyst is held with Babcock's forceps during dissection.
Figure 3. Dead space in the bed of the cyst after its excision is being closed by approximation of fascia with interrupted sutures of No. 1-0 polyglactin.
Figure 4. The dead space in the bed of the cyst has been occluded. Redundant portion of the vagina has been excised.
Figure 5. Vaginal edges have been approximated with interrupted sutures of No. 1-0 polyglactin.
Discussion
Urinary
continence is maintained when the intraurethral pressure remains
higher than the intravesical pressure. If the two pressures equalize
or intravesical pressure exceeds the intraurethral pressure, urinary
incontinence occurs. During Valsalva's maneuver the urethra gets
compressed against the vagina and subvaginal fascia, which maintains
the intraurethral pressure. If this support is weakened by anatomical
factors (e.g. by childbirth trauma, postmenopausal atrophy of
connective tissue, and chronic stress on the pelvic floor by lifting
heavy weights, chronic cough, constipation, or obesity.) or
neurological damage to the muscles (e.g. with pudendal neuropathy
caused by childbirth trauma or ageing), urinary stress incontinence
can occur.[4,5]
In
the case presented here, there was none of the factors listed above
causing damage to the fascia between the vagina and the urethra, nor
was there any neurological damage to the pudendal nerve. She had no
urinary incontinence in the past. Her urinary incontinence manifested
first time 2 days after the operative removal of the vaginal wall
cyst, 1 day after removal of her urinary catheter. There had been no
damage to the bladder neck, urethra, or the fascia under them. Thus
it appears that she had fascial defect prior to the operation, and
urinary stress incontinence manifested after removal of the vaginal
wall cyst which was supporting the urethra till the time of the
operation. It could not be anticipated as there have been no such
cases reported in the world literature.
It
is recommended that suburethral fascial buttressing be done after
removal of large anterior vaginal wall cysts, if the fascia in that
area appears to be deficient. Routine use of a transobturator tape
insertion in such cases cannot be recommended until more cases of
this type are reported.
References
- Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. Standardisation Sub-committee of the International Continence Society. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167-78.
- Luber KM. The definition, prevalence, and risk factors for stress urinary incontinence. Rev Urol 2004; 6 Suppl 3:S3.
- DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994; 170:1713.
- American College of Obstetricians and Gynecologists. Urinary incontinence in women. Obstet Gynecol 2005; 105:1533.
- Rogers RG. Clinical practice. Urinary stress incontinence in women. N Engl J Med. 2008 Mar 6. 358(10):1029-36.
Citation
Parulekar
SV. Urinary Stress Incontinence Due To Anterior vaginal Wall
Cyst, JPGO 2015. Volume 3 No. 1. Available from: http://www.jpgo.org/2016/01/urinary-stress-incontinence-due-to.html