Urinary Stress Incontinence Due To Anterior vaginal Wall Cyst

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

1. 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.
2. Luber KM. The definition, prevalence, and risk factors for stress urinary incontinence. Rev Urol 2004; 6 Suppl 3:S3.
3. DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994; 170:1713.
4. American College of Obstetricians and Gynecologists. Urinary incontinence in women. Obstet Gynecol 2005; 105:1533.
5. 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