1.02 - Urinary Incontinence & Prolapse

Question 1

What is urinary incontinence?

Answer 1

The involuntary leakage of urine.

Question 2

Give the common types of female urinary incontinence.

Answer 2

• urge incontinence
• stress incontinence

Question 3

What is urge incontinence?

Answer 3

The sudden and uncontrollable need to pass urine, having to rush to the bathroom and not arriving before urination occurs.

Caused by overactivity of the detrusor muscle of the bladder (AKA overactive bladder).

Question 4

What is stress incontinence?

Answer 4

Weakness of the pelvic floor and sphincter muscles allows urine to leak at times of increased pressure on the bladder (e.g. laughing, coughing).

Question 5

Describe the other causes of incontinence:

a) overflow incontinence

b) bladder fistulae

c) urethral diverticulum

d) congenital anomalies

e) functional incontinence

f) temporary incontinence

Answer 5

a) leakage of urine from an overfull urinary bladder, often in the absence of any urge to urinate.

b) opening between the bladder and another organ (e.g. vagina or rectum).

c) out-pocketing of urethra into the anterior vaginal wall.

d) e.g. ectopic ureter.

e) physical or mental barriers that prevent the patient from reaching the toilet (e.g. immobility, dementia).

f) due to reversible factors (e.g. incontinence, UTI).

Question 6

What are the risk factors for urinary incontinence?

Answer 6

• increased age
• post-menopausal
• increased BMI
• previous pregnancies / vaginal deliveries
• pelvic organ prolapse
• pelvic floor surgery
• neurological conditions (e.g. MS)
• cognitive impairment and dementia

Question 7

What are the modifiable lifestyle factors that can contribute to urinary incontinence?

Answer 7

• caffeine consumption
• alcohol consumption
• medications
• BMI

Question 8

How can the severity of urinary incontinence be assessed?

Answer 8

• frequency of urination
• frequency of incontinence
• nighttime urination
• use of pads / changes of clothing

Question 9

Purpose of pelvic examination in urinary incontinence.

Answer 9

Assess pelvic tone and examine for:
- pelvic organ prolapse
- atrophic vaginitis
- urethral diverticulum
- pelvic masses

Ask the patient to cough and watch for leakage from the urethra.

Question 10

Explain how to assess pelvic tone.

Answer 10

Bimanual examination and ask the woman to squeeze against the examining fingers.

Graded using the modified Oxford grading system.

Question 11

How should urinary incontinence be investigated?

Answer 11

• bladder diary
• urine dipstick / MSU
• post-void vladder volume
• urodynamic testing

Question 12

What is urodynamic testing?

Answer 12

Objective assessment of the presence and severity of urinary symptoms. A thin catheter is inserted into the bladder, and another into the rectum.

The pressures within the bladder and rectum are compared. The bladder is filled with liquid, and various outcome measures are taken.

Question 13

Describe the outcome measures of urodynamic testing:

a) cystometry

b) uroflowmetry

c) leak point pressure

d) post-void residual bladder volume

e) video urodynamic testing

Answer 13

a) measures the detrusor muscle contraction and pressure

b) measures the flow rate

c) the point at which the bladder pressure results in leakage of urine - the patient is asked to cough, move or jump when the bladder is filled to various capacities. Tests for stress incontinence.

d) tests for incomplete emptying of the bladder.

e) involves filling the bladder with contrast and taking xray images as the bladder is emptied.

Question 14

What are some lifestyle interventions recommended for urinary incontinence?

Answer 14

• caffeine reduction
• moderate fluid intake
• BMI <30kg/m2

Question 15

What are some physical therapies recommended for urinary incontinence?

Answer 15

Pelvic floor muscle training as a first-line treatment to women with stress of mixed urinary incontinence.

Electrical stimulation is an option for women who cannot actively contract pelvic floor muscles.

Question 16

What are some behavioural therapies recommended for urinary incontinence?

Answer 16

Bladder training as a first-line treatment for women with urgency of mixed urinary incontinence.

Question 17

What is the role of absorbent containment products / toileting aids in urinary incontinence?

Answer 17

Should not be used to treat, ONLY:
- coping strategy pending definitive treatment
- adjunct to ongoing therapy
- long-term management only AFTER all treatment options explored

Question 18

What is the role of catheters in the treatment of urinary incontinence?

Answer 18

Consider catheterisation for women in whom persistent urinary retention is causing incontinence, symptomatic infection or renal dysfunction.

Offer intermittent urethral catheterisation to women who can be taught to self-catheterise or who have a carer who can perform the technique.

Question 19

What are the surgical options to manage stress incontinence?

Answer 19

Tension-free vaginal tape - mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall.

Autologous sling procedure - strip of fascia from the abdominal wall looped under the urethra and up behind the pubic symphysis.

Colposuspension - stitches to connect the anterior vaginal wall and the pubic symphysis, pulling the vaginal wall forwards and supporting the urethra.

Intramural urethral bulking - injections around the urethra to reduce the diameter and support.

Question 20

What is the medical management of stress incontinence?

a) drug name

b) class

c) MOA

d) adverse effects

e) contraindications

Answer 20

a) duloxetine

b) SNRI

c) increases bladder capacity and increases sphincter muscle tone

d) anxiety, constipation, diarrhoea, dry eyes, fatigue, sexual dysfunction, vision disorders, n+v

e) MAOIs; uncontrolled narrow-angle glaucoma

Question 21

What is the first-line medical management of urge incontinence?

a) drug name

b) drug class

c) MOA

d) side effects

e) contraindications

Answer 21

a) oxybutynin; solifenacin

b) anticholinergic

c) antagonises ACh at muscarinic receptors on the detrusor muscle, resulting in relaxation.

d) constipation; dizziness; drowsiness; dry eyes; palpitations; vision disorders

e) acute-angle glaucoma; GI obstruction; myasthenia gravis; severe ulcerative colitis; urinary retention

Question 22

What is the second-line medical management of urge incontinence?

a) drug name

b) drug class

c) MOA

d) side effects

e) contraindications

Answer 22

Antimuscarinics not recommended in elderly pts due to increased risk of falls and worsening of dementia.

a) mirabegron

b) sympathomimetic

c) agonises b3 receptors on detrusor muscle, causing relaxation.

d) arrhythmias; constipation; diarrhoea; dizziness; headache

e) BP ≥ 180/110mmHg

Question 23

What are some more invasive options for urge incontinence?

Answer 23

• Botulinum toxin Type A injection
• percutaneous sacral nerve stimulation
• augmentation cystoplasty
• urinary diversion (urostomy)

Question 24

What is pelvic organ prolapse and what is its (broad) cause?

Answer 24

Descent of pelvic organs into the vagina as a result of weakness of the ligaments and muscles surrounding the uterus, rectum and bladder.

Question 25

What is uterine prolapse?

Answer 25

Uterus descends into the vagina.

Question 26

What is vault prolapse?

Answer 26

In women who have had a hysterectomy, the top of the vagina (vault) descends into the vagina.

Question 27

What is a rectocele?

Answer 27

Posterior vaginal wall defect allows the rectum to prolapse forwards into the vagina.

Women can develop faecal loading in the rectocele, resulting in constipation, urinary retention and a palpable lump in the vagina.

Question 28

What is a cystocele?

Answer 28

Anterior vaginal wall defect allows the bladder to prolapse backwards into the vagina.

Prolapse of the urethra (urethrocele), or urethra and bladder (cystourethrocele) is possible.

Question 29

Risk factors for pelvic organ prolapse.

Answer 29

• multiple vaginal deliveries
• instrumental, prolonged or traumatic delivery
• advanced age
• post menopause
• obesity
• chronic respiratory disease (coughing)
• chronic constipation (straining)

Question 30

Presentation of pelvic organ prolapse.

Answer 30

• sensation of ‘something coming down’ in the vagina
• dragging or heavy sensation
• urinary symptoms (incontinence, urgency, frequency, weak stream)
• bowel symptoms (constipation, incontinence, urgency)
• sexual dysfunction (pain, altered sensation)

Question 31

Examination of pelvic organ prolapse.

Answer 31

Patient should empty their bladder / bowel before examination.

Various positions attempted (dorsal and left lateral positions).

Sim’s speculum used to support anterior / posterior vaginal wall, while the other vaginal wall is examined.

Woman asked to cough or ‘bear down’.

Question 32

How is uterine prolapse severity graded?

Answer 32

Pelvic organ prolapse quantification (POP-Q):

Grade 0: normal

Grade 1: lowest part is >1cm above introitus

Grade 2: lowest part <1cm of introitus

Grade 3: lowest past >1cm below introitus

Grade 4: full descent with eversion of vagina

A prolapse below the introitus can be referred to as uterine prolapse.

Question 33

What are the broad options for management of pelvic organ prolapse.

Answer 33

• conservative management
• vaginal pessary
• surgery

Question 34

What are the conservative management options for pelvic organ prolapse?

Answer 34

Conservative management appropriate for women able to cope with mild symptoms.

• physiotherapy (pelvic floor exercises)
• weight loss
• lifestyle changes (reduced caffeine, incontinence pads)
• treatment of related symptoms (anticholinergic medications)
• vaginal oestrogen cream

Question 35

Outline the role of vaginal pessaries in the treatment of pelvic organ prolapse.

Answer 35

Inserted into the vagina to provide extra support to the pelvic organs:

• ring pessaries
• cube pessaries
• donut pessaries

Women often have to try a few types of pessary before finding the correct comfort and symptom relief. They should be removed and cleaned regularly.

Oestrogen cream can help protect the vaginal walls from irritation and erosion.

Question 36

What is the role of surgery and complications for the treatment of pelvic organ prolapse?

Answer 36

Many methods of surgical correction, including hysterectomy.

Complications include:
- pain
- bleeding
- infection
- DVT
- risk of anaesthetic
- damage to bladder / bowel
- recurrence of prolapse
- altered experience of sex

NOTE mesh repairs are recommended to be AVOIDED by NICE.