16: Urinary incontinence and pelvic prolapse: Pathophysiology, evaluation, and medical management Flashcards
Define “Urinary incontinence”.
Complaint of any involuntary leakage of urine.
What symptom describes the complaint of involuntary leakage on effort, exertion, sneezing, or coughing?
Stress urinary incontinence.
Describe the symptom of “Urgency” in urinary incontinence.
Complaint of a sudden compelling desire to pass urine, which is difficult to defer.
What is “Urgency urinary incontinence”?
Complaint of involuntary leakage accompanied by or immediately preceded by urgency.
Which type of incontinence is described as a voluntary loss of urine associated with a change of body position, such as rising from seated or lying positions?
Postural incontinence.
Define “Nocturnal enuresis”.
Complaint of involuntary loss of urine that occurs during sleep.
What term describes involuntary leakage associated with both urgency and activities like exertion, effort, sneezing, or coughing?
Mixed incontinence.
What does “Continuous urinary incontinence” refer to?
Complaint of continuous leakage.
Which type of incontinence occurs when the woman is unaware of how the urinary incontinence happened?
Insensible incontinence.
Define “Coital incontinence”.
Complaint of involuntary loss of urine with coitus.
What pharmacologic agents are classified as Sympathomimetics that can affect the lower urinary tract?
Ephedrine, methylphenidate, cocaine, amphetamine.
What potential effects on the urinary tract can Sympathomimetics cause?
They can increase outlet resistance, exacerbate obstructive symptoms/overactive bladder symptoms, decrease detrusor contractility, and precipitate retention.
Name the pharmacologic agents classified as Sympatholytics.
Terazosin, doxazosin, tamsulosin, alfuzosin, silodosin.
What is the potential effect of Sympatholytics on the urinary tract?
What is the potential effect of Sympatholytics on the urinary tract?
Which agents are categorized as Anticholinergics that might impact the lower urinary tract?
Oxybutynin, fesoteridine, solifenacin, trospium, darifenacin.
How do Anticholinergics potentially affect the urinary tract?
They can contribute to urinary retention, especially in patients with outlet obstruction.
List the pharmacologic agents that are Diuretics, as per the table.
Furosemide, thiazides, spironolactone, triamterene, bumetanide.
How do Diuretics directly affect the bladder?
They do not affect the bladder directly. However, due to increased urine production, they can aggravate incontinence problems.
What are the main components assessed during a focused pelvic examination?
External genitalia and vagina, urethra, bladder, cervix, uterus, adnexa/parametria, and anus and perineum.
When examining the external genitalia and vagina, what aspects related to general appearance are assessed?
Hair distribution, the presence of lesions, estrogen effect, and discharge.
During the pelvic examination, which structures are checked for general appearance, lesions, and discharge?
External genitalia, vagina, and cervix.
Which pelvic structures are evaluated for masses, tenderness, and other conditions during the examination?
Urethra, bladder, cervix, uterus, and adnexa/parametria.
How is the uterus examined during a focused pelvic examination?
It is evaluated for size, contour, position, mobility, tenderness, consistency, descent, or support
When assessing the adnexa/parametria during the pelvic examination, which conditions or signs should be looked for?
Masses, tenderness, organomegaly, and nodularity.
Based on modern medical practices, why might a detailed assessment of the vagina’s estrogen effect be crucial for post-menopausal women?
Lower estrogen levels post-menopause can lead to vaginal atrophy, with symptoms like dryness, irritation, and dyspareunia, impacting quality of life and sexual function.
During a pelvic examination, what are the primary concerns when inspecting the anus and perineum?
During a pelvic examination, what are the primary concerns when inspecting the anus and perineum?
What are the criteria for Stage 0 in the Baden-Walker Classification and the POP-Q Staging Criteria?
Aa, Ap, Ba, Bp at –3 cm, and C or D ≤ – (tvl – 2) cm
Which stage in the Baden-Walker Classification and the POP-Q Staging Criteria has criteria that do not meet Stage 0 and has a leading edge < –1 cm?
Stage I
For which stage is the leading edge ≥ –1 cm but ≤ +1 cm in the Baden-Walker Classification and the POP-Q Staging Criteria?
Stage II
Which stage in the Baden-Walker Classification and the POP-Q Staging Criteria has a leading edge that’s more than +1 cm but less than + (tvl – 2) cm?
Stage III
In the Baden-Walker Classification and the POP-Q Staging Criteria, for which stage is the leading edge ≥ + (tvl – 2) cm?
Stage IV
If a patient has a leading edge of exactly +1 cm based on the Baden-Walker Classification and the POP-Q Staging Criteria, which stage would they fall under?
Stage II
What are the surgical repair options for POP?
Transvaginal or abdominal approaches using native tissue, biological mesh, or permanent mesh.
What are the risk factors for recurrence after POP repair?
Advanced POP preoperatively, previous pelvic floor surgery, levator avulsion, enlarged genital hiatus, and possibly increased BMI.
What are the conservative management options for recurrent POP?
Observation, pelvic floor physical therapy, vaginal estrogen, weight loss, and pessaries.
What is Stage 0 in the POP-Q system?
Stage 0 represents no prolapse; the organs are perfectly supported.
What is Stage 1 in the POP-Q system?
Stage 1 represents minimal prolapse; the most distal portion of the prolapsed organ is more than 1 cm above the level of the hymen.
What is Stage 2 in the POP-Q system?
Stage 2 is marked prolapse; the most distal portion of the prolapse is within 1 cm of the hymen, either 1 cm or less proximal or distal.
What is Stage 3 in the POP-Q system?
Stage 3 is moderate to severe prolapse; the most distal portion of the prolapse is more than 1 cm below the hymen but no further than 2 cm less than the total vaginal length.
What is Stage 4 in the POP-Q system?
Stage 4 is total or complete prolapse; the most distal portion of the prolapse is at least (total vaginal length - 2 cm) below the hymen.
What are the key measurement points in the POP-Q system, and what do they represent?
Aa, Ba: anterior wall; Ap, Bp: posterior wall; C: cervix/vaginal cuff; D: posterior fornix; TVL: total vaginal length.
Which of the following represents the largest risk factor for recurrence after surgical repair of pelvic organ prolapse (POP)?
a. BMI > 30
b. Chronic constipation
c. ≥ Stage 3 POP-Q preoperatively
d. COPD
c. ≥ Stage 3 POP-Q preoperatively
Explanation: Patients with advanced POP (≥ stage 3 POP-Q) preoperatively are at an increased risk of recurrence after primary POP surgery.
What is the recommended management for asymptomatic anatomical recurrence of POP?
a. Immediate surgical repair
b. Observation
c. Pessaries
d. Physical therapy
b. Observation
Explanation: Asymptomatic or minimally symptomatic recurrences can be managed conservatively, and observation is recommended.
Stage 2 of the POP-Q system signifies:
a. No prolapse
b. Prolapse more than 1 cm above the hymen
c. Prolapse within 1 cm of the hymen
d. Complete prolapse
c. Prolapse within 1 cm of the hymen
Explanation: Stage 2 in POP-Q is marked prolapse where the most distal portion of the prolapse is within 1 cm of the hymen.
What is the imaging modality best suited to visualize the placement of synthetic mesh from prior POP repairs?
a. MRI
b. Pelvic US
c. X-ray
d. Computerized tomography scan
b. Pelvic US
Explanation: Pelvic ultrasound (US) can show the relationship of the prolapse to previously inserted mesh and can be an office-based procedure.
Apical prolapse refers to the descent of which part of the female pelvis?
a. Anterior vaginal wall
b. Posterior vaginal wall
c. Uterus or vaginal cuff
d. Bladder
c. Uterus or vaginal cuff
Explanation: Apical prolapse involves the descent of the upper (apical) portion of the vagina, including the uterus or vaginal cuff (after hysterectomy).
Which procedure has the lowest recurrence rates for POP but forgoes future vaginal intercourse?
a. Sacrocolpopexy
b. Sacrospinous fixation
c. Colpocleisis
d. Pelvic floor repair with mesh
c. Colpocleisis
Explanation: Obliterative procedures like colpocleisis have the lowest recurrence rates but come at the cost of forgoing vaginal intercourse in the future.
What is apical prolapse, and which compartments are involved?
Apical prolapse refers to the descent of the upper (apical) portion of the vagina, including the uterus or vaginal cuff (after hysterectomy). It’s one of three main compartments for prolapse, along with the anterior and posterior compartments.
What is a physical exam quantification for pelvic organ prolapse? What is reference point?
POP Q
Hymen
List the elements of POP Q? Aa, Ap, C, TVL?
Aa: anterior vaginal wall, 3 cm proximal to hymen, Range -3 to +3
Ba: most distal position of upper anterior vaginal wall
Ap: posterior vaginal wall, 3 cm proximal to hymen, Range -3 to +3
Bp: most distal position of upper anterior vaginal wall
C: most distal edge of cervix or vaginal cuff (8)
TVL: total vaginal length
D: posterior fornix (cannot measure with hysterectomy)
pb: perineal body (10)
What physical exam is important for leakage after sacrocolpopexy?
Fluid in vaginal vault
Defects at vaginal apex
Leak per meatus (strain/cough)
PVR
Presence/absence of prolapse
Urethral hypermobility
Patient s/p sacrocolpopexy with new onset leakage, what is ddx?
Vesicovaginal fistula
Ureterovaginal fistula
SUI
UUI
How do you evaluate for vesicovaginal fistula? ureterovaginal fistula?
Vesicovaginal → cystogram
Ureterovaginal → imaging of upper tracts (CTU/RGP)
