224 - Pelvic Floor Disorders Urogyn/Uro

Question 1

List 2 reflexes that usually protect against fecal incontinence

Answer 1

• Rectosigmoid junction guarding reflex
  
  • Holds stool in the sigmoid colon
  • Fluid is absorbed here
• Recto-anal inhibitory reflex
  
  • Reflex contraction of external anal sphincter, puborectalis
  • Holds stool in the rectum

Question 2

List the structures responsible for pelvic organ support at each level:

• Level 1 (top of vagina)
• Level 2 (length of vagina)
• Level 3 (most distal)

Answer 2

• Level 1 (top of vagina)
  
  • Uterosacral + cardinal ligaments
• Level 2 (length of vagina)
  
  • Arcus tendineous fascia pelvis
• Level 3 (most distal)
  
  • Perineal muscles

Question 3

List 2 agents that will alter stool consistency and treat fecal incontinece

Answer 3

Psyllium-husk fiber supplement

Low dose loperamide

Changing stool consistence = first line treatment to treat functional fecal incontinence

Question 4

List 5 functional abnormalities that can contribute to fecal incontinence

Answer 4

• Constipation/fecal impaction
• Stool characteristics
  
  • Loose stool = hard to control
• Physical mobility
  
  • Can’t get to the bathroom
• Drugs
• Cognitive impairment

First line tx = psyllium-husk fiber or low dose loperamide

Question 5

What are the primary supports of the pelvic viscera?

Answer 5

Levator ani muscles + coccygeus

Levator ani consists of puborectalis, pubococcygeus, and iliococcygeus

Question 6

Are pelvic floor disorders a common part of normal aging?

Answer 6

No!

But they are prevalent - affect 1/3 women

Question 7

Which ligament is involved in a sacrocolpopexy surgery for pelvic floor reconstruction?

Answer 7

Anterior longitudinal ligament of the sacrum

Question 8

What kind of incontinence is likely to result from neuromuscular injury to the pudendal nerve?

Answer 8

Stress urinary incontinence

• External urethral sphincter not strong enough to hold pee in, especially during increases in presure (jumping, sneezing)

Question 9

Is the coccygeus muscle part of levator ani?

Answer 9

No

Question 10

List 5 risk factors for pelvic floor disorders

Answer 10

• Aging
• Obesity
• Childbirth
• Constipation
• Smoking

Question 11

List the 3 tiers of management for urgency urinary incontinence

(Tier 1 is the most conservative)

Answer 11

• Tier 1 = conservative
  
  • Bladder retraining
  • Fluid management
• Tier 2 = medications
  
  • ​Antimuscarinic
  • Beta-3 agonist
• Tier 3 = procedural (but still kind of medical)
  
  • Sacral neuromodulation
  • Intravesical onobotulinum toxin

Question 12

The Levator Ani Muscles include which of the following muscle groups?

1. Puborectalis, Pubococcygeus, Iliococcygeus
2. Puborectalis, Pubococcygeus, Obturator internus
3. Puborectalis, Pubococcygeus, Iliococcxygeus, Coccygeus
4. Pubococcygeus, Obturator internus, Piriformis

Answer 12

a. Puborectalis, Pubococcygeus, Iliococcygeus

Question 13

What is the innervation to levator ani?

Answer 13

Pudendal nerve

And also anterior roots of S2, S3, S4

Thank you @Alba!

Question 14

What kind of incontinence is likely to occur due to a CNS injury?

Answer 14

Urgency urinary incontinence

• When pressure in the bladder is sensed, there is a problem with the central pathways that are supposed to prevent detrusor contraction and increase sympathetic tone (these things help us hold our pee)
• Result is spontaneous detrusor contraction

Sx = not enough warning between feeling like you have to go and then going

Question 15

What is the first line treatment for functional fecal incontenence?

Answer 15

Change stool consistency

Psyllium husk fiber or low-dose loperamide