4.1 Maintenance of urinary continence and pelvic organ prolapse

Question 1

How do pelvic splanchinc nerves, pontine storage centre help with the storage (continence) of urine?

Answer 1

Nervous pathway: afferent sympathetic pathways in hypogastric nerves
• Pelvic splanchnic nerves: control of bladder outlet and inhibition of detrusor muscles → help to relax the bladder
• Pontine storage centre → pudendal nerve: contraction of EUS
• Sympathetic: contraction of IUS (involuntary)

Question 2

How do pelvic splanchinc nerves, pontine micturition centre help with the voiding of urine?

Answer 2

Nervous pathway: pontine micturition centre activates spinal reflex pathways with increased parasympathetic transmissions to bladder
• Pelvic splanchnic nerves: contraction of detrusor muscles and relaxation of IUS
• Pontine micturition centre → pudendal nerve: EUS relaxation
• Relaxation of pelvic floor muscles

Question 3

how does levator ani (pubovaginalis) help with urine continence?

Answer 3

Contraction pulls the vagina forward towards the pubic symphysis → approximates the two urethral walls

Question 4

how does intrinsic urethral features help with urine continence?

Answer 4

Contraction of urethral muscle (approximates urethral walls) → in response to rises in intra-abdominal pressure

Question 5

Urinary incontinence is the complaint of any ____________________:
• Common problem encountered by many people → feelings of embarrassment + no realisation that medical help is available
o Up to 50% of women experience urinary incontinence at some point → 69% experience incontinence while 69% feel urgency but no leakage in Singapore
• Marked effects on the quality of life and daily activities

Answer 5

involuntary leakage of urine

Question 6

urinary incontinence (urge, 14%)

• cause
• symptoms
• signs
• post void residual

Answer 6

Associated with urgency (urge to go to the toilet immediately; cannot stop)

• detrusor instability
• urge, enuresis, large volume
• none
• low

Question 7

urinary incontinence (stress- 50%)

• cause
• symptoms
• signs
• post void residual

Answer 7

Associated with raised intra-abdominal pressure (e.g. coughing, sneezing)

• sphincter insufficiency
• triggers, no eneurisis, small volue
• atrophy, prolapse, cystocele
• low

Question 8

urinary incontinence (overflow)

• cause
• symptoms
• signs
• post void residual

Answer 8

Associated with incomplete bladder emptying

• outlet obstruction, detrusor underactive
• small volume, enuresis, frequency
• BPH, palpable bladder, neurodeficits
• high

Question 9

urinary incontinence (functional)

• cause
• symptoms
• post void residual

Answer 9

• environment, musculoskeletal disease, cognitive impairment
• varied volume, restraints
• low

Question 10

what do patients with continuous urinary incontinence complains of?

Answer 10

Complains of continuous involuntary loss of urine (usually related to urinary fistulae or congenital defects like ectopic ureter)

Question 11

What are the risk factors for urinary incontience in women?

Answer 11

The risk factors for urinary incontinence in women include age (especially menopausal women due to oestrogen loss), pregnancy, obesity, previous hysterectomy, raised IAP, functional impairment (affecting ability to go to the toilet), medical conditions:
• Pregnancy: antenatal period (raised IAP → stress incontinence) and vaginal delivery
• Raised IAP: includes chronic cough, constipation
• Functional impairment: reduced mobility and manual dexterity
• Medical conditions: neurological/musculoskeletal disease, health conditions (e.g. diabetes, stroke, heart and respiratory diseases)

Question 12

what is the presentation of the bladder in a patient with a suprapontine lesion?

Answer 12

Detrusor overactivity (without detrusor sphincter dyssynergia)

Question 13

what is the presentation of the bladder in a patient with a suprasacral (above S1) lesion?

Answer 13

Detrusor overactivity with detrusor sphincter dyssynergia (spastic neurogenic bladder) → urge incontinence

Question 14

what is the presentation of the bladder in a patient with a sacral (below S1) lesion?

Answer 14

Abnormally high bladder compliance + active sphincter → detrusor underactivity (flaccid neurogenic bladder) → overflow incontinence

Question 15

what is cystocoele?

Answer 15

prolapse of the bladder

Question 16

what is rectocoele?

Answer 16

prolapse of the rectum

Question 17

what is enterocoele?

Answer 17

intestinal herniation through vaginal wall (occasional)

Question 18

what is urinary prolapse?

Answer 18

medial compartment → prolapse of uterus (with the bladder in front of it as well)

Question 19

when will a vaginal vault prolapse occur?

Answer 19

if not supported by the uterosacral and cardinal ligaments during hysterectomy

Question 20

what are the risk factors for pelvic organ prolapse?

Answer 20

• advancing age
• Risk increases with parity (especially after first two births → risk increases thereafter but less steeply):
  • Weight causes pressure on the pelvic floor, weakening support function → urinary incontinence during pregnancy
  • Need to strengthen pelvic floor after delivery to regain full continence (Kegel exercises)
• reduced oestrogen: menopause affects the pelvic floor
• raised IAP: Exerts added force on pelvic floor → either intermittent repetitive insults (chronic cough, constipation) or continuous (e.g. obesity)
• hysterectomy
• connective tissue disorders: Congenital prolapse, Ehlers-Danlos syndrome (affects collagen)

Question 21

How does childbirth lead to risk of prolapse and incontinence?

Answer 21

Characteristics Childbirth
• Increasing parity increases the risk of prolapse and incontinence
• Stretching and small tears of the pelvic floor muscles and ligaments during vaginal delivery reduces supportive strength
• Damage to the pudendal nerve (due to pressure, associated nerve ischaemia) causes incontinence and prolapse
• Assisted vaginal delivery causes tears and injuries
• Other factors: macrosomic babies, inadequate repair of large perineal tears → long-lasting dysfunction of pelvic floor

Question 22

how does menopause cause incontinence?

Answer 22

Reduced oestrogen after menopause → vaginal & urethral atrophy

Question 23

how does increasing age cause incontinence?

Answer 23

Reduced bladder capacity with age → urgency and urge incontinence

Question 24

how does chronic cough/ constipation cause incontinence and prolapse?

Answer 24

Diseases with symptoms of chronic cough and constipation → raised IAP → increased risk of incontinence and prolapse

Question 25

hyow does hysterectomy cause prolapse?

Answer 25

cardinal ligaments are not re-attached to vaginal vault during surgery:
• Induces premature menopause if bilateral oophorectomy is performed in the same setting

Question 26

What are the medical impacts of incontinence and prolapse?

Answer 26

Category Impacts Medical Causes other symptoms (apart from urinary leakage and vaginal lumps):
• Lower backache & lower back pain
• Exposed vaginal tissue beyond introitus → ulceration from external friction → discomfort and infection
• Other urinary symptoms: frequency, urgency, recurrent UTIs, voiding dysfunction (e.g. incomplete bladder emptying, hesitancy, straining)
• Bowel dysfunction (posterior vaginal bulge from rectocoele or enterocoele) → longstanding constipation and worsening prolapse