Bladder and pelvic floor

Question 1

Pelvic organ prolapse rx

Answer 1

parity, vaginal birth, FORCEPS!!!, obesity, chronic cough/straining, surgeries, not smoking

Question 2

Pelvic organ prolapse signs

Answer 2

Bladder signs (when anterior vaginal wall is involved)
○ Stress urinary incontinence (coughing, laughing sneezing, heavy lifting -> leaking) early on
○ Advanced prolapse -> kink in urethra -> obstruction: slow stream, retention
Prolapse signs: sensation of lump in the vagina, dragging sensation, urinary incontinence, splinting to evacuate bowels/difficulty, low back ache
Sexual signs: urination with sex, fecal incontinence with sex, dyspareunia (not common)
Bowel signs (will all sides, but commonly with posterior)
○ constipation and incomplete emptying, urgency, incontinence, straining, digital pressure inside vagina to completely evacuate.

Question 3

SX of complicated prolapse

Answer 3

external, pelvic pain, recurrent UTI, retention of urine or feaces, AUB

indication of surgery if these SX!

Question 4

Pelvic prolapse examination

Answer 4

Pelvic organ prolapse quantification
- grades severity, cough stress test, assess pelvic floor muscles

SIMS speculum exam with cough

Coexistence of pathology (CST): patients who present with prolapse are often comorbid
?epithelial and mucosal ulceration
Evaluate anal sphincters tone +/- presence of rectal prolapse if bowel signs present

Question 5

Grading prolapse

Answer 5

0 normal: cervix at level of the ischial spines with the anterior and posterior walls sitting well away from the hymen

1: just behind the hymen
2: at the hymen
3: extends out past the hymen but is easily replaced
4: maximum descent that may be difficult to replace

Question 6

POP IX

Answer 6

Urine dipstick
post voiding residual volume US
urodynamics if urinary incontinence: to determine if stress or urge incontinence (involuntary loss of urine due to urgency). Need to replace uterus in to pelvis and prolapse can mask incontinence.

Question 7

POP MX

Answer 7

management only if symptomatic

Conservative
○ Lifestyle: avoid straining, treat chronic cough, weight loss
○ Local estrogen
○ Pelvic floor exercise and physio
○ Insertion of ring or pessary (only if not sexually active)
Surgical : vaginal or abdominal
○ Cystocele/rectocele: vaginal repair/colporrhaphy
○ Uterine prolapse: abdominal sacropexy

Question 8

Stress incontinence definition

Answer 8

Weakness of the pelvic floor and sphincter muscles -> incontinence at times of increased intra-abdominal pressure

Question 9

Stress incontinence causes

Answer 9

• Caffeine
  
  • Alcohol
  • Smoking (chronic cough -> persistent raised intrabdominal pressure)
  • Neurological conditions
  • Diabetes
  • Childbearing
  • Vaginal delivery !!!!
  • Menopause
  • Medication (block alpha receptor (prazosin)

Question 10

Stress incontinence SX

Answer 10

• How does it affect you
  
  • Bladder signs
    ○ When: cough, sport, continuous (if continuous insensible loss think urinary fissure)
    ○ Duration
    ○ Severity
    ○ Frequency
    ○ Nocturia
    ○ Urgency
    ○ UTIs
  • Prolapse signs (dragging sensation, vaginal bulge)
  • Sexual signs
  • Bowel signs (constipation, incontinence)
  • Neurological conditions (stroke and dementia)
  • OSA, CCF can cause polyuria Nocturia
  • Pain or hematuria require further IX as stone and tumors can cause bladder irritation that may mimic incontinence.

Question 11

young with urinary incontinence

Answer 11

MS!!!

Question 12

Stress incontinence exam

Answer 12

Pelvic and abdominal exam

Assess for atrophic vaginitis, fistula, prolapse, pelvic floor muscle bulk and strength, cough stress test

Test perineal sensation for neurological condition

Question 13

IX of Stress incontinence

Answer 13

Bladder diary for 2wk before management
Rule out infection
Post void residual volume
Cytology or cystoscopy (if suspicious of cancer, smokers with urgency or hematuria)
Dye test of fistula suspected
US if mass suspected
Urodynamic testing if unclear diagnosis, if first like MX is ineffective or if requiring surgery

Question 14

urodynamics

Answer 14

• Specific to urinary incontinence
  
  • Invasive but helps to determine potential causes
  • Indications
    ○ Uncertain diagnosis
    ○ Failure of response to initial MX
    ○ Consideration of surgical treatment
    Components
    ○ Cystometry (measuring of bladder pressure vs abdo pressure via rectal transducer)
    ○ Uroflowmetry (measuring urine flow over time)
    ○ Pressure-flow study (determine whether poor flow is due to obstruction or detrusor weakness)
    ○ Urethral leak point pressure

Question 15

Management of stress incontinence

Answer 15

Conservative: weight loss, promote good bladder bowel habits, fluid optimization, correct post menopausal vaginal changes (vaginal estrogen), pelvic floor physio, vaginal devices/continence pessaries (prolapse)

Pelvic floor muscle training (56% success rate, better success when supervised by continence physio)

Surgical: slings (most common can be synthetic* or autologous), Burch colposuspension (less common), urethral bulking agents (injectables): Definitive management

Medical: duloxetine (SNRI antidepressant) is second line where surgery is less preferred

Question 16

Urge incontinence AKA overactive bladder

Answer 16

due to overactivity of detrusor muscle

DDX

- Infections: bacterial cystitis, prostatitis, urethritis
- Endometriosis
- Bladder cancer, bladder calculus, interstitial cystitis, urethral abnormalities
- Polyuria (diabetes), fibroids, psychogenic, ovarian cyst

SX

• urge to void immediately preceeding or accompanied by loos of urine.
• urination >7x/d, >1 nocturia, bedwetting
• Will be very conscious of always having access to the bathroom, may avoid activities or places. Impacts QOL

Question 17

Urge incontinence causes

Answer 17

• Neurogenic: Parkinson’s, stroke, tumor -> overactivity of detrusor muscle
  
  • LUTI
  • CCF, DM, OSA
  • Caffeine, alcohol, constipations, impaired mobility
    
    • Diuretics, antidepressants

Question 18

urodynamics for urge incontinence

Answer 18

Urodynamics (invasive IX to determine cause)
- Indicated in uncertain DX, failure to respond to initial TX, considering surgical intervention, suspicion of other pathology
Cystometry (measuring of bladder pressure vs abdo pressure via rectal transducer)
Uroflowmetry (measuring urine flow over time)
Pressure-flow study (determine whether poor flow is due to obstruction or detrusor weakness)
Urethral leak point pressure
- Helps by showing
○ Bladder pressure and intra-abdominal pressure
○ Can see bladder contracting when not asked to contract -> true urge incontinence
○ When you put fluid in, the patient w urge will report sensation of bladder being full w minimal volume present

Question 19

MX of urge incontinence

Answer 19

Conservative
Bladder training, reverse DIAPERS causes, fluid optimization

Medical 
Anticholinergics: Oxybutynin, ditropan 
inhibits involuntary detrusor muscle contractions
Selective for M2 and M3
ADRS: dry mouth, constipation, dry eyes

Desmopressin
Decreases urine production
Used mainly in predominant Nocturia or nocturnal polyuria
RX of creating hyponatremia in older patients

Mirabegron (beta 3 agonists)
Less anticholinergic ADRs
CI in uncontrolled HTN
Stimulates SNS -> HTN -> hypertensive crisis

Surgical
Intravesical botox
In MS patients. Also used in idiopathic overactive bladder
Repeated every 6-10mon

Sacral neuromodulation: in refractory cases

Question 20

Reversible causes of incontinence - elderly

Answer 20

DIAPPERS

Delirium & diabetes (can improve control)
Infection (UTI is a very common cause of leakage & worsening incontinence, doesn’t have to have dysuria)
Atrophic vaginitis 
Pharmaceuticals e.g., diuretics 
Psychological 
Excess fluid
Restricted mobility
Stool constipation

Question 21

Mixed incontinence

Answer 21

Combination of urge and stress

Need to identify which one is more significant impact and address first

Common story: pt w stress incontinence → goes to the toilet more often to prevent leakage (e.g., before leaves house ect), but they will overcompensate - bad bladder training by going all the time & then develops urge

Question 22

Overflow incontinence

Answer 22

• Can happen in PTs with chronic urinary retention due to an obstruction to the outflow of urine
  
  • Incontinence occurs w/o an urge to pass urine
  • Causes: anticholinergics, fibroids, pelvic tumor, neurological
  • Rare in women, more in males

Question 23

Interstitial cystitis

Answer 23

Long standing urinary urgency and lower abdominal pain that is better with voiding

Normal pelvic and abdominal exams

IX

- Negative urine MCS and cytology 
- Cystoscopy -> "hunnner lesions"!!! in bladder (bright red vessels visible on cystoscopy)