Bladder and pelvic floor Flashcards
Pelvic organ prolapse rx
parity, vaginal birth, FORCEPS!!!, obesity, chronic cough/straining, surgeries, not smoking
Pelvic organ prolapse signs
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.
SX of complicated prolapse
external, pelvic pain, recurrent UTI, retention of urine or feaces, AUB
indication of surgery if these SX!
Pelvic prolapse examination
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
Grading prolapse
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
POP IX
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.
POP MX
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
Stress incontinence definition
Weakness of the pelvic floor and sphincter muscles -> incontinence at times of increased intra-abdominal pressure
Stress incontinence causes
- Caffeine
- Alcohol
- Smoking (chronic cough -> persistent raised intrabdominal pressure)
- Neurological conditions
- Diabetes
- Childbearing
- Vaginal delivery !!!!
- Menopause
- Medication (block alpha receptor (prazosin)
Stress incontinence SX
- 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.
- Bladder signs
young with urinary incontinence
MS!!!
Stress incontinence exam
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
IX of Stress incontinence
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
urodynamics
- 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
Management of stress incontinence
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
Urge incontinence AKA overactive bladder
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
Urge incontinence causes
- Neurogenic: Parkinson’s, stroke, tumor -> overactivity of detrusor muscle
- LUTI
- CCF, DM, OSA
- Caffeine, alcohol, constipations, impaired mobility
- Diuretics, antidepressants
urodynamics for urge incontinence
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
MX of urge incontinence
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
Reversible causes of incontinence - elderly
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
Mixed incontinence
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
Overflow incontinence
- 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
Interstitial cystitis
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)
