Continence and Prolapse Flashcards
What are the types of genitourinary prolapse?
Anterior compartment
- urethrocele or cystocele or cystourethrocele
Posterior compartment
- rectocele
Middle compartment
- uterine or vaginal vault (post-hysterectomy) or enterocele (pouch of douglas and small bowel)
How can genitourinary prolapses be classified into stages?
Based on where the most distal part of the prolapse lays on straining
1 - >1cm above hymen
2 - Within 1cm distal or proximal to hymen
3 - >1cm below hymen
4 - Complete eversion
How can genitourinary prolapses present?
Feeling of vaginal fullness/pressure Seeing bulge urinary incontinence (any type) feeling of incomplete emptying constipation or fecal incontinence dyspareunia vaginal flatus
How would you examine a patient with a genitourinary prolapse?
Standing and left lateral positions
Ask patient to strain and cough
Sims speculum
How can genitourinary prolapses be managed conservatively?
What would you prescribe if there was co-existing vaginal atrophy?
Treat cough or constipation
Weight loss and smoking cessation
Stop heavy lifting
Atrophy: Vaginal oestrogen creams
What are the side affects and risks of vaginal pessaries for prolapse?
Can cause discharge, odour, vaginal erosions, fistulas and sepsis
What surgical options are available for genitourinary prolapse? What type of prolapse would each be used for?
Cystourethocele: anterior colporrhaphy or colposuspension
Rectocele: posterior colporrhaphy
Uterocele: hysterectomy
Vaginal vault: sacrocolpoplexy
What is the first line non-surgical management option for urogenital prolapse?
16 weeks of pelvic floor muscle exercises
AND/OR
vaginal pressary
What is a colposuspension?
Sutures to suspend bladder neck to pelvic side wall
What is colpocleisis?
Closing off of vaginal canal
What are the types of urinary incontinence?
Stress Urge Mixed Overflow Functional
What is stress incontinence?
Involuntary leaking of urine upon exertion
e.g. when coughing or sneezing
Due to incompetent sphincter
What is urge incontinence?
Involuntary leakage of urine alongside or just after urgency
Due to detrusor overactivity
e.g. Suddenly need toilet then v quickly leak
What is mixed incontinence?
Both stress and urge together
Leak when coughing and also get sudden urges with leakage
What is overflow incontinence?
Involuntary leakage of urine due to chronic bladder outflow obstruction
What is functional incontinence?
Can’t get to toilet in time due to mobility issues
What are the main risk factors for urinary incontinence?
Advancing age
Vaginal delivery
Overweight
Others include:
Forceps, heavy baby, diabetes, frequent UTI, neurological disease, pelvic tumours, stool impaction, family history, hysterectomy
How is urinary incontinence investigated?
Bladder diary for 3 days
Urine dip - infection, glucose, protein?
Speculum - prolapse? visualise if able to contract pelvic flood muscles
Quality of life questionnaire
Post micturition bladder scan - residual volume
When are urodynamic studies done for urinary incontinence?
When you are unsure of the cause following bladder diary, examinations etc.
How can urinary incontinence be temporarily managed?
Pads - done until diagnosis and full management plan in place
What lifestyle changes are suggested in the management of urge incontinence?
Reduce caffeine
Lose weight - if BMI >30
Drink 2L per day
What is the stepwise management plan for urge incontinence?
1 - Bladder training
2 - Medication
3 - Botulinin toxin A injections
4 - percutaneous sacral nerve stimulation
What is bladder retraining?
6 week plan where patients have scheduled voiding times with increasing time intervals
What medication can be used for urge incontinence?
What is given to frail elderly women?
Antimuscarinics - effect may take 4 weeks to be seen
- Oxybutynin - immediate release
- Tolterodine - immediate release
- Darifenacin
Mirabegron for elderly as oxybutynin contraindicated
What is the MOA, ADR’s and CI’s for antimuscarinics in urge incontinence?
MoA - Relax urinary smooth muscle
ADR - Constipation, dizzy, dry mouth and eyes, flushing, temperature
CI - severe UC and urinary retention, oxybutynin not for frail elderly
How long does botulinin toxin A for incontinence last?
What are the risks?
Benefits seen after 4 days. Last 6-9 months
Risks - urinary retention requiring catheter, UTI
Describe the use of percutaneous sacral nerve stimulation in urge incontinence
Done in 2 stages - test phase and then implantation if test successful
Percutaneous sacral nerve stimulation
What medication can be used if nocturnal symptoms of urge incontinence are particularly severe?
Desmopressin
What is the conservative management for stress incontinence?
Pelvic floor exercises
8 Contractions 3x a day for 3 months
What is the surgical management for stress incontinence?
Colposuspension
Autologus rectal fascial sling
Retropubic mid-urethral mesh sling - NICE recommend offering the other 2 first as some concerns over mesh slings
What are the risks of surgical management of stress incontinence?
Damage to bladder and bowel Damage to nerves Urge incontinence Pelvic pain Dyspareunia
What are the specific risks of using a mesh sling for stress incontinence?
Vaginal mesh exposure can lead to pain
Discharge and bleeding
Mesh may come through bladder or urethra –> urinary symptoms
Women should be warned it is not reversible - the mesh may never be able to be completely removed
What management options are available for stress incontinence if the women doesn’t want surgery?
Intramural bulking agents
Duloxetine
What are the risks of intramural bulking agents?
Urinary retention
Urge incontinence
UTI
What are the ADR’s associated with duloxetine?
GI disturbance Dry mouth Headache Decreased libido Anorgasmia
What is the first line management for mixed incontinence?
Either bladder retraining therapy or pelvic floor muscle exercises
a bladder diary shows
a) reduced volume that is always the same
b) reduced volume that differs each time
What is the likely diagnosis?
a) bladder wall pathology eg carcinoma
b) overactive bladder i.e. detrusor overactivity
Describe the appearance of a flow rate graph (x axis is time and y axis is rate) for
a) stress
b) obstruction
a) very quick rise and then fall in flow rate as little resistance so get superflow
b) reduced flow rate and urinates over a longer period of time i.e. takes longer to empty bladder as reduced flow rate
