Female Urinary Incontinence

Question 1

What are the major risk factors for developing Urinary Incontinence? [5]

Answer 1

Age, menopause 
Smoking
Pelvic Floor Trauma, parity, surgery
Denervation eg MS
Connective tissue Disease

Question 2

Define stress UI? [2]

Answer 2

Intra-abdominal pressure exceeds urethral pressure resulting in involuntary leakage.

Question 3

Define Overactive Bladder (OAB) Syndrome? [3]
3 features of OAB
2 types

Answer 3

Symptom complex generally related to Detrusor Overactivity or urethrovesicular dysfunction
- Urgency +/- urge incontinence
- Frequency
- Nocturia
Types: neurogenic, idiopathic

Question 4

What are the specific risk factors for OAB? [4]

Answer 4

DM
Advanced Age
UTIs
Smoking

Question 5

Investigations for incontinence [4]

Answer 5

Urine dipstick test
Urinalysis
Post-voiding residual volume assessment
Urodynamic investigations - uroflowmetry, multichannel cystometry

Question 6

OAB mx
Conservative [2]
Pharmacological [4]

Answer 6

Treat the symptoms
Conservative: life-style interventions + bladder training program
Pharmacological treatment: antimuscarinic, TCA, botox, neuromodulation

Question 7

Incontinence management modalities [4]

Answer 7

Lifestyle changes
Medical treatments: duloxetine
Physiotherapy PFMT
Surgery

Question 8

Antimuscarinics for OAB

Give names of oral medication and transdermal

Answer 8

Oxybutinin

Kentera patches

Question 9

Life style mods for OAB and incontinence [4]

Answer 9

Normalise fluid intake
Reduce caffeine, fizzy drinks, chocolate
Stop smoking
Weight loss

Question 10

Physiotherapy is applicable for both incontinence and OAB. Describe PFMT and how its used differently in both instances

Answer 10

SUI: Reinforcement of cortical awareness of pelvic muscle groups, hypertrophy of muscle fibers leading to increase in muscle tone and strength
OAB: Reinforcement of cortical awareness over detrusor and voiding. Training involves timed voiding with gradually increasing intervals.

Question 11

TVT vs TOT
What 2 risks are shared by the two procedures
What specific risk is associated with TVT and TOT? [2]

Answer 11

Risks of both TVT and TOT:
Bladder TVT/vaginal TOT perforation, vaginal and urethral erosions

TVT: severe vascular injuries due to blind penetration of retropubic space
TOT: disabling thigh pain

Question 12

Pelvic organ prolapse define

Types [4]

Answer 12

Protrusion of pelvic organs towards or through vaginal wall
Ax:
- Urethrocele
- Cystocele
- Uterovaginal prolapse
- Enterocele
- Rectocele

Question 13

Explain the following terms

• Urethrocele
• Cystocele
• Uterovaginal prolapse
• Enterocele

Answer 13

• Urethrocele: prolapse of lower anterior vaginal wall involving urethra only
• Cystocele: prolapse of upper anterior vaginal wall involving bladder
• Uterovaginal prolapse: prolapse of uterus, vagina and upper vagina
• Enterocele: prolapse of upper posterior wall of vagina usually containing small bowel loops
• Rectocele: prolapse of lower posterior wall of vagina involving rectum bulging

Question 14

Risk factors of pelvic organ prolapse [9]

Answer 14

Pregnancy and vaginal birth
Previous pelvic surgeries
Advancing age
Obesity
Hormonal
Hypermobility
Heavy lifting occupations
Sport - weight lifting, high impact aerobics, long distance running

Question 15

Pelvic organ prolapse
Symptoms [2]
Signs

Answer 15

Sy:

• vaginal, urinary or bowel symptoms
• POPQ score (gold standard objective assessment)

Signs
- Protrusion into vagina on examination

Question 16

Pelvic organ prolapse

Grading - first [2], second [2], third [3], procidentia

Answer 16

Grading:
o First degree: lowest part of prolapse descend halfway down vaginal axis to introitus
o Second degree: lowest part of prolapse extends to introitus and through introitus on straining
o Third degree: lowest part of prolapse extends through introitus and outside vagina
o Procidentia: uterus lies outside of vagina

Question 17

Pelvic organ prolapse

Investigation [4]

Answer 17

Ix:

• clinical dx
• USS/MRI can identify fascial defects or rectocele into sacrum
• urodynamics (concurrent urinary infection or to exclude occult stress)
• renal USS/ IVU (if suspect ureteric obstruction)

Question 18

Pelvic organ prolapse management - conservative [4]

Answer 18

o	Physiotherapy 
	Pelvic floor muscle training (PFMT)
	Other: 
- perineometer
- biofeedback
- vaginal cones
- electrical stimulation
o	Silicone ring pessaries

long shelf life and non-absorbent to secretions and odours, hypoallergenic. Fitted in clinic between posterior aspect of symphysis pubis and posterior vaginal fornix then 6 monthly changes by GP (with topical oestrogen if post-menopausal)

Question 19

Explain PFMT
Indications
Not effective in…?

Answer 19

Indications: mild cases and women who want more children

Not effective in severe or fascial defects

Question 20

Silicone ring pessaries [4]

Answer 20

Fitted in clinic
Placed between posterior aspect of symphysis pubis and posterior vaginal fornix
6 monthly changes by GP
Topical estrogen if post-menopause

Question 21

Surgery for Pelvic organ prolapse

Answer 21

Birch colposuspension

• Fix lateral vaginal fornices to ipsilateral ligaments
• aiming to relieve symptoms
• restore or maintain bladder and bowel fxn
• maintain vaginal capacity for sexual function

Question 22

Complication

Answer 22

Can cause worsening of condition > rectocele, enterocoele

Question 23

Complications of pelvic organ prolapse

Answer 23

Ureteric obstruction