Gynae: urinary incontinence and prolapse Flashcards
What are the main points to explore in HxPC for a lady who presents with urinary incontinence?
- Could you tell me more about that?
- How long has it been going on for? How have things changed over time? How often?
- Tell me what tends to happen
- Do you suddenly get the feeling you need to get to the toilet immediately?
- Do you find that you sometimes “leak” urine?
- What is you were to cough/sneeze/laugh/run for the bus?
- Are you passing urine more often than usual?
- Each time, are you passing a small or a large amount?
- Have you noticed any changes in your urine?
- Do you ever have to get up in the night to go to the toilet?
What other symptoms are important to ask about when taking a history on incontinence?
- UTI – dysuria, pain in abdomen
- Retention – trouble “getting started”, problems emptying bladder, poor stream
- Prolapse – “dragging” feeling, something “coming out”
- Faecal incontinence (may coexist)
- PV bleeding
What background Hx should you elicit when taking a Hx on incontinence? What are important risk factors for incontinence?
- Past obstetric history
- Method of delivery? Complications?
- Development of transient retention following birth
- Hoping to have more children in the future?
- Past gynae history
- Menopausal? Any abnormal bleeding?
- Infection?
- Smears up to date? Ever had an abnormal smear?
- Any operations? – especially gynae/abdo
- Have you ever had any other medical problems?
- Diabetes? Kidney problems? Neurological problems?
- Could I ask if there are any conditions which seem to run in your family?
- Has anyone in your family suffered from a gynaecological disease?
- Has anyone in your family ever had endometrial or colon cancer?
- Are you on any medications?
- What are you using for contraception?
- Do you drink? Smoke (chronic cough causes incontinence)?
What examinations should you perform for prolapse?
- Abdominal examination
- speculum examination
- bimanual pelvic examination – assess pelvic tone
- Examination is not likely to yield much but can use Sim’s speculum to reveal a prolapse. A pelvic mass and an over-distended bladder should be palpated for.
What investigations should you perform for prolpase?
- Urine dipstick + MC&S.
- “urine diary’’: give a clearer idea of the pattern of her problems (time + volume of fluid intake and micturition.)
- Urodynamic testing: should be performed before a woman with genuine stress incontinence is sent for surgery OR when overactive bladder does not respond to medical therapy.
- If there is suggestion of retention then post-micturition USS/catheterisation would be required;
- If there is suggestion of a fistula then methylene blue dye could be used.
- Can use bladder scan to determine residual volume post-voiding
- Abdo x-ray is suspect calculi
Describe how urodynamic testing/cystometry works and how to interpret the results?
- Catheter in bladder to measure pressure whilst it is filled and patient coughs
- Pressure transducer in rectum/ vagina to measure abdominal pressure
- The ‘true detrusor pressure’= bladder pressure-abdo pressure
- Detrusor pressure does not normally change with filling/ coughing.
- If leak occurs with cough, but detrusor pressure stays the same, it is urodynamic stress incontinence
- If there is involuntary detrusor contraction-overactive bladder
Describe the physiology of continence
- Filling requires adequate bladder capacity+ competent urethral sphincter – mediated by sympathetics (centrally controlled by pons)
- Voiding phase dependent on detrusor contractility + urethral relaxation – under conscious control and mediated by parasympathetics. Occurs when the pressure inside the bladder exceeds the pressure in the urethra.
- Urethral pressure is determined by the urethral muscles and the pelvic floor.
- Bladder pressure is determined by the detrusor muscle.
- Normally, both urethral and bladder pressure are equally affected by intra-abdominal pressure, as rises in pressure are transmitted equally to both (and cancel out). As bladder fills, there is no increase in pressure as it expands.
What are the causes of incontinence?
- Genuine stress incontinence – >50%
- Overactive bladder – 35%
- Some combination – 10%
- Other causes – chronic retention with overflow, fistula (rare)
Other factors may also predispose or exacerbate; these include: faecal impaction, decreased mobility, confusional states, drugs (e.g. hypnotics, diuretics), polyuria (e.g. DM), obesity
What is genuine stress incontinence?
Complaint of urine leak on exertion. This occurs when the urethral neck has slipped below the pelvic floor and out of the abdomen. Therefore increases in intra-abdominal pressure only affect the bladder, causing involuntary “leaking” of a small amount of urine. Can also be from weak sphincter.
Outline the management for GSI (genuine stress incontinence)
Conservative: reduce caffeine/alcohol/fizzy drinks, weight loss (may cause 50% reduction in symptoms), pelvic floor exercises (minimum 3 months, with a physio), stop smoking (gives cough)
Duloxetine: serotonin and norepinephrine reuptake inhibitor – causes enhanced urethral striated sphincter activity and contraction. SEs include: dry mouth, nausea, dizziness, feeling tired, increased sweating. Severe SEs include: serotonin syndrome, increased suicidal ideal and liver toxicity
Surgical
- Colposuspension (lap or open): lifting neck of bladder and stitching to the fibrous tissue attached to pubic bones. SEs include: difficulty emptying bladder, recurrent UTIs, dyspareunia, failure, overactive bladder (17%), prolapse, pain with interval stitches
- Autologous fascial sling: part of rectum fascia is used to make an autologous sling that is placed around neck of bladder. SEs include: failure of treatment, difficulty emptying bladder, development of urge incontinence
What is overactive bladder?
Defined as urgency, with or without urge incontinence, in absence of infection
This occurs when the detrusor contracts uncontrollably, causing urge incontinence. Can be spontaneous or triggered by cough. It is important to distinguish this from GSI, as the management is quite different.
Outline the management for overactive bladder
Conservative: weight loss, bladder retraining (educate, timed voiding with systematic delay, positive reinforcement lasts for minimum 6 weeks- the idea is to gradually increase the intervals between voiding), reduce caffeine, fizzy drinks etc.
Bladder stabilising drugs: Antimuscarinics e.g. Oxybutynin (1st line, immediate release but avoid in frail old women), tolterodine (immediate release) or darifenacin block detrusor activity. Can also give Mirabegron (Beta 3 agonist) if concern about anticholinergic SEs in older patients.s
Surgery is major and almost never performed; sacral nerve stimulation may be (S3 root, 30-50% fix)
What is overflow incontinence?
Pressure of urine overwhelms sphincter due to bladder overfilling due to neurogenic cause/ outlet obstruction.
List some causes of acute urinary retention
Childbirth (esp with epidural)
vulval/perineal pain
surgery
drugs
retroverted gravid uterus
pelvic mass
neurological disease (MS/Stroke)
What examinations should you perform for a suspected prolapse?
Examination with a Sim’s speculum, in order to visualise the anterior and posterior vaginal walls (the lady bearing down to reveal any prolapse)
Abdo+ bimanual examination (exclude mass)
What are the types of prolapse?
Uterine prolapse: cervix still in vagina (grade 1), cervix at introitus (grade 2), cervix descends out of introitus (grade 3), procidentia – all of uterus comes out of entroitus (grade 4)
Prolapses of anterior wall of vagina: cystocoele (upper part, bladder only) or urethrocoele (lower part, urethra only)
Prolapses in the posterior wall there may be a rectocoele (lower part, anterior rectum) or enterocoele (upper part, contains loop of small bowel).
Apical - prolapse of uterus,cervix and upper vagina
Can grade with POP score (pelvic organ prolapse)
