Gynaecology: Pelvic Organ Prolapse & Urinary Incontinence Flashcards
Define pelvic organ prolapse
Refers to the descent of pelvic organs into the vagina.
What is pelvic organ prolapse the result of?
Weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.
Define uterine prolapse
Uterine prolapse is where the uterus itself descends into the vagina.
Who does vault prolapse occur in?
Occurs in women that have had a hysterectomy, and no longer have a uterus
What happens in vault prolapse?
The top of the vagina (the vault) descends into the vagina.
What is a rectocele?
A rectocele is a type of prolapse where the supportive wall of tissue between a woman’s rectum and vaginal wall weakens. Without the support of these pelvic floor muscles and ligaments, the front wall of the rectum sags and bulges into the vagina, and in severe cases, protrudes out of the vaginal opening.
Cause of a rectocele?
Defect in posterior vaginal wall
What symptom are rectoceles particularly associated with?
Constipation
Symptoms of rectocele?
- Constipation
- Urinary retention
- Palpable lump in vagina
As a result of faecal loading
How can constipation be relieved in a rectocele?
Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels
What is a cystocele?
Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele).
What is the prolapse of both the bladder and the urethra called?
Cystourethrocele
What is the result of a a defect in the ANTERIOR vaginal wall?
Cystocele
What is the result of a a defect in the POSTERIOR vaginal wall?
Rectocele
Risk factors for pelvic organ prolapse?
The result of weak and stretched muscles and ligaments:
- Multiple vaginal deliveries
- Instrumental, prolonged or traumatic delivery
- Advanced age and postmenopause status
- Obesity
- Chronic respiratory disease causing coughing
- Chronic constipation causing straining
Typical presenting symptoms of pelvic organ prolapse?
- A feeling of “something coming down” in the vagina
- A dragging or heavy sensation in the pelvis
- Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
- Bowel symptoms, such as constipation, incontinence and urgency
- Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
Women may have identified a lump or mass in the vagina, and often will already be pushing it back up themselves.
When will the pelvic organ prolapse become worse?
on straining or bearing down.
What should patients ideally do before examination of a prolapse?
They should empty their bladder and bowels before exam
What is used to assist examination in pelvic organ prolapse?
A Sim’s speculum is a U-shaped, single-bladed speculum that can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined.
Where is a Sim’s speculum held to examine a rectocele?
Held on the anterior wall
Where is a Sim’s speculum held to examine a cystocele?
Held on the posterior wall
What can you ask the patient to do to assess the full descent of the prolapse?
Cough or ‘bear down’
What system is used to grade uterine prolapses?
Pelvic organ prolapse quantification (POP-Q)
Describe grade 0 of the POP-Q
Normal
Describe grade 1 of the POP-Q
The lowest part is more than 1cm above the introitus
Describe grade 2 of the POP-Q
The lowest part is within 1cm of the introitus (above or below)
Describe grade 3 of the POP-Q
The lowest part is more than 1cm below the introitus, but not fully descended
Describe grade 4 of the POP-Q
Full descent with eversion of the vagina
What can a prolapse extending beyond the introitus be referred to as?
uterine procidentia.
What are the 3 management options for prolpse?
1) Conservative management
2) Vaginal pessary
3) Surgery
Who is conservative management appropriate for in prolapse?
For women that are able to cope with mild symptoms, do not tolerate pessaries or are not suitable for surgery.
What does conservative management in prolapse involve?
Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
Vaginal oestrogen cream
What are vaginal pessaries?
Vaginal pessaries are inserted into the vagina to provide extra support to the pelvic organs.
Purpose of vaginal pessaries in prolapse?
They can create a significant improvement in symptoms and can easily be removed and replaced if they cause any problems.
Name some different types of vaginal pessaries
- Ring pessaries
- Shelf and Gellhorn pessaries
- Cube pessaries
- Donut pessaries
- Hodge pessaries
Where do ring pessaries sit?
Sit around the cervix holding the uterus up
Where do Shelf and Gellhorn pessaries sit?
Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
Where do Hodge pessaries sit?
Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.
How to choose a vaginal pessary in prolapse?
Women often have to try a few types of pessary before finding the correct comfort and symptom relief
How to care for vaginal pessaries?
Pessaries should be removed and cleaned or changed periodically (e.g. every four months).
Vaginal pessaries can cause vaginal irritation and erosion over time.
What can be prescribed to help with this?
Oestrogen cream
What is the definitive management for prolapse?
Surgery e.g. hysterectomy
Potential complications of prolapse surgery?
- Pain, bleeding, infection, DVT and risk of anaesthetic
- Damage to the bladder or bowel
- Recurrence of the prolapse
- Altered experience of sex
What are the 2 types of urinary incontinence?
1) Urge
2) Stress
Cause of urge incontinence?
Overactivity of detrusor muscle of bladder
What is urge incontinence also known as?
Overactive bladder
Typical description of urge incontinence?
Suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs.
Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access.
This can have a significant impact on their quality of life, and stop them doing work and leisure activities.
Cause of stress incontinence?
Stress incontinence is due to weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder.
What is mixed incontinence?
A combination of urge and stress incontinence.
Description of pelvic floor:
The pelvic floor consists of a sling of muscles that support the contents of the pelvic.
There are three canals through the centre of the female pelvic floor: the urethral, vaginal and rectal canals.
When the muscles of the pelvic floor are weak, the canals become lax, and the organs are poorly supported within the pelvis.
Typical description of stress incontinence?
Urinary leakage when laughing, coughing or surprised.
Is there an urge to pass urine in overflow incontinence?
No
What is important to identify in mixed incontinence?
Which of the two is having the more significant impact and address this first.
Differentiate between urinary leakage with coughing or sneezing (stress incontinence), and incontinence due to a sudden urge to pass urine with loss of control on the way to the toilet (urge incontinence).
What is overflow incontinence?
Overflow incontinence can occur when there is chronic urinary retention due to an obstruction to the outflow of urine.
Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine.
Causes of overflow incontinence?
- Anticholinergic medications e.g. procyclidine
- Fibroids
- Pelvic tumours
- Neurological conditions e.g. MS, diabetic neuropathy, spinal cord injuries
Is overflow incontinence more common in men or women?
Men
What happens if a woman presents with overflow incontinence?
Women with suspected overflow incontinence should be referred for urodynamic testing and specialist management.
Risk factors for urinary incontinence?
- Increased age
- Postmenopausal status
- Increase BMI
- Previous pregnancies and vaginal deliveries
- Pelvic organ prolapse
- Pelvic floor surgery
- Neurological conditions, such as multiple sclerosis
- Cognitive impairment and dementia
What are some modifiable lifestyle factors that can contribute to urinary incontinence symptoms?
- Caffeine consumption
- Alcohol consumption
- Medications
- Body mass index (BMI)
How can the severity of urinary incontinence be assessed?
by asking about:
a) Frequency of urination
b) Frequency of incontinence
c) Nighttime urination
d) Use of pads and changes of clothing
What should examination during urinary incontinence examine for?
Should assess the pelvic tone and examine for:
1) Pelvic organ prolapse
2) Atrophic vaginitis
3) Urethral diverticulum
4) Pelvic masses
During the examination, ask the patient to cough and watch for leakage from the urethra.
how can the strength of the pelvic muscle contractions be assessed in urinary incontinence?
during a bimanual examination by asking the woman to squeeze against the examining fingers
How is the strength of the pelvic muscle contractions graded?
using the modified Oxford grading system
Describe the grades (0-5) of the modified Oxford grading system for pelvic muscle contractions
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
What investigations can be done in urinary incontinence?
1) Bladder diary
2) Urine dipstick testing (for infection, microscopic haematuria etc)
3) Post-voidal residual bladder bolume
4) Urodynatic testing
What is a bladder diary?
A bladder diary should be completed, tracking fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days.
Why should a post-void residual bladder volume be measured in urinary incontinence?
To assess for incomplete emptying
How is post-void residual bladder volume measured?
Using a bladder scan
What are urodynamic tests?
Urodynamic tests are a way of objectively assessing the presence and severity of urinary symptoms.
How soon before urodynamic tests should patients stop taking any anticholinergic and bladder related medications?
5 days before
What happens in urodynamic tests?
A thin catheter is inserted into the bladder, and another into the rectum. These two catheters can measure the pressures in the bladder and rectum for comparison.
The bladder is filled with liquid, and various outcome measures are taken.
What outcome measures are taken in urodynamic tests?
- Cystometry
- Uroflowmetry
- Leak point pressure
- Post-void residual bladder volume
- Video urodynamic testing (not routine)
What is cystometry?
measures the detrusor muscle contraction and pressure
It is important to distinguish between urge and stress incontinence as this dictates management.
What does management of STRESS incontinence involve?
- Avoiding caffeine, diuretics and overfilling of the bladder
- Avoid excessive or restricted fluid intake
- Weight loss (if appropriate)
- Pelvic floor exercises
- Surgery
- Duloxetine is an SNRI antidepressant used second line where surgery is less preferred
What is uroflowmetry?
Measures flow rate
What is post-void residual bladder volume?
Tests for incomplete emptying of the bladder
What is leak point pressure?
The point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities.
This assesses for stress incontinence
What is video urodynamic testing?
Involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.
Which drug is prescribed in stress incontinence if surgery is not preferred?
Duloxetine - an SNRI antidepressant
How long must pelvic floor exercises be done before considering surgery in stress incontinence?
At least 3 months and must be supervised
How many pelvic floor exercises should be completed daily?
Women should aim for at least eight contractions, three times daily.
Purpose of pelvic floor exercises?
Pelvic floor exercises are used to strengthen the muscles of the pelvic floor. They increase the tone and improve the support for the bladder and bowe
What is involved in tension-free vaginal tape (TVT) procedures?
Involve a mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence.
What is involved in autologous sling procedures?
Work similarly to TVT procedures but a strip of fascia from the patient’s abdominal wall is used rather than tape
Where the stress incontinence is caused by a neurological disorder or other surgical methods have failed, what may specialist centres offer?
An operation to create an artificial urinary sphincter.
This involves a pump inserted into the labia that inflates and deflates a cuff around the urethra, allowing women to control their continence manually.
What are the surgical options for stress incontinence?
1) Tension-free vaginal tape (TVT) procedures
2) Autologous sling procedures
3) Colposuspension
4) Intramural urethral bulking
What is involved in intrammural urethral bulking?
Involves injections around the urethra to reduce the diameter and add support
Stepwise management of urge incontinence (and overactive bladder)?
Stepwise:
1) Bladder retraining
2) Anticholinergic medication
3) Mirabegron (alternative to anticholinergic medication)
4) Invasive procedures where medical treatment fails
What is involved in colposuspension?
Involves stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra
When would mirabegron be used as an alternative medical treatment for urge incontinence?
Has a less anticholinergic burden
What is involved in bladder retraining in urge incontinence?
Gradually increasing the time between voiding for at least six weeks is first-line
1st line management for urge incontinence?
Bladder retraining
Examples of anticholinergic medications used in urge incontinence?
oxybutynin, tolterodine and solifenacin
Why must anticholinergics be used with caution in elderly patients?
Side effects such as ry mouth, dry eyes, urinary retention, constipation and postural hypotension.
ALSO can lead to a cognitive decline, memory problems and worsening of dementia
What is an alternative to anticholinergic medications used in urge incontinence?
Mirabegron
Contraindication of mirabegron?
Uncontrolled HTN
Mechanism of mirabegron in leading to HTN when using for treatment of urge incontinence?
It works as a beta-3 agonist, stimulating the sympathetic nervous system, leading to raised blood pressure.
This can lead to a hypertensive crisis and an increased risk of TIA and stroke.
What must be monitired regularly during treatment with mirabegron?
Blood pressure
What are some invasive options for overactive bladder that has failed to respond to retraining and medical management?
1) Botulinum toxin type injection into bladder wall
2) Percutaneous sacral nerve stimulation –> involves implanting a device in the back that stimulates the sacral nerves
3) Augmentation cystoplasty –> involves using bowel tissue to enlarge the bladder
4) Urinary diversion –> involves redirecting urinary flow to a urostomy on the abdomen
