Gynecology - Pelvic Organ Prolapse + Urinary Incontinence Flashcards
Pelvic relaxation especially apparent in postmenopausal because
Decreased endogenous estrogen
Gravity
Nl aging
Multiparity
Complete procidentia
Complete eversion of vagina with entire uterus prolapsing outside the vagina
Scoring to quantify pelvic organ prolapse
Baden-Walker Halfway scoring system
0 = normal 1 = descensus 1/2 way to hymen 2 = descensus to hymen 3 = descensus 1/2 past hymen 4 = max descent
Exam conducted with patient straining
More common use POP Q scale now
Tx pelvic organ prolapse
Kegel exercises (tighten and release levator ani muscles)
Pessaries
Surgery
- hysterectomy + apical suspension
- colpocleisis
- anterior and posterior colporrhaphy
Low dose vaginal estrogen
Vaginal vault prolapse occurs most commonly in pts
Who have undergone hysterectomy
vagina inverts into vaginal canal and possibly outside of body!
Urinary continence at rest is possible because
the intraurethral pressure exceeds the intravesical pressure.
Continuous contraction of the internal sphincter is one of the primary mechanisms for maintaining continence at rest.
The external sphincter provides about 50% of urethral resistance and is the second line of defense against incontinence.
continence is also maintained via the action of the submucosal vasculature of the urethra. When this vasculature complex fills with blood, the intraurethral pressure is increased, thus preventing involuntary loss of urine
SNS provides continence via HYPOGASTRIC nerve (T10-L2)
Somatic NS for VOLUNTARY prevention of urination by innervating striated muscle of external sphincter via PUDENDAL N
What provides mech for micturition
PSNS for micturition - pelvic N (S2-S4)
Goal of diagnostic testing in incontinence
Distinguish between stress and urgency
Work up of incontinence
Voiding diary or bladder chart
UA/UCx
Stress test
- fill bladder w/ water through catheter, cough, see if lose urine
- = stress incontinence
- post void residual measured (50-100mL is ok, above is not)
Cotton swab test
- dx hypermobile urethra assoc w/ stress incontinence
- cotton swab in urethra, strain, if change in cotton swab angle > 30 deg = hypermobile urethra
Urodynamics
- for those contemplating surery
- urethral function via urethrocystometry, pressure, profilometry
- bladder filling via cystometry
- bladder emptying via uroflowmetry
Cystometry
- measure P and V relationship of bladder during filling and pressure flow study during voiding
- nl bladder capacity = 400- 600 mL
Uroflowmetry
- measures rate of urine flow and flow time through urethra when pt asked to spontaneously void
- good for dx outflow obstruction and abnl bladder reflexes (complaint = hesitancy, fullness, urinary retention)
Stress incontinence - pathogenesis
Involuntary loss of urine through intact urethra in response to inc in intra-ab pressure (cough, sneeze, exercise)
Can also have hypermobile urethra
Usually 2/2 laxity of pubourethra ligaments, suburethral vaginal hammock, and pubococcygeus muscles
- in some, may be due to weakness in internal urethral sphincter
Stress incontinence
- dx
- tx
Dx
- stress test
- urodynamics
Tx
1st line - lifestyle and behavior changes - wt loss, caffeine restrict, fluid management, bladder train, Kegels, PT
Med therapy - not great
- alpha adrenergic agonists (midodrine, pseudoephedrine)
- b-adrenergic receptor antagonists (propanolol)
- TCAs (imipramine)
- SNRI (duloxetine)
Devices
- incontinence pessaries
Surgery
- bladder neck sling *
- ab retropubic urethropexies*
- midurethral sling**
- = These all aim to resuspend hypermobile urethra
- = provide reinforcement at midurethra to pubic bone
Urgency Incontinence - pathogenesis
Involuntary loss of urine assoc w/ urgency
Usually assoc w/ detrussor overactivity but not always
Some conditions to cause involuntary bladder contractions:
- UTI
- bladder stone
- bladder ca
- urethral diverticula
- foreign bodies
- stroke
- SC injury
- parkinsons
- MS
- DM
Urgency Incontinence - clinical signs
Urgency
Frequency
Nocturia
Urgency Incontinence
- dx
- tx
Dx - clinical
Tx
- depends on etiology underlying!
Idiopathic
- lifestyle/behavior mod + meds + surgery combo
Lifestyle/behavior mods
- wt loss, caffeine restrict, fluid managment, Kegel, PT
Meds
- anticholinergics (Oxybutynin, tolterodine, fesoterodine, solifenacin, trospium, darifenancin)
- not ok for pts with gastric retention and angle closure glaucoma or dementia
Surgery
- sacral and periph neuromodulation
- bladder injections
- augmentation cystoplasty
- Botox into detrussor
Overflow incontinence - pathogenesis
Usually 2/2 underactive or acontractile detrusor muscle from many causes (fecal compaction, meds, neuro dz, MS)
Bladder ctxn weak –> incomplete void –> urinary retention
Bladder outlet obstruction from surgical procedures can also cause
Can also happen after anesthesia or epidural
Overflow incontinence - sx
Dribbling
Sx of stress incontinence + urge incontinence too
Overflow incontinence - tx
Meds
- reduce urethral closing pressure: prazosin, terazosin, phenoxybenzamine
- striated muscle relaxants: diazepam, dantrolene
- Cholinergics: bethanechol
Intermittent self cath
Surgery if bladder outlet obstruction
Bypass incontinence - pathogenesis
Result of urinary fistula between bladder and vagina
Continuous incontinence! Painless
2/2 pelvic radiation and pelvic surgery usually (hysterectomy)
- fistulas apparent usually after 14 days postop
Bypass incontinence - dx
Methylene blue into bladder and see if leaking into vagina
For ureterovaginal fistula, IV indigo carmine and see if comes out through vagina
VCUG can see number and location of fistulas. Can also use IVP
Bypass incontinence - tx
Surgery
wait 3-6 mo before repairing post op fistulas
Abx for uti
Estrogen for post menopausal women while wait
Functional incontinence
Factors outside lower urinary tract
Physical Mental (delirium, dementia)
Common in geriatrics
Causes of Continuous incontinence
Fistula (pathognomonic)
Surgery
Tx detrussor instability
Anticholinergics (oxybutynin)
TCAs are not first line b/c of other side effects
Central and lateral cystoceles are repaired by
fixing defects in the pubocervical fascia or reattaching it to the sidewall, if separated from the white line.
Rectocele repaired by
repairing defects in rectovaginal fascia
Uterine prolapse is surgically treated by
a vaginal hysterectomy
Vaginal vault prolapse is treated
either by supporting the vaginal cuff to the uterosacral ligaments, sacrospinous ligament or sacrocolpopexy.
Do anterior and posterior repairs provide apical support of vagina?
No
