Incontinence and Pelvic Organ Prolapse Flashcards
What percentage of americam n women can be affected by icnotinence?
as many as 30-40%
What are some factors that influence developing incontinence?
gender age hormonal status previous vaginal delivery and birthin trauma CT differences neurologic conditions medications
What’s the most important muscle in the pelvus floor?
levator ani
Where are the beta adrenergic receptors in the bladder?
bladder dome
Where are the alpha-1 receptors?
trigone
urethral smooth muscle
Where are the muscarinic receptors?
in the deep layer throughout.
THe internal sphincter is smooth muscle under involuntary control of what receptors?
alpha 1
The external sphincter is skeletal muscle supplied by what nerve?
somatic pudendal nerve - under voluntary control
The function of the urethra is affected by estrogen because….
the blood vessels assist the layer sin coming together to close the urethra and vasculature decreases with decreasing estrogen levels
this is why menopause is a factor
Sympathetics are involved with hwat bladder function in general terms?
storage of urine - bladder dome relaxation
WHere do these sympathetics come from?
T10-L2 to inferior mesenteric ganglion and palvic plexus. then hypogastric and pelvic nerves to the bladder
Parasympathetics are involved with what bladder funcion?
actually peeing
Detrussor muscle will do what when exposed to cholinergic muscuarinic receptor agonists?
contract - make you pee
What are the muscarinic receptor subtypes in bladder smooth muscl
mainly M2 and M3
Activating M2 receptors does what?
inhibits bladder relaxation
Activating M3 receptors does what?
promotes bladder contraction (so M2 and M3 promote the same result by different means)
What are the beta adrenergic receptors in the detrusor?
B2 and B3 (again, promote relaxation)
Where is the micturition center?
pons
What are some major drgus taht influence bladder fucntion?
antidepressants/antipsychotics
sedatives
diuretics - increase
caffeine - increase
anticholinergics - urinary retention or used to treat incontinence
alcohol - sedation and bladder irritating
narcotis
What are the three main type sof incontinence?
stress
urge
mixed
What is stress incontinence?
leakage of small amoutns of urine when itnraabdominal pressure is increased (with walking, running, lifting, coughing, etc.)
very common
What is urge incontinence?
overactive bladder - irritation and overativity of the bladder musculature itself. they’ll have the urge to urinate and then leak large amounts of urine shortly after they have that urge - can’t get to the bathroom in time sometimes
What are the typical causes of stress I?
pelvic floor weakness
loss of elasticity
hormoneal or connective tissue effects
What are the typical causes of urge?
inappropriate bladder contractions - PVC of the bladder, abnormal nerve signals
What is overflow incontinence?
caused by either a blockage of the outlet (like BPH) or weak bladder muscle function resultin gin frequent or constnat dribbling
What is functional incont?
untimely urination due toinability to get to a bathroom either from mobility issues, obstacles, communication or cognitive problems
What are the common causes of transient incontinence?
DIAPPERS Delirium Infection Atropic vaginitis Pharmaceuticals Pysychological disorder (esp depression) Excessive urine output Reduced mobility (functional) or reversible urinary retention Stool impaction
What are the risks for stress incontinence?
age
pregnancy with childborth
menipause
hysterectomy/pelvic surgery
obestiy
chronically increased intraabodminal rpessure from chronic cough,smoking, constipation or occupational lifting
neurological conditions affecting urethral tone.
What is the rterm for poor urethral sphincter function?
instrinsic sphincter deficiency
What are the factors that can lead to problems with urethra not closing adequately?
nerve damage
scarring
decreased vascularity
What is the most common cause of urge incont. others?
most frequently caused by detrusor overactivity or inacbility to suppress detrusor contractions
also UTI, bladder stones, bladder cancer, etc
Wht pertinent things on the PMH should be considered?
Obstetric and gynecologic history Deliveries, surgeries, estrogen status Diabetes Stroke Lumbar disc disease Neurologic disease Chronic lung disease (coughing) Fecal impaction or constipation Cognitive impairment Medications!
What can you do for diagnosis?
general inspection for atrophy, neurologic function (bulbocavernosus reflex), anal wink, levator ani testing
have then cough and look for leakage
bimanual to assess for pelvic masses or stool impaction
How can we tell if there is residual volume post void?
urinarlysis with catheter
What are the options fo rstress icintoinence?
weight loss fluid reduction caffeine reduction smoking cessation control of constipation pelvic floor muscle exercises (kegels) occlusive devices like pessaries or urethral inserts Estrogen intravaginally surgery
What are two other medications that can be used for stree incotninences?
Duloxetine
alpha adrenergic drugs
What are the treatments for urge incont?
bladder retraining with scheduled voiding fluid restriciton eliminate meds that make it worse pelvic floor muscle exercises meds tibial nerve stimulation implantable sacral nerve stimulator
What meds can be used for urge incont
anticholinergics
beta-agonists
estrogen
botulinum toxin injections
What muscle is exercised by the kegel exercises?
levator ani
What are extracorporeal magnetic innervation
stimulates the pelvic floor muscle sin people whoa re unable to sense whethe they are contracting the muscles or not
How doe s apessary work?
it’s a disc with a round ball and you put it up into the vagina so that the ball pushes against the bladder anteriorly to help hold it all up
Meds are only technically approved for what?
urge incotninence
But what are the drugs you can try for stress incontinence?
estrogen
alpha agonists like pseudoephedrine
For urge incontinence, you can do anticholienrgic agents. What are some examples?
oxybutinin, detrol, trospium
What are the contraindications for these anticholinergic agents?
narrow angle glaucoma
dementia (make them worse)
GI obstruciton
urinary retention
What is the main bet agonists used for urge incontinence?
mirabegron
B3 agonist
What are the side effects of beta agonists here?
urinary retention, icnreased blood pressure, nausea and vomiting, headache, dizziness
What is bladder training?
teach them to ignore bladder urgency and re-establish control over the bladder - do scheduled voiding only
When should you refer someone on?
Recurrent Urinary Tract Infections New onset neurologic symptoms Markedly enlarged prostate Pelvic organ prolapse past the introitus Pelvic pain and incontinence Persistent hematuria or proteinuria Large post void residual (200 ml) Previous pelvic surgery or radiation Uncertain diagnosis
WHat ar ethe main symptoms with prolapse?
bulge symtpms - sense of a bulge, protrusion, heaviness or pressure
and urinary symptoms - incontinence, frequency, weak stream, etc
bowel symptoms
sexual symptoms - dyspareunia, decreased sensation
pain in the vagina, bladder, rectum, pelvis, or low back pain
