Incontinence and Pelvic Organ Prolapse - Nordin Flashcards
What are the types of incontinence?
***Stress Incontinence: intraabdominal pressure is increased (such as when walking or running or lifting)
***Urge Incontinence/Detrusor Overactivity/Overactive Bladder
***Mixed: Stress and Urge incontinence occurring together.
Overflow: caused by either a blockage of the outlet (prostate enlargement) or weak bladder muscle function, results in frequent or constant dribbling
Functional: Untimely urination due to inability to get to a bathroom either from mobility issues, obstacles, communication/cognitive problem
Transient: Temporary condition causing incontinence such as medication, infection, illness
What is the mechanism of stress incontinence?
When intra-abdominal pressure exceeds urethral closing pressure => muscles that normally keep the urethra closed are prevented from squeezing as tightly as they should
Pelvic floor weakness
Loss of elasticity
Hormonal or connective tissue effects impacting the urethral sphincter
What is the mechanism of urge incontinence?
Involuntary leakage which is preceded by sudden urge to urinate => results in inappropriate bladder contractions
“PVC” of the bladder
Abnormal nerve signals
What is the neuronal control of the bladder?
Detrusor muscle contracts when exposed to cholinergic muscarinic receptor agonists
(Activating M3 receptors: SMOOTH MUSCLE CONTRACTION
Activating M2 receptors: INHIBITS BLADDER RELAXATION)
Beta adrenergic: B2 and B3 receptors in detrusor
Stimulation results in: RELAXATION OF DETRUSOR smooth muscle
Alpha-1 agonists: INCREASE URETHRAL RESISTANCE
Alpha-1 antagonists: BLOCK URETHRAL CONTRACTION
What are the non-pharmacological treatment approaches for the types of incontinence?
Weight loss if obese, fluid reduction, caffeine reduction, smoking cessation (to decrease chronic cough), control of constipation
Pelvic floor muscle exercises (kegel exercises)
Occlusive devices: Pessaries
Surgery
Urge: Bladder retraining/scheduled voiding, Fluid restriction
What commonly prescribed medications can affect bladder function?
Antidepressants/Antipsychotics/Sedatives/Hypnotics => retention
Diuretics/Caffeine => frequency and urgency
Anticholinergics => retention (overflow)
Alcohol => frequency
Narcotics => retention, constipation
Alpha-adrenergic agonists => increased tone, retention
Alpha-adrenergic blockers => decreased tone, (stress incontinence)
Beta-adrenergic agonists => inhibited detrusor fxn, retention
ACE Inhibitors => cough (stress incontinence)
What are the physical examination elements used to evaluate incontinence?
History: leak urine?, how often they urinate, problems with voiding,
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!
Evaluation of pelvic support (levator ani): squeeze test
Ask patient to cough and look for leakage of urine
Bimanual examination/DRE to assess for pelvic masses/stool impaction
What is pelvic organ prolapse and what problems and symptoms are associated with it?
Movement of pelvic organs (uterus, bladder) from normal position downward toward or through the vaginal opening
Sx: Sensations of bulge/protrusion, heaviness or pressure, Incontinence, frequency, urgency, weak stream, incomplete emptying, need to change position to void, bowel incontinence, Dyspareunia, decreased sensation
Problems: Cystocele, Cystourethrocele, Uterine Prolapse, Rectocele, Enterocele
What are the risk factors for pelvic organ prolapse?
General: Increased age, menopause, obesity
Increased intra abdominal pressure: Chronic cough from smoking, lung disease, Chronic constipation, Repeated heavy lifting
Obstetric: Pregnancy, Delivery with prolonged labor, instruments, episiotomy, Increased parity
Previous hysterectomy or prolapse surgery
Genetic factors or diseases affecting connective tissue
What are the treatment options for pelvic organ prolapse?
Observation
Lifestyle modification/treatment of medical conditions
Pelvic Floor Muscle Exercises
Pessary use
Surgery
What are the Transient causes of incontinence (DIAPPERS)?
Delirium
Infection (acute urinary tract infection)
Atrophic vaginitis
Pharmaceuticals
Psychological disorder, especially depression
Excessive urine output (e.g., hyperglycemia)
Reduced mobility (i.e., functional incontinence) or reversible (e.g., drug-induced) urinary retention
Stool impaction
What are the pharmacological treatment approaches for the types of incontinence?
Stress: Estrogen (intravaginal to strengthen wall), Duloxetine (more side effects), Alpha adrenergic drugs (contract urethral sphincter) (rarely used)
Urge: Anticholinergics, Beta-agonists (mirabegron), Estrogen (intravaginal, NOT systemic), Botulinum toxin injections
What are the Anticholinergic drugs used to treat Urge Incontinence?
Nonselective: fesoterodine (toviaz), oxybutynin (ditropan), tolterodine (detrol), trospium (sanctura)
Selective: darifenacin (enablex), solifenacin (vesicare)
What is the Beta agonist drug used to treat Urge Incontinence?
Mirabegron
B3 adrenergic receptor agonist => Relaxes detrusor muscle
