Incontinence and Prolapse Flashcards
What is urinary inconinence?
Involuntary leakage of urine
What are the types of urinary incontinence?
Stress incontinence
Overactive bladder syndrome
Mixed
Overflow incontinence
What are risk factors for urinary incontinence?
Age Women who have had children Post-menopausal women Obesity Smoking Lack of exercise
What is stress incontinence?
Involuntary leakage of urine when there is increased intra-abdominal pressure with the absence of detrusor muscle contraction
Occurs when intravesical pressure exceeds urethral closing pressure
Who are most commonly affected by stress incontinence?
After childbirth
After pelvic surgery
Oestrogen deficiency
What is the presentation of stress incontinence?
Triggered by coughing, sneezing, exercise
Leakage is often a small volume
Prolapse of urethral and anterior vaginal wall could be present
What is the investigation of stress incontinence?
Exclude UTI
Frequency/volume charts showing normal volume frequency and bladder capacity
Urodynamic studies
What is the lifestyle management for stress incontinence?
Weight loss Smoking cessation Avoid constipation Avoid heavy lifting Caffeine reduction
What is the conservative management of stress incontinence?
Pelvic floor muscle exercises for 3 months
What is the medical management of stress incontinence?
Duloxetine
When is stress incontinence managed medically?
If patient declines or is unsuitable for conservative or surgical options
What are some side effects of duloxetine?
Difficulty sleeping headaches Dizziness Blurred vision Change in bowel habits Nausea and vomiting Dry mouth Sweating Decreased appetite and weight loss Decreased libido
What are the surgical options for stress incontinence management?
Bulking agents Autologous rectus fascial sling Laparoscopic or open colposuspension Artificial urinary sphincters Tension free vaginal tapes
What is overactive bladder (urge incontinence)?
When an individual has increased urgency and frequency to void urine
What are the causes of OAB (urge incontinence)?
Idiopathic Pelvic sugery Multiple sclerosis Spina bifida Secondary to pelvic floor/incontinence surgery
What is the presentation of OAB (urge incontinence)?
Frequency Urgency With or without incontinence Triggered by hearing running water, cold weather, key in lock Larger volumes of leakage May have nocturia
How might a patient with OAB (urge incontinence) describe their condition?
“If I have to go I have to go immediately”
What do investigations show in OAB (urge incontinence)?
Frequency/volume charts - increased frequency, smaller volumes, may have nocturia
Urodynamic testing - over-activity of the detrusor muscle
What is the lifestyle management of OAB (urge incontinence)?
Decrease fluid intake
Minimise caffeine and diuretics, reduce alcohol
Use of pads
Bladder retraining
What is the medical management of OAB (urge incontinence)?
Anticholinergic - oxybutynin - tolterodine or solifenacin preferred in the elderly ad it can cause cognitive impairment Intravaginal oestrogens Desmopressin if nocturia
What is the surgical management of OAB (urge incontinence)?
Botox
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
What is overflow incontinence?
Leakage of urine from a full urinary bladder, often with the absence of an urge to urinate
What are causes of overflow incontinence?
Inactive detrusor muscle (neurological conditions)
Involuntary bladder spasms
Cystocele or uterine prolapse
Men > women
What is the presentation of overflow incontinence?
Leakage of urine
Often with absence of urge to urinate
What investigations are done for overflow incontinence?
Frequency/volume charts
Urodynamic testing - inactivity of the detrusor muscle
What is urogenital prolapse?
Descent of one of the pelvic organs resulting in protrusion of the vaginal
What is prolapse of the bladder called?
Cystocele
What is prolapse of the rectum called?
Rectocele
What organs can prolapse?
Bladder Uterus Vagina Rectum Small bowel
What is urogenital prolapse caused by?
Weakening of pelvic floor normally secondary to childbirth
What is first degree prolapse?
Mild protrusion on examination
-1cm of introitus
What is second degree prolapse?
Prolapse present at introitus of vagina/anus/urethra
Between -1cm and +1cm of introitus
What is third degree prolapse?
Prolapse protruding outside of introitus
Beyond +1cm of introitus
What is fourth degree prolapse?
Procidentia - complete prolapse
What are the degrees of uterine prolapse?
1st degree - cervix remains in vagina
2nd degree - cervix at vaginal orifice
3rd degree - cervix outside vagina
4th degree - entirely outside vagina
What is vaginal vault prolapse?
Drop of the top of the vgina into lower vagina
When is vaginal vault prolapse common?
Post-hysterectomy
What are the risk factors for urogenital prolapse?
Increasing age Multiparity with vaginal deliveries Obesity Spina bifida Smoking Heavy lifting
What is the presentation of urogenital prolapse?
Sensation of pressure, heaviness Incontinence Frequency, urgency Difficulty voiding or incomplete emptying Dyspareunia
What investigations are done for urogenital prolapse?
Speculum examination
Urodynamic studies
Bladder scan - check for outflow obstruction
Urinalysis to exclude UTI
What is the lifestyle management of urogenital prolapse?
Weight loss Avoid constipation Smoking cessation Avoid heavy lifting Caffeine reduction
What is the conservative management of urogenital prolapse?
Physiotherapy - pelvic floor training
Ring pessary
What is the surgical management of cystocele?
Anterior colporrhaphy
What is the surgical management of uterine prolapse?
Hysterectomy
Sacro-hysteropexy
What is the surgical management of vaginal vault prolapse?
Sacrospinous fixation
What is the surgical management of rectocele?
Posterior colporrhaphy
