Incontinence and Prolapse

Question 1

What is the definition of urinary incontinence?

Answer 1

The complaint of any involuntary leakage of urine

Question 2

What are the 3 types of incontinence?

Answer 2

Stress
Urgency
Mixed

Question 3

What is stress incontinence?

Answer 3

Involuntary leakage on effort/exertion

Can occur when coughing or sneezing

Question 4

What is urgency incontinence?

Answer 4

Involuntary urine leakage accompanied or immediate preceded by a sudden urgency to urinate

Question 5

What is a mixed urinary incontinence?

Answer 5

When there is involuntary urine leakage associated with both urgency and exertion.

Question 6

What is wet overactive bladder?

Answer 6

This is urgency which occurs along with urgency incontinence
Has increased frequency and nocturia
Can have dry OAB where incontinence does not occur

Question 7

What specific things should be asked about in the history?

Answer 7

Caffeine intake 
Storage symptoms:
 - frequency
- urgency
 - constant leaking?
Voiding symptoms
 - hesitancy
 - straining 
 - poor flow
Post-micturition symptoms
 - incomplete
 - incontinence

Question 8

What are the appropriate examinations in UI?

Answer 8

BMI
Abdo exam
Vaginal exam
PR exam
May also require cognitive assessment if history dictates it

Question 9

Overactive bladder is caused by what?

Answer 9

Involuntary contractions of the detrusor muscle

Question 10

What investigations should be done for UI?

Answer 10

Urinalysis
Post void residual
Urodynamics
Cystoscopy
Imaging (USS)

Question 11

List some non medical management options for UI?

Answer 11

Weight loss
Fluid restrictions
Caffeine reduction
Bladder training
Pelvic Floor Physiotherapy

Question 12

List some anti-muscarinic agents

Answer 12

Oxybutynin
Tolterodine
Darifenacin

Question 13

How do antimuscarinics help with OAB?

Answer 13

Reduce intravesical pressure
increase compliance
Raise volume threshold before micturition
Reduce uninhibited contractions

Question 14

List some side effects of antimuscarinic agents?

Answer 14

Dry mouth
Constipation
Blurred vision
Somnolence

Question 15

What class of drug is Mirabegron?

Answer 15

B3 agonist

Question 16

How do B3 agonists work?

Answer 16

Relaxes smooth muscle of bladder through activation of the B3 adrenoreceptor
This increases the voiding interval and inhibits spontaneous contractions

Question 17

Other than antimuscarinics, what other managements can be used for overactive bladder (OAB)?

Answer 17

Desmopressin (if nocturia)
Topical oestrogen
Botox
Percutaneous sacral nerve stimulator
Augmentation cystoplasty

Question 18

What is first line management in overactive bladder?

Answer 18

Anti-muscarinic

Question 19

What is another medication management in stress incontinence?

Answer 19

Duloxetine

Use after conservative measures e.g. PFE do not work

Question 20

What is the mechanism of action in duloxetine?

Answer 20

Combined noradrenaline and serotonin reuptake inhibitor - this will increase the intraurethral pressure

Question 21

What is a cystocele?

Answer 21

An anterior pelvic prolapse

Question 22

What are the symptoms of a cystocele?

Answer 22

Bulging
Pressure
'Dragging'
Difficulty voiding
Difficulty inserting tampons
Pain on intercourse

Question 23

What is an enterocele?

Answer 23

Vaginal vault prolapse

i.e. middle / apical prolapse

Question 24

What is a rectocele?

Answer 24

A posterior prolapse

Question 25

What symptoms might present specifically to a rectocele?

Answer 25

Difficulty defecating | Incomplete defecation b

Question 26

What is a complete eversion?

Answer 26

This is when all compartments of the vagina prolapse outside of the body

Question 27

List some risk factors for vaginal prolapse:

Answer 27

``` Older age Parity - especially vaginal delivery Post menopausal oestrogen deficiency Obesity Neurological conditions Genetic connective tissue disorder ```

Question 28

What investigations may need to be done for prolapse?

Answer 28

USS MRI Anorectal manometry Endoanal USS

Question 29

What are the main management options for prolapse?

Answer 29

Conservative Mechanical - pessaries Surgery

Question 30

When are pessaries appropriate?

Answer 30

Mild to moderate prolapses If not finished having family Patient request

Question 31

What are some complications of pessaries?

Answer 31

Discharge Ulcerations leading to fistulas Fibrous bands

Question 32

How often must pessaries be changed?

Answer 32

Every 6 months

Question 33

List the appropriate surgery options for the type of prolapse:

Answer 33

Anterior - Vaginal repair Posterior - Vaginal repair Apical - Vaginal: Sacrospinous fixation, Colpocliesis - Abdominal: Sacrohysteropexy, Sacrocolpopexy, Pectopexy

Question 34

What is sacrolcolpopexy?

Answer 34

Attach a mesh between the sacrum and the vaginal prolapse material