Incontinence and Prolapse Flashcards
What is incontinence?
Involuntary leakage of urine
What type of incontinence is a) provoked? b) unprovoked?
a) Stress b) Urge (OAB)
What is the most common type of incontinence? What is it due to?
Stress: poor closure of the bladder
When does stress incontinence occur?
On exertion or effort (e.g. sneezing, coughing, laughing)
Describe what happens in urge incontinence?
There is a sudden, compelling desire to urinate that is difficult to delay, and can cause urgency which can lead to incontinence
Mixed incontinence is a combination of which types?
Urge and stress
Women who have an overactive bladder often do what?
Drink an excessive amount of fluid, and have a high caffeine intake
What defines an overactive bladder? What are some symptoms which are commonly associated?
Urgency which occurs with or without incontinence / frequency and nocturia
What is overactive bladder known as if it occurs a) with incontinence? b) without incontinence?
a) wet OAB b) dry OAB
What happens to the detrusor muscle to cause OAB?
Hyperactivity, there are involuntary contractions
Which type of incontinence is more likely to be idiopathic? What are some common risk factors for the other type?
OAB (urge) / stress - childbirth and pregnancy, obesity, chronic cough
What effect does caffeine have on the bladder muscle? This of more importance in which type of incontinence?
It is a bladder muscle irritant, more relevant in urge incontinence
Which type of medications are especially bad for causing incontinence?
Psychoactive medications (acting on the CNS)
What are some examples of storage symptoms?
Frequency, nocturia, urgency, constant leakage
What are some examples of voiding symptoms?
Hesitancy, straining, poor flow
What are some important aspects of examination when somebody presents with incontinence?
BMI, abdominal exam, vaginal exam, PR exam
The total urine passed in one day should be less than what?
< 1800ml
Patients with incontinence are often asked to keep a bladder diary, what should be recorded in this? How long is it done for?
How often they go to the toilet and how much is passed, any leakage, how much they are drinking / 3 days
What two investigations should be done on every woman presenting with incontinence?
Urinalysis and post-void residual
What is the purpose of doing urinalysis when people present with incontinence?
To rule out a UTI (nitrates/WCC), bladder cancer/stones (blood) and diabetes (glucose)
What are some further investigations which could be done for incontinence but are not done routinely?
Urodynamics, cystoscopy, imaging
When are urodynamics used as an investigation for incontinence?
If the woman is undergoing surgery, if medical treatment has failed or if outflow obstruction is suspected
What happens in overflow incontinence?
There is a bladder outflow obstruction where the voiding sensation is inadequate, leading to dribbling incontinence
Overflow incontinence can arise as a result of what?
Previous surgery for incontinence or prolapse
How can overflow incontinence be treated?
Treat the underlying cause, alpha blockers or intermittent self-catheterisation
What is the first step in the management of stress incontinence?
Conservative management: weight loss, physiotherapy for pelvic floor exercises, smoking cessation, cut down alcohol/caffeine
If conservative management for stress incontinence has failed, what are some other options?
Incontinence pessary, duloxetine (not usually 1st line), surgery (mid-urethral tape surgery)
What will a bladder diary of someone with OAB show?
Frequent, small volume voids through the day and night
What are the main lifestyle interventions that can be used as treatment options for an overactive bladder?
Reduce caffeine/alcohol/chocolate, keep fluid intake between 1.5-2.5L/day, weight loss aiming for BMI < 30
Apart from lifestyle interventions, what are some other conservative treatment options for OAB?
Pelvic floor exercises for 3 months, bladder retraining for 6 weeks
What is the first line pharmacological management for OAB? How do these work?
Anti-muscarinic agents / they relax bladder smooth muscle and hence increase bladder capacity
Which specific anti-muscarinic agent is used first for OAB? It often has poor tolerance due to what? If oral methods are intolerant, what can be tried instead?
Oxybutynin / side effects e.g. dry eyes and blurred vision, dry mouth, sedation / transdermal
When should you review a patient after starting anti-muscarinic agents for OAB? If they haven’t worked, what is the next line management?
4-6 weeks / consider surgical options
Anti-muscarinic are generally not prescribed to who? Why?
Those aged > 85, they can cause confusion/dementia
Mirabegron is another pharmacological agent which can be used for OAB. What group of drugs does this belong to? How does it work?
Beta 3 agonists / relaxes bladder smooth muscle
What happens in an a) anterior b) middle/apical and c) posterior prolapse?
a) bladder drops into the vagina b) uterus drops into the vagina c) bowel drops into the vagina
How common in pelvic organ prolapse?
Occurs in 50% of parous women, with 10-20% being symptomatic
A cystocele is another name for an anterior prolapse, what can prolapse here? What is a more specific symptom of this type of prolapse?
Bladder or anterior vaginal wall / incontinence
Middle/apical organ prolapses (enteroceles) can cause what specific symptom?
Back pain
A rectocele is another name for a posterior prolapse, what can prolapse here? What is a more specific symptom of this type of prolapse?
Rectum or posterior vaginal wall / incomplete defaecation
What are the most significant contributors to the aetiology of prolapse?
Age, childbirth and family history, as well as increased intra abdominal pressure (e.g. obesity, chronic cough)
What is the most common presenting complaint of a prolapse?
A dragging sensation down below, which gets worse as the day progresses
What are some groups of symptoms you would want to ask about if a woman presented with a prolapse?
Urinary symptoms, bowel symptoms, sexual dysfunction
What position would you want to examine a woman in for suspected prolapse to assess the full extent? How will the prolapse be demonstrated?
While standing or squatting/ Valsalva manoeuvre or coughing
Is prolapse routinely investigated for?
No, only if it is of sudden onset as this may be due to pressure from a pelvic mass
In the quantification system for prolapse, all sites are measured in relation to which structure?
Hymenal ring
What are some conservative management options for prolapse?
Weight loss, smoking cessation, pelvic floor exercises for 3 months, pessaries
When would pessaries be used instead of surgery in the management of prolapse?
If that was the preference, not completed family, only mild-moderate, for frail patients
What are some complications of using a pessary?
Discharge, ulcerations which may lead to fistula
How often should a pessary be changed? What is used alongside it?
Every 6 months / topical oestrogen
Sex is only possible with what kind of pessary?
Ring
What is the surgical management of uterine prolapse?
Vaginal hysterectomy with vault support
What is the surgical management of anterior or posterior prolapses?
Vaginal repair
What is the surgical management for uterine prolapse if the woman doesn’t want a hysterectomy?
Sacrohysteroplexy
