Incontinence And Prolapse

Question 1

What is urinary incontinence?

Answer 1

The involuntary leakage of urine

Common and distressing problem affecting quality of life

Question 2

What is stress incontinence?

Answer 2

Involuntary leakage of urine during increased intra-abdominal pressure (in the absence of detrusor contraction)

Question 3

What are the risk factors for stress incontinence?

Answer 3

Childbirth (most common cause)
Oestrogen-deficient states
Pelvic surgery
Irradiation

Question 4

What is urge incontinence?

Answer 4

AKA overactive bladder syndrome

Presence of urgency with frequency and nocturia in the absence of UTI or other pathology.

Question 5

What does urodynamic testing show in urge incontinence?

Answer 5

Overactivity of the detrusor muscle

Question 6

What are the causes of urge incontinence?

Answer 6

Neurological conditions like MS, spina bifida
Most cases idiopathic
Some caused by pelvic/incontinence surgery

Question 7

What are the other causes of urinary incontinence? (Not stress or urge)

Answer 7

Overflow incontinence (2o to retention, often no urge)
Bladder fistulas (opening between bladder and another organ)
Urethral diverticulum (out-pocketing of the urethra into the anterior vaginal wall)
Congenital abnormalities e.g. ectopic ureter
Functional incontinence (physical/mental barriers preventing reaching the toilet)
Temporary incontinence (due to reversible factors e.g. constipation, UTI)

Question 8

What are the clinical features of stress incontinence?

Answer 8

Leakage on coughing, sneezing or exercise
Small volume of leakage
Prolapse of urethra and anterior vaginal wall may also be present

Question 9

What are the clinical features of urge incontinence?

Answer 9

Sensation of urgently needing to pass urine followed by involuntary leakage
Frequency
Nocturia
Triggers - hearing running water, cold weather
Larger volumes of incontinence than stress
Bladder contractions may also be triggered by coughing or sneezing

Question 10

What are the investigations for incontinence?

Answer 10

Exclude UTI
Frequency/volume charts
- stress - normal frequency and bladder capacity
- urge - increased frequency
Urodynamic studies
- performed in stress incontinence when considering surgery to confirm diagnosis and rule out concomitant detrusor overactivity

Question 11

What is the conservative management for stress incontinence?

Answer 11

Weight loss, smoking cessation
Treat risk factors like conditions that cause raised intraabdominal pressure e.g. chronic cough
Supervised pelvic floor muscle training (at least 3 months)

Question 12

What is the surgical management for stress incontinence?

Answer 12

Tension free vaginal tape (may lead to chronic pelvic pain)
Burch colposuspension (rarely performed now there’s TVT)
Laparoscopic colposuspension
Peri-urethral injection (bulking agents under LA, suitable for elderly/cannot tolerate surgery)
Transobturator midurethral slings

Question 13

What is the medical management for stress incontinence?

Answer 13

Duloxetine

• for moderate to severe incontinence
• considered after surgical intervention/for patients where surgery isn’t appropriate

Question 14

What is the conservative management of urge incontinence?

Answer 14

Good fluid intake
Avoid caffeine and diuretics e.g. alcohol
Bladder retraining

Question 15

What is the medical management for urge incontinence?

Answer 15

Anticholinergics (oxybutynin, solifenacin, tolterodine)
Intravaginal oestrogen (may ameliorate symptoms for those with vaginal atrophy)
Botulinum toxin A
Neuromodulation and sacral nerve stimulation

Question 16

What are the side effects of anticholinergics?

Answer 16

Dry eyes
Dry mouth
Constipation
Blurred vision 
Arrhythmia
Confusion

Question 17

What are the contraindications of anticholinergics?

Answer 17

Acute angle closure glaucoma
Myasthenia gravis
GI obstruction

Question 18

What is the surgical management for urge incontinence?

Answer 18

Detrusor myomectomy and augmentation cytoplasty

Reserved only for those with debilitating symptoms

Question 19

Why does a genitouinary prolapse occur?

Answer 19

When there is a weakness in the supporting structures allowing the pelvic organs to protrude within the vagina

Question 20

What are the causes of prolapse?

Answer 20

Congenital
Prolonged labour
Trauma from instrumental delivery
Lack of postnatal pelvic floor exercise
Obesity
Chronic cough
Constipation 
(Exacerbated by menopause)

Question 21

What are the different types of prolapse?

Answer 21

Cystocoele (residual urine within this may cause frequency and dysuria)
Rectocoele
Enterocoele
Uterine prolapse

Question 22

How is a prolapse graded?

Answer 22

First degree - lowest part of prolapse descends halfway down vaginal axis to the introitus
Second degree - lowest part of prolapse extends to the level of the introitus
Third degree - the lowest part extends beyond the introitus to outside the vagina
Procidenta (4th degree uterine prolapse) - uterus lies outside the vagina

Question 23

What are the symptoms of prolapse?

Answer 23

Asymptomatic
Dragging sensation/discomfort/feeling of something coming down
Dyspareunia
Backache
Cystocoele - urgency, frequency, incomplete bladder emptying, urinary retention if urethra kinked
Rectocoele - constipation, difficulty with defaecation

Question 24

What are the preventative measures for prolapse?

Answer 24

Lower parity
Better obstetric practices
Pelvic floor exercises

Question 25

What is the conservative management for prolapse?

Answer 25

Lose weight
Stop smoking
Stop straining 
Improve muscle tone with exercise and physio 
Pessaries

Question 26

What is the surgical management for prolapse?

Answer 26

If symptoms severe/woman is sexually actively/pessaries have failed
Excise redundant tissue and strengthen support
Marked uterine prolapse - hysterectomy/laparoscopic sacrohysteropexy