Incontinence and Prolapse

Question 1

Define urge incontinence?

Answer 1

urinary incontinence is accompanied by or immediately preceded by urgency (complaint of sudden compelling desire to pass urine which is difficult to defer)

Question 2

Define overactive bladder syndrome?

Answer 2

urgency that occurs with or without urgency UI and usually with frequency and nocturia

Question 3

Describe some complaints of urge incontinence?

Answer 3

urgency and frequency but only small voided volumes, may be triggers to the urgency e.g. key in lock or running water

Question 4

What is urge incontinence characterised by?

Answer 4

detrusor contractions during inhibition of voiding, contractions increase in amplitude which increases the urgency until there is uncontrollable passage of urine

Question 5

What is the most common cause of urge incontinence?

Answer 5

idiopathic detrusor overactivity which usually occurs in middle aged females

Question 6

What type of incontinence does atrophic vaginitis cause? How can it be treated?

Answer 6

urge incontinence

topical oestrogen

Question 7

Describe mixed incontinence?

Answer 7

both features of urge and stress incontinence

this is common

Question 8

Treatment of urge incontinence?

Answer 8

lifestyle advice, bladder drill, pelvic floor physio (if mixed), drugs e.g. antimuscarinics solifenacin or beta agonists mirabegron, botox, neuromodulation, reconstructive surgery

Question 9

Explain how antimuscarinics work vs beta agonists in urge incontinence?

Answer 9

antimuscarinics block the parasympathetics to stop detrusor contractions e.g. solifenacin
beta agonists activate the sympathetics to increase detrusor relaxation e.g. mirabegron

Question 10

Define stress incontinence?

Answer 10

involuntary leakage of urine on effort, exertion, sneezing or coughing causing increased intra-abdominal pressure without a detrusor contraction
due to damage or weakness of the pelvic floor/ urethral function

Question 11

Risk factors for stress incontinence?

Answer 11

pregnancies, childbirth, menopause, age, obesity, smoking (as this causes a chronic cough)

Question 12

Exam for stress incontinence?

Answer 12

can do standing or supine stress test where ask person to cough and look for leakage of urine

Question 13

Treatment of stress incontinence?

Answer 13

lifestyle advice, physio, pessaries, drugs e.g. duloxetine which is a combined NA and SSRI thought to increase intraurethral closure pressure, incontinence pads, surgery

Question 14

Explain what causes overflow incontinence?

Answer 14

occurs due to the bladder not emptying properly when urinating causing urine to leak out later
this is more common in men due to prostatic obstruction but in women can occur due to obstruction of the urethra due to prolapse or due to poor contractile bladder muscle

Question 15

Presentation of overflow incontinence?

Answer 15

acutely they may complain of painful urinary retention, in later presentation they have a palpable bladder, chronic retention, wet at night and renal impairment, mass is dull to percussion

Question 16

What drug must you stop in someone with overflow incontinence?

Answer 16

anticholinergics/ antimuscarinics

as thats inhibiting bladder contraction so makes it worse

Question 17

Treatment of overflow incontinence?

Answer 17

often people have to be taught self catheterisation and are unlikely to ever be able to pass urine spontaneously again

Question 18

List and explain four types of pelvic organ prolapse?

Answer 18

cystocele - most common type of pelvic organ prolapse, bladder drops into the vagina
rectocele- rectum bulges into or out of the vagina
enterocoele- small intestine bulges into the wall of the vagina
uterine prolapse

Question 19

Explain the degrees of uterine prolapse?

Answer 19

1st degree- in vagina
2nd degree- at interiotus
3rd degree- outside vagina
procidentia- entirely outside vagina

Question 20

Risk factors for prolapse?

Answer 20

ageing 
prior pelvic surgery e.g. hysterectomy
menopause and hypoestrognism 
loss of muscle tone 
multiple vaginal births
obesity 
chronic constipation, coughing or heavy lifting 
uterine fibroids
family history 
connective tissues disorders e.g. marfans or ehlers danlos

Question 21

4 categories of treatment for prolapse?

Answer 21

conservative
physical
pessaries
surgery

Question 22

Describe conservative treatment for prolapse?

Answer 22

reassure

avoid heavy lifting, lose weight, stop smoking, reduce constipation

Question 23

Describe physical treatment for prolapse?

Answer 23

pelvic floor muscle exercises (kegel) are effective in prolapse when the prolapse is up to vaginal entry
minimum 4-6 months supervised trial of PFME training
even with more significant prolapse PFME may help with the symptoms

Question 24

Describe who pessaries are suitable for with prolapse?

Answer 24

women unfit for surgery
relief of symptoms whilst awaiting surgery
further pregnancies planned or already pregnant
as a diagnostic test for prolapse or to ensure insertion won’t cause SUI
at patient request

Question 25

Symptoms of prolapse?

Answer 25

bulging, pressure, feeling of a mass
difficulty voiding or defecting 
incomplete emptying 
splinting vaginal wall (have to press fingers on vagina to evacuate stool)
pain with intercourse
pain inserting a tampon