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Obs and Gynae > Incontinence and prolapse > Flashcards

Incontinence and prolapse Flashcards

1
Q

What does prolapse mean?

A

Downward protrusion of hollow organ thorough its introitus or natural opening

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2
Q

What is the different between a prolapse and a hernia?

A

Hernia is a protrusion through an abnormal opening

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3
Q

3 types of prolapses that can be seen in the vagina and where they come from?

A

Cystocele from anterior compartment, enterocele from posterior compartment, rectocele from rectum

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4
Q

Denervation of what nerve can lead to prolapse?

A

pudendal nerve

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5
Q

Disruption to the pelvic floor support can lead to what 2 main symptoms?

A

Urethral hypermobility and therefore stress incontinence, descent and pelvic organ prolapse

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6
Q

What congenital abnormality is linked to prolapse? what CT disorder can cause pelvic floor disorder?

A

Spina bifida, Ehlers Danlos

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7
Q

Indirect vs direct trauma in obstetric complications of pelvic floor muscles?

A

indirect - stretch of the pudendal nerve, direct - tearing of levators or CT fascia

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8
Q

% of women that undergo surgery for pelvic organ prolapse in their lives

A

10%

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9
Q

Risk factors for POP?

A

Parity, racial, smoking/resp disease, exercise, occupation, obstetric indirect and direct trauma, spina bifida, obesity

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10
Q

Symptoms of POP?

A

Feeling of a lump, can feel it dragging down, lower back pain, urinary symptoms of incontinence and urgency, difficulty voiding

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11
Q

3 classifications of POP through the anterior wall?

A

Cystocele, urethrocele, cystourethrocele

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12
Q

what prolapse will you find at the posterior wall lower half?

A

Rectocele

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13
Q

What prolapse would you find at the posterior wall upper half?

A

enterocele

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14
Q

2 prolapses in the middle compartment?

A

vaginal vault and uterine

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15
Q

3 grades of prolapse?

A 
1 = descend into the vagina
2 = descent to the opening of introitus
3 = descent through the opening of the introitus
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16
Q

what does procidentia mean?

A

When there is a 4th degree prolapse and the fundus of the uterus passes through the introitus

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17
Q

Non surgical management options of prolapse?

A

Pessaries, HRT, stop smoking, lose weight, pelvic floor exercises, electrical stimulation

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18
Q

What can occur if pessaries are forgotten about?

A

Discharge, bleeding, granulation, fistulas, malignant change

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19
Q

Surgical procedure to fix a cystocele?

A

Anterior colporrhaphy

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20
Q

How do you perform a vault suspension?

A

Sacrospinous fixation, sacrocolpopexy, sacrohysteropexy

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21
Q

What two forces try and expel urine from the bladder?

A

intravesical and intra-abdominal pressure

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22
Q

What is the force that prevents expulsion of urine from the bladder?

A

urethral sphincter pressure

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23
Q

Muscle that predominantly controls the bladder?

A

Detrusor muscle

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24
Q

What muscle type is the urethral sphincter made from?

A

striated muscle

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25
Q

How does the urethral sphincter maintain the high pressure required to ensure continence?

A

the fibres of the sphincter are interlinked with the levators of the pelvic floor

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26
Q

what happens in obstructed voiding?

A

Sphincter resistance is higher than intra vesical and intra abdominal and leads to pathological obstructed voiding

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27
Q

What nerve roots and type of fibres innervate the detrusor muscle?

A

Parasympathetic cholinergic fibres from s2-s4

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28
Q

What innervates the external urethral sphincter?

A

Pudendal nerves

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29
Q

What muscles are responsible for the stretch receptor reflex and where are they found?

A

M2 and M3 muscarinic receptors found in the detrusor muscle

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30
Q

Where does the descending inhibitory influence on the stretch receptor reflex come from?

A

Pontine Centre

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31
Q

What happens during the micturition reflex?

A

Pontine inhibition is stopped, detrusor allowed to contract, urethra must relax first

32
Q

What kind of incontinence results from urethral sphincter weakness?

A

Stress urinary incontinence

33
Q

What type of incontinence occurs from detrusor overactivity?

A

Urgency incontinence

34
Q

What type of incontinence develops when the bladder isnt emptying properly?

A

Overflow incontinence

35
Q

What is true incontinence within the urinary tract?

A

Structural abnormality in the form of a fistula or congenital

36
Q

What can cause underactive detrusor muscle?

A

Episode of urinary retention, CNS/MS, Ageing

37
Q

What can cause an outflow obstruction?

A

POP, previous surgery for stress incontinence

38
Q

3 main types of urinary incontinence

A

stress urinary incontinence, urgency urinary incontinence, mixed urinary incontinence

39
Q

Main type of urinary incontinence in early years vs late?

A

early - stress, late - mixed and urgency as nerve supply breaks down

40
Q

What would you need to ask about during history taking of urinary incontinence?

A

Determine urgency or stress type, duration, severity - pads, ADLs, on coughing, blood, previous incontinence/prolapse/UTIs/surgery, Fluid intake, obstetric, gynae, medical, DH

41
Q

What are you looking for on examination of someone with incontinence?

A

Cough - any incontinence or prolapse, any masses, palpable bladder, any faecal impaction, atrophic vaginitis

42
Q

How can you investigate urinary incontinence?

A

Urinalysis, bladder diary, urodynamics, imaging renal tracts, post voidal residual

43
Q

Lifestyle advice for reducing urinary incontinence?

A

Reduce weight, smoking cessation, less caffeine, modify high or low water intakes, treat constipation, review medications

44
Q

What is mainstay treatment of SUI?

A

PFMT with physio

45
Q

What is mainstay treatment of UUI?

A

bladder retraining and antimuscarinics

46
Q

Adjuvant treatments to PFMT?

A

biofeedback, electrical treatment, vaginal cones

47
Q

types of stress incontinence surgical treatment?

A

Synthetic mid urethral tape, open colposuspension, autologous rectus fascial sling, periurethral injectables

48
Q

Which nerve can be damaged by surgical treatment of SUI?

A

obturator

49
Q

What 2 things can be inserted to prevent SUI?

A

Vaginal mesh and continence vaginal devices like contiform

50
Q

What behaviour treatments are available for UUI?

A

bladder training for 6 weeks, TENS, acupuncture, PTNS

51
Q

What are 2 antimuscarinics given in UUI?

A

solifenacin, oxybutynin

52
Q

What is a sympatheticomimetic given to work on the urethral sphincter during UUI?

A

mirabegron

53
Q

What is the weekly progression goal of bladder training?

A

1 hour increasing by 15-30 minutes each week to a 2-3 voiding interval goal

54
Q

What is an extended treatment that can be given to detrusor overactivity leading to UUI?

A

botulinum toxin type Z intradetrusor injections with cystoscopy

55
Q

How does SNM treat UUI?

A

Stimulates S3

56
Q

How much urine in the bladder leads to your first sensation to urinate?

A

150mls

57
Q

How many mls is max capacity of urine in bladder?

A

500mls

58
Q

What 2 things are controlled by the pontine micturition centre?

A

detrusor muscle contraction and urethral relaxation

59
Q

How is a leakproof mucosal seal maintained within the bladder?

A

Oestrogenised supple urothelium

60
Q

what can be attached to improve urethral support?

A

Tension Free Vaginal Tape

61
Q

History questions about uncontinence?

A

Urogynae history - SUI, UUI, frequency, noctural diuresis. Voiding issues - frequency, hesitancy, urgency, incomplete emptying, Poor flow, post micturition dribble, Straining
Sensation - pain when passing urine, painful micturition
Haematuria
Bowel function
Do they drink - coke, caffeine, carbonated, tea, alcohol
History of chest problems, cardiac issues, diabetes, neuro

62
Q

What medication in an incontinence history do you need to ask about?

A

Beta blockers, antidepressants, diuretics, alpha blockers, lithium, sedatives

63
Q

What are you looking for on examination of a women experiencing urinary incontinence?

A

General health, weight and mental state, vulva, atrophy, scarring, cough induced SUI, pelvic muscle power assessment

64
Q

What 2 positions do you get the patient to strain in when examining a uterine or vaginal prolapse?

A

left lateral and lithotomy position

65
Q

How do you screen for CNS assessment?

A

Lower limb assessment - power, tone, reflexes, sensation

Perineal - reflexes, sensation, anal tone

66
Q

2 investigations usually performed when investigating bladder function?

A

Urinalysis and bladder diary

67
Q

Lifestyle measure for SUI?

A

lose weight, drinking routine, correct cough

68
Q

Physical therapy interventions for SUI?

A

PFMT for 3 months, electrical stimulation, biofeedback

69
Q

Who is biofeedback offered to as intervention for SUI?

A

Those who cannot contract their pelvic floor muscles

70
Q

Surgical measures to reduce SUI?

A

Tension Free Vaginal Tape, Burch colposuspension, Periurethral injections of silicone, hyaluronic acid, collagen

71
Q

What therapy can be offered for SUI for people who are against surgery?

A

Duloxetine - norepinephrine and SRI to increase sphincter activity during filling

72
Q

What needs to be carried out if conservative methods of SUI fail?

A

Urodynamic studies

73
Q

What 3 things does uroflowmetry look into?

A

cystometry, urethral pressures, imaging techniques

74
Q

Lifestyle advice for UUI?

A

Weight, smoking, drinking caffeine, chronic cough, treat constipation

75
Q

What does bladder control teach?

A

Better corticol inhibitions in the Pontine Centre to provide better inhibitory signals over detrusor activity

76
Q

Pharmacological intervention for UUI?

A

Anticholinergics, vaginal oestrogen in PM, botulinum injections

77
Q

Investigation to prove UUI?

A

Urodynamic studies

Obs and Gynae (27 decks)

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