Incontinence and prolapse Flashcards
What does prolapse mean?
Downward protrusion of hollow organ thorough its introitus or natural opening
What is the different between a prolapse and a hernia?
Hernia is a protrusion through an abnormal opening
3 types of prolapses that can be seen in the vagina and where they come from?
Cystocele from anterior compartment, enterocele from posterior compartment, rectocele from rectum
Denervation of what nerve can lead to prolapse?
pudendal nerve
Disruption to the pelvic floor support can lead to what 2 main symptoms?
Urethral hypermobility and therefore stress incontinence, descent and pelvic organ prolapse
What congenital abnormality is linked to prolapse? what CT disorder can cause pelvic floor disorder?
Spina bifida, Ehlers Danlos
Indirect vs direct trauma in obstetric complications of pelvic floor muscles?
indirect - stretch of the pudendal nerve, direct - tearing of levators or CT fascia
% of women that undergo surgery for pelvic organ prolapse in their lives
10%
Risk factors for POP?
Parity, racial, smoking/resp disease, exercise, occupation, obstetric indirect and direct trauma, spina bifida, obesity
Symptoms of POP?
Feeling of a lump, can feel it dragging down, lower back pain, urinary symptoms of incontinence and urgency, difficulty voiding
3 classifications of POP through the anterior wall?
Cystocele, urethrocele, cystourethrocele
what prolapse will you find at the posterior wall lower half?
Rectocele
What prolapse would you find at the posterior wall upper half?
enterocele
2 prolapses in the middle compartment?
vaginal vault and uterine
3 grades of prolapse?
1 = descend into the vagina 2 = descent to the opening of introitus 3 = descent through the opening of the introitus
what does procidentia mean?
When there is a 4th degree prolapse and the fundus of the uterus passes through the introitus
Non surgical management options of prolapse?
Pessaries, HRT, stop smoking, lose weight, pelvic floor exercises, electrical stimulation
What can occur if pessaries are forgotten about?
Discharge, bleeding, granulation, fistulas, malignant change
Surgical procedure to fix a cystocele?
Anterior colporrhaphy
How do you perform a vault suspension?
Sacrospinous fixation, sacrocolpopexy, sacrohysteropexy
What two forces try and expel urine from the bladder?
intravesical and intra-abdominal pressure
What is the force that prevents expulsion of urine from the bladder?
urethral sphincter pressure
Muscle that predominantly controls the bladder?
Detrusor muscle
What muscle type is the urethral sphincter made from?
striated muscle
How does the urethral sphincter maintain the high pressure required to ensure continence?
the fibres of the sphincter are interlinked with the levators of the pelvic floor
what happens in obstructed voiding?
Sphincter resistance is higher than intra vesical and intra abdominal and leads to pathological obstructed voiding
What nerve roots and type of fibres innervate the detrusor muscle?
Parasympathetic cholinergic fibres from s2-s4
What innervates the external urethral sphincter?
Pudendal nerves
What muscles are responsible for the stretch receptor reflex and where are they found?
M2 and M3 muscarinic receptors found in the detrusor muscle
Where does the descending inhibitory influence on the stretch receptor reflex come from?
Pontine Centre
What happens during the micturition reflex?
Pontine inhibition is stopped, detrusor allowed to contract, urethra must relax first
What kind of incontinence results from urethral sphincter weakness?
Stress urinary incontinence
What type of incontinence occurs from detrusor overactivity?
Urgency incontinence
What type of incontinence develops when the bladder isnt emptying properly?
Overflow incontinence
What is true incontinence within the urinary tract?
Structural abnormality in the form of a fistula or congenital
What can cause underactive detrusor muscle?
Episode of urinary retention, CNS/MS, Ageing
What can cause an outflow obstruction?
POP, previous surgery for stress incontinence
3 main types of urinary incontinence
stress urinary incontinence, urgency urinary incontinence, mixed urinary incontinence
Main type of urinary incontinence in early years vs late?
early - stress, late - mixed and urgency as nerve supply breaks down
What would you need to ask about during history taking of urinary incontinence?
Determine urgency or stress type, duration, severity - pads, ADLs, on coughing, blood, previous incontinence/prolapse/UTIs/surgery, Fluid intake, obstetric, gynae, medical, DH
What are you looking for on examination of someone with incontinence?
Cough - any incontinence or prolapse, any masses, palpable bladder, any faecal impaction, atrophic vaginitis
How can you investigate urinary incontinence?
Urinalysis, bladder diary, urodynamics, imaging renal tracts, post voidal residual
Lifestyle advice for reducing urinary incontinence?
Reduce weight, smoking cessation, less caffeine, modify high or low water intakes, treat constipation, review medications
What is mainstay treatment of SUI?
PFMT with physio
What is mainstay treatment of UUI?
bladder retraining and antimuscarinics
Adjuvant treatments to PFMT?
biofeedback, electrical treatment, vaginal cones
types of stress incontinence surgical treatment?
Synthetic mid urethral tape, open colposuspension, autologous rectus fascial sling, periurethral injectables
Which nerve can be damaged by surgical treatment of SUI?
obturator
What 2 things can be inserted to prevent SUI?
Vaginal mesh and continence vaginal devices like contiform
What behaviour treatments are available for UUI?
bladder training for 6 weeks, TENS, acupuncture, PTNS
What are 2 antimuscarinics given in UUI?
solifenacin, oxybutynin
What is a sympatheticomimetic given to work on the urethral sphincter during UUI?
mirabegron
What is the weekly progression goal of bladder training?
1 hour increasing by 15-30 minutes each week to a 2-3 voiding interval goal
What is an extended treatment that can be given to detrusor overactivity leading to UUI?
botulinum toxin type Z intradetrusor injections with cystoscopy
How does SNM treat UUI?
Stimulates S3
How much urine in the bladder leads to your first sensation to urinate?
150mls
How many mls is max capacity of urine in bladder?
500mls
What 2 things are controlled by the pontine micturition centre?
detrusor muscle contraction and urethral relaxation
How is a leakproof mucosal seal maintained within the bladder?
Oestrogenised supple urothelium
what can be attached to improve urethral support?
Tension Free Vaginal Tape
History questions about uncontinence?
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
What medication in an incontinence history do you need to ask about?
Beta blockers, antidepressants, diuretics, alpha blockers, lithium, sedatives
What are you looking for on examination of a women experiencing urinary incontinence?
General health, weight and mental state, vulva, atrophy, scarring, cough induced SUI, pelvic muscle power assessment
What 2 positions do you get the patient to strain in when examining a uterine or vaginal prolapse?
left lateral and lithotomy position
How do you screen for CNS assessment?
Lower limb assessment - power, tone, reflexes, sensation
Perineal - reflexes, sensation, anal tone
2 investigations usually performed when investigating bladder function?
Urinalysis and bladder diary
Lifestyle measure for SUI?
lose weight, drinking routine, correct cough
Physical therapy interventions for SUI?
PFMT for 3 months, electrical stimulation, biofeedback
Who is biofeedback offered to as intervention for SUI?
Those who cannot contract their pelvic floor muscles
Surgical measures to reduce SUI?
Tension Free Vaginal Tape, Burch colposuspension, Periurethral injections of silicone, hyaluronic acid, collagen
What therapy can be offered for SUI for people who are against surgery?
Duloxetine - norepinephrine and SRI to increase sphincter activity during filling
What needs to be carried out if conservative methods of SUI fail?
Urodynamic studies
What 3 things does uroflowmetry look into?
cystometry, urethral pressures, imaging techniques
Lifestyle advice for UUI?
Weight, smoking, drinking caffeine, chronic cough, treat constipation
What does bladder control teach?
Better corticol inhibitions in the Pontine Centre to provide better inhibitory signals over detrusor activity
Pharmacological intervention for UUI?
Anticholinergics, vaginal oestrogen in PM, botulinum injections
Investigation to prove UUI?
Urodynamic studies
