Incontinence and Vaginal Prolapse Flashcards
what are the 2 phases in micturition
storage
continence phase
STORAGE PHASE MICTURITION
control
- Controlled at highest level by continence centres of brain then in turn continence centres of spinal cord
- Relaxation of detrusor muscle of bladder and contraction of internal and external urethral sphincters
STORAGE PHASE MICTURITION
sympathetic innervation
- To stimulate storage impulses from cerebral cortex to pons which is responsible for coordinating actions of urinary sphincters and bladder,
- Area involved in storage phases is the pontine continence centre
- Signals sent to sympathetic nuclei in spinal cord and detrusor muscle and internal urethral sphincter of bladder
- Impulses travel from spinal cord to bladder via sympathetic hypogastric nerve (T10-L2)
- This stimulates: relaxion of detrusor muscle in bladder wall via stimulation of B3 adrenoreceptors in fundus and body of bladder, contraction of IUS – via stimulation of a1 adrenoreceptor at bladder neck
STORAGE PHASE OF MICTURITION
somatic innervation
- EUS is under voluntary somatic control
- Impulses travel to EUS via pudendal nerve (S2-S4) to cholinergic receptors on striated muscles leading to contraction of sphincter
- Coordinated relaxation of detrusor muscle and contraction of urethral sphincters allows bladder to fill with urine, store it for hours
- As the bladder fills, the rugae in bladder walls flatten and walls distent increasing capacity
- As the bladder fills it expands to allow inner pressure remain constant and lower than urethral pressure
VOIDING PHASE OF MICTURITION
- urinary flow rate
- bladder capacity
- when does voiding occur
- 20-25ml/s in men / 25-30ml/s women
- 300-550ml
- Afferent nerves in bladder signal the need to void bladder at around 400ml filling
VOIDING PHASE OF MICUTRITION
regulation of micturition
- Parasympathetic control
- Bladdr afferents signals ascend spinal cord and project to pontine micturition centre and cerebrum.
- Under voluntary decision to urinate, neurones of pontine micturition centre fire to excite sacral preganglionic neurones
- Stimulation to pelvic nerve causing release of Ach working on M3 muscarinic receptors on detrusor causing contraction and increase intra-vesicular pressure
- Consious reduction in voluntary contraction of external urethral sphincter from cerebral cortex allows distention of urethra and passing of urine
- In women urination is assisted by gravity
what is urodynamics
combination of tests looking at ability of bladder to store and void urine. Examples include; uroflowmetry, post void residual measurement and cystometry, urethral pressure profilometry, video-urodynamic
what is uroflowmetry?
Non invasice that can screen for voiding difficulties
Patient voids in privacy on a commode incorporating a urinary flow meter,measures voided volume over time and plots it on a graph
what is cystometry
- Measuring the pressure/volume relationship of bladder during filling and voiding and useful test of bladder function
- Bladder filled with saline via catheter and first sensation of filling, first desire to void and any strong desire to void recorded
- Electronic subtraction of intra-abdominal pressure from the intravesical enables the detrusor pressure to be calculated
- During filling the patient is asked to cough at regular inervals and to stand, in order to provoke bladder
- The presence of detrusor contractions and leakage through urethra noted
- Woman then asked to void at the end of the test, for pressure/flow analysis
what is video urodynamics
- Combines fluoroscopic imaging of bladder neck with cystometry, while fillinf the bladder with iodine based contrast medium
- Enables detection of detrusor sphincter dyssnegia, vesico-ureteric reflux, or presence of abnormalities in renal tract that are commonly seen in women with neurogenic bladder problems
what is ambulatory urodynamic monitoring
- Small recording device is worn and information is later downloaded to a computer for analysis and review
- The bladder is filled naturaly and the woman should carry out her normal activities including those that prooke symptoms
- Useful for investigating detrusor over activity when standard laboratory urodynamics have failed to replicate symptoms experienced by woman in normal environment
what is urinary incontinence, types and risk factors
Involuntary, spontaneous urine loss that occurs either with strenuous physical activity (stress incontinence) or associated with uncontrollable sense of urgency (urgency incontinence) or it can be mixed
Can be caused by; alterations in anatomical support, neuromuscular function of pelvic floor, idiopathic
Risk factors – increased prevalence in puerperal period, older, obese women with neurological conditions
epidemiology of urinary incontinence
Lower prevalence in black, Hispanic and Asian women
Prevelance increases during adult life and plateau between 50-70 year then increases again after 70
aetiology of urinary incontinence
- Increasing parity / Vaginal delivery / episiotomy – stress incontinence
- Due to weakening and strethching of muscles and connective issues during delivery and damage to pudendal and pelvic nerves
- Excess weight increases pressure on pelvic tissues, causing chronic strain, stretching and weakening of muscles, nerves and other pelvic structures
describe some precursors to urinary incontinence
Burning urination, trouble starting urinary flow, inability to stop urine flow, needing to push and strain while urinating, needing to urinate ore than once to empty bladder, nocturia
what neurological condition is associated with increased incidence of urinary incontinence in older women
dementia
what can concomitant urinary incontinence and chronic constipation in young women with longstanding history of urinary incontinence indicate
spina bifida
what commonly coexists with urinary incontinence
faecal incontinence
why can incontinence be associated with stroke
- interruption of central nervous system inhibitory pathways is associated with stress, urgency, and overflow incontinence
- Detrusor overactivity resulting from upper motor neuron lesions after stroke may present as urinary urgency and urgency incontinence.
describe how urinary incontinence can be a consequence of neurological damage
caused by Parkinson’s disease or may be caused indirectly as a result of physical limitations imposed by the disease. Furthermore, upper motor neuron lesions, as seen in Parkinson’s disease and multiple sclerosis, that affect descending pathways from the brain may lead to delayed sensation, urinary retention, and resultant overflow incontinence
what drugs may lead to urinary incontinence
Diuretic use may cause polyuria, frequency, and urgency. In addition, caffeine consumption may cause frequency and urgency
describe stress incontinence
limited almost exclusively to women. Stress incontinence is the passive loss of urine in response to increased intraabdominal pressure, such as that caused by coughing, laughing, or sneezing.
describe urgency incontinence
Urge incontinence is the involuntary loss of urine accompanied by a sense of urgency or impending loss and is associated with increased bladder activity.
describe overactive bladder
(detrusor overactivity) - urgency with or without urgency incontinence; usually with frequency and nocturia in the absence of an underlying metabolic or pathological condition
describe mixed incontinence
combination of stress and urgency incontinence symptoms
describe nocturnal enuresis
involuntary loss of urine occurring during sleep
what is continuous incontinence
continuous loss of urine
what is overflow incontinence
urinary leakage from an over-distended bladder; terminology is no longer widely used
describe bypass and overflow incontinence
- Bypass incontinence is continuous incontinence occurring when the normal continence mechanism is bypassed, as with fistulae and symptoms may be intermittent or continuous.
- Overflow incontinence is continuous or intermittent insensible loss of small volumes of urine resulting from an overfilled or atonic bladder.
prevelance of bypass/overflow incontinence
- Of all women that have hysteresctomies 0.05% develop fistula and subsequent bypass incontinence
- Uncommon – follows trauma, instrumentation, surgery, anaesthesia
- Occurs mid reproductive age and onward, overflow incontinence more common in later years
causes of bypass incontinence
- fistulae may result from surgical or obstetric trauma, irradiation, or malignancy
- most common cause by far (in developed countries) is unrecognized surgical trauma (obstructed labor in other parts of the world).
- Roughly 75% of fistulae occur after abdominal hysterectomy.
- Signs of a urinary fistula (watery discharge) usually occur from 5 to 30 days after surgery, although they may be present in the immediate postoperative period.
overflow incontinence causes
- trauma (vulvar, perineal, radical pelvic surgery)
- irritation/infection (chronic cystitis, herpetic vulvitis, herpes zoster)
- anesthesia (spinal, epidural, caudal)
- pressure (uterine leiomyomata, pregnancy)
- anatomic defect (cystocele, retroversion, or prolapse of the uterus)
- neurologic disorder (multiple sclerosis, diabetes, spinal cord tumors, herniated disc, stroke, amyloid disease, pernicious anemia, Guillain- Barré syndrome, neurosyphilis)
- systemic disease (hypothyroidism, uremia)
- medications (antihistamines, appetite suppressants, β-adrenergic agents, parasympathetic blockers, vincristine, carbamazepine)
- radiation therapy, behavioral problems (psychogenic, infrequent voiding).
bypass and overflow incontinence risk factors
- surgery or radiation treatment.
- Most common after uncomplicated hysterectomy, although pelvic adhesive disease, endometriosis, or pelvic tumors increase the individual risk.
signs and symptoms of bypass incontinence
- Continuous loss of urine (often from the vagina or rectum)
- Fistulae from the vagina to the bladder (vesicovaginal), urethra (urethrovaginal), or ureter (ureterovaginal).
signs and symptoms of overflow incontinence
- Frequent loss of small volumes of urine (may or may not be related to increases in intraabdominal pressure)
- Midline lower abdominal mass (with or without tender- ness) that disappears with catheterization
- Ability for spontaneous voiding may or may not be compromised
differentials of bypass incontinence
- Overflow incontinence
- Urge incontinence
- Ectopic ureter
differentials of overflow incontinence
- Other forms of incontinence (stress, bypass/fistula)
- Chronic urinary tract infections
- Urinary tract obstruction
- Neurologic conditions presenting as an adynamic bladder
investigations for overflow/bypass incontinence
Laboratory
• Urinalysis
• Abrupt onset incontinence in older patients – suggest infection
Imaging
• Ureterovaginal fistulae- excretory urography to evaluate possible uretal dilattion or obstruction
• Retrograde urography
• Ultrasonography demonstrates distended bladder in patients with overflow incontinence
Special tests
• Cystoscopy if vesicovaginal fistula found to find location
• Urodynamic testing considered for those with overflow incontinence that is either recurrent or unrelated to obvious cause
Diagnostic procedures
• When fistula suspected – installation of dilute solution of methylene blue into bladder while tampon is in place in vagina documnts vesicovaginal fistula
• IV indigo carmine – overflow incotninese
• Cystometrogram confirms diagnosis
Distended, hypotonic bladder is typical of patients with overflow incontinence
management of bypass incontinence
- urinary diversion, protection of the vulva from continuous moisture
- Vesicovaginal fistulae from post operative period treated with large caliber transurethral catheter drainage
- Spontaneous heeling within 2-4 weeks
- Prompt placement of ureteral stent, for 2 weeks
- Surgical repair of genitourinary fistulae delayed 2-4 months to allow healing
- Successful surgical repair consists of dissection of fistulous tract and reapproximation of tissue
- No drugs
management of overflow incontinence
- treat UTI if needed
- prompt and continuous drainage if retention
- timed voiding to reduce bladder volume, suprapubic pressure or crede maneuver to reduce residual volume
- drugs – often unsatisfactory and require long term catheter drainage/ antibiotics if UTI / acetylcholine like drugs – bethanechol chloride 10-50mg 3 or 4 times a day
prevelance of stress incontinence
10% to 15% of all women and 30% to 60% of women after menopause.
Mid productive age onward
More common during 40s and beyond, more common after menopause
aetiology of stress incontinence
Unequal transmission of intraabdominal pressure to the bladder and urethra. Generally associated with an anatomic defect such as a cystocele, urethrocele, or cystourethrocele. The degree of incontinence is often not correlated with the scale of pelvic relaxation.
stress incontinence risk factors
Multiparity, obesity, chronic cough, heavy lifting, intrinsic tissue weakness or atrophic changes resulting from estrogen loss
signs and symptoms of stress incontinence
Loss of small spurts of urine in association with transient increases in intraabdominal pressure
Associated cystocele, urethrocele, or cystourethrocele
differentials of stress incontinence
- Mixed incontinence (stress and urge)
- Urge incontinence (detrusor instability)
- Intrinsic sphincter defect (ISD)
- Low pressure urethra
- Urinary tract fistula
- Urinary tract infection
- Urethral diverticulum
- Overflow incontinence
investigations for stress incontinence
- urinalysis – non specific
- radiographic studies – not much use
- special tests – Q-tip test – cotton tipped applicator dipped In 2% lidocaine placed in urethra and rotated with straining measured
- bonney/marshal-marchetti test – non specific, unreliable
- pelvic examination – have patient strain or cought while vaginal opening is observed
evidence of loss of support for urethra or bladder
management of stress incontinence
- weight reduction
- treat chronic cough
- timed voiding
- topical or systemic oestrogen replacement or therapy
- pessary therapy
- pelvic muscle exercises (kegel exercises)
- collagen injections
- surgical repair
drugs
• phenylpropanolamine 75-150mg – mild stress incontinence
• + chlorpheniramine 75mg/12mg PO every 6 hours
• Imipramine hydrochloride 50-150mg PO daily – mixed incontinence and enuresis
• Duloxetine???
• Oestrogen topically or systemically to improve tissue tone, reduce irritation and prepare tissues for surgical or pessary therapy
prevelence of urge incontinence
35% of patients with incontinence
Mid reproductive age and onward
More common during 40s and after
causes of urge incontinence
Allergy, bladder stone, bladder tumor, caffeinism, central nervous system tumors, detrusor muscle instabil- ity, interstitial cystitis, multiple sclerosis, Parkinson’s disease, radiation cystitis, radical pelvic surgery, spinal cord injury, urinary tract infections (Urinary tract infections [UTI]; acute or chronic).
risk factors for urge incontinence
frequent UTI
signs and symptoms of urge incontinence
- Reduced bladder capacity and early, intense sensations of bladder fullness
- Spontaneous and uninhibitable contractions of the bladder muscles, resulting in large-volume, uncontrolled urine loss
- Loss possibly provoked by activities such as hand washing or a change in position or posture or after (not during) changes in intra-abdominal pressure such as a cough or sneeze
differentials for urge incontinence
- Mixed incontinence (stress and urge)
- Stress incontinence
- UTI
- Urinary tract fistula
- Interstitial cystitis
- Urethritis
urge incontinence investigations
- Urinalysis recommended – infection?
- Radiographic studies little use
- Measure postvoif urinary residual volume
- Evaluation of sphincter tone and function
Reduced bladder capacity, early first sensation, uninhibited bladder contractions
urge incontinence management
- Treat UTI
- Timed voiding
- Medical therapy
- Surgical role is limited
- Diet – reduce caffeine and other bladder irritants
- Flavoxate hydrochloride (Urispas) 100 to 200 mg PO three times a day to four times a day (fewer side effects, more expensive than some).
- Imipramine hydrochloride (Tofranil) 25 to 50 mg PO twice a day to three times a day (good for mixed incon- tinence and enuresis, 60% to 75% effective).
- Oxybutynin hydrochloride (Ditropan) 5 to 10 mg PO three times a day to four times a day (side effects common [75%], 60% to 80% effective).
- Phenylpropanolamine hydrochloride (Propadrine) 50 mg PO twice a day (α-adrenergic sympathomimetic).
- Propantheline bromide (Pro-Banthine) 15 to 30 mg PO three times a day to four times a day (few side effects, variable absorption, 60% to 80% effective).
- Darifenacin (Enablex) 7.5 mg PO daily (works by blocking the M3 muscarinic acetylcholine receptor, which is primarily responsible for bladder muscle contractions).
- Solifenacin (Vesicare) 5 mg PO daily (urinary antispas- modic of the anticholinergic class).
FAECAL INCONTINENCE
what causes nerve damage to be the cause
- a long-term habit of straining to pass stool
- brain injury
- spinal cord injury
FAECAL INCONTINENCE
how can neurologic disease cause it
affect the nerves of the anus, pelvic floor, or rectum can cause fecal incontinence. These diseases include; dementia, MS, parkinsons, stroke, type 2 diabetes
FAECAL INCONTINENCE
loss of stretch in rectum
If your rectum is scarred or inflamed, it becomes stiff and can’t stretch as much to hold stool. Your rectum can get full quickly, and stool can leak out. Rectal surgery, radiation therapy in the pelvic area, and inflammatory bowel disease can cause scarring and inflammation in your rectum.
FAECAL INCONTINENCE
haemorrhoids
Hemorrhoids can keep the muscles around your anus from closing completely, which lets small amounts of stool or mucus to leak out
FAECAL INCONTINENCE
rectal prolapse
a condition that causes your rectum to drop down through your anus—can also keep the muscles around your anus from closing completely, which lets small amounts of stool or mucus leak out.
FAECAL INCONTINENCE
physical inactivity
If you are not physically active, especially if you spend many hours a day sitting or lying down, you may be holding a lot of stool in your rectum. Liquid stool can then leak around the more solid stool. Frail, older adults are most likely to develop constipation-related fecal incontinence for this reason.
FAECAL INCONTINENCE
childbirth by vaginal delivery
Childbirth sometimes causes injuries to the anal sphincters, which can cause fecal incontinence. The chances are greater if
• your baby was large
• forceps were used to help deliver your baby
• you had a vacuum-assisted delivery
• the doctor made a cut, called an episiotomy, in your vaginal area to prevent the baby’s head from tearing your vagina during birth
FAECAL INCONTINENCE
rectocele
Rectocele is a condition that causes your rectum to bulge out through your vagina. Rectocele can happen when the thin layer of muscles separating your rectum from your vagina becomes weak. Stool may stay in your rectum because the rectocele makes it harder to push stool out.
causes of prolapse
- pregnancy and vaginal delivery – uncommon in nulliparous women. Vaginal delivery may cause mechanical injuries and denervation of pelvic floor. Risk increased with large babies, prolonged second stage, instrumental delivery
- congenita factors – abnormal collagen metabolism eg ehlers danlos syndrome
- menopause – deterioration of collagenous connective tissue occurring following oestrogen withdrawal
- chronic predisposing factors – chronic increase in intra-abdominal pressure eg obesity, chronic cough, constipation, heavy lifting, pelvic mass
- iatrogenic factors – pelvic surgery
what is prolapse
prolapse is protusion of the uterus and/or vagina beyond normal anatomical confines (bladder, urethra, rectum and bowel are also involved
classification of prolapse
cystocele
uterine (apical)
enterocele
retrocele
cystocele prolapse
Prolapse of anterior vaginal wall involving bladder. Often associated prolapse of urethra (cysto-urethrocele)
uterine prolapse
Prolapse of uterus, cervix and upper vagina
If uterus has been removed, the vault on top of the vagina, where the uterus used to be, can prolapse
enterocele prolapse
Prolapse of upper posterior wall of vagina. The resulting pouch contains loops of small bowel
retrocele prolapse
Prolapse of lower posterior wall of vagina involving anterior wall of rectum
what classification system is used to grade prolapses
baden walker classification
describe the baden walker classification of prolapses
1st degree - Lowest part of the prolapse descends halfway down the vaginal axis to introituse
2nd degree - Lowest part of prolapse extends to level of introituse and through introituse on straining
3rd degree - Lowest part of prolapse extends through introitus and lies outside vagina
(procidentia)
PROLAPSE
symptoms
- general
- dragging sensation, discomfort and heaviness in pelvis
- feeling of a ‘lump coming down’
- dyspareunia or difficulty inserting tampons
- discomfort and backake
cysto-uretrhocele
• urinary urgncy and frequency
• incomplete bladder emptying
• urinary retention or reducd flow where urethra is kinked by descent of anterior vaginal wall
rectocele
• constipation
• difficulty with defecation
these become worse with prolonged standing and at end of day
in grade ¾ there may be mucosal ulceration and lichenification causing vaginal bleeding and discharge
PROLAPSE
examination
- exclude pelvic masses with bimanual examination
- vaginal examination with woman in left lateral position using Sims speculum
- walls checked for descent and atrophy
- volsellum may be applied to cervix so that traction will demonstrate severity of uterine prolapse
- prolapse may sometimes be only demonstrated with the woman standing or straining
- assessment of pelvic floor muscle strength
PROLAPSE
modified oxford system for grading pelvic floor muscle strength
system of grading using vaginal palpation of pelvic floor muscles 0 -no conraction 1 - flicker 2 - weak 3 - moderate 4 - good 5 - strong
PROLAPSE
quality of life assessment
- symptoms can affect qualiy of life, causing social, psychological, occupational, sexual limitations
- self completion questionnaires allow comprehensive assessment of prolapse symptoms and their impact such as international consultation on incontinence questionnaire (ICIQ-VS)
PROLAPSE
investigations
- USS to exclude pelvic or abdominal masses
- Urodynamics required if urinary incontinence is present
- ECG, CXR, FBC, U&E
prevention of pelvic organ prolapse
- Reduction of prolonged labour
- Reduction of trauma caused by instrumental delivery
- Encouraging persistence with postnatal pelvic floor exericses
- Weight reduction
- Treatment of chronic constipation
- Treatment of chronic cough
PROLAPSE
physiotherapy
Useful in mild prolapse in younger women who find intravaginal devices unacceptable and not ready for definitive surgical treatment
• Pelvic floor muscle exercises – unlikely to benefit older women with significant uterovaginal prolapse
• Biofeedback and vaginal cones
PROLAPSE intravaginal devices (pessaries)
- Changed 6 monthly and topical oestrogen to reduce risk of vaginal erosion
- Ring pessary – different sizes, ring placed between posterior aspect of the symphysis pubis and posterior fornix of vagina
- Shelf pessary – used when correctly sized ring pessary will not sit in the vagina and/or perineum is deficient
- Hodge pessary – used to correct uterine retroversion
- Cube and doughnut – very rarely used, for significant prolapse when others not retained
what factors influence management of prolapse
- Severity of symptoms
- Extension of signs - (aysymptoatic not need treatment)
- Age, parity, wish ofr further pregnancies
- Sexual activity
- Aggrevating factors such as smoking and obesity
- Urinary symptoms
- Other gynae problems eg menorrhagia
PROLAPSE
surgical management for anterior compartment defect
- Anterior colporrhaphy (anterior repair)
- paravaginal repair
PROLAPSE Anterior colporrhaphy (anterior repair)
- Appropriate for the repair of a cysto-urethrocele.
- A longitudinal incision is made on the anterior vaginal wall and the vaginal skin separated by dissection from the pubocervical fascia.
- Buttressing sutures are placed on the fascia.
- The surplus vaginal skin is excised and the skin is closed.
- The repair is traditionally performed under regional or general anaesthesia; however, it can also be performed under local anaesthesia, allowing early mobilization and discharge home.
- Whilst morbidity is low, the long-term success rate of conventional anterior colporrhaphy is disappointing; recurrence rates of up to 30% have been reported. This may in part be due to failure to identify a co-existing apical defect.
PROLAPSE
paravagina repair
- Abdominal approach to correct an anterior defect.
- The retropubic space is opened through a Pfannenstiel incision and the bladder is swept medially, exposing the pelvic sidewall.
- The lateral sulcus of the vagina is elevated and reattached to the pelvic sidewall using interrupted sutures.
- A cure rate of 70–90% has been reported (may also be done laparoscopically).
- It isn’t a commonly performed procedure, it is very invasive if performed via laparotomy, and the authors personal experience suggests higher recurrence rates than published data suggest.
PROLAPSE MANAGEMENT
posterior compartment deficit
Posterior colpoperineorrhaphy (posterior repair) • Appropriate for correction of a rectocele and deficient perineum. • It involves the repair of a rectovaginal fascial defect and removal of excess vaginal skin.
PROLAPSE
surgical management for uterovaginal (apical) prolapse
- vaginal hysterectomy
- manchester repair (fothergill repair)
- hysteropexy
PROLAPSE MANAGEMENT
vaginal hysterectomy
May be combined with the above procedures, in cases of significant uterine descent or menstrual problems
PROLAPSE MANAGEMENT
manchester repair
- Now rarely performed.
- Cervical amputation is followed by approximation and shortening of the cardinal ligaments anterior to the cervical stump.
- This is combined with an anterior and posterior colporrhaphy.
PROLAPSE MANAGEMENT
hysteropexy
- Can be performed if patient wishes to preserve uterus as an open or laparoscopic procedure
- Uterus and cervix are attached to sacrum using bifurcated non-absorbable mesh.
- Theoretical advantage of hysteropexy is stronger apical support when compared with vaginal hysterectomy.
PROLAPSE
management for vaginal vault prolapse
sacrospinous ligament fixation
sacrocopoplexy
PROLAPSE
sacrospinous ligament fixation
- Involves suturing the vaginal vault to the sacrospinous ligaments, using a vaginal approach.
- Low immediate postoperative morbidity; success rate 70–85%.
PROLAPSE
sacrocopoplexy
- The vault is attached to the sacrum using a non-absorbable mesh, and if can be performed either as an open procedure or laparoscopically.
- It has a higher success rate, of around 90%, and a better anatomical result than sacrospinous fixation.
