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Endo/Repro Block2 > Incontinence & Pelvic Prolapse > Flashcards

Incontinence & Pelvic Prolapse Flashcards

1
Q

Is incontinence an inevitable part of aging?

A

NO

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2
Q

What muscle forms the striated sphincter of the urethra?

What muscle forms the middle and lower thirds of the urethral sphincter?

What muscle contributes to the upper and middle thirds of the urethral sphincter?

A

one of the heads of the bulbocavernosus [it has 3] that joins the ischiocavernosus

  • upper 2/3= ischiocavernosus fibers
  • lower 2/3 = bulbocavernosus fibers

[overlap in middle]

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3
Q

What type of R’s are in the bladder dome?

What axn do they potentiate?

A

B-adrenergic R

used for urine storage

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4
Q

What type of R’s are in the bladder trigone and urethral Sm. M?

What axn do they potentiate?

A

a-1 R’s

used in urine storage

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5
Q

What type of R’s are in deep layer of entire bladder?

What axn are they responsible for?

A

muscarinic R’s

used for bladder emptying

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6
Q

What is the internal urethral sphincter composed of?

What kind of control is it under?

What R’s are found here?

A

Sm. M

involuntary control

a-1 R’s

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7
Q

What components make up the external urethral sphincter?

what type of control is it under?

what R’s are here?

A

Sk.M

voluntary control; supplied by the pudendal N

Somatic R’s

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8
Q

How does E affect the urethral fxn?

A

decreased E = less vascular and decreased fxn?

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9
Q

Which ANS parts control urine storage?

which control bladder emptying?

A

SNS: for urine storage

PNS: for bladder emptying

[think fight/flight–> don’t want to pee while you r running from a bear]

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10
Q

How does cholinergic stimulation affect the bladder?

A

detrusor muscle [deep muscle] contrx when stimulated due to muscarinic R’s here

  • M1-M5 subtypes are present
  • bladder sm. M contains M2 & M3 R’s
    • M2R: sm. M contrxn
    • M3R: inhibits bladder relaxation

***muscarinics trigger/sustain muscle contrxn

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11
Q

How does Adrenergic R stimulation in the bladder work?

A

B adrenergics: B2 & B3 R’s are in detrusor muscle

  • stimulation of B-R’s–> RELAXATION OF DETRUSOR

a-adrenergic: a-1A subtype in bladder base, prox urethra, & BVs

  • alpha agonists: INCREASE URETHRAL RESISTANCE
  • alpha antagonists: BLOCK URETHRAL CONTRXN
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12
Q

iN ORDER TO URINATE, WHAT HAS TO HAPPEN [WHICH MUSCLES FIRE/RELAX]?

A

bladder distension sensed by PNS:

Detrusor [deep] muscle of bladder needs to CONTRACT

Internal Urethral Sphincter needs to RELAX

***this is a reflex/primitive loop/control

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13
Q

An injury to the CNS can lead to what in bladder control?

A

lose voluntary control–>return to primitive reflex [infants have this]

**damage micturation center is MC to result in this

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14
Q

what does the fxn of the bladder, urethra, & pelvic floor depend on?

A

function of N’s & local factors

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15
Q

injury to the spinal cord can have what affect on the bladder?

A

get neurogenic bladder

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16
Q

Which 2 main classes of drugs cause bladder relaxation?

A

Ca+ channel blockers & B-blockers

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17
Q

Some antidepressants have what effect on the bladder?

A

some have **anticholinergic effects–> **relaxation

18
Q

3 main types of incontinence?

describe each?

A

Stress: leak small amts of urine when intra-abd P is ^^ [ex: walk, run, or lift]

Urge/Detrusor overactivity/overactive bladder: leak large amts shortly after sudden urge to urinate [mediated by bladder muscle contrxn]

Mixed: stress & urge happe together

think SUM

19
Q

What is the mehcanism of stress incontinence?

A

muscles that normally keep urethra closed are prevented from contraacting as tightly as they should

  • pelvic floor weakness
  • loss of elasticity
  • H or CT effects impact urethral sphincter
20
Q

What is the MOA of urge incontinence?

A

inappropriate bladder contrxns

  • PVC of bladder
  • abn nerve signals
21
Q

Describe these other 3 types of incontinence?

Overflow

Fxnl

Transient

A
  • —Overflow: caused by either a blockage of the outlet (prostate enlargement) or weak bladder muscle function, results in frequent or constant dribbling
  • —Functional: Untimely urination due to inability to get to a bathroom either from mobility issues, obstacles, communication/cognitive problem
  • —Transient: Temporary condition causing incontinence such as medication, infection, illness
    • —DIAPPERS acronym
22
Q

What does DIAPPERS stand for?

A

Causes of transient incontinence

Delirium

Infxn

Atrophic Vaginitis

Pharmaceuticals

Psychological DO

Excessive UO

Reduced mobility [fxnl incontinence] or Reversible [drug induced] U retention

Stool Impaction

23
Q

what is the basis for Kegels and pessaries?

A

Kegels = exercises to strengthen pelvic floor

Pessaries = structural support

  • BASIS FOR BOTH: a well supported pelvic floor renders the urethra fairly immobile–> good closure [when mobile it cant]
24
Q

What helps us Dx urinary problems?

A

HIstory!!!

  • keep a urinary diary
  • pertinent medical Hx [OB hx, Dm, stroke, disc herniation etc]

PE & bimanual exam [for masses]

  • —Atrophy/Estrogen deficiency
  • —Neurologic function
    • —Bulbocavernosus reflex: pudendal nerve
    • —Anal wink: S2, S3, S4
  • —Evaluation of pelvic support (levator ani) via squeeze test or cough test
25
Q

What are some tests we can run to help with the Dx of incontinence?

A

UA:

  • can be obtained while measuring **post void residual **volume
  • assess for infxn or urinary tract pathology

cytometry [on referral]

  • objective assessment of bladder fxn
  • can determine whether stress or urge
  • can assess urethra if multichanneled [simple cyto doesnt assess this]
26
Q

What are non-medication Tx’s for stress incontinence?

A
  • weight loss [if obeses], fluid redxn, caffeine redxn, smoking cessation [to decrease chronic cough], control constipation
  • pelvic floor muscle exercises [biofeedback]
  • occlusive devices
    • pessaries
    • urethral inserts
27
Q

What are medical interventions to Tx stress incontinence?

A

Medications:

  • E [intravaginal]
  • Duloxetine
  • a-adrenergics [rare]

Surgery: suburethral sling

28
Q

What are some Txs for Urge/overactive bladder?

A
  • bladder retraining/schedule voids
  • fluid restrxn
  • elim. meds or offending agents [caffiene]
  • pelvic floor muscle exercises
  • Meds
  • tibial nerve stimulation [shares nerve pathways
  • implantable neuromodulators
29
Q

What are Kegels?

A

pelvic floor strengthening

  • NOT to be done while urinating/stop UQ
  • sometimes use weights called kegel cones
  • electrical stimulation
  • biofeedback
30
Q

are any meds approved for SUI?

A

nope

but topical estrogen is MC: thickens periurethral tissues;; systemic worsens UI,

A-agonists are rarely used–>not proven effective

31
Q

What medications are used for urge incontinence most often?

what are some contraindications?

A

Anticholinergic Agents: comp antagonist @ MuscR –> relax detrusor muscle

  • nonselective: fesoterodine, oxybutynin [M3 & M2], tolterodine [M3 selective], trospium
  • Selective: darifenacin, solifenacin
    • have fewer SE’s [dry mouth via M3R is not an issue]
  • Contraindications:
    • narrow angle glaucoma, dementia, GI obstrxn, U retention
32
Q

What are the 2nd line of medications used for UI?

What is a drug that can be used and has similar effects [hint think plastic Surg]

A

Beta agonists:** **mirabegron, M3R agonist

  • relaxes detrusor
  • SE:
    • ^^bP, N/V, D/C, HA, dizzy
    • risk for urinary retention

*similar drug: *botulinum toxin!!! into detrusor

33
Q

What is a CBT for UI/OAB?

A

Bladder training!!

  • scheduled voiding
    • ignore urge as long as possible
    • gradually increase time
  • 4-12 wks shows improvement!
34
Q

What is pelvic organ prolapse?

A

—Movement of pelvic organs (uterus, bladder) from normal position downward toward or through the vaginal opening

Can include: vagina, uterus, cystocele & rectocele & enterocele

35
Q

What are Sx’s of POP?

A
  • many pts Asx’c
  • bulge Sx’s:b
    • ​sensations of bulge/protrusion, heaviness or P
  • urinary Sx’s
    • ​incontinence, freq, urgency, weak stream, incomplete emptying, need to change position to void
  • bowel Sx’s: incontinence or difficulty evacuating
  • Sex Sx’s: dyspareunia, decreased sensation
  • Pain Sx’s: pain in vagina, bladder, rectum, pelvic pain, low back pain
36
Q

what are risk factors for POP?

A
  • increased age, menopause, obesity
  • increased intraabd P
    • chronic cough [smoker or lung dz]
    • chronic constipation
    • repeated heavy lifting
  • obstetrics!!!
    • preg, delivery w/ prolonged labor, instruments, episiotomy
    • increased parity [lots of kids]
    • hysterectomy or prolapse surg in past
  • genetic factors or dz’s affecting CT
37
Q

What are the grades of POP [baden-walker classification]

A

0: in normal position
1: descent halfway to hymen
2: decent to hymen
3: descent halfway past hymen
4: maximum possible descent for each site

38
Q

What do you do on PE for POP?

A

—Assess for signs of atrophy
—Neurologic tests (sacral reflexes)
—Observe with valsalva without speculum
-—Note presence of bulge
—Examine with speculum using fixed blade
—Note position of protruding part in relation to the hymen

39
Q

What is the Tx for POP?

A

—Observation/lifestyle management [lose weight, stop smoking, Tx cough etc]
—Pelvic Floor Muscle Exercises- kegels, improve U Sx’s but no proof if reverses POP
—Pessary use- mechanical support, have risk of B, pain, vag erosion
—Surgery

40
Q
A

Endo/Repro Block2 (11 decks)

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