Incontinence & Pelvic Prolapse

Question 1

Is incontinence an inevitable part of aging?

Answer 1

NO

Question 2

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?

Answer 2

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]

Question 3

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

What axn do they potentiate?

Answer 3

B-adrenergic R

used for urine storage

Question 4

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

What axn do they potentiate?

Answer 4

a-1 R’s

used in urine storage

Question 5

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

What axn are they responsible for?

Answer 5

muscarinic R’s

used for bladder emptying

Question 6

What is the internal urethral sphincter composed of?

What kind of control is it under?

What R’s are found here?

Answer 6

Sm. M

involuntary control

a-1 R’s

Question 7

What components make up the external urethral sphincter?

what type of control is it under?

what R’s are here?

Answer 7

Sk.M

voluntary control; supplied by the pudendal N

Somatic R’s

Question 8

How does E affect the urethral fxn?

Answer 8

decreased E = less vascular and decreased fxn?

Question 9

Which ANS parts control urine storage?

which control bladder emptying?

Answer 9

SNS: for urine storage

PNS: for bladder emptying

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

Question 10

How does cholinergic stimulation affect the bladder?

Answer 10

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

Question 11

How does Adrenergic R stimulation in the bladder work?

Answer 11

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

Question 12

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

Answer 12

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

Question 13

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

Answer 13

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

**damage micturation center is MC to result in this

Question 14

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

Answer 14

function of N’s & local factors

Question 15

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

Answer 15

get neurogenic bladder

Question 16

Which 2 main classes of drugs cause bladder relaxation?

Answer 16

Ca+ channel blockers & B-blockers

Question 17

Some antidepressants have what effect on the bladder?

Answer 17

some have **anticholinergic effects–> **relaxation

Question 18

3 main types of incontinence?

describe each?

Answer 18

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

Question 19

What is the mehcanism of stress incontinence?

Answer 19

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

Question 20

What is the MOA of urge incontinence?

Answer 20

inappropriate bladder contrxns

• PVC of bladder
• abn nerve signals

Question 21

Describe these other 3 types of incontinence?

Overflow

Fxnl

Transient

Answer 21

• —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

Question 22

What does DIAPPERS stand for?

Answer 22

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

Question 23

what is the basis for Kegels and pessaries?

Answer 23

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]

Question 24

What helps us Dx urinary problems?

Answer 24

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

Question 25

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

Answer 25

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]

Question 26

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

Answer 26

* **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

Question 27

What are medical interventions to Tx stress incontinence?

Answer 27

Medications: * **E [intravaginal]** * Duloxetine * a-adrenergics [rare] **Surgery**: suburethral sling

Question 28

What are some Txs for Urge/overactive bladder?

Answer 28

* 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

Question 29

What are Kegels?

Answer 29

pelvic floor strengthening * NOT to be done while urinating/stop UQ * sometimes use weights called kegel cones * electrical stimulation * biofeedback

Question 30

are any meds approved for SUI?

Answer 30

nope ## Footnote but **topical estrogen** is MC: thickens periurethral tissues;; systemic worsens UI, A-agonists are rarely used--\>not proven effective

Question 31

What medications are used for urge incontinence most often? what are some contraindications?

Answer 31

**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

Question 32

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]

Answer 32

**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

Question 33

What is a CBT for UI/OAB?

Answer 33

Bladder training!! * scheduled voiding * ignore urge as long as possible * gradually increase time * 4-12 wks shows improvement!

Question 34

What is pelvic organ prolapse?

Answer 34

—Movement of pelvic organs (uterus, bladder) from normal position downward toward or through the vaginal opening Can include: vagina, uterus, cystocele & rectocele & enterocele

Question 35

What are Sx's of POP?

Answer 35

* 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

Question 36

what are risk factors for POP?

Answer 36

* 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

Question 37

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

Answer 37

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

Question 38

What do you do on PE for POP?

Answer 38

—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

Question 39

What is the Tx for POP?

Answer 39

—**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**