Incontinence & Prolapse

Question 1

What structures does urinary continence depend on?

Answer 1

• bladder neck support
• external urethral sphincter
• smooth muscle in urethral wall
• compresor urethrae
• levator ani

Question 2

What are the risk factors for urinary incontinence?

Answer 2

Women (pregnancy, childbirth, menopause)
Age (loss of muscle strength)
Obesity (increased pressure)
Smoking (chronic cough)
Other diseases - diabetes, kidney disease

Question 3

Name three types of incontinence

Answer 3

Stress
Urge
Overflow

Question 4

What examinations should be done in an incontinent patient?

Answer 4

Abdomen
Pelvis/perineum
Rectal
Neurological

Question 5

What investigations should be done in a patient with suspected incontinence?

Answer 5

Stress test
Post void residual (normal 10-80, abnormal >100-150)
Urine analysis
Bladder diary

Question 6

What lifestyle measures can help with incontinence?

Answer 6

Bladder retraining
Fluid intake 
Weight loss 
Pelvic Floor exercises 
Bladder drill

Question 7

State the drugs used in urinary incontinence

Answer 7

Antimuscarinic agents
Beta 3 agonists e.g mirabegron
Duloxetine

Question 8

How do antimuscarinic drugs help incontinence?

Answer 8

Prevent involuntary contraction of detrusor muscle

Question 9

What are the side effects of antimuscarinic drugs?

Answer 9

Dry mouth
Constipation
Nausea
Headache

Question 10

How does Mirabegron work?

Answer 10

Relaxes bladder smooth muscle through activation of beta 3 adrenoreceptors to increase voiding interval and inhibit spontaneous contractions

Question 11

What is uroflowmetry?

Answer 11

Measurement of volume of urine expelled from the bladder each second (ml)

Question 12

What are the indications for uroflowmetry?

Answer 12

Hesitancy, voiding difficulty, neuropathy, history of urine retention, post-op follow up

Question 13

What does cystometry measure?

Answer 13

Pressure/volume of the bladder at different stages

• filing
• provocation
• voiding

Question 14

Describe the conservative management of stress incontinence

Answer 14

Lifestyle, physio, drugs - duloxetine, pads, pessaries

Question 15

Describe the surgical management of stress incontinence

Answer 15

Low tension tape, intra-urethral injection, artificial sphincter, colposuspension, autologous fascial sling

Question 16

Which structures can be involved in a prolapse?

Answer 16

Uterus, vagina, bladder, small bowel, rectum

Question 17

Describe the classification of prolapse

Answer 17

1st - cervix drops just not the vagina
2nd - cervix drops into opening
3rd - cervix is outside the vagina
4th/Prodentia - entire uterus is outside

Question 18

Name the different types depending on what is pushing the vagina

Answer 18

Cystocele - bladder
Enterocele - small bowel
Urethrocele - uterus
Rectocele - rectum

Question 19

What are the symptoms of cystocele?

Answer 19

Bulging, pressure, ‘mass’, difficulty voiding, incomplete emptying, splinting vaginal wall, difficulty inserting tampon, pain with intercourse

Question 20

In prolapse what do patients typically complain of?

Answer 20

Dragging sensation/lump

Urinary incontinence

Question 21

What are the symptoms of rectocele?

Answer 21

Difficulty defection, incomplete defection

Question 22

How is the pelvic organ prolapse quantification system used?

Answer 22

Patient straining - 6 specific sites
At rest - 3 sites
Measure each site in relation to the hymenal ring which is fixed - above is negative value, below is a positive value

Question 23

What are the variations of vaginal prolapse?

Answer 23

Herniation of urethra, bladder, rectouterine pouch or rectum - presents as a lump in the vaginal wall

Question 24

What is the conservative treatment for prolapse?

Answer 24

Reassure
Avoid heavy lifting 
Loose weight 
Stop smoking 
Reduce constipation 
Vaginal oestrogen for symptomatic atrophic vaginitis 
Pelvic Floor exercises

Question 25

Which women are suitable for pessary?

Answer 25

Unfit for surgery , symptomatic relief whilst waiting for surgery, pregnant or further pregnancies planned, diagnostic test for prolapse, patient request

Question 26

What surgical treatment is available for prolapse?

Answer 26

Vaginal hysterectomy
Sacrospinous fixation
Sacrocolpoplexy
Mesh techniques

Question 27

What nerves are at risk in a sacrospinous fixation?

Answer 27

Pudendal neuromuscular bundle

Sciatic nerve

Question 28

Describe incontinence surgery

Answer 28

Trans-obturator approach through obturator foramen to create a sling posterior to the urethra
Incisions - vagina and groin