Incontinence + prolapse

Question 1

Incontinence - classification

Answer 1

Urinary incontinence = complaint of any involuntary leakage of urine
1. Stress urinary incontinence = involuntary leakage of urine on effort or exertion, or on sneezing or coughing. Commonly arises from urethral sphincter weakness
2. Urge urinary incontinence (same as overactive bladder syndrome) = involuntary leakage of urine accompanied by, or immediately preceded by, a strong desire to void
3. Mixed urinary incontinence = involuntary leakage associated with both urgency and effort/exertion. Usually, one of these is predominant
4. Overflow incontinence = when bladder becomes large and flaccid and has little or no detrusor tone or function; usually due to injury or insult, e.g. after surgery or post-partum. Dx when urinary residual volume >50% of bladder capacity; bladder simply leaks when full
5. Continuous urinary incontinence = continuous leakage, classically associated with fistula or congenital abnormality (e.g. ectopic ureter)
Other = UTIs, medications, immobility, cognitive impairment

Question 2

Stress urinary incontinence - general

Answer 2

Incidence 10%, occurs when intravesical pressure > closing pressure on urethra

Question 3

Stress urinary incontinence - symptoms (2)

Answer 3

• Leakage of urine when sneezing, coughing, running, jumping or carrying heavy loads
• Leakage usually a small, discrete amount, coinciding with the physical activity

Question 4

Stress urinary incontinence - signs (2)

Answer 4

• Prolapse of the urethra and anterior vaginal wall may be present
• May be possible to demonstrate stress incontinence by asking the woman to cough with a fairly full bladder

Question 5

Stress urinary incontinence - ix

Answer 5

1. MSU sample - taken to exclude infection or glycosuria
2. Frequency/volume chart (typically shows normal frequency and functional bladder capacity)
3. Urodynamic studies (consider when surgery is indicated to confirm dx, check for coexisting detrusor overactivity)

Question 6

Stress urinary incontinence - mx (conservative - includes pharmacological)

Answer 6

1. Lifestyle intervention (reduce weight if BMI > 30, smoking cessation, tx chronic cough and constipation)
2. Pelvic floor muscle training (first line - for at least 3mo)
3. Biofeedback (use of device to convert effect of pelvic floor contraction into a visual or auditory signal - objective ax of improvement)
4. Vaginal cones

Pharmacological

5. Duloxetine
   - SNRI (serotonin-norepinephrine reuptake inhibitor)
   - Mediocre efficacy, not first line
   - Side effects (5) = nausea, dyspepsia, dry mouth, insomnia/drowsiness, dizziness

Question 7

Stress urinary incontinence - indications for conservative mx (includes

Answer 7

1. Mild or easily manageable symptoms
2. Family incomplete
3. Symptoms manifest during pregnancy
4. Surgery contraindicated by coexisting medical conditions
5. Surgery declined by patient

Question 8

Stress urinary incontinence - mx (surgical)

Answer 8

1. ** Tension-free vaginal tape (TVT)
   - Most commonly performed surgical procedure
   - Complications = moderately
2. Transobturator tape
3. Periurethral injections
4. Burch colposuspension
5. Laparoscopic colposuspension

Question 9

Overactive bladder syndrome - general

Answer 9

Def = urgency +/- urge incontinence (usually with frequency or nocturia)

• Implies probable detrusor overactivity
• Idiopathic in most cases

Question 10

OAB - symptoms

Answer 10

1. Urinary frequency
2. Urgency
3. Urge incontinence
4. Nocturia
5. Triggers for bladder contractions = cold weather, opening the front door, hearing running water, or increased intra-abdominal pressure (may lead to complaint of stress incontinence, which may be misleading)

Note: ask about QoL bc may be significantly impaired by the unpredictability and large volume of leakage

Question 11

OAB - ix (3+5)

Answer 11

1. Urine culture
2. Frequency/volume chart
3. ** Urodynamics - dx

Need to rule out the following:

1. Diabetes
2. Hypercalcaemia
3. Prolapse
4. Faecal impaction
5. UTI, interstitial cystitis

Question 12

OAB - mx (conservative + pharmacological)

Answer 12

Conservative

1. Behavioural therapy (consume 1-1.5L of liquids/d, avoid caffeine and alcohol, review diuretic and antipsychotic use)
2. Bladder retraining (suppressing urge and extending intervals between voidings)
3. Hypnotherapy and accupuncture

Pharmacological

4. Anticholinergic (antimuscarinic drugs) - oxybutinin, tolterodine, fesoterodine
5. Estrogens (may be tried in women with vaginal atrophy - often helps with symptoms of urgency, urge incontinence, frequency and nocturia)

Question 13

Anticholinergics - adverse effects

Answer 13

1. Dry mouth
2. Constipation
3. Nausea, dyspepsia
4. Blurred vision, dizziness and insomnia
5. Palpitation and arrhythmias

Question 14

Anticholinergics - contraindications

Answer 14

1. Acute (narrow angle) glaucoma
2. Myasthenia gravis
3. Urinary retention or outflow constipation
4. Severe ulcerative colitis
5. Gastrointestinal obstruction

Question 15

OAB - mx (surgical + other)

Answer 15

1. Botulinium toxin A (5)
   - Blocks neuromuscular transmission, causing temporary paralysis
   - Efficacy of 90%
   - Injected cystoscopically into detrusor, usually under LA
   - Can cause urinary retention in 5-10% of cases, in which case intermittent self-catheterisation may be needed
   - Repeat injections are required every 6-12mo; long-term effects unknown
2. Neuromodulation and sacral nerve stimulation (continuous stimulation of S3 nerve root via implanted electrical pulse generator; thought to improve the ability to suppress detrusor contractions)
3. Surgical management
   - Reserved for those with debilitating symptoms and who have failed to benefit from medical, behavioural and/or neuromodulation therapy
   - Procedures = detrusor myomectomy, augmentation cystoplasty
   - Limited efficacy, hihg complication rates
   - Permanent urinary diversion occasionally indicated in intractable incontinence

Question 16

Prolapse - etiology/risk factors

Answer 16

1. Pregnancy and vaginal delivery
2. Abnormal collagen metabolism - e.g. Ehlers-Danlos syndrome
3. Menopause and increasing age
4. Chronic increase in intra-abdominal pressure (e.g. obesity, chronic cough, constipation, heavy lifting, pelvic mass - 5)
5. Iatrogenic factors (pelvic surgery - e.g. hysterectomy, Burch colposuspension)

Question 17

Prolapse - classification (4)

Answer 17

1. Cystocele (anterior vaginal wall, often involving bladder; if urethra is involved, use the term cysto-urethrocele)
2. Uterine (apical) prolapse (prolapse of uterus, cervix and upper vagina)
3. Enterocele (prolapse of upper posterior wall of vagina; resulting pouch usually contains loops of small bowel)
4. Rectocele (prolapse of lower posterior wall of vagina, involving anterior wall of rectum)

Question 18

Prolapse - definition

Answer 18

Protrusion of uterus and/or vagina beyond normal anatomical confines; bladder, urethra, rectum and bowel are also commonly involved

Question 19

Prolapse - POPQ scoring (5)

Answer 19

1. TVL = total vaginal length
2. Hymenal ring is the reference point and is given a value of 0
3. If the prolapse extends beyond the hymenal ring, the POPQ score is positive; the POPQ score is negative if the prolapse is above the hymenal ring
4. Note - POPQ describes the maximal observed descent in each compartment when the woman strains (Valsalva manoeuvre) except for TVL, which is measured at rest
5. Each compartment (anterior, apical and posterior) is staged separately

Question 20

Prolapse - POPQ staging

Answer 20

Stage 0 = no prolapse demonstrated (points Aa, Ap, Ba, Bp =/+1cm but +[TVL-2]cm

Question 21

Prolapse - symptoms

Answer 21

1. Dragging sensation within pelvis, feeling of a ‘lump coming down’
2. Backache
3. Dyspareunia or difficulty in inserting tampons
4. Cystourethrocele - urinary urgency/frequency, or urinary retention
5. Rectocele - constipation, difficulty with defecation (may digitally reduce it to defecate)

Note

• Symptoms tend to become worse with prolonged standing and towards the end of the day
• In grade 3 or 4 prolapse, there may be mucosal ulceration and lichenification, resulting in vaginal bleeding and discharge
• Do QoL assessment

Question 22

Prolapse - examination

Answer 22

1. Exclude pelvic masses with a bimanual examination
2. Vaginal examination best carried out with woman in left lateral position, using a Sims speculum
3. Walls should be checked for descent or atrophy
4. Sometimes, prolapse may only be demonstrated with the woman standing or straining
5. Ax pelvic floor muscle strength (vaginal palpation of pelvic floor muscles)

Question 23

Prolapse - quality of life assessment (4)

Answer 23

1. Social limitations
2. Psychological limitations
3. Occupational limitations
4. Sexual limitations

Question 24

Prolapse - ix

Answer 24

1. USS to exclude pelvic or abdominal masses (if suspected clinically)
2. Urodynamics (if urinary incontinence present)
3. Assessing fitness for surgery = ECG, CXR, FBE, UEC

Question 25

Prolapse - mx (conservative)

Answer 25

1. Weight reduction
2. Treatment of chronic constipation and chronic cough (including smoking cessation)

Physiotherapy

3. Pelvic floor muscle exercises (will improve tone in young women, but unlikely to benefit women with significant uterovaginal prolapse)
4. Biofeedback and vaginal cones

Other

5. Pessaries - ring pessary (most commonly used), shelf pessary (if ring pessary will not sit in vagina)
   - For women who decline surgery or for whom surgery is contraindicated
   - Should be changed 6-monthly
   - Topical estrogen may be given to reduce the risk of vaginal erosion

Question 26

Prolapse - mx (surgical) - 4

Answer 26

1. Anterior compartment defect (cystourethrocele)
   - Anterior colporrhaphy (anterior repair)
2. Posterior compartment defect (rectocele, deficient perineum)
   - Posterior colpoperineorrhaphy
3. Uterovaginal (apical) prolapse
   - Hysteropexy (if pt wishes to preseve uterus) - uterus and cervix attached to sacrum
   - Vaginal hysterectomy + anterior/posterior repair (if significant uterine descent or menstrual problems)
4. Vaginal vault prolapse (when upper part of vagina comes down)
   - Sacrospinous ligament fixation (suturing vaginal vault to sacrospinous ligaments; risk of postoperative dyspareunia bc vaginal axis changed)
   - Sacrocolpoplexy (vault attached to sacrum using mesh)