Incontinence + prolapse Flashcards
Incontinence - classification
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
Stress urinary incontinence - general
Incidence 10%, occurs when intravesical pressure > closing pressure on urethra
Stress urinary incontinence - symptoms (2)
- Leakage of urine when sneezing, coughing, running, jumping or carrying heavy loads
- Leakage usually a small, discrete amount, coinciding with the physical activity
Stress urinary incontinence - signs (2)
- 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
Stress urinary incontinence - ix
- MSU sample - taken to exclude infection or glycosuria
- Frequency/volume chart (typically shows normal frequency and functional bladder capacity)
- Urodynamic studies (consider when surgery is indicated to confirm dx, check for coexisting detrusor overactivity)
Stress urinary incontinence - mx (conservative - includes pharmacological)
- Lifestyle intervention (reduce weight if BMI > 30, smoking cessation, tx chronic cough and constipation)
- Pelvic floor muscle training (first line - for at least 3mo)
- Biofeedback (use of device to convert effect of pelvic floor contraction into a visual or auditory signal - objective ax of improvement)
- Vaginal cones
Pharmacological
- Duloxetine
- SNRI (serotonin-norepinephrine reuptake inhibitor)
- Mediocre efficacy, not first line
- Side effects (5) = nausea, dyspepsia, dry mouth, insomnia/drowsiness, dizziness
Stress urinary incontinence - indications for conservative mx (includes
- Mild or easily manageable symptoms
- Family incomplete
- Symptoms manifest during pregnancy
- Surgery contraindicated by coexisting medical conditions
- Surgery declined by patient
Stress urinary incontinence - mx (surgical)
- ** Tension-free vaginal tape (TVT)
- Most commonly performed surgical procedure
- Complications = moderately - Transobturator tape
- Periurethral injections
- Burch colposuspension
- Laparoscopic colposuspension
Overactive bladder syndrome - general
Def = urgency +/- urge incontinence (usually with frequency or nocturia)
- Implies probable detrusor overactivity
- Idiopathic in most cases
OAB - symptoms
- Urinary frequency
- Urgency
- Urge incontinence
- Nocturia
- 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
OAB - ix (3+5)
- Urine culture
- Frequency/volume chart
- ** Urodynamics - dx
Need to rule out the following:
- Diabetes
- Hypercalcaemia
- Prolapse
- Faecal impaction
- UTI, interstitial cystitis
OAB - mx (conservative + pharmacological)
Conservative
- Behavioural therapy (consume 1-1.5L of liquids/d, avoid caffeine and alcohol, review diuretic and antipsychotic use)
- Bladder retraining (suppressing urge and extending intervals between voidings)
- Hypnotherapy and accupuncture
Pharmacological
- Anticholinergic (antimuscarinic drugs) - oxybutinin, tolterodine, fesoterodine
- Estrogens (may be tried in women with vaginal atrophy - often helps with symptoms of urgency, urge incontinence, frequency and nocturia)
Anticholinergics - adverse effects
- Dry mouth
- Constipation
- Nausea, dyspepsia
- Blurred vision, dizziness and insomnia
- Palpitation and arrhythmias
Anticholinergics - contraindications
- Acute (narrow angle) glaucoma
- Myasthenia gravis
- Urinary retention or outflow constipation
- Severe ulcerative colitis
- Gastrointestinal obstruction
OAB - mx (surgical + other)
- 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 - 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)
- 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
Prolapse - etiology/risk factors
- Pregnancy and vaginal delivery
- Abnormal collagen metabolism - e.g. Ehlers-Danlos syndrome
- Menopause and increasing age
- Chronic increase in intra-abdominal pressure (e.g. obesity, chronic cough, constipation, heavy lifting, pelvic mass - 5)
- Iatrogenic factors (pelvic surgery - e.g. hysterectomy, Burch colposuspension)
Prolapse - classification (4)
- Cystocele (anterior vaginal wall, often involving bladder; if urethra is involved, use the term cysto-urethrocele)
- Uterine (apical) prolapse (prolapse of uterus, cervix and upper vagina)
- Enterocele (prolapse of upper posterior wall of vagina; resulting pouch usually contains loops of small bowel)
- Rectocele (prolapse of lower posterior wall of vagina, involving anterior wall of rectum)
Prolapse - definition
Protrusion of uterus and/or vagina beyond normal anatomical confines; bladder, urethra, rectum and bowel are also commonly involved
Prolapse - POPQ scoring (5)
- TVL = total vaginal length
- Hymenal ring is the reference point and is given a value of 0
- 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
- Note - POPQ describes the maximal observed descent in each compartment when the woman strains (Valsalva manoeuvre) except for TVL, which is measured at rest
- Each compartment (anterior, apical and posterior) is staged separately
Prolapse - POPQ staging
Stage 0 = no prolapse demonstrated (points Aa, Ap, Ba, Bp =/+1cm but +[TVL-2]cm
Prolapse - symptoms
- Dragging sensation within pelvis, feeling of a ‘lump coming down’
- Backache
- Dyspareunia or difficulty in inserting tampons
- Cystourethrocele - urinary urgency/frequency, or urinary retention
- 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
Prolapse - examination
- Exclude pelvic masses with a bimanual examination
- Vaginal examination best carried out with woman in left lateral position, using a Sims speculum
- Walls should be checked for descent or atrophy
- Sometimes, prolapse may only be demonstrated with the woman standing or straining
- Ax pelvic floor muscle strength (vaginal palpation of pelvic floor muscles)
Prolapse - quality of life assessment (4)
- Social limitations
- Psychological limitations
- Occupational limitations
- Sexual limitations
Prolapse - ix
- USS to exclude pelvic or abdominal masses (if suspected clinically)
- Urodynamics (if urinary incontinence present)
- Assessing fitness for surgery = ECG, CXR, FBE, UEC
Prolapse - mx (conservative)
- Weight reduction
- Treatment of chronic constipation and chronic cough (including smoking cessation)
Physiotherapy
- Pelvic floor muscle exercises (will improve tone in young women, but unlikely to benefit women with significant uterovaginal prolapse)
- Biofeedback and vaginal cones
Other
- 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
Prolapse - mx (surgical) - 4
- Anterior compartment defect (cystourethrocele)
- Anterior colporrhaphy (anterior repair) - Posterior compartment defect (rectocele, deficient perineum)
- Posterior colpoperineorrhaphy - 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) - 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)
