Incontinence & Prolapse Flashcards
What structures does urinary continence depend on?
- bladder neck support
- external urethral sphincter
- smooth muscle in urethral wall
- compresor urethrae
- levator ani
What are the risk factors for urinary incontinence?
Women (pregnancy, childbirth, menopause) Age (loss of muscle strength) Obesity (increased pressure) Smoking (chronic cough) Other diseases - diabetes, kidney disease
Name three types of incontinence
Stress
Urge
Overflow
What examinations should be done in an incontinent patient?
Abdomen
Pelvis/perineum
Rectal
Neurological
What investigations should be done in a patient with suspected incontinence?
Stress test
Post void residual (normal 10-80, abnormal >100-150)
Urine analysis
Bladder diary
What lifestyle measures can help with incontinence?
Bladder retraining Fluid intake Weight loss Pelvic Floor exercises Bladder drill
State the drugs used in urinary incontinence
Antimuscarinic agents
Beta 3 agonists e.g mirabegron
Duloxetine
How do antimuscarinic drugs help incontinence?
Prevent involuntary contraction of detrusor muscle
What are the side effects of antimuscarinic drugs?
Dry mouth
Constipation
Nausea
Headache
How does Mirabegron work?
Relaxes bladder smooth muscle through activation of beta 3 adrenoreceptors to increase voiding interval and inhibit spontaneous contractions
What is uroflowmetry?
Measurement of volume of urine expelled from the bladder each second (ml)
What are the indications for uroflowmetry?
Hesitancy, voiding difficulty, neuropathy, history of urine retention, post-op follow up
What does cystometry measure?
Pressure/volume of the bladder at different stages
- filing
- provocation
- voiding
Describe the conservative management of stress incontinence
Lifestyle, physio, drugs - duloxetine, pads, pessaries
Describe the surgical management of stress incontinence
Low tension tape, intra-urethral injection, artificial sphincter, colposuspension, autologous fascial sling
Which structures can be involved in a prolapse?
Uterus, vagina, bladder, small bowel, rectum
Describe the classification of prolapse
1st - cervix drops just not the vagina
2nd - cervix drops into opening
3rd - cervix is outside the vagina
4th/Prodentia - entire uterus is outside
Name the different types depending on what is pushing the vagina
Cystocele - bladder
Enterocele - small bowel
Urethrocele - uterus
Rectocele - rectum
What are the symptoms of cystocele?
Bulging, pressure, ‘mass’, difficulty voiding, incomplete emptying, splinting vaginal wall, difficulty inserting tampon, pain with intercourse
In prolapse what do patients typically complain of?
Dragging sensation/lump
Urinary incontinence
What are the symptoms of rectocele?
Difficulty defection, incomplete defection
How is the pelvic organ prolapse quantification system used?
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
What are the variations of vaginal prolapse?
Herniation of urethra, bladder, rectouterine pouch or rectum - presents as a lump in the vaginal wall
What is the conservative treatment for prolapse?
Reassure Avoid heavy lifting Loose weight Stop smoking Reduce constipation Vaginal oestrogen for symptomatic atrophic vaginitis Pelvic Floor exercises
Which women are suitable for pessary?
Unfit for surgery , symptomatic relief whilst waiting for surgery, pregnant or further pregnancies planned, diagnostic test for prolapse, patient request
What surgical treatment is available for prolapse?
Vaginal hysterectomy
Sacrospinous fixation
Sacrocolpoplexy
Mesh techniques
What nerves are at risk in a sacrospinous fixation?
Pudendal neuromuscular bundle
Sciatic nerve
Describe incontinence surgery
Trans-obturator approach through obturator foramen to create a sling posterior to the urethra
Incisions - vagina and groin
