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Women's Health > L19/20: Continence, Bladder and Bowel > Flashcards

L19/20: Continence, Bladder and Bowel Flashcards

1
Q

How does bladder function work to empty the bladder? (6 steps)

A
  1. Urine goes down from kidney via ureter
  2. Bladder fills up
  3. Detrusor muscle senses filling
  4. Sends message to contract
  5. Pelvic floor relax
  6. Empty bladder
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2
Q

Why is bladder problem diagnosis hard?

A
  • Cannot be seen
  • Might not correlate structure to pain
  • Psychosocial effects
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3
Q

What does the pelvic floor anatomy look like in females?

EXAM QUESTION

A
  1. Urethra
  2. Vagina
  3. Anus
  4. Pelvic floor muscles
  5. Other superficial muscle
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4
Q

What does the sympathetic nervous system do to the bladder in terms of micturition?

A

activate to Store

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5
Q

What does the parasympathetic nervous system do to the bladder in terms of micturition?

A

activate to Pour (emptying)

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6
Q

What are you in charge of in terms of micturition?

A
  • Always working to tell you when to go
  • you are in control of pelvic floor and external anal sphincter
  • You are not in control of intrinsic bladder neck sphincter or internal anal sphincter
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7
Q

What are 8 roles of the pelvic floor?

A
  1. Support pelvic organs ( bladder, uterus, bowel )
  2. Withstand increases in IAP (Eg. cough, sneeze, jump, laugh, run) –> contract to control movement of bladder, uterus and bowel
    • If do not have this functions = issues)
  3. Continence ! (Keeping urine in bladder and stool in rectum)
  4. Contribute to urethral and anal closing pressure (Important for resisting leaking)
  5. Detrusor inhibition (Reciprocal inhibition of detrusor and pelvic floor
    • If contract pelvic floor = will relax detrusor (due to micturition is a process where detrusor contracts and pelvic floor relaxes)
    • Don’t want to be contract both at same time = trying to empty bladder but can’t go = this is possible diagnosis where pelvic floor doesn’t relax )
  6. Support with defaecation ( valsalva) (Some relaxation and some contraction)
  7. Sensory function during intercourse Pedundal nerve through pelvis (sensory, motor and nociception)
  8. Co-contraction with diaphragm, TrA, and, multifidus (Postural control mechanism –> MSK)
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8
Q

What are 3 pelvic floor assessment? EXAM

A
  1. Superficial palpation
    • TrA
    • Observe accessory muscle movement / diaphragm
    • Perinealobservation ?
  2. Real time ultrasound
    • Trans abdominal ( lift seen and can be measured in mm)
  3. Vaginal examination (VE)
    • Only performed by trained women’s health physiotherapist
    • Post graduate WH physio’s/ Level 1 , 2, 3 pelvic floor course (APA)
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9
Q

What does the perineal body look like?

A
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10
Q

What are 6 characteristics of real time ultrasound?

A
  1. Lift measured in mm
  2. Not gold standard assessment
  3. Skill of physiotherapist?
  4. Access to RTUS
  5. Biofeedback for patients
  6. Co –contraction with TrA
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11
Q

What are 5 advantages of real time ultrasound?

A
  1. Biofeedback
  2. More accurate then superficial palpation
  3. Lift of pelvic floor
  4. Depression of pelvic floor
  5. Can save results
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12
Q

What are 4 disadvantages of real time ultrasound?

A
  1. Poor USS skills
  2. Poor quality of equipment ( images)
  3. Full bladder?
  4. Cost –effective in MSK clinic?
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13
Q

What are the 4 roles of perineal body?

A
  1. Sexual function
  2. Vaginal closure and support
  3. External anal sphincter (Voluntary)
  4. Common area of perineal trauma in childbirth If it have become weak and not healed
    • It feels different, not the same
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14
Q

What are 2 sub categories of incontinence?

A
  1. Functional ( eg. SUI, OAB –weak pelvic floor) (Had a baby which was delivered vaginally –> now leaking when cough and sneeze)
  2. Neurogenic: examples:
    • MS
    • SCI
    • Parkinson’s
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15
Q

What is Stress Urinary Incontinence?

EXAM QUESTION

A

complaint of involuntary leakage on effort or exertion, or on sneezing or coughing.

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16
Q

How do you diagnose Stress Urinary Incontinence?

A
  1. Subjective Ax (Standardised questionnaires can be very helpful)
  2. 1 hour pad weight test (standardised)
  3. bladder neck descent (BND)
  4. urodynamic testing (UD).
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17
Q

What is the 1 hr pad weight est?

A
  • Weight pad before
  • Wear for an hour (do exercise)
  • Weight pad after
    • >12g = abnormal (urine in the pad)
    • Can be a good outcome but not always okay for patient
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18
Q

What is a UD (Urodynamic testing)?

A

(not always needs to be diagnosed –> mainly before surgery)

  • Insert catheter with saline into the bladder
  • Get them to cough, sneeze
  • What do they look for?
    • Under ultrasound where they can see urine leaking
    • Over-activity of detrusor with filling
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19
Q

Stress continence and bladder neck are always more effected in ___ births than ____ births.

A

vaginal; C sections

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20
Q

_____ elevates and supports urethra and bladder neck (sphincter)

A

PFM

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21
Q

During Increased ______ urethra is compressed by PFM and bladder neck = no UI.

A

IAP,

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22
Q

PFM resists _______ (upward/downward) motion of bladder neck with increased IAP

A

downward

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23
Q

There is usually _______ pelvic floor post delivery (ie. Thinned / distended)

A

Weakened

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24
Q

What is the PFMT Treatment for SUI?

EXAM QUESTION

A
  1. 12 weeks minimum pelvic floor program (PFMT)
    • To get muscular hypertrophy
  2. “Knack” before activity (ie. Lifting)
    • Manual overriding to stop leaking
    • Activation of pelvic floor before coughing, squeezing
  3. Evidence for PFMT and SUI –increase hypertrophy, strength, and endurance, or PFM –there fore PFM resisting downward movement of bladder neck with increases in IAP.
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25
Q

______ form a cylinder while muscles of the PF and diaphragm form its base and lid.

A

TA

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26
Q

When should TA be integrated into SUI therapy?

A

Functional PFMT (Pelvic floor therapy)

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27
Q

Deep trunk muscles form a functional unit to balance changes in _____ and stabilise the ______. How successful is it?

A

intra-abdominal pressure; spine 50% in leaking (very successful)

28
Q

What is knack?

A

Leaking

29
Q

What are the 3 other treatments of SUJ?

A
  1. TVT / TVT –O surgery
    • Tension free transvaginal tape
  2. Bulking agent injections –bladder neck
  3. Ovestin cream / vagifem ( oestrogen supplement)
30
Q

How does TVT (transvaginal tape) work?trear

A
  • Pieces of mesh that slings under the urethra –> stops it from getting bladder neck descent when creating IAP
  • It stops their leaking but does not fix pelvic floor
  • Need to get physio as high risk of prolapse
  • Mesh: for prolapse and incontinence surgery
  • Long term –> high rates in chronic pain
  • Onsly used sparingly for right patient SUI pessary = Decrease BMI
31
Q

How do bulking agent injections- bladder neck for treatment of SUI work?

A

Injection to stabilise bladder neck

32
Q

How does Ovestin cream / vagifem ( oestrogen supplement) as treatment of SIJ work?

A
  1. Normalises urogenital epithelium
  2. Decreases vaginal atrophy from reduced oestrogen
  3. Improves urethral closure by increasing sphincter muscle thickness
33
Q

When is Ovestin cream / vagifem ( oestrogen supplement) used?

A
  • Post-partum or post-menopause
  • Used to help with tissue health
34
Q

Why is SUI pessary a treatment for SUI?

A
  • Urethral stability
  • Not very long prognostic outcomes –> short outcomes is good
35
Q

How is decreasing BMI a treatment for SUI?

A

Decrease pressure on pelvic organs / pelvic floor

36
Q

What are 8 characteristics of Overactive bladder (OAB) / urge urinary incontinence (UUI)? EXAM QUESTION

A
  1. Provoked (Only running water, coffee..etc) or unprovoked detrusor overactivity
  2. Urinary urgency / incontinence
  3. Increased frequency of voiding per day (normal 4-6) with 1.5L of fluid. Commonly > 8.
  4. Low voided volumes (<100mls)
  5. Incomplete bladder emptying / post void residuals (PVR)
  6. Key in the door
  7. Running water
  8. Drinking a glass of water
37
Q

What is Overactive bladder (OAB) / urge urinary incontinence (UUI)?

A

Comes from the bladder and then becomes centralised

38
Q

What are 19 characteristics of Overactive bladder (OAB) / urge urinary incontinence (UUI)?

EXAM QUESTION

A
  1. Provoked (Only running water, coffee..etc) or unprovoked detrusor overactivity
  2. Urinary urgency / incontinence
  3. Increased frequency of voiding per day (normal 4-6) with 1.5L of fluid. Commonly > 8.
  4. Low voided volumes (<100mls)
  5. Incomplete bladder emptying (I walk away and then I need to go again) / post void residuals (PVR)
  6. Key in the door (Brain telling body there is a toilet behind the door –> needs to go)
  7. Running water
  8. Drinking a glass of water
  9. Poor bladder habits –(eg. “just in case”)  PVR –post void residual
  10. Caffeine / alcohol –bladder wall stimulant
  11. Stress / anxiety –bladder wall stimulant
  12. Medical conditions ( eg. Endometriosis) Pain in pelvis
  13. Dehydration –concentrated urine / <1 litre fluid /day (Needs to be very severely)
  14. Weak PFM ? (Pelvic floor muscles –> autonomic NS allows bladder to become overactive (not inhibiting))
  15. Pelvic organ prolapse –visceral sensitisation? (Bladder falling into pelvic wall)
  16. Post menopausal woman –tissue atrophy
  17. Certain medications ( ace inhibitors)
  18. UTI -urinary tract infection
  19. Differential diagnosis –> symptoms can be similar (almost the same)
    • Can make them worst if do bladder retraining as they have residual in their bladder (infection stays in bladder)
39
Q

What is Overactive bladder (OAB) / urge urinary incontinence (UUI)?

A

Comes from the bladder and then becomes centralised

40
Q

What are 4 characteristics of UTI (urinary tract infection)?

A
  1. Dysuria (painful urination) –most common symptom.
  2. Urinary frequency
  3. Urinary urgency
  4. Hematuria ( blood in urine) Go to hospital
41
Q

What are ICS guidelines for a UTI?

A
  • Dipstick or urine microscopy and culture
  • Referral to a medical doctor is recommended.
  • Treatment: Anti-biotics, fluid intake, rest, underlying cause?
42
Q

What is the treatment of UTI?

A

Anti-biotics, fluid intake, rest, underlying cause?

43
Q

What does an overactive bladder look like?

A
44
Q

What is the management for an OAB (overactive bladder)? EXAM QUESTION

A
45
Q

What are the 8 treatments for OAB?

A
  1. 2-day bladder diary (see example)
  2. Bladder retraining (defer urge to void and find a distraction) based on bladder diary- - Desensitise the bladder
  3. Reduce stimulants in diet
  4. Fluid manipulation (overhydrated / dehydrated)
  5. PFMT
  6. Hold onto PFM when urgent
  7. Don’t panic when you have urgency (Stress stimulates adrenaline which runs through system and sits on bladder wall –> eg. take a few deep breaths )
  8. Anticholinergics (Vesicare, Betmiga, Ditropan, Oxytrol patches) dry mouth with Ditropan.
46
Q

What are 3 functions of Anticholinergics for OAB? EXAM QUESTION

A
  1. Blocks muscarinic receptors at detrusor muscle, therefore, reducing bladder contractility
  2. Inhibits cholinergic neurotransmission at muscarinic receptor sites ( detrusor)
  3. Decreases bladder wall / detrusor contractility therefore decreasing urinary urgency associated with OAB
47
Q

What does an example of a bladder diary for OAB look like?

A

Emptying into a container over 24 hrs 200mL - should not be getting a urge rating of 9/10

48
Q

Refractory neurogenic detrusor overactivity refers to the clinical condition that is no longer manageable by ________

A

anticholinergic therapy

49
Q

What is the treatment option for refractory neurogenic detrusor overactivity(DO) ? What happens if this option fails?

A

detrusor injections of botulinum toxin (Botox).

Good for bladder that doesn’t respond to medication therapy and physiotherapy bladder augmentation or sacral anterior root stimulation offers excellent outcomes, although at much higher costs and risks to the patients.

50
Q

What does a pelvic organ prolapse look like?

A
51
Q

What is a prolapse?

A
  • Hernia of bladder, uterus or bowel pushing into vaginal wall (pushing into cervix)
  • Lacking connective tissue and pelvic floor support
52
Q

What are the 5 grades of pelvic organ prolapse?

EXAM QUESTION

A
  1. Grade 1 –asymptomatic
  2. Grade 11a –symptomatic (before introitus)
  3. Grade 11b –beyond introitus
  4. Grade 3 –large grade POP (surgical)
  5. Grade 4 –large grade POP (surgical)
53
Q

What are the 5 types of pelvic organ prolapse? EXAM QUESTION

A
  1. Cystocele -Bladder
  2. Uterine –uterus / cervix
  3. Rectocele –rectum
  4. Entrocele –small bowel
  5. Urethrocele -urethra
54
Q

What are 7 symptoms of a pelvic organ prolapse?

A
  1. a heavy sensation or dragging in the vagina
  2. something ‘coming down’ or a lump in the vagina
  3. sexual problems of pain or less sensation
  4. your bladder might not empty as it should, or your urine stream might be weak
  5. urinary tract infections (UTI’s)
  6. Difficulty emptying bowels ( rectocele)
  7. lower abdominal or back ache
55
Q

What are 7 potential causes of a pelvic organ prolapse?

EXAM QUESTION

A
  1. Vaginally parous women –vaginal deliveries
  2. LAM injury ++
  3. High BMI
  4. Chronic cough
  5. Chronic constipation
  6. Hysterectomy?
  7. Genetics –connective tissue
56
Q

What does the boat in the dry dock metaphor symbolise?

A

Pelvic organ prolapse

  • Water: pelvic floor
  • Rope: connective tissue
  • If the rope or the pelvic floor is weak the boat will sink (some descend) = symptomatic
57
Q

What are some pelvic floor safe exercises for prolapse post-natally? EXAM QUESTION

A
58
Q

What are the 6 treatments for POP?

A
  1. PFMT Cochrane Review.
  2. Ergonomics (limit heavy lifting / increases in IAP)
  3. Reduce constipation and straining
  4. Reduce BMI
  5. Pessary
  6. Prolapse surgery
    • Anterior repair
    • Posterior repair
    • Hysterectomy +/-sacrospinous colpoplexy
59
Q

What are the 3 types of prolapse surgery? Are they successful?

A
  1. Anterior repair
  2. Posterior repair
  3. Hysterectomy +/-sacrospinous colpoplexy (SSC)
    • Hold the old cervix up up once the hysterectomy has been done
60
Q

What happens in fecal urgency and incontinence?

A
  1. Urgency of stool resulting in a rush to the toilet and urge faecal incontinence
  2. Passive leakage of feces or flatus Incontinence due to faecal impaction and overflow of fecal material is a differential diagnosis (plain x-ray) for fecal loading endoanal USS for EAS and IAS disruption.
61
Q

What are 3 reasons why Fecal urgency and incontinence occur?

A
  1. Injury to the anal sphincter during childbirth is the major cause of fecal incontinence / urgency in women. –3rdand 4thdegree perineal tears / trauma
  2. Weak pelvic floor muscles ( poor sphincter control, poor rectal sensation, and poor anorectal angle of puborectalis)
  3. Poor stool form ( bristol stool Chart type 6-7) loose stool
62
Q

What are 4 Bowel continence mechanisms?

A
  1. External anal sphincter (EAS)
  2. Internal anal sphincter (IAS)
  3. Stool form ( Bristol stool scale)
  4. Anorectal angle (puborectalis)
63
Q

What is the Bristol Stool Scale?

A
64
Q

What is the most ideal type in the Bristol Stool Scale?

A

Type 3-4 is ideal

65
Q

Why is it important to look at the anal sphincter in Fecal urgency and incontinence? EXAM QUESTION

A

If there is a tear –> no matter how much muscle force –> won’t have stability

66
Q

What are 9 treatments for fecal urgency and incontinence?

A
  1. Identify ‘normal’ bowel habits.
  2. Establish a regular bowel routine and make time to respond to the sensation of needing to empty the bowel.
  3. Eat a balanced diet with regular meals.
  4. Adjust the intake of fibre to achieve a consistency of stool that can be controlled. (eg. Metamucil) Stool softener
  5. Referral to dietician
  6. Caffeine, found in coffee, tea, coke, and some chocolate is a gut stimulant and may exacerbate urgency. PFMT to increase strength, endurance, and co-ordination.
  7. Fast Twitch PFMT –reaction time
  8. Appropriate pads for FI –decrease skin irritation.
    • If wearing urinary pads = not ideal (need to be specific pads) = comfort
  9. Referral to colorectal surgeon if no response to conservative management (6-12 months)(sphincter revision / colonoscopy / investigations)
67
Q

What are 5 psychosocial issues with UI?

A
  1. Importance of individuals perspective of UI
  2. Related to Family, workplace, and community.
  3. Treatment should shouldalways include the psychosocial aspect of their health care.
  4. Your clinical findings might not = patients bother.!
  5. Lower urinary tract questionnaires to assess quality of life:
    • Eg. Pelvic floor Impact Questionnaire

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