Pelvic Floor Disorders Flashcards
What are the 3 general categories of pelvic floor disorders?
Urinary Incontinence
Pelvic Organ Prolapse
Anal Incontinence
In what age group is the incidence of UI/POP the highest?
70-79yo
What are some urethral causes of urinary incontinence?
Urethral sphincter incompetence
Detrusor instability
Retention with overflow
Functional
What are some extraurethral causes of urinary incontinence?
Congenital
Fistula
What is the incidence of USI?
1/3 in women over 55yo
What are the RFs for UI?
Sex (F>M) Age (Older>younger) Obesity Smoking (chronic cause, increased risk of overactive bladder) Renal disease DM
What is overactive bladder syndrome?
Urgency, with or without urge urinary incontinence, usually with frequency and nocturia in the absence of pathologic or metabolic conditions that might explain these symptoms
What is the difference between OAB wet and dry?
Wet has (urge) incontinence, in dry it is absent
What is mixed UI?
Involuntary leakage associated with urgency and also with exertion, sneezing, or coughing (SUI)
What evaluation should be carried out in UI Ix?
Stress test
Post void residual
Urinalysis
Bladder diary
When can pelvic floor exercises be used?
SUI
MUI
Not in UUI
(Min 3 months)
What pharmacological therapy can be used for OAB syndrome?
Antimuscarinic agents
What effects do antimuscarinics have on urination?
Reduce intra-vesical pressure
Increase compliance
Raise volume threshold for micturition
Reduce uninhibited contractions
What are some S/E of antimuscarinics?
Dry mouth
Constipation
Blurred vision
Somnolence
What should be used in OAB if antimuscarinics have been deemed ineffective or are contraindicated?
Mirabegron- β3 Agonists
What is the MOA of β3 Agonists?
Relax bladder smooth muscle through activation of the β3 adrenoceptor
Selective agonist for the human β3 adrenoceptor with low intrinsic activity for β1 and β2
Increase voiding interval and inhibit spontaneous bladder contractions during filling suggesting a potential clinical application for these agents
What specific drug choices should be offered first to women with OAB or MUI?
Oxybutynin (immediate release) or
Tolterodine (immediate release) or
Propiverine (immediate release)
What are 2nd line antimuscarinic treatments for OAB?
Trospium (immediate release) or
Oxybutynin (extended release) or
Darifenacin or
An alternative immediate release drug
What is uroflowmetry?
Measurement of volume of urine (ml) expelled from the bladder each second
When is uroflowmetry indicated?
Hesitancy Voiding difficulty Neuropathy History of urine retention Post-operative follow up
When are multichannel urodynamics indicated?
Uncertain diagnosis
Fail respond to treatment
Prior surgery
What does flow rate enable you to measure?
Peak flow
Mean flow
Voided volume (minimum 200mls void required)
What is cystometry?
A method by which the pressure/volume relationship of the bladder is measured during filling, provocation and during voiding
What is an abnormal Post Void Residual (PVR)?
> 100-150cc
What are the causes of overflow incontinence?
Obstruction of urethra
Poor contractile bladder muscle
What must be found out in OUI?
PVR
What must be stopped in OUI?
Anticholinergics
What is the conservative treatment of SUI?
Lifestyle
Physiotherapy
Drugs: duloxetine (combined noradrenaline and serotonin reuptake inhibitor- increases intraurethral closure pressure)
Others- pads, vaginal pessaries
What is the surgical treatment of SUI?
Low tension vaginal tape
Intraurethral injection
Artificial sphincters
Colposuspension
What is the conservative treatment of OAB?
Lifestyle- avoid caffeine
Physiotherapy
Drugs- antimuscarinics
What is the surgical treatment of OAB (rarely used)?
Augmentation cystoplasty Sacral nerve modulation Tibial nerve stimulation Bladder overdistension Botox injections
What are the 3 compartments of prolapse?
Anterior (cystocele)
Middle or Apical (vaginal vault prolapse/enterocele)
Posterior (rectocele)
What is procidentia?
Complete prolapse of compartment/structure
What is the Pelvic Organ Prolapse Quantification System?
Patient straining- 6 specific sites are evaluated, at rest 3 sites
Measure each site (cm) in relation to hymenal ring, which is fixed. Hymenal ring is zero point of reference
If site is above hymen, assigned -ve number, if prolapse below, measurement +ve
What is the conservative management of uterovaginal prolapse?
Reassure
Avoid heavy lifting, loose weight, stop smoking, reduce constipation
Vaginal oestrogens: only if symptomatic atrophic vaginitis
What is the medical and surgical management of prolapse?
Expectant management
Physio
Pessary
Surgical- abdo, vaginal, lap, robotic assisted lap, mesh kits
Who is suitable for a pessary in POP?
Women unfit for surgery Relief symptoms whilst awaiting surgery Further pregnancies planned or pregnant As diagnostic test for prolapse/ensure correction of large cystourethrocele not cause SUI Patient request
How is uterine/vault prolapse repaired?
Vaginal hysterectomy
Manchester repair (cervix amputated, uterosacral ligaments shortened)
Sacrospinous Fixation
Others: Abdominal/laparoscopic sacrocolpopexy, mesh techniques, colpocleisis
