Pelvic floor disorders Flashcards
What is urinary incontinence?
Affects up to 10% women
4 main types:
1) Stress: due to poor bladder closure
2) Urge: overactive bladder
3) Overflow: poor bladder contraction
4) Functional: difficulty reaching the toilet
50% do not seek help due to embarrassment
Risk factors for urinary incontinence
Obesity - 3x risk
Parity
Mode of delivery - vaginal > CS
Family hx
Medical hx - recurrent UTI, eneurisis in childhood
High impact activities
Caffeine intake
DM
Vaginal atrophy
Stroke
Discuss stress incontience
Occurs when bladder pressure exceeds urethral pressure in absence of detrusor activity
Most common cause - occurs in 50% cases
Causes:
- Pregnancy and childbirth esp. if labour prolonged and operative vaginal delivery
- Obesity and chronic cough can exacerbate
Clinical features:
- Urinary leakage when coughing, laughing etc
Diagnosis:
- Clinical, confirmed via urodynamic testing
Investigations:
- Bladder diary over >3days to identify patterns and contributing factors
- Dipstick for infection & DM
- Urodynamics to test bladder and urethral function
Management
- Conservative: cut caffeine, lose weight, avoid alcohol, pelvic floor exercises for 12 weeks
- Surgery: if no imporvement after conservative options - colposuspension to support bladder neck
**Tape surgery no longer available on NHS unless no other options**
Injections: periurethral bulking agents for women unsuitable for surgery - benefits short lived
Discuss urge incontinence and overactive bladder
Sudden urge to go + involuntary micturition
Affects up to 35% women at some point in life
Clinical features: esp. seen in those who drink caffeine
Diagnosis: urinary frequency, nocturia
Investigations: small volume voids day and night on bladder diary
Management: lifestyle changes, bladder training
Medication: long and short acting muscarinics to relax bladder and increase capacity e.g. oxybutynin (although poor compliance due to side effects)
Vaginal oestrogens
Injection of botox into bladder wall
Surgery: clam augmentation ileocystoplasty where a loop of bowel is used to increase bladder capacity but is associated with malignancy
Discuss overflow incontinence
More common in men
Combined continuous urinary leakage and incomplete bladder emptying caused by impaired detrusor contractility or bladder outlet obstruction
Management: alpha blockers/ self catheterisation
What is genital prolapse?
One or more pelvic organs descending through the pelvic floor to vagina
50% parous women have a degree of prolapse
10-20% seek help
Classification of prolapse
Cystocele: bladder wall prolapse
Rectocele: bowel
Enterocele: hernia and prolapse of rectouterine pouch
Vault: descent of vault after hysterectomy
Procidentia: uterus and vagina walls
Causes of genital prolapse
Multifactorial
Childbirth: damage to levator ani muscle, pudendal nerve or both leading to weakened muscular and neurological support of pelvic floor
Ageing
Family hx
Post menopausal oestrogen deficiency leads to atrophy of pelvic support
Increased abdo pressure: obesity
Clinical features of genital prolapse
Sensation of dragging down
Worse as day goes on
Tissues can become ulcerated
May be associated with urinary incontinence or difficulty urinating
Symptoms of genital prolapse by area
- Bulge/ pressure: lump, dragging sensation, back ache, discharge, bleeding
- Urinary: incomplete emptying, need to digitate to void, frequency, urgency, UTI, incontinence
- Bowel: incomplete empyting, constipation, incontinence
- Sexual: obstruction, reduced sensation, reduced libido, pain
Investigation for genital prolapse
V/E during cough to elicit prolapse
Bimanual exam to exclude masses
Management of genital prolapse
Reduce symtpoms and increase support of pelvic floor
Conservative: weight loss, pelvic floor exercises
Pessaries: mechanical support
Surgery: hysterectomy and vault support is 1st line
Sacrohysteropexy: uterus secured to sacrum using mesh
Vaginal vault suspended to sacrospinous ligament or sacrum
