Pelvic floor disorders evaluation & treatment Flashcards
give the 3 general categories of disorder?
urinary incontinence
Pelvic organ prolapse
Anal incontinence
give the two physical reasons for urinary incontinence and examples (1-4) (2-2)
urethral: urethral sphincter incompetence Deptrouser instability retention with overflow functional
Extraurethral
congenital
Fistula
give the 4 types of urinary incontinence
Stress incontinence
Urge incontinence
Mixed incontinence
Overflow incontinence
give the risk factors for urinary incontinence
sex: women more likely than men to have stress incontinence (+preg, childbirth, menopause, shorter urethra)
Age: muscles in bladder and urethra lose strength
obesity: inc pressure on bladder
Smoking: Chronic cough can cause episodes (+risk of overactive bladder)
other disease
kidney/DM
what is urge urinary incontinence?
involuntary urine leakage accompanied/preceded by urgency
Overactive bladder syndrome
- what is it?
- two types?
- urgency with or without urge urinary incontinence (normally frequency + nocturia)
- wet and dry where incontinence is present or absent
Urge incontinence
-what is it?
-typically preceded by an urge to void and can involve a trigger such as running water, opening a door, removing undergarments
mixed urinary incontinence
-what is it?
-involuntary leakage assoc with urgency and also with exertion/coughing
how do you differentiate between OAB/urge incontinence from stress incontinence?
OAB/UUI- bladder muscle experiencing frequent involuntary contractions
SUI-bladder muscle experiences stress related contractions and the support muscles are unable to remain completely shut
how do you asses urinary incontinence?
- Hx
- examination
-Main complaint, impact on lifestyle
description of symptoms and quantification- duration, frequency and severity as well as any prev treatment
quantity of urine loss and use of a pad
-abdo masses, e.g. palpable bladder Pelvis/perineum external genitalia e.g. atrophic vaginitis vaginal prolapse gyn malignancy, fistula Rectal tone, masses, teach Kegals Neurological (reflexes, sensory motor) standing or supine stress tests \+post ovoidal residual urinalysis bladder diary
treatment of OAB? (7)
-lifestyle advice
bladder retraining- min 6/52, aims to increase bladder capacity and decrease frequency
bladder drill
Combination of bladder retraining with antimuscarinic if frequency a problem
sensible fluid intake
caffeine reduction (slow to avoid withdrawal)
weight reduction if BMI > 30
-Pelvic floor physio
PFME good in SUI, MUI but not in UUI
min 3 months
-Drugs
see later
Botox
neuromodulation
reconstructive surgery
Name the specific type of drugs used in OAB?
- SE?
- name an alternative to the main class used, it’s class and mode of action
- What should be offered to women with OAB or mixed UI? second line?
Antimuscarinics
they reduce intravesical pressure and raise volume threshold for micturition, reduce uninhibited contractions
+Beta receptor agonists activate the sympathetic system
-SE: dry mouth, constipation, Blurred vision, somnolence
-Mirabegron
selective Beta 3 adrenoreceptor agonist
relaxes smooth muscle through activation of the Beta3 adrenoreceptor
these increase the voiding interval and inhibit spontaneous bladder contractions during filling
indicated only if antimuscarinics unsuitable
-Oxybutynin, tolterodine, propiverine (IR)
Trospium (IR), oxybutynin (extended release) or darifenacin)
what is uroflowmetry?
-indications for investigation?
the volume of unrine expelled from the bladder each second
-hesitancy Voiding difficulty Neuropathy Hx urine retention Post op follow up
multichannel urodynamics
-indications?
-uncertain Dx
failure to respond to treatment
what is cystometry?
pressure/volume relationship of the bladder is measured during filling, provocation and during voiding
Overflow incontinence
- causes?
- what must clinician do?
-Obstructed urethra
poor contractile bladder muscle
-find post void residual volume and stop anticholinergics
Stress urinary incontinence treatment
- conservative (4)
- surgical (4)
-Conservative
lifestyle
lose weight, smoking cessation, avoid caffeine & excessive fluid intake
physio
pelvic floor muscles retraining, biofeedback, electrical stimulation, pessaries
Drugs
combined noradrenaline and serotonin reuptake inhibitor
Other
incontinence pads, vaginal pessary
-Surgical Low tension vaginal tape intraurethral injection artificial sphincters Colposuspension
Overactive bladder treatment
- conservative (3)
- Surgical (5)
Conservative
lifestyle
avoid caffeinated drinks
Physio
bladder training
Drugs
antimuscarinic drugsblock detrusor muscarinic receptors and reduce contractility
-augmentation cystoplasty sacral nerve modulation tibial nerve stimulation bladder over distension botox
name the 3 compartments of pelvic organ prolapse
Anterior
Middle/apical
Posterior
Name the 4 degrees of prolapse and their positions
1st deg- in vagina
2nd deg- at interiotus
3rd deg- outside vagina
Procidentia- entirely outside vagina
Cystocele (anterior)
- what is it?
- symptoms?
-bladder herniates into the vagina due to pubocervical fascia tear
-bulging pressure mass difficulty voiding incomplete emptying splinting vaginal wall difficulty inserting tampon pain with intercourse
Enterocele (middle/apical)
- what is it?
- symptoms?
-vaginal hernia in which the peritoneal sac containing a portion of the small bowel extends into the rectovaginal space
-bulging pressure mass difficulty voiding incomplete emptying splinting vaginal wall difficulty inserting tampon pain with intercourse
Rectocele (posterior)
- what is it?
- symptoms?
- herniation (bulge) of the front wall of the rectum into the back wall of the vagina. weakened rectovaginal septum
-bulging pressure mass difficulty defecating incomplete defecation splinting vaginal wall/perineum difficulty inserting tampon
complete eversion, give the 2 forms?
Uterine procidentia
Complete uterine prolapse
