Pelvic Floor Dysfunction

Question 1

Outline some Contributing factors and Risk Factors for female urinary incontinence.

Answer 1

Modifiable:

• Smoking
• Obesity
• Drugs /diuretics
• Constipation
• Chronic illness

Non-modifiable:

• Pregnancy
• Age
• Sex

Contributing factors:

• Caffeine
• Alcohol
• Smoking
• Pelvic organ prolapse
• Infection
• Meds
• Poor mobility

Question 2

What is the Diappers acronym for Incontinence?

Answer 2

DIAPPERS

• Delirium
• Infection
• Atrophic urethritis/vaginitis
• Pharmaceuticals
• Psychological (depression)/Psychosocial
• Excessive excretion
• Reduced mobility
• Stool impaction

Question 3

What investigations can you do for female urinary incontinence?

Answer 3

• MSU +/- cytology
• post-void residual urine - U/S or in-out catheter or bladder scan
• bladder diary/QOL questionaire
  
  • volume and function of capacity
  • timing of voiding and fluid intake
• urodynamics (indications:
  
  • uroflometry
  • cystometry
  • urethral pressure profilometry
• cystoscopy (recurrent UTI, haematuria, painful bladder syndrome/interstitial cystisis)

Question 4

Conservative Management of Urinary incontinence?

Answer 4

Conservative:

• weight loss
• diary/water intake before bed/caffiene/alcohol
• pelvic floor physiotherapy
  
  • techniques
  • muscle training
  • bladder training (urge suppression techniques, patient education, scheduled voiding) - 50-86% cure rate.
• pessaries - ring with silicon in vagina.
  
  • no infection, bleeding, this might be first line
  • can fall out - shape/size

Question 5

What is the management of urinary incontinence in terms of pharm and procedures?

Answer 5

Drug Therapy:

• vaginal estrogens
• anticholinergics
  
  • oxybutynin - immediate release (anti-SLUD)
    
    • close-angle glaucoma is one contraindication (become blind) - blurred vision SE related to anterior chamber
  • tolterodine - slow release so better tolerance of side effects. Both tolterodine and solifenacin is private scripts.
  • solifenacin
• mirabegron
  
  • new drug - can’t give in HTN, promotes bladder storage.
  • mostly renal - beta3-adrenergic

Cystoscopy and Cystodistension

Cystoscopic injection of botox

• refractory OAB, paralyses muscle and relax bladder wall and detrusor muscle. 100 units.
• risk of urinary retention
• reinject

Question 6

Complications of mid-urethral slings?

Answer 6

• bleeding or haematoma
• bladder perforation
• urethral injury
• de novo worsening of OAB
• voiding dysfunction
• mesh exposure
• groin pain (only with TOT) - resolves at 12 weeks
  
  • dyspareunia - 1 form of pain after.
  • mobility and voiding pain too

Question 7

What is pelvic organ prolapse? What are different categorisations?

Answer 7

• protrusion of pelvic organ into vaginal canal due to damage of pelvic supportive structures.
  
  • a vaginal bulge - herniation of pelvic organs
• Categorizations:
  
  • cystocele - anterior vaginal wall descent
  • urethrocele
  • enterocele = atypical descent
  • procidentia = major prolapse (drags bladder and rectum)
  • urethral prolapse
  • rectal prolapse

Question 8

What is the presentation of someome with pelvic organ prolapse?

Answer 8

• asymptomatic
• bulge - dragging pain, lump, bulge
• bladder symptoms
  
  • stress incontinence
  • incomplete voiding
  • recurrent UTI
• sexual dysfunction
• rectal symptoms
• if very large fecal urgency and urinary urgency (cystocele, rectocele).

Question 9

What is the endopelvic fascia? Why is it important?

Answer 9

• paracolpium = utero-sacral and cardinal ligaments
• most important supportive connective tissue/smooth muscle in the pelvic area.
• levator ani reinforces EPF.

Question 10

What are the levels of pelvic support? How do they relate to different types of prolapse?

Answer 10

1. level 1
   
   • cardinal-uterosacral ligament complex
     
     • uterine prolapse
     • supports vagina and cervix.
     • drag bladder and rectum
2. level 2
   
   • endopelvic fascia - supported by levator ani
     
     • vagina + rectum
     • ant = cystocele/ post = rectocele - pebbling of fecal matter
3. Level 3
   
   • fusion of the lower vagina to perineal membrane -
     
     • low-rectocele - push up perineum post-defecation

Question 11

What is the cause of Pelvic organ prolapse?

Answer 11

• parity
• traumatic birth
  
  • baby >10pounds
  • prolonged stage 2
  • >4 children
  • instrumental delivery
• age
• menopause
• previous symptoms
• large pelvic organ tumours

Can be exacerbated by:

• increased intra-abdominal pressure (cough, constipation, heavy lifting)
• decreased connective tissue quality (menopause, diabetes, smoking, steroids)

Question 12

What is the treatment of POP?

Answer 12

Non-surgical/Conservative:

• lifestyle changes - weight loss
• avoid exacerbating activities (e.g. weight lifting)
• pelvic floor exercises
• oestrogen replacement
• pessary:
  
  • SE
    
    • UTI
    • vaginal infection
    • bleeding
    • vaginal erosion

Surgical:

• cystocele = anterior colporrhaphy
• rectocele = posterior colporrhaphy
• enterocele = enterocele repair (McCall)
• Uterine prolapse = vaginal hysterectomy
• vault prolapse = sacrospinous fixation
• recurrent = mesh - 10% have erosion causing pain

Question 13

What is the classification systems for POP? Describe the Grades

Answer 13

Baden Walker Halfway System: 0-4 grading

1. some bulge leading point not reaching hymen
2. prolapse reaches hymen
3. prolapse beyond hymen
4. leading point is external

Quantification POPQ scale - complicated :P

• measured in cm in reference to the hymen ring.