Pelvic Floor Dysfunction and Treatment Flashcards
What does P.O.P stand for?
Pelvic organ prolapse
Give examples of urethral and extraurethral causes of incontinence
Urethral
- stress (external urethral sphincter dysfunction)
- overactive (detrusor instbility)
Extraurethral
- congenital malformation
- fistula
HOw many women over the age of 55 experience stress incontinence, and how many require surgical treatment for this?
1 in 3 women = stress incontinence
1 in 10 women require treatment
What are the risk factors for incontinence?
- women (pregnancy, childbirth, menopause, short urethra)
- age
- overweight (increased BMI => increased pressure causing incontinence)
- smoking (chronic cough)
HOw many times per day is normal to void a bladder?
Between 4 and 8
> 8 = increased frequency
if >60 then 1 episode of nocturia = normal
HOw much fluid is normally held in a bladder before needing to go?
400-500mls
Patients with an overactive bladder may NOT leak. TRUE/FALSE
TRUE
- can be wet or dry
- can have increased frequency and urgency but not leak
How can the urethra be straightened to fix prolapse?
Pessary
Surgery (prevent prolapse causing kink in urethra)
WHat risk is associated with re-straightening the urethra after fixing a prolapse?
May cause patients to not have prolapse, but have stress incontinence risk instead
=> warn patients of this as they may deem minor prolapse more manageable than incontinence
What questions must you ask about a patient’s sexual contact in order to assess the severity of their incontinence or prolapse?
- Do you avoid sexual contact due to incontinence/prolapse?
- Do you leak during sexual contact?
- Is the leak urinary or faecal?
- If faecal, is this solid/liquid/gas?
At what volume does an overactive bladder feel full?
150-200ml
HOw can you specifically ask about quantity of urine lost during incontinence?
- number of pads patient uses per day
- type of pads used
Why should examination of a patient with incontinence start in the abdomen?
- Look for a mass which could be increasing the pressure in the abdomen or on the bladder
What does atrophic vaginitis indicate may be the cause of incontinence?
- AV = thinning, drying and inflammation of the vaginal walls
- caused by lack of oestrogen after menopause
- thinning of the bladder and urethral linings can also occur and cause urinary symptoms
What should be looked for on a digital rectal examination if a patient suffers from incontinence?
- rectal tone
- masses?
How can a speculum be used to assess for prolapse during an examination?
- speculum pulled against the anterior wall of vagina to see if posterior wall bulges (and vice versa)
=> Minimal prolapse - Patient also asked to cough as speculum is withdrawn to see if cervix follows
What is recorded in a bladder diary?
- Time of Day
- Frequency
- Volume
- Fluid Intake Vol.
Why is restricting fluids a bad idea for patients with overactive bladders or incontinence?
- Urine becomes more concentrated
=> more irritant to bladder
=> want to void at small volumes
What other substances are irritant to the bladder?
- caffeine (this takes around 6 hrs to exit system)
- alcohol
- certain fruit juices
If a patient does not fill out their bladder diary, what does this make you worry about?
They wont be committed to treatment
Describe the treatment pathway used for incontinence
- Lifestyle modification
- Bladder Drill Training
- Pelvic Floor Physio Exercises
- Drugs (Anticholinergics, Mirabegron)
- Botox
- Neuromodulation
- Reconstructive Surgery
How do anticholinergics work to prevent incontinence, but what side effect does this cause?
- Stops muscles of bladder contracting
- BUT also affects other muscle groups e.g. eyes and mouth (causing dryness)
- Also increased risk of dementia if on for long term
What are the 1st, 2nd and 3rd line drugs used for incontinence?
1st - Tolterodine 2mg BD (can use MR if side effects)
2nd - Mirabegron
3rd - Solifenacin
Describe how Mirabegron works and what must be checked before and after starting this drug in patients?
- Beta Agonist
=> relaxes bladder - Check BP before and after starting to check it is not increasing
How long should drugs for incontinence be trialled for before swapping?
6-8 weeks
Combinations of drugs can be used to treat incontinence. TRUE/FALSE?
TRUE
If incontinence has improved after 6 months, can drugs be stopped?
Yes patient can be taken off the drugs and restarted if symptoms recur
What type of neuromodulation is used to treat overactive bladder and symptoms of urge incontinence?
- Percutaneous Posterior tibial nerve stimulation (PTNS),
- least invasive form of neuromodulation
- Almost like “acupuncture” at back of ankle
If drugs make no difference in incontinence treatment, botox can be used. Where is this injected and what does it do?
- Botox injected into detrusor muscle
=> Temporary paralysis
=> prevents contraction
What must patients be taught how to do first before having botox to paralyse the detrusor muscle?
- Intermittent Self catheterisation
- In case bladder cannot contract at all to let urine out
What are urodynamics used for?
- investigate why the bladder is leaking
- i.e. make link to stress or not stress incontinence
What findings on urodynamics would indicate obstruction?
- High pressure (probe usually in rectum/vagina)
- Low flow rate
What drugs should you check for in a patients drug hx if they present with overflow incontinence?
- anticholinergics
What non-pharmacological methods can be used to treat stress incontinence?
- continence pessary (designed to sit under bladder neck)
- Physiotherapy
- surgery
Why is surgical mesh no longer inserted transvaginally as a treatment for prolapse or incontinence?
- risk of erosion
Even after having a hysterectomy, women can still present with vault prolapse. TRUE/FALSE?
TRUE
What is a Procedentia?
- uterus, bladder, bowel etc are all contained in prolapse
- AND prolapse is outwith the body
How are prolapses roughly scored using the POP-Q?
- anything within vagina = negative score
- anything outwith vagina = positive score
HOw can prolapse be treated?
- avoid heavy lfiting
- lose weight (BMI limit for surgery = 30)
- Stop smoking
- Decrease constipation and straining
- vaginal oestrogens if atrophic vaginitis present
When would a ring pessary potentially NOT work in prolapse, and what could be used instead?
- Posterior wall (or 3rd degree) prolapse
- Change to CUBE if sexually active (patient needs to be able to remove this themself)
- Could also use shelf pessary which is now made of silicone rather than hard plastic
What surgery can be used in prolapse to close the vagina?
Colpocleisis
Why is sacrospinous fixation difficult if patients have had a hysterectomy?
- No cervix present
- Usually top of vagina or the cervix would be attached to the ligament with a stitch and this becomes more difficult
What other surgical fixation procedures can be used to treat prolapse?
Uteropexy = Fixation of a displaced uterus
Cervicopexy
Colpopexy
