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REPRODUCTION & GYNAECOLOGY > Pelvic Floor Dysfunction and Treatment > Flashcards

Pelvic Floor Dysfunction and Treatment Flashcards

1
Q

What does P.O.P stand for?

A

Pelvic organ prolapse

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2
Q

Give examples of urethral and extraurethral causes of incontinence

A

Urethral

  • stress (external urethral sphincter dysfunction)
  • overactive (detrusor instbility)

Extraurethral

  • congenital malformation
  • fistula
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3
Q

HOw many women over the age of 55 experience stress incontinence, and how many require surgical treatment for this?

A

1 in 3 women = stress incontinence

1 in 10 women require treatment

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4
Q

What are the risk factors for incontinence?

A
  • women (pregnancy, childbirth, menopause, short urethra)
  • age
  • overweight (increased BMI => increased pressure causing incontinence)
  • smoking (chronic cough)
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5
Q

HOw many times per day is normal to void a bladder?

A

Between 4 and 8
> 8 = increased frequency
if >60 then 1 episode of nocturia = normal

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6
Q

HOw much fluid is normally held in a bladder before needing to go?

A

400-500mls

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7
Q

Patients with an overactive bladder may NOT leak. TRUE/FALSE

A

TRUE

  • can be wet or dry
  • can have increased frequency and urgency but not leak
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8
Q

How can the urethra be straightened to fix prolapse?

A

Pessary

Surgery (prevent prolapse causing kink in urethra)

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9
Q

WHat risk is associated with re-straightening the urethra after fixing a prolapse?

A

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

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10
Q

What questions must you ask about a patient’s sexual contact in order to assess the severity of their incontinence or prolapse?

A
  • 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?
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11
Q

At what volume does an overactive bladder feel full?

A

150-200ml

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12
Q

HOw can you specifically ask about quantity of urine lost during incontinence?

A
  • number of pads patient uses per day

- type of pads used

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13
Q

Why should examination of a patient with incontinence start in the abdomen?

A
  • Look for a mass which could be increasing the pressure in the abdomen or on the bladder
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14
Q

What does atrophic vaginitis indicate may be the cause of incontinence?

A
  • 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
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15
Q

What should be looked for on a digital rectal examination if a patient suffers from incontinence?

A
  • rectal tone

- masses?

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16
Q

How can a speculum be used to assess for prolapse during an examination?

A
  • 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
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17
Q

What is recorded in a bladder diary?

A
  • Time of Day
  • Frequency
  • Volume
  • Fluid Intake Vol.
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18
Q

Why is restricting fluids a bad idea for patients with overactive bladders or incontinence?

A
  • Urine becomes more concentrated
    => more irritant to bladder
    => want to void at small volumes
19
Q

What other substances are irritant to the bladder?

A
  • caffeine (this takes around 6 hrs to exit system)
  • alcohol
  • certain fruit juices
20
Q

If a patient does not fill out their bladder diary, what does this make you worry about?

A

They wont be committed to treatment

21
Q

Describe the treatment pathway used for incontinence

A
  • Lifestyle modification
  • Bladder Drill Training
  • Pelvic Floor Physio Exercises
  • Drugs (Anticholinergics, Mirabegron)
  • Botox
  • Neuromodulation
  • Reconstructive Surgery
22
Q

How do anticholinergics work to prevent incontinence, but what side effect does this cause?

A
  • 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
23
Q

What are the 1st, 2nd and 3rd line drugs used for incontinence?

A

1st - Tolterodine 2mg BD (can use MR if side effects)
2nd - Mirabegron
3rd - Solifenacin

24
Q

Describe how Mirabegron works and what must be checked before and after starting this drug in patients?

A
  • Beta Agonist
    => relaxes bladder
  • Check BP before and after starting to check it is not increasing
25
Q

How long should drugs for incontinence be trialled for before swapping?

A

6-8 weeks

26
Q

Combinations of drugs can be used to treat incontinence. TRUE/FALSE?

A

TRUE

27
Q

If incontinence has improved after 6 months, can drugs be stopped?

A

Yes patient can be taken off the drugs and restarted if symptoms recur

28
Q

What type of neuromodulation is used to treat overactive bladder and symptoms of urge incontinence?

A
  • Percutaneous Posterior tibial nerve stimulation (PTNS),
  • least invasive form of neuromodulation
  • Almost like “acupuncture” at back of ankle
29
Q

If drugs make no difference in incontinence treatment, botox can be used. Where is this injected and what does it do?

A
  • Botox injected into detrusor muscle
    => Temporary paralysis
    => prevents contraction
30
Q

What must patients be taught how to do first before having botox to paralyse the detrusor muscle?

A
  • Intermittent Self catheterisation

- In case bladder cannot contract at all to let urine out

31
Q

What are urodynamics used for?

A
  • investigate why the bladder is leaking

- i.e. make link to stress or not stress incontinence

32
Q

What findings on urodynamics would indicate obstruction?

A
  • High pressure (probe usually in rectum/vagina)

- Low flow rate

33
Q

What drugs should you check for in a patients drug hx if they present with overflow incontinence?

A
  • anticholinergics
34
Q

What non-pharmacological methods can be used to treat stress incontinence?

A
  • continence pessary (designed to sit under bladder neck)
  • Physiotherapy
  • surgery
35
Q

Why is surgical mesh no longer inserted transvaginally as a treatment for prolapse or incontinence?

A
  • risk of erosion
36
Q

Even after having a hysterectomy, women can still present with vault prolapse. TRUE/FALSE?

A

TRUE

37
Q

What is a Procedentia?

A
  • uterus, bladder, bowel etc are all contained in prolapse

- AND prolapse is outwith the body

38
Q

How are prolapses roughly scored using the POP-Q?

A
  • anything within vagina = negative score

- anything outwith vagina = positive score

39
Q

HOw can prolapse be treated?

A
  • avoid heavy lfiting
  • lose weight (BMI limit for surgery = 30)
  • Stop smoking
  • Decrease constipation and straining
  • vaginal oestrogens if atrophic vaginitis present
40
Q

When would a ring pessary potentially NOT work in prolapse, and what could be used instead?

A
  • 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
41
Q

What surgery can be used in prolapse to close the vagina?

A

Colpocleisis

42
Q

Why is sacrospinous fixation difficult if patients have had a hysterectomy?

A
  • No cervix present

- Usually top of vagina or the cervix would be attached to the ligament with a stitch and this becomes more difficult

43
Q

What other surgical fixation procedures can be used to treat prolapse?

A

Uteropexy = Fixation of a displaced uterus
Cervicopexy
Colpopexy

REPRODUCTION & GYNAECOLOGY (58 decks)

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