Pelvic Support, UTI, Incontinence Flashcards
What are the known risk factors for pelvic support defects?
- advancing age
- genetic predisposition
- parity
- menopause
- prior pelvic surgery
- connective tissue disorders
- elevated intra-abdominal pressure as in obesity or chronic constipation
The pelvic organs are primarily supported by what muscles, fasciae, and ligaments?
- levator muscles
- urogenital diaphragm and endopelvic fascia
- uterosacral and cardinal ligaments
What is a cystocele?
bladder prolapse
What is an enterocele?
a herniation of the small bowel through a true hernia at the top of the vagina
Define procidentia.
uterine prolapse in which the cervix descends beyond the vulva
How is pelvic organ prolapse staged?
- stage 0: no prolapse
- stage 1: the leading part of the prolapse is >1 cm above the hymen
- stage 2: the leading edge is 1 cm or less above the hymen
- stage 3: the leading edge is more than 1 cm beyond the hymen, but less than the length of the vagina
- stage 4: complete eversion
Why do many with cystocele or urethrocele complain or urinary incontinence? Why do others present with hydronephrosis or hydroureter?
- early on, many complain of incontinence because when the bladder loses support, the mobility of the urethra increases as it pulls away from its attachment to the pubic symphysis
- later, with stage 3 or 4 prolapse, the urethra may lose so much support that it actually kinks, producing an obstruction
Describe the Q-tip test.
- a q-tip is placed into the bladder and pulled back until resistance is met, then the patient is asked to bear down
- if there is urethral hypermobility, the end of the swab rotates upward, beyond 30 degrees
- this is suggestive of the urethral-vesicular junction being deflected downward by the intra-abdominal pressure
How are pessaries used in the treatment of pelvic organ prolapse?
- they are a non-surgical option made of rubber, plastic, or silicon, useful in all stages of prolapse as first-line therapy
- they are either supportive or space-occupying
What is a colpopexy?
attachment of the vaginal cuff to the sacral promontory in an effort to surgically treat pelvic organ prolapse
What is a colpocleisis?
a surgical treatment for pelvic organ prolapse in which the lumen of the vagina is completely obliterated, suitable for those at high risk with other procedures who do not desire vaginal intercourse
What are common presenting signs of pelvic organ prolapse?
- urinary or fecal loss or retention
- vaginal pressure or heaviness
- abdominal low back, vaginal, or perineal pain or discomfort
- mass sensation
- difficulty with sexual relations, walking, lifting, or standing
Describe the normal reflex in place for voiding.
stretch receptors within the detrusor muscle signal to the brain the need to void and the brain then decides if it is a socially acceptable situation in which to do so, providing descending input
Urge Incontinence
- a form of incontinence due to a loss of bladder inhibition and resulting detrusor overactivity
- it is more common in those with comorbidities such as bladder abnormalities, altered bladder microbiome, or neurologic disorders
- presents with a urgency, frequency, and possibly nocturne
- these patients will lose a large amount of fluid
Stress Incontinuence
- a form of incontinence due to a structural defect which allows increased intra-abdominal pressure to be transmitted to the bladder but not urethra, typically secondary to a loss of integrity of the endopelvic fasciae
- presents with loss of small amounts of urine during activities that increase intra-abdominal pressure
Describe the cause of urge, stress, and overflow incontinence.
- urge: loss of bladder inhabitation secondary to bladder abnormalities, altered microbiome, or neurologic disorders
- stress: loss of endoplavic fasciae integrity, leading to a transfer of intra-abdominal pressure to the bladder but not urethra
- overflow: obstruction or loss of neurologic control
What is urodynamic testing?
- a measure of pressure and volume as the bladder fills and the flow rate as it empties
- said to be multichannel if a transducer is placed in the vagina or rectum to also measure intra-abdominal pressure
What lifestyle modifications have been shown to improve urinary incontinence?
- weight loss
- caffeine reduction
- fluid management
- reduction of physical exertion
- cessation of smoking
What are some non-surgical options for the treatment of urinary incontinence?
- lifestyle modifications
- kegel exercises to strength the pelvic floor
- behavioral training to improve bladder control and capacity
- anticholinergic agents
Cystitis
- a infection fo the bladder
- most often due to E. coli; Staph saprophyticus is characteristically seen in young, sexually active women; K. pneumoniae is a common agent; Proteus mirabilis is likely if the urine is alkaline with an ammonia scent
- presents with dysuria, urinary frequency, urgency, and suprapubic pain, but systemic symptoms are absent
- urine is cloudy with WBC, dipstick is positive for leukocyte esterase and nitrites, culture grows greater than 100K colonies
- sterile pyuria (cystitis with a negative urine culture) suggests urethritis due to Chlamydia trachoma’s or Neisseria gonorrhoeae
What three-day regimens are used in the treatment of cystitis?
- TMP-SMX
- ciprofloxacin, levofloxacin, gatifloxacin
- nitrofurantoin
