POP & Urinary Incontinence Flashcards
What is a prolapse?
Protrusion of an organ or structure beyond its normal anatomical confines.
What is a female POP?
Refers to the descent of the pelvic organs towards or through the vagina
Either within the vagina but beyond it’s anatomical confines or beyond the vagina (exteriosistation)
Why must the abdomino-pelvic cavity walls be of sufficient flexibility?
To withstand changes in volumes of these organs and also pressure changes within the cavity
If the pelvic floor is normal all the pelvic viscera will be what?
Maintained in their position both at rest and in periods of increased intra-abdominal pressure
What are the 3 distinct anatomical layers of the pelvic floor (function as one unit)?
Endo-pelvic Fascia: network of fibro-muscular connective-type tissue that has a “hammock-like” configuration and surrounds the various visceral structures (Uteroscaral ligaments / Pubocervical Fascia / Rectovaginal Fascia).
Pelvic Diaphragm: layer of striated muscles with its fascial coverings (Levator ani & coccygeus).
Urogenital Diaphragm: the superficial & deep transverse perineal muscles with their fascial coverings.
These 3 layers do not parallel each other and vary in strength & thickness from place to place.
What is the endopelvic fascias components?
Fibro-muscular component can stretch (Uteroscarals)
Connective tissue does not stretch or attenuate instead it breaks.
Where does the uterosacral/cardinal complex tend to break?
Medially (around the cervix)
Easily palpated by down traction on the Cervix and if intact allows limited side-side movement of the cervix.
Where does the pubocervical fascia tend to break?
Tend to break at lateral attachments or immediately in front of the cervix
What defects/breaks can be seen in the rectovaginal fascia?
Tends to break Centrally:
If upper defect: Enterocele.
If lower defect: perineal body descent & Rectocele.
What are the common risk factors of POP?
- Pregnancy and vaginal birth
- Higher the parity the higher the risk
- Forceps delivery
- Large baby (>4500gm)
- Prolonged second stage
- Advancing age
- Obesity
Is previous pelvic surgery a risk factor for POP?
Yeah…
Continence procedures, while elevating the bladder neck, may lead to defects in other pelvic compartments:
Burch colposuspension- Potential defect in the posterior vaginal wall - predisposes to rectocele and enterocele formation
What are some other risk factors for POP?
Hormonal factors (age and then drop in oestrogen level)
Quality’ of Connective Tissue
Constipation
Occupation with Heavy Lifting
Exercise (Weight lifting, high-impact aerobics and long-distance running increase the risk of urogenital prolapse)
Prolapses are traditionally classified depending on the site of the defect and the presumed pelvic viscera that are involved. What are these classifications?
Urethrocele: Prolapse of the lower anterior vaginal wall involving the urethra only.
Cystocele: Prolapse of the upper anterior vaginal wall involving the bladder.
Uterovaginal prolapse. This term is used to describe prolapse of the uterus, cervix and upper vagina.
Enterocele: Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel (apical prolapse-Vagina out totally and bowel dropping into it – vault prolapse)
Rectocele: Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina.
(Implies an unrealistic certainty as to the structures on the other side of the vaginal bulge. This is often a false assumption, particularly in women who have had previous prolapse surgery)
What are the typical vaginal symptoms in a woman with pelvic organ prolapse?
Sensation of a bulge or protrusion
Seeing or feeling a bulge or protrusion
Pressure
Heaviness
Difficulty in inserting tampons
What are the typical urinary symptoms in a woman with pelvic organ prolapse?
Urinary Incontinence
Frequency/ Urgency
Weak or prolonged urinary stream/ Hesitancy/ Feeling of incomplete emptying
Manual reduction of prolapse to start or complete voiding
What are the typical bowel symptoms in a woman with pelvic organ prolapse?
Incontinence of flatus, or liquid or solid stool
Feeling of incomplete emptying/ Straining
Urgency
Digital evacuation to complete defecation
* Splinting, or pushing on or around the vagina or perineum, to start or complete defecation
What scoring system for POP is considered currently as the gold standard?
POPQ-endorsed by the ICS
Stage 1-4
How is POP assessed?
Examination to exclude pelvic mass
Record the position of examination: left lateral Vs Lithotomy Vs Standing.
Quality of Life
Objective Assessment:
Baden- Walker- Halfawy Grading
POPQ Score
Others
What investigations are done for associative symptoms if not just a prolapse (clinical diagnosis only for a prolapse)?
USS / MRI: Allow identification of fascial defects/ measurement of Levator ani thickness (research only).
Urodynamics: concurrent UI or to exclude Occult SI.
IVU or Renal USS (if suspicion of ureteric Obstruction).
For a pelvic mass why would an USS be done?
USS for exclusion of post menopausal bleeding causes like endometrial cancer or want to exclude a pelvic mass
What can be done as prevention of POP?
Avoid constipation.
Effective management chronic chest pathology (COAD & asthma).
Smaller family size.
Improvements in antenatal and intra-partum care: Antenatal and post-natal pelvic floor muscle training has not yet been shown to conclusively reduce the incidence of prolapse, although there are logical reasons to think that it may be protective.
Avoid things that will cause sustained increased intra-abdominal pressure
How can physiotherapy be used in the context of prolapse?
Pelvic floor muscle training (PFMT):
Increase the pelvic floor strength & bulk- relieve the tension on the ligaments
Cases of mild prolapse.
Younger women who have not yet completed their family.
No role in advanced cases.
Cannot treat fascial defects.
Education about pelvic floor exercises may be supplemented with the use of a perineometer and biofeedback, vaginal cones and electrical stimulation.
In what stages of prolapse is PFMT helpful?
Strengthen the pelvic floor muscles & the muscular components of the endopelvic fascia – improves patients symptoms specifically for Stage 1 or 2 prolapse (limited role if outside vagina-stage 3 & 4)
What are pessaries made of today
Silicone mostly as it is advantageous due to its hypoallergenic nature and it is non absorbent etc
Is a vaginal pessary treatment as effective as surgery?
At I year follow-up successful pessary treatment is as effective as surgery
What is the aim of surgical treatment in POP?
Relieve symptoms,
Restore/maintain bladder & bowel function and
Maintain vaginal capacity for sexual function.
What is crucial to remember in POP surgical treatment?
Prophylactic Antibiotics.
Thrombo-embolic prophylaxis.
Postoperative Urinary Vs SPC
When is surgical treatment for POP usually indicated?
Usually indicated due to impact on QoL &/or exteriorised prolapse (stages 3/4)
- Patient choice & informed decision
- Depend on age, sexual activity, patient expectations
Where is surgery directed towards?
The prolapsing compartment(s)-usually combinations
How does prolapse occur?
Prolapse occur due to progressive weakness of the pelvic floor muscles followed by breakdown in fascial support.
What percentage of multiparous women are affected?
Affect 50% of multiparous women with 10% symptomatic.
What is the assessment and management of POP?
Assessment is multi-dimensional including Pelvic examination, assessment of pelvic floor, symptom bother & Impact on QoL.
Management would be tailored to patients needs and would include PFMT, Conservative & Surgical Management.
What is the vesico-ureteric mechanism?
Protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder
One way valve to prevent any infection spread-stops low level urinary infection like cystitis from becoming upper urinary tract infection or an acute pyelonephritis
What is the cortical influence on bladder emptying?
Cortical Influence (Pontine micturition centre) — Activation of parasympathetic pathway & Inhibition of Sympathetic pathway
What is stress urinary incontinence (SUI)?
Involuntary leakage on effort or exertion, on sneezing or coughing
What is urge urinary incontinence (UUI)?
Involuntary leakage accompanied by or immediately preceded by urgency
What are risk factors for UI?
Age
Parity
Menopause
Smoking
Medical problems
Chronic increased Intra abdo pressure
Pelvic floor trauma
Denervation
Connective tissue disease
Surgery
What is the main risk factor for SI?
Pregnancy and childbirth
(Fibrous part of fibromuscular components distend and can then break)
What are irritation symptoms?
- Urgency ; Sudden compelling desire to void that is difficult to defer.
- Increased daytime frequency (>7)
- Nocturia (>1)
- Dysuria
- Haematuria ☻
What are the symptoms of overactive bladder (OAB)?
Urgency usually associated with frequency, nocturia and urgency incontinence
What are the symptoms of incontinence?
Stress UI
Urgency UI
Coital Incontinence
Severity: How many pads/ day?
What are voiding symptoms?
Voiding Symptoms:
Straining to void
Interrupted flow
Recurrent UTI ☻
What should be asked about fluid intake?
Quantity & content
What are symptoms of a prolapse?
Vaginal lump/dragging sensation in vagina
What are bowel symptoms?
Anal Incontinence, Constipation, faecal evacuation dysfunction, IBS.
How are patient’s incontinence assessed?
3 days Urinary Diary :
- Fluid intake: Quantity & Quality
- Urine Out-Put (exclude Nocturnal Polyuria)
- Daytime Frequency,
- Nocturia
- Average voided volume.
Urine dipstick
What should be included in the examination of a women with bladder/pelvic floor problems?
- Gynaecological
- Pelvic floor assessment (Oxford scale)
- General
- Abdominal
- Neurological (if indicated by Hx)
Prolapse
Stress incontinence
Uro-genital atrophy changes
Pelvic mass (space occupying leasion)
Pelvic floor tone, strength, awareness
What investigations are done for urinary incontinence?
Urinalysis: Multistix +/- MSSU
Post voiding residual volume assessment (usually by bladder scanning) only If symptoms of voiding difficulties.
Urodynamics: ONLY indicated if surgical treatment is contemplated.
What are indications for urodynamics?
Indications for urodynamics:
- Confirm diagnosis
- Differentiate USI vs detrusor overactivity vs Mixed UI
- Investigate voiding symptoms
If confirm DO in refractory OAB - offer Botox/SNM
How is urinary incontinence managed?
Lifestyle changes
- Stop smoking
- Lose weight
- Eat more healthily to avoid constipation
- Stop drinking alcohol and caffeine
Medical treatments
Physiotherapy
- PFMT (+/-electrical stimulation, vaginal cones)
Surgery
What MUST be offered to all women with UI?
CONSERVATIVE MANAGEMENT
- Should be completed prior to contemplating surgical treatment
What is stress urinary incontinence caused by?
Intra-abdominal pressure exceeds urethral pressure, resulting in leakage
Urethral closure pressure is increased by:
- Pelvic floor muscle training
- Surgery
- Pharmacological agents
What pharmacological treatment is used for SUI & OAB?
SUI=Duloxetine (May experience N&V)
OAB=Anticholinergics Mirabegron & Vaginal oestrogen
What surgery is available for UI?
- Autologous (Rectus) fascial slings
- Colposuspension (open/laparoscopic)
- Urethral bulking
What is overactive bladder syndrome and what are its defining symptoms?
A symptom complex usually, but not always, related to urodynamically demonstrable detrusor overactivity (DO)
Defining symptoms: urgency (with/without urgency incontinence), usually with frequency and nocturia
What are the risk factors for UI?
Advanced age
Diabetes
Urinary tract infections
Smoking
OAB is a chronic condition therefore Symptoms may wax and wane
How is OAB managed?
Treat symptoms
No immediate cure
Multidisciplinary approach
What is involved in the conservative management of OAB?
Life style interventions:
- Normalise fluid intake
- Reduce caffeine, Fizzy drinks, Chocolate
- Stop Smoking
- Weight loss
Bladder training programme: Timed voiding with gradually increasing intervals - Continence nurse
What is the principle of bladder retraining and what is it achieved by?
Principle:
The re-establishment of cortical control over detrusor function and voiding
Achieved by:
Timed bladder emptying programme
In-patient/ Outpatient
What is the pharmacological treatment for OAB?
Antimuscarinic
- Oral or transdermal (Oxybutynin, Solifenacin etc)
Tricyclic antidepressants
- Imipramine
Mirabegron (Beta 3 agonist (antispasmodic))
What are recent advances in treatment of OAB?
Botox (100-150 units for idiopathic DO)
- Cystoscopy/GA
- CISC
Neuromodulation
- Sacral (S2-4) - needle stimulation
- Reflex inhibition to the detrusor muscle
