prolapse and incontinence Flashcards
what is the order of the most common prolapses in women?
- cyctourethrocele
- uterine descent
- rectocele
- vaginal vault-> occurs post hysterectomy, the vagina can prolapse within or outside the vagina
what are the muscles that make up the pelvic floor?
- levator ani
- internal obturator and piriform muscles
- superficial and deep perineal muscles
which conditions are associated with prolapse?
- spina bifida
- connective tissue disorders
what are symptoms of prolapse
- the feeling of something coming down- worse with standing, straining or defamation
- uterine descent can cause backache and discomfort when it rubs on clothes, and can sometimes notice bloody plurenent discharge
- urinary symptoms= occur with cystocele and cystourethrocele- increased frequency, micturition and incomplete emptying- predisposing to UTI. stress incontinence may also be present
- bowel symptoms- rectocele can cause incomplete bowel emptying- can be received by pushing back on the prolapse digitally
what is conservative management of prolapse?
- weight loss
- stopping smoking to reduce cough
- treating constipation
- pelvic floor exercises
what are some medical managents for prolapse?
- HRT- can be useful in minor degrees of prolapse because they can increase the skin collagen content.
- vaginal pessary- ring pessary
why is HRT sometimes used before surgery?
- HRT can reduce the liability of atrophic tissues, making tissue handling easier in surgery
what are the different types of surgical management for cytocele?
- anterior colporrhaphy: used for cystocele or cystourethrocele
what is the surgical management for rectocele?
posterior colporrhaphy: used to repair rectocele
what is the surgical management of uterine prolapse?
- vaginal hysterectomy for
what is the management of vaginal vault prolapse?
- sacrospinus fixation
- be careful of the pudendal nerve, the sacral plexus and the sciatic nerve
why is sacral colpopexy no longer used for vaginal vault prolapse?
- there is a risk of intraoperative haemorrhage and infection of the mesh
what are risk factors for prolapse?
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining
what are the 3 main forms of managing prolapse?
- Conservative management
- Vaginal pessary
- Surgery
what medication is used to treat stress incontinence?
duloxetine
.
.
what is it called when the uterus protrudes outside the vagina?
providentia
what type of follow-up should people with vaginal pesarries have?
- change every 4-6 months
- need to check mucosa for erosion- can cause recto-vaginal fistula- especially shelf pessaries
- check for bleeding and offensive discharge
what is stress incontinence?
- involuntary urine leakage with sneezing or coughing
- caused by damage to pelvic muscle wall
what is urge incontinence?
- inability to hold when you need to go
- caused by overactivity of detrusor (bladder wall) muscles
which factors predispose to stress incontinence?
Pregnancy and vaginal birth
Obesity
Family history of incontinence
Increasing age –although incontinence isnot an inevitable part of ageing
what are the causes or urge incontinence?
Too much alcohol or caffeine
Poor fluid intake – this can cause strong, concentrated urine to collect in your bladder, which can irritate the bladder and cause symptoms of overactivity
Urinary tract infection (UTI)
Constipation-> feel the bladder is not emptying properly
Bladder tumour> irritation to bladder wall and bladder not compliant to pressure changes
Medications
what is the cause of of overactive bladder?
frequency and noturia along with urgency, may not leak
what is the main treatment of urge incontinence?
medication
what is the main treatment for stress incontinence?
surgery
what is first line treatment for stress incontinence?
- pelvic floor training
- for at least 3 months
- at least 8 contractions 3 times a day
what is first line for urge incontinence?
- bladder training for at least 6 weeks after making a bladder diary for 3 weeks
which medical treatments are available for urge incontinence?
- antimuscarinic drugs
e.g.
Oxybutynin
Tolterodine
Darifenacin
use merebegron-> for frail elderly women
which medical treatments are available for urge incontinence?
- antimuscarinic drugs
e.g.
Oxybutynin- avoid in frail old women as affects cognition
Tolterodine
Darifenacin
review after 4 weeks
what is invasive treatment for overactive bladder?
- use botulin toxin A injection
- if doesn’t work can use self-catheterisation
when can duloxetine be used?
for patients with stress incontinence who have not responded to pelvic floor exercises
what do urodynamic studies show?
Urodynamic studies (UDS) test how well the bladder, sphincters, and urethra hold and release urine. These tests can show how well the bladder works and why there could be leaks or blockages.
What should be suspected in women with continuous dribbling after prolonged labour, and how can it be investigated?
- vesicovaginal fistula
- do urninary dye studies- using cystoscopy
