prolapse and incontinence

Question 1

what is the order of the most common prolapses in women?

Answer 1

• cyctourethrocele
• uterine descent
• rectocele
• vaginal vault-> occurs post hysterectomy, the vagina can prolapse within or outside the vagina

Question 2

what are the muscles that make up the pelvic floor?

Answer 2

• levator ani
• internal obturator and piriform muscles
• superficial and deep perineal muscles

Question 3

which conditions are associated with prolapse?

Answer 3

• spina bifida

- connective tissue disorders

Question 4

what are symptoms of prolapse

Answer 4

• 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

Question 5

what is conservative management of prolapse?

Answer 5

• weight loss
• stopping smoking to reduce cough
• treating constipation
• pelvic floor exercises

Question 6

what are some medical managents for prolapse?

Answer 6

• HRT- can be useful in minor degrees of prolapse because they can increase the skin collagen content.
• vaginal pessary- ring pessary

Question 7

why is HRT sometimes used before surgery?

Answer 7

• HRT can reduce the liability of atrophic tissues, making tissue handling easier in surgery

Question 8

what are the different types of surgical management for cytocele?

Answer 8

• anterior colporrhaphy: used for cystocele or cystourethrocele

Question 9

what is the surgical management for rectocele?

Answer 9

posterior colporrhaphy: used to repair rectocele

Question 10

what is the surgical management of uterine prolapse?

Answer 10

• vaginal hysterectomy for

Question 11

what is the management of vaginal vault prolapse?

Answer 11

• sacrospinus fixation

- be careful of the pudendal nerve, the sacral plexus and the sciatic nerve

Question 12

why is sacral colpopexy no longer used for vaginal vault prolapse?

Answer 12

• there is a risk of intraoperative haemorrhage and infection of the mesh

Question 13

what are risk factors for prolapse?

Answer 13

Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining

Question 14

what are the 3 main forms of managing prolapse?

Answer 14

1. Conservative management
2. Vaginal pessary
3. Surgery

Question 15

what medication is used to treat stress incontinence?

Answer 15

duloxetine

Question 16

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Answer 16

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Question 17

what is it called when the uterus protrudes outside the vagina?

Answer 17

providentia

Question 18

what type of follow-up should people with vaginal pesarries have?

Answer 18

• 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

Question 19

what is stress incontinence?

Answer 19

• involuntary urine leakage with sneezing or coughing

- caused by damage to pelvic muscle wall

Question 20

what is urge incontinence?

Answer 20

• inability to hold when you need to go

- caused by overactivity of detrusor (bladder wall) muscles

Question 21

which factors predispose to stress incontinence?

Answer 21

Pregnancy and vaginal birth
Obesity
Family history of incontinence
Increasing age –although incontinence isnot an inevitable part of ageing

Question 22

what are the causes or urge incontinence?

Answer 22

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

Question 23

what is the cause of of overactive bladder?

Answer 23

frequency and noturia along with urgency, may not leak

Question 24

what is the main treatment of urge incontinence?

Answer 24

medication

Question 25

what is the main treatment for stress incontinence?

Answer 25

surgery

Question 26

what is first line treatment for stress incontinence?

Answer 26

• pelvic floor training
• for at least 3 months
• at least 8 contractions 3 times a day

Question 27

what is first line for urge incontinence?

Answer 27

• bladder training for at least 6 weeks after making a bladder diary for 3 weeks

Question 28

which medical treatments are available for urge incontinence?

Answer 28

• antimuscarinic drugs
  e.g.
  Oxybutynin
  Tolterodine
  Darifenacin

use merebegron-> for frail elderly women

Question 29

which medical treatments are available for urge incontinence?

Answer 29

• antimuscarinic drugs
  e.g.
  Oxybutynin- avoid in frail old women as affects cognition
  Tolterodine
  Darifenacin

review after 4 weeks

Question 30

what is invasive treatment for overactive bladder?

Answer 30

• use botulin toxin A injection

- if doesn’t work can use self-catheterisation

Question 31

when can duloxetine be used?

Answer 31

for patients with stress incontinence who have not responded to pelvic floor exercises

Question 32

what do urodynamic studies show?

Answer 32

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.

Question 33

What should be suspected in women with continuous dribbling after prolonged labour, and how can it be investigated?

Answer 33

• vesicovaginal fistula

- do urninary dye studies- using cystoscopy