PROLAPSE AND INCONTINENCE Flashcards
How common is urogenital prolapse?
Affects 40% of post-menopausal women
Lifetime risk is up to 19%
Types of urogenital prolapse?
Which is most common?
Cystocele or cystourethrocele - most common type
Rectocele
Uterine prolapse
Vault prolapse
Others: urethrocele, enterocele
What causes urogenital prolapse?
Weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder
What is a uterine prolapse?
When the uterus itself descends into the vagina
What is a vault prolapse?
Occurs in women that have had a hysterectomy
The vault of the vagina (top) descends into the vagina
What is a rectocele?
Posterior vaginal wall defect allows the rectum to prolapse forwards into the vagina
Symptoms specific for rectocele?
Significant constipation, urinary retention - due to Faecal loading
Many women will push the prolapsed contents back into the vagina, correcting the anatomical position of the rectum, and allowing them to open their bowels
What is a cystocele?
Defect in the anterior vaginal wall allows the bladder to prolapse backward into the vagina
What is a cystourethrocele?
Prolapse f the bladder and the urethra
What is an enterocele?
Herniation of the punch of Douglas into the vagina (including small intestine)
Risk factors for urogenital prolapse?
Increasing age and post menopausal status
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Obesity
Chronic resp disease causing coughing
Chronic constipation causing straining
Spina bifida
Presentation of a urogenital prolapse?
sensation of pressure, heaviness, ‘bearing-down’, dragging in the vagina or pelvis
urinary symptoms: incontinence, frequency, urgency, weak stream, retention
Bowel symptoms: constipation, incontinence, urgency
Sexual dysfunction: pain, altered sensation and reduced enjoyment
Bulge which can be pushed back in and worsens on straining or bearing down
Examination for a urogenital prolapse?
Empty bladder and bowels before examination
Examine on dorsal and left lateral position
Use a sim’s speculum - U-shaped single-bladed speculum which can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined e.g. hold on anterior wall to examine for a rectocele
Cough test - ask to cough to assess full descent of prolapse and see if stress incontinence
Ask woman to “bear down” for the same reasons as above
What grading system do we use for urogenital prolapse?
Pelvic Organ Prolapse Quantification System (POP-Q)
Outline the POP-Q system
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
Management options for a urogenital prolapse?
Conservative
Pessary
Surgery
Conservative management of urogenital prolapse?
Weight loss
Pelvic floor msucle exercises - may include referral to physio - do these for at least 16 weeks!
High fibre diet to avoid constipation
Avoid lifting heavy objects
For any stress incontinence: Reduce caffeine intake and Incontinence pads
Vaginal oestrogen cream to ease some symptms e.g. dyspareunia or vaginal dryness
Types of vaginal pessaries?
Ring pessary
Shelf and gellhorn pessary
Cube pessary
Donut pessary
Hodge pessary
Which pessary is used if pt is sexually active?
Ring pessary
Management of vaginal pessaries?
Women often have to try a few types of pessary before finding the correct comfort and symptom relief
Remove and clean them or change them every 4-6 months
Can last up to 10 years
May need oestrogen cream to help protect vaginal walls from irritation
Side effects of vaginal pessaries?
BV - smelly discharge
Irritation, soreness or bleeding in vagina
Stress incontinence
UTI
Interference with sex
Surgical options for a rectocele?
Posterior colporrhaphy
Sugrical options for a uterine prolapse?
Hysterectomy
Sacrohysteropexy (mesh attaches cervix to sacral region)
Surgical options for cystocele or cystourethrocele?
Anterior colporrhaphy
Complications of pelvic organ prolapse surgery?
Pain, bleeding, infection, DVT
risks associated with anaesthetic
Damage to the bladder or bowel
Recurrence of the prolapse
Altered experience of sex
Vaginal discharge or bleeding
The controversy over mesh repairs for urogenital prolapse?
NICE recommend mesh procedures should be avoided entirely
They can cause chronic pain, mesh exposure (where it sticks out through the surgery cut and into the vaginal canal), altered sensation, dyspareunia, abnormal bleeding, urinary/bowel problems
Risk factors that predispose a person to develop stress urinary incontinence?
Increasing age
Pregnancy and vaginal delivery - may damage pudendal or pelvix nerves
Increased pressure on tummy e.g. pregnancy or obesity
Constipation
Prolapse
Oestrogen deficient states
FHx
Smoking - chronic cough -> may contribute
Damage to bladder during surgery
Certain meds - ACEi, diuretics, antidepressants, HRT, sedatives
Causes if urge urinary incontinence?
Idiopathic in most cases
Comoboridites - obesity, T2DM, chronic UTI
Neurological conditions e.g. parkinsons, MS, injury to pelvic or spinal nerves
Certain meds- diuretics, antidepressants, HRT, parasympathomimetics
Can be exacerbated by caffeinated, acidic or alcoholic drinks
Causes if overflow urinary incontinence?
Bladder outflow obstruction e.g. Bladder stones, Constipation
Systemic neurological disease
Meds that decrease bladder contractility - ACEi, antidepressants, antihistamines, antimuscarinics, Antiparkinsonian drugs, beta agonist, CCBs, opioids, sedatives and hypnotics
Epidemiology of urinary incontinence in women?
Prevalence increases up to middle age, plateaus between 50-70 and then rises again with advanced age - likely due to higher rates of idiopathic detrusor activity and risk factors e.g. diabetes and medications
Moderate-severe incontinence predominantly occurs in older age groups with the slight incontinence more common in younger women
Prevalence of urinary incontinence is higher in women than men
What is urinary incontinence?
The involuntary leakage of urine
What is stress urinary incontinence?
The involuntary leakage of urine on effort or exertion i..e during increased intra-abdominal pressure e.g. sneezing or coughing
What is urgency urinary incontinence?
Involuntary leakage of urine accompanied by a sudden compelling desire to pass urine which is diffiuclt to defer, in the absence of UTI or other obvious pathology
Part of overactive bladder syndrome
What is overactive bladder syndrome?
Urinary urgency usually associated with increased frequency and Nocturia
Its OAB wet if there is incontinence present, or OAB dry if absent
What is mixed urinary incontinence?
Stress + urgency incontinence
I.e. involuntary leakage associated with urgency and physical stress
What is overflow incontinence?
Detruser underactivitiy or bladder outlet obstruction which results in urinary retention and leakage of urine
There may be straining to urinate or the person may feel the bladder was incompletely emptied
Often in the absence of any urge to urinate
Complications of urinary incontinence?
Impairment of QOL -
Psychological problems - depression, enxiety, shame, loss of self confidence
Social isolation - avoidance of places where it may be difficult to access a bathroom
Sexual problems
Loss of sleep - particuarly in overactive bladder where Nocturia is common
Falls and fractures
Financial problems - cost of absorbent products and laundry
What questions should you ask to determine the type of urinary incontinence?
Does it occur when coughing, sneezing or on effort/exertion - stress Incontinence
Is there sudden urgency? - urge incontinence
Voiding diffiuclty e.g. straining or incomplete emptying - overflow incontinence
Constant leakage of urine - fistula
Post-void dribbling, pain, urgency, frequency, recent UTI, vaginal discharge and dyspareunia - urethral diverticulum?
Pelvic examination for urinary incontinence?
During pelvic examination:
Cough test - observe external urethral meatus for leakage
Assess pelvic muscle tone and contraction during bimanual examination by asking the woman to contract her pelvic floor muscles and squeeze the examining finger
Also look for evidence of pelvic organ prolapse, urethral diverticulum, pelvic mass or atrophic vaginitis
Drugs thta may be associated with urinary incontinence?
Alpha 1 adrenoreceptor antagonists
Antipsychotics
Anticholinergics
Anti-parkinsonism drugs
Antidepressants
Benzodiazepines
Beta blockers
Diuretics
HRT
Investigating cause of urinary incontinence?
Urine dipstick
Vaginal examination to exclude pelvic organ prolapse
Urodynamic studies
Ask woman to keep a bladder diary for at least 3 days which includes activities, fluids she drinks, voided volume and frequency, episodes or urgency or incontinence, pad and clothing changes
What should you ask in a history to determine the cause of urinary incontinence?
Fluid intake, amount and type
Symptoms e.g. haematuria, bladder/urethral pain, recurrent UTI, constant leakage
What medications
Previous history of UTI, low spinal surgery, prolapse, hysterectomy, obs&gynae history
Neurological conditions
Systemic disease e.g. look for diabetes
Consider and look for cognitive impairment
Assessing the severity of urinary incontinence?
Ask how often the woman is incontinent, at what times, and during which activities.
Ask about the use of pads (including pad size) or changing of clothing.
Ask the woman how often she passes urine, including at night.
Ask the woman to keep a bladder diary for a minimum of 3 days, making sure that variations in her usual activities (for example working and leisure days) are covered.
What system do we use to grade the strength of pelvic muscle contractions?
Modified oxford grading system
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
What are urodynamic tests?
A way of objectively assessing the presence and severity of urinary symptoms
A thin catheter is inserted into the bladder, and anther into the rectum. These 2 catheters can then measure the pressures in the bladder and rectum for comparison. The bladder is filled with liquid and various outcome measures are taken:
Cystometry - detrusor muscle contraction and pressure measurement
Uroflowmetry - measures flow rate
Leak point pressure - the point at which the bladder pressure results in leakage of urine e.g. pt is asked to cough when bladder is filled to various capacities
Post-voidal residual bladder volume - tests for incomplete bladder emptying
What is functional urinary incontinence?
When there are physical or mental barriers that prevent a pt reaching the toilet
Lifestyle advice for urinary incontinence?
Manage any reversible causes
Reduce caffeine intake
Reduce fluid intake
Weight loss if BMI >=30
Smoking cessation
Management of stress urinary incontinence?
Lifestyle advice
3 months supervised pelvic floor muscle training - a minimum of 8 pelvic floor muscle contractions at least 3 times a day
If this fails then refer to a urologist or gynaecologist for further surgical management, or 2nd line duloxetine
Surgical treatment options for stress urinary incontinence?
Colposuspension - lifting the neck of the bladder and stitching it there
Sling surgery - sling is placed around the neck of the bladder to support it. It can be made from pt rectus fascia, can be donated or from an animal
Vaginal mesh surgery - not offered on NHS now
Intramural urethral bulking agents - substance injected into walls of urthra to slow it to stay closed with more force
Artificial urinary sphincter - artificial ring of muscle to prevent urine flowing from the bladder to the urethra
What is duloxetine and how does it work for stress incontinence?
A SNRI
Increase the synaptic concentrations of noradrenaline and serotonin within the pudendal nerve which increases stimulation of urethral striated muscle within the sphincter = enhanced contraction
Management of urgency incontinence?
Lifestyle advice
Referral for bladder training lasting at least 6 weeks with the aim of gradually increasing the intervals between voiding
If symptoms persist:
- anticholinergic - oxybutinin, tolterodine or darifenacin
- mirabegron (beta-3 agonist) can be used if concern about anticholinergic SE in frail elderly patients
If symptoms persist:
Specialist referral: Tx options include injection of botulinum toxin type A into the bladder wall, percutaneous sacral nerve stimulation, augmentation cystoplasty or urinary diversion
Monitoring when a pt is on mirabegron?
Blood pressure - it’s a beta-3 agonist that stimulates the sympathetic nervous system which can cause hypertension! This can increase risk of hypertensive crisis, TIA and stroke
Anticholinergic side effects?
Dry mouth
Dry eyes
Urinary retention
Postural hypotension
Constipation
Cognitive decline, memory problems amd worsening of dementia
Social impact of urinary incontinence?
Stigma
Embarrassment and shame
Social withdrawal and isolation
Loneliness and depression
Can impact on relationships
Limits activities
Workplace challenges
Financial burden
Reduced self-esteem
Impact on mental health
Receptors found on the bladder
Muscarinic receptor M3
Beta adrenergic receptor B3
Receptors found on internal urinary sphincter (males only)
Alpha 1 receptor
Receptors found on external urethral sphincter?
Nicotinic receptor
Outline physiology of micturition (voiding part)
Parasympathetic
When there is a full bladder there is increased firing of the afferent pelvic nerve to the sacral region of the spinal cord
This causes:
Pelvic efferent nerve releases ACh which binds M3 on the detrusor muscle = contraction
Inhibition of the Pudendal nerve to stop contraction of the external urethral sphincter (this is under our control)
Inhibition of Hypogastric sympathetic nerve
Outline physiology of urinary retention?
Sympathetic
Slow impulses from the afferent pelvic nerve to the sacral spinal region.
This causes:
The Hypogastric nerve releases noradrenaline which binds to beta 3 receptor on detrusor muscle = relaxation
It also binds to alpha 1 receptor on the internal sphincter (only in males) = contraction of internal sphincter
There is also stimulation of the pudendal nerve using ACh to cause contraction of the external urethral sphincter
What nerve sends impulses to the spinal cord about the fullness of the bladder
Sensory pelvic nerve
Why are Anticholinergics used to treat urge incontinence?
They block the action of acetylcholine on the M3 receptor on the detrusor muscle. This prevents bladder contraction = reduces overactivity, increasing bladder capacity and decreasing the urgency to urinate
How does mirabegron work to manage urge incontinence?
It is a beta-3 adrenergic receptor agonist
It stimulates the beta-3 receptors on the detrusor muscle of the bladder, causing relaxation of the bladder muscle and increasing bladder capacity
What is bladder retraining?
A therapy to help people learn to hold on to more urine in their bladder
It involves waiting a few minutes longer before going to the toilet to allow the bladder to stretch. Overtime the bladder should be able to comfortably hold larger amounts of urine without discomfort
What are the 2 holes within the pelvic floor?
Urogenital hiatus - situated anterior allows for passage of urethra and vagina in females
Rectal hiatus - situated centrally allows for passage of anal canal
What is the perineal body?
A fibrous node which joins the pelvic floor to the peruneum
Lies between the urogenital hiatus and the anal canal
Roles of pelvic floor muscles?
Support of abdominopelvic viscera – through their tonic contraction.
Resistance to increases in intra-pelvic/abdominal pressure – during activities such as coughing or lifting heavy objects.
Urinary and faecal continence – the muscle fibres have a sphincter action on the rectum and urethra. They relax to allow urination and defecation.
The three main components of the pelvic floor?
Levator ani muscles
Coccygeus muscle
Fascia coverings of the muscles
Which 3 muscles make up the levator ani muscle?
Pubococcygeus
Puborectalis
Iliococcygeus
