Prolapse and Incontinence Flashcards
What supports the upper third of the vagina?
Ligaments attach to cervic and suspend uterus
Cardinal ligaments -> pelvic brim
Uterosacral ligaments -> sacrum
What supports the mid portion of the vagina?
Endofascial condensation (endopelvic fascia) -> pelvic side walls
What supports the lower third of the vagina?
Levator ani muscle which incorporates the perineal body (pelvic diaphragm)
pubic symphysis -> pelvic brim, sacrum
What nerve supplies the levator ani?
Pudendal (S2,3,4)
keeps the poo off the floor
What is a urethrococele?
Lower anterior wall prolapse
Involves urethra
What is a cystocele?
Upper anterior wall prolapse
Involves bladder
May be combined with urethrococele
What is an apical prolapse?
Prolapse of uterus, cervix and upper vagina
What is an enterococele?
Prolapse of upper posterior wall
Contains intestinal contents from pouch of Douglas
What is a rectocoele?
Prolapse of lower posterior wall
Involves anterior wall of rectum
What causes prolapse?
Vaginal delivery - mechanical injury and denervation of pelvic floor
Congenital factors - abnormal collagen metabolism
Menopause: deterioration of collagenous connective tissue after oestrogen withdrawal
Chronic factors: obesity, chronic cough, constipation, heavy lifting, pelvic mass
Iatrogenic: pelvic surgery
How does prolapse present?
Dragging sensation, worse at end of the day or when standing up
Urinary frequency
Stress incontinence
Difficulty defecating
How are pessaries used for prolapse?
Act as artificial pelvic floor
Changed every 6-9 months
May need HRT to prevent ulceration
What surgery is used for uterine prolapse?
Vaginal hysterectomy - most subsequently present with vaginal vault prolapse
Hysteropexy - uterus and cervix are attached to sacrum via mesh
What surgery is indicated for vaginal vault prolapse?
Sacrocolpopexy - vault is attached to sacrum
Sacrospinous fixation - suspend vault to sacrospinous ligament
Can cause nerve or vessel injury
What surgery is indicated for stress incontinence?
Tension free vaginal tape
Trans-obturator tape procedure
Burch colpo-suspension
What is required for continence?
Functioning sphincter Properly positioned bladder neck Thick urethral mucosa (oestrogen) Compliant bladder Higher control centre
What is required to void the bladder?
Detrusor contractility and urethral relaxation
What volume does the bladder hold?
500ml
Urge to void at 200ml
What is the neural control of the bladder?
Parasympathetic - VOID
Sympathetic - HOLD
What causes incontinence?
Uncontrolled increase in detrusor pressure (bladder>urethra pressure) - OAB
Increased intra-abdominal pressure transmitted to bladder but not urethra because upper urethra neck has slipped from abdomen
How are urinary symptoms investigated?
Urine dipstick
- nitrites = infection
- glucose = diabetes
- blood = bladder carcinoma or calculi
Urinary diary
Post micturition USS
Urodynamic studies - differentiates between OAB and stress
Cystoscopy
How will cystometry show difference in urinary stress incontinence and detrusor instability?
USI - both bladder and abdo pressure increase at the time of cough
Detrusor instability - bladder pressure increases more than urethra when bladder fills
What causes stress incontinence?
Pregnancy and vaginal delivery
Obesity
Postmenopausal
Bladder neck has slipped below pelvic floor because the supports are weak
When intra-abdominal pressure increases, only bladder pressure increases, not urethra
What treatment is available for stress incontinence?
Pelvic floor exercises Vaginal cones Duloxetine - SNRI which increases sphincter activity TVT TOT
What is the tension free vaginal tape?
Tape placed in U shape under mid urethra and tension adjusted to prevent leakage
Inserted via cut in ant wall of vagina
What is transobturator tape?
Tape passed via transobturator foramen so doesn’t enter retropubic space and bladder perforation is rare
What is overactive bladder?
Urgency +/- frequency and nocturia without infection
What is detrusor overactivity?
Involuntary detrusor contraction during filling phase which may be spontaneous or provoked
What causes OAB?
Idiopathic
Post operation for USI
Neuropathy
What investigations are done for OAB?
Urinary diary - frequent passage of small volumes of urine especially at night
How is OAB managed?
Reduce fluid intake and avoid caffeine Bladder training Anticholinergics Oestrogens Botox
What is acute urinary retention?
Unable to pass urine for >12hrs
Caused by childbirth, epidural, vulval or perineal pain, surgery,retroverted gravid uterus
What causes chronic retention and urinary overflow?
Bladder overdistension eventually causes overflow
Urethral obstruction - pelvic mass, incontinence surgery
Detrusor inactivity - autonomic neuropathy, previous overdistension of bladder
What is painful bladder syndrome?
Suprapubic pain with bladder filling
How do urinary fistulae present?
Constant leakage
