prolapse/incontinence Flashcards
what is a prolapse
weakness of supporting structures allows the pelvic organs to sag within the vagina
what is prolapse due to
may be congenital but usually from stretching during childbirth
risk factors during childbirth for prolapse
push before dilatation, long stage 2, great force in stage 3. poor perineal repair
what can weakness be exacerbated by
menopausal atrophy, coughing/straining- increase intra abdominal pressure. may cause incontinence
degrees of uterine prolapse
1st- cervix stays inside the vagina, 2nd- protrudes from the introitus when standing and straining, 3rd- uterine fundus lies outside the vagina
symptoms uterine prolapse
‘dragging’ or ‘something coming down’- worse by day. cystitis, freq, stress incontinence, difficulty defacating.
how to examine in prolapse
examine vaginal walls in left lateral position with a sims speculum. ask patient to bear down to demonstrate the prolapse
additional studies in uterine prolapse
urodynamic studies to exclude detrusor overacitivity and assess voiding
prevention uterine prolapse
lower parity, pelvic floor exercises
treatment mild prolapse
decrease intra abdominal pressure- lose weight, stop smoking, stop straining. increase muscle tone by exercises or physio. if postmenopausal- topical oestrogen- estriol cream or estradiol
treatment severe prolapse
surgery- excise redundant tissue and strengthen supports
disadvantage of surgery for prolapse
reduce vaginal width- surgery must compromise between treating prolapse and maintain sexually active
marked prolapse best treated by
hysterectomy
what is a temporary measure for prolapse or for the frail
ring pessaries- insert into the posterior fornix
problems with ring pessaries
discomfort, infection, ulceration
how often to change ring pessaries
every 6-12m
if the ring pessaries keep falling out what is an alternative
shelf pessary
what wall is weak in cystocele
upper anterior wall
what is involved in cystocele
bladder. residual urine within cystocele may cause freq and dysuria
what wall is weak in urethrocele
lower anterior wall bulges
what happens in urethrocele
lower anterior wall bulges and displaces the urethra, impairing sphincter mechanisms
what type of prolapse leads to stress incontinence
urethrocele
treatment cystocele
trans vaginal mesh repair
what wall is weak in rectocele
middle posterior wall
what wall is weak in enterocele
upper posterior vaginal wall. may contain loops of bowel from pouch of douglas
how is continence maintained
external sphincter and pelvic floor muscles
micturition
external sphincter and pelvic floor muscles relax and bladder detrusor muscle contracts
what happens in urge incontinence
bladder may be overactive with high detrusor activity
management urge
bladder training, pelvic floor physio, antimuscarinics- oxybutyrin, desmopressin- for nocturia
what happens in stress incontinence
intra abdominal pressure rises. commoner in paroud women.
management stress
pelvic floor exercises, duloxetine, surgery- increase intraurethral pressure and reduce prolapse.
what is true incontinence
continuous leakage due to congenital eg ectopic ureters, or acquired eg vesicovaginal fistula from trauma, malignancy, radiotherapy
causes voiding difficulty
CNS, obstructive, bladder overdistension, after epidural, detrusor weakness, myopathy, drugs
treatment voiding difficulty
acute catheter, tamsulosin for detrusor weakness. alpha blockers
