prolapse/incontinence

Question 1

what is a prolapse

Answer 1

weakness of supporting structures allows the pelvic organs to sag within the vagina

Question 2

what is prolapse due to

Answer 2

may be congenital but usually from stretching during childbirth

Question 3

risk factors during childbirth for prolapse

Answer 3

push before dilatation, long stage 2, great force in stage 3. poor perineal repair

Question 4

what can weakness be exacerbated by

Answer 4

menopausal atrophy, coughing/straining- increase intra abdominal pressure. may cause incontinence

Question 5

degrees of uterine prolapse

Answer 5

1st- cervix stays inside the vagina, 2nd- protrudes from the introitus when standing and straining, 3rd- uterine fundus lies outside the vagina

Question 6

symptoms uterine prolapse

Answer 6

‘dragging’ or ‘something coming down’- worse by day. cystitis, freq, stress incontinence, difficulty defacating.

Question 7

how to examine in prolapse

Answer 7

examine vaginal walls in left lateral position with a sims speculum. ask patient to bear down to demonstrate the prolapse

Question 8

additional studies in uterine prolapse

Answer 8

urodynamic studies to exclude detrusor overacitivity and assess voiding

Question 9

prevention uterine prolapse

Answer 9

lower parity, pelvic floor exercises

Question 10

treatment mild prolapse

Answer 10

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

Question 11

treatment severe prolapse

Answer 11

surgery- excise redundant tissue and strengthen supports

Question 12

disadvantage of surgery for prolapse

Answer 12

reduce vaginal width- surgery must compromise between treating prolapse and maintain sexually active

Question 13

marked prolapse best treated by

Answer 13

hysterectomy

Question 14

what is a temporary measure for prolapse or for the frail

Answer 14

ring pessaries- insert into the posterior fornix

Question 15

problems with ring pessaries

Answer 15

discomfort, infection, ulceration

Question 16

how often to change ring pessaries

Answer 16

every 6-12m

Question 17

if the ring pessaries keep falling out what is an alternative

Answer 17

shelf pessary

Question 18

what wall is weak in cystocele

Answer 18

upper anterior wall

Question 19

what is involved in cystocele

Answer 19

bladder. residual urine within cystocele may cause freq and dysuria

Question 20

what wall is weak in urethrocele

Answer 20

lower anterior wall bulges

Question 21

what happens in urethrocele

Answer 21

lower anterior wall bulges and displaces the urethra, impairing sphincter mechanisms

Question 22

what type of prolapse leads to stress incontinence

Answer 22

urethrocele

Question 23

treatment cystocele

Answer 23

trans vaginal mesh repair

Question 24

what wall is weak in rectocele

Answer 24

middle posterior wall

Question 25

what wall is weak in enterocele

Answer 25

upper posterior vaginal wall. may contain loops of bowel from pouch of douglas

Question 26

how is continence maintained

Answer 26

external sphincter and pelvic floor muscles

Question 27

micturition

Answer 27

external sphincter and pelvic floor muscles relax and bladder detrusor muscle contracts

Question 28

what happens in urge incontinence

Answer 28

bladder may be overactive with high detrusor activity

Question 29

management urge

Answer 29

bladder training, pelvic floor physio, antimuscarinics- oxybutyrin, desmopressin- for nocturia

Question 30

what happens in stress incontinence

Answer 30

intra abdominal pressure rises. commoner in paroud women.

Question 31

management stress

Answer 31

pelvic floor exercises, duloxetine, surgery- increase intraurethral pressure and reduce prolapse.

Question 32

what is true incontinence

Answer 32

continuous leakage due to congenital eg ectopic ureters, or acquired eg vesicovaginal fistula from trauma, malignancy, radiotherapy

Question 33

causes voiding difficulty

Answer 33

CNS, obstructive, bladder overdistension, after epidural, detrusor weakness, myopathy, drugs

Question 34

treatment voiding difficulty

Answer 34

acute catheter, tamsulosin for detrusor weakness. alpha blockers