Prolapse & Incontinence

Question 1

What is stress incontinence?

Answer 1

Leakage of urine with increases in intra-abdominal pressure i.e. lifting, coughing, sneezing, exercise

Question 2

What is urge incontinence?

Answer 2

Leakage of urine associated with sudden urge to void

Can be associated with storage symptoms - frequency, dysuria

Question 3

What are the causes of stress incontinence?

Answer 3

• Poor sphincter function
• Hypermobility of bladder neck/urethra and weak pelvic floor muscles

Pelvic floor affected by

• high impacted activity
• child birth esp. traumatic (forceps)
• menopause
• pelvic surgery

Question 4

What are the causes of urge incontinence?

Answer 4

Overactive bladder (increased contractions) - CVA, local irritants (malignancy, UTI)

Poor bladder tone - neuropathy, drugs, trauma/injury

Question 5

What are the conservative Rx options of urge incontinence?

Answer 5

Bladder re-training - deferment techniques, distractive techniques

Pelvic floor exercises may help - reduces nerve hyperstimulation

Fluid intake - reduce, especially close to bed, avoid caffeine and alcohol

Question 6

What are the pharmacological/surgical Rx options for urge incontinence?

Answer 6

Anticholinergics - oxybutinin (cognitive/memory impairment if dementia, urinary retention, bowel issues, dry mouth/eyes)

Cystoscopy with botox injection - 1st line surgery, ~80% success

Sacral nerve ablation - refractory

Question 7

What are the transient causes of incontinence?

Answer 7

DIAPERS
- delirium, infection, atrophic vaginitis (menopause), pharmacological (medications), excess output (intake, polyuria), restricted mobility, stool impaction

Question 8

What Ix for incontinence?

Answer 8

• Urinanalysis and MCS - infection, diabetes
• Bladder diary
• Urodynamics - cystometry, uroflowmetry
• Post-void residual volume
• QoL questionnaire

Question 9

What are the conservative Rx options for stress incontinence?

Answer 9

Pelvic floor exercises (with physio or biofeedback)
Weight loss
Smoking cessation
Fluid restriction - avoid caffeine and alcohol
Topical oestrogens

Question 10

What are surgical Rx options for stress incontinence?

Answer 10

Sling procedure - 80% success

+/- injection of peri-urethral bulking agent

Question 11

How common is incontinence?

Answer 11

12% all women >65y

Question 12

What are considered abnormal urinary symptoms?

Answer 12

Voiding >8/day
Voiding >2/night
Urgency
Dysuria

Question 13

What are important features on history to identify in women presenting with incontinence?

Answer 13

• Age, menopause status, weight, smoking
• Childbearing - how many, local trauma, vaginal or C-section, forceps
• HOPC - how many times go during the day and night, amount leaked, how much leaked (pad use), triggers for leakage, urgency, dysuria, haematuria, incomplete emptying, straining/hesitancy
• Constipation and straining
• Fluid intake, alcohol, caffeine
• Associated symptoms - prolapse (bulging, draging, lump, tampon helps symptoms), infection (recurrent UTI, fever, pain), vaginal irritation/dryness, consider cognition, mobility & access issues
• Affect on mood, sex/relationships, function
• Medical hx - previous obstruction, pelvic trauma or surgery, stroke, diabetes, neurological issues, parkinsons, prolapse, cancer
• Medications - anticholinergics, antihypertensives
• FHx - prolapse, neurological issues

Question 14

Specific features on examination for incontinence?

Answer 14

General - BMI, dexterity
Pelvic exam - Atrophic vaginitis, prolapse, cough test
Neuro exam if relevant - focal signs, cognition
Abdo exam - constipation, local mass