urinary incontinence Flashcards
baseline investigations for urinary incontinence
urinalysis + culture
frequency/volume chart: 3days
stress incontinence
complaint of involuntary loss of urine of effort or physical exertion including sporting activities, sneezing or coughing
mechanism of stress incontinence
pathophysio
- intravesical pressure exceeds closing pressure
- 2 mechanisms
– urethral hypermobility - impaired pelvic floor support
– intrinsic sphincter deficiency - denervation or weakness of sphincter mechanism
management of stress incontinence
conservative - weight loss, pelvic floor muscle training, incontinence right
medical - vaginal oestrogen, duloxetine (last line)
surgical
- bulking agents - increase size, remain closed under pressure
- fascial slings - behind urethra to support it
- colposuspension - tissue around neck of bladder _ suspending it to ileopectineal ligament
urgency incontinence
involuntary loss of urine assoc with urgency
- cause by overactiveity of detrusor muscle of bladder (overactive bladder)
rush to bathroom, not arriving in time before urination occurs
- poor QoL - dont want to be far from loo
management of urgency incontinence
3months lifestyle changes/conservative
Anticholinergic before medication
1st line = solifenacin 5mg, up to 10mg -> review 4-6wks
o NOT oxybutynin if old frail
2nd line = tolterodine 2mg (another anticholinergic)
3rd line = mirabegron 50mg – BP monitoring
o Works differently to antimuscarinics – sympathetic/adrenergic control, B3 adrenoceptor agonist activates receptor, increases relaxation (increased storage capacity + decreased voiding frequency)
o Vs antimuscarinics – blocks receptor, inhibits involuntary contraction (delayed voiding)
- Topical oestrogen if atrophic
- Refer to CATS
- Onward referral from CATS to urogynaecology
If 3 individual medications fail, try comnination therapy
o Botox
o Percutaneous tibial nerve stimulation – privately
o Sacral nerve stimulators
when do women require contraception after giving birth
after day 21
can start POP any time postpartum - even if breastfeeding
COCP UKMEC4 if breastfeeding <6wks postpartum, can start >=6wks if breastfeeding (UKMEC2)
IUD/IUS - within 48hrs or after 4wks
lactational amenorrhoea method (LAM)
- 98% effective providing owmen is fully breast feeding, amenorrhoeic + 6months postpartum
pelvic organ prolapse
result of weakness, lengthening of ligaments + muscles surrounding uterus, rectum + bladdder
50% can expect to have some degree of prolapse - 10-20% symptomatic
risk factors of pelvic organ prolapse
- Giving birth to large baby
- Menopause
- Old age
- Obesity – increases pressure on pelvic floor
- Smoking – chronic cough causes epidodes of high pressure in the abdomen or aggravate prolapse that has other causes
- Heavy lifting
- Constipation
- Hereditary – FH of weakness in connective tissue (marfans, Ehlers-Danlos)
- Prior pelvic surgery
- Hispanic or white
presentation of pelvic organ prolapse
- Mild usually asymptomatic
- Moderate-severe –
o Sensation of heaviness or pulling in pelvis
o Tissue protruding from your vagina
o Urinary problems – incontinence, urine retention
o Trouble having bowel movement
o Feeling as sitting on small ball or as if something falling out vagina
o Sexual concerns – looseness in tone of vaginal tissue
o Worse as the days goes on
what are the 3 compartments of pelvic organ prolapse
anterior
middle or apical
posterior
anterior prolapse
o Cystocele
o Defect in anterior vaginal wall, allowing bladder to prolapse backwards into vagina
o Prolapse of urethra is also possible (urethrocele)
o Prolapse of both = cystourethrocele
Specific sx – same as middle (difficulty voiding/incomplete, pain with intercourse, difficulty inserting tampon)
middle or apical compartment prolapse
Enterocele/vaginal vault prolapse
o Vault = in women who have had a hysterectomy, top of vagina (vault) descends into vagina
Specific Sx – difficulty voiding/incomplete, pain with intercourse, difficulty inserting tampon
posterior compartment prolapse
Rectocele
o Defect in posterior vaginal wall
o Particularly assoc with constipation – can develop faecal loading in part of rectum prolapsed
—>Can cause significant constipation, urinary retention (compression of urethra)
o Palpable lump – women can push lump back allow them to open bowels
Specific Sx – difficultly defeacation/incomplete, difficulty inserting tampon
classification of uteroovaginal prolapse
o 1st degree – in vagina
o 2nd degree – at interiotus
o 3rd degree – outside vagina
o Procidentia – entirely outside vagina
pelvic organ prolapse quantification system (POP-Q)
