Urinary Incontinence and Pelvic Floor Disorders Flashcards
Most common symptoms of pelvic organ prolapse
- Bulge symptoms
- Urinary incontinence
- Dyspareunia
Cystocele
Rectocele
Uterine prolapse
Vaginal vault prolapse
Only occurs after hysterectomy!
Risk factors for pelvic organ prolapse
- Age
- Vaginal delivery
- Menopause
- Chronically increased intra-abdominal pressure
- Constipation
- Obesity
- Pelvic floor trauma
- Connective tissue disorders
Components of the levator ani
- Puborectalis
- Pubococcygeus
- Iliococcygeus
Endopelvic fascia
- Fibro-muscular sheath attaching the pelvic muscles to the pelvic side-walls
- Above the levator ani muscle
- Includes:
- Arcus tendineus
- Cardinal ligaments
- Utero-sacral ligaments
“Levels” of support in the pelvic floor
-
Level 1: Apical
- Cardinal ligaments and uterosacral ligaments support the uterus
- Defect in this level causes a uterovaginal prolapse
-
Level 2: Mid-Vaginal
- Arcus tendineus and the levator ani fascia support the upper 2/3 of the vagina
- Defect in this level causes a cystocele
-
Level 3: Distal Vaginal
- Urogenital diaphragm and perineal body support the distal vagina
- Defect in this level causes a rectocele
Why are older patients more at risk for pelvic floor injury?
With age there is a loss of collagen content, and the collagen that remains is mostly mature, heavily-crosslinked collagen which is less flexible than immature collagen.
“Expectant management”
Do nothing
Treatment options for pelvic floor prolapse
- Expectant management (if symptoms are tolerable)
- Pelvic floor physical therapy
- Vaginal pessaries (intra-vaginal support)
- Surgery (hysterectomy & reconstruction)
When does pelvic floor prolapse become pathologic?
When there is an issue of obstruction with urination or defecation
Parasympathetic bladder innervation
Sympathetic bladder innervation
Somatic bladder innevation
Neural control of the bladder during storage
Neural control of the bladder during micturition
___ enables us to exert voluntary control over the micturition reflex
Central control of the pontine micturition center enables us to exert voluntary control over the micturition reflex
Urge incontinence
- Syndrome of urge to urinate followed by involuntary leakage
- Often associated with nocturia
- Pathophysiology involves detrusor hyperactivity, leading to involuntray detrusor muscle contractions
Lifestyle modifications to reduce symptoms of incontinence
- Weight loss
- Normalize fluid intake
- Decreasing bladder irritants (alcohol, soda, caffeine)
- Minimizing constipation
- Smoking cessation
Therapy for urge incontinence
-
Lifestyle:
- Reduce irritants, stop smoking, lose weight, less fluids
-
Behavioral:
- Bladder training
- Prompted voiding
-
Pharmacologic:
- Beta adrenergic agonists
- Anti-muscarinics
Most commonly perscribed medication for urge incontinence
Oxybutinin
An anti-muscarinic agent that reduces contraction of the detrusor
Major categories of urinary incontinence, presentation, and basic pathophys
-
Urge incontinence:
- Urge to urinate w/ leak, frequently w/ nocturia
- Detrusor hyperactivity
-
Stress incontinence:
- Leak of urine with coughing, sneezing, etc.
- Increases in intra-abdominal pressure, pelvic floor insufficiency, and loss of sphincter tone
-
Mixed incontinence:
- Mixture of urge and stress incontinence
-
Overflow incontinence:
- Continuous leakage or dribbling from incomplete bladder emptying
- Caused by detrusor hypoactivity, peripheral neuropathy, damage to spinal nerves, and pelvic organ destruction
Treatment for stress incontinence
- Kegel exercises
- Physical therapy
- Pessiaries
- Urethral bulking agents
- Surgical treatment (mid-urethral sling)
Treatment for overflow incontinence
- Correction of underlying impairment
- Possible straight catheterization for patients with spinal cord injury
Enterocele
Herniation at the top of the vagina that allows the peritoneum of the cul-de-sac containing small bowel to herniate through.
What is the prevalence of pelvic organ prolapse among parous women?
50%!!!
HALF!
However, most women are asymptomatic, and they generally do not need therapy of any sort.
Procidentia
When the cervix descends beyond the vulva.
Pessaries
Removable rubber or silicone supports that may be placed within the vagina to reduce symptoms of pelvic floor prolapse
Considered the first-line therapy for symptomatic pelvic floor prolapse along with lifestyle modification and physical therapy.
Surgical solutions to severe, symptomatic pelvic floor prolapse often involve ___.
Surgical solutions to severe, symptomatic pelvic floor prolapse often involve hysterectomy
This is beause most of them involve the attachment of the vaginal apex to the uterosacral or sacrospinous ligaments, necessitating the removal of the uterus.
Colpocleisis
- Complete surgical obliteration of the vaginal lumen
- Procedure for women who have no desire for future child bearing and have high risk of complications from open surgery
- The surgeon sews together the front and back walls of the vagina to shorten the vaginal canal. This prevents the vagina walls from bulging inward, and provides support to hold up the uterus.
Post-delivery stress incontinence
Not uncommon for women following vaginal delivery
Most is self-limited, lasting 4-6 months and then going away without intervention. However, it may also represent pelvic floor insufficiency and may persist.
Most important cause of stress urinary incontinence
“Ureteral hypermobility”
Which is another way of saying loss of constraining structural support to the urethra by other pelvic structures and ligaments (pelvic floor insufficiency)
Pelvic Organ Prolapse Quantification (POP-Q)
- Stage 0: No prolapse. Cervix is at least as high as vaginal length
- Stage 1: Leading part > 1 cm above hymen
- Stage 2: Leading part <1 cm above or below hymen
- Stage 3: Leading part >1 cm below hymen, but less than whole vaginal length
- Stage 4: Complete prolapse and eversion
Q-tip test
- Test for urethral hypermobility in stress urinary incontinence
- Patient lies in lithotomy position. A cotton swab is lubricated with lidocaine jelly and placed into the baldder, then pulled back until resistance is met. Patient is asked to bear down.
- If there is urethral hypermobility, the end of the swab rotates upward (>30o is considered positive), suggesting that the UVJ is being deflected downward by intrraabdominal pressure.
Stage III and IV pelvic organ prolapse patients without incontinence likely have ____ continence.
Stage III and IV pelvic organ prolapse patients without incontinence likely have “simulated” continence.
Essentially, there is a kink or functional obstruction in the outflow tract which is producing “continence”, but not by the usual mechanism. This same kink may cause hydronephrosis or hydroureter as well, so renal ultrasound is indicated to evaluate in these cases.
Sacral colpoplexy
- Treatment for pelvic floor insufficiency in women without a uterus specifically
- Vaginal cuff is anchored to the sacral promontory
Surgical options for stress urinary incontinence
- Retropubic colposuspension
- Suburethral sling
- Bulking injection
Retropubic colposuspension
Suspension and stabilization of the anterior vaginal wall in a retropubic position.
Also called the “Burch” procedure
Suburethral sling
- Sling is placed around the urethra to lift it back into place and exert upward pressure, preventing stress urinary incontinence
Bulking injection for stress urinary incontinence
- Injection of collagen, carbon-coated beads, and fat transurethrally or periurethrally around the bladder neck and proximal urethra.
- Effectively like placing a “washer” around the urethra
- Especially useful in cases of intrinsic sphincter insufficiency, as tightening of the tissue can simulate an intrinsic sphincter’s pressure
- May produce temporary (from swelling) or long-standing urinary retention as a complication
Normal post-void residual
50-60 mL
Post-void residual of how much strongly suggests overflow incontinence?
> 300 mL
Mid-urethral sling is indicated for ___.
Colpocleisis is indicated for ___.
Bulking agent injection is indicated for ___.
Mid-urethral sling is indicated for ureteral hypermobility-induced stress incontinence.
Colpocleisis is indicated for pelvic floor insufficiency, not stress incontinence.
Bulking agent injection is indicated for internal sphincter dysfunction-induced stress incontinence.
“Drain pipe” urethra
Finding of constant leakage of the urethra on cystourethroscopy
Describes a urethra that is scarred, poorly vascularized, and rigid with no internal sphincter function. This is usually a result of recurrent scar formation due to multiple pelvic surgeries.
This is the major indication for bulking agent injection.
Two forms of pelvic organ prolapse that may be associated with urge incontinence
- Cystocele
-
Urethrocele
- Note: Many other forms may be associated with stress incontinence, in addition to the above
Indication for Kegel exercises
Indicated to prevent pelvic prolapse
BUT, once pelvic prolapse has happened, they won’t reduce it.
Whenever a patient presents with urinary incontinence, ___ should be ruled out
Whenever a patient presents with urinary incontinence, UTI should be ruled out
Differentiation of overflow incontinence and stress incontnience may be suspected based on ___ in the history and confirmed based on ___.
Differentiation of overflow incontinence and stress incontnience may be suspected based on risk factors in the history and confirmed based on results of bladder ultrasound.
Risk factors for overflow would be neuropathy, diabetes, or MS.
Risk factors for stress would be multiparity, old age, pelvic floor insufficiency, chronic increased intraabdominal pressure.
Voiding diary
Useful for patients who have symptoms of mixed urinary incontinence to assess which interventions may be most useful for this particular patient
Urodynamic testing
Involves measurement of the bladder filling and emptying (cystometry), urine flow, and pressure.
Typically reserved for patients with complicated urinary incontinence (stress, urgency) who are at the point of considering surgery
