urinary incontinence and pelvic organ prolapse Flashcards
A 59 year old gravida 3, para 1021 whose last menstrual period was 10 years ago presents complaining of leaking urine x 9 months. She states it occurs when she laughs, coughs or sneezes. She states it is interfering with her social life and at work and wants to know if anything can be done.
After seeing you in the office and after completing a voiding diary and questionnaires, your patient receives a diagnosis of stress urinary incontinence. She undergoes a mid-urethral sling procedure and reports significant improvement with incontinence within a month of surgery.
incidence
-Though it is usually associated with higher incidence in the menopausal years, urinary incontinence may occur in younger cisgender women
-Incidence by age:
-25% of young patients
-44-57% of middle aged or postmenopausal patients
-75% of older patients
-Urinary incontinence is present in 50% of cisgender female nursing home residents
-It is the cause for nursing home admission in 6% of such patients
-Indirectly, it causes isolation and depression in the elderly
-Can contribute to skin breakdown and decubiti in non-ambulatory patients
physiology of continence
-Brainstem allows for opening of urethral sphincter and relaxation of detrusor muscle, permitting urination
-Increased sympathetic tone contributes to contraction of the internal urethral sphincter
-Increased parasympathetic tone contracts the detrusor muscle
-Normal bladder volume: 300-500 cc
-RF:
-Increasing age
-AFAB sex
-menopause
-Local trauma to the lower genital tract:
-Cystocele
-Rectocele
-neurological injury or illness:
-MS
-ALS
-neurogenic blacder
-spinal cord injury or ds
types of urinary incontinence
-In general, there are three major types of urinary incontinence affecting cisgender women
-Stress urinary incontinence
-Leakage occurs with laughing, coughing, sneezing, running, jumping
-Urge incontinence (detrusor overactivity, “overactive bladder”)
-“Key-in-lock syndrome”
-Mixed incontinence (stress urinary incontinence and urge incontinence)
-functional urinary incontinence due to cognitive or mobility impairment with intact lower urinary tract
-postmicturition leakage following complete urination
-postural urinary incontinence due to change of body position
diff dx of urinary incontinence
-Urinary etiologies:
-stress urinary incontinence
-detrusor overactivity
-mixed incontinence
-UTI
-vaginitis
-fistulae
-congenital- ectopic ureter, episadias
-Non-urinary etiologies:
-functional:
-neurologic
-cognitive
-psychologic
-physical impairment
-environmental
-pharmacologic
-metabolic
approach to the pt with urinary incontinence
-History
-Voiding diary
-Physical exam
-Urinalysis and urine culture
-Measurement of postvoid residual volume
-Via bladder scan
-Via straight catheterization
history
-Medical, surgical, gynecologic and neurologic history
-Neurological history should include history of: stroke, diabetes, multiple sclerosis, disk disease, amyotrophic lateral sclerosis
-Duration
-Dysuria
-Nocturia
-Urgency
-Pad use
-Fluid intake
-Frequency of events
-Effect on activities of daily living
voiding diaries and questionnaires
-Voiding diaries may be kept for 3-5 days
-Includes:
-Type and amount of liquids consumed by patient
-Time when liquids are consumed
-Amount of urine voided
-Time when voiding occurs
-Amount of urine lost during leakage, and why
physical exam in assessment of urinary incontinence
-Complete abdominal and pelvic exams
-Evaluation of pelvic floor, including muscle strength
-Take this opportunity to teach Kegel exercises
-Focused neurological exam
-Mental status exam
-Bulbocavernosus reflex- touch clit with q-tip and anus constricts
-Sensory and motor exams of lower extremities
-Rectal exam
-evaluate tone, tenderness, presence or absence of hemorrhoids
-Rule out fecal impaction, tumors, rectovaginal fistulae
specialized tests for stress urinary incontinence
-Cough stress test
-Have patient arrive with full bladder
-Do not collect urine prior to physical exam
-Test may be performed while patient is supine
-Have patient cough
-Should see urine leak during cough
-If not, repeat while patient is standing
-If patient leaks urine while coughing, it is diagnostic of stress urinary incontinence
-Q-tip test for urethral mobility
-Place a sterile cotton applicator lubricated with lidocaine gel in the urethra
-Measure the angle between the horizontal plane and the Q-tip
-Have the patient perform a Valsalva maneuver
-If the increase in the angle is >30 degrees, it suggests poor pelvic support and abnormal bladder neck descent
-Lack of urethral mobility renders a less favorable outcome for surgical intervention, such as sling procedure
-Such patients may benefit instead for injection of urethral bulking agents
-postvoid residual volume
-have pt empty bladder
-perform straight catheterization or perform bladder scan via
-If residual volume is <150 cc, the patient has normal bladder emptying
-No need for urodynamic testing if diagnosis is clear upon history, physical, voiding diary and urinary questionnaires
-For complicated patients, refer for urodynamic testing
urinary incontinence workup
-Urinalysis and culture
-Point of care testing may be used
-Send culture if indicated and treat accordingly
-Evaluate further any microscopic hematuria, if present
management for all types of urinary incontinence: lifestyle modificatoins
-Weight loss
-Bladder training
-Fluid management
-Decrease caffeine intake
-Limit fluid intake to <2 liters per day
-Kegel exercises
-Biofeedback
other management strats in tx of stress urinary incontinence
-Urethral bulking agents for patients with symptoms of stress urinary incontinence but without urethral sphincteric deficiency
-Collagen
-Pyrolytic carbon-coated beads
-Calcium hydroxylapatite
-Surgical intervention indicated for pts who have not improved after lifestyle modifications
-The polypropylene midurethral sling is the most effective and safe procedure available
-Acts as a hammock to support the bladder neck and the urethra
-May be placed by a retropubic or transobturator approach
-Reoperation rate is about 2.6%
-An autologous pubofascial vaginal sling may also be used
management of urge incontinence
-Medications
-Many patients are on multiple agents
-High risk of drug-drug interactions
-Antimuscarinic agents
-More effective than placebo
-Many drug-drug interactions
-Many adverse drug reactions
-Beta agonists
-Produces detrusor muscle relaxation
-Mirabegron:
-Contraindicated in patients with:
-Severe uncontrolled hypertension
-ESRD
-Significant hepatic disease
-Vibegron
-Onabotulinumtoxin A
-Functions as a muscle paralytic
-A multicenter randomized trial comparing antimuscarinics to botulinum toxin demonstrated that antimuscarinics were as effective as botulinum toxin A
-However, more patients using botulinum toxin A reported complete resolution of urge incontinence compared to those using antimuscarinics
Your 85 yo mildly demented gravida 5, para 4014, last menstrual period 40 years ago, is cared for in the home by certified home health aides. The patient’s aide brings her to see you on an emergent basis because she was bathing the patient and noted “a large pink thing down there.”
The patient and aide deny any history of vaginal or rectal bleeding, or of recent vaginal penetration, and the patient denies any history of pelvic or abdominal pain.
Your patient is diagnosed with complete procidentia. Treatment options (observation, pessary, hysterectomy, or LeFort colpocleisis) are discussed with the patient and her son. They opt for a pessary. You fit her with a Gellhorn pessary and have her make an appointment for re-evaluation in 6 weeks.
pelvic organ prolapse
-The descent of the uterus, if present, or the vaginal vault
-About 3% of patients are symptomatic
-Symptoms include a sense of pressure, difficulty with sexual function, or difficulty with urination or with bowel movements
-Risk factors:
-Parity
-Obesity
-Advanced age
-Chronic constipation
physical exam in the pt with suspected pelvic organ prolapse
-Abdominal and pelvic exams
-Note any ulceration of vaginal or cervical tissue
-Note any cystocele or rectocele
-Prolapse may be immediately evident or may appear with Valsalva maneuver
-Assess pelvic floor strength
-Perform postvoid residual volume
-Management of pelvic organ prolapse may reveal occult urinary incontinence
-Additional workup
-Consider urinalysis and culture with urinary symptoms
cystocele and rectocele
-Cystocele (pic):
-Herniation of the anterior vaginal wall due to damage to the pubocervical fascia
-Usually caused by trauma due to childbirth
-Rectocele:
-Defect of the rectovaginal septum
-Usually caused by trauma to the perineal body during childbirth
-The perineal body stabilizes the rectovaginal septum
sx and signs of cystocele and rectocele
-Cystocele
-Anterior vaginal mass
-Vaginal fullness
-Sense of “something coming down” or “falling out”
-Difficulty with urination
-Rectocele
-A sense of heaviness or bearing down
-Constipation
-Posterior vaginal mass
-cystocele and rectocele- pic
baden-walker system of staging pelvic organ prolapse
dont need to know
Pelvic organ prolapse-quantification (POP-Q) system of classification of pelvic organ prolapse
-Stage 0: no prolapse
-Stage 1: most distal prolapse is > 1 cm above the hymen
-Stage 2: most distal prolapse is between 1 cm above and 1 cm below the hymen
-Stage 3: most distal prolapse is >1 cm below hymen but 2 cm shorter than entire vaginal length
-Stage 4: complete procidentia
management of pelvic organ prolapse
-Lifestyle modifications
-Treatment of constipation
-Kegel exercises
-Medical management
-Pessaries
-These support the pelvic structures and can work quite well
-Require fitting
-Some trial and error
-Should be used with estrogen cream
-Must be cleaned and replaced about every 6-8 weeks by patient or by clinician
surgical management of pelvic organ prolapse
-1. Abdominal sacral colpopexy
-2. uterosacral ligament fixation
-3. sacrospinous ligament fixation:
-all 3 correct upper vaginal prolapse
-last 2 are done at time of hysterectomy
-LeFort Colpocleisis:
-vaginal vault prolapse
-indicated in uterine prolapse in pts who do not want further possibility of vaginal penetration
-For patients who can tolerate major surgery:
-Hysterectomy
-Remember to support vaginal apex, if possible, with abdominal sacral colpopexy or sacrospinous ligament fixation
-For patients who cannot tolerate hysterectomy:
-Colpocleisis
-Closure of vaginal vault in patients who no longer desire vaginal penetration
-Complete colpocleisis
-LeFort colpocleisis
abdominal sacral colpopexy
-Apex of vagina is sewn to fascia or to other structure
-Fascia is harvested from thigh
-Other end of fascia is affixed to periosteum of sacrum
sacrospinous ligament fixation
-similar to abdominal sacral colpopexy but instead utilizes sacrospinous ligament for attachment
colpocleisis: closure of vaginal vault
-COMPLETE COLPOCLEISIS:
-Patient must understand that vaginal penetration is impossible after surgery
-Requires prior hysterectomy
-LEFORT COLPOCLEISIS
-Patient must understand that vaginal penetration is impossible after surgery
-Requires dilation and curettage or endometrial biopsy prior to surgery -> rules out incidental endometrial CA
-Lateral channels (“double barrel vagina” remain to permit drainage from vagina
LeFort colpocleisis
which of the following the most appropriate management of a large cystocele in a symptomatic 85yo pt with multiple medical problems
-pessary
-LeFort colpocleisis
-timed voiding
-intermittent catheterization
