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cOGtext > Urinary Incontinence and Prolapse > Flashcards

Urinary Incontinence and Prolapse Flashcards

1
Q

What are the 3 layers that make up the pelvic floor?

A

(ext to int)

perineal membrane -> muscles of perineal pouches -> pelvic diaphragm

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2
Q

What are the 2 muscle groups of the pelvic diaphragm?

A

levator ani and coccygeus

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3
Q

What are the 3 parts of the levator ani muscle?

A

PPI

Puborectalis
Puboccocygeus
Illiococcygeus

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4
Q

What are the supporting structures of level 1 of the pelvic floor (cervix and upper vagina)?

A

uterosacral, transverse cervical and pubocervical ligaments

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5
Q

What is the supporting structure of level 2 of the pelvic floor (middle vagina)?

A

pelvic fascia

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6
Q

What are the supporting structures of level 3 of the pelvic floor (lower vagina)?

A

levator ani muscles and perineal body

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7
Q

What is contained within the female deep perineal pouch?

A 
part of urethra
vagina
clitoral neurovascular bundle
extensions of ischioanal fat pads
smooth muscle
external urethral sphincter and compressor urethrae
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8
Q

What is contained within the female superficial perineal pouch?

A 
- Clitoris and crura (‘legs’ of the clitoris,
invisible to the naked eye)
- Bulbs of vestibule
- Bulbospongiosus
- Ischiocavernosus
- Also contains greater vestibular glands,
superficial transverse perineal muscle
and branches of internal pudendal
vessels and pudendal nerve
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9
Q

What are the 3 main causes of pelvic floor weakness?

A

1 - increased intra-abdominal pressure
2 - pelvic floor muscle trauma and denervation
3 - connective tissue disorder

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10
Q

Give examples of causes of increased intra-abdominal pressure in pelvic floor weakness?

A

obesity, chronic cough, occupational/recreational

exercise, constipation, intra-abdominal mass

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11
Q

Give examples of causes of pelvic floor muscle trauma and denervation in pelvic floor weakness?

A

obstetric trauma, pelvic fracture or surgery,

congenital

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12
Q

Give examples of causes of connective tissue disorders in pelvic floor weakness?

A

Age related, Oestrogen deficiency, Congenital or acquired

connective tissue disorders, Drug related: e.g. steroids

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13
Q

Define stress incontinence

A

Involuntary leakage of urine when there is increase intra-abdominal pressure, with the absence of detrusor muscle contraction

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14
Q

Name common predisposing risk factors of stress incontinence

A

Childbirth, pelvic surgery and oestrogen deficiency

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15
Q

Is prolapse seen in stress incontinence?

A

prolapse of urethra and anterior vagina wall can be present

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16
Q

What are some lifestyle changes and conservative methods that are used to manage stress incontinence?

A

Lifestyle: weight loss, smoking cessation, avoid constipation, smoking cessation, avoid heavy
lifting, caffeine reduction

Conservative: Pelvic floor muscle exercises for 3 months (often with physiotherapists), use of pads

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17
Q

What medical management is available for stress incontinence?

A

(if unsuitable for conservative or surgical options)

1st line: Duloxetine (adequate counselling of side effects needed)

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18
Q

What are some side effects of duloxetine?

A

difficulty sleeping, headaches, dizziness, blurred vision, change in bowel habits, nausea and vomiting, dry mouth, sweating, decreased appetite and weight loss
and decreased libido

19
Q

What are some surgical options for managing stress incontinence?

A

-Bulking agents
-Autologous rectus fascial sling
-Laparoscopic or open colposuspension
-Artificial urinary sphincters (In severe cases where previous surgery has failed)
-Tension free vaginal tape is the most commonly performed procedure, after other methods
are tried (Currently a national pause on mesh vaginal surgery so not recommended)

20
Q

Define urge incontinence

A

When an individual has increased urgency and frequency to void urine

21
Q

What are some causes of urge incontinence in women?

A

idiopathic, pelvic surgery, multiple sclerosis, spina bifida

22
Q

What is the volume of leakage difference in stress and urge incontinence?

A

Much larger volumes of leakage in urge incontinence

23
Q

Name some triggers of urge incontinence

A

Hearing running water, cold weather

24
Q

Name some triggers of stress incontinence

A

Sneezing, coughing, exercise

25
Q

What are some lifestyle changes and conservative methods that are used to manage urge incontinence?

A

Lifestyle: decrease fluid intake, minimise caffeine and diuretics (alcohol), use of pads

Bladder retraining with Incontinence team

26
Q

What medical management is available for urge incontinence?

A
  • Oxybutynin (anticholinergic) – not first line anti-cholinergic esp in elderly as can cause
    cognitive impairment. Tolterodine or Solifenacin preferred.
  • Mirabegron esp in the elderly is safer
  • Intravaginal oestrogens (useful for vaginal atrophy)
  • Consider desmopressin if nocturia
27
Q

What are some surgical options for managing urge incontinence?

A

Botox, Percutaneous sacral nerve stimulation, and augmentation cystoplasty

28
Q

What investigations should be done for incontinence symptoms?

A

Exclude UTI
Frequency/volume charts
Urodynamic testing

29
Q

Define overflow incontinence

A

Leakage of urine from a full urinary bladder, often with the absence of the urge to urinate

30
Q

What are some causes of overflow incontinence in women?

A
  • Inactive detrusor muscle: neurological conditions e.g. M.S -> no urge to urinate
  • Involuntary bladder spasms: can occur in cardiovascular disease and diabetes
  • Cystocele or uterine prolapse can block urine exit if severe
31
Q

Define urogenital prolapse

A

Descent of one of the pelvic organs resulting in protrusion of the vaginal wall

32
Q

What defines a 1st degree urogenital prolapse?

A

Mild protrusion on examination (-1cm of introitus)

33
Q

What defines a 2nd degree urogenital prolapse?

A

Prolapse present at introitus of vagina/anus/urethra (between -1cm and +1cm of introitus)

34
Q

What defines a 3rd degree urogenital prolapse?

A

Prolapse protruding outside of the introitus (beyond +1cm)

35
Q

What defines a 4th degree urogenital prolapse?

A

Complete prolapse - termed procidentia

36
Q

What are some risk factors of urogenital prolapse?

A

increasing age
multiparity, vaginal deliveries
obesity
spina bifida

37
Q

What are some symptoms of urogenital prolapse?

A

sensation of pressure, heaviness, ‘bearing down’

urinary incontinence, frequency, urgency

38
Q

What are non-surgical options for management of urogenital prolapse?

A

Lifestyle: weight loss, avoid constipation, smoking cessation, avoid heavy lifting, caffeine reduction

Pelvic floor training: kegels, pilates, supervised PFE with physio

Ring pessary

39
Q

What is the surgical management of cystocele/cystourethrocele?

A

anterior colporrhaphy

40
Q

What are surgical management options for uterine prolapse?

A

hysterectomy, sacrohysteropexy, sacrospinous fixation (sutures placed in
sacrospinous ligament medial to the ischial spine to fix prolapse in place)

41
Q

What is the surgical management of rectocele?

A

posterior colporrhaphy

42
Q

What is the appropriate management of a UTI in a non-pregnant women?

A

Trimethoprim or nitrofurantoin for 3 days

43
Q

What is the appropriate management of a UTI in a symptomatic pregnant women?

A

Urine culture done

Nitrofurantoin (1st and 2nd trimester), Trimethoprim 3rd trimester

44
Q

What is the appropriate management of a UTI in an asymptomatic pregnant women?

A

Urine culture should be done at 1st antenatal visit

High risk of progressing to acute pyelonephritis

Immediate course of Nitrofurantoin (avoid near term pregnancy), amoxicillin or cefalexin for 7 days should be started

Urine culture after treatment, for test of cure.

cOGtext (11 decks)

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