Urinary Incontinence and Prolapse Flashcards
What are the 3 layers that make up the pelvic floor?
(ext to int)
perineal membrane -> muscles of perineal pouches -> pelvic diaphragm
What are the 2 muscle groups of the pelvic diaphragm?
levator ani and coccygeus
What are the 3 parts of the levator ani muscle?
PPI
Puborectalis
Puboccocygeus
Illiococcygeus
What are the supporting structures of level 1 of the pelvic floor (cervix and upper vagina)?
uterosacral, transverse cervical and pubocervical ligaments
What is the supporting structure of level 2 of the pelvic floor (middle vagina)?
pelvic fascia
What are the supporting structures of level 3 of the pelvic floor (lower vagina)?
levator ani muscles and perineal body
What is contained within the female deep perineal pouch?
part of urethra vagina clitoral neurovascular bundle extensions of ischioanal fat pads smooth muscle external urethral sphincter and compressor urethrae
What is contained within the female superficial perineal pouch?
- 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
What are the 3 main causes of pelvic floor weakness?
1 - increased intra-abdominal pressure
2 - pelvic floor muscle trauma and denervation
3 - connective tissue disorder
Give examples of causes of increased intra-abdominal pressure in pelvic floor weakness?
obesity, chronic cough, occupational/recreational
exercise, constipation, intra-abdominal mass
Give examples of causes of pelvic floor muscle trauma and denervation in pelvic floor weakness?
obstetric trauma, pelvic fracture or surgery,
congenital
Give examples of causes of connective tissue disorders in pelvic floor weakness?
Age related, Oestrogen deficiency, Congenital or acquired
connective tissue disorders, Drug related: e.g. steroids
Define stress incontinence
Involuntary leakage of urine when there is increase intra-abdominal pressure, with the absence of detrusor muscle contraction
Name common predisposing risk factors of stress incontinence
Childbirth, pelvic surgery and oestrogen deficiency
Is prolapse seen in stress incontinence?
prolapse of urethra and anterior vagina wall can be present
What are some lifestyle changes and conservative methods that are used to manage stress incontinence?
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
What medical management is available for stress incontinence?
(if unsuitable for conservative or surgical options)
1st line: Duloxetine (adequate counselling of side effects needed)
What are some side effects of duloxetine?
difficulty sleeping, headaches, dizziness, blurred vision, change in bowel habits, nausea and vomiting, dry mouth, sweating, decreased appetite and weight loss
and decreased libido
What are some surgical options for managing stress incontinence?
-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)
Define urge incontinence
When an individual has increased urgency and frequency to void urine
What are some causes of urge incontinence in women?
idiopathic, pelvic surgery, multiple sclerosis, spina bifida
What is the volume of leakage difference in stress and urge incontinence?
Much larger volumes of leakage in urge incontinence
Name some triggers of urge incontinence
Hearing running water, cold weather
Name some triggers of stress incontinence
Sneezing, coughing, exercise
What are some lifestyle changes and conservative methods that are used to manage urge incontinence?
Lifestyle: decrease fluid intake, minimise caffeine and diuretics (alcohol), use of pads
Bladder retraining with Incontinence team
What medical management is available for urge incontinence?
- 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
What are some surgical options for managing urge incontinence?
Botox, Percutaneous sacral nerve stimulation, and augmentation cystoplasty
What investigations should be done for incontinence symptoms?
Exclude UTI
Frequency/volume charts
Urodynamic testing
Define overflow incontinence
Leakage of urine from a full urinary bladder, often with the absence of the urge to urinate
What are some causes of overflow incontinence in women?
- 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
Define urogenital prolapse
Descent of one of the pelvic organs resulting in protrusion of the vaginal wall
What defines a 1st degree urogenital prolapse?
Mild protrusion on examination (-1cm of introitus)
What defines a 2nd degree urogenital prolapse?
Prolapse present at introitus of vagina/anus/urethra (between -1cm and +1cm of introitus)
What defines a 3rd degree urogenital prolapse?
Prolapse protruding outside of the introitus (beyond +1cm)
What defines a 4th degree urogenital prolapse?
Complete prolapse - termed procidentia
What are some risk factors of urogenital prolapse?
increasing age
multiparity, vaginal deliveries
obesity
spina bifida
What are some symptoms of urogenital prolapse?
sensation of pressure, heaviness, ‘bearing down’
urinary incontinence, frequency, urgency
What are non-surgical options for management of urogenital prolapse?
Lifestyle: weight loss, avoid constipation, smoking cessation, avoid heavy lifting, caffeine reduction
Pelvic floor training: kegels, pilates, supervised PFE with physio
Ring pessary
What is the surgical management of cystocele/cystourethrocele?
anterior colporrhaphy
What are surgical management options for uterine prolapse?
hysterectomy, sacrohysteropexy, sacrospinous fixation (sutures placed in
sacrospinous ligament medial to the ischial spine to fix prolapse in place)
What is the surgical management of rectocele?
posterior colporrhaphy
What is the appropriate management of a UTI in a non-pregnant women?
Trimethoprim or nitrofurantoin for 3 days
What is the appropriate management of a UTI in a symptomatic pregnant women?
Urine culture done
Nitrofurantoin (1st and 2nd trimester), Trimethoprim 3rd trimester
What is the appropriate management of a UTI in an asymptomatic pregnant women?
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.
