Urinary incontinence and prolapse Flashcards
voiding phase
coordinated activity:
relaxation of sphincters
contraction of detrusor muscle
normal position of ureter creates sphincter effect
urinary incontinence history
stress/urge frequency amount of leakage pad use lifestyle modifications fluid intake prolapse faecal symptoms
obstetric history urinary incontinence
birth weight
perineal trauma
forceps delivery
duration of second stage
previous surgery urinary incontinence
hysterectomy
incontinence operations
pelvic floor repair
medical and family history urinary incontinence
lung disease, COPD meds
connective tissue disease
diabetes
HTN (for diuretics)
examination in urinary incontinence
obesity scars abdominal/pelvic masses visible incontinence prolapse pelvic floor tone CNS
quantitative tools in incontinence
urinalysis diaries pad tests renal tract imaging and cystoscopy cystometry
urinalysis in incontinence
Screening for infection
Some patients will be cured by treatment
Sign of underlying abnormality
Stone
Tumour
Plumbing
Active infection can cause false diagnosis at cystometry
diaries in incontinence
Patient completed record (3-7 days)
Allows estimate of intake, functional bladder volume and frequency:
Excessive intake (>2000ml)
Confirms symptoms
Used as adjunct to bladder drill
pad tests in incontinence
Objective measure of amount of leakage
Duration 1 hour to 24 hours
Shorter tests of dubious value:
Poor reproducibility
Poor correlation with other measures
24 hour pad test at home is best
renal tract imaging and cystoscopy, incontinence
Haematuria
Recurrent UTI
Painful bladder
Sensory urgency
cystometry in incontinence
Functional test of bladder function
Capacity
Flow rate and voiding function
Demonstrate leakage with intravesical pressure
urge incontinence definition
overactivity of the detrusor muscle of the bladder
stress incontinence definition
weakness of pelvic floor and sphincter muscles
causes of urinary incontinence
stress incontinence urge incontinence overflow incontinence bladder fistulae urethral diverticulum congenital anomalies, ectopic ureter functional incontinence temporary incontinence
causes of urge incontinence
idiopathic MS spina bifida pelvic incontinence/ surgery childhood uti
pelvic floor canals
urethral
vagina
rectal canals
risk factors for stress incontinence
oestogen deficient states
pelvic surgery
irradiation
causes of stress incontinence
incompetent urethral sphincter: childbirth, menopause, prolapse, chronic cough
positional displacement
intrinsic weakness
examination stress incontinence
Involuntary leakage of urine on exertion
Mobile bladder neck
Prolapse: cystocele, urethrocele
Cystometry: Normal capacity bladder Leakage in absence of detrusor pressure rise Provoked by cough test Usually small to moderate loss
causes of overflow incontinnce
anticholinergic medications
fibroids
pelvic tumours
MS, diabetic nephropathy, spinal cord injuries
risk factors for urinary incontinence
Increased age
Postmenopausal status
Increase BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions, such as multiple sclerosis
Cognitive impairment and dementia
examination in urinary incontinence
pelvic organ prolapse
atrophic vaginitis
urethral diverticulum
pelvic masses
investigation of urinary incontinence
bladder diary
urine dipstick testing
post-void residual bladder volume with bladder scan
urodynamic testing
lifestyle factors
caffeine
alcohol
medications
BMI
urodynamic tests
stop anticholinergic and bladder-related medications around 5 days before tests
thin catheter into bladder and then into rectum
cystometry
uroflometry
leak point pressure
post-void residual bladder volume tests
video urodynamic testing
cystometry
Cystometry measures the detrusor muscle contraction and pressure
uroflometry
Uroflowmetry measures the flow rate
leak point pressure
Leak point pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence.
post-void residual bladder volume tests
Post-void residual bladder volume tests for incomplete emptying of the bladder
video urodynamic testing
Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.
general measures in incontinence
Sensible fluid intake:
1,500-2,500ml/day
Tea, coffee, alcohol are all diuretic
Mobility aids or downstairs toilets
Pads, bedpans, commodes etc.
management of stress incontinence
Avoiding caffeine, diuretics and overfilling of the bladder
Avoid excessive or restricted fluid intake
Weight loss (if appropriate)
Supervised pelvic floor exercises for at least three months before considering surgery
Surgery
Duloxetine is an SNRI antidepressant used second line where surgery is less preferred
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surgical measures for stress UI
burch colposuspension laproscopic colposuspension tension free vaginal tape transobturator rapes intramural urethrl bulking periurethral injections
burch colposuspension
this is now rarely performed due to the introduction of vaginal tapes. It involves inserting sutures between the paravaginal fascia and Cooper’s ligament.
tension free vaginal tape
Tension free vaginal tape (TVT) – the most commonly performed operation with a high objective cure rate. It involves a tape being placed under the mid urethra via a small vaginal incision.
There has been recent controversy over this procedure with many women reporting complications of erosions into the vagina, urethra and bladder resulting in chronic pelvic pain.
urge incontinence management
lifestyle Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
Mirabegron is an alternative to anticholinergic medications
Invasive procedures where medical treatment fails
medical management of urge incontinence
oxybutynin, solifenacin, tolterodine
intravaginal oestrogen
boutilism toxin A
neuromodulation and sacral nerve stimulation
surgical management of stress incontinence
detrusor myomectomy and augmentation cystoplasty
urinary diversion
anticholinergic side effects
dry mouth urinary retention constipation postural hypotension cognitive decline, memory problems, worsening of dementia
mirabegnon urge incontinence
contraindicated in uncontrolled HTN
b3 agonist
less of anticholinergic burden
prolapse
Pelvic organ prolapse refers to the descent of pelvic organs into the vagina.
Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.
vault prolapse
Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina.
Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina.
rectocele
defect in posterior vaginal wall
rectum prolpses forwards into the vagina
associated with constipation and urinary retention
cystocele
defect in anterior vaginal wall
bladder prolapses backwards into vagina
risk factors for pelvic organ prolapse
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining
Connective tissue disease
Smoking
presenting symptoms
A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
examination findings in prolapse
empty bladder and bowel
Sim’s speculum
cough or bear down
grades of uterine prolapse
POP-Q
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
uterine procidentia
A prolapse extending beyond the introitus can be referred to as uterine procidentia
management of prolapse
conservative
vaginal pessary
surgical
conservative measures for prolapse
Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
Vaginal oestrogen cream
vaginal pessaries for prolapse
Ring pessaries are a ring shape, and sit around the cervix holding the uterus up
Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
Cube pessaries are a cube shape
Donut pessaries consist of a thick ring, similar to a doughnut
Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.
give oestrogen cream to prevent irritation from pessary
possible complications of pelvic organ surgery
Pain, bleeding, infection, DVT and risk of anaesthetic
Damage to the bladder or bowel
Recurrence of the prolapse
Altered experience of sex
mesh repairs complications
Chronic pain
Altered sensation
Dyspareunia (painful sex) for the women or her partner
Abnormal bleeding
Urinary or bowel problems
complications of pelvic organ prolapse
Recurrent prolapse
Haemorrhage and vault haematoma
Vault infection
DVT
New incontinence
Ureteric or bladder injury
