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Gynaecology > Urinary incontinence and prolapse > Flashcards

Urinary incontinence and prolapse Flashcards

1
Q

voiding phase

A

coordinated activity:
relaxation of sphincters
contraction of detrusor muscle
normal position of ureter creates sphincter effect

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2
Q

urinary incontinence history

A 
stress/urge
frequency
amount of leakage
pad use
lifestyle modifications
fluid intake
prolapse
faecal symptoms
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3
Q

obstetric history urinary incontinence

A

birth weight
perineal trauma
forceps delivery
duration of second stage

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4
Q

previous surgery urinary incontinence

A

hysterectomy
incontinence operations
pelvic floor repair

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5
Q

medical and family history urinary incontinence

A

lung disease, COPD meds
connective tissue disease
diabetes
HTN (for diuretics)

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6
Q

examination in urinary incontinence

A 
obesity
scars
abdominal/pelvic masses
visible incontinence
prolapse
pelvic floor tone
CNS
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7
Q

quantitative tools in incontinence

A 
urinalysis
diaries
pad tests
renal tract imaging and cystoscopy
cystometry
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8
Q

urinalysis in incontinence

A

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

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9
Q

diaries in incontinence

A

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

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10
Q

pad tests in incontinence

A

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

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11
Q

renal tract imaging and cystoscopy, incontinence

A

Haematuria

Recurrent UTI

Painful bladder

Sensory urgency

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12
Q

cystometry in incontinence

A

Functional test of bladder function

Capacity

Flow rate and voiding function

Demonstrate leakage with intravesical pressure

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13
Q

urge incontinence definition

A

overactivity of the detrusor muscle of the bladder

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14
Q

stress incontinence definition

A

weakness of pelvic floor and sphincter muscles

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15
Q

causes of urinary incontinence

A 
stress incontinence
urge incontinence
overflow incontinence
bladder fistulae
urethral diverticulum
congenital anomalies, ectopic ureter
functional incontinence
temporary incontinence
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16
Q

causes of urge incontinence

A 
idiopathic
MS
spina bifida 
pelvic incontinence/ surgery
childhood uti
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17
Q

pelvic floor canals

A

urethral
vagina
rectal canals

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18
Q

risk factors for stress incontinence

A

oestogen deficient states
pelvic surgery
irradiation

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19
Q

causes of stress incontinence

A

incompetent urethral sphincter: childbirth, menopause, prolapse, chronic cough

positional displacement

intrinsic weakness

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20
Q

examination stress incontinence

A

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
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21
Q

causes of overflow incontinnce

A

anticholinergic medications
fibroids
pelvic tumours
MS, diabetic nephropathy, spinal cord injuries

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22
Q

risk factors for urinary incontinence

A

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

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23
Q

examination in urinary incontinence

A

pelvic organ prolapse
atrophic vaginitis
urethral diverticulum
pelvic masses

24
Q

investigation of urinary incontinence

A

bladder diary
urine dipstick testing
post-void residual bladder volume with bladder scan
urodynamic testing

25
Q

lifestyle factors

A

caffeine
alcohol
medications
BMI

26
Q

urodynamic tests

A

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

27
Q

cystometry

A

Cystometry measures the detrusor muscle contraction and pressure

28
Q

uroflometry

A

Uroflowmetry measures the flow rate

29
Q

leak point pressure

A

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.

30
Q

post-void residual bladder volume tests

A

Post-void residual bladder volume tests for incomplete emptying of the bladder

31
Q

video urodynamic testing

A

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.

32
Q

general measures in incontinence

A

Sensible fluid intake:

1,500-2,500ml/day

Tea, coffee, alcohol are all diuretic

Mobility aids or downstairs toilets

Pads, bedpans, commodes etc.

33
Q

management of stress incontinence

A

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

`

34
Q

surgical measures for stress UI

A 
burch colposuspension
laproscopic colposuspension
tension free vaginal tape
transobturator rapes
intramural urethrl bulking
periurethral injections
35
Q

burch colposuspension

A

this is now rarely performed due to the introduction of vaginal tapes. It involves inserting sutures between the paravaginal fascia and Cooper’s ligament.

36
Q

tension free vaginal tape

A

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.

37
Q

urge incontinence management

A 
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

38
Q

medical management of urge incontinence

A

oxybutynin, solifenacin, tolterodine
intravaginal oestrogen
boutilism toxin A
neuromodulation and sacral nerve stimulation

39
Q

surgical management of stress incontinence

A

detrusor myomectomy and augmentation cystoplasty

urinary diversion

40
Q

anticholinergic side effects

A 
dry mouth
urinary retention
constipation
postural hypotension
cognitive decline, memory problems, worsening of dementia
41
Q

mirabegnon urge incontinence

A

contraindicated in uncontrolled HTN
b3 agonist
less of anticholinergic burden

42
Q

prolapse

A

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.

43
Q

vault prolapse

A

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.

44
Q

rectocele

A

defect in posterior vaginal wall
rectum prolpses forwards into the vagina
associated with constipation and urinary retention

45
Q

cystocele

A

defect in anterior vaginal wall

bladder prolapses backwards into vagina

46
Q

risk factors for pelvic organ prolapse

A

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

47
Q

presenting symptoms

A

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

48
Q

examination findings in prolapse

A

empty bladder and bowel
Sim’s speculum
cough or bear down

49
Q

grades of uterine prolapse

POP-Q

A

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

50
Q

uterine procidentia

A

A prolapse extending beyond the introitus can be referred to as uterine procidentia

51
Q

management of prolapse

A

conservative
vaginal pessary
surgical

52
Q

conservative measures for prolapse

A

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

53
Q

vaginal pessaries for prolapse

A

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

54
Q

possible complications of pelvic organ surgery

A

Pain, bleeding, infection, DVT and risk of anaesthetic

Damage to the bladder or bowel

Recurrence of the prolapse

Altered experience of sex

55
Q

mesh repairs complications

A

Chronic pain

Altered sensation

Dyspareunia (painful sex) for the women or her partner

Abnormal bleeding

Urinary or bowel problems

56
Q

complications of pelvic organ prolapse

A

Recurrent prolapse

Haemorrhage and vault haematoma

Vault infection

DVT

New incontinence

Ureteric or bladder injury

Gynaecology (10 decks)

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