Urinary incontinence and prolapse Flashcards
what are some predisposing factors for incontinence
pelvic changes
neurology (UMNL, LMNL)
aging–can be aided by giving back some estrogen
mobility
renal
COPD
what are some precipitating factors for incontinence
irritative–UTI, FB
medications–direct vs. indirect
intercurrent illness
what happens if you damage the anterior vaginal wall pubocervical fascia
herniation of the bladder (cystocele) and/or urethra (uretherocele) into the vaginal lumen
what happens if you damage the endopelvic fascia of the rectovaginal septum in the posterior vaginal wall
herniation of the rectum (rectocele) into the vaginal lumen
what happens if you get injury to or stretching of the uterosacral and cardinal ligaments
can result in descensus/prolapse of the uterus (uterine prolapse)
what is an enterocele
prolapse of the small intestine after hysterectomy
what are the common presenting symptoms of pelvic prolapse
pelvic pressure and discomfort
dyspareunia
difficulty evacuating the bowels and bladder
low back discomfort
often associated with a visible or palpable bulge in the vagina
what processes most commonly compromise pelvic support
pregnancy and subsequent delivery
chronic increases in intra-abdominal pressure from obesity, chronic cough or chronic heavy lifting
connective tissue disorders
atrophic changes due to aging to estrogen deficiency
in what population is pelvic relaxation most commonly seen
post menopausal women
due to decreased endogenous estrogen, effects of gravity over time, normal aging in the setting of previous pregnancy and vaginal delivery
why does atrophy increase risk for pelvic relaxation
associated with compromised elasticity, diminished vascular support and laxity in structural elements
tissues become less resilient to forces of gravity and increased intra-abdominal pressure and accumulative stresses on the pelvic support system take effect
what is the prevalence of pelvic organ prolapse
2.9-9%
(some studies–11-19% chance of undergoing surgery)
lower rates in african american vs caucasian women
risk factors for pelvic organ prolapse
advancing age
menopause
parity
conditions resulting in chronically elevated intra-abdominal pressure
hysterectomy (for apical prolapse)
- risk increases four and eightfold with the first two vaginal deliveries respectively
- obstructed labour and traumatic delivery are also risk factors
why does stress incontinence appear to “improve” sometimes as prolapse worsens
as the support for the anterior vaginal wall weakens and the bladder descends, a kink is introduced into the urethra–> mechanical obstruction that masquerades as improvement
what is “splinting”
when there is trouble voiding the bowels due to apical or rectal prolapse and to aid in defecation patients will apply manual pressure to the perineum or posterior vaginal wall
how is prolapse best examined
separate the labia and view the vagina while the patients strains or coughs
SPLIT SPECULUM exam should be performed using Sims speculum or lower half of a Grave speculum (examine anterior, posterior and midline defects)
what is complete procidentia
complete eversion of the vagina with the entire uterus prolapsing outside the vagina
how do you quantify pelvic prolapse
POP-Q
Pelvic Organ Prolapse Quantitative scale
focuses on the physical extent of the vaginal wall prolapse and not in which organ is presumed to be prolapsing within the defect
uses 6 points within the vagina that are measured relative to a fixed point of reference (hymen)
ddx for cystocele and urethrocele
urethral diverticula
Gartner cysts
Skene gland cysts
tumours of urethra and bladder
ddx for rectocele
obstructive lesions of the colon and rectum (lipomas, fibromas, sarcomas)
ddx for uterine prolapse
cervical elongation
prolapsed cervical polyp
prolapsed uterine fibroid
prolapsed cervical and endometrial tumours
how do you treat asymptomatic prolapse
can be monitored-does not necessarily require tx (expectant management)
if patient is bothered–> can intervene
what is the basis for treatment of prolapse
essentially a structural problem therefore treatment revolves around reinforcing lost support to pelvis
list treatment modalities for prolapse
- kegel exercises/pelvic floor physio
- mechanical support devices (pessaries)
- surgical repair
- low dose vaginal estrogen in post menopausal women
why do we treat post menopausal women with prolapse with vaginal estrogen
improves tissue tone, facilitates reversal of atrophic changes in the vaginal mucosa
what is the mainstay of conservative management of prolapse
pessaries
act as mechanical support devices to replace the lost structural integrity of the pelvis and to diffuse the forces of descent over a wider area
indicated for any patient who desires non surgical management and in those for whom surgery is contraindicated
recurrence rate of prolapse after surgical correction
may be up to 30%
how do you surgically correct a cystocele
anterior colporrhaphy
how do you surgically correct a rectocele
posterior colporrhaphy
what is a colporhhaphy
repairs the fascial defects through which the herniation occurs
how do you surgically repair an enterocele
reinforce the rectovaginal fascia and the posterior vaginal wall
how might you manage significant uterine prolapse
vaginal or abdominal hysterectomy may be needed –> in itself not curative–> need to also do an apical suspension procedure
how do you correct vaginal prolapse occuring after hysterectomy
suspend the vaginal apex to fixed points within the pelvis such as the sacrum
how many women over the age of 75 experience urinary incontinence daily
20%
what is the most common kind of urinary incontinence
stress
what is urgency urinary incontinence
involuntary loss of urine assoc with urgency–may be assoc with detrusor overactivity
what is mixed incontinence
urge and stress incontinence together
list conditions associated with overflow urinary incontinence
diabetes
neuro diseases
severe genital prolapse
post-surgical obstruction from urinary continence procedures
what is bypass urinary incontinence
usually due to urinary fistula formed between the urinary tract and vagina
usually happens due to pelvic surgery or radiation
what is functional urinary incontinence
any condition that interferes with ability to reach toilet in timely fashion
often seen in elderly with dementia or limited mobility
risk factors for urinary incontinence
AGE
obesity (worse for stress type)
T2DM (especially urgency)
pregnancy, vaginal delivery, pelvic surgery, medication (alpha blockers), smoking, genetics
what med is a risk factor for incontinence
alpha blockers
what is the mechanism behind urinary continence at rest
intraurethral pressure exceeds the intravesical pressure
how do you stay continent
continuous contraction of the internal sphincter
external sphincter provides about 50% of urethral resistance and is the second line of defence
when UVJ is in proper position, any sudden increase in intra abdo pressure is transmitted equally to bladder and proximal third of urethra–> as long as intraurethral pressure remains higher than intravesical, continence is preserved
what role does the SNS play in micturition
provides continence and prevents micturition by contracting bladder neck and internal sphincters
HYPOGASTRIC nerve originating in T10-L2
what role does the PSNS play in micturition
allows micturition to occur
PELVIC nerve from S2, 3, 4
what role does the somatic nervous system play in micturition
voluntary prevention of micturition
innervates striated muscle of the external sphincter and pelvic floor via PUDENDAL nerve
how does micturition occur
stretch receptors in bladder wall–> CNS–> inhibition of SNS and pudendal nerve–> relaxation of urethra, external sphincter and levator ani muscles–> activation of PSNS pelvic nerve–> contraction of detrusor
list bladder storage symptoms
daytime frequency
urgency
nocturia
list voiding symptoms
hesitancy
slow stream
intermittency
dysuria
straining
spraying
incomplete emptying
retention
immediate voiding
postvoid leakage
position dependent voiding
what should you include on an exam for urinary incontinence
pelvic
rectal
neuro exam (full) including deep tendon reflexes, pelvic floor contractions and bulbocavernosus reflex
what is the goal of diagnostic testing for urinary incontinence
distinguish between stress incontinence and urgency incontinence –> because treatments are different
what are usual initial tests for urinary incontinence
stress test
cotton swab test
cystometrogram
uroflowmetry
- can also use voiding diary/bladder chart
- UA and culture should be done to rule out infection
how do you do a stress test for urinary incontinence
fill bladder with up to 300 mL of NS through catheter–> ask patient to cough–> observe loss or urine–> if you see loss of urine it is genuine stress incontinence
get PVR after, and the rule out urinary retention and infection
what is the cotton swab test for urinary incontinence
purpose is to diagnose a hypermobile urethra associated with stress incontinence
insert lubricated cotton swab into urethra to angle of the UVJ–> when patient strains as if urinating, UVJ descends and cotton swab moves upward–> change in angle is normally less than 30 degrees–> if above 30, likely hypermobile urethra
what are urodynamic studies
functional studies of the lower urinary tract
usually reserved for patients contemplating surgery and for those in whom a clear diagnosis cannot be made on preliminary tests
what are the 3 major component of urodynamic studies
- evaluation of the urethral function–> urethrocystometry, urethral pressure profilometry
- bladder filling–> cystometry
- bladder emptying–> uroflowmetry and voiding cystometry or pressure flow studies
what does cystometry measure
part of urodynamic studies
measures the pressure and volume relationship of the bladder during filling and/or pressure flow study during voiding
can check bladder sensation, capacity, detrusor activity and bladder compliance
pressure sensors are placed into the bladder to measure intravesical pressure and into either the vagina or rectum to measure abdo pressure as the bladder is filled with fluid in retrograde fashion
when does the sensation to void typically occcur
when bladder filled with 150 mL of fluid
normal capacity is 400-600 mL
what is the consequence of having a hypermobile urethra
increases in intra-abdo pressure are no longer transmitted equally to the bladder and urethra
instead, increases in intra-abdo pressure are transmitted primarily to the bladder–> causes stress incontinence as causes intra-vesical pressure to exceed intra-urethral pressure
what are some lifestyle and behavior mods that can be used to treat stress incontinence
weight loss
caffeine restriction
fluid management
bladder training
pelvic floor muscle exercises
physical therapy
what are the medical therapy options for stress incontinence
limited
alpha adrenergic agonists (midodrine, pseudoephedrine), beta adrenergic receptor antagonists and agonists (propanolol), TCAs and SNRIs have been tried, but limited data for use
what are some surgical/mechanical solutions to stress incontinence
incontinence pessaries–> physically elevates and supports the urethra restoring normal anatomical relationships
surgery is frequently tx of choice–> Burch procedure (abdominal retropubic urethroplexy), bladder neck sling, tension free mid-urethral slings
what causes detrusor overactivity
most is idiopathic
UTIS bladder stones bladder cancer urethral diverticula foreign bodies stroke spinal cord injury Parkinson's disease MS DM
what are the most common drugs used to treat urgency incontinence
anticholinergics with antimuscarinic effects
act by increasing the bladder capacity and decreasing urgency resulting in decreased accidents
may take up to 4 weeks to work
side effects of anticholinergics
dry mouth
blurred near vision
tachycardia
drowsiness
decreased cognitive function
constipation
who should not take anticholinergics
those with gastric retention, angle closure glaucoma and those with dementia (can worsen it)
list common medications used for urgency incontinence
- oxybutinin (Ditropan) 5 mg PO TID to QID
- Tolterodine (Detrol) 2 mg PO BID
there are others but im too lazy
list surgical treatment options for urgency incontinence
sacral and peripheral (posterior tibial nerve) neuromodulation
bladder injections–> botulinum toxin into detrusor muscle
augmentation cystoplasty –> for severe and refractory cases
what usually causes overflow incontinence in women
underactive or acontractile destrusor muscle –> bladder contractions are weak or non existent
causes incomplete voiding, urinary retention, overdistention of the bladder
neurogenic causes of overflow urinary incontinence
LMN disease
spinal cord injury
DM
MS
obstructive causes of overflow urinary incontinence
post surgical urethral obstruction
post op overdistention
pelvic masses
fecal impaction
pharmacological causes of overflow urinary incontinence
anticholinergics
alpha adrenergic agents
epidural and spinal anesthesia
other causes?
cystitis and urethritis
psychogenic (psychosis or severe depression)
idiopathic
how do you manage overflow urinary incontinence medically
agents that reduce urethral closing pressure:
prazosin
terazosin
phenobenzamine
striated muscle relaxants to reduce bladder outlet resistance:
diazepam
dantrolene
cholinergic agents to increase bladder contractility:
bethanechol
how does bypass incontinence usually present
continuous incontinence
what causes most urinary fistulas
in north america it is pelvic surgery or radiation
in developing countries, obstetric trauma is commonly a cause
what is the primary treatment for urinary fistulas
surgery–> wait 3-6 months before attempting to repair post surgical fistulas
abx for infection and estrogen for postmenopausal women helps during this period
