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Obstetrics and Gynecology > Urinary incontinence and prolapse > Flashcards

Urinary incontinence and prolapse Flashcards

1
Q

what are some predisposing factors for incontinence

A

pelvic changes

neurology (UMNL, LMNL)

aging–can be aided by giving back some estrogen

mobility

renal

COPD

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2
Q

what are some precipitating factors for incontinence

A

irritative–UTI, FB

medications–direct vs. indirect

intercurrent illness

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3
Q

what happens if you damage the anterior vaginal wall pubocervical fascia

A

herniation of the bladder (cystocele) and/or urethra (uretherocele) into the vaginal lumen

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4
Q

what happens if you damage the endopelvic fascia of the rectovaginal septum in the posterior vaginal wall

A

herniation of the rectum (rectocele) into the vaginal lumen

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5
Q

what happens if you get injury to or stretching of the uterosacral and cardinal ligaments

A

can result in descensus/prolapse of the uterus (uterine prolapse)

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6
Q

what is an enterocele

A

prolapse of the small intestine after hysterectomy

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7
Q

what are the common presenting symptoms of pelvic prolapse

A

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

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8
Q

what processes most commonly compromise pelvic support

A

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

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9
Q

in what population is pelvic relaxation most commonly seen

A

post menopausal women

due to decreased endogenous estrogen, effects of gravity over time, normal aging in the setting of previous pregnancy and vaginal delivery

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10
Q

why does atrophy increase risk for pelvic relaxation

A

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

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11
Q

what is the prevalence of pelvic organ prolapse

A

2.9-9%

(some studies–11-19% chance of undergoing surgery)

lower rates in african american vs caucasian women

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12
Q

risk factors for pelvic organ prolapse

A

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
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13
Q

why does stress incontinence appear to “improve” sometimes as prolapse worsens

A

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

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14
Q

what is “splinting”

A

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

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15
Q

how is prolapse best examined

A

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)

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16
Q

what is complete procidentia

A

complete eversion of the vagina with the entire uterus prolapsing outside the vagina

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17
Q

how do you quantify pelvic prolapse

A

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)

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18
Q

ddx for cystocele and urethrocele

A

urethral diverticula

Gartner cysts

Skene gland cysts

tumours of urethra and bladder

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19
Q

ddx for rectocele

A

obstructive lesions of the colon and rectum (lipomas, fibromas, sarcomas)

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20
Q

ddx for uterine prolapse

A

cervical elongation

prolapsed cervical polyp

prolapsed uterine fibroid

prolapsed cervical and endometrial tumours

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21
Q

how do you treat asymptomatic prolapse

A

can be monitored-does not necessarily require tx (expectant management)

if patient is bothered–> can intervene

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22
Q

what is the basis for treatment of prolapse

A

essentially a structural problem therefore treatment revolves around reinforcing lost support to pelvis

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23
Q

list treatment modalities for prolapse

A
  1. kegel exercises/pelvic floor physio
  2. mechanical support devices (pessaries)
  3. surgical repair
  4. low dose vaginal estrogen in post menopausal women
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24
Q

why do we treat post menopausal women with prolapse with vaginal estrogen

A

improves tissue tone, facilitates reversal of atrophic changes in the vaginal mucosa

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25
Q

what is the mainstay of conservative management of prolapse

A

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

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26
Q

recurrence rate of prolapse after surgical correction

A

may be up to 30%

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27
Q

how do you surgically correct a cystocele

A

anterior colporrhaphy

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28
Q

how do you surgically correct a rectocele

A

posterior colporrhaphy

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29
Q

what is a colporhhaphy

A

repairs the fascial defects through which the herniation occurs

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30
Q

how do you surgically repair an enterocele

A

reinforce the rectovaginal fascia and the posterior vaginal wall

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31
Q

how might you manage significant uterine prolapse

A

vaginal or abdominal hysterectomy may be needed –> in itself not curative–> need to also do an apical suspension procedure

32
Q

how do you correct vaginal prolapse occuring after hysterectomy

A

suspend the vaginal apex to fixed points within the pelvis such as the sacrum

33
Q

how many women over the age of 75 experience urinary incontinence daily

A

20%

34
Q

what is the most common kind of urinary incontinence

A

stress

35
Q

what is urgency urinary incontinence

A

involuntary loss of urine assoc with urgency–may be assoc with detrusor overactivity

36
Q

what is mixed incontinence

A

urge and stress incontinence together

37
Q

list conditions associated with overflow urinary incontinence

A

diabetes

neuro diseases

severe genital prolapse

post-surgical obstruction from urinary continence procedures

38
Q

what is bypass urinary incontinence

A

usually due to urinary fistula formed between the urinary tract and vagina

usually happens due to pelvic surgery or radiation

39
Q

what is functional urinary incontinence

A

any condition that interferes with ability to reach toilet in timely fashion

often seen in elderly with dementia or limited mobility

40
Q

risk factors for urinary incontinence

A

AGE

obesity (worse for stress type)

T2DM (especially urgency)

pregnancy, vaginal delivery, pelvic surgery, medication (alpha blockers), smoking, genetics

41
Q

what med is a risk factor for incontinence

A

alpha blockers

42
Q

what is the mechanism behind urinary continence at rest

A

intraurethral pressure exceeds the intravesical pressure

43
Q

how do you stay continent

A

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

44
Q

what role does the SNS play in micturition

A

provides continence and prevents micturition by contracting bladder neck and internal sphincters

HYPOGASTRIC nerve originating in T10-L2

45
Q

what role does the PSNS play in micturition

A

allows micturition to occur

PELVIC nerve from S2, 3, 4

46
Q

what role does the somatic nervous system play in micturition

A

voluntary prevention of micturition

innervates striated muscle of the external sphincter and pelvic floor via PUDENDAL nerve

47
Q

how does micturition occur

A

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

48
Q

list bladder storage symptoms

A

daytime frequency

urgency

nocturia

49
Q

list voiding symptoms

A

hesitancy

slow stream

intermittency

dysuria

straining

spraying

incomplete emptying

retention

immediate voiding

postvoid leakage

position dependent voiding

50
Q

what should you include on an exam for urinary incontinence

A

pelvic

rectal

neuro exam (full) including deep tendon reflexes, pelvic floor contractions and bulbocavernosus reflex

51
Q

what is the goal of diagnostic testing for urinary incontinence

A

distinguish between stress incontinence and urgency incontinence –> because treatments are different

52
Q

what are usual initial tests for urinary incontinence

A

stress test

cotton swab test

cystometrogram

uroflowmetry

  • can also use voiding diary/bladder chart
  • UA and culture should be done to rule out infection
53
Q

how do you do a stress test for urinary incontinence

A

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

54
Q

what is the cotton swab test for urinary incontinence

A

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

55
Q

what are urodynamic studies

A

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

56
Q

what are the 3 major component of urodynamic studies

A
  1. evaluation of the urethral function–> urethrocystometry, urethral pressure profilometry
  2. bladder filling–> cystometry
  3. bladder emptying–> uroflowmetry and voiding cystometry or pressure flow studies
57
Q

what does cystometry measure

A

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

58
Q

when does the sensation to void typically occcur

A

when bladder filled with 150 mL of fluid

normal capacity is 400-600 mL

59
Q

what is the consequence of having a hypermobile urethra

A

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

60
Q

what are some lifestyle and behavior mods that can be used to treat stress incontinence

A

weight loss

caffeine restriction

fluid management

bladder training

pelvic floor muscle exercises

physical therapy

61
Q

what are the medical therapy options for stress incontinence

A

limited

alpha adrenergic agonists (midodrine, pseudoephedrine), beta adrenergic receptor antagonists and agonists (propanolol), TCAs and SNRIs have been tried, but limited data for use

62
Q

what are some surgical/mechanical solutions to stress incontinence

A

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

63
Q

what causes detrusor overactivity

A

most is idiopathic

UTIS
bladder stones
bladder cancer
urethral diverticula
foreign bodies 
stroke
spinal cord injury
Parkinson's disease 
MS
DM
64
Q

what are the most common drugs used to treat urgency incontinence

A

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

65
Q

side effects of anticholinergics

A

dry mouth

blurred near vision

tachycardia

drowsiness

decreased cognitive function

constipation

66
Q

who should not take anticholinergics

A

those with gastric retention, angle closure glaucoma and those with dementia (can worsen it)

67
Q

list common medications used for urgency incontinence

A
  1. oxybutinin (Ditropan) 5 mg PO TID to QID
  2. Tolterodine (Detrol) 2 mg PO BID

there are others but im too lazy

68
Q

list surgical treatment options for urgency incontinence

A

sacral and peripheral (posterior tibial nerve) neuromodulation

bladder injections–> botulinum toxin into detrusor muscle

augmentation cystoplasty –> for severe and refractory cases

69
Q

what usually causes overflow incontinence in women

A

underactive or acontractile destrusor muscle –> bladder contractions are weak or non existent

causes incomplete voiding, urinary retention, overdistention of the bladder

70
Q

neurogenic causes of overflow urinary incontinence

A

LMN disease

spinal cord injury

DM

MS

71
Q

obstructive causes of overflow urinary incontinence

A

post surgical urethral obstruction

post op overdistention

pelvic masses

fecal impaction

72
Q

pharmacological causes of overflow urinary incontinence

A

anticholinergics

alpha adrenergic agents

epidural and spinal anesthesia

other causes?

cystitis and urethritis

psychogenic (psychosis or severe depression)

idiopathic

73
Q

how do you manage overflow urinary incontinence medically

A

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

74
Q

how does bypass incontinence usually present

A

continuous incontinence

75
Q

what causes most urinary fistulas

A

in north america it is pelvic surgery or radiation

in developing countries, obstetric trauma is commonly a cause

76
Q

what is the primary treatment for urinary fistulas

A

surgery–> wait 3-6 months before attempting to repair post surgical fistulas

abx for infection and estrogen for postmenopausal women helps during this period

Obstetrics and Gynecology (21 decks)

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