urinary incontinence and prolapse Flashcards
What is stress urinary incontinence?
-leakage of urin during an increase in intra-abdo pressure
What is an overactive bladder?
-leakage assoc. with urgency usually and detrusor activity
What symptoms are seen with urinary incontinence:
- irritative
- voiding difficultie
- others
Irritative:
- frequency
- urgency
- nocturia
- dysuria
voiding difficulties:
- hesistancy
- poor flow
- incomplete emptying
What investigations are done for urinary incontinence?
urodynamic studies - differentiate between SUI and OAB in pt. considered for surgery
uroflowmetry:
-empty bladder and flow rate measured
Cystometry:
- sensor in bladder and rectum/vagina
- sensor on detrusor
- when bladder fills pressure in rectum and vagina and bladder is the same
- when voiding, pressure in the bladder increases over the abdo. pressure
- when coughing, pressure in the bladder is same as abdo/rectum/vagina: all go up
- detrusor pressure should only go up on voiding
Describe the conservative management of stress incontinence?
Lifestyle (loose weight, stop smoking, avoid caffeinated drinks, avoid excessive fluid intake)
Physiotherapy: pelvic floor muscle retraining, biofeedback, electrical stimulation, pessaries
Drugs: Duloexetine : combined noradrenaline and serotonin reuptake inhibitor (increase intraurethral closure pressure)
Others: incontinence pads, vaginal pessaries
Describe surgical management of stress incontinence
Low tension vaginal tape
Intraurethral injection
Artificial sphincters
Colposuspension
Describe conservative treatment of overactive bladder
Lifestyle: avoid caffeinated drinks
Physiotherapy:bladder training
Drugs: antimuscarinic drugs (oxybutynin) block detrusor muscarinic receptors and decrease the ablility of detrusor muscles to contract
B-3 receptor agonists
Describe the surgical management of OAB
RARELY USED Botox injections Sacral nerve modulation Augmentation cystoplasty Bladder overdistension
What are the differen degrees of pelvic organ prolapse?
1st degree (in vagina), 2nd degree (at interiotus), 3rd degree (outside vagina) Procidentia (entirely outside vagina)
-uterine arteries lie over ureters and the ureters can get obstructed
Describe the anatomical types of prolapse?
urethrocele (urethra),
cytocele (bladder),
rectocele (rectum),
enterocele (pouch of Douglas containing small bowel)
vaginal vault
uterus and cervix
What are the symptoms seen with:
- any prolapse
- cystourethrocele
- uterine/vault prolapse
- rectocele
Any:
- asymptomatic,
- feeling SCD
- coital difficulties
Cystourethrocele:
- stress urinary incontinence
- urinary retention,
- recurrent UTI
Uterine/vault prolapse:
backache
- ulceration if procidentia /everted
Rectocele:
constipation
dyschezia
What is included in the assessment of pelvic organ prolapse?
If significant urinary symptoms:
MSSU
bladder chart
consider drug treatment/referral urodynamics
If significant faecal incontinence:
referral colorectal surgeons
If pelvic/intra-abdominal mass
ultrasound/other imaging
What is the conservative management for uterovaginal prolapse?
Reassure
Avoid heavy lifting, loose weight, stop smoking, reduce constipation
Vaginal oestrogens: only if symptomatic atrophic vaginitis
Physiotherapy
Pessary
Who is suitable for pessary use with pelvic organ prolapse?
Women unfit for surgery
Relief symptoms whilst awaiting surgery
Further pregnancies planned or pregnant
As diagnostic test for prolapse/ensure correction of large cystourethrocele not cause SUI
Patient request
When is surgical management of pelvic organ prolapse done
Only consider after failed conservative management and if major impact on quality of life
If concurrent urinary/faecal incontinence: investigate/manage prior to prolapse surgery
Move towards site specific reconstructive surgery, not just ‘treating the bulge’, treating fascial defect
Maintenance of coital function (not shorten or narrow vagina)
Tension free repair: may need graft tissue to bridge tissue
