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Year 3 Clinical > Urinary Incontinence and Prolapse > Flashcards

Urinary Incontinence and Prolapse Flashcards

1
Q

Define urinary incontinence?

A

Complaint of any involuntary leakage of urine

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2
Q

Occurrence of urinary incontinence in females?

A

Most common in older females; incidence is rising due to the ageing female population

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3
Q

Types of urinary incontinence?

A

Overactive bladder (OAB)

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4
Q

What is stress UI?

A

Involuntary urine leakage on effort, exertion, sneezing, coughing, etc

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5
Q

What is urgency UI?

A

Involuntary urine leakage accompanied OR immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to delay)

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6
Q

What is mixed UI?

A

Involuntary urine leakage assoc. with both urgency AND exertion, effort, sneezing, coughing, etc

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7
Q

What is OAB?

A

Urgency that occur with/without urgency UI and usually with frequency and nocturia

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8
Q

Types of OAB?

A

OAB ‘wet’ - OAB that occurs with incontinence

OAB ‘dry’ - OAB that occurs without incontinence

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9
Q

Risk factors for UI?

A

Age

Parity

Obesity

Pregnancy and obstetric history

Menopause

UTIs

Smoking

FH of UI

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10
Q

Impact of urinary incontinence of QoL?

A

Sexual:
• Avoidance of sexual contact and intimacy

Occupational:
• Absence from work
• Decreased productivity

Physical:
• Limitations of cessation of physical activities

Domestic:
• Requirements for specialised underwear, bedding
• Special precautions with clothing

Psychological:
• Guilt / depression
• Loss of self-respect and dignity
• Fear of being burdensome, lack of bladder control and urine odour
• Apathy / denial

Social:
• Reduction in social interaction
• Alteration of travel plans

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11
Q

Approaching the patient with UI?

A

Categorise it the UI

Ask for a bladder diary (3 days) and tell the patient to reduce their caffeine intake in that time

Separate symptoms into:
• Storage symptoms
• Voiding symptoms
• Post-micturition symptoms

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12
Q

Storage symptoms assoc. with UI?

A

Frequency, nocturia

Urgency

UUI, SUI

Constant leak

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13
Q

Voiding symptoms assoc. with UI?

A

Hesitancy

Straining to void

Poor flow

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14
Q

Post-micturition symptoms assoc. with UI?

A

Incontinence

Incomplete emptying

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15
Q

Examination of patient with UI?

A

Check BMI (if high, increased likelihood of SUI)

Abdominal examination - check for masses, inc. at the bladder

Vaginal examination - check for atrophy, prolapse, SUI (ask the patient to cough) and fistulas

PR exam - check anal tone and for masses

Cognitive impairment

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16
Q

Differentiating OAB with urge incontinence from stress incontinence?

A

OAB is assoc. with frequent, involuntary detrusor contractions; the detrusor instability can cause symptoms of urgency or the sudden loss of urine (UUI)

With SUI, when the bladder muscle experiences a stress-related contraction, the support muscles are unable to remain completely shut; this can be caused by urethral hypermobility:
• Significant displacement of the urethra and bladder neck during exertion and increased abdominal P
• Urethral sphincter weakness (can occur after trauma, hypo-oestrogenism, ageing or surgical procedures)

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17
Q

Ix for UI?

A

Urinalysis (for a UTI)

Post-void residual - a certain V of urine is left behind, in the bladder, after voiding; check if this V is abnormal

Urodynamics

Cystoscopy

Imaging

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18
Q

Conservative Mx of UI?

A

Lifestyle interventions:
• Caffeine
• Fluid intake
• Weight loss

Pelvic Floor Exercises (PFE) for 3 months

Bladder retraining for 6 weeks

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19
Q

Spectrum of treatments available for OAB?

A 
From least to most invasive:
• Lifestyle advice
• Bladder drill
• Pelvic floor physiotherapy
• Drugs 
• Botulinum toxin
• Neuromodulation
• Reconstructive surgery
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20
Q

Anti-muscarinic agents used to treat OAB?

A

Oxybutynin

Tolteridone

Darifenicin

Once started, review at 4 weeks; if oral is not tolerated, use transdermal

21
Q

Mechanics of action of anti-muscarinics, in the treatment of OAB?

A

Reduce intravesical P

Increased bladder compliance

Raise the threshold volume for micturition

Reduce uninhibited contractions

22
Q

Side effects of anti-muscarinics?

A

Dry mouth
Constipation
Blurred vision
Somnolence

23
Q

Other drugs used in the treatment of OAB?

A

Mirabegron (β3-agonists) - selectively activates β3-adrenoceptrs to relax bladder smooth muscle; it also increases the voiding interval and inhibits spontaneous bladder contractions during filling

Desmopressin can be added is the patient experiences nocturia

Topical oestrogen

24
Q

Non-pharmacological management of OAB?

A

Botox - the patient must know and be willing to intermittent self-catheterise

Percutaneous sacral nerve stimulator

Augmentation cytoplasty

25
Q

Mx of SUI?

A

Duloxetine - conservative measure are used first; it is a combined noradrenaline and serotonin reuptake inhibitor and it increases the intrautethral closure pressure

Surgery:
• Tension-free tape
• Colposuspension
• Intramural bulking agents
• Artificial sphincters
26
Q

3 compartments that can be involved with pelvic prolapse?

A
  • Anterior
  • Middle or apical
  • Posterior
27
Q

Occurrence of pelvic organ prolapse?

A

Common - it occurs in up to 50% of parous women and 10-20% are symptomatic

Incidence is increasing, due to increased female life expectancy and increased expectations for QoL

28
Q

Which prolapses affect the anterior compartment?

A

Cystocoele

ADD IMAGE

29
Q

Symptoms of a cystocoele?

A

Bulging

Pressure

Mass effect

Difficulty voiding, incomplete emptying, difficulty inserting tampon

Pain with intercourse

Splinting vaginal wall

30
Q

Which prolapses affect the middle / apical compartment?

A

Vaginal vault prolapse

Enterocoele

31
Q

Symptoms of prolapses of the middle / apical compartment?

A

Bulging

Pressure

Mass effect

Difficulty voiding, incomplete emptying, difficulty inserting tampon

Pain with intercourse

Splinting vaginal wall

NOTE - these are the same as for the anterior compartment

32
Q

Which proplapses affect the posterior compartment?

A

Bulging

Pressure

Mass effect

Difficulty defecating, incomplete defecation

Splinting of the vaginal wall or perineum

Difficulty inserting a tampon

33
Q

Types of complete eversion?

A

i.e: affecting all compartment

Uterine procidentia

Complete uterine prolapse

?????????

34
Q

Risk factors for prolapse?

A

Age

Parity and vaginal delivery

Post-menopausal oestrogen deficiency

Obesity

Neurological conditions, e.g: spina bifida and muscular dystrophy

Genetic CT disorders, e.g: Marfan’s syndrome, ehlers-danlos syndrome

35
Q

History factors to consider with prolapse?

A

Pressure and dragging sensations

Urinary and bowel symptoms

Sexual dysfunction

36
Q

Ix of a patient with prolapse?

A

It is a clinical diagnosis (history + examination)

USS, MRI scan

Anorectal manometry

Endoanal USS

37
Q

What is the Pelvic Organ Prolapse Quantification System (POP-Q)?

A

6 specific sites are evaluated while the patient is straining

3 sites are measures at rest

38
Q

How are measurements for POP-Q made?

A

Measure each site (cm) in relation to the hymenal ring; this fixed point is the zero point of reference

If the site is above the hymen, the measurement is -ve

If the site is below the hymen, the measurement is +ve

39
Q

Interpret these POP-Q figures?

ADD IMAGE

A

Normal

40
Q

Interpret these POP-Q figures?

ADD IMAGE

A

…..

41
Q

Staging of prolapses?

A

Used more often than POP-Q, as it is simpler

Stage 0 – no prolapse

Stage I – 1cm above hymen

Stage II - -1 and +1 in relation to hymen

Stage III - > 1cm beyond hymen

Stage IV – complete vaginal eversion

42
Q

Mx options for prolapse?

A

Conservative Mx

Mechanical devices (pessaries)

Surgery

43
Q

When can pessaries be used to manage prolapses?

A

For a mild-moderate prolapse

If the patient’s family is not yet complete

Frail patients

At patient request, e.g: if they do not wish to have surgery

44
Q

Complications of pessaries?

A

Discharge

Ulcerations (may lead to a fistula) - requires pessary removal, treatment with topical oestrogen and then reinsertion

Fibrous bands

45
Q

Duration of use of a single pessary?

A

Change 6 monthly

46
Q

Surgery for prolapses?

A

Anterior:
• Vaginal repair

Posterior:
• Vaginal repair

Apical:
• Vaginal - sacrospinous fixation, colpocliesis (very effective but no sexual intercourse afterwards, i.e: it is only done in older women who are no longer sexually active)
• Abdominal - sacrohysteropexy, sacrocolpopexy, pectopexy

47
Q

Describe the procedure of a sacrohysteropexy

A

Surgical procedure to correct uterine prolapse

It inv. a resuspension of the prolapsed uterus, using a strip of synthetic mesh to lift the uterus and hold it in place

Allows for normal sexual function and preserves childbearing function

48
Q

Describe the procedure of a sacrocolpopexy

A

Uses mesh for repair

Year 3 Clinical (100 decks)

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