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gynaecology > urinary incontinence and prolapse > Flashcards

urinary incontinence and prolapse Flashcards

1
Q

what is genitourinary prolapse? Pathophysiology?

A

genitourinary prolapse occurs where there is weakness to the pelvic floor and thus allowing descent of the pelvic organs (urethra, bladder, rectum, vaginal vault and uterus).
This weakness is due to injury, nerve damage, disruption and stretching to the supporting structures.
This results in protrusions of vaginal wall

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2
Q

which muscle is the main support of the pelvic organs?

A 
Levator ani 
(and endopelvic fascia)
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3
Q

what are the different types of prolapse from the anterior compartment ?

A

urethrocele - prolapse of urethra into vagina - can lead to stress urinary incontinence

cystocele - prolapse of bladder into vagina - can lead to increased frequency and UTIs

urethrocystocele - most common form of prolapse. both bladder and urethra prolapse into vagina

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4
Q

what are the different types of prolapses from the middle compartment?

A

uterine prolapse - uterus prolapses into vagina = 2nd most common type of prolapse

vaginal vault prolapse (after hysterectomy the vagina is a blind ending)

enterocele - pouch of douglas prolapses down into vagina =3rd most common type of prolapse

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5
Q

what are the different types of prolapses from the posterior compartment?

A

rectocele - rectum prolapses into vagina

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6
Q

what is the 1st, 2nd and 3rd most common type of prolapse?

A

urethrocystocele - most common
uterine prolapse - second common
enterocele - third most common

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7
Q

how can uterine prolapses be classified (degrees of uterine prolapse) ?

A

1st degree - cervix remains with vagina
2nd degree - cervix protrudes out
3rd degree / procidenta - uterus lies entirely out of vagina

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8
Q

what are the stages of any vaginal prolapse?

A

stage 1: >1cm above hymen
stage 2: within 1cm of hymen
stage 3: >1cm below plane of hymen
stage 4: complete eversion from vagina

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9
Q

what are the risk factors for vaginal prolapse?

A

age - life time of stresses, with menopause less oestrogen which helps to keep structures springy and supportive

vaginal delivery - stretching of ligament, muscles and pelvic floor makes them weaker
increased parity

increase in abdominal pressure - chronic constipation and straining, obesity, heavy lifting and chronic cough

hysterectomy

family history, connective tissue disorders (Ehlers danlos, marfans)

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10
Q

what factors of vaginal increases the risk of vaginal prolapse?

A

forceps use
prolonged 2nd stage
large baby
<25 yrs of age at first delivery

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11
Q

how does uterine prolapse present? (vaginal symptoms only)

A 
feeling of fullness, heaviness, pressure
may feel something coming out, dragging sensation
may see or can touch a bulge 
spotting 
pain in vagina/ abdomen
difficulty retaining tampons
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12
Q

how does uterine prolapse present? (urinary symptoms only)

A 
frequency / nocturia
urge/ stress incontinence
feeling of incomplete emptying 
interrupted flow
UTI
may need to reduce prolapse before urinating
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13
Q

how does uterine prolapse present? (bowel symptoms only)

A

constipation and straining
urgency of stools and incontinence
may need to reduce prolapse before hand
feeling of incomplete evacuation

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14
Q

how does uterine prolapse present? (coital symptoms only)

A

dyspareunia
loss of vaginal sensation
vaginal flatus
vaginal discharge

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15
Q

overall how do uterine prolapses present?

A 
mild ones can be asymptomatic 
urinary symptoms
vaginal symptoms
coital problems
bowel symptoms
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16
Q

how are vaginal prolapses examined?

A

Examine standing and lying

  • ask patient to strain to see if prolapse comes out
  • may see a bulge anyway
    • from ruggae can assess if anterior / posterior

lying down:
- speculum - use a speculum on anterior wall to assess for posterior wall prolapases and vice verse (asking them to cough strain

may see hypertrophy, ulceration of the cervix or vaginal mucosa

rectal examination may be required if bowel symptoms

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17
Q

how can we distinguish between a rectocele and enterocele ?

A

simultaneous rectal and vaginal digital exam and ask patient to cough
mas felt in rectocele not enterocele

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18
Q

what investigations could be done for someone with a vaginal prolapse with urinary symptoms?

A

mainly trying to assess for the complications, as the diagnosis is made clinically

UEs, renal USS, MSU/ urinalysis (UTIs)
urodynamic studies
post void residual volume - bladder USS or catheter

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19
Q

what investigations could be done for someone with a vaginal prolapse with bowel symptoms?

A

mainly to assess complications, as diagnosis is made clinically

  • anal manometry
  • defecography
  • endoanal USS
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20
Q

what are the conservative management for vaginal prolapse

A 
weight loss advice
avoid heavy lifting 
pelvic floor exercises 
treat cough/ constipation 
smoking cessation

watchful waiting to see if things progress e.g. obstruction or vaginal erosions

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21
Q

what are the methods of treating vaginal prolapse?

A

conservative
vaginal pessary
oestrogen vaginal creams
surgery

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22
Q

what is a vaginal pessary?

A 
A structure (mainly a vaginal ring pessary is used) which is inserted into the vagina to hold structures in place and prevent prolapse
can be changed every 6 months and can still sex with pessary in or some women know how to take out and insert again 
good for those who don't want surgery
23
Q

what happens at review appointments in those with vaginal prolapse?

A

change pessaries
look for progression
look for vaginal erosions and apply cream

24
Q

what are the complications of a vaginal pessary?

A

vaginal discharge and odour
vesicovaginal and rectovaginal fistulas
faecal compaction
hydronephrosis

25
Q

give an example of a vaginal oestrogen cream? how does this help with prolapse?

A

ovestin
helps to make tissue more healthy and strong and protect from erosions
also helps with vaginal dryness, soreness post menopause

26
Q

what surgical can be used for vaginal prolapses?

A

vaginal wall repair operation

surgery for urethral/ bladder prolapse

- anterior colporrhaphy 
- colposuspension

surgery for uterine prolapse:

  • hysterectomy
  • sacrospinous fixation

surgery for rectocele/ enterocele
- posterior colporrhaphy

obliterative surgery

27
Q

what is vaginal repair operation and what are the complications?

A

the walls of the vagina are folded and reinforced (plication) and then mesh used to support

complications of mesh - erosions, bleeding, dyspareunia and pelvic pain

28
Q

what is anterior colporrhaphy

A

anterior fibromuscular vaginal wall plication

mesh reinforcement can be used

29
Q

what is colposusspension?

A

used for urethral spinchter incontinence associated with urethrocystocele

the paravaginal fascia on either side of bladder neck and base is sutured to pelvic side walls

30
Q

what is a sacrospinous fixation?

A

fix uterus to sacrospinous ligaments

31
Q

what is posterior colporrhaphy?

A

levator ani muscle plication +/- mesh reinforcement

32
Q

what is obliterative surgery for prolapse?

A

move pelvic viscera back into pelvis and close off vagina

100% effective but no intercourse

33
Q

what are the complications of prolapses?

A

ulceration and infection of organs prolapsed out of vagina
stress incontinence, chronic retention, UTIs
bowel dysfunction
urinary prolapse gradually worsens.

correction of prolapse can also result in stress incontinence (everything more straight, no kinks to prevent leaks)

34
Q

what is urinary incontinence?

A

involuntary leakage of urine

35
Q

who is urinary incontinence mainly seen in?

A

older women / post menopausal/ parous women

risk factors are same for prolapse however also added risk factors include neurological conditions

36
Q

what are the different types of urinary incontinence?

A 
functional urinary incontinence
stress urinary incontinence
urge urinary incontinence
mixed urinary incontinence
overflow incontinence
bladder fistula
urethral diverticulum - into anterior vaginal wall
ectopic urethra
37
Q

what is functional urinary incontinence?

A

cant get to the toilet in time e.g. mobility

38
Q

what is stress urinary incontinence? including associations and risk factors?

A

leakage of urine with increase strain / abdominal pressure e.g. cough / sneeze
associated with weakened pelvic floor muscles e.g. after birth due to denervation (therefore associated with genitourinary prolapse)

risk factors include - oestrogen deficiency, pelvic surgery or irradiation

39
Q

what is urge urinary incontinence?

A

involuntary leakage of urine preceeded by sudden urge to micturate. also get nocturia and frequency

a.k.a overactive bladder syndrome (can also get dry overactive bladder syndrome where there is urgency but no leakage)
often triggered by cold air or running water

40
Q

what does urodynamic testing of urge urinary incontinence show?

A

overactivity of detrusor muscle

41
Q

who is urge urinary incontinence most likely in?

A

neurological conditions - parkinsons, stroke, MS, dementia, spinal cord injury, spina bifida
idiopathic

diabetic neuropathy
UTI irritates parasympathetic nerves to lead to urgency and frequency

42
Q

what is mixed urinary incontinence?

A

both stress and urge

43
Q

what is overflow incontinence?

A

bladder full and thus leaks

44
Q

what do you want to ask in history of someone with urinary incontinence?

A

want to differentiate urge from stress urinary incontinence

  • does it occur with coughing/ standing (stress)
  • do they get a sudden desire to want to urinate (urge)
  • day time frequency and nocturia
  • loss of bladder control
  • feeling of incomplete emptying
  • dysuria

any associated symptoms e.g. prolapse, neurological

assess lifestyle factors - bowel habits, heavy lifting, children, method of delivery

45
Q

how is someone with urinary incontinence examined?

A

digital assessment of pelvic floor strength
bimanual exam to assess prolapse presence / speculum
look for signs of vaginal atrophy
look for skin soreness due to urine contact
abdominal exam
neuro exam

46
Q

what investigations should be done with someone presenting with urinary incontinence?

A

bladder chart - for at least 3 weeks for all women- includes when you went toilet, volume passed and how many times. can make urinary freq/volume chart
- stress has normal frequency, urge is increased

urine dipstick - rule out UTI

urodynamic studies
bladder scans - assess residual volume
measure urine flow rates - if neurological problem suspected

47
Q

how are urodynamic studies conducted?

A

pressure outside bladder measured by a catheter inside rectum
pressure inside bladder measured by urinary catheter and sensor
difference between these gives detrusor pressure

slowly fill bladder with saline. patient asked to state when they feel urge to urinate and to cough at different stages

can distinguish between urge and stress

48
Q

how is stress incontinence managed?

A

conservative - pelvic floor exercises, weight loss, treat cough/ constipation
medical - Duloxetine = first line
surgical
- colposuspension (laparoscopic or open)
- intramural bulking agents
- tension free vaginal tape
- rectal fascial sling

49
Q

What is duloxetine? what are the side effects?

A

serotonin - NA retuptake inhibitor
works at Unufs nucleus to increase pudendal nerve activity and help with sphincter activity

side effects = abdo pain, changes to dreams, anxiety, constipation, reduced appetite, dry mouth, drowsiness

50
Q

how is urge urinary incontinence managed?

A

conservative - bladder training (1st line, minimum of 6 weeks), avoid caffeine
medical:
- anticholinergics (Oxybutynin, tolterodine, solifenacin)
- intravaginal oestrogen
- botulinum A toxin into bladder wall
- Mirabegron

surgery - detrusor myomectomy and augmentation cystoplasty

neuromodulation and sacral nerve stimulation

51
Q

what are the functions, side effects and contraindications of using anti-cholinergics for urge incontinence?

A 
function to relax detrusor 
side effects: Xeropthalmia, Xerostomia, Constipation, blurred vision, arrhythmias 
contraindicated - myasthenia gravis, GI obstruction, acute closed angle glaucoma
52
Q

what is mirabegron and what are the side effects?

A

B3 agonist - detrusor relaxation
side effects: sickness, dizziness, constipation, increased HR

need BP checked by GP once a month

53
Q

how is overflow incontinence treated?

A

relieve obstruction
intermittent self catheterisation
indwelling catheter if chronic retention, patient cant self catheterise and skin is becoming irritated from incontinence

54
Q

how is micturition controlled?

A

pelvic nerve (parasympathetic) controls the detrusor muscle - contracts to allow emptying of the bladder

hypogastric nerve (sympathetic) - inhibits detrusor muscle and contracts the internal urethral sphincter - urine continence

pudendal nerve - controls external urethral sphincter (voluntary)

gynaecology (7 decks)

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