urinary incontinence and prolapse

Question 1

what is genitourinary prolapse? Pathophysiology?

Answer 1

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

Question 2

which muscle is the main support of the pelvic organs?

Answer 2

Levator ani 
(and endopelvic fascia)

Question 3

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

Answer 3

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

Question 4

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

Answer 4

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

Question 5

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

Answer 5

rectocele - rectum prolapses into vagina

Question 6

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

Answer 6

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

Question 7

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

Answer 7

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

Question 8

what are the stages of any vaginal prolapse?

Answer 8

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

Question 9

what are the risk factors for vaginal prolapse?

Answer 9

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)

Question 10

what factors of vaginal increases the risk of vaginal prolapse?

Answer 10

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

Question 11

how does uterine prolapse present? (vaginal symptoms only)

Answer 11

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

Question 12

how does uterine prolapse present? (urinary symptoms only)

Answer 12

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

Question 13

how does uterine prolapse present? (bowel symptoms only)

Answer 13

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

Question 14

how does uterine prolapse present? (coital symptoms only)

Answer 14

dyspareunia
loss of vaginal sensation
vaginal flatus
vaginal discharge

Question 15

overall how do uterine prolapses present?

Answer 15

mild ones can be asymptomatic 
urinary symptoms
vaginal symptoms
coital problems
bowel symptoms

Question 16

how are vaginal prolapses examined?

Answer 16

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

Question 17

how can we distinguish between a rectocele and enterocele ?

Answer 17

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

Question 18

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

Answer 18

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

Question 19

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

Answer 19

mainly to assess complications, as diagnosis is made clinically

• anal manometry
• defecography
• endoanal USS

Question 20

what are the conservative management for vaginal prolapse

Answer 20

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

Question 21

what are the methods of treating vaginal prolapse?

Answer 21

conservative
vaginal pessary
oestrogen vaginal creams
surgery

Question 22

what is a vaginal pessary?

Answer 22

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

Question 23

what happens at review appointments in those with vaginal prolapse?

Answer 23

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

Question 24

what are the complications of a vaginal pessary?

Answer 24

vaginal discharge and odour
vesicovaginal and rectovaginal fistulas
faecal compaction
hydronephrosis

Question 25

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

Answer 25

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

Question 26

what surgical can be used for vaginal prolapses?

Answer 26

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

Question 27

what is vaginal repair operation and what are the complications?

Answer 27

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

Question 28

what is anterior colporrhaphy

Answer 28

anterior fibromuscular vaginal wall plication | mesh reinforcement can be used

Question 29

what is colposusspension?

Answer 29

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

Question 30

what is a sacrospinous fixation?

Answer 30

fix uterus to sacrospinous ligaments

Question 31

what is posterior colporrhaphy?

Answer 31

levator ani muscle plication +/- mesh reinforcement

Question 32

what is obliterative surgery for prolapse?

Answer 32

move pelvic viscera back into pelvis and close off vagina | 100% effective but no intercourse

Question 33

what are the complications of prolapses?

Answer 33

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)

Question 34

what is urinary incontinence?

Answer 34

involuntary leakage of urine

Question 35

who is urinary incontinence mainly seen in?

Answer 35

older women / post menopausal/ parous women | risk factors are same for prolapse however also added risk factors include neurological conditions

Question 36

what are the different types of urinary incontinence?

Answer 36

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

Question 37

what is functional urinary incontinence?

Answer 37

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

Question 38

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

Answer 38

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

Question 39

what is urge urinary incontinence?

Answer 39

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

Question 40

what does urodynamic testing of urge urinary incontinence show?

Answer 40

overactivity of detrusor muscle

Question 41

who is urge urinary incontinence most likely in?

Answer 41

neurological conditions - parkinsons, stroke, MS, dementia, spinal cord injury, spina bifida idiopathic diabetic neuropathy UTI irritates parasympathetic nerves to lead to urgency and frequency

Question 42

what is mixed urinary incontinence?

Answer 42

both stress and urge

Question 43

what is overflow incontinence?

Answer 43

bladder full and thus leaks

Question 44

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

Answer 44

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

Question 45

how is someone with urinary incontinence examined?

Answer 45

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

Question 46

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

Answer 46

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

Question 47

how are urodynamic studies conducted?

Answer 47

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

Question 48

how is stress incontinence managed?

Answer 48

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

Question 49

What is duloxetine? what are the side effects?

Answer 49

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

Question 50

how is urge urinary incontinence managed?

Answer 50

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

Question 51

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

Answer 51

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

Question 52

what is mirabegron and what are the side effects?

Answer 52

B3 agonist - detrusor relaxation side effects: sickness, dizziness, constipation, increased HR need BP checked by GP once a month

Question 53

how is overflow incontinence treated?

Answer 53

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

Question 54

how is micturition controlled?

Answer 54

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)