Urinary Incontinence and Prolapse Flashcards by Kerry Hendrie

What are the 3 main categories of pelvic floor disorders?

Urinary incontinence
Pelvic organ prolapse
Anal incontinence

How well did you know this?

Not at all

Perfectly

List the 4 main types of urinary incontinence

Stress
Urge
Overflow or OAB
Mixed

How well did you know this?

Not at all

Perfectly

List risk factors for urinary incontinence

Being female
Increasing age
Parity (vaginal delivery)
Obesity
Obstetric History
Menopause
UTI 
Family history
Smoking
Kidney disease
Diabetes

How well did you know this?

Not at all

Perfectly

What is stress incontinence?

Leakage of urine on exertion as the urethra is not supported

How well did you know this?

Not at all

Perfectly

When does stress incontinence occur?

Sudden movements or increases in intrabdominal pressure

How well did you know this?

Not at all

Perfectly

Stress incontinence does not involve urgency. True/False?

True

How well did you know this?

Not at all

Perfectly

What is urinary urgency?

Sudden compelling desire to pass urine that is difficult to resist

How well did you know this?

Not at all

Perfectly

What is urge incontinence?

Leakage and immediately preceded by urgency (sudden compelling desire to urinate)

How well did you know this?

Not at all

Perfectly

Does involuntary urine leakage occur in urge incontinence?

Yes

How well did you know this?

Not at all

Perfectly

What is mixed incontinence?

Leakage associated with both urgency and stress

How well did you know this?

Not at all

Perfectly

What is overflow incontinence?

Urgency +/- incontinence due to chronic urinary retention (bladder outflow obstruction)

How well did you know this?

Not at all

Perfectly

How is overactive bladder different from stress incontinence?

OAB involves involuntary detrusor contraction; stress can be caused by pressure or urethral hypermotility

How well did you know this?

Not at all

Perfectly

When is overactive bladder dry and when is it wet?

Wet when urge incontinence is present, dry when it is not

How well did you know this?

Not at all

Perfectly

What specific symptom do patients often complain about with overflow incontinence?

Frequency

Nocturia

How well did you know this?

Not at all

Perfectly

List symptoms to ask about in urinary incontinence

Storage (frequency, nocturia, urgency, incontinence)
Incontinence (exacerbating factors, timing, volume)
Voiding (hesitancy, straining, poor flow)
Post-micturation (dribbling, incomplete emptying)

How well did you know this?

Not at all

Perfectly

List other important features of the history to ask about in urinary incontinence

PMHx (prolapse, DM, fistula)
Obstetric history
DHx (bladder stimulants, psychoactive meds)
SHx (sex, diet)

How well did you know this?

Not at all

Perfectly

How can incontinence be tested for on examination?

General: BMI, age, cognitive assessment
Abdominal: masses, pain
Vaginal: atrophy, prolapse, incontince (‘cough’)
PR: masses, tone

How well did you know this?

Not at all

Perfectly

Atrophy of the vagina is typically due to…

Menopause

How well did you know this?

Not at all

Perfectly

How can incontinence be investigated?

Bladder diary for 3 days
Urinalysis (UTI, blood)
Post void residual
Urodynamics (catheter in rectum and bladder)
Cystoscopy (tumour, stones)
Imaging (kidney, bladder)

How well did you know this?

Not at all

Perfectly

What is classified as a normal amount of urine to void a day?

Less than 8 times a day

Less than 2800 ml a day

How well did you know this?

Not at all

Perfectly

What does cystometry measure?

Pressure-volume relationship of the bladder during filling, provocation and voiding

How well did you know this?

Not at all

Perfectly

List the spectrum of treatments for overactive bladder, from least to most invasive

Lifestyle advice
Bladder retraining (6 weeks)
Pelvic floor exercises/physio (3 months)
Drugs
Botulinum toxin
Neuromodulation
Reconstructive surgery

How well did you know this?

Not at all

Perfectly

List lifestyle advice given in OAB

Remove bladder stimulants (caffeine, alcohol)
Fluid intake (1.5-2.5l)
Weight loss (BMI <30)

How well did you know this?

Not at all

Perfectly

Which drug class is the most commonly used for overactive bladder? Name the most used agents

Antimuscarinics

Oxybutynin, tolterodine, darifenicin

What is the mode of action of antimuscarinics? When should they be reviewed?

Reduce intravesical pressure Iincreasing volume threshold for micturation Reduces uninhibited contractions After 4-6 weeks

List side effects of antimuscarinics

``` Dry mouth Constipation Blurred vision Somnolence Confusion Dementia ```

What drug class can help relax the bladder? Give an example

B3 adrenoceptor agonist | Mirabegron

What is the mode of action of B3 agonists?

Relaxes bladder by targeting B3 receptor Increase voiding interval Inhibit spontaneous bladder contractions

List other options for management in OAB

``` Desmopressin Topical oestrogen Botox (short-term) Percutaneous sacral nerve stimulation Augmentation cystoplasty ```

What symptom can be managed well with desmopressin in OAB?

Nocturia

List conservative options for management of stress incontinence

Weight loss Physiotherapy Incontinence pessary (rubber around urethra) Bladder neck bulking agents (fillers around bladder) Medication

What surgical methods can be used for stress incontinence?

Low-tension vaginal tape Colposuspension (laparotomy) Autologous sling (laparatomy)

Which drug can be used for stress incontinence?

Duloxetine

What percentage of parous women develop a pelvic organ prolapse?

50%

Which part of the vaginal wall does a cystocele come from? Which organ is involved?

Anterior | Bladder

Which part of the vaginal wall does a enterocele come from? Which organ is involved?

Middle/Apical | Uterus/vault

Which part of the vaginal wall does a rectocele come from? Which organ is involved?

Posterior | Bowel

List risk factors for pelvic organ prolapse

``` Age Parity Mode of delivery Pelvic surgery Menopause status Obesity Neurological disease Chronic constipation/coughing/heavy lifting Uterine fibroids Connective tissue disorders (marfans, EDS) ```

List symptoms to ask about in pelvic prolapse

``` Prolapse (pressure, dragging) Storage (frequency, urgency) Incontinence (timing, volume) Voiding (hesitance, straining) Post-micturation (incomplete emptying) Bowel (incomplete emptying) Sexual dysfunction ```

List a part of the history that is important to ask about in pelvic prolapse

Obstetric history

How does a cystocele present?

Bulging pressure Difficult voiding, incomplete bladder emptying Urgency incontinence Stress incontinence

How does a uterine prolapse present?

``` Dragging Back pain Mass Difficulty inserting/ retaining tampon Dyspareunia ```

How does a rectocele present?

Bulging pressure Difficulty emptying Digitation Difficulty voiding, incomplete emptying

What is a complete eversion?

All compartments turned inside-out

How are pelvic prolapses classified?

1st degree: in vagina 2nd degree: at interiotus 3rd degree: outside vagina Procidentia: completely outside vagina

What is the POP-Q system?

Pelvic organ prolapse quantification system | Measure each site of prolapse in relation to hymenal ring: if above hymen, -ve, if below hymen, +ve

How is pelvic prolapse investigated?

USS MRI Anorectal manometry Endoanal USS

List conservative management options for pelvic prolapse

Weight loss Pelvic floor exercises (3 months) Improve constipation Vaginal pessary

What should be given if someone has pelvic prolapse with atrophic vaginitis?

Oestrogen

What type of vaginal pessary is more suitable for young women who are sexually active?

Patient managed pessary | e.g. cube

What type of vaginal pessary is more suitable for elderly women?

Permanent pessary Change every 6 months e.g. ring, shelf, gelhorn

List common complications of vaginal pessaries

Failure Discomfort Discharge

How can pelvic prolapse be managed surgically?

Pelvic floor repair (anterior or posterior) Sacrospinous fixation (apical) Calpocliesis (apical, close open vagina) Sacrohysteropexy (laparoscopic/open, abdominal)

What is calpocliesis?

Procedure involving closure of vagina

What is sacrohysteropexy?

Resuspension of the prolapsed uterus by attaching it to the sacrum using a strip of synthetic mesh to lift the uterus and hold it in place

List features of pelvic floor dysfunction

Incontinece of urine or faeces Difficulty with defaecation Chronic pain Prolapse

List types of chronic pain associated with pelvic floor dysfunction

Vulvodynia (burning or irritation in vulvar area) Vaginismus (involuntary spams prevent penetration) Pelvic pain

Which grading sytem is used to determine pelvic floor muscle function and strength?

``` Oxford grading system 0 - no contraction 1 - flicker 2 - weak squeeze, no lift 3 - fair squeeze, definite lift 4 - good squeeze with lift 5 - strong squeeze with a lift ```

What is biofeedback training?

Computer-based technique, using a translabial or abdominal ultrasound Help strengthens urethral and anal sphincter muscles and pelvic floor muscles and help gain control over the bladder