Urinary Incontinence and Prolapse Flashcards
What are the 3 main categories of pelvic floor disorders?
Urinary incontinence
Pelvic organ prolapse
Anal incontinence
List the 4 main types of urinary incontinence
Stress
Urge
Overflow or OAB
Mixed
List risk factors for urinary incontinence
Being female Increasing age Parity (vaginal delivery) Obesity Obstetric History Menopause UTI Family history Smoking Kidney disease Diabetes
What is stress incontinence?
Leakage of urine on exertion as the urethra is not supported
When does stress incontinence occur?
Sudden movements or increases in intrabdominal pressure
Stress incontinence does not involve urgency. True/False?
True
What is urinary urgency?
Sudden compelling desire to pass urine that is difficult to resist
What is urge incontinence?
Leakage and immediately preceded by urgency (sudden compelling desire to urinate)
Does involuntary urine leakage occur in urge incontinence?
Yes
What is mixed incontinence?
Leakage associated with both urgency and stress
What is overflow incontinence?
Urgency +/- incontinence due to chronic urinary retention (bladder outflow obstruction)
How is overactive bladder different from stress incontinence?
OAB involves involuntary detrusor contraction; stress can be caused by pressure or urethral hypermotility
When is overactive bladder dry and when is it wet?
Wet when urge incontinence is present, dry when it is not
What specific symptom do patients often complain about with overflow incontinence?
Frequency
Nocturia
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)
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 can incontinence be tested for on examination?
General: BMI, age, cognitive assessment
Abdominal: masses, pain
Vaginal: atrophy, prolapse, incontince (‘cough’)
PR: masses, tone
Atrophy of the vagina is typically due to…
Menopause
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)
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
What does cystometry measure?
Pressure-volume relationship of the bladder during filling, provocation and voiding
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
List lifestyle advice given in OAB
Remove bladder stimulants (caffeine, alcohol) Fluid intake (1.5-2.5l) Weight loss (BMI <30)
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
