Urinary Incontinence and Prolapse Flashcards
What essentially, is urinary incontinence?
The complaint of any involuntary leakage of urine
POP
Protrusion of pelvic organs
What are the 3 general categories of pelvic floor disorders?
- Urinary incontinence.
- Pelvic organ prolapse.
- Anal incontinence.
Stress
Involuntary urine leakage on effort or exertion or on sneezing or coughing.
Urgency
Involuntary urine leakage accompanied or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to delay)
- going to the toilet around 8 times a day
Mixed
Involuntary urine leakage associated with both urgency and exertion, effort, sneezing or coughing
Overactive Bladder
Defined as urgency that occurs with or without urgency UI and usually with frequency and nocturia. OAB that occurs with incontinence is known as ‘OAB wet’. OAB that occurs without incontinence is known as ‘OAB dry’
List common causes of urinary incontinence.
- Age – more common with urgency incontinence
- Parity – vaginal birth (although c-section isn’t 100% protective)
- Obesity – BMI >35 (increased pressure on bladder due to increased weight)
- Pregnancy
- Obstetric history
- Menopause – oestrogen levels drop and everything becomes more ‘baggy’
- UTI
- Smoking - a chronic cough can cause episodes of incontinence, or aggravate incontinence that has other causes (smokers are also at risk of developing overactive bladder)
- FH
The older you get, the more likely you are to become incontinent …
Yes, sadly
Why does getting older make you more likely to become incontinent?
As people get older, the muscles in the bladder and urethra lose some of their strength.
Changes with age reduce how much your bladder can hold and increases the changes of involuntary urine release
What 4 life factors, make women more likely to become incontinent?
- Pregnancy
- Childbirth
- Menopause
- Short urethra
What should you always ask about when someone presents with UI?
Caffeine intake
What should you ask someone to do when they present with UI?
Keep a bladder diary for 3 days
List 6 storage symptoms.
- Frequency
- Nocturia
- Urgency
- UUI – urge urinary incontinence
- SUI – stress urinary incontinence
- Constant leak
List 3 voiding symptoms.
- Hesitancy
- Straining to void
- Poor flow
List 3 incontinence symptoms.
- Exacerbating factors
- Timing
- Volume
List 2 postmicturition symptoms.
- Incontinence
* Incomplete emptying
If someone says they have large volumes of urine, what do they probably have?
Urge incontinence
What 5 things should be part of an examination of someone with UI?
- BMI
- Abdo exam – look for masses, incl. bladder
- Vaginal exam – atrophy, prolapse, SUI, fistula
- PR – masses, tone
- Cognitive impairment
During an examination ask the patient to cough, if they pee then they have ______ incontinence
Stress
In OAB, there is involuntary ________ contractions
Detrusor
Detrusor instability can cause symptoms of urgency + sudden loss of urine
What does this describe?
Urge urinary incontinence
What can stress urinary incontinence be caused by?
This can be caused by urethral hypermotility; significant displacement of the urethra and bladder neck during exertion and increased abdominal pressure; or urethral sphincter weakness, in which the bladder sphincter cannot generate enough resistance to retain urine during stress maneuvers
In women, when can urethral sphincter weakness occur after?
Trauma, hypoestrogenism, aging, or surgical procedures
What 2 investigations should be done in someone with UI?
Urinalysis
+
Post-void residual (shows if person is emptying bladder properly)
What, seen on urinalysis, should make you cautious of bladder cancer and renal stones?
Blood
__________ must be done before any bladder cancer surgery is done
Cystoscopy
What are the 3 categories of management of UI?
- Lifestyle interventions – cut down on caffeine, alcohol, fluid intake (1.5-2.5 L), weight loss (BMI <30)
- Pelvic floor exercise (minimum of 3 months before you can see a difference)
- Bladder retraining (takes 6 weeks)
Why can not drinking enough actually make you pee more?
If you don’t drink enough your urine becomes very concentrated which irritates your bladder and you pee more
Going from least to most invasive, what are the different categories of management for OAB.
- Lifestyle
- Bladder drill
- Pelvic floor physiotherapy
- Drugs
- Botox
- Neuromodulation
- Reconstructive surgery
Name 3 antimuscarinic drugs.
- Oxybutynin
- Tolterodine
- Darifenicin
Outline the 4 functions of antimuscarinic drugs in UI.
- Reduce intra-vesical pressure
- Increase compliance
- Raise volume threshold for micturition
- Reduce uninhibited contractions
What should be done after 4-6 weeks of starting a patient on antimuscarinics?
Review the patient at 4-6 weeks after initiating this medication to see if they are taking it and if they are tolerating it
List the 4 main side effects of antimuscarinics.
- Dry mouth
- Constipation
- Blurred vision
- Somnolence - sleepy
Why do the side effects of antimuscarinics occur?
As antimuscarinics are anti-cholingeric
What is Mirabegron?
A selective agonist for the human β3 adrenoreceptor with low intrinsic activity for β1 and β2
What does Mirabegron do to the bladder?
Relaxes bladder smooth muscle through activation of the β3 adrenoreceptor
Increase – voiding interval
Decrease – spontaneous bladder contractions during filling
If a patient suffers from nocturia, what should you prescribe them?
Desmopressin
What does botox do to the bladder?
Paralyses the bladder and makes it less likely to contract BUT the person must be capable of self-catheterisation to perform this
What does sympathetic (adrenergic) control of the bladder do?
Increases relaxation
What does parasympathetic (cholingeric) control of the bladder do?
Inhibits involuntary contractions
B3 adrenoreceptor agonists act to activate sympathetic (adrenergic) receptors. What is the result of this?
Increases relaxation of the detrusor muscle wall
Increases storage capacity
+
Decreases voiding frequency
Antimuscarinics act to block parasympathetic (cholingeric) receptors. What is the action of this?
What does parasympathetic (cholingeric) control of the bladder do?
Inhibits involuntary contractions of the detrusor muscle wall
Delayed voiding
What is Duloxetine?
Combined noradrenaline and serotonin reuptake inhibitor (increase intraurethral closure pressure)
What is always 1st line management for stress incontinence?
Weight loss !!!
Then you can use Duloxetine
What is always 1st line management for UI?
Weight loss !!!
Then you can use Duloxetine
Name 4 surgical options for UI.
- Tension free tape
- Colposuspension
- Intramural bulking agents
- Artificial sphincters
What are the 3 categories of pelvic prolapse?
- Anterior
- Middle/apical
- Posterior
How many parous (had a baby before) women have a pelvic prolapse?
50%
What is a Cystocele?
An ANTERIOR pelvic prolapse
What is an Enterocele?
Vaginal wall prolapse
What is a Rectocele?
Posterior pelvic prolapse
If someone has bladder symptoms with a prolapse, what type of prolapse is it?
Anterior - Cystocele
Describe a complete eversion prolapse.
ALL compartments !!
Uterine Procidentia
+
Complete uterine prolapse
What are the 2 main symptoms of a rectocele?
- Difficulty defecation
* Incomplete defecation
What are the 2 main symptoms of a cystocele?
- Difficulty voiding
* Pain on intercourse
What is the 1 main symptom of a enterocoele?
- Incomplete emptying
List potential causes of a pelvic prolapse.
- Age
- Parity and vaginal delivery
- Postmenopausal oestrogen and deficiency
- Obesity
- Neurological condition e.g. spina bifida and muscular dystrophy
- Genetic connective tissue disorder e.g. Marfans, EDS
What 4 main features should you cover in a history of someone with a suspected pelvic prolapse?
- Pressure, dragging
- Urinary symptoms
- Bowel symptoms
- Sexual dysfunction
Ix’s are rarely done in a suspected prolapse
TRUE
Outline the results of a POP-Q.
If a site is above the hymen, assigned a negative number
If site prolapses below the hymen, the measurement is positive
Look at different stages of a pelvic prolapse.
If a site is above the hymen, assigned a negative number
If site prolapses below the hymen, the measurement is positive
Outline management of pelvic prolapse.
- Conservative management
- Mechanical devices (Pessaries)
- Surgery
What should be done in a woman with a pelvic prolapse but no symptoms?
Nothing
When can an asymptomatic prolapse often be found?
Smear
What are pessaries?
Things you stick in the vagina to keep everything up and out the way
Who likes pessaries?
Young girls usually as you can take them out
What complications are associated with pessaries?
- Discharge
- Ulcerations (leading to fistula)
- Fibrous bands
How often should pessaries be changed?
6 monthly
What may be given to keep tissues healthy, not dry etc in women who use pessaries?
Topical oestrogen
What type of surgery is done for an anterior prolapse?
Vaginal repair
What type of surgery is done for an posterior prolapse?
Vaginal repair
What types of surgery can be done for an apical prolapse?
Vaginal – sacrospinous fixation, colpocliesis.
Abdominal – sacrohysteropexy, sacrocolpopexy, pectopexy.
If there are no symptoms of a prolapse, what should be done?
NOTHING !!!
People with what type of incontinence often have a prolapse too?
Stress
Describe sacrospinous fixation for a prolapse.
Fix vagina or cervix back up to the top
