Urinary Incontinence and Prolapse Flashcards
what are the urethral causes of incontinence
urethral sphincter incompetence (stress)
detrusor instability (urgency)
retention with overflow
functional
what are the extra urethral causes of incontinence
congenital
fistula
what are the 4 types of urinary incontinece
stress
urge
mixed
overflow
what are the risk factors for incontinence
female pregnancy childbirth (esp large baby) menopause (weakens pelvic muscles and thinning of urothelium) age - weakened muscles, bladder capacity decreases obesity - increased abdo pressure smoking- chronic cough diabetes
what urinary symptoms will you get in overactive bladder
urgency
frequency
what is important to ask when assessing QOL in incontinence
if having sex- do they leak during sex
what Ix for incontinence
Exam:
exclude mass in abdomen
look for atrophic vaginitis in external genitalia
look for prolapse, fistula or malignancy
PR tone, masses
teach kegels
neuro-check reflexes, sensory and motor innervation
standing or supine stress test
post void residue (retention)
urinalysis (exclude infection)
bladder diaries
stress:
- flow volume chart
- exclude UTI
- urodynamics when surgery considered
can fluid restriction help incontinence
no- makes urine more concentrated which irritates the bladder causing more leakage
what should you avoid drinking in urinary incontinence
fluids that irritate the bladder: caffeine, alcohol
try and space caffeine 6 hours apart
what causes incontinence during intercourse
during orgasm- urge
during penetration- stress
how can you tell urgency from a full bladder
urgency incontinence will have fear of leackage
what precedes urge incontinece
urge to void and triggers e.g. running water
how much are you normally meant to drink
24mls/kg/24hrs
what is normal bladder capacity
500mls
above 80 y/o ~200mls
can be stretched to litre
why is prolapse associated with stress incontence
weakened pelvic support
what is normal urine flow rate
20-60mls per second
if >80 slower ~10mls
why might someone have a poor flow rate
underactive bladder or obstruction of urethra (commonly prolapse of anterior vaginal wall)
is there a pressure difference in the bladder, bowel or abdominal cavity
no
what is cystometry
catheters with sensors are inserted to measure pressure - used to differentiate the contractions in the bladder from the basic pressure in the abdomen
if the pressures are the same = no worries
if independent contractions of the bladder might be sign of overactive bladder UI
what is detrusor pressure
(cystometry)
vesicle pressure - abdo pressure
what is normal post residual volume
<100ml (more than this abnormal, 1st desire to void at 150-200ml, strong desire at 400mls)
how do antimuscarinics affect the bladder
cause an underactive bladder- affects storage and voiding
-weaker contractions= reduced flow rate= high post void residue
independent contractions of the bladder without accompanying contractions of rectal pressure=?
overactive bladder
leakage accompanying cough =?
stress UI
low max flow rate and high bladder pressure =?
bladder outlet obstruction
usually prolapse
what general treatment for urinary incontinence
- avoid caffeine, spicy food and dark chocolate
- pads
- physical therapy
- control diabetes
- bladder drills (holding for as long as possible)
what is duloxetine
SSNRI
increases serotonin and norepinephrin in synaptic cleft
increases contractility and tone of urethral sphincter
what is uroflowmetry
screens for voiding difficulties- patient urinates in proivate into comode with urinary flow meter
what is urodynamics
cystometry and uroflowmetry
what management for SUI
- surgery in england not scotland
- conservative: -weight loss, smoking cessation, treat constipation
- pelvic floor exercises
- biofeedback
- duloxetine (rarely used)
Pessaries (work in 50%)
Surgeries (low tension vaginal tapes, intraurethral injections, artificial sphincters, colposuspension)
what s
what management for overative bladder
avoid caffeine, alcohol, chocolate, tannins, tomatoes, citrus and spicy foods
- drink at least 25 ml/kg a day
- BMI <30
- treat constipation, eat high fibre diet
- exclude UTI
- bladder training
- pelvic floor excercises
(consider topical oestrogen if vaginal atrophy)
should try 3 months non pharmacological management
1st line- tolterodine (antimuscarinic) review at 4-6 wks 2nd line- solifenacin (antimuscarinic) review 4-6 weeks 3rd line- mirabegron (beta 3-adrenoceptor agonist- relaxed bladder) MONITOR BP risk of severe hypertension
botox
neuromodulation (posterior tibial nerve)
surgery
what do antimuscarinics increase the risk of
dementia and death - monitor mental function
what are the antimuscarinic side effects
Constipation; dizziness; drowsiness; dry mouth; dyspepsia; flushing; headache; nausea; palpitations; skin reactions; tachycardia; urinary disorders; vision disorders; vomiting
how do antimuscarinics help OAB
block parasympathetic innervation and relax detrusor
why might OAB be confused with SUI
as symptoms can be brought on by coughing/ sneezing
how do beta agonists help OAB
increase adrenegic (sympathetic) control- increase relaxation of the bladder
what are the indications for urodynamics
hesitancy voiding difficulty neuropathy Hx of urinary retention post op follow up uncertain diagnosis failure to respond to Tx prior to surgery
what should you teach if high residual volume
self catheterisation
WHAT DRUGS SHOULD YOU STOP IF PATIENT HAS OVERFLOW INCONTINENCE
long term anticholinergics
what spine things can cause retention and overflow
cauda equina
spinal anaesthesia
what is procindentia
prolapse when entirely out of vagina
what are the degrees of prolpase
1st- in vagina
2nd- at interiotus
3rd- outwith vagina
procidentia- entirely outwith vagina
what score to quantify prolapse
POP-Q
what RF for prolase
same as incontinence
lifting
surgery
why do people with oedema in feet get nocturnal polyuria
as when lie down fluids flows into abdomen
what is an anterior prolapse
cystocele:
-bulging pressure ‘mass’, difficulty voiding, incomplete emptying, splitting vaginal wall
what are the features of an anterior/ middle or apical prolapse
bulging pressure ‘mass’, difficulty voiding, incomplete emptying, splitting vaginal wall, difficulty inserting tampon, pain with intercourse
what is a middle/ apical prolpase
enterocele (intestines)
what is a posterior prolapse
rectocele
what are the symptoms of a rectocele
bulging pressure mass difficulty defecating incomplete defecation splitting vaginal wall or perineum difficulty inserting tampon
what is the management for a prolapse
avoid heavy lifting weight loss smoking cessation reassure physio pessary surgery
what are the surgery options for prolapse
vaginal hysterectomy Manchester repair (cervix amputated, uterosacral ligaments shortened), sacrospinous fixation, abo/ laparoscopic sacrocolpexy, mesh techniques (controversial), colpoplexy
when would you give a pessary not surgery or conservative
do surgery if young and dont want foreign body in vagina
pessary if not fit for surgery/ to relieve while waiting for surgery. also if further pregnancies planned/ pregnant
conservative if not concerned about symptoms/ young and will improve with physio
what are the types of pessary
supportive pessaries (for mild- mod prolapse):
- ring (easily inserted and removed, stay in during sex, suited fro all types of prolapse)
- gehrung (stays in during sex, hard to fit and remove)
space occupying pessaries (advances or severe prolapse):
- donut (needs to be removed for sex, hard to put in)
- cube (needs to be removed every night, difficult to put in and take out, remove for sex, may can vaginal erosion)
- gelhorn (hard to insert and remove, remove for sex)
- inflatable (easy to insert/ take out, remove for sex)
- shelf (hard to insert and remove, remove for sex)
