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Reproduction & Sexual Health > Urinary incontinence and prolapse > Flashcards

Urinary incontinence and prolapse Flashcards

1
Q

what does the pelvic floor separate?

A

the pelvic cavity from the perineum

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2
Q

what are the 3 layers of the pelvic floor?

A

pelvic diaphragm
muscles of perineal pouches
perineal membrane

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3
Q

Describe the pelvic diaphragm.

A

deepest layer of pelvic floor
consists of 2 (skeletal) muscle groups - levator ani, coccyges
sling appearance

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4
Q

What is the purpose of the anterior gap between the medial borders of the pelvic diaphragm?

A

urogenital hiatus

passage for urethra (M&F) and vagina (F)

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5
Q

what is the tendinous arch of levator ani?

A

thickened area of fascia which covers obturator internus

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6
Q

What does the levator ani attach?

A

pubic bones, ischial spines and tendinous arch of levator ani

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7
Q

List the 3 parts of levator ani muscle.

A

puborectalis
pubococcygeus
iliococcygeus (from ilium to coccyx)

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8
Q

When levator ani contracts, it allows urination and defaecation.
T/F?

A

FALSE

levator ani is tonically contracted most of the time - it must relax to allow urination and defaecation

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9
Q

which nerves innervate levator ani?

A

pudendal nerve and nerve to levator ani

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10
Q

What is the perineal body?

A

between urogenital hiatus and rectum (in both sexes) and is site where most muscles attach. if damaged, then the patient is much more likely to suffer incontinence and prolapse.

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11
Q

What are the pelvic ligaments?

A 
fibrous endo-pelvic fascia provide support to pelvic organs
uteruosacral 
transverse cervical (aka. cardinal)
lateral ligament of bladder
lateral rectal
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12
Q

Where is the deep perineal pouch?

A

lies below the fascia covering the inferior aspect of the pelvic diaphragm
lies above the perineal membrane

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13
Q

What does the deep perineal pouch contain?

A

part of the urethra (+ vagina in F), bulbourethral (Cowper’s) glands in M, neurovascular bundles for penis/clitoris, extensions of the sischioanal fat pads and muscles.

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14
Q

What is the name for the female equivalent of the bulbourethral gland in males?

A

Bartholin’s gland

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15
Q

Where does the perineal membrane attach?

A

laterally to the sides of the pubic arch - closing the urogenital triangle

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16
Q

How many openings does the perineal membrane have in females?

A

2 - one for urethra and one for vagina

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17
Q

what gives passive support to the pelvic organs?

A

perineal body + perineal membrane

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18
Q

What does the superficial perineal pouch (males) contain?

A

root of penis - bulb, crura and associated muscles
also proximal spongy urethra, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve

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19
Q

corpus spongiosum is found in which part of penis?

A

bulb

20
Q

corpus cavernous is found in which part of penis?

A

crura

21
Q

Which muscles are associated with the penis and the superficial perineal pouch?

A

bulbospongiosus and ischiocavernosus

22
Q

Describe the blood flow through the male erectile tissue.

A

crura and bulb = erectile tissue (differ in tissue type)
90% of blood flow will go through corpus cavernosum during erection. It wouldn’t be good for blood to go through spongiosum since it contains the urethra and sperm still needs to pass through it

23
Q

What does the superficial perineal pouch (female) contain?

A

clitoris and crura
bulbs of vestibule
associated muscles - bulobospongiosus and ischicavernosus
also greater vestibular glands, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve.

24
Q

What is the name for the area where the 2 crura come together in females?

A

the clitoris

25
Q

What are the different names for the greater vestibular glands depending on sex?

A

bartholin’s glands in females

cowper’s glands in males

26
Q

Where is a lateral episiotomy directed?

A

away from perineal body to avoid tearing it

27
Q

Describe how the pelvic floor helps maintain faecal continence.

A

tonic contraction of puborectalis bends anorectum anteriorly

active contraction maintains continence after rectal filling - reduces angle of anorectum

28
Q

What is prolapse?

A

common gynaecological disorder, can involve uterus, vagina or both (also bladder and rectum)
- failure of support of pelvic organs

29
Q

Describe vaginal prolapse.

A

Herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia.
Presents as a lump in vaginal wall.

30
Q

Describe the presentation of uterine prolapse.

A

“dragging” sensation
feeling of a “lump”
urinary incontinence

31
Q

Describe the different degrees of uterine prolapse.

A

1st - cervix drops into upper vagina
2nd - cervix low in vagina but above its opening
3rd - cervix completely exits vagina
4th - both cervix and uterus outside the vagina

32
Q

What is the treatment/repair for prolapse? Describe it.

A

Sacrospinous fixation
sutures placed in sacrospinous ligament - just medial to ischial spine
to repair cervical/vault descent
performed vaginally

33
Q

What are the risks of sacrospinous fixation?

A

injury to pudendal NVB and sciatic nerve

34
Q

Describe incontinence surgery (trans-obturator approach).

A

Mesh through obturator canal - create a sling around urethra

35
Q

89 y/o woman lives in nursing home, her carers noticed she is needing chawed several times a day due to wet underwear. Difficulty starting to urinate and aware of an increasing vulval swelling. Limited mobility and ex-smoker with BMI of 32.
Diagnosis and why?

A

urinary obstruction with overflow
Difficulty initiating micturition (voiding)
Constantly wet underwear, vulval swelling = prolapse

36
Q

58 y/o nurse concerned with increasing damp episodes when physically active and sometimes on coughing and sneezing. married with 4 children, smokes 20/day, BMI 39.
Diagnosis and why?

A

stress urinary incontinence
physical activity / coughing and sneezing causing damp episodes (raised IAP)

4 kids, smoker, BMI are risk factors

37
Q

75 y/o retired lawyer reports having to rush to the toiler otherwise she leaks. Increased frequency, especially at night. having to restrict daily activities. Not married, no kids, non-smoker; drinks at least 1 bottle of wine/night. BMI 26.
Diagnosis and why?

A

Overactive bladder
increased urgency and frequency - night rising.

risk factors: drinks at least 1 bottle of wine a night

38
Q

When investigating urinary incontinence in a woman, which investigations would you consider?

A 
abdo and vaginal exam
urinalysis
renal function test (U&Es)
frequency volume chart (FVC)
urodynamics
39
Q

What sort of values would you expect to see on a fluid volume chart and urodynamics in a patient with stress UI?

A

normal urinary volumes

cough signs on urodynamics and detrusor muscle pressure peaks when not filling bladder (sign of stress)

40
Q

What sort of values would you expect on a fluid volume chart and urodynamics of a patient with an ovaractive bladder?

A

going often and little urinary volumes on FVC
increased rate, frequency, volume
detrusor muscle pressure has multiple peaks once filled

41
Q

What treatment would you give to a patient with stress urinary incontinence?

A

pelvic floor exercises

42
Q

What would you treat an OAB with?

A

oxybutynin (ACh inhibitor)

43
Q

What is the first line pessary? PROS/CONS?

A

ring pessary
PROS: easily inserted/removed, cheaper
CONS: changed every 6/12

44
Q

Which pessary would you recommend in advanced stage prolapse? PROS/CONS?

A

cube
PROS: can be removed if you want to have sex, self-insertion, removal
CONS: removed every night
(very few scenarios this would be used)

45
Q

Which pessary is 2nd line? PROS/CONS?

A

Gelhorn pessary
for severe prolapse
CONS: change every 6/12, more expensive (washed then reinserted)

46
Q

Which pessary is 3rd line?

PROS/CONS?

A

shelf
PROS: cheap, every 6/12
CONS: if wrong size, e.g. too big, the vagina wall around it undergoes pressure necrosis

Reproduction & Sexual Health (15 decks)

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