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PRIYA REPRO > urinary incontinence and prolapse > Flashcards

urinary incontinence and prolapse Flashcards

1
Q

which structure separates the pelvic cavity from the perineum?

A

the pelvic floor

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2
Q

what is the pelvic floor and what is it’s role?

A

a group of muscles which provide support to pelvic organs and maintains both urinary and faecal continence in women

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3
Q

which structures are responsible for urinary continence?

A

externa urethra sphincter
compressor urethrae
levator ani

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4
Q

which muscle provides faecal continence?

A

contraction of the puborectalis muscle

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5
Q

what is the puborectalis muscle?

A

U shaped sling, extending from the bodies of the pubic bones, past the urogenic hiatus and around the anal canal
it’s tonic contraction bends the canal anteriorely, creating the anorectal angle at the anorectal junction (where the rectum meets the anus)

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6
Q

what are the 3 layers of pelvic floor (?) from external to internal?

A

perineal membrane
muscles of perineal pouch
pelvic diaphragm

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7
Q

which 2 muscle groups make up the pelvic diaphragm?

A

levator ani and coccygeus

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8
Q

what is the coccygeus?

A

sheet of muscle and fibrous tissue of the pelvis

together with the levator ani, it comprises the pelvic diaphragm that forms the inferior wall of the true pelvis

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9
Q

where is the coccygeus located?

A

inferior to the levator ani muscles

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10
Q

what is the function of levator ani?

A

supports and raises the pelvic visceral structure

helps in proper sexual functioning, defecation, urination and allowing various structures to pass through it

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11
Q

what are the levator ani muscles comprised of? PPI

A

puborectalis
pubococcygeus
iliococcygeus

(Medial to lateral)

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12
Q

what does the coccygeus connect?

A

the ischial spines to the coccyx

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13
Q

is the levator ani contracted or relaxed normally?

A

contracted

they must relax to release urine and faeces

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14
Q

what is endopelvic fascia?

A

supportive apparatus of the pelvis; contains a mixture of fibrous tissue, areolar tissue and connective tissue

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15
Q

what is the nerve supply to the destrusor muscle?

A

parasympathetic nerves derived from the pelvic sphlanchnics

S2,3,4

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16
Q

what is the nerve supply to the urethral smooth muscle?

A

sympathetic nerves derived from the spinal cord at T10 to L2 but descending to the bladder and urethra via the hypogastric nerves

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17
Q

what is the nerve supply to the striated urethral sphincter and pelvic floor (levator ani) muscles?

A

branches of the pudendal nerve S2,3,4

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18
Q

what are the ligaments of the pelvic diaphragm?

A 
utero-sacral ligament
transverse cervical ligament (cardinal ligament)
tendinous arch of pelvic fascia 
tendinous arch of levator ani 
lateral ligament of bladder
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19
Q

describe level one of the pelvic floor supports?

A

the cervix and upper vagina

- uterosacral, transverse cervical and pubocervical ligaments

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20
Q

describe level 2 of the pelvic floor supports?

A

middle vagina

- pelvic fascia

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21
Q

describe level 3 of the pelvic floor supports?

A

lower vagina

- levator ani muscles and perineal body

22
Q

where is the deep perineal pouch located?

A

superficial to the pelvic diaphragm

above the perineal membrane

23
Q

what does the female deep perineal pouch contain?

A
  • part of the urethra
  • vagina
  • clitoral neurovascaular bundle
  • extensions of ischioanal fat pads
  • smooth muscle
  • external urethral sphincter and compressor urethrae
24
Q

what does the male deep perineal pouch contain?

A
  • part of urethra
  • bubourethral glands
  • neurovascular bundle of penis
  • extensions of ischioanal fat pads
  • smooth muscle
  • external urethral sphincter and compressor urethrae
25
Q

where is the perineal membrane located?

A

superficial to the deep perineal pouch

26
Q

what is the role of the perineal pouch?

A

completes the urogenital triangle by attaching to the sides of the pubic arch
provides an area of attachment for the external genitalia

27
Q

where is the superficial perineal pouch located?

A

superficial to the perineal membrane

contains female erectile tissue / male root of penis and their relevant structure

28
Q

what is located in the female superficial perineal pouch.

A
  • clitoris and crura (legs of the clitoris, invisiable to the naked eye)
  • bulbs of vestibule
  • bulbospongiosus
  • ischiocavernosus
  • also contains greater vesitublar glands, supericial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve
29
Q

what is located in the male superficial perineal pouch?

A

??

30
Q

what is the location of the ischiocavernous compared to the bulbospongiosus?

A

it is LATERAL

31
Q

which 3 things cause the pelvic floor to weaken?

A

increased intra-abdo pressure
pelvic floor muscle trauma and denervation
CTD

32
Q

what is stress incontinence?

A

involuntary urine leakage when there is increased intra-abdominal pressure, with the absence of detrusor muscle contraction

33
Q

what causes stress incontinence?

A

childbirth, pelvic surgery, oestrogen deficienct, coughing, sneezing, exercise, prolapse of urethra and anterior vaginal wall could be present

34
Q

what are the investigations for stress incontinence?

A
  1. exclude UTI
  2. frequency . volume charts (charts will show normal frequency and bladder capacity)
  3. urodynamic studies
35
Q

what is the management of stress incontinence?

A
  • weight loss, smoking cessation avoid heavy lifting, caffine reduction
  • duloxetine (not first line, SE = blurred vision, dizziness, difficulty sleeping, weight loss, decreased labido)
  • surgical = bulking agents, autologous rectal fascial sling, laparoscopic or open colposuspension, artifical urinary spincters, tension free vaginal tape
36
Q

what is urge incontinence?

A

increased urgency and frequency to void urine + sometimes nocturia

  • larger volumes than stress incontinence
  • if i have to go, I have to go immediately
37
Q

triggers / causes for urge incontinence?

A

hearing running water, cold weather

pelvic surgery, MS, spina bifida

38
Q

investigations for urge incontinence?

A
  1. frequency / volume charts will show increased frequency

2. urodynamic testing will show over-activity of the detrusor muscle

39
Q

management for urge incontinence?

A
  • decrease fluid intake, minimise caffine and diuretics (alcohol), use of pads
  • bladder retraining with incontinence team
  1. oxybutynin (anticholinergic) - not first line anticholinergic esp in elderly, causes cognitive impairement so toleriodine prefered
  2. mirabegron - safer in elderly
    • intravaginal oestrogens (vaginal atrophy used for)
      - consider desmopressin if nocturia
40
Q

what is overflow incontinence?

A

leakage of urine from a full urinary bladder, often with absence of an urge to urinate

41
Q

causes / risk factors for overflow incontinence?

A
  • inactive detrusor muscle: neurological conditions eg MS (no urge to urinate)
  • involuntary bladder spams: can occur in cardio disease and diabetes
  • cystocele or uterine prolapse can block urine exit if severe
  • men > women due to prostate-related conditions
42
Q

investigations for overflow incontinence?

A

frequency / volume charts

urodynamic testing shows inactivity of destrusor muscles

43
Q

what is urogenital prolapse?

A

descent of one of the pelvic organs, resulting in the protrusion of the vaginal wall
- can involve bladder (cystocele), uterus, vagina and / or rectum (retrocele)

44
Q

what is first degree urogenital prolapse?

A

mild protrusion o examination (-1cm of introitus (opening))

45
Q

what is 2nd degree urogenital prolapse?

A

prolapse present at introitus of vagina/anus/urethra (between -1cm and +1cm of introitus)

46
Q

what is 3rd degree urogenital prolapse?

A

prolapse protruding outside of the introitus (beyond 1cm introitus)

47
Q

what is 4th degree urogenital prolapse?

A

procindentia (complete prolapse)

48
Q

what are the risk factors for urogenital prolapse?

A

increasing age (40% are post-menopausal)
multiparity, vaginal deliveries
obesity
spina bifida

49
Q

what are the clinical signs for urogenital prolapse?

A
  • pressure, heaviness, bearing down, urinary incontinence, frequency, urgency
50
Q

what is the management for urogenital prolapse?

A
  • most dont require treatment
  • lifestyle changes
  • pelvic floor trainig eg kegels, pilates, physio
  • ring pessary
  • surgery eg cystocele / cystourethrocele : anterior colporrhaphy, uterine prolapse = hysterectomy, rectocele = posterior colporrhaphy
51
Q

management of UTI?

A

non-pregnant woman = urine culture should be sent if >65 or haematuria, trimethroprim or nitrofuratoin for 3 days

symptomatic pregnant woman : urine uclture done, nitrofuratoin (1st and 2nd trimester), trimethropri (3rd trimester)

asymtpomtic pregnant woman
urine culture done at first antenatal visit, high risk of progressing to acute pyelonephritis, immedite course of nitrofuratoin, amox or cefalexin for 7 days

catheterised patients : treat only symptomatic bacteria within 7 days of antibiotics

PRIYA REPRO (15 decks)

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