Urinary Incontinence and Prolapse Flashcards
What are the urethral causes of urinary incontinence?
Urethral sphincter incontinence = stress incontinence
Detrusor instability = overactive bladder (OAB)
Retention with overflow
Functional
What are some features of retention with overflow?
May be related to prolapse or pessary insertion
On and off leakage of urine
Often complain of abdominal pain
What are some extraurethral causes or urinary incontinence?
Congenital, fistula
What are the types of urinary incontinence?
Stress, urge, mixed, overflow
How common is urinary incontinence?
1 in 3 women >=55 suffer from stress incontinence
30-40% of those aged >= 75 in Europe suffer from OAB
What are the risk factors for urinary incontinence?
Female = pregnancy, childbirth, menopause, short urethra
Age, kidney disease or diabetes
Obesity = increases pressure on bladder
Smoking = chronic cough, higher risk of OAB
Why does urinary incontinence incidence increase with age?
Bladder and urethral muscles lose strength
Bladder capacity reduces with age
What is the definition of urgency?
Sudden compelling desire to pass urine which is difficult to defer
What is nocturia?
Having to wake at night to void
What is urge urinary incontinence (UUI) defined as?
Involuntary urine leakage accompanied by or immediately preceded by urgency
What is an overactive bladder defined as?
Urgency, with or without UUI, usually with frequency and nocturia in the absence of another cause that would explain symptoms
What are the two types of overactive bladder?
Wet = urge urinary incontinence present Dry = urge urinary incontinence absent
What is mixed urinary incontinence defined as?
Involuntary leakage associated with urgency and also with exertion (e.g sneezing)
What impact can urinary incontinence have on quality of life?
Avoidance of sexual contact and absence from work
Reduction in social interaction and physical activity
Alteration of travel plans and need for special bedding
Depression, guilt and loss of self respect
What are some features of the physical examination of a patient with urinary incontinence?
Abdomen = masses, palpable bladder Rectal = tone, masses Neurological = reflexes, sensory, motor Pelvis/perineum = external genitalia (atrophic vaginitis), prolapse (50% of SI), fistula
What are some investigations done for a patient with urinary incontinence?
Standing/supine stress test = ask patient to cough
Post voidal residual = US or catheter
Bladder diary and urine dipstick
What are the treatments for OAB from least to most invasive?
Lifestyle advice, bladder training, pelvic floor physio, medication, botox injection, neuromodualtion, reconstructive surgery
What are some lifestyle advice for patients with an overactive bladder?
Bladder retraining = minimum 6 weeks, aim to increase capacity and decrease frequency
Sensible fluid intake, caffeine reduction, BMI <=30
What are some features of pelvic floor muscle exercises for urinary incontinence?
Effective for stress and mixed incontinence
Minimum of 3 months supervised trial with physio
What are some features of using antimuscarinics for urinary incontinence?
Side effects = dry mouth, constipation, blurred vision and somnolence
Examples = solifenacin (1st line), tolterodine, oxybutin (non-selective)
What are some of the effects that antimuscarinics can have in urinary incontinence?
Reduce intravesical pressure and increase compliance
Raise volume threshold for urination
Reduce uninhibited contractions
What is the most commonly used therapy for OAB after lifestyle changes?
Antimuscarinics
What are some other medications used to treat urinary incontinence?
B3 adrenoceptor agonists = mirabegron
What are some features of mirabegron as a treatment for urinary incontinence?
Selective agonist = relaxes bladder smooth muscle
Increases voiding interval and inhibits spontaneous bladder contractions during filling
What are some features of percutaneous posterior tibial nerve stimulation as a treatment for urinary incontinence?
12 weeks of treatment = 30mins once a week
Improves OAB by 30-40%
What is uroflowmetry?
Measurement of volume of urine expelled from bladder each second
What are the indications for uroflowmetry?
Hesitancy, voiding difficulty, neuropathy, history of urine retention, post-operative follow up
What does the measurement of urine flow rate allow?
Measurement of peak flow (should be 20-60ml), mean flow and voided volume
What occurs during cystometry?
Pressure/volume relationship of bladder is measured during filling, provocation and during voiding
What are mutlichannel urodynamics used for?
Uncertain diagnosis, non-response to treatment and possibly prior to surgery
How is overflow incontinence managed and what causes it?
Obstruction of urethra and poor contractile bladder muscle = must find out post voidal residual and stop anticholinergics immediately
What are some conservative treatment options for stress incontinence?
Lose weight, stop smoking, avoid caffeine and excessive fluid intake, pelvic floor retraining, biofeedback, electrical stimulation, pessaries, incontinence pads
What medication can be used to treat stress incontinence?
Duloxetine = combined noradrenaline and SSR inhibitor
What are the surgical options for treating stress incontinence?
Low tension vaginal tape, intra-urethral injection, artificial sphincters, colposuspension, autologous fascial sling
What are the three compartments of the vagina where prolapse can occur?
Anterior = cystocele Middle/apical = vaginal vault prolapse/enterocele Posterior = rectocele
How common are pelvic organ prolapses?
Up to 50% of parous women = 10-20% symptomatic
11% lifetime risk of surgery
What are the classifications of uterovaginal prolapses?
1st degree = in vagina
2nd degree = at interiotus
3rd degree = outside vagina
Procidentia = entirely outside vagina
What are the symptoms of an anterior or middle/apical prolapse?
Bulging, pressure, difficulty voiding, incomplete emptying, splinting vaginal wall, pain during sex, difficulty inserting tampon
What are the symptoms of posterior prolapse?
Bulging, pressure, difficulty defaecating, incomplete defaecation, splinting vaginal wall or perineum, difficulty inserting tampon
What occurs in a complete eversion prolapse?
Uterine procidentia, complete uterine prolapse
How is the Pelvic Organ Prolapse Quantification System (POP-Q) used?
Patient asked to strain = 6 specific sites evaluated, 3 sites evaluated at rest
Measure at each site (cm) in relation to hymenal ring
How is the POP-Q scored?
If site is above hymen its assigned negative number
If site is below hymen its assigned positive number
What are the risk factors for pelvic organ prolapse?
Aging, pelvic surgery, menopause, loss of muscle tone, multiple vaginal births, obesity, chronic cough or constipation, uterine fibroids, family history, connective tissue disorder (e.g Marfan’s)
What are the conservative management options for pelvic organ prolapse?
Avoid heavy lifting, weight loss, stop smoking, reduce constipation, vaginal oestrogens (if symptomatic atrophic vaginitis)
What physical exercises can be given to treat pelvic organ prolapse?
4-6 months of pelvic floor muscle exercises
What patients are given a pessary to treat pelvic organ prolapse?
Unfit for surgery, relief of symptoms while awaiting surgery, pregnant/planning future pregnancy, diagnostic test, patient request
What are the surgical options for treating pelvic organ prolapse?
Vaginal hysterectomy or sacrospinous fixation
Manchester repair = cervix amputated, uterosacral ligaments shortened
Abdominal/laparoscopic sacrocolpopexy or colpocleisis
Mesh techniques = not since 2014 in Scotland
