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cOGTEXT > Urinary Incontinence and Prolapse > Flashcards

Urinary Incontinence and Prolapse Flashcards

1
Q

what does the pelvic floor do?

A

separates pelvic cavity from perineum

provides support to pelvic organs and maintains urinary and faecal continence in women

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2
Q

what 3 muscles are involved in urinary continence in females?

A

external urethral sphincter
compressor urethrae
levator ani

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3
Q

what muscle is involved in faecal continence in females?

A

puborectalis muscle

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4
Q

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

A

perineal muscle
muscles of perineal pouches
pelvic diaphragm

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5
Q

what are the 2 muscle groups in the pelvic diaphragm?

A

levator ani

coccygeus

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6
Q

what are the 3 parts of levator ani from medial to lateral?

A

PPI

  • puborectalis (U shaped sling behind rectum)
  • pubococcygeus
  • iliococcygeus
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7
Q

normal state of pelvic diaphragm?

A

normally contracted

must relax to release urine and faeces

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8
Q

innervation of pelvic diaphragm?

A

pudental nerve

nerve to levator ani

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9
Q

what are the 2 supporting structures to the pelvic diaphragm?

A

endopelvic fascia

ligaments

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10
Q

innervation of detrusor muscle?

A

parasympathetics derived from pelvic splanchnic nerves S2, 3 and 4

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11
Q

innervation of urethral smooth muscle?

A

sympathetics derived from spinal cord at T10 to L2

these decsend to the urethra and bladder via the hypogastric nerves

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12
Q

innervation of urethral sphincter and pelvic floor (levator ani) muscles?

A

branches of the pudental nerve, S2, 3 and 4

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13
Q

what are the main supportive ligaments of the pelvis?

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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14
Q

what are the 3 levels of support at the pelvic floor?

A

support at cervix and upper vagina
support at middle vagina
support at lower vagina

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15
Q

support at cervix and upper vagina?

A

uterosacral, transverse cervical and pubocervical ligaments

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16
Q

support at middle vagina?

A

pelvic fascia

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17
Q

support at lower vagina?

A

levator ani muscles and perineal body

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18
Q

where is the deep perineal pouch?

A

superficial to the pelvic diaphragm

above the perineal membrane

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19
Q

what does the deep perineal pouch contain in females?

A 
part of urethra
vagina
clitoral neurovascular bundle
extensions of ischioanal fat pads
smooth muscle
external urethral sphincter and compressor urethrae
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20
Q

what does the deep perineal space contain in males?

A 
part of urethra
bulbourethral glands
neurovascular bundle of penis
extensions of ischioanal fat pads
smooth muscle
external urethral sphincter and compressor urethrae
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21
Q

what is the most superior structure in the deep perineal pouch?

A

dorsal vein of clitoris/penis

sits above urethra (commonly mistaken for urethra)

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22
Q

where is the perineal membrane?

A

superficial to deep perineal pouch

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23
Q

what is perineal membrane made of?

A

tough deep fascia

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24
Q

function of perineal membrane?

A

completes urogenital triangle by attaching to sides of the pubic arch
final line of defence for the pelvic organs along with the perineal body
provides an area of attachment for the external genitalia

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25
Q

where is the superficial perineal pouch?

A

superficial to perineal membrane

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

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26
Q

what is contained within the female superficial perineal pouch?

A

clitoris and crura (legs of clitoris, invisible to naked eye)
bulbs of vestibule
bulbospongiosus
ischiocavernosus
greater vestibular glands
superficial transverse perineal muscle
branches of internal pudendal vessels and pudendal nerve

27
Q

what is contained within the male superficial perineal pouch?

A 
bulbospongiosus
ischiocavernosus
anal sphincter
deep transverse perineal
superficial transverse perineal
pelvic diaphragm/levator ani muscles
obturator internus
perineal body
ano-coccygeal body
sacrum and coccyx
ischial tuberosities
sacrotuberous ligament
28
Q

where is ischiocavernosus found in both males and females?

A

lateral to bulbospongiosus

29
Q

what can cause the pelvic floor to weaken?

A

increased intra-abdominal pressure (obesity, cough, constipation, mass etc)
pelvic floor trauma and denervation (obstetric, fracture, surgery, congenital)
connective tissue disorder (age, oestrogen deficiency, drug related, congenital/acquired connective tissue disorder)

30
Q

what is stress incontinence?

A

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

31
Q

causes of stress incontinence?

A

after childbirth
pelvic surgery
oestrogen deficiency (menopause)

32
Q

clinical features of stress incontinence?

A

triggered by coughing, sneezing, exercise etc (anything that increases abdo pressure)
leakage usually a small volume
prolapse of urethra and anterior vaginal wall may be present

33
Q

investigations in stress incontinence?

A

exclude UTI
frequency/volume chart (bladder diary)
- diary will show normal frequency and bladder capacity in stress incontinence
should do urodynamic studies

34
Q

how is stress incontinence managed?

A

lifestyle
conservative measures (pelvic floor exercise for 3 months, use of pads)
medical management if patient declines or unsuitable for surgery

35
Q

medical management of stress incontinence?

A

duloxetine (SNRI antidepressant)

need to discuss side effects with patient

36
Q

side effects of duloxetine?

A 
difficulty sleeping
headaches
dizziness
blurred vision
change in bowel habit
nausea and vomiting
dry mouth
sweating
decreased appetite
weight loss
decreased libido
37
Q

surgical management of stress incontinence?

A

bulking agents
autologous rectus fascial sling
laparoscopic or open colposuspension
artificial urinary sphincters (only in severe cases where previous surgery failed)

38
Q

what is urge incontinence?

A

increased urgency and frequency to void urine

often have nocturia

39
Q

clinical features of urge incontinence?

A

can be triggered by hearing running water, cold weather etc
usually larger volumes of urine leak compared to stress
little warning

40
Q

causes of urge incontinence?

A

idiopathic
pelvic surgery
multiple sclerosis
spina bifida

41
Q

investigations in urge incontinence?

A

frequency/volume charts (bladder diary)
- will show increased frequency
urodynamic testing should be done
- shows over-activity of detrusor muscle

42
Q

management of urge incontinence?

A

lifestyle
bladder retraining with incontinence team
medical
surgical

43
Q

medical management of urge incontinence?

A

oxybutynin (anti-cholinergic)
- tolterodine/solifenacin preferred in elderly due to cog impairment
mirabegron (esp safer in elderly)
intra-vaginal oestrogen (good in vaginal atrophy)
consider desmopressin if nocturia present

44
Q

surgical management of urge incontinence?

A

botox
percutaneous sacral nerve stimulation
augmentation cystoplasty

45
Q

what is overflow incontinence?

A

leakage of urine from a full urinary bladder

often with the absence of an urge to urinate

46
Q

causes of overflow incontinence?

A

inactive detrusor muscle (neurological conditions eg MS) causing lack of an urge to urinate
involuntary bladder spasms can occur in cardio disease and diabetes
cytocele or uterine prolapse can block exit if severe
prostate related conditions

47
Q

who is overflow incontinence more common in?

A

men

due to prostate related conditions

48
Q

investigations in overflow incontinence?

A

frequency/volume charts

urodynamic testing shows inactivity of detrusor muscle

49
Q

management of overflow incontiencne?

A

treat the cause

50
Q

1st degree prolapse?

A

mild protrusion on examination (-1cm away from interoitus)

51
Q

2nd degree prolapse?

A

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

52
Q

3rd degree prolapse?

A

prolapse protruding outside of the interoitus (beyond +1cm of interoitus)

53
Q

4th degree prolapse?

A

procidentia (complete prolapse)

54
Q

risk factors for prolapse?

A 
age 
multiparity
vaginal deliveries
obesity
spina bifida
55
Q

clinical signs of prolapse?

A

sensation of pressure, heaviness or “bearing down”

urinary incontinence, frequency, urgency

56
Q

management of prolapse?

A 
doesnt need management if mild and asymptomatic
lifestyle changes
pelvic floor training
ring pessary
surgery
57
Q

what surgery can be done for a cystocele/cystourethrocele?

A

anterior colporrhaphy

58
Q

what surgery can be done for a uterine prolapse?

A

hysterectomy
sacrohysteropexy
sacrospinous fixation

59
Q

what surgery can be done for a rectocele?

A

posterior colporrhaphy

60
Q

management of UTI in non-pregnant women?

A

trimethoprim or nitrofurantoin for 3 days

send urine culture if age >65 or haematuria present

61
Q

how is UTI managed in symptomatic pregnant women?

A

nitrofurantoin (1st and 2nd trimester)
trimethoprim (3rd trimester)
urine culture done

62
Q

how is UTI managed in asymptomatic pregnant women?

A

nitrofurantoin (avoid near term pregnancy), amoxicillin or cefalexin for 7 days
urine culture should be done at 1st antenatal visit and another done after to treatment to test for cure
high risk of progressing to pyelonephritis

63
Q

how is UTI managed in catheterised patients?

A

only treat if symptomatic with bacteria in urine

antibiotics for 7 days

cOGTEXT (17 decks)

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