urogenital aging: prolapse + incontinence Flashcards
muscles supporting perineum/pelvis
leavtor ani -
pubovaginalis, puborectalis, pubococcygeus, iliococcygeus
coccygeus
nerves supporting pelvis / perineum
pudendal (s2, s3, s4) sacral plexus (s2, s3)
RFs for pelvic floor prolapse + urinary incontinence
- age
- menopause
- parity (incl operative deliv)
- obesity
- chronic cough
- constipation
- heavy lifting
- CT disorders (ehlers danlos)
- neuropathies:
S1-S4, DM, congenital
symptoms of prolapse
mass/bulge at introitus
feeling of heaviness (esp with standing, lifting, end of day)
bladder or bowel symptoms
cystocele signs + symptoms
fullness/pressure occasional urgency incomplete emptying incontinence splinting/digitation for emptying recurrent UTI ureteric obstruction
rectocele signs + symptoms
pressure in vag
constipation
splinting/digitation for defecation
incomplete emptying
procidentia
complete protrusion of cervix/uterus from vagina
enterocele definition
true hernia of pelvic floor
procidentia or post-hysterectomy
bowels/omentum protrude through uterosacral lig into rectovaginal pouch
vault prolapse
protrusion of apex of vault into vagina after hysterectomy
physical exam for prolapse
- atrophy
- strain/cough
- speculum to isolate each compartment + grade
- reduce prolapse + cough for occult stress urinary incontinence
- check levator ani strength (kegel)
grading systems for prolapse
baden walker
- 0 normal
- 1 halfway to hymen
- 2 at hymen
- 3 halfway beyond hymen
- 4 more than half way
POPq
managment of prolapse
- expectant - minimal symptoms
- kegels or pelvic floor physio
- pessaries: if don’t want surgery, not candidate, or waiting, clean every 3 months (or self), risks = bleeding, infection, worse urine/bowel, rare: fistulas
- surgery
can combine above /w vag estrogen + lubricants
surgeries for prolapse
- cystocele: ant repair
- rectocele: post repair
- uterine prolapse: vag hyst + vault suspension
- enterocoele: purse string closure of sac +/- McCall culdoplasty
- vault prolapse: vag vault suspesnion or lap sacrocolpopexy with mesh
if not sex active or want lower risk surg:
- colpocleisis or vaginectomy surgeries for procindentia
- can also do incontinence surg at same time
continence mechanisms
invol internal sphincter
external sphincter
mucosal coaptation
urinary symptoms
freq
nocturia
urgency - can be motor or sensory
incontinence (urgency, stress, mixed)
enuresis (incontinence)
noctural enuresis
continuous urinary incontinence
urinary incontinence types/causes
- stress
- urgency (OAB)
- mixed
- overflow incontinence - full bladder, often no urge (weak bladder or outlet obstruction)
- functional - incontinence from mobility, cognitive impairment
other causes
- infection
- tumour
- bladder stone
- foreign body
- suburethral diverticulum
- fistulae
- interstitial cystitis
over active bladder diagnosis
- triad: urgency, freq, nocturia +/- incontinence
- dx on symptoms
- r/o other causes: UTI, GSM
points on urinary hx
- freq
- urge
- incontinence: stress, running water, activity, overflow, cont, fistula
- nocturia
- impact on QOL
- voiding: slow, dribble, hesitancy, strain, bladder sensation, pain
- UTI - dysuria, hematuria
- contributing: caffeine, medhx, DM, thyroid, CNS disease, disc disease, drugs, psych
physical exam for urinary system
- genitourinary atrophy
- cough/strain: bladder neck hypermobility
- palpate bladder neck + urethra for diverticulum
- reduce prolapse and cough for SUI
work up for evaluation
- PVR urine (bladder scan or by in-and-out)
- urinalysis and urine C + S
- +/- cystoscopy for stone/tumour
- consider urodynamics if hx + phx inconsistent, tx not working, prev surgery, distinguishes SUI + OAB
urodynamics components
- filling cystometrogram:
- first sensation: 100-250cc
- first desire to void: 200-330
- strong desire: 350-650
- detrusor stable/overactive
- compliance (change in pressure /w change in vol)
for SUI:
- max urethral closure pressure
- valsalva leak point pressure
tx for OAB
- r/o other cuases
- behaviour: eliminate irritants (caffeine), total fluids < 1.5 - 2L
- bladder retrain: timed voiding every 2-3 hrs, double void to ensure empty
- pelvic floor physio/training
- meds: anticholinergics (se - dry), mirabegron (B3 adrenergic agonist, se - HTN)
- botox injections
- sacral neuromodulation
treatment for stress urinary incontinence
- expectant
- bladder drills
- pelvic floor physio/exercise
- surgery:
- retropubic urethropexy (burch)
- lap. sling (mesh)
- autologous fascial sing
- midurethral slings: retropubic (TVT), transobturator tape
