urogyanecological problems Flashcards
Types of incontinence
urge - directly preceded by urge
stress - involuntary leakage when intra-abdo pressure increases a bit (laugh/cough)
overactive bladder - increased frequency and nocturia - not necessarily incontinent
mixed: both
Overflow incontinence - due to detrusor underactivity or bladder outlet obstruction
Continuous
innervation of bladder muscles
detrusor is inactivated by muscarinic cholinergic
urethral sphincter has dual inervation - sympathetic and somatic (voluntary)
What type of muscle is in internal and external sphincter
interna; - smooth
external striated
what is intrinsic sphincter deficiency
when sphincter closing pressure is very low
caused by weakness of sphincter muscles
rare
RF for stress incontinence
age
traumatic delivery
obesity
previous pelvic surgery
What is detrusor overactivity
Pt complains of overactive bladder cause detrusor goes crazy
Only causes incontinence if it’s associated with urethral sphincter weakness
Urge incontinence
What are RF for urge incontinence
smoking, obesity, childhood bed wetting
What symptoms are associated with incontinence?
sexual dysfunction, faecal incontinence, prolapse
What are some red flags?
haematuria, rectal bleeding, singificant pain
Ix for incontinence
MSU
bladder diary for 3 days
Pad test (give pad and do provocation tests - washing hands, climbing stairs)
Pelvic, renal tract US if in pain
Conservative measures for incontinence
Reducing fluid intake (<2.5L)
Reducing caffeine
Bladder retraining - longer interval between voiding
Pelvic floor exercises
What diagnoses can you make from urodynamic studies
Detrusor overactivity
Detrusor overactivity incontinence
Urodynamic stress incontinence (leakage associated wiht increased abdo pressure)
mixed incontinence - features of both
s/e off anticholinergic
dry mouth
constipation
blurred vision
Surgical mx of stress incontinence
- mid urethral tape (can lead to bladder perforation and voiding problems)
- burch colposuspension
SUrgery gives good outcomes
Mx of detrusor overactivity
botulinum toxin is good
surgery is second line
presentation of prolapse
Bulge, heaviness or protrusion at introitus
lower abdo pain and dragging
back pain
diff voiding bowels and bladder/incontince
sexual difficulty
What are the three stages of prolapse
- doesn’t reach hymen
- reaches hymen
- vagina is outside hymen
What is prolapse of anterior wall called
cystocele if upper half
uterocele if lower half
What is prolapse of posterior wall called
enterocele if upper half
rectocele if lower half
Cause of stress incontinence
pelvic floor weakness
intrinsic sphincter deficiency
Mx stress incontinence
Conservative: avoid caffeine, restrict water intake, BMI <30, stop smoking
1st line: pelvic floor retraining for 3 months
REFER TO SECONDARY CENTRE
2nd line: surgical procedure - colposuspension to lift neck of bladder
3rd line: duloxetine (enhances sphincter contraction) if they don’t want surgery
Mx urge incontinence
Conservative: avoid caffeine, restrict water intake, BMI <30, stop smoking
1st line: bladder retraining for 6 weeks (increase intervals between voiding)
2nd line: bladder stabilising drugs antimuscarinics (OXYBUTYNIN)
3rd line: beta-3 agonist (mirabegron) if s/e from antimuscarinic
4th line: botox injection
Mx of vaginal prolapse
Lifestyle: lose weight, don’t lift, treat constipation
Medical:
pelvic floor exercises
oestrogens - relieve symptoms and offer help if vaginal atrophy
Vaginal ring pessary (change every 6 months) this can cuase irritation and interfere w/ sex
Surgical:
if not preference for preserving uterus - hysterectomy
preservation of uterus - vaginal sacrospinous hysteropexy
vault prolapse - vaginal sacrospinous hysteropexy
