urogynae Flashcards
out of the following which is the most common cause of urinary incontinence
a) OAB
b) stress incontinence
c) overflow incontinence
d) mixed incontinence
b) stress incontinence (37%)
then mixed 33% and then urge 22%
what type of urinary incontinence is the following definition describing:
“involuntary bladder SM contraction of the detrusor muscles during the filling phase that can be provoked or unprovoked”
a) Urge incontinence
b) stress incontinence
c) overflow incontinence
d) mixed incontinence
a) urge incontinence = OAB = detrusor muscle overactivity
what type of urinary incontinence is the following definition describing:
“involuntary leakage of urine during increases in intra-abdominal pressure in the absence of detrusor contraction”
a) Urge incontinence
b) stress incontinence
c) overflow incontinence
d) mixed incontinence
b) stress incontinence
what are the some of the causes of overactive bladder
detrusor muscle overactivity can be due to:-
main risk factor = increasing age (rises in middle age, plateaus age 50-70, then rises again)
often idiopathic
neurological: MS, parkinsons, DM, spinal cord injury
co-morbidities increase risk: obesity, type 2 DM
medications: parasympathethetics (as stimulation of this nerve makes us Pee) aceytlcholine, anti-depressants
can be exacerbated by alcohol, caffeine, acidic fruit drinks
what are some of the causes/contributing factors to causing stress incontinence
age
obesity
smoker= chronic cough
multiparty with vaginal deliveries
constipation
drugs that cause chronic cough e.g. ace inhibitors
damage to integrity of pelvic floor muscles e.g. hysterectomy, PMW low oestrogen, a/s with prolapse
Sonia comes to clinic complaining of having to strain to wee and feeling as though she is unable to empty her bladder fully. What type of urinary incontinence could be causing her symptoms
overflow incontinence; due to detrusor muscle inactivity or bladder outflow obstruction
what are some of the causes of overflow urinary incontinence
a/s with neurological conditions
medications that decrease detrusor muscle contractility:-
ACE inhibitors
Antidepressants
Antihistamines
Antimuscarinics
Antiparkinsonian drugs
Beta–adrenergic agonists (e.g. salbutamol)
Calcium channel blockers
Opioids
Sedatives & hypnotics
Sue comes to clinic complaining of a constant need to urinate. She denies any features of urgency or stress incontinence, has a normal BMI and non-smoker. what type of urinary incontinence do you think she is describing
continuous incontinence can be due to severe overflow incontinence (detrusor under-activity) or a fistula
out of the following list of anti cholinergic used in treatment of OAB which are non selective:-
A) oxybutynin
b) tolterodine
c) solifenacin
d) Propiverine
e) Trospium
f) Fesoterodine
non selective (remember the Ts and Ps)
= b) tolterodine
d) propiverine
e) trospium
out of the following list of anti cholinergic used in treatment of OAB which are selective selective:-
A) oxybutynin
b) tolterodine
c) solifenacin
d) Propiverine
e) Trospium
f) Fesoterodine
selective - a, c, f
out of the following list of anti cholinergic used in treatment of OAB which would you avoid in elderly females and why?
A) oxybutynin
b) tolterodine
c) solifenacin
d) Propiverine
e) Trospium
f) Fesoterodine
a) oxybutynin due to effect on cognitive impairment –> falls risk
what assessment model can be used to assess pelvic floor muscle strength? briefly describe
modified oxford grading system (scoring system of 0-5)
0= no pelvic floor strength, no contraction
5= strong pelvic floor strength, good contraction
how can you assess the severity of urinary incontinence
bladder diary for 3 DAYS (3 days important bit), ensuring it covers variation in days e.g. work/home life etc
what are some of the lifestyle interventions you should suggest to someone with urinary incontinence
reduce BMI < 30
reduce caffeine, alcohol intake, reduce fluid intake
smoking cessation
(note these are the same for stress and urinary incontinece)
when should we consider doing urodynamics
avoid if obvious stress incontinence
can do if urge incontinence (OAB), or mixed, unsure
- previous surgery for stress incontinence
- anterior or apical prolapse
- symptoms of voiding dysfunction
what is the first line management in urge incontinence (OAB) once lifestyle modifications
supervised bladder retaining for minimum 6 weeks
( if no improvement after 6 weeks then consider pharmacological management)
what is first line pharmacological management in OAB
antimuscarinics/anticholinergics - bind to M3 receptor on the bladder detrusor muscle and block action of acetylcholine leads to relaxation of detrusor muscle.
(remember parasympathetic = peeing, pelvic splanchnic nerves s2-s4, release Ach that bind to M3 receptors in bladder muscle - causes contraction –> peeing)
use one with the lowest cost e.g. oxybutynin, tolterodine, darifenacin
how long does it take for anticholinergics to work and what are common SE
can take up to 4 weeks to work
dry mouth, constipation, dry eyes, impairment in cognition
if anticholinergics don’t work or CI what is the second line pharmacological management for OAB (urge incontinence)
mirabegron - selective B3 agonist
what nerve and neurotransmitter are responsible for micturition?
parasympathetic nerves specifically pelvic splanchnic nerves (s2-s4), release acetylcholine that bind to M3 receptors in the bladder and cause contraction of the detrusor muscle –> peeing
If prescribing an anticholinergic to treat OAB (urge incontinence) when should you review the patient? what would you warn them re SE
SE can indicate the drug is starting to work!
review everyone at 4 weeks to assess efficacy/ SE and consider titrating or switching alternative or referral to secondary care etc.
what is the longterm f.u for patients established on anticholinergic treatment for OAB
annual review, unless >75 years then 6 monthly
in a post menopausal woman with urinary incontinence and vaginal atrophy what could you consider prescribing
vaginal oestrogen e.g. estring (vaginal ring used for 3 months continuous release of oestrogen), review annually
for patients with troublesome nocturia symptoms what pharmacological adjunct could be prescribed? what populations would you avoid
desmopressin (avoid in over 65 year olds, known hyponatraemia or hypertension, CVD)
what is the advice regarding urine aids/ pads etc
advised not to use as a treatment but can be used as an aid whilst a/w Rx/ assessment. If using review annually to assess skin integrity etc
if pharmacological methods fail to improve symptoms of urge incontinence (OAB) then referral to secondary care is indicated. What options would be considered there?
botox injections into bladder wall - botulinum toxin A blocks acetylcholine release
percutaneous sacral nerve stimulation
augmentation cystoplasty ( uses part of bowel to make the bladder bigger!)
urinary diversion
after lifestyle measures what is the next step in management of stress incontinence (urinary leakage on coughing/exercise)
pelvic floor physio for minimum trial of 3 months
(minimum of 8 contractions three times a day)
squeezy app
Lydia has been completed 3 months of pelvic floor training with pelvic physios but hasn’t seen a huge improvement in her stress incontinence symptoms. What is the next step
refer to urogynae (secondary care referral) consider surgical options
what are the surgical options for stress incontinence
colposuspension
rectal sheath sling
bulking agents
if a patient declines surgical options for stress incontinence what is a second line pharmacological option that could be considered
duloxetine (SNRI)- increases contraction of the urethral sphincter
what is the name of the grading system used for assessment of pelvic organ prolapse
a) DSRP
b) ROME III
c) POP P
d) POP Q
d) POP Q
when should you consider imaging in management of prolapse
if urinary symptoms with prolapse and considering surgery
pain
symptoms not explained by examination findings
symptoms of obstructive defecation or faecal incontinence
what type of prolapse might be found in each anatomical landmark
Anterior
Posterior
Central
Procidentia
anterior = cystocele or urethrocele
posterior = rectocele or enterocele
central: vault prolpapse, uterine prolpase
procidentia: prolapse of the apical, anterior and posterior vaginal components through the introitus
describe the POP Q assessment of pelvic organ prolapse
Stages 0 - 4, as stage increases to 4 = increase in decent of the prolapse beyond the hymen and introitus
stage 0 = no prolapse/decent of pelvic organs
stage 1 = prolapse is > 1cm superior to the level of the hymen
stage 2 = prolapse is within 1cm of the hymen
stage 3 = prolapse is >1cm below level of the hymen but not protruding > 2cm below level of total vaginal length
stage 4 = complete eversion = procidentia
name the first stage of lifestyle interventions that can be used to help prolapse symptoms
decrease weight <30kg/m2
treat constipation
avoid excessive straining/heavy lifting
if the prolapse demonstrates signs of atrophy what topical treatment could you use
topical oestrogen
what is the first line treatment of stage 1 or 2 prolapse
pelvic floor training for at least 16 weeks
name the mainstay of treatment (non-pharmacological) used in the management of prolapse excluding surgical options
pessaries - need to be changed every 6 months to avoid complications
consider impact on sex (can still have sex with a ring pessary)
can be used in conjunction with pelvic floor training
what is the next step in management of prolapse if pessaries and pelvic floor training don’t improve symptoms
surgical management
- Manchester repair (uterine saving)
- hysterectomy + sacrospinous fixation
-Vaginal sacrospinous hysteropexy with sutures (uterus preserving)
