Urogynaecology Flashcards
What are the three types of incontinence?
What are they caused by?
What are the causes?
STRESS (mechanical) -due to changes in pressure -either ↑intra-abdominal pressure (straining/heavy lifting/obesity/coughing/pelvis mass) -or ↓urethral pressures (weak pelvic floor muscles) RF: ↑parity; A/w prolapse
URGE
- detrusser instability or hyper-reflexia
- involuntary bladder contractions
- can be assosiated with overactive bladder syndrome where small amounts of urine irritates bladder (nocturne)
MIXED (third of women)
What things should you ask in an incontinence history?
SOCRATES
Storage symptoms
- Frequency
- Urgency (can you wait when you need to go)
- Nocturia
- Incomplete emptying
- Infection (heamaturia, pain, appearance, pain, smell)
Voiding symptoms
- hesitancy
- poor stream
- terminal dribble
- spraying/splitting
SIGNS OF INCONTINANCE
-any accidents?
(cough/run/laugh/sneeze)
-Severity (how is it impacting your life)
- Obsetric history (how many, MOD, how big?)
- Gynae history (smears, infections, prolapse-dragging sensation)
- Systems-bowels
PMH: diabetes (neurogenic bladder), constipation, chronic cough
DH: diuretics, laxatives, ace inhibitors
LIFESTYLE: caffeine, alcohol, carbonated drinks, smoking, illicit drugs
What should an examination of a woman with incontinence involve?
Incontinance exam/investigations
1. Weight and BMI – cause of stress incontinence
- Urine dip – test nitrites (inf.), blood, leucocytes, protein, if +ve and symptomatic, start Abx → MCS
- Abdo exam -exclude mass and full bladder (refer if palpable)
- Pelvic exam (bimanual)
- modified Oxford scale 0-5 for pelvic muscle strength - Speculum exam (look for atrophy as can cause urinary frequency and UTIs)
- Cough while on couch (urine leak/prolapse)
- Bladder scan – urinary retention (>500ml is significant)
- QoL assessment – ICIQ, I-QOL
** DRE for men– check for prostatic enlargement (BPH, pros Ca - refer)
What is first line management for EITHER stress or urge incontinence?
1st line LIFESTYLE CHANGES (both urge and stress)
- Reduce smoking
- Reduce alcohol
- Reduce caffeinated drinks
- Loose weight
- Cure chronic cough
- Avoid lifting
After lifestyle factors what can we recommend to women with EITHER urge or stress incontinence?
2nd line PELVIC FLOOR TRAINING (both urge and stress)
- Women should be referred to physiotherapist and they should be recommended to be doing at least 8 contractions at least 3 times a day for 3 months
- This helps more with stress incontinence, but used for both
After physiotherapy what is the next step of management for URGE incontinence?
Urge incontinance managment (after lifestyle and physio)
- Ask women to keep a BLADDER DIARY for 3 days
- Bladder training drills (try and hold wee for 5 minutes longer etc.)
After bladder diaries and bladder drills what is the next stage of management for urge incontinence?
Urge incontinance (after lifestyle, physio, diary)
Anticholinergics +/- Vaginal Oestrogens
-1st - OXYBUTYNIN, tolterodine or darifenacin
-ALSO give vaginal oestrogen if they have vaginal atrophy
-Follow up in 3 months (refer if no change)
What should you do if anticholinergics haven’t worked for Urge incontinance? (3)
Urge incontinance
- try a second anticholinergic (oxybutynin, tolterodine or darifenacin
- If that doesnt work, do Urodynamics and MDT to check got the right diagnosis
- Do CYTSOSCOPY AND BOTOX
- relax muscle
- risk of detrusser paralysis!! - self catheterise
Others include
- Sacral nerve (S3) stimulation via the tibial nerve
- Surgery (only for extreme refractory cases)
- cystoplast (add bowel to bladder wall)
- urinary diversion (urostomy bag)
What should you do to confirm the type of incontinence if the picture is more confusing?
What do graphs show?(stress/urge/overactive)
Do urodynamic studies (∆ DIAGNOSTIC)
-catheter in urethra
-catheter in vagina/rectum to intra abdominal measure pressure
-STRESS will show sharp peaks
that correspond with intra-abdo pressure (flat detruser pressure)
-URGE will show peaks that correspond to detrusor pressure (flat intra-abdo pressure)
-OVERACTIVE will show involuntary contraction of bladder during FILLING
Describe what a vaginal prolapse feels like?
What are risk factors?
Vaginal prolapse
- feels like somethings coming down
- worse on lifting/end of day
- usually not painful just uncomfortable
- can see vaginal bulge-push back in
- generalised lower back pain
- dyspareunia
Childbirth is major risk factor
What are the two possible positions of prolapses?
ANTERIOR PROLAPSE - aka cystocele - bladder pushing through anterior vaginal wall
POSTERIOR PROLAPSE - Rectocele (lower) or enterocoele (upper)
Might also see cervical prolapse, vault prolapse (after hysterectomy)
How are prolapses graded?
Depending on their descent relative to the hymen (the POPQ score or Baden Walker system)
0-normal position
1-descent halfway
2-descent to hymen
3-descent past hymen (obvious from outside)
4-maximum (procidenta)
How can we managed prolapses?
1st line LIFESTYLE - weight loss, avoid heavy lifting and lifestyle factors, pelvic floor excersises
2nd line either pessaries or surgery
PESSARIES - small rings placed into vagina to hold everything up (can have sex with doughnut ones but not Gellhorn ones)
SURGICAL REPAIR - if pessaries not tolerated. Risk of recurrence is 1/3
What should you be careful off when prescribing anticholinergics in the elderly?
What can you do about this?
Neurological toxicity of anticholinergic
Use one that doesnt cross blood brain barrier (Trospium or mirabegnon)
Name a couple of risk factors for STRESS incontinance?
Stress incontinacne
- ↑parity
- Obesity
- A/w prolapse
- weak pelvic floor
