Week 4 - G - Urinary Incontinence, Pelvic organ prolapse and Uterovaginal prolapse

Question 1

Urinary incontinence can be urethral or extraurethral Urethral incontinence can be due * Urethral sphincter incompetence * Detrusor instability * Retention with overflow * Functional What are the two causes of extraurethral incontinence?

Answer 1

Urethral incontinence can be due * Urethral sphincter incompetence * Detrusor instability * Retention with overflow * Functional

Extraurethral incontinence: * Congenital * Fistula

Question 2

What are the different types of urinary incontinence?

Answer 2

Stress incontinence Urge incontinence Mixed incontinence Overflow incontinence

Question 3

An overactive bladder mainly presents as which type of incontinence? It can cause both stress and urge incontinence What are the symptoms of an overactive bladder?

Answer 3

Overactive bladder presents mainly as urge urinary incontinence The symptoms of an overactive bladder are: * Urgency * Frequency * Nocturia Basically the same as urge incontinence

Question 4

What is the prevalence of men and women with urinary incontinence?

Answer 4

1in3 women have urinary incontinence 1in10 men have urinary incontinence

Question 5

Why are woman more likely to have stress urinary incontinence?

Answer 5

Pregnancy Childbirth Menopause Short urethra

Question 6

What are other risk factors for urinary incontinence?

Answer 6

Age - as you get older the strength of muscles in the bladder and urethra decrease Obesity Smoking Family history Chronic cough

Question 7

Definitions * the complaint of any involuntary leakage of urine? * involuntary leakage on effort or exertion, or on sneezing or coughing.? * involuntary leakage accompanied by, or immediately preceded by urgency. ? * The complaint of having to wake at night one or more times to void.

Answer 7

* The complaint of any involuntary leakage of urine - URINARY INCONTINENCE (UI) * Involuntary leakage on effort or exertion, or on sneezing or coughing - STRESS URINARY INCONTINENCE (SUI) * Involuntary leakage accompanied by or immediately preceded by urgency - URGE URINARY INCONTINENCE (UUI) * The complaint of having to wake at night one or more times to void - NOCTURIA

Question 8

Urgency, with or without urge urinary incontinence, usually with frequency and nocturia in the absence of pathologic or metabolic conditions that might explain these symptoms What is this?

Answer 8

This is overactive bladder syndrome

Question 9

What is overactive bladder syndrome (OAB) wet and OAB dry?

Answer 9

OAB wet - this is where there is an overactive bladder (having an urgency to urinate, usually accompanied by frequency or nocturia) with urge incontinence (involuntary leakage accompained by or preceded by urgency) OAB dry - this where there is an overactive bladder without urge incontinence

Question 10

Urge incontinence - Typically preceded by an urge to void, and can involve a trigger such as running water, opening a door, removing undergarments. Define mixed urinary incontinence?

Answer 10

Involuntary urinary leakage associated with urgency and also with exertion, sneezing or coughing

Question 11

When a patient presents with incontinence it is important to categorise which type it is - can this be done purely from a history? How long should you ask the patinet to start on a bladder diary for?

Answer 11

NICE guidelines says the type of urgency can be determined from a good clinical history Ask patient to keep a diary of micturition for 3 days

Question 12

If someone has a constant leak, what do you think this may be? If the patient presents with mixed urinary incontinence, what should be treated first?

Answer 12

If someone has a constant leak, thin fistula or congenital abnormality If the patient presents with MUI, important to treat the overactive bladder as this can be made worse by operations for stress urinary incontinence

Question 13

On examination of the patient presenting with urinary incontinence, what is looked at? (4 examinations)

Answer 13

* Abdo exam - looking for pelvic masses * Vaginal exam - atrophy, prolapse, SUI (ask patinet to cough), fistula * PR exam - masses, tone (this is for overflow incontinence in men * Cognitive impairment examination

Question 14

An overactive bladder can have a huge impact on the patients quality of life: Pshycologically Socially Sexually Domestically Occupationally Physically How can it affect all these areas? IMportant to ask in an incontinence history

Answer 14

Psychologically people may feel embarrassed about the leaking and smell of urine, others may feel guilt and become depressed Socially - OAB may restrict social interaction due to fear of leakege Sexually - Women may avoid sex due to fear of urine leakage DOmestically- costs money to buy loads of pads Occupationally - can impact quality of work Physically - physical exercise may be reduced - fear

Question 15

What are the areas to ask about in how urinary incontinence affects the quality of the persons life again?

Answer 15

* Psychologically * Sexually * Domestically * Occupationally * Physically * Socially

Question 16

It is important to differentiate OAB with UUI from OAB with SUI Remember it can be mixed Describe OAB with UUI? Describe OAB with SUI?

Answer 16

OAB with UUI - the women has an urge frequently to go to the toilet but not quite there yet but then has involuntary leaking of the bladder accompanied or preceded by urgency OAB with SUI - women has urge to urinate but not quite there yet, then upon eg exertion, coughing or sneezing, is incontinent

Question 17

In SUI, the sphincter cant maintain the shut position when the intra-abdominal pressure raises What can urethral sphincter weakness be due to in women?

Answer 17

Can be due to: Trauma - eg pregnancy Hypooestroegnism - menopause Aging Surgical procedures

Question 18

What is associated with 50% of all SUI? Felt on vaginal examintion Remember, BMI, Abdo, Vaginal, PR and cognitive

Answer 18

This would be a vaginal prolapse

Question 19

How can you test for SUI on the physical examaintion?

Answer 19

Ask the women to stand or lie supine and ask them to cough - if urine is leaked this can show SUI

Question 20

What are the exercises that may be useful to teach upon physical examaintion to help treat vaginal prolapse and prevent uterine prolaspe? (this exercise essentially strengthens the pelvic floor)

Answer 20

Kegel exercise - The many actions performed by Kegel muscles include holding in urine and avoiding defecation. Reproducing this type of muscle action can strengthen the Kegel muscles. (the Kegel muscles mean the muscles that make up the levator ani - puborectalis, pubococcygeus, iliococcygeus)

Question 21

What are the two important conditions to rule out in a patient presenting with urinary incontinence?

Answer 21

Rule out UTI (dipstick test) and rule out diabetes (fasting glucose)

Question 22

What investigations can be carried out in people with urinary incontinence?

Answer 22

Stress test - standing (cough) or supine (valsalva manoevure) Post voidal residual volume -can use USS for this Urodynamics - Can help to differentiate types of incontinence if unclear, especially if results of less invasive tests are inconclusive. Cystocoscopy - rarely done but if recurrent constant urine infections

Question 23

What is the post voidal residual volume measurement that is abnormal?

Answer 23

PVR Normal: age dependent (10-80mls) Abnormal: > 100-150mls Indicator of urinary retention - use catheter to drain the urine left in the bladder after voiding

Question 24

How many voids per day is seen as frequent?

Answer 24

Greater than 8 voids per day on the bladder diary is seen as frequent in an adult

Question 25

What are some lifestyle interventions? How long are pelvic floor exercises carried out if SUI symptoms? How long is bladder drills (training) carried out? - this is to increase time between voiding

Answer 25

Do not drink caffeine as it is a mild diuretic and stimulates detrusor activity, monitor fluid intake and lose weight Pelvic floor exercises are carried out 8 contractions, 3times daily for 3 months Bladder drills are carried out for 6 weeks to try help increase the time between voiding

Question 26

Bladder retraining - min 6/52, aiming to increase bladder capacity and decrease frequency - useful in both SUI and UUI What BMI merits an attempt of weight reduction in a patinet with incontinence?

Answer 26

Weight reduction if BMI >30

Question 27

Pelvic floor muscle exercises (PFME) are effective in stress incontinence and mixed urinary incontinence but insufficient evidence to assess their efficacy in urge incontinence. May have a role when combined with bladder retraining Minimum 3 months supervised trial of PFME training What drug is given in the pharmacological treatment of stress urinary incontinence? What type of drug is it?

Answer 27

For SUI - duloxetine or pseudoephedrine Duloxetine is a serotonin noradrenaline reuptake inhibitor (SNRIs - used in depression treatment) and can be given as an alternative to surgery in SUI

Question 28

After lifestyle changes and bladder training, what are the 1st line pharmacological treatment for overactive bladder? (or urge urinary incontinence)

Answer 28

1st line would be an antimuscarinc - eg oxybutynin or tolterodine Competitively antagonises M1,M2,M3 muscarinic acetylcholine receptors

Question 29

What effects do the antimuscarincs have?

Answer 29

They reduce intra-vesical pressure Increase threshold for micturition INcrease compliance

Question 30

What are the anti-muscarinic side effects?

Answer 30

Side effects include Constipation, dry mouth, somnolence (makes you drowsy) blurred vision

Question 31

If the 1st line therapy of anti-muscarinics eg oxybutynin or tolterdoine fails, what is the 2nd line pharmacological therapy?

Answer 31

This would be Mirabegron, a beta-3-adrenoceptor agonist - relaxes bladder smooth muscle through activation of the B3 adrenoreceptor

Question 32

Mirabegron is recommended as an option for treating the symptoms of overactive bladder only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects Nice guldines - 2013/15 What is 1st and 2nd line drugs for people with OAB or mixed UI?

Answer 32

1st line - antimuscarinic - oxybutynin or tolterodine 2nd line - beta-3-adrenorecptor agonsit - mirabegron

Question 33

If the 1st and 2nd line drugs fail in the treatment of OAB or UUI or mixed UI, what injection is occasionally given?

Answer 33

Botulimin toxin (Botox)

Question 34

What are the indications for urodynamics?

Answer 34

Uncertain diagnosis Failure to respond to treatment

Question 35

What causes overflow incontincne? What investigation must you carry out? What drugs should be stopped?

Answer 35

Obstruction of urethra or poor contractility of bladder muscle Carry out PR exam (male) and always Post voiding residual (PVR) volume Stop anti-cholinergics as these delay voiding

Question 36

In SUI After trying - Lifestyle (loose weight, stop smoking, avoid caffeinated drinks, avoid excessive fluid intake) - Physiotherapy: pelvic floor muscle retraining, biofeedback, electrical stimulation, pessaries - Drugs: Duloexetine : combined noradrenaline and serotonin reuptake inhibitor (increase intraurethral closure pressure) What surgical procedures can be attempted?

Answer 36

Colosuspension - the Retropubic colposuspension (Burch colposuspension) stabilises the anterior vaginal wall, bladder neck, and proximal urethra in a retropubic position. This prevents their descent and allows for urethral compression against a stable suburethral layer. Colosuspension has largely been replaced by tension fre vaginal tapes - TVT

Question 37

OAB vs SUI vs MUI

• Urgency?
• Frequency with urgency? (greater than 8times/24hours)
• Leaking during physical activity? (coughing, sneezing, lifting)
• Amount of urinary leakage?
• Difficult to reach toilet in time following the urge to void?
• Waling to pass urine at night?

Answer 37

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Question 38

There are 3 compartments of a pelvic organ prolapse: Anterior Middle or apical Posterior How common is pelvic organ prolapse in parous women? A prolapse occurs when weakness of the supporting structures allows the pelvic organs to sag within the vagina

Answer 38

Up to 50% of parous women experience a pelvic organ prolapse

Question 39

What are the classifications of a uterovaginal prolapse? (this differs from the other pelvic organ prolapse)

Answer 39

1st degree - slippage of cervix slightly further into the vagina 2nd degree - at introitus 3rd degree - uterus lies outside the vagina Uterine procidentia - the uterus is completely outside of the vagina

Question 40

Name the symptoms of an anterior prolapse? What is the usual cause of an anterior pelvic organ prolapse?

Answer 40

Bulging, pressure/mass, difficulty voiding and incomplete emptying, difficulty inserting tampon and pain with intercouse Usual cause of an anterior prolapse is a cystocele

Question 41

The symptoms of a middle/apical (also known as vaginal vault) prolaspe are the same as an anterior prolaspe What is this type of prolapse known as?

Answer 41

This is an enterocele - happens when the small intestine prolapses into the pouch of douglas (rectouterine pouch)

Question 42

What compartment is a rectocele? What are the symptoms?

Answer 42

Difficulty defecating, bulging, pressure, diffculty inserting tampon Rectocele is a posterior compartment

Question 43

Clincial evaluation of pelvic organ prolapse Take a good history - pressure, dragging Urinary symptoms Bowel symptoms Sexual dysfunction What is the measurement system used for pelvic organ prolapse?

Answer 43

POP-Q - pelvic organ prolapse quantification system

Question 44

What is the conservative management of a pelvic organ prolapse?

Answer 44

Reassure Avoid heavy lifting, losse weight, stop smoking, reduce constipation Only give vaginal oestrogens if atrophic vaginits

Question 45

What are the prolapse treatment option?

Answer 45

Imrpove muscle tone with exercise and physiotherapy Pessary - when surgey isnt an option currently - usually only temporary or in the frail Surgery - of which there are many different types

Question 46

In the management of pelvic organ prolapse, who are pessaries offered to?

Answer 46

Women who are unfit for surgery Women who are awaiting surgery Women with further pregnancies planned Patient request

Question 47

Surgery is usually the best treatment option for uterovaginal prolapse if physiotherapy doesnt work What is the usual surgery carried out?

Answer 47

Vaginal hysterectomy to remove uterus Sacrospinous fixation of uterus - used in uterovaginal/vaginal vault prolapse

Question 48

In women with a previous hysterectomy or who have undergone hysterectomy, what may be used to treat the vaginal vault prolapse?

Answer 48

Sacrocolpopexy - Sacrocolpopexy can be done abdominally, laparoscopically, or robotically. Synthetic mesh is fixed to the anterior and posterior vagina and attached to the anterior longitudinal ligament to resuspend the vaginal apex.