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Y4 CBLs > Obs&Gyn Urinary incontinence > Flashcards

Obs&Gyn Urinary incontinence Flashcards

1
Q

What problems does urogynecology deal with?

A
  • urinary incontinence
  • bladder-related problems
  • prolapse
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2
Q

What’s incontinence?

A

Incontinence is the involuntary loss of urine which is both a social and hygienic problem

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3
Q

What’s required for continence?

A

Continence requires:

  • normal anatomy
  • good closure of the urethral sphincters/muscle
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4
Q

Classifiction of incontinence (4)

A
  • overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
  • stress incontinence: leaking small amounts when coughing or laughing
  • mixed incontinence: both urge and stress
  • overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
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5
Q

Risk factors for urinary incontinence

A
  • advancing age
  • previous pregnancy and childbirth
  • high body mass index
  • hysterectomy
  • family history
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6
Q

Pathophysiology of stress incontinence

A
  • Anatomy: decent of bladder neck & superior part of urethra outside of abdo cavity means increased abdo pressure (e.g. during sneezing) only exerted on bladder & not on neck & urethra so urine forced out of bladder
  • Decent of bladder neck caused by: inc age, inc parity (especially prolonged 2nd stage of labour), postmenopausal women, chronic raised intra-abdo pressure: obesity, COPD, constipation
  • Increased abdo pressure caused by: sneezing, coughing, laughing, activity
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7
Q

Aetiology of urge incontinence

A
  • largely idiopathic
  • associated disease: MS, autonomic neuropathy, spinal lesions, pelvic surgery (damaging nerve connections)
  • can be exacerbated (but not caused by): caffeine, alcohol & smoking
  • urge incontinence can be caused by: infection, stones or tumours
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8
Q

Signs and symptoms of stress incontinence

A
  • Factors provoking leakage: coughing, sneezing, exertion

O/E:

  • try to provoke incontinence
  • speculum to look for prolapse
  • assess severity and impact on daily life
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9
Q

Signs and symptoms of urge incontinence

A
  • frequency
  • nocturia
  • urgency

Important to assess severity and impact on daily life.

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10
Q

Initial investigations for urinary incontinence

A
  • bladder diary for minimum of 3 days
  • urinalysis & mid stream sample to rule out UTI
  • vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
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11
Q

Specialised investigations for urinary incontinence

A

Urodynamics:

  • Uroflowmetery: measurement of flow rate (simple & non-inasive)
  • Cystometry: Measures intra-abdominal & urethral pressure, can diagnose urge & stress by exclusion of urge
  • Videocystourethrography (VCU): Bladder filled w/ dye then x-rays

Imaging:

  • Cystoscopy-visualization of bladder (few indications) can show polyps, calculi and malignancy
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12
Q

When to refer urgently with bladder problems?

A

Urgent Referral:

  • microscopic haematuria (>50yo)
  • visible haematuria
  • recurrent & persistent UTI w/ hameaturia
  • suspected malignancy
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13
Q

Management of urge incontinence

A
  • bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
  • bladder stabilising drugs: antimuscarinics are first-line e.g. Oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)*
  • Invasive: bladder wall injection w/ botulinum A toxin. Sacral nerve stimulation to reduce detrusor overactivity

* Immediate release oxybutynin should, however, be avoided in ‘frail older women’

*mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

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14
Q

Management of stress incontinence

A
  • pelvic floor muscle training: at least 8 contractions performed 3 times per day for a minimum of 3 months
  • Physiotherapy: to increase muscle tone and strength, & increase cortical connection to these muscles. 40-60% will need no further treatment than physio

*Bladder retraining should be used in conjunction

  • Duloxetine as 2nd line
  • surgical procedures: e.g. retropubic mid-urethral tape procedures
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15
Q

Surgeries for stress incontinence

A
  • 1st line surgery: Retropubic mid -urethral tape procedure (high efficacy, good recovery rate and decreased cost)
  • 2nd line: Colposuspension
  • 3rd Line: autologous rectus fascial sling
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16
Q

Definition of vaginal prolapse

A
  • Descent of a pelvic organ beyond its normal anatomical position.
  • Descent is into the only potential space → the vagina
  • Pressure can force wall of vagina, uterus or cervix through vaginal orifice
17
Q

Types of urogenital prolapse

A

Type of prolapse depends on organ which has descended:

  1. Cystourethrocele: (most common) bladder or urethra descend
  2. Uterine Prolapse: descent of uterus
  3. Rectocele: prolapse of the front wall of rectum into posterior vaginal wall
  4. Enterocele: prolapse of pouch of douglas with small intestine into the vagina
  5. Vaginal Vault Prolapse: descent of vaginal vault (post hysterectomy) often with combination of above prolapses
18
Q

The classification system of urogenital prolapse (3)

A

Baden-Walker Classification

1st Degree: cervix visible when perineum depressed (w/in vagina)

2nd degree: cervix prolapsed through introitus (fundus remains in vagina)

3rd Degree: (procidentia) entire uterus outside introitus

19
Q

Epidemiology of urogenital prolapse

A
  • 50% of parous women have some level of prolapse
  • 10-20% seek medical help
  • Leading cause of hysterectomy in women >50yo
  • By age of 80 1 in 10 women will have had surgery for prolapse
20
Q

Aetiology of urogenital prolapse

A
  • Defect of ligaments & muscles (or no nerve connection) of pelvic floor
  • 2% in nulliparous women (? congenital cause: ?connective tissue disease)
21
Q

Risk factors for urogenital prolapse

A
  • Childbirth (leading cause): parity, instrumental delivery, delayed 2nd stage
  • Ageing: post-menopausal atrophy
  • Chronic conditions: cough, constipation, masses (inc abdo pressures e.g. obesity)
  • Previous pelvic surgery
22
Q

General signs and symptoms of urogenital prolapse

A
  • local discomfort
  • awareness of “something coming down”
  • difficulty retaining tampon
  • spotting
  • dysparaeunia/loss of sensation
  • can be exacerbated by coughing, sneezing & straining
23
Q

Signs and symptoms of cystourethrocele

A
  • incontinence
  • frequency
  • urgency
  • poor stream
  • may require manipulation of prolapse to micturate
24
Q

Symptoms of rectocele

A
  • constipation
  • urgency to pass stool
  • tenesmus
  • may require manipulation to defecate
25
Q

What to examine in suspected urogenital prolapse?

A

Assess vagina using a sims speculum, observing movement of prolapse and urinary incontinence on straining

26
Q

Investigations in suspected urogenital prolapse

A
  • Clinical diagnosis
  • Swabs/urinalysis/MSSU → if infection suspected
  • Referral for urodynamics if associated incontinence
27
Q

Management of urogenital prolapse

A
  • Conservative: weight loss, stop smoking, treat chronic cough/constipation, avoid lifting and high impact physical exercise
  • Pelvic floor exercises: referral to specialist physiotherapy
  • HRT replacement (topical or oral) → improve collagen content
  • Vaginal pessaries: simple measure, difficulty finding correct size initially, may occasionally cause local irritation. Sex possible w/ pessary
  • Surgery
28
Q

Types of surgery for urogenital prolapse

A
  • anterior/posterior colporrhaphy
  • hysterectomy
  • Manchester repair
  • Fothergill procedure
  • sacrospinous fixation
  • sacral colpopexy
29
Q

Questions in history for suspected urinary incontinence

A
  • Daytime frequency and nocturia
  • Presence of urgency
  • Any leakage and when this occurs
  • Any feeling of incomplete bladder emptying
  • Presence of bladder pain/symptoms of cystitis
  • Any haematuria
  • Presence of recurrent proven urine infections
  • Symptoms of a bulge/discomfort within the vagina
  • Need to assess length and severity of symptoms
  • Ask about any previous treatment
  • Establish usual fluid intake and what this comprises
  • Ask about potential co-morbidities, eg chronic cough, constipation
  • Ask about whether a patient is sexually active and if there are any complications
  • Ensure full medical, surgical and medication history is taken
30
Q

What information ‘Bladder dairy’ should include?

A
  • Fluid input
  • Type of fluid
  • Volume voided
  • Day
  • Night
  • Episodes of leakage
31
Q

How does a urodynamic assessment look like? (1 stage)

A

•Involves a measurement of pressures and flow

It’s comprised of two stages:

1.Storage/Filling phase

  • Bladder filled at a pre-determined rate
  • Patient is asked to describe bladder sensations such as: first and normal desire to void, urgency, bladder pain
  • Patient is asked to cough, listen to taps or perform other activities that may cause leakage

Information is gained as to: actual bladder capacity, presence of detrusor contractions, type of leakage

32
Q

How does detrusor overactivity look on cystometry?

A
33
Q

How does stress incontinence look on cystometry?

A
34
Q
A
35
Q

2nd stage of urodynamic assessment

A

Voiding phase

  • starts when the patient is given permission to void

It gives information about:

  • Flow rates and stream
  • Complete/Incomplete bladder emptying
  • Detrusor muscle pressure required to empty bladder i.e. if the patient strains to void
36
Q

Mirabegron

  • class
  • use
  • caution
  • SEs
A

Class: b3 receptor agonist and activates b3 adrenoreceptors in the bladder causing

  • Relaxation of the bladder
  • Improved filling and storage of urine

Use if:

  • Antimuscarinics are contra-indicated or clinically ineffective
  • In patients who cannot tolerate the side effects of antimuscarinics

Caution: Lower doses should be used if renal or hepatic impairment

Common side effects: UTIs, palpitations and increase in blood pressure (hence do not used if severe or uncontrolled hypertension

Y4 CBLs (32 decks)

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