Continence and Prolapse

Question 1

What are the types of genitourinary prolapse?

Answer 1

Anterior compartment
- urethrocele or cystocele or cystourethrocele

Posterior compartment
- rectocele

Middle compartment
- uterine or vaginal vault (post-hysterectomy) or enterocele (pouch of douglas and small bowel)

Question 2

How can genitourinary prolapses be classified into stages?

Answer 2

Based on where the most distal part of the prolapse lays on straining
1 - >1cm above hymen
2 - Within 1cm distal or proximal to hymen
3 - >1cm below hymen
4 - Complete eversion

Question 3

How can genitourinary prolapses present?

Answer 3

Feeling of vaginal fullness/pressure
Seeing bulge
urinary incontinence (any type) 
feeling of incomplete emptying
constipation or fecal incontinence 
dyspareunia 
vaginal flatus

Question 4

How would you examine a patient with a genitourinary prolapse?

Answer 4

Standing and left lateral positions

Ask patient to strain and cough

Sims speculum

Question 5

How can genitourinary prolapses be managed conservatively?

What would you prescribe if there was co-existing vaginal atrophy?

Answer 5

Treat cough or constipation
Weight loss and smoking cessation
Stop heavy lifting

Atrophy: Vaginal oestrogen creams

Question 6

What are the side affects and risks of vaginal pessaries for prolapse?

Answer 6

Can cause discharge, odour, vaginal erosions, fistulas and sepsis

Question 7

What surgical options are available for genitourinary prolapse? What type of prolapse would each be used for?

Answer 7

Cystourethocele: anterior colporrhaphy or colposuspension

Rectocele: posterior colporrhaphy

Uterocele: hysterectomy

Vaginal vault: sacrocolpoplexy

Question 8

What is the first line non-surgical management option for urogenital prolapse?

Answer 8

16 weeks of pelvic floor muscle exercises
AND/OR
vaginal pressary

Question 9

What is a colposuspension?

Answer 9

Sutures to suspend bladder neck to pelvic side wall

Question 10

What is colpocleisis?

Answer 10

Closing off of vaginal canal

Question 11

What are the types of urinary incontinence?

Answer 11

Stress
Urge
Mixed
Overflow
Functional

Question 12

What is stress incontinence?

Answer 12

Involuntary leaking of urine upon exertion

e.g. when coughing or sneezing

Due to incompetent sphincter

Question 13

What is urge incontinence?

Answer 13

Involuntary leakage of urine alongside or just after urgency

Due to detrusor overactivity

e.g. Suddenly need toilet then v quickly leak

Question 14

What is mixed incontinence?

Answer 14

Both stress and urge together

Leak when coughing and also get sudden urges with leakage

Question 15

What is overflow incontinence?

Answer 15

Involuntary leakage of urine due to chronic bladder outflow obstruction

Question 16

What is functional incontinence?

Answer 16

Can’t get to toilet in time due to mobility issues

Question 17

What are the main risk factors for urinary incontinence?

Answer 17

Advancing age
Vaginal delivery
Overweight

Others include:
Forceps, heavy baby, diabetes, frequent UTI, neurological disease, pelvic tumours, stool impaction, family history, hysterectomy

Question 18

How is urinary incontinence investigated?

Answer 18

Bladder diary for 3 days
Urine dip - infection, glucose, protein?
Speculum - prolapse? visualise if able to contract pelvic flood muscles
Quality of life questionnaire
Post micturition bladder scan - residual volume

Question 19

When are urodynamic studies done for urinary incontinence?

Answer 19

When you are unsure of the cause following bladder diary, examinations etc.

Question 20

How can urinary incontinence be temporarily managed?

Answer 20

Pads - done until diagnosis and full management plan in place

Question 21

What lifestyle changes are suggested in the management of urge incontinence?

Answer 21

Reduce caffeine
Lose weight - if BMI >30
Drink 2L per day

Question 22

What is the stepwise management plan for urge incontinence?

Answer 22

1 - Bladder training
2 - Medication
3 - Botulinin toxin A injections
4 - percutaneous sacral nerve stimulation

Question 23

What is bladder retraining?

Answer 23

6 week plan where patients have scheduled voiding times with increasing time intervals

Question 24

What medication can be used for urge incontinence?

What is given to frail elderly women?

Answer 24

Antimuscarinics - effect may take 4 weeks to be seen

• Oxybutynin - immediate release
• Tolterodine - immediate release
• Darifenacin

Mirabegron for elderly as oxybutynin contraindicated

Question 25

What is the MOA, ADR's and CI's for antimuscarinics in urge incontinence?

Answer 25

MoA - Relax urinary smooth muscle ADR - Constipation, dizzy, dry mouth and eyes, flushing, temperature CI - severe UC and urinary retention, oxybutynin not for frail elderly

Question 26

How long does botulinin toxin A for incontinence last? What are the risks?

Answer 26

Benefits seen after 4 days. Last 6-9 months Risks - urinary retention requiring catheter, UTI

Question 27

Describe the use of percutaneous sacral nerve stimulation in urge incontinence

Answer 27

Done in 2 stages - test phase and then implantation if test successful Percutaneous sacral nerve stimulation

Question 28

What medication can be used if nocturnal symptoms of urge incontinence are particularly severe?

Answer 28

Desmopressin

Question 29

What is the conservative management for stress incontinence?

Answer 29

Pelvic floor exercises 8 Contractions 3x a day for 3 months

Question 30

What is the surgical management for stress incontinence?

Answer 30

Colposuspension Autologus rectal fascial sling Retropubic mid-urethral mesh sling - NICE recommend offering the other 2 first as some concerns over mesh slings

Question 31

What are the risks of surgical management of stress incontinence?

Answer 31

``` Damage to bladder and bowel Damage to nerves Urge incontinence Pelvic pain Dyspareunia ```

Question 32

What are the specific risks of using a mesh sling for stress incontinence?

Answer 32

Vaginal mesh exposure can lead to pain Discharge and bleeding Mesh may come through bladder or urethra --> urinary symptoms Women should be warned it is not reversible - the mesh may never be able to be completely removed

Question 33

What management options are available for stress incontinence if the women doesn't want surgery?

Answer 33

Intramural bulking agents Duloxetine

Question 34

What are the risks of intramural bulking agents?

Answer 34

Urinary retention Urge incontinence UTI

Question 35

What are the ADR's associated with duloxetine?

Answer 35

``` GI disturbance Dry mouth Headache Decreased libido Anorgasmia ```

Question 36

What is the first line management for mixed incontinence?

Answer 36

Either bladder retraining therapy or pelvic floor muscle exercises

Question 37

a bladder diary shows a) reduced volume that is always the same b) reduced volume that differs each time What is the likely diagnosis?

Answer 37

a) bladder wall pathology eg carcinoma | b) overactive bladder i.e. detrusor overactivity

Question 38

Describe the appearance of a flow rate graph (x axis is time and y axis is rate) for a) stress b) obstruction

Answer 38

a) very quick rise and then fall in flow rate as little resistance so get superflow b) reduced flow rate and urinates over a longer period of time i.e. takes longer to empty bladder as reduced flow rate