exam 3 - urinary incontinence and pelvic organ prolapse Flashcards
(28 cards)
A 59 year old G3 P1021…leaking with laughing, coughing, sneezing.
Diagnosed with stress urinary incontinence. Treated with mid-urethral sling. Improved in 1 month.
incidence
-Occurs across age groups: 25% young, 44-57% middle-aged/postmenopausal, 75% older adults
-50% of cis women in nursing homes
-It is the cause for nursing home admission in 6% of such patients
-Leads to isolation, depression, skin breakdown
physiology of continence
-Brainstem allows for opening of urethral sphincter and relaxation of detrusor muscle, permitting urination
-Increased sympathetic tone contributes to contraction of the internal urethral sphincter
-Increased parasympathetic tone contracts the detrusor muscle
-Normal bladder volume: 300-500 cc
-RF:
-Increasing age
-AFAB sex
-menopause
-Local trauma to the lower genital tract:
-Cystocele
-Rectocele
-neurological injury or illness:
-MS
-ALS
-neurogenic blacder
-spinal cord injury or ds
-Brainstem + autonomic tone coordinate sphincter/detrusor
-Normal baladder capacity: 300–500 cc
-RF: age, AFAB sex, menopause, trauma, MS, ALS, spinal injury
types of urinary incontinence
-In general, there are three major types of urinary incontinence affecting cisgender women
-Stress urinary incontinence
-Leakage occurs with laughing, coughing, sneezing, running, jumping
-Urge incontinence (detrusor overactivity, “overactive bladder”)
-“Key-in-lock syndrome”
-Mixed incontinence (stress urinary incontinence and urge incontinence)
-functional urinary incontinence due to cognitive or mobility impairment with intact lower urinary tract
-postmicturition leakage following complete urination
-postural urinary incontinence due to change of body position
differential diagnosis
-Urinary: SUI, detrusor overactivity, UTI, vaginitis, fistulas, congenital
-Non-urinary: cognitive, neurologic, meds, mobility
approach to pt
-History, voiding diary, physical exam
-UA, urine culture
-Postvoid residual by scan or catheter
history
-Include neuro/gyne/surgical Hx
-Assess: duration/frequency of events, urgency, nocturia, pad use, daily impact
voiding diary
-Track for 3–5 days: fluid intake, void times/volumes, leakage episodes, why it occurs
physical exam
-Complete abdominal and pelvic exams
-Evaluation of pelvic floor, including muscle strength
-Take this opportunity to teach Kegel exercises
-Focused neurological exam
-Mental status exam
-Bulbocavernosus reflex- touch clit with q-tip and anus constricts
-Sensory and motor exams of lower extremities
-Rectal exam
-evaluate tone, tenderness, presence or absence of hemorrhoids
-Rule out fecal impaction, tumors, rectovaginal fistulae
specialized tests
-Cough stress test
-Have patient arrive with full bladder
-Do not collect urine prior to physical exam
-Test may be performed while patient is supine
-Have patient cough
-Should see urine leak during cough
-If not, repeat while patient is standing
-If patient leaks urine while coughing, it is diagnostic of stress urinary incontinence
-Q-tip test for urethral mobility
-Place a sterile cotton applicator lubricated with lidocaine gel in the urethra
-Measure the angle between the horizontal plane and the Q-tip
-Have the patient perform a Valsalva maneuver
-If the increase in the angle is >30 degrees, it suggests poor pelvic support and abnormal bladder neck descent
-Lack of urethral mobility renders a less favorable outcome for surgical intervention, such as sling procedure
-Such patients may benefit instead for injection of urethral bulking agents
-postvoid residual volume
-have pt empty bladder
-perform straight catheterization or perform bladder scan via
-If residual volume is <150 cc, the patient has normal bladder emptying
-No need for urodynamic testing if diagnosis is clear upon history, physical, voiding diary and urinary questionnaires
-For complicated patients, refer for urodynamic testing
urinary incontinence workup
-UA, culture
-Investigate hematuria further if present
management for all types of urinary incontinence: lifestyle modificatoins
-Weight loss, bladder training, fluid management (<2 L/day), ↓ caffeine
-Kegels, biofeedback
aother management strats in tx of stress urinary incontinencestress incontinence treatment
-Urethral bulking agents for patients with symptoms of stress urinary incontinence but without urethral sphincteric deficiency
-Collagen
-Pyrolytic carbon-coated beads
-Calcium hydroxylapatite
-Surgical intervention indicated for pts who have not improved after lifestyle modifications
-The polypropylene midurethral sling is the most effective and safe procedure available
-Acts as a hammock to support the bladder neck and the urethra
-May be placed by a retropubic or transobturator approach
-Reoperation rate is about 2.6%
-An autologous pubofascial vaginal sling may also be used
urge incontinence treatment
-Medications
-Many patients are on multiple agents
-High risk of drug-drug interactions
Antimuscarinic agents
-More effective than placebo
-Many drug-drug interactions
-Many adverse drug reactions
Beta agonists: Produces detrusor muscle relaxation
-Mirabegron: Contraindicated in patients with:
-Severe uncontrolled hypertension
-ESRD
-Significant hepatic disease
-Vibegron
Onabotulinumtoxin A
-Functions as a muscle paralytic
-A multicenter randomized trial comparing antimuscarinics to botulinum toxin demonstrated that antimuscarinics were as effective as botulinum toxin A
-However, more patients using botulinum toxin A reported complete resolution of urge incontinence compared to those using antimuscarinics
Your 85 yo mildly demented gravida 5, para 4014, last menstrual period 40 years ago, is cared for in the home by certified home health aides. The patient’s aide brings her to see you on an emergent basis because she was bathing the patient and noted “a large pink thing down there.”
The patient and aide deny any history of vaginal or rectal bleeding, or of recent vaginal penetration, and the patient denies any history of pelvic or abdominal pain.
Your patient is diagnosed with complete procidentia. Treatment options (observation, pessary, hysterectomy, or LeFort colpocleisis) are discussed with the patient and her son. They opt for a pessary. You fit her with a Gellhorn pessary and have her make an appointment for re-evaluation in 6 weeks.
pelvic organ prolapse
-Uterine/vaginal vault descent
-About 3% of patients are symptomatic
-Sx: pressure, sexual dysfunction, urinary/bowel issues
-RF: parity, age, constipation, obesity
physical exam in the pt with suspected pelvic organ prolapse
-Abd/pelvic exam, Valsalva
-Check for ulcers, cystocele/rectocele
-Postvoid residual
-UA/culture
cystocele & rectocele
-Cystocele (pic):
-Herniation of the anterior vaginal wall due to damage to the pubocervical fascia
-Usually caused by trauma due to childbirth
-Rectocele:
-Defect of the rectovaginal septum
-Usually caused by trauma to the perineal body during childbirth
-The perineal body stabilizes the rectovaginal septum
-Cystocele = anterior wall defect (pubocervical fascia)
-Rectocele = posterior wall defect (rectovaginal septum)
sx of cystocele & rectocele
-Cystocele: vaginal fullness, anterior bulge, urinary issues
-Rectocele: heaviness, constipation, posterior bulge
Baden-Walker staging
Don’t need to know
POP-Q system
- Stage 0: No prolapse
- Stage 1: >1 cm above hymen
- Stage 2: Between +1 and -1 cm
- Stage 3: >1 cm below hymen
- Stage 4: Complete procidentia (entire vaginal canal everted)
prolapse management
-Lifestyle modifications
-Treatment of constipation
-Kegel exercises
Medical management: Pessaries
-These support the pelvic structures and can work quite well
-Require fitting
-Some trial and error
-Should be used with estrogen cream
-Must be cleaned and replaced about every 6-8 weeks by patient or by clinician
Pessaries are medical devices made of silicone or plastic that are inserted into the vagina to help support pelvic organs that have prolapsed
surgical prolapse management
-1. Abdominal sacral colpopexy
-2. uterosacral ligament fixation
-3. sacrospinous ligament fixation:
-all 3 correct upper vaginal prolapse
-last 2 are done at time of hysterectomy
-LeFort Colpocleisis:
-vaginal vault prolapse
-indicated in uterine prolapse in pts who do not want further possibility of vaginal penetration
-For patients who can tolerate major surgery:
-Hysterectomy
-Remember to support vaginal apex, if possible, with abdominal sacral colpopexy or sacrospinous ligament fixation
-For patients who cannot tolerate hysterectomy:
-Colpocleisis
-Closure of vaginal vault in patients who no longer desire vaginal penetration
-Complete colpocleisis
-LeFort colpocleisis
Patient Type Best Surgical Option
Young, healthy, sexually active = Sacral colpopexy
Moderate-risk, uterus removed = Sacrospinous or uterosacral fixation
Frail, no intercourse desired = Colpocleisis (LeFort or complete)
abdominal sacral colpopexy
-Vaginal apex sutured to sacral periosteum using fascial graft (from thigh)
