Gynae: Urinary Incontinence & Prolapse Flashcards
(30 cards)
What do we mean by pelvic organ prolapse?
Why does pelvic organ prolapse occur?
- Descent of pelvic organs (uterus, bladder or rectum) from normal position into the vagina
- Due to weakness of ligaments & muscles surrounding pelvic organ (uterus, rectum & bladder)
What is a uterine prolapse?
Uterus descends from it’s normal position into vagina
What is a vault prolapse?
Occurs in women who have had hysterectomy; top of vagina (vault) descends from normal position into the vagina
What is rectocele?
What is rectocele associated with?
- Rectum prolpases/descends/moves forward into the vagina due to defect in posterior vaginal wall
- Associated with constipation. Women may get faecal loading in part of rectum that has prolapsed; this can lead to constipation, urinary retention if compressing urethra and a palpable lump in vagina.
*NOTE: women may use their fingers to push lump backwards- correcting position of rectum- allowing them to open bowels
What is cystocele?
- Bladder prolapses/descends/moves backwards into vagina due to defect in anterior vaginal warll
- Urethrocele= prolapse of urethra
- Cystourethrocele= prolapse of bladder & urethra
State some risk factors for pelvic organ prolapse
- Multiple vaginal deliveries
- Instrumental, prolonged or traumatic delivery
- Increasing age
- Post-menopausal
- Obesity
- Chronic respiratory disease (leading to chronic cough)
- Chronic constipation leading to straining
Describe typical presentation of pelvic organ prolapse
- Feeling of something coming down in the vagina
- Dragging or heavy sensation in pelvis
- Urinary symptoms:
- Urgency
- Frequency
- Weak stream
- Retention
- Incontinence
- Bowel symptoms:
- Constipation
- Urgency
- Incontinence
- Sexual dysfunction
- Dyspareunia
- Altered sensation
*
Discuss how you should examine a woman with suspected pelvic organ prolapse
- Pt should ideally empty bladder & bowel
- Examine in multiple positions including dorsal & left lateral position
- Use Sim’s speculum to support anterior & posterior vaginal wall in turn whilst examining other vaginal walls (hold on anterior wall to look for rectocele and hold on posterior wall to look for cystocele)
- Ask women to cough or bear down to assess full extent of prolapse
Uterine prolapses can be graded using the POP-Q (pelvic organ prolapse quantification) system; describe this grading system
- Grade 0: Normal
- Grade 1: The lowest part is more than 1cm above the introitus
- Grade 2: The lowest part is within 1cm of the introitus (above or below)
- Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
- Grade 4: Full descent with eversion of the vagina
*Introitus: opening to the vagina
What is uterine procidentia?
Uterus lies entirely outside the introitus (same as grade 4 on POP-Q)
Management for pelvic organ prolapses can be split into 3 categories: state these
- Conservative management
- Vaginal pessary
- Surgery
Discuss the conservative management of pelvic organ prolapse
Can help all women. Women with mild symptoms, who don’t tolerate pessaries or are not suitable for surgery may also benefit:
- Weight loss
- Pelvic floor exercises
- Vaginal oestrogen cream
- If have associated stress incontinence
- Decrease caffeine
- Not drinking too much
- Anticholinergic medications
For pessaries, discuss:
- How they work
- Different types
- How to use pessaries
- Risks & how to reduce
- Inserted into vagina to provide extra support to pelvic organs
- Types:
- Ring: sit around cervix holding uterus up
- Shelf & Gellhorn: flat disc with stem that sits below uterus (with stem pointing down)
- Cube: cube shaped
- Donut: thick ring
- Hodge: one side hooked around posterior aspect of cervix and other side extends into vagina
- Often have to try multiple types. Remove and clean or change periodically (e.g. every 4 months)
- Can cause vaginal irritation & erosion over time so oestrogen cream can be used to help protect vagina from irritation
Surgery is only definitive treatment option for pelvic organ prolapse; state some surgical options available for pelvic organ prolapse
- Uterine prolapse → hysterectomy, sacrohysteropexy (**lift the uterus back into its normal position)
- Vault prolapse → sacrocolpopexy
- Cystocele/Cystourethrocele → colposuspension (lift neck of bladder and hold in place with stitches), anterior colporrhaphy (push bladder back to normal position and strengthen anterior vaginal wall using stitches)
- Rectocele → posterior colporrhaphy
.State some potential complications of surgery for pelvic organ prolapse
- Usual surgical complications:
- Pain
- Bleeding
- Infection
- DVT
- Risk of anaesthetic
- Damage to surrounding structures e.g. bladder, bowel
- Recurrence of prolapse
- Altered sexual experience
NICE recommend that mesh procedures should be avoided. State some potential complications of mesh repairs
*Mesh repairs involve inserting plastic mesh to support pelvic organs
- Chronic pain
- Altered sensation
- Dyspareunia for the women or her partner
- Abnormal bleeding
- Urinary or bowel problems
State, and describe the typical presentation, of the 6 types of urinary incontinence
- Stress: involuntary leakage on effort or exertion, sneezing, coughing, laughing etc..
- Urgency: involuntary leakage accompanied by, or immediately preceded by, sudden compelling desire to urinate which is difficult to defer. UUI is subtype of OAB (OAB is urinary urgency usually associated with frequency & nocturia with or without incontince ‘wet OAB or ’dry OAB’)
- Mixed: features of both stress & urgency
- Overflow: involuntary leakage and pt may feel be straining when trying to urinate or feel their bladder is not completely empty
- Continuous: constant leakage of urine
- Functional: involuntary leakage because despite being aware of urge to urinate patient is unable to get to bathroom (due to physicla or mental impairment)
Explain the pathophysiology of each of the 5 types of urinary incontinence
- Stress: Intra-abdominal pressure > urethral sphincter pressure. Impaired urethral support most commonly due to weakness of pelvic floor muscles
- Urgency: detrusor hyperactivity leading to uninhibited bladder contraction, a rise in intravesical pressure, leakage of urine
- Mixed: mix of both stress & urgency
- Overflow: chronic retention leads to progressive stretching of bladder wall leads to loss of bladder sensation and damage to efferent fibres of sacral reflex. This results in bladder filling with urine and becoming grossly distended. Intravesical pressure increases and is > urethral sphincter pressure leading to leakage of urine
- Continuous: anatomical abnormality e.g. ectopic ureter, bladder fistula or due to severe overflow incontinence
- Functional: as in previous definition, pt unable to get to toilet in time due to physical or mental impairment e.g. impaired mobility, dementia, visual problems
State some risk factors for incontinence
- Increased age
- Postmenopausal status
- Obesity
- Previous pregnancies and vaginal deliveries
- Pelvic organ prolapse
- Pelvic floor surgery
- Neurological conditions, such as multiple sclerosis
- Cognitive impairment and dementia
What questions should you include in incontinence history to assess:
- For modifiable risk factors
- Severity
Assess for modifiable lifestyle factors that can contribute to symptoms:
- Caffeine consumption
- Alcohol consumption
- Medications
- Body mass index (BMI)
Assess the severity by asking about:
- Frequency of urination
- Frequency of incontinence
- Nighttime urination
- Use of pads and changes of clothing
Discuss how you should examine a woman presenting with urinary incontinence
Assess for:
- Pelvic organ prolapse
- Atrophic vaginitis
- Urethral diverticulum
- Pelvic masses
- Leakage of urine when pt asked to cough
- Strength of pelvic muscle contractions during bimanual pelvic examination
What investigations would you consider in women presenting with urinary incontinence and why?
- Bladder diary
- Urine dipstick: infection, haematuria, glucosuria
- Post-void bladder scan: incomplete emptying
- Urodynamic testing: not always required but may be done in pts with urge incontinence not responding to treatment, urinary retention, previous surgery, unclear diagnosis
How long prior to urodynamic testing must pts stop taking anticholinergic and bladder related medications?
~5 days
Discuss how urodynamic tests are done- including what measurements are taken
