Incontinence and Pelvic Organ Prolapse

Question 1

What percentage of americam n women can be affected by icnotinence?

Answer 1

as many as 30-40%

Question 2

What are some factors that influence developing incontinence?

Answer 2

gender
age
hormonal status
previous vaginal delivery and birthin trauma
CT differences
neurologic conditions
medications

Question 3

What’s the most important muscle in the pelvus floor?

Answer 3

levator ani

Question 4

Where are the beta adrenergic receptors in the bladder?

Answer 4

bladder dome

Question 5

Where are the alpha-1 receptors?

Answer 5

trigone

urethral smooth muscle

Question 6

Where are the muscarinic receptors?

Answer 6

in the deep layer throughout.

Question 7

THe internal sphincter is smooth muscle under involuntary control of what receptors?

Answer 7

alpha 1

Question 8

The external sphincter is skeletal muscle supplied by what nerve?

Answer 8

somatic pudendal nerve - under voluntary control

Question 9

The function of the urethra is affected by estrogen because….

Answer 9

the blood vessels assist the layer sin coming together to close the urethra and vasculature decreases with decreasing estrogen levels

this is why menopause is a factor

Question 10

Sympathetics are involved with hwat bladder function in general terms?

Answer 10

storage of urine - bladder dome relaxation

Question 11

WHere do these sympathetics come from?

Answer 11

T10-L2 to inferior mesenteric ganglion and palvic plexus. then hypogastric and pelvic nerves to the bladder

Question 12

Parasympathetics are involved with what bladder funcion?

Answer 12

actually peeing

Question 13

Detrussor muscle will do what when exposed to cholinergic muscuarinic receptor agonists?

Answer 13

contract - make you pee

Question 14

What are the muscarinic receptor subtypes in bladder smooth muscl

Answer 14

mainly M2 and M3

Question 15

Activating M2 receptors does what?

Answer 15

inhibits bladder relaxation

Question 16

Activating M3 receptors does what?

Answer 16

promotes bladder contraction (so M2 and M3 promote the same result by different means)

Question 17

What are the beta adrenergic receptors in the detrusor?

Answer 17

B2 and B3 (again, promote relaxation)

Question 18

Where is the micturition center?

Answer 18

pons

Question 19

What are some major drgus taht influence bladder fucntion?

Answer 19

antidepressants/antipsychotics
sedatives
diuretics - increase
caffeine - increase
anticholinergics - urinary retention or used to treat incontinence
alcohol - sedation and bladder irritating
narcotis

Question 20

What are the three main type sof incontinence?

Answer 20

stress
urge
mixed

Question 21

What is stress incontinence?

Answer 21

leakage of small amoutns of urine when itnraabdominal pressure is increased (with walking, running, lifting, coughing, etc.)

very common

Question 22

What is urge incontinence?

Answer 22

overactive bladder - irritation and overativity of the bladder musculature itself. they’ll have the urge to urinate and then leak large amounts of urine shortly after they have that urge - can’t get to the bathroom in time sometimes

Question 23

What are the typical causes of stress I?

Answer 23

pelvic floor weakness
loss of elasticity
hormoneal or connective tissue effects

Question 24

What are the typical causes of urge?

Answer 24

inappropriate bladder contractions - PVC of the bladder, abnormal nerve signals

Question 25

What is overflow incontinence?

Answer 25

caused by either a blockage of the outlet (like BPH) or weak bladder muscle function resultin gin frequent or constnat dribbling

Question 26

What is functional incont?

Answer 26

untimely urination due toinability to get to a bathroom either from mobility issues, obstacles, communication or cognitive problems

Question 27

What are the common causes of transient incontinence?

Answer 27

``` DIAPPERS Delirium Infection Atropic vaginitis Pharmaceuticals Pysychological disorder (esp depression) Excessive urine output Reduced mobility (functional) or reversible urinary retention Stool impaction ```

Question 28

What are the risks for stress incontinence?

Answer 28

age pregnancy with childborth menipause hysterectomy/pelvic surgery obestiy chronically increased intraabodminal rpessure from chronic cough,smoking, constipation or occupational lifting neurological conditions affecting urethral tone.

Question 29

What is the rterm for poor urethral sphincter function?

Answer 29

instrinsic sphincter deficiency

Question 30

What are the factors that can lead to problems with urethra not closing adequately?

Answer 30

nerve damage scarring decreased vascularity

Question 31

What is the most common cause of urge incont. others?

Answer 31

most frequently caused by detrusor overactivity or inacbility to suppress detrusor contractions also UTI, bladder stones, bladder cancer, etc

Question 32

Wht pertinent things on the PMH should be considered?

Answer 32

``` Obstetric and gynecologic history Deliveries, surgeries, estrogen status Diabetes Stroke Lumbar disc disease Neurologic disease Chronic lung disease (coughing) Fecal impaction or constipation Cognitive impairment Medications! ```

Question 33

What can you do for diagnosis?

Answer 33

general inspection for atrophy, neurologic function (bulbocavernosus reflex), anal wink, levator ani testing have then cough and look for leakage bimanual to assess for pelvic masses or stool impaction

Question 34

How can we tell if there is residual volume post void?

Answer 34

urinarlysis with catheter

Question 35

What are the options fo rstress icintoinence?

Answer 35

``` weight loss fluid reduction caffeine reduction smoking cessation control of constipation pelvic floor muscle exercises (kegels) occlusive devices like pessaries or urethral inserts Estrogen intravaginally surgery ```

Question 36

What are two other medications that can be used for stree incotninences?

Answer 36

Duloxetine | alpha adrenergic drugs

Question 37

What are the treatments for urge incont?

Answer 37

``` bladder retraining with scheduled voiding fluid restriciton eliminate meds that make it worse pelvic floor muscle exercises meds tibial nerve stimulation implantable sacral nerve stimulator ```

Question 38

What meds can be used for urge incont

Answer 38

anticholinergics beta-agonists estrogen botulinum toxin injections

Question 39

What muscle is exercised by the kegel exercises?

Answer 39

levator ani

Question 40

What are extracorporeal magnetic innervation

Answer 40

stimulates the pelvic floor muscle sin people whoa re unable to sense whethe they are contracting the muscles or not

Question 41

How doe s apessary work?

Answer 41

it's a disc with a round ball and you put it up into the vagina so that the ball pushes against the bladder anteriorly to help hold it all up

Question 42

Meds are only technically approved for what?

Answer 42

urge incotninence

Question 43

But what are the drugs you can try for stress incontinence?

Answer 43

estrogen | alpha agonists like pseudoephedrine

Question 44

For urge incontinence, you can do anticholienrgic agents. What are some examples?

Answer 44

oxybutinin, detrol, trospium

Question 45

What are the contraindications for these anticholinergic agents?

Answer 45

narrow angle glaucoma dementia (make them worse) GI obstruciton urinary retention

Question 46

What is the main bet agonists used for urge incontinence?

Answer 46

mirabegron | B3 agonist

Question 47

What are the side effects of beta agonists here?

Answer 47

urinary retention, icnreased blood pressure, nausea and vomiting, headache, dizziness

Question 48

What is bladder training?

Answer 48

teach them to ignore bladder urgency and re-establish control over the bladder - do scheduled voiding only

Question 49

When should you refer someone on?

Answer 49

``` Recurrent Urinary Tract Infections New onset neurologic symptoms Markedly enlarged prostate Pelvic organ prolapse past the introitus Pelvic pain and incontinence Persistent hematuria or proteinuria Large post void residual (200 ml) Previous pelvic surgery or radiation Uncertain diagnosis ```

Question 50

WHat ar ethe main symptoms with prolapse?

Answer 50

bulge symtpms - sense of a bulge, protrusion, heaviness or pressure and urinary symptoms - incontinence, frequency, weak stream, etc bowel symptoms sexual symptoms - dyspareunia, decreased sensation pain in the vagina, bladder, rectum, pelvis, or low back pain