Incontinence and Prolapse

Question 1

What is incontinence?

Answer 1

Involuntary leakage of urine

Question 2

What type of incontinence is a) provoked? b) unprovoked?

Answer 2

a) Stress b) Urge (OAB)

Question 3

What is the most common type of incontinence? What is it due to?

Answer 3

Stress: poor closure of the bladder

Question 4

When does stress incontinence occur?

Answer 4

On exertion or effort (e.g. sneezing, coughing, laughing)

Question 5

Describe what happens in urge incontinence?

Answer 5

There is a sudden, compelling desire to urinate that is difficult to delay, and can cause urgency which can lead to incontinence

Question 6

Mixed incontinence is a combination of which types?

Answer 6

Urge and stress

Question 7

Women who have an overactive bladder often do what?

Answer 7

Drink an excessive amount of fluid, and have a high caffeine intake

Question 8

What defines an overactive bladder? What are some symptoms which are commonly associated?

Answer 8

Urgency which occurs with or without incontinence / frequency and nocturia

Question 9

What is overactive bladder known as if it occurs a) with incontinence? b) without incontinence?

Answer 9

a) wet OAB b) dry OAB

Question 10

What happens to the detrusor muscle to cause OAB?

Answer 10

Hyperactivity, there are involuntary contractions

Question 11

Which type of incontinence is more likely to be idiopathic? What are some common risk factors for the other type?

Answer 11

OAB (urge) / stress - childbirth and pregnancy, obesity, chronic cough

Question 12

What effect does caffeine have on the bladder muscle? This of more importance in which type of incontinence?

Answer 12

It is a bladder muscle irritant, more relevant in urge incontinence

Question 13

Which type of medications are especially bad for causing incontinence?

Answer 13

Psychoactive medications (acting on the CNS)

Question 14

What are some examples of storage symptoms?

Answer 14

Frequency, nocturia, urgency, constant leakage

Question 15

What are some examples of voiding symptoms?

Answer 15

Hesitancy, straining, poor flow

Question 16

What are some important aspects of examination when somebody presents with incontinence?

Answer 16

BMI, abdominal exam, vaginal exam, PR exam

Question 17

The total urine passed in one day should be less than what?

Answer 17

< 1800ml

Question 18

Patients with incontinence are often asked to keep a bladder diary, what should be recorded in this? How long is it done for?

Answer 18

How often they go to the toilet and how much is passed, any leakage, how much they are drinking / 3 days

Question 19

What two investigations should be done on every woman presenting with incontinence?

Answer 19

Urinalysis and post-void residual

Question 20

What is the purpose of doing urinalysis when people present with incontinence?

Answer 20

To rule out a UTI (nitrates/WCC), bladder cancer/stones (blood) and diabetes (glucose)

Question 21

What are some further investigations which could be done for incontinence but are not done routinely?

Answer 21

Urodynamics, cystoscopy, imaging

Question 22

When are urodynamics used as an investigation for incontinence?

Answer 22

If the woman is undergoing surgery, if medical treatment has failed or if outflow obstruction is suspected

Question 23

What happens in overflow incontinence?

Answer 23

There is a bladder outflow obstruction where the voiding sensation is inadequate, leading to dribbling incontinence

Question 24

Overflow incontinence can arise as a result of what?

Answer 24

Previous surgery for incontinence or prolapse

Question 25

How can overflow incontinence be treated?

Answer 25

Treat the underlying cause, alpha blockers or intermittent self-catheterisation

Question 26

What is the first step in the management of stress incontinence?

Answer 26

Conservative management: weight loss, physiotherapy for pelvic floor exercises, smoking cessation, cut down alcohol/caffeine

Question 27

If conservative management for stress incontinence has failed, what are some other options?

Answer 27

Incontinence pessary, duloxetine (not usually 1st line), surgery (mid-urethral tape surgery)

Question 28

What will a bladder diary of someone with OAB show?

Answer 28

Frequent, small volume voids through the day and night

Question 29

What are the main lifestyle interventions that can be used as treatment options for an overactive bladder?

Answer 29

Reduce caffeine/alcohol/chocolate, keep fluid intake between 1.5-2.5L/day, weight loss aiming for BMI < 30

Question 30

Apart from lifestyle interventions, what are some other conservative treatment options for OAB?

Answer 30

Pelvic floor exercises for 3 months, bladder retraining for 6 weeks

Question 31

What is the first line pharmacological management for OAB? How do these work?

Answer 31

Anti-muscarinic agents / they relax bladder smooth muscle and hence increase bladder capacity

Question 32

Which specific anti-muscarinic agent is used first for OAB? It often has poor tolerance due to what? If oral methods are intolerant, what can be tried instead?

Answer 32

Oxybutynin / side effects e.g. dry eyes and blurred vision, dry mouth, sedation / transdermal

Question 33

When should you review a patient after starting anti-muscarinic agents for OAB? If they haven't worked, what is the next line management?

Answer 33

4-6 weeks / consider surgical options

Question 34

Anti-muscarinic are generally not prescribed to who? Why?

Answer 34

Those aged > 85, they can cause confusion/dementia

Question 35

Mirabegron is another pharmacological agent which can be used for OAB. What group of drugs does this belong to? How does it work?

Answer 35

Beta 3 agonists / relaxes bladder smooth muscle

Question 36

What happens in an a) anterior b) middle/apical and c) posterior prolapse?

Answer 36

a) bladder drops into the vagina b) uterus drops into the vagina c) bowel drops into the vagina

Question 37

How common in pelvic organ prolapse?

Answer 37

Occurs in 50% of parous women, with 10-20% being symptomatic

Question 38

A cystocele is another name for an anterior prolapse, what can prolapse here? What is a more specific symptom of this type of prolapse?

Answer 38

Bladder or anterior vaginal wall / incontinence

Question 39

Middle/apical organ prolapses (enteroceles) can cause what specific symptom?

Answer 39

Back pain

Question 40

A rectocele is another name for a posterior prolapse, what can prolapse here? What is a more specific symptom of this type of prolapse?

Answer 40

Rectum or posterior vaginal wall / incomplete defaecation

Question 41

What are the most significant contributors to the aetiology of prolapse?

Answer 41

Age, childbirth and family history, as well as increased intra abdominal pressure (e.g. obesity, chronic cough)

Question 42

What is the most common presenting complaint of a prolapse?

Answer 42

A dragging sensation down below, which gets worse as the day progresses

Question 43

What are some groups of symptoms you would want to ask about if a woman presented with a prolapse?

Answer 43

Urinary symptoms, bowel symptoms, sexual dysfunction

Question 44

What position would you want to examine a woman in for suspected prolapse to assess the full extent? How will the prolapse be demonstrated?

Answer 44

While standing or squatting/ Valsalva manoeuvre or coughing

Question 45

Is prolapse routinely investigated for?

Answer 45

No, only if it is of sudden onset as this may be due to pressure from a pelvic mass

Question 46

In the quantification system for prolapse, all sites are measured in relation to which structure?

Answer 46

Hymenal ring

Question 47

What are some conservative management options for prolapse?

Answer 47

Weight loss, smoking cessation, pelvic floor exercises for 3 months, pessaries

Question 48

When would pessaries be used instead of surgery in the management of prolapse?

Answer 48

If that was the preference, not completed family, only mild-moderate, for frail patients

Question 49

What are some complications of using a pessary?

Answer 49

Discharge, ulcerations which may lead to fistula

Question 50

How often should a pessary be changed? What is used alongside it?

Answer 50

Every 6 months / topical oestrogen

Question 51

Sex is only possible with what kind of pessary?

Answer 51

Ring

Question 52

What is the surgical management of uterine prolapse?

Answer 52

Vaginal hysterectomy with vault support

Question 53

What is the surgical management of anterior or posterior prolapses?

Answer 53

Vaginal repair

Question 54

What is the surgical management for uterine prolapse if the woman doesn't want a hysterectomy?

Answer 54

Sacrohysteroplexy