Incontinence And Prolapse Flashcards
(26 cards)
What is urinary incontinence?
The involuntary leakage of urine
Common and distressing problem affecting quality of life
What is stress incontinence?
Involuntary leakage of urine during increased intra-abdominal pressure (in the absence of detrusor contraction)
What are the risk factors for stress incontinence?
Childbirth (most common cause)
Oestrogen-deficient states
Pelvic surgery
Irradiation
What is urge incontinence?
AKA overactive bladder syndrome
Presence of urgency with frequency and nocturia in the absence of UTI or other pathology.
What does urodynamic testing show in urge incontinence?
Overactivity of the detrusor muscle
What are the causes of urge incontinence?
Neurological conditions like MS, spina bifida
Most cases idiopathic
Some caused by pelvic/incontinence surgery
What are the other causes of urinary incontinence? (Not stress or urge)
Overflow incontinence (2o to retention, often no urge) Bladder fistulas (opening between bladder and another organ) Urethral diverticulum (out-pocketing of the urethra into the anterior vaginal wall) Congenital abnormalities e.g. ectopic ureter Functional incontinence (physical/mental barriers preventing reaching the toilet) Temporary incontinence (due to reversible factors e.g. constipation, UTI)
What are the clinical features of stress incontinence?
Leakage on coughing, sneezing or exercise
Small volume of leakage
Prolapse of urethra and anterior vaginal wall may also be present
What are the clinical features of urge incontinence?
Sensation of urgently needing to pass urine followed by involuntary leakage
Frequency
Nocturia
Triggers - hearing running water, cold weather
Larger volumes of incontinence than stress
Bladder contractions may also be triggered by coughing or sneezing
What are the investigations for incontinence?
Exclude UTI
Frequency/volume charts
- stress - normal frequency and bladder capacity
- urge - increased frequency
Urodynamic studies
- performed in stress incontinence when considering surgery to confirm diagnosis and rule out concomitant detrusor overactivity
What is the conservative management for stress incontinence?
Weight loss, smoking cessation
Treat risk factors like conditions that cause raised intraabdominal pressure e.g. chronic cough
Supervised pelvic floor muscle training (at least 3 months)
What is the surgical management for stress incontinence?
Tension free vaginal tape (may lead to chronic pelvic pain)
Burch colposuspension (rarely performed now there’s TVT)
Laparoscopic colposuspension
Peri-urethral injection (bulking agents under LA, suitable for elderly/cannot tolerate surgery)
Transobturator midurethral slings
What is the medical management for stress incontinence?
Duloxetine
- for moderate to severe incontinence
- considered after surgical intervention/for patients where surgery isn’t appropriate
What is the conservative management of urge incontinence?
Good fluid intake
Avoid caffeine and diuretics e.g. alcohol
Bladder retraining
What is the medical management for urge incontinence?
Anticholinergics (oxybutynin, solifenacin, tolterodine)
Intravaginal oestrogen (may ameliorate symptoms for those with vaginal atrophy)
Botulinum toxin A
Neuromodulation and sacral nerve stimulation
What are the side effects of anticholinergics?
Dry eyes Dry mouth Constipation Blurred vision Arrhythmia Confusion
What are the contraindications of anticholinergics?
Acute angle closure glaucoma
Myasthenia gravis
GI obstruction
What is the surgical management for urge incontinence?
Detrusor myomectomy and augmentation cytoplasty
Reserved only for those with debilitating symptoms
Why does a genitouinary prolapse occur?
When there is a weakness in the supporting structures allowing the pelvic organs to protrude within the vagina
What are the causes of prolapse?
Congenital Prolonged labour Trauma from instrumental delivery Lack of postnatal pelvic floor exercise Obesity Chronic cough Constipation (Exacerbated by menopause)
What are the different types of prolapse?
Cystocoele (residual urine within this may cause frequency and dysuria)
Rectocoele
Enterocoele
Uterine prolapse
How is a prolapse graded?
First degree - lowest part of prolapse descends halfway down vaginal axis to the introitus
Second degree - lowest part of prolapse extends to the level of the introitus
Third degree - the lowest part extends beyond the introitus to outside the vagina
Procidenta (4th degree uterine prolapse) - uterus lies outside the vagina
What are the symptoms of prolapse?
Asymptomatic
Dragging sensation/discomfort/feeling of something coming down
Dyspareunia
Backache
Cystocoele - urgency, frequency, incomplete bladder emptying, urinary retention if urethra kinked
Rectocoele - constipation, difficulty with defaecation
What are the preventative measures for prolapse?
Lower parity
Better obstetric practices
Pelvic floor exercises
