Pelvic Floor Disorders

Question 1

What are the 3 general categories of pelvic floor disorders?

Answer 1

Urinary Incontinence
Pelvic Organ Prolapse
Anal Incontinence

Question 2

In what age group is the incidence of UI/POP the highest?

Answer 2

70-79yo

Question 3

What are some urethral causes of urinary incontinence?

Answer 3

Urethral sphincter incompetence
Detrusor instability
Retention with overflow
Functional

Question 4

What are some extraurethral causes of urinary incontinence?

Answer 4

Congenital

Fistula

Question 5

What is the incidence of USI?

Answer 5

1/3 in women over 55yo

Question 6

What are the RFs for UI?

Answer 6

Sex (F>M)
Age (Older>younger)
Obesity
Smoking (chronic cause, increased risk of overactive bladder)
Renal disease
DM

Question 7

What is overactive bladder syndrome?

Answer 7

Urgency, with or without urge urinary incontinence, usually with frequency and nocturia in the absence of pathologic or metabolic conditions that might explain these symptoms

Question 8

What is the difference between OAB wet and dry?

Answer 8

Wet has (urge) incontinence, in dry it is absent

Question 9

What is mixed UI?

Answer 9

Involuntary leakage associated with urgency and also with exertion, sneezing, or coughing (SUI)

Question 10

What evaluation should be carried out in UI Ix?

Answer 10

Stress test
Post void residual
Urinalysis
Bladder diary

Question 11

When can pelvic floor exercises be used?

Answer 11

SUI
MUI
Not in UUI
(Min 3 months)

Question 12

What pharmacological therapy can be used for OAB syndrome?

Answer 12

Antimuscarinic agents

Question 13

What effects do antimuscarinics have on urination?

Answer 13

Reduce intra-vesical pressure
Increase compliance
Raise volume threshold for micturition
Reduce uninhibited contractions

Question 14

What are some S/E of antimuscarinics?

Answer 14

Dry mouth
Constipation
Blurred vision
Somnolence

Question 15

What should be used in OAB if antimuscarinics have been deemed ineffective or are contraindicated?

Answer 15

Mirabegron- β3 Agonists

Question 16

What is the MOA of β3 Agonists?

Answer 16

Relax bladder smooth muscle through activation of the β3 adrenoceptor
Selective agonist for the human β3 adrenoceptor with low intrinsic activity for β1 and β2
Increase voiding interval and inhibit spontaneous bladder contractions during filling suggesting a potential clinical application for these agents

Question 17

What specific drug choices should be offered first to women with OAB or MUI?

Answer 17

Oxybutynin (immediate release) or
Tolterodine (immediate release) or
Propiverine (immediate release)

Question 18

What are 2nd line antimuscarinic treatments for OAB?

Answer 18

Trospium (immediate release) or
Oxybutynin (extended release) or
Darifenacin or
An alternative immediate release drug

Question 19

What is uroflowmetry?

Answer 19

Measurement of volume of urine (ml) expelled from the bladder each second

Question 20

When is uroflowmetry indicated?

Answer 20

Hesitancy
Voiding difficulty
Neuropathy
History of urine retention
Post-operative follow up

Question 21

When are multichannel urodynamics indicated?

Answer 21

Uncertain diagnosis
Fail respond to treatment
Prior surgery

Question 22

What does flow rate enable you to measure?

Answer 22

Peak flow
Mean flow
Voided volume (minimum 200mls void required)

Question 23

What is cystometry?

Answer 23

A method by which the pressure/volume relationship of the bladder is measured during filling, provocation and during voiding

Question 24

What is an abnormal Post Void Residual (PVR)?

Answer 24

> 100-150cc

Question 25

What are the causes of overflow incontinence?

Answer 25

Obstruction of urethra | Poor contractile bladder muscle

Question 26

What must be found out in OUI?

Answer 26

PVR

Question 27

What must be stopped in OUI?

Answer 27

Anticholinergics

Question 28

What is the conservative treatment of SUI?

Answer 28

Lifestyle Physiotherapy Drugs: duloxetine (combined noradrenaline and serotonin reuptake inhibitor- increases intraurethral closure pressure) Others- pads, vaginal pessaries

Question 29

What is the surgical treatment of SUI?

Answer 29

Low tension vaginal tape Intraurethral injection Artificial sphincters Colposuspension

Question 30

What is the conservative treatment of OAB?

Answer 30

Lifestyle- avoid caffeine Physiotherapy Drugs- antimuscarinics

Question 31

What is the surgical treatment of OAB (rarely used)?

Answer 31

``` Augmentation cystoplasty Sacral nerve modulation Tibial nerve stimulation Bladder overdistension Botox injections ```

Question 32

What are the 3 compartments of prolapse?

Answer 32

Anterior (cystocele) Middle or Apical (vaginal vault prolapse/enterocele) Posterior (rectocele)

Question 33

What is procidentia?

Answer 33

Complete prolapse of compartment/structure

Question 34

What is the Pelvic Organ Prolapse Quantification System?

Answer 34

Patient straining- 6 specific sites are evaluated, at rest 3 sites Measure each site (cm) in relation to hymenal ring, which is fixed. Hymenal ring is zero point of reference If site is above hymen, assigned -ve number, if prolapse below, measurement +ve

Question 35

What is the conservative management of uterovaginal prolapse?

Answer 35

Reassure Avoid heavy lifting, loose weight, stop smoking, reduce constipation Vaginal oestrogens: only if symptomatic atrophic vaginitis

Question 36

What is the medical and surgical management of prolapse?

Answer 36

Expectant management Physio Pessary Surgical- abdo, vaginal, lap, robotic assisted lap, mesh kits

Question 37

Who is suitable for a pessary in POP?

Answer 37

``` Women unfit for surgery Relief symptoms whilst awaiting surgery Further pregnancies planned or pregnant As diagnostic test for prolapse/ensure correction of large cystourethrocele not cause SUI Patient request ```

Question 38

How is uterine/vault prolapse repaired?

Answer 38

Vaginal hysterectomy Manchester repair (cervix amputated, uterosacral ligaments shortened) Sacrospinous Fixation Others: Abdominal/laparoscopic sacrocolpopexy, mesh techniques, colpocleisis