PROLAPSE AND INCONTINENCE

Question 1

How common is urogenital prolapse?

Answer 1

Affects 40% of post-menopausal women
Lifetime risk is up to 19%

Question 2

Types of urogenital prolapse?
Which is most common?

Answer 2

Cystocele or cystourethrocele - most common type
Rectocele
Uterine prolapse
Vault prolapse

Others: urethrocele, enterocele

Question 3

What causes urogenital prolapse?

Answer 3

Weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder

Question 4

What is a uterine prolapse?

Answer 4

When the uterus itself descends into the vagina

Question 5

What is a vault prolapse?

Answer 5

Occurs in women that have had a hysterectomy
The vault of the vagina (top) descends into the vagina

Question 6

What is a rectocele?

Answer 6

Posterior vaginal wall defect allows the rectum to prolapse forwards into the vagina

Question 7

Symptoms specific for rectocele?

Answer 7

Significant constipation, urinary retention - due to Faecal loading
Many women will push the prolapsed contents back into the vagina, correcting the anatomical position of the rectum, and allowing them to open their bowels

Question 8

What is a cystocele?

Answer 8

Defect in the anterior vaginal wall allows the bladder to prolapse backward into the vagina

Question 9

What is a cystourethrocele?

Answer 9

Prolapse f the bladder and the urethra

Question 10

What is an enterocele?

Answer 10

Herniation of the punch of Douglas into the vagina (including small intestine)

Question 11

Risk factors for urogenital prolapse?

Answer 11

Increasing age and post menopausal status
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Obesity
Chronic resp disease causing coughing
Chronic constipation causing straining
Spina bifida

Question 12

Presentation of a urogenital prolapse?

Answer 12

sensation of pressure, heaviness, ‘bearing-down’, dragging in the vagina or pelvis
urinary symptoms: incontinence, frequency, urgency, weak stream, retention
Bowel symptoms: constipation, incontinence, urgency
Sexual dysfunction: pain, altered sensation and reduced enjoyment

Bulge which can be pushed back in and worsens on straining or bearing down

Question 13

Examination for a urogenital prolapse?

Answer 13

Empty bladder and bowels before examination

Examine on dorsal and left lateral position
Use a sim’s speculum - U-shaped single-bladed speculum which can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined e.g. hold on anterior wall to examine for a rectocele
Cough test - ask to cough to assess full descent of prolapse and see if stress incontinence
Ask woman to “bear down” for the same reasons as above

Question 14

What grading system do we use for urogenital prolapse?

Answer 14

Pelvic Organ Prolapse Quantification System (POP-Q)

Question 15

Outline the POP-Q system

Answer 15

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

Question 16

Management options for a urogenital prolapse?

Answer 16

Conservative
Pessary
Surgery

Question 17

Conservative management of urogenital prolapse?

Answer 17

Weight loss
Pelvic floor msucle exercises - may include referral to physio - do these for at least 16 weeks!
High fibre diet to avoid constipation
Avoid lifting heavy objects
For any stress incontinence: Reduce caffeine intake and Incontinence pads
Vaginal oestrogen cream to ease some symptms e.g. dyspareunia or vaginal dryness

Question 18

Types of vaginal pessaries?

Answer 18

Ring pessary
Shelf and gellhorn pessary
Cube pessary
Donut pessary
Hodge pessary

Question 19

Which pessary is used if pt is sexually active?

Answer 19

Ring pessary

Question 20

Management of vaginal pessaries?

Answer 20

Women often have to try a few types of pessary before finding the correct comfort and symptom relief
Remove and clean them or change them every 4-6 months
Can last up to 10 years
May need oestrogen cream to help protect vaginal walls from irritation

Question 21

Side effects of vaginal pessaries?

Answer 21

BV - smelly discharge
Irritation, soreness or bleeding in vagina
Stress incontinence
UTI
Interference with sex

Question 22

Surgical options for a rectocele?

Answer 22

Posterior colporrhaphy

Question 23

Sugrical options for a uterine prolapse?

Answer 23

Hysterectomy
Sacrohysteropexy (mesh attaches cervix to sacral region)

Question 24

Surgical options for cystocele or cystourethrocele?

Answer 24

Anterior colporrhaphy

Question 25

Complications of pelvic organ prolapse surgery?

Answer 25

Pain, bleeding, infection, DVT risks associated with anaesthetic Damage to the bladder or bowel Recurrence of the prolapse Altered experience of sex Vaginal discharge or bleeding

Question 26

The controversy over mesh repairs for urogenital prolapse?

Answer 26

NICE recommend mesh procedures should be avoided entirely They can cause chronic pain, mesh exposure (where it sticks out through the surgery cut and into the vaginal canal), altered sensation, dyspareunia, abnormal bleeding, urinary/bowel problems

Question 27

Risk factors that predispose a person to develop stress urinary incontinence?

Answer 27

Increasing age Pregnancy and vaginal delivery - may damage pudendal or pelvix nerves Increased pressure on tummy e.g. pregnancy or obesity Constipation Prolapse Oestrogen deficient states FHx Smoking - chronic cough -> may contribute Damage to bladder during surgery Certain meds - ACEi, diuretics, antidepressants, HRT, sedatives

Question 28

Causes if urge urinary incontinence?

Answer 28

Idiopathic in most cases Comoboridites - obesity, T2DM, chronic UTI Neurological conditions e.g. parkinsons, MS, injury to pelvic or spinal nerves Certain meds- diuretics, antidepressants, HRT, parasympathomimetics Can be exacerbated by caffeinated, acidic or alcoholic drinks

Question 29

Causes if overflow urinary incontinence?

Answer 29

Bladder outflow obstruction e.g. Bladder stones, Constipation Systemic neurological disease Meds that decrease bladder contractility - ACEi, antidepressants, antihistamines, antimuscarinics, Antiparkinsonian drugs, beta agonist, CCBs, opioids, sedatives and hypnotics

Question 30

Epidemiology of urinary incontinence in women?

Answer 30

Prevalence increases up to middle age, plateaus between 50-70 and then rises again with advanced age - likely due to higher rates of idiopathic detrusor activity and risk factors e.g. diabetes and medications Moderate-severe incontinence predominantly occurs in older age groups with the slight incontinence more common in younger women Prevalence of urinary incontinence is higher in women than men

Question 31

What is urinary incontinence?

Answer 31

The involuntary leakage of urine

Question 32

What is stress urinary incontinence?

Answer 32

The involuntary leakage of urine on effort or exertion i..e during increased intra-abdominal pressure e.g. sneezing or coughing

Question 33

What is urgency urinary incontinence?

Answer 33

Involuntary leakage of urine accompanied by a sudden compelling desire to pass urine which is diffiuclt to defer, in the absence of UTI or other obvious pathology Part of overactive bladder syndrome

Question 34

What is overactive bladder syndrome?

Answer 34

Urinary urgency usually associated with increased frequency and Nocturia Its OAB wet if there is incontinence present, or OAB dry if absent

Question 35

What is mixed urinary incontinence?

Answer 35

Stress + urgency incontinence I.e. involuntary leakage associated with urgency and physical stress

Question 36

What is overflow incontinence?

Answer 36

Detruser underactivitiy or bladder outlet obstruction which results in urinary retention and leakage of urine There may be straining to urinate or the person may feel the bladder was incompletely emptied Often in the absence of any urge to urinate

Question 37

Complications of urinary incontinence?

Answer 37

Impairment of QOL - Psychological problems - depression, enxiety, shame, loss of self confidence Social isolation - avoidance of places where it may be difficult to access a bathroom Sexual problems Loss of sleep - particuarly in overactive bladder where Nocturia is common Falls and fractures Financial problems - cost of absorbent products and laundry

Question 38

What questions should you ask to determine the type of urinary incontinence?

Answer 38

Does it occur when coughing, sneezing or on effort/exertion - stress Incontinence Is there sudden urgency? - urge incontinence Voiding diffiuclty e.g. straining or incomplete emptying - overflow incontinence Constant leakage of urine - fistula Post-void dribbling, pain, urgency, frequency, recent UTI, vaginal discharge and dyspareunia - urethral diverticulum?

Question 39

Pelvic examination for urinary incontinence?

Answer 39

During pelvic examination: Cough test - observe external urethral meatus for leakage Assess pelvic muscle tone and contraction during bimanual examination by asking the woman to contract her pelvic floor muscles and squeeze the examining finger Also look for evidence of pelvic organ prolapse, urethral diverticulum, pelvic mass or atrophic vaginitis

Question 40

Drugs thta may be associated with urinary incontinence?

Answer 40

Alpha 1 adrenoreceptor antagonists Antipsychotics Anticholinergics Anti-parkinsonism drugs Antidepressants Benzodiazepines Beta blockers Diuretics HRT

Question 41

Investigating cause of urinary incontinence?

Answer 41

Urine dipstick Vaginal examination to exclude pelvic organ prolapse Urodynamic studies Ask woman to keep a bladder diary for at least 3 days which includes activities, fluids she drinks, voided volume and frequency, episodes or urgency or incontinence, pad and clothing changes

Question 42

What should you ask in a history to determine the cause of urinary incontinence?

Answer 42

Fluid intake, amount and type Symptoms e.g. haematuria, bladder/urethral pain, recurrent UTI, constant leakage What medications Previous history of UTI, low spinal surgery, prolapse, hysterectomy, obs&gynae history Neurological conditions Systemic disease e.g. look for diabetes Consider and look for cognitive impairment

Question 43

Assessing the severity of urinary incontinence?

Answer 43

Ask how often the woman is incontinent, at what times, and during which activities. Ask about the use of pads (including pad size) or changing of clothing. Ask the woman how often she passes urine, including at night. Ask the woman to keep a bladder diary for a minimum of 3 days, making sure that variations in her usual activities (for example working and leisure days) are covered.

Question 44

What system do we use to grade the strength of pelvic muscle contractions?

Answer 44

Modified oxford grading system 0: No contraction 1: Faint contraction 2: Weak contraction 3: Moderate contraction with some resistance 4: Good contraction with resistance 5: Strong contraction, a firm squeeze and drawing inwards

Question 45

What are urodynamic tests?

Answer 45

A way of objectively assessing the presence and severity of urinary symptoms A thin catheter is inserted into the bladder, and anther into the rectum. These 2 catheters can then measure the pressures in the bladder and rectum for comparison. The bladder is filled with liquid and various outcome measures are taken: Cystometry - detrusor muscle contraction and pressure measurement Uroflowmetry - measures flow rate Leak point pressure - the point at which the bladder pressure results in leakage of urine e.g. pt is asked to cough when bladder is filled to various capacities Post-voidal residual bladder volume - tests for incomplete bladder emptying

Question 46

What is functional urinary incontinence?

Answer 46

When there are physical or mental barriers that prevent a pt reaching the toilet

Question 47

Lifestyle advice for urinary incontinence?

Answer 47

Manage any reversible causes Reduce caffeine intake Reduce fluid intake Weight loss if BMI >=30 Smoking cessation

Question 48

Management of stress urinary incontinence?

Answer 48

Lifestyle advice 3 months supervised pelvic floor muscle training - a minimum of 8 pelvic floor muscle contractions at least 3 times a day If this fails then refer to a urologist or gynaecologist for further surgical management, or 2nd line duloxetine

Question 49

Surgical treatment options for stress urinary incontinence?

Answer 49

Colposuspension - lifting the neck of the bladder and stitching it there Sling surgery - sling is placed around the neck of the bladder to support it. It can be made from pt rectus fascia, can be donated or from an animal Vaginal mesh surgery - not offered on NHS now Intramural urethral bulking agents - substance injected into walls of urthra to slow it to stay closed with more force Artificial urinary sphincter - artificial ring of muscle to prevent urine flowing from the bladder to the urethra

Question 50

What is duloxetine and how does it work for stress incontinence?

Answer 50

A SNRI Increase the synaptic concentrations of noradrenaline and serotonin within the pudendal nerve which increases stimulation of urethral striated muscle within the sphincter = enhanced contraction

Question 51

Management of urgency incontinence?

Answer 51

Lifestyle advice Referral for bladder training lasting at least 6 weeks with the aim of gradually increasing the intervals between voiding If symptoms persist: - anticholinergic - oxybutinin, tolterodine or darifenacin - mirabegron (beta-3 agonist) can be used if concern about anticholinergic SE in frail elderly patients If symptoms persist: Specialist referral: Tx options include injection of botulinum toxin type A into the bladder wall, percutaneous sacral nerve stimulation, augmentation cystoplasty or urinary diversion

Question 52

Monitoring when a pt is on mirabegron?

Answer 52

Blood pressure - it’s a beta-3 agonist that stimulates the sympathetic nervous system which can cause hypertension! This can increase risk of hypertensive crisis, TIA and stroke

Question 53

Anticholinergic side effects?

Answer 53

Dry mouth Dry eyes Urinary retention Postural hypotension Constipation Cognitive decline, memory problems amd worsening of dementia

Question 54

Social impact of urinary incontinence?

Answer 54

Stigma Embarrassment and shame Social withdrawal and isolation Loneliness and depression Can impact on relationships Limits activities Workplace challenges Financial burden Reduced self-esteem Impact on mental health

Question 55

Receptors found on the bladder

Answer 55

Muscarinic receptor M3 Beta adrenergic receptor B3

Question 56

Receptors found on internal urinary sphincter (males only)

Answer 56

Alpha 1 receptor

Question 57

Receptors found on external urethral sphincter?

Answer 57

Nicotinic receptor

Question 58

Outline physiology of micturition (voiding part)

Answer 58

Parasympathetic When there is a full bladder there is increased firing of the afferent pelvic nerve to the sacral region of the spinal cord This causes: Pelvic efferent nerve releases ACh which binds M3 on the detrusor muscle = contraction Inhibition of the Pudendal nerve to stop contraction of the external urethral sphincter (this is under our control) Inhibition of Hypogastric sympathetic nerve

Question 59

Outline physiology of urinary retention?

Answer 59

Sympathetic Slow impulses from the afferent pelvic nerve to the sacral spinal region. This causes: The Hypogastric nerve releases noradrenaline which binds to beta 3 receptor on detrusor muscle = relaxation It also binds to alpha 1 receptor on the internal sphincter (only in males) = contraction of internal sphincter There is also stimulation of the pudendal nerve using ACh to cause contraction of the external urethral sphincter

Question 60

What nerve sends impulses to the spinal cord about the fullness of the bladder

Answer 60

Sensory pelvic nerve

Question 61

Why are Anticholinergics used to treat urge incontinence?

Answer 61

They block the action of acetylcholine on the M3 receptor on the detrusor muscle. This prevents bladder contraction = reduces overactivity, increasing bladder capacity and decreasing the urgency to urinate

Question 62

How does mirabegron work to manage urge incontinence?

Answer 62

It is a beta-3 adrenergic receptor agonist It stimulates the beta-3 receptors on the detrusor muscle of the bladder, causing relaxation of the bladder muscle and increasing bladder capacity

Question 63

What is bladder retraining?

Answer 63

A therapy to help people learn to hold on to more urine in their bladder It involves waiting a few minutes longer before going to the toilet to allow the bladder to stretch. Overtime the bladder should be able to comfortably hold larger amounts of urine without discomfort

Question 64

What are the 2 holes within the pelvic floor?

Answer 64

Urogenital hiatus - situated anterior allows for passage of urethra and vagina in females Rectal hiatus - situated centrally allows for passage of anal canal

Question 65

What is the perineal body?

Answer 65

A fibrous node which joins the pelvic floor to the peruneum Lies between the urogenital hiatus and the anal canal

Question 66

Roles of pelvic floor muscles?

Answer 66

Support of abdominopelvic viscera – through their tonic contraction. Resistance to increases in intra-pelvic/abdominal pressure – during activities such as coughing or lifting heavy objects. Urinary and faecal continence – the muscle fibres have a sphincter action on the rectum and urethra. They relax to allow urination and defecation.

Question 67

The three main components of the pelvic floor?

Answer 67

Levator ani muscles Coccygeus muscle Fascia coverings of the muscles

Question 68

Which 3 muscles make up the levator ani muscle?

Answer 68

Pubococcygeus Puborectalis Iliococcygeus