Prolapse and Incontinence Flashcards

1
Q

What supports the upper third of the vagina?

A

Ligaments attach to cervic and suspend uterus
Cardinal ligaments -> pelvic brim
Uterosacral ligaments -> sacrum

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2
Q

What supports the mid portion of the vagina?

A

Endofascial condensation (endopelvic fascia) -> pelvic side walls

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3
Q

What supports the lower third of the vagina?

A

Levator ani muscle which incorporates the perineal body (pelvic diaphragm)
pubic symphysis -> pelvic brim, sacrum

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4
Q

What nerve supplies the levator ani?

A

Pudendal (S2,3,4)

keeps the poo off the floor

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5
Q

What is a urethrococele?

A

Lower anterior wall prolapse

Involves urethra

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6
Q

What is a cystocele?

A

Upper anterior wall prolapse
Involves bladder
May be combined with urethrococele

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7
Q

What is an apical prolapse?

A

Prolapse of uterus, cervix and upper vagina

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8
Q

What is an enterococele?

A

Prolapse of upper posterior wall

Contains intestinal contents from pouch of Douglas

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9
Q

What is a rectocoele?

A

Prolapse of lower posterior wall

Involves anterior wall of rectum

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10
Q

What causes prolapse?

A

Vaginal delivery - mechanical injury and denervation of pelvic floor

Congenital factors - abnormal collagen metabolism

Menopause: deterioration of collagenous connective tissue after oestrogen withdrawal

Chronic factors: obesity, chronic cough, constipation, heavy lifting, pelvic mass

Iatrogenic: pelvic surgery

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11
Q

How does prolapse present?

A

Dragging sensation, worse at end of the day or when standing up
Urinary frequency
Stress incontinence
Difficulty defecating

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12
Q

How are pessaries used for prolapse?

A

Act as artificial pelvic floor
Changed every 6-9 months
May need HRT to prevent ulceration

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13
Q

What surgery is used for uterine prolapse?

A

Vaginal hysterectomy - most subsequently present with vaginal vault prolapse

Hysteropexy - uterus and cervix are attached to sacrum via mesh

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14
Q

What surgery is indicated for vaginal vault prolapse?

A

Sacrocolpopexy - vault is attached to sacrum

Sacrospinous fixation - suspend vault to sacrospinous ligament
Can cause nerve or vessel injury

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15
Q

What surgery is indicated for stress incontinence?

A

Tension free vaginal tape
Trans-obturator tape procedure
Burch colpo-suspension

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16
Q

What is required for continence?

A
Functioning sphincter
Properly positioned bladder neck
Thick urethral mucosa (oestrogen)
Compliant bladder
Higher control centre
17
Q

What is required to void the bladder?

A

Detrusor contractility and urethral relaxation

18
Q

What volume does the bladder hold?

A

500ml

Urge to void at 200ml

19
Q

What is the neural control of the bladder?

A

Parasympathetic - VOID

Sympathetic - HOLD

20
Q

What causes incontinence?

A

Uncontrolled increase in detrusor pressure (bladder>urethra pressure) - OAB

Increased intra-abdominal pressure transmitted to bladder but not urethra because upper urethra neck has slipped from abdomen

21
Q

How are urinary symptoms investigated?

A

Urine dipstick

  • nitrites = infection
  • glucose = diabetes
  • blood = bladder carcinoma or calculi

Urinary diary
Post micturition USS
Urodynamic studies - differentiates between OAB and stress
Cystoscopy

22
Q

How will cystometry show difference in urinary stress incontinence and detrusor instability?

A

USI - both bladder and abdo pressure increase at the time of cough

Detrusor instability - bladder pressure increases more than urethra when bladder fills

23
Q

What causes stress incontinence?

A

Pregnancy and vaginal delivery
Obesity
Postmenopausal

Bladder neck has slipped below pelvic floor because the supports are weak
When intra-abdominal pressure increases, only bladder pressure increases, not urethra

24
Q

What treatment is available for stress incontinence?

A
Pelvic floor exercises
Vaginal cones
Duloxetine - SNRI which increases sphincter activity
TVT
TOT
25
What is the tension free vaginal tape?
Tape placed in U shape under mid urethra and tension adjusted to prevent leakage Inserted via cut in ant wall of vagina
26
What is transobturator tape?
Tape passed via transobturator foramen so doesn't enter retropubic space and bladder perforation is rare
27
What is overactive bladder?
Urgency +/- frequency and nocturia without infection
28
What is detrusor overactivity?
Involuntary detrusor contraction during filling phase which may be spontaneous or provoked
29
What causes OAB?
Idiopathic Post operation for USI Neuropathy
30
What investigations are done for OAB?
Urinary diary - frequent passage of small volumes of urine especially at night
31
How is OAB managed?
``` Reduce fluid intake and avoid caffeine Bladder training Anticholinergics Oestrogens Botox ```
32
What is acute urinary retention?
Unable to pass urine for >12hrs | Caused by childbirth, epidural, vulval or perineal pain, surgery,retroverted gravid uterus
33
What causes chronic retention and urinary overflow?
Bladder overdistension eventually causes overflow Urethral obstruction - pelvic mass, incontinence surgery Detrusor inactivity - autonomic neuropathy, previous overdistension of bladder
34
What is painful bladder syndrome?
Suprapubic pain with bladder filling
35
How do urinary fistulae present?
Constant leakage