Prolapse and Incontinence

Question 1

What supports the upper third of the vagina?

Answer 1

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

Question 2

What supports the mid portion of the vagina?

Answer 2

Endofascial condensation (endopelvic fascia) -> pelvic side walls

Question 3

What supports the lower third of the vagina?

Answer 3

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

Question 4

What nerve supplies the levator ani?

Answer 4

Pudendal (S2,3,4)

keeps the poo off the floor

Question 5

What is a urethrococele?

Answer 5

Lower anterior wall prolapse

Involves urethra

Question 6

What is a cystocele?

Answer 6

Upper anterior wall prolapse
Involves bladder
May be combined with urethrococele

Question 7

What is an apical prolapse?

Answer 7

Prolapse of uterus, cervix and upper vagina

Question 8

What is an enterococele?

Answer 8

Prolapse of upper posterior wall

Contains intestinal contents from pouch of Douglas

Question 9

What is a rectocoele?

Answer 9

Prolapse of lower posterior wall

Involves anterior wall of rectum

Question 10

What causes prolapse?

Answer 10

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

Question 11

How does prolapse present?

Answer 11

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

Question 12

How are pessaries used for prolapse?

Answer 12

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

Question 13

What surgery is used for uterine prolapse?

Answer 13

Vaginal hysterectomy - most subsequently present with vaginal vault prolapse

Hysteropexy - uterus and cervix are attached to sacrum via mesh

Question 14

What surgery is indicated for vaginal vault prolapse?

Answer 14

Sacrocolpopexy - vault is attached to sacrum

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

Question 15

What surgery is indicated for stress incontinence?

Answer 15

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

Question 16

What is required for continence?

Answer 16

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

Question 17

What is required to void the bladder?

Answer 17

Detrusor contractility and urethral relaxation

Question 18

What volume does the bladder hold?

Answer 18

500ml

Urge to void at 200ml

Question 19

What is the neural control of the bladder?

Answer 19

Parasympathetic - VOID

Sympathetic - HOLD

Question 20

What causes incontinence?

Answer 20

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

Question 21

How are urinary symptoms investigated?

Answer 21

Urine dipstick

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

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

Question 22

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

Answer 22

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

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

Question 23

What causes stress incontinence?

Answer 23

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

Question 24

What treatment is available for stress incontinence?

Answer 24

Pelvic floor exercises
Vaginal cones
Duloxetine - SNRI which increases sphincter activity
TVT
TOT

Question 25

What is the tension free vaginal tape?

Answer 25

Tape placed in U shape under mid urethra and tension adjusted to prevent leakage
Inserted via cut in ant wall of vagina

Question 26

What is transobturator tape?

Answer 26

Tape passed via transobturator foramen so doesn’t enter retropubic space and bladder perforation is rare

Question 27

What is overactive bladder?

Answer 27

Urgency +/- frequency and nocturia without infection

Question 28

What is detrusor overactivity?

Answer 28

Involuntary detrusor contraction during filling phase which may be spontaneous or provoked

Question 29

What causes OAB?

Answer 29

Idiopathic
Post operation for USI
Neuropathy

Question 30

What investigations are done for OAB?

Answer 30

Urinary diary - frequent passage of small volumes of urine especially at night

Question 31

How is OAB managed?

Answer 31

Reduce fluid intake and avoid caffeine
Bladder training
Anticholinergics
Oestrogens
Botox

Question 32

What is acute urinary retention?

Answer 32

Unable to pass urine for >12hrs

Caused by childbirth, epidural, vulval or perineal pain, surgery,retroverted gravid uterus

Question 33

What causes chronic retention and urinary overflow?

Answer 33

Bladder overdistension eventually causes overflow
Urethral obstruction - pelvic mass, incontinence surgery
Detrusor inactivity - autonomic neuropathy, previous overdistension of bladder

Question 34

What is painful bladder syndrome?

Answer 34

Suprapubic pain with bladder filling

Question 35

How do urinary fistulae present?

Answer 35

Constant leakage