Urinary Incontinence and Pelvic Floor Disorders

Question 1

Most common symptoms of pelvic organ prolapse

Answer 1

• Bulge symptoms
• Urinary incontinence
• Dyspareunia

Question 2

Cystocele

Answer 2

Question 3

Rectocele

Answer 3

Question 4

Uterine prolapse

Answer 4

Question 5

Vaginal vault prolapse

Answer 5

Only occurs after hysterectomy!

Question 6

Risk factors for pelvic organ prolapse

Answer 6

• Age
• Vaginal delivery
• Menopause
• Chronically increased intra-abdominal pressure
• Constipation
• Obesity
• Pelvic floor trauma
• Connective tissue disorders

Question 7

Components of the levator ani

Answer 7

1. Puborectalis
2. Pubococcygeus
3. Iliococcygeus

Question 8

Endopelvic fascia

Answer 8

• Fibro-muscular sheath attaching the pelvic muscles to the pelvic side-walls
• Above the levator ani muscle
• Includes:
  
  1. Arcus tendineus
  2. Cardinal ligaments
  3. Utero-sacral ligaments

Question 9

“Levels” of support in the pelvic floor

Answer 9

• Level 1: Apical
  
  • Cardinal ligaments and uterosacral ligaments support the uterus
  • Defect in this level causes a uterovaginal prolapse
• Level 2: Mid-Vaginal
  
  • Arcus tendineus and the levator ani fascia support the upper 2/3 of the vagina
  • Defect in this level causes a cystocele
• Level 3: Distal Vaginal
  
  • Urogenital diaphragm and perineal body support the distal vagina
  • Defect in this level causes a rectocele

Question 10

Why are older patients more at risk for pelvic floor injury?

Answer 10

With age there is a loss of collagen content, and the collagen that remains is mostly mature, heavily-crosslinked collagen which is less flexible than immature collagen.

Question 11

“Expectant management”

Answer 11

Do nothing

Question 12

Treatment options for pelvic floor prolapse

Answer 12

• Expectant management (if symptoms are tolerable)
• Pelvic floor physical therapy
• Vaginal pessaries (intra-vaginal support)
• Surgery (hysterectomy & reconstruction)

Question 13

When does pelvic floor prolapse become pathologic?

Answer 13

When there is an issue of obstruction with urination or defecation

Question 14

Parasympathetic bladder innervation

Answer 14

Question 15

Sympathetic bladder innervation

Answer 15

Question 16

Somatic bladder innevation

Answer 16

Question 17

Neural control of the bladder during storage

Answer 17

Question 18

Neural control of the bladder during micturition

Answer 18

Question 19

___ enables us to exert voluntary control over the micturition reflex

Answer 19

Central control of the pontine micturition center enables us to exert voluntary control over the micturition reflex

Question 20

Urge incontinence

Answer 20

• Syndrome of urge to urinate followed by involuntary leakage
• Often associated with nocturia
• Pathophysiology involves detrusor hyperactivity, leading to involuntray detrusor muscle contractions

Question 21

Lifestyle modifications to reduce symptoms of incontinence

Answer 21

• Weight loss
• Normalize fluid intake
• Decreasing bladder irritants (alcohol, soda, caffeine)
• Minimizing constipation
• Smoking cessation

Question 22

Therapy for urge incontinence

Answer 22

• Lifestyle:
  
  • Reduce irritants, stop smoking, lose weight, less fluids
• Behavioral:
  
  • Bladder training
  • Prompted voiding
• Pharmacologic:
  
  • Beta adrenergic agonists
  • Anti-muscarinics

Question 23

Most commonly perscribed medication for urge incontinence

Answer 23

Oxybutinin

An anti-muscarinic agent that reduces contraction of the detrusor

Question 24

Major categories of urinary incontinence, presentation, and basic pathophys

Answer 24

• Urge incontinence:
  
  • Urge to urinate w/ leak, frequently w/ nocturia
  • Detrusor hyperactivity
• Stress incontinence:
  
  • Leak of urine with coughing, sneezing, etc.
  • Increases in intra-abdominal pressure, pelvic floor insufficiency, and loss of sphincter tone
• Mixed incontinence:
  
  • Mixture of urge and stress incontinence
• Overflow incontinence:
  
  • Continuous leakage or dribbling from incomplete bladder emptying
  • Caused by detrusor hypoactivity, peripheral neuropathy, damage to spinal nerves, and pelvic organ destruction

Question 25

Treatment for stress incontinence

Answer 25

* **Kegel exercises** * Physical therapy * Pessiaries * Urethral bulking agents * Surgical treatment (**mid-urethral sling**)

Question 26

Treatment for overflow incontinence

Answer 26

* Correction of underlying impairment * Possible **straight catheterization** for patients with spinal cord injury

Question 27

Enterocele

Answer 27

Herniation at the top of the vagina that allows the peritoneum of the cul-de-sac containing small bowel to herniate through.

Question 28

What is the prevalence of pelvic organ prolapse among parous women?

Answer 28

50%!!! HALF! However, most women **are asymptomatic**, and they generally **do not need therapy of any sort.**

Question 29

Procidentia

Answer 29

When the cervix descends beyond the vulva.

Question 30

Pessaries

Answer 30

Removable rubber or silicone supports that may be placed within the vagina to reduce symptoms of pelvic floor prolapse Considered the **first-line therapy for symptomatic pelvic floor prolapse** along with **lifestyle modification** and **physical therapy**.

Question 31

Surgical solutions to severe, symptomatic pelvic floor prolapse often involve \_\_\_.

Answer 31

Surgical solutions to severe, symptomatic pelvic floor prolapse often involve **hysterectomy** This is beause most of them involve the **attachment of the vaginal apex to the uterosacral or sacrospinous ligaments,** necessitating the removal of the uterus.

Question 32

Colpocleisis

Answer 32

* Complete surgical obliteration of the vaginal lumen * Procedure for women who have **no desire for future child bearing** and have **high risk of complications from open surgery** * The surgeon sews together the front and back walls of the vagina to shorten the vaginal canal. This **prevents the vagina walls from bulging inward, and provides support to hold up the uterus.**

Question 33

Post-delivery stress incontinence

Answer 33

Not uncommon for women following **vaginal delivery** **Most is self-limited, lasting 4-6 months** and then going away without intervention. However, it may also represent pelvic floor insufficiency and may persist.

Question 34

Most important cause of stress urinary incontinence

Answer 34

"Ureteral hypermobility" Which is another way of saying loss of constraining structural support to the urethra by other pelvic structures and ligaments (pelvic floor insufficiency)

Question 35

Pelvic Organ Prolapse Quantification (POP-Q)

Answer 35

* Stage 0: No prolapse. Cervix is at least as high as vaginal length * Stage 1: Leading part \> 1 cm above hymen * Stage 2: Leading part \<1 cm above or below hymen * Stage 3: Leading part \>1 cm below hymen, but less than whole vaginal length * Stage 4: Complete prolapse and eversion

Question 36

Q-tip test

Answer 36

* Test for **urethral hypermobility in stress urinary incontinence** * Patient lies in lithotomy position. A cotton swab is lubricated with lidocaine jelly and placed into the baldder, then pulled back until resistance is met. Patient is asked to bear down. * If there is urethral hypermobility, the end of the swab rotates upward (**\>30^o is considered positive**), suggesting that the UVJ is being deflected downward by intrraabdominal pressure.

Question 37

Stage III and IV pelvic organ prolapse patients without incontinence likely have ____ continence.

Answer 37

Stage III and IV pelvic organ prolapse patients without incontinence likely have **"simulated"** continence. Essentially, there is a kink or functional obstruction in the outflow tract which is producing "continence", but not by the usual mechanism. This same kink may cause **hydronephrosis or hydroureter** as well, so **renal ultrasound** is indicated to evaluate in these cases.

Question 38

Sacral colpoplexy

Answer 38

* Treatment for pelvic floor insufficiency in **women without a uterus specifically** * Vaginal cuff is anchored to the **sacral promontory**

Question 39

Surgical options for stress urinary incontinence

Answer 39

* Retropubic colposuspension * Suburethral sling * Bulking injection

Question 40

Retropubic colposuspension

Answer 40

Suspension and stabilization of the anterior vaginal wall in a retropubic position. Also called the "Burch" procedure

Question 41

Suburethral sling

Answer 41

* Sling is placed around the urethra to lift it back into place and exert upward pressure, preventing stress urinary incontinence

Question 42

Bulking injection for stress urinary incontinence

Answer 42

* Injection of collagen, carbon-coated beads, and fat transurethrally or periurethrally around the bladder neck and proximal urethra. * Effectively like placing a "washer" around the urethra * Especially useful in cases of intrinsic sphincter insufficiency, as tightening of the tissue can simulate an intrinsic sphincter's pressure * May produce temporary (from swelling) or long-standing **urinary retention** as a complication

Question 43

Normal post-void residual

Answer 43

50-60 mL

Question 44

Post-void residual of how much strongly suggests overflow incontinence?

Answer 44

**\> 300 mL**

Question 45

Mid-urethral sling is indicated for \_\_\_. Colpocleisis is indicated for \_\_\_. Bulking agent injection is indicated for \_\_\_.

Answer 45

Mid-urethral sling is indicated for **ureteral hypermobility-induced stress incontinence**. Colpocleisis is indicated for **pelvic floor insufficiency, not stress incontinence**. Bulking agent injection is indicated for **internal sphincter dysfunction-induced stress incontinence**.

Question 46

"Drain pipe" urethra

Answer 46

Finding of **constant leakage of the urethra** on **cystourethroscopy** Describes a urethra that is **scarred, poorly vascularized, and rigid** with no internal sphincter function. This is usually a result of recurrent scar formation due to **multiple pelvic surgeries.** This is the major indication for **bulking agent injection.**

Question 47

Two forms of pelvic organ prolapse that may be associated with urge incontinence

Answer 47

* **Cystocele** * **Urethrocele** * Note: Many other forms may be associated with stress incontinence, in addition to the above

Question 48

Indication for Kegel exercises

Answer 48

Indicated to ***prevent*** pelvic prolapse ## Footnote **BUT, once pelvic prolapse has happened, they won't reduce it.**

Question 49

Whenever a patient presents with urinary incontinence, ___ should be ruled out

Answer 49

Whenever a patient presents with urinary incontinence, **UTI** should be ruled out

Question 50

Differentiation of overflow incontinence and stress incontnience may be suspected based on ___ in the history and confirmed based on \_\_\_.

Answer 50

Differentiation of overflow incontinence and stress incontnience may be suspected based on **risk factors** in the history and confirmed based on **results of bladder ultrasound**. Risk factors for overflow would be **neuropathy, diabetes, or MS.** Risk factors for stress would be **multiparity, old age, pelvic floor insufficiency, chronic increased intraabdominal pressure.**

Question 51

Voiding diary

Answer 51

Useful for patients who have symptoms of mixed urinary incontinence to assess which interventions may be most useful for this particular patient

Question 52

Urodynamic testing

Answer 52

Involves measurement of the bladder filling and emptying (cystometry), urine flow, and pressure. Typically reserved for patients with complicated urinary incontinence (stress, urgency) who are at the point of considering surgery