urinary incontinence and pelvic organ prolapse Flashcards
(28 cards)
A 59 year old gravida 3, para 1021 whose last menstrual period was 10 years ago presents complaining of leaking urine x 9 months. She states it occurs when she laughs, coughs or sneezes. She states it is interfering with her social life and at work and wants to know if anything can be done.
After seeing you in the office and after completing a voiding diary and questionnaires, your patient receives a diagnosis of stress urinary incontinence. She undergoes a mid-urethral sling procedure and reports significant improvement with incontinence within a month of surgery.
incidence
-any age
-25% of young pts
-44-57% of middle aged or postmenopausal pts
-75% of older pts
-50% of nursing home residents
-cause for nursing home admission in 6%
-causes isolation and depression in the elderly
-contribute to skin breakdown and decubiti in non-ambulatory
physiology of continence
-Brainstem controls
-Normal volume: 300-500 cc
-RF:
-Increasing age
-female
-menopause
-Local trauma:
-Cystocele
-Rectocele
-neuro injury or illness:
-MS
-ALS
-neurogenic bladder
-spinal cord injury or ds
types of urinary incontinence
-3 types
-Stress:
-Leakage occurs with laughing, coughing, sneezing, running, jumping
-Urge (detrusor overactivity, “overactive bladder”)
-“Key-in-lock syndrome”
-Mixed incontinence (stress urinary incontinence and urge incontinence)
-functional incontinence due to cognitive or mobility impairment with intact lower urinary tract
-postmicturition leakage following complete urination
-postural urinary incontinence due to change of body position
diff dx of urinary incontinence
-Urinary etiologies:
-stress urinary incontinence
-detrusor overactivity
-mixed incontinence
-UTI
-vaginitis
-fistulae
-congenital- ectopic ureter, episadias
-Non-urinary etiologies:
-functional:
-neurologic
-cognitive
-psychologic
-physical impairment
-environmental
-pharmacologic
-metabolic
approach to the pt with urinary incontinence
-Hx + PE
-Voiding diary
-UA and cx
-Measure postvoid residual volume
-Via bladder scan
-Via straight catheterization
history
-Medical, surgical, gynecologic and neurologic history
-Neuro hx: stroke, DM, MS, disk disease, ALS
-Duration
-Dysuria
-Nocturia
-Urgency
-Pad use
-Fluid intake
-Frequency of events
-Effect on activities of daily living
voiding diaries and questionnaires
-kept for 3-5 days
-Includes:
-Type, time, amount of liquids consumed
-Amount and time voided
-Amount of urine lost during leakage, and why
physical exam in assessment of urinary incontinence
-abdominal and pelvic exams
-pelvic floor, including muscle strength
-teach Kegel exercises
-Focused neuro exam
-Mental status exam
-Bulbocavernosus reflex- touch clit with q-tip and anus constricts
-Sensory and motor exams of LE
-Rectal exam:
-tone, tenderness, hemorrhoids
-R/o fecal impaction, tumors, rectovaginal fistulae
specialized tests for stress urinary incontinence
-Cough stress test
-pt arrive with full bladder
-Do not collect urine prior to PE
-Test can be supine
-Have patient cough
-Should see urine leak during cough
-If not, repeat standing
-If leaks -> dx
-Q-tip test for urethral mobility
-Place a sterile cotton applicator lubricated with lidocaine gel in the urethra
-Measure the angle between the horizontal plane and the Q-tip
-pt Valsalva maneuver
-If angle increase >30 degrees -> poor pelvic support and abnormal bladder neck descent
-Lack of urethral mobility -> less favorable outcome for surgical intervention, such as sling procedure
-these pts get injection of urethral bulking agents
-postvoid residual volume
-have pt empty bladder
-perform straight catheterization or perform bladder scan via
-residual volume <150cc -> normal bladder emptying
-No need for urodynamic testing if dx is clear upon hx, PE, voiding diary and urinary questionnaires
-For complicated pts, refer for urodynamic testing
urinary incontinence workup
-UA and cx
-Point of care testing may be used
-Send culture if indicated and treat accordingly
-Evaluate further any microscopic hematuria, if present
management for all types of urinary incontinence: lifestyle modificatoins
-Wt loss
-Bladder training
-Fluid management
-Decrease caffeine intake
-Limit fluid intake to <2L / day
-Kegel exercises
-Biofeedback
other management strats in tx of stress urinary incontinence
-Urethral bulking agents for pts stress incontinence but w/o urethral sphincteric deficiency
-Collagen
-Pyrolytic carbon-coated beads
-Calcium hydroxylapatite
-Surgery -> pts with no improvement after lifestyle modifications
-polypropylene midurethral sling -> most effective and safe
-Acts as a hammock to support the bladder neck and the urethra
-May be placed by a retropubic or transobturator approach
-Reoperation rate- 2.6%
-An autologous pubofascial vaginal sling may also be used
management of urge incontinence
-Medications
-Many pts are on multiple agents
-High risk of drug-drug interactions
-Antimuscarinic agents
-Many DDI and ADR
-Beta agonists- detrusor muscle relaxation
-1. Mirabegron:
-CI in pts with:
-Severe uncontrolled HTN
-ESRD
-Significant hepatic ds
-2. Vibegron
-Onabotulinumtoxin A
-Functions as a muscle paralytic
-botulinum toxin A
Your 85 yo mildly demented gravida 5, para 4014, last menstrual period 40 years ago, is cared for in the home by certified home health aides. The patient’s aide brings her to see you on an emergent basis because she was bathing the patient and noted “a large pink thing down there.”
The patient and aide deny any history of vaginal or rectal bleeding, or of recent vaginal penetration, and the patient denies any history of pelvic or abdominal pain.
Your patient is diagnosed with complete procidentia. Treatment options (observation, pessary, hysterectomy, or LeFort colpocleisis) are discussed with the patient and her son. They opt for a pessary. You fit her with a Gellhorn pessary and have her make an appointment for re-evaluation in 6 weeks.
pelvic organ prolapse
-descent of the uterus, if present, or the vaginal vault
-3% are symptomatic
-sense of pressure, difficulty with sexual function, or difficulty with urination or with DM
-RF:
-Parity
-Obesity
-Advanced age
-Chronic constipation
physical exam in the pt with suspected pelvic organ prolapse
-Abdominal and pelvic exams
-Note any ulceration of vaginal or cervical tissue
-Note any cystocele or rectocele
-at rest or may appear with Valsalva maneuver
-Assess pelvic floor strength
-Perform postvoid residual volume
-Management of pelvic organ prolapse may reveal occult urinary incontinence
-Additional workup
-Consider urinalysis and culture with urinary symptoms
cystocele and rectocele
-Cystocele (pic):
-Herniation of the anterior vaginal wall due to damage to the pubocervical fascia
-trauma due to childbirth
-Rectocele:
-Defect of the rectovaginal septum
-trauma to perineal body during childbirth
-The perineal body stabilizes the rectovaginal septum
sx and signs of cystocele and rectocele
-Cystocele
-Anterior vaginal mass
-Vaginal fullness
-Sense of “something coming down” or “falling out”
-Difficulty with urination
-Rectocele
-A sense of heaviness or bearing down
-Constipation
-Posterior vaginal mass
-cystocele and rectocele- pic
baden-walker system of staging pelvic organ prolapse
dont need to know
Pelvic organ prolapse-quantification (POP-Q) system of classification of pelvic organ prolapse
-Stage 0: no prolapse
-Stage 1: most distal prolapse is > 1 cm above the hymen
-Stage 2: most distal prolapse is between 1 cm above and 1 cm below the hymen
-Stage 3: most distal prolapse is >1 cm below hymen but 2 cm shorter than entire vaginal length
-Stage 4: complete procidentia
management of pelvic organ prolapse
-Lifestyle modifications
-tx of constipation
-Kegel exercises
-Medical management
-Pessaries
-Require fitting
-Some trial and error
-use with estrogen cream
-cleaned and replaced about every 6-8 weeks by patient or by clinician
surgical management of pelvic organ prolapse
-1. Abdominal sacral colpopexy
-2. uterosacral ligament fixation
-3. sacrospinous ligament fixation:
-all 3 correct upper vaginal prolapse
-last 2 are done at time of hysterectomy
-LeFort Colpocleisis:
-vaginal vault prolapse
-indicated in uterine prolapse in pts who do not want further possibility of vaginal penetration
-For patients who can tolerate major surgery:
-Hysterectomy
-Remember to support vaginal apex, if possible, with abdominal sacral colpopexy or sacrospinous ligament fixation
-For patients who cannot tolerate hysterectomy:
-Colpocleisis
-Closure of vaginal vault in patients who no longer desire vaginal penetration
-Complete colpocleisis
-LeFort colpocleisis
abdominal sacral colpopexy
-Apex of vagina is sewn to fascia or to other structure
-Fascia is harvested from thigh
-Other end of fascia is affixed to periosteum of sacrum
