Urinary incontinence and prolapse

Question 1

what are some predisposing factors for incontinence

Answer 1

pelvic changes

neurology (UMNL, LMNL)

aging–can be aided by giving back some estrogen

mobility

renal

COPD

Question 2

what are some precipitating factors for incontinence

Answer 2

irritative–UTI, FB

medications–direct vs. indirect

intercurrent illness

Question 3

what happens if you damage the anterior vaginal wall pubocervical fascia

Answer 3

herniation of the bladder (cystocele) and/or urethra (uretherocele) into the vaginal lumen

Question 4

what happens if you damage the endopelvic fascia of the rectovaginal septum in the posterior vaginal wall

Answer 4

herniation of the rectum (rectocele) into the vaginal lumen

Question 5

what happens if you get injury to or stretching of the uterosacral and cardinal ligaments

Answer 5

can result in descensus/prolapse of the uterus (uterine prolapse)

Question 6

what is an enterocele

Answer 6

prolapse of the small intestine after hysterectomy

Question 7

what are the common presenting symptoms of pelvic prolapse

Answer 7

pelvic pressure and discomfort

dyspareunia

difficulty evacuating the bowels and bladder

low back discomfort

often associated with a visible or palpable bulge in the vagina

Question 8

what processes most commonly compromise pelvic support

Answer 8

pregnancy and subsequent delivery

chronic increases in intra-abdominal pressure from obesity, chronic cough or chronic heavy lifting

connective tissue disorders

atrophic changes due to aging to estrogen deficiency

Question 9

in what population is pelvic relaxation most commonly seen

Answer 9

post menopausal women

due to decreased endogenous estrogen, effects of gravity over time, normal aging in the setting of previous pregnancy and vaginal delivery

Question 10

why does atrophy increase risk for pelvic relaxation

Answer 10

associated with compromised elasticity, diminished vascular support and laxity in structural elements

tissues become less resilient to forces of gravity and increased intra-abdominal pressure and accumulative stresses on the pelvic support system take effect

Question 11

what is the prevalence of pelvic organ prolapse

Answer 11

2.9-9%

(some studies–11-19% chance of undergoing surgery)

lower rates in african american vs caucasian women

Question 12

risk factors for pelvic organ prolapse

Answer 12

advancing age

menopause

parity

conditions resulting in chronically elevated intra-abdominal pressure

hysterectomy (for apical prolapse)

• risk increases four and eightfold with the first two vaginal deliveries respectively
• obstructed labour and traumatic delivery are also risk factors

Question 13

why does stress incontinence appear to “improve” sometimes as prolapse worsens

Answer 13

as the support for the anterior vaginal wall weakens and the bladder descends, a kink is introduced into the urethra–> mechanical obstruction that masquerades as improvement

Question 14

what is “splinting”

Answer 14

when there is trouble voiding the bowels due to apical or rectal prolapse and to aid in defecation patients will apply manual pressure to the perineum or posterior vaginal wall

Question 15

how is prolapse best examined

Answer 15

separate the labia and view the vagina while the patients strains or coughs

SPLIT SPECULUM exam should be performed using Sims speculum or lower half of a Grave speculum (examine anterior, posterior and midline defects)

Question 16

what is complete procidentia

Answer 16

complete eversion of the vagina with the entire uterus prolapsing outside the vagina

Question 17

how do you quantify pelvic prolapse

Answer 17

POP-Q

Pelvic Organ Prolapse Quantitative scale

focuses on the physical extent of the vaginal wall prolapse and not in which organ is presumed to be prolapsing within the defect

uses 6 points within the vagina that are measured relative to a fixed point of reference (hymen)

Question 18

ddx for cystocele and urethrocele

Answer 18

urethral diverticula

Gartner cysts

Skene gland cysts

tumours of urethra and bladder

Question 19

ddx for rectocele

Answer 19

obstructive lesions of the colon and rectum (lipomas, fibromas, sarcomas)

Question 20

ddx for uterine prolapse

Answer 20

cervical elongation

prolapsed cervical polyp

prolapsed uterine fibroid

prolapsed cervical and endometrial tumours

Question 21

how do you treat asymptomatic prolapse

Answer 21

can be monitored-does not necessarily require tx (expectant management)

if patient is bothered–> can intervene

Question 22

what is the basis for treatment of prolapse

Answer 22

essentially a structural problem therefore treatment revolves around reinforcing lost support to pelvis

Question 23

list treatment modalities for prolapse

Answer 23

1. kegel exercises/pelvic floor physio
2. mechanical support devices (pessaries)
3. surgical repair
4. low dose vaginal estrogen in post menopausal women

Question 24

why do we treat post menopausal women with prolapse with vaginal estrogen

Answer 24

improves tissue tone, facilitates reversal of atrophic changes in the vaginal mucosa

Question 25

what is the mainstay of conservative management of prolapse

Answer 25

pessaries act as mechanical support devices to replace the lost structural integrity of the pelvis and to diffuse the forces of descent over a wider area indicated for any patient who desires non surgical management and in those for whom surgery is contraindicated

Question 26

recurrence rate of prolapse after surgical correction

Answer 26

may be up to 30%

Question 27

how do you surgically correct a cystocele

Answer 27

anterior colporrhaphy

Question 28

how do you surgically correct a rectocele

Answer 28

posterior colporrhaphy

Question 29

what is a colporhhaphy

Answer 29

repairs the fascial defects through which the herniation occurs

Question 30

how do you surgically repair an enterocele

Answer 30

reinforce the rectovaginal fascia and the posterior vaginal wall

Question 31

how might you manage significant uterine prolapse

Answer 31

vaginal or abdominal hysterectomy may be needed --> in itself not curative--> need to also do an apical suspension procedure

Question 32

how do you correct vaginal prolapse occuring after hysterectomy

Answer 32

suspend the vaginal apex to fixed points within the pelvis such as the sacrum

Question 33

how many women over the age of 75 experience urinary incontinence daily

Answer 33

20%

Question 34

what is the most common kind of urinary incontinence

Answer 34

stress

Question 35

what is urgency urinary incontinence

Answer 35

involuntary loss of urine assoc with urgency--may be assoc with detrusor overactivity

Question 36

what is mixed incontinence

Answer 36

urge and stress incontinence together

Question 37

list conditions associated with overflow urinary incontinence

Answer 37

diabetes neuro diseases severe genital prolapse post-surgical obstruction from urinary continence procedures

Question 38

what is bypass urinary incontinence

Answer 38

usually due to urinary fistula formed between the urinary tract and vagina usually happens due to pelvic surgery or radiation

Question 39

what is functional urinary incontinence

Answer 39

any condition that interferes with ability to reach toilet in timely fashion often seen in elderly with dementia or limited mobility

Question 40

risk factors for urinary incontinence

Answer 40

AGE obesity (worse for stress type) T2DM (especially urgency) pregnancy, vaginal delivery, pelvic surgery, medication (alpha blockers), smoking, genetics

Question 41

what med is a risk factor for incontinence

Answer 41

alpha blockers

Question 42

what is the mechanism behind urinary continence at rest

Answer 42

intraurethral pressure exceeds the intravesical pressure

Question 43

how do you stay continent

Answer 43

continuous contraction of the internal sphincter external sphincter provides about 50% of urethral resistance and is the second line of defence when UVJ is in proper position, any sudden increase in intra abdo pressure is transmitted equally to bladder and proximal third of urethra--> as long as intraurethral pressure remains higher than intravesical, continence is preserved

Question 44

what role does the SNS play in micturition

Answer 44

provides continence and prevents micturition by contracting bladder neck and internal sphincters HYPOGASTRIC nerve originating in T10-L2

Question 45

what role does the PSNS play in micturition

Answer 45

allows micturition to occur PELVIC nerve from S2, 3, 4

Question 46

what role does the somatic nervous system play in micturition

Answer 46

voluntary prevention of micturition innervates striated muscle of the external sphincter and pelvic floor via PUDENDAL nerve

Question 47

how does micturition occur

Answer 47

stretch receptors in bladder wall--> CNS--> inhibition of SNS and pudendal nerve--> relaxation of urethra, external sphincter and levator ani muscles--> activation of PSNS pelvic nerve--> contraction of detrusor

Question 48

list bladder storage symptoms

Answer 48

daytime frequency urgency nocturia

Question 49

list voiding symptoms

Answer 49

hesitancy slow stream intermittency dysuria straining spraying incomplete emptying retention immediate voiding postvoid leakage position dependent voiding

Question 50

what should you include on an exam for urinary incontinence

Answer 50

pelvic rectal neuro exam (full) including deep tendon reflexes, pelvic floor contractions and bulbocavernosus reflex

Question 51

what is the goal of diagnostic testing for urinary incontinence

Answer 51

distinguish between stress incontinence and urgency incontinence --> because treatments are different

Question 52

what are usual initial tests for urinary incontinence

Answer 52

stress test cotton swab test cystometrogram uroflowmetry * can also use voiding diary/bladder chart * UA and culture should be done to rule out infection

Question 53

how do you do a stress test for urinary incontinence

Answer 53

# fill bladder with up to 300 mL of NS through catheter--> ask patient to cough--> observe loss or urine--> if you see loss of urine it is genuine stress incontinence get PVR after, and the rule out urinary retention and infection

Question 54

what is the cotton swab test for urinary incontinence

Answer 54

purpose is to diagnose a hypermobile urethra associated with stress incontinence insert lubricated cotton swab into urethra to angle of the UVJ--> when patient strains as if urinating, UVJ descends and cotton swab moves upward--> change in angle is normally less than 30 degrees--> if above 30, likely hypermobile urethra

Question 55

what are urodynamic studies

Answer 55

functional studies of the lower urinary tract usually reserved for patients contemplating surgery and for those in whom a clear diagnosis cannot be made on preliminary tests

Question 56

what are the 3 major component of urodynamic studies

Answer 56

1. evaluation of the urethral function--> urethrocystometry, urethral pressure profilometry 2. bladder filling--> cystometry 3. bladder emptying--> uroflowmetry and voiding cystometry or pressure flow studies

Question 57

what does cystometry measure

Answer 57

part of urodynamic studies measures the pressure and volume relationship of the bladder during filling and/or pressure flow study during voiding can check bladder sensation, capacity, detrusor activity and bladder compliance pressure sensors are placed into the bladder to measure intravesical pressure and into either the vagina or rectum to measure abdo pressure as the bladder is filled with fluid in retrograde fashion

Question 58

when does the sensation to void typically occcur

Answer 58

when bladder filled with 150 mL of fluid normal capacity is 400-600 mL

Question 59

what is the consequence of having a hypermobile urethra

Answer 59

increases in intra-abdo pressure are no longer transmitted equally to the bladder and urethra instead, increases in intra-abdo pressure are transmitted primarily to the bladder--> causes stress incontinence as causes intra-vesical pressure to exceed intra-urethral pressure

Question 60

what are some lifestyle and behavior mods that can be used to treat stress incontinence

Answer 60

weight loss caffeine restriction fluid management bladder training pelvic floor muscle exercises physical therapy

Question 61

what are the medical therapy options for stress incontinence

Answer 61

limited alpha adrenergic agonists (midodrine, pseudoephedrine), beta adrenergic receptor antagonists and agonists (propanolol), TCAs and SNRIs have been tried, but limited data for use

Question 62

what are some surgical/mechanical solutions to stress incontinence

Answer 62

incontinence pessaries--> physically elevates and supports the urethra restoring normal anatomical relationships surgery is frequently tx of choice--> Burch procedure (abdominal retropubic urethroplexy), bladder neck sling, tension free mid-urethral slings

Question 63

what causes detrusor overactivity

Answer 63

most is idiopathic ``` UTIS bladder stones bladder cancer urethral diverticula foreign bodies stroke spinal cord injury Parkinson's disease MS DM ```

Question 64

what are the most common drugs used to treat urgency incontinence

Answer 64

anticholinergics with antimuscarinic effects act by increasing the bladder capacity and decreasing urgency resulting in decreased accidents may take up to 4 weeks to work

Question 65

side effects of anticholinergics

Answer 65

dry mouth blurred near vision tachycardia drowsiness decreased cognitive function constipation

Question 66

who should not take anticholinergics

Answer 66

those with gastric retention, angle closure glaucoma and those with dementia (can worsen it)

Question 67

list common medications used for urgency incontinence

Answer 67

1. oxybutinin (Ditropan) 5 mg PO TID to QID 2. Tolterodine (Detrol) 2 mg PO BID there are others but im too lazy

Question 68

list surgical treatment options for urgency incontinence

Answer 68

sacral and peripheral (posterior tibial nerve) neuromodulation bladder injections--> botulinum toxin into detrusor muscle augmentation cystoplasty --> for severe and refractory cases

Question 69

what usually causes overflow incontinence in women

Answer 69

underactive or acontractile destrusor muscle --> bladder contractions are weak or non existent causes incomplete voiding, urinary retention, overdistention of the bladder

Question 70

neurogenic causes of overflow urinary incontinence

Answer 70

LMN disease spinal cord injury DM MS

Question 71

obstructive causes of overflow urinary incontinence

Answer 71

post surgical urethral obstruction post op overdistention pelvic masses fecal impaction

Question 72

pharmacological causes of overflow urinary incontinence

Answer 72

anticholinergics alpha adrenergic agents epidural and spinal anesthesia other causes? cystitis and urethritis psychogenic (psychosis or severe depression) idiopathic

Question 73

how do you manage overflow urinary incontinence medically

Answer 73

agents that reduce urethral closing pressure: prazosin terazosin phenobenzamine striated muscle relaxants to reduce bladder outlet resistance: diazepam dantrolene cholinergic agents to increase bladder contractility: bethanechol

Question 74

how does bypass incontinence usually present

Answer 74

continuous incontinence

Question 75

what causes most urinary fistulas

Answer 75

in north america it is pelvic surgery or radiation in developing countries, obstetric trauma is commonly a cause

Question 76

what is the primary treatment for urinary fistulas

Answer 76

surgery--> wait 3-6 months before attempting to repair post surgical fistulas abx for infection and estrogen for postmenopausal women helps during this period