Urinary Incontinence and Prolapse Flashcards by Aliya Hussain

Define urinary incontinence?

Complaint of any involuntary leakage of urine

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Occurrence of urinary incontinence in females?

Most common in older females; incidence is rising due to the ageing female population

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Types of urinary incontinence?

Overactive bladder (OAB)

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What is stress UI?

Involuntary urine leakage on effort, exertion, sneezing, coughing, etc

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What is urgency UI?

Involuntary urine leakage accompanied OR immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to delay)

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What is mixed UI?

Involuntary urine leakage assoc. with both urgency AND exertion, effort, sneezing, coughing, etc

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What is OAB?

Urgency that occur with/without urgency UI and usually with frequency and nocturia

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Types of OAB?

OAB ‘wet’ - OAB that occurs with incontinence

OAB ‘dry’ - OAB that occurs without incontinence

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Risk factors for UI?

Age

Parity

Obesity

Pregnancy and obstetric history

Menopause

UTIs

Smoking

FH of UI

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Impact of urinary incontinence of QoL?

Sexual:
• Avoidance of sexual contact and intimacy

Occupational:
• Absence from work
• Decreased productivity

Physical:
• Limitations of cessation of physical activities

Domestic:
• Requirements for specialised underwear, bedding
• Special precautions with clothing

Psychological:
• Guilt / depression
• Loss of self-respect and dignity
• Fear of being burdensome, lack of bladder control and urine odour
• Apathy / denial

Social:
• Reduction in social interaction
• Alteration of travel plans

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Approaching the patient with UI?

Categorise it the UI

Ask for a bladder diary (3 days) and tell the patient to reduce their caffeine intake in that time

Separate symptoms into:
• Storage symptoms
• Voiding symptoms
• Post-micturition symptoms

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Storage symptoms assoc. with UI?

Frequency, nocturia

Urgency

UUI, SUI

Constant leak

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Voiding symptoms assoc. with UI?

Hesitancy

Straining to void

Poor flow

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Post-micturition symptoms assoc. with UI?

Incontinence

Incomplete emptying

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Examination of patient with UI?

Check BMI (if high, increased likelihood of SUI)

Abdominal examination - check for masses, inc. at the bladder

Vaginal examination - check for atrophy, prolapse, SUI (ask the patient to cough) and fistulas

PR exam - check anal tone and for masses

Cognitive impairment

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Differentiating OAB with urge incontinence from stress incontinence?

OAB is assoc. with frequent, involuntary detrusor contractions; the detrusor instability can cause symptoms of urgency or the sudden loss of urine (UUI)

With SUI, when the bladder muscle experiences a stress-related contraction, the support muscles are unable to remain completely shut; this can be caused by urethral hypermobility:
• Significant displacement of the urethra and bladder neck during exertion and increased abdominal P
• Urethral sphincter weakness (can occur after trauma, hypo-oestrogenism, ageing or surgical procedures)

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Ix for UI?

Urinalysis (for a UTI)

Post-void residual - a certain V of urine is left behind, in the bladder, after voiding; check if this V is abnormal

Urodynamics

Cystoscopy

Imaging

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Conservative Mx of UI?

Lifestyle interventions:
• Caffeine
• Fluid intake
• Weight loss

Pelvic Floor Exercises (PFE) for 3 months

Bladder retraining for 6 weeks

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Spectrum of treatments available for OAB?

From least to most invasive:
• Lifestyle advice
• Bladder drill
• Pelvic floor physiotherapy
• Drugs 
• Botulinum toxin
• Neuromodulation
• Reconstructive surgery

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Anti-muscarinic agents used to treat OAB?

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Oxybutynin

Tolteridone

Darifenicin

Once started, review at 4 weeks; if oral is not tolerated, use transdermal

Mechanics of action of anti-muscarinics, in the treatment of OAB?

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Reduce intravesical P

Increased bladder compliance

Raise the threshold volume for micturition

Reduce uninhibited contractions

Side effects of anti-muscarinics?

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Dry mouth
Constipation
Blurred vision
Somnolence

Other drugs used in the treatment of OAB?

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Mirabegron (β3-agonists) - selectively activates β3-adrenoceptrs to relax bladder smooth muscle; it also increases the voiding interval and inhibits spontaneous bladder contractions during filling

Desmopressin can be added is the patient experiences nocturia

Topical oestrogen

Non-pharmacological management of OAB?

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Botox - the patient must know and be willing to intermittent self-catheterise

Percutaneous sacral nerve stimulator

Augmentation cytoplasty

Mx of SUI?

Duloxetine - conservative measure are used first; it is a combined noradrenaline and serotonin reuptake inhibitor and it increases the intrautethral closure pressure ``` Surgery: • Tension-free tape • Colposuspension • Intramural bulking agents • Artificial sphincters ```

3 compartments that can be involved with pelvic prolapse?

* Anterior * Middle or apical * Posterior

Occurrence of pelvic organ prolapse?

Common - it occurs in up to 50% of parous women and 10-20% are symptomatic Incidence is increasing, due to increased female life expectancy and increased expectations for QoL

Which prolapses affect the anterior compartment?

Cystocoele ADD IMAGE

Symptoms of a cystocoele?

Bulging Pressure Mass effect Difficulty voiding, incomplete emptying, difficulty inserting tampon Pain with intercourse Splinting vaginal wall

Which prolapses affect the middle / apical compartment?

Vaginal vault prolapse Enterocoele

Symptoms of prolapses of the middle / apical compartment?

Bulging Pressure Mass effect Difficulty voiding, incomplete emptying, difficulty inserting tampon Pain with intercourse Splinting vaginal wall NOTE - these are the same as for the anterior compartment

Which proplapses affect the posterior compartment?

Bulging Pressure Mass effect Difficulty defecating, incomplete defecation Splinting of the vaginal wall or perineum Difficulty inserting a tampon

Types of complete eversion?

i.e: affecting all compartment Uterine procidentia Complete uterine prolapse ?????????

Risk factors for prolapse?

Age Parity and vaginal delivery Post-menopausal oestrogen deficiency Obesity Neurological conditions, e.g: spina bifida and muscular dystrophy Genetic CT disorders, e.g: Marfan's syndrome, ehlers-danlos syndrome

History factors to consider with prolapse?

Pressure and dragging sensations Urinary and bowel symptoms Sexual dysfunction

Ix of a patient with prolapse?

It is a clinical diagnosis (history + examination) USS, MRI scan Anorectal manometry Endoanal USS

What is the Pelvic Organ Prolapse Quantification System (POP-Q)?

6 specific sites are evaluated while the patient is straining 3 sites are measures at rest

How are measurements for POP-Q made?

Measure each site (cm) in relation to the hymenal ring; this fixed point is the zero point of reference If the site is above the hymen, the measurement is -ve If the site is below the hymen, the measurement is +ve

Interpret these POP-Q figures? ADD IMAGE

Normal

Interpret these POP-Q figures? ADD IMAGE

.....

Staging of prolapses?

Used more often than POP-Q, as it is simpler Stage 0 – no prolapse Stage I – 1cm above hymen Stage II - -1 and +1 in relation to hymen Stage III - > 1cm beyond hymen Stage IV – complete vaginal eversion

Mx options for prolapse?

Conservative Mx Mechanical devices (pessaries) Surgery

When can pessaries be used to manage prolapses?

For a mild-moderate prolapse If the patient's family is not yet complete Frail patients At patient request, e.g: if they do not wish to have surgery

Complications of pessaries?

Discharge Ulcerations (may lead to a fistula) - requires pessary removal, treatment with topical oestrogen and then reinsertion Fibrous bands

Duration of use of a single pessary?

Change 6 monthly

Surgery for prolapses?

Anterior: • Vaginal repair Posterior: • Vaginal repair Apical: • Vaginal - sacrospinous fixation, colpocliesis (very effective but no sexual intercourse afterwards, i.e: it is only done in older women who are no longer sexually active) • Abdominal - sacrohysteropexy, sacrocolpopexy, pectopexy

Describe the procedure of a sacrohysteropexy

Surgical procedure to correct uterine prolapse It inv. a resuspension of the prolapsed uterus, using a strip of synthetic mesh to lift the uterus and hold it in place Allows for normal sexual function and preserves childbearing function

Describe the procedure of a sacrocolpopexy

Uses mesh for repair

Urinary Incontinence and Prolapse Flashcards

(48 cards)