Urinary Incontinence and Prolapse

Question 1

what are the urethral causes of incontinence

Answer 1

urethral sphincter incompetence (stress)
detrusor instability (urgency)
retention with overflow
functional

Question 2

what are the extra urethral causes of incontinence

Answer 2

congenital

fistula

Question 3

what are the 4 types of urinary incontinece

Answer 3

stress
urge
mixed
overflow

Question 4

what are the risk factors for incontinence

Answer 4

female
pregnancy
childbirth (esp large baby)
menopause (weakens pelvic muscles and thinning of urothelium)
age - weakened muscles, bladder capacity decreases
obesity - increased abdo pressure
smoking- chronic cough 
diabetes

Question 5

what urinary symptoms will you get in overactive bladder

Answer 5

urgency

frequency

Question 6

what is important to ask when assessing QOL in incontinence

Answer 6

if having sex- do they leak during sex

Question 7

what Ix for incontinence

Answer 7

Exam:
exclude mass in abdomen
look for atrophic vaginitis in external genitalia
look for prolapse, fistula or malignancy
PR tone, masses
teach kegels
neuro-check reflexes, sensory and motor innervation

standing or supine stress test
post void residue (retention)
urinalysis (exclude infection)
bladder diaries

stress:
- flow volume chart
- exclude UTI
- urodynamics when surgery considered

Question 8

can fluid restriction help incontinence

Answer 8

no- makes urine more concentrated which irritates the bladder causing more leakage

Question 9

what should you avoid drinking in urinary incontinence

Answer 9

fluids that irritate the bladder: caffeine, alcohol

try and space caffeine 6 hours apart

Question 10

what causes incontinence during intercourse

Answer 10

during orgasm- urge

during penetration- stress

Question 11

how can you tell urgency from a full bladder

Answer 11

urgency incontinence will have fear of leackage

Question 12

what precedes urge incontinece

Answer 12

urge to void and triggers e.g. running water

Question 13

how much are you normally meant to drink

Answer 13

24mls/kg/24hrs

Question 14

what is normal bladder capacity

Answer 14

500mls
above 80 y/o ~200mls
can be stretched to litre

Question 15

why is prolapse associated with stress incontence

Answer 15

weakened pelvic support

Question 16

what is normal urine flow rate

Answer 16

20-60mls per second

if >80 slower ~10mls

Question 17

why might someone have a poor flow rate

Answer 17

underactive bladder or obstruction of urethra (commonly prolapse of anterior vaginal wall)

Question 18

is there a pressure difference in the bladder, bowel or abdominal cavity

Answer 18

no

Question 19

what is cystometry

Answer 19

catheters with sensors are inserted to measure pressure - used to differentiate the contractions in the bladder from the basic pressure in the abdomen

if the pressures are the same = no worries
if independent contractions of the bladder might be sign of overactive bladder UI

Question 20

what is detrusor pressure

Answer 20

(cystometry)

vesicle pressure - abdo pressure

Question 21

what is normal post residual volume

Answer 21

<100ml (more than this abnormal, 1st desire to void at 150-200ml, strong desire at 400mls)

Question 22

how do antimuscarinics affect the bladder

Answer 22

cause an underactive bladder- affects storage and voiding

-weaker contractions= reduced flow rate= high post void residue

Question 23

independent contractions of the bladder without accompanying contractions of rectal pressure=?

Answer 23

overactive bladder

Question 24

leakage accompanying cough =?

Answer 24

stress UI

Question 25

low max flow rate and high bladder pressure =?

Answer 25

bladder outlet obstruction | usually prolapse

Question 26

what general treatment for urinary incontinence

Answer 26

- avoid caffeine, spicy food and dark chocolate - pads - physical therapy - control diabetes - bladder drills (holding for as long as possible)

Question 27

what is duloxetine

Answer 27

SSNRI increases serotonin and norepinephrin in synaptic cleft increases contractility and tone of urethral sphincter

Question 28

what is uroflowmetry

Answer 28

screens for voiding difficulties- patient urinates in proivate into comode with urinary flow meter

Question 29

what is urodynamics

Answer 29

cystometry and uroflowmetry

Question 30

what management for SUI

Answer 30

- surgery in england not scotland - conservative: -weight loss, smoking cessation, treat constipation - pelvic floor exercises - biofeedback - duloxetine (rarely used) Pessaries (work in 50%) Surgeries (low tension vaginal tapes, intraurethral injections, artificial sphincters, colposuspension) what s

Question 31

what management for overative bladder

Answer 31

avoid caffeine, alcohol, chocolate, tannins, tomatoes, citrus and spicy foods - drink at least 25 ml/kg a day - BMI <30 - treat constipation, eat high fibre diet - exclude UTI - bladder training - pelvic floor excercises (consider topical oestrogen if vaginal atrophy) should try 3 months non pharmacological management ``` 1st line- tolterodine (antimuscarinic) review at 4-6 wks 2nd line- solifenacin (antimuscarinic) review 4-6 weeks 3rd line- mirabegron (beta 3-adrenoceptor agonist- relaxed bladder) MONITOR BP risk of severe hypertension ``` botox neuromodulation (posterior tibial nerve) surgery

Question 32

what do antimuscarinics increase the risk of

Answer 32

dementia and death - monitor mental function

Question 33

what are the antimuscarinic side effects

Answer 33

Constipation; dizziness; drowsiness; dry mouth; dyspepsia; flushing; headache; nausea; palpitations; skin reactions; tachycardia; urinary disorders; vision disorders; vomiting

Question 34

how do antimuscarinics help OAB

Answer 34

block parasympathetic innervation and relax detrusor

Question 35

why might OAB be confused with SUI

Answer 35

as symptoms can be brought on by coughing/ sneezing

Question 36

how do beta agonists help OAB

Answer 36

increase adrenegic (sympathetic) control- increase relaxation of the bladder

Question 37

what are the indications for urodynamics

Answer 37

``` hesitancy voiding difficulty neuropathy Hx of urinary retention post op follow up uncertain diagnosis failure to respond to Tx prior to surgery ```

Question 38

what should you teach if high residual volume

Answer 38

self catheterisation

Question 39

WHAT DRUGS SHOULD YOU STOP IF PATIENT HAS OVERFLOW INCONTINENCE

Answer 39

long term anticholinergics

Question 40

what spine things can cause retention and overflow

Answer 40

cauda equina | spinal anaesthesia

Question 41

what is procindentia

Answer 41

prolapse when entirely out of vagina

Question 42

what are the degrees of prolpase

Answer 42

1st- in vagina 2nd- at interiotus 3rd- outwith vagina procidentia- entirely outwith vagina

Question 43

what score to quantify prolapse

Answer 43

POP-Q

Question 44

what RF for prolase

Answer 44

same as incontinence lifting surgery

Question 45

why do people with oedema in feet get nocturnal polyuria

Answer 45

as when lie down fluids flows into abdomen

Question 46

what is an anterior prolapse

Answer 46

cystocele: | -bulging pressure 'mass', difficulty voiding, incomplete emptying, splitting vaginal wall

Question 47

what are the features of an anterior/ middle or apical prolapse

Answer 47

bulging pressure 'mass', difficulty voiding, incomplete emptying, splitting vaginal wall, difficulty inserting tampon, pain with intercourse

Question 48

what is a middle/ apical prolpase

Answer 48

enterocele (intestines)

Question 49

what is a posterior prolapse

Answer 49

rectocele

Question 50

what are the symptoms of a rectocele

Answer 50

``` bulging pressure mass difficulty defecating incomplete defecation splitting vaginal wall or perineum difficulty inserting tampon ```

Question 51

what is the management for a prolapse

Answer 51

``` avoid heavy lifting weight loss smoking cessation reassure physio pessary surgery ```

Question 52

what are the surgery options for prolapse

Answer 52

vaginal hysterectomy Manchester repair (cervix amputated, uterosacral ligaments shortened), sacrospinous fixation, abo/ laparoscopic sacrocolpexy, mesh techniques (controversial), colpoplexy

Question 53

when would you give a pessary not surgery or conservative

Answer 53

do surgery if young and dont want foreign body in vagina pessary if not fit for surgery/ to relieve while waiting for surgery. also if further pregnancies planned/ pregnant conservative if not concerned about symptoms/ young and will improve with physio

Question 54

what are the types of pessary

Answer 54

supportive pessaries (for mild- mod prolapse): - ring (easily inserted and removed, stay in during sex, suited fro all types of prolapse) - gehrung (stays in during sex, hard to fit and remove) space occupying pessaries (advances or severe prolapse): - donut (needs to be removed for sex, hard to put in) - cube (needs to be removed every night, difficult to put in and take out, remove for sex, may can vaginal erosion) - gelhorn (hard to insert and remove, remove for sex) - inflatable (easy to insert/ take out, remove for sex) - shelf (hard to insert and remove, remove for sex)