Urinary incontinence and prolapse

Question 1

what does the pelvic floor separate?

Answer 1

the pelvic cavity from the perineum

Question 2

what are the 3 layers of the pelvic floor?

Answer 2

pelvic diaphragm
muscles of perineal pouches
perineal membrane

Question 3

Describe the pelvic diaphragm.

Answer 3

deepest layer of pelvic floor
consists of 2 (skeletal) muscle groups - levator ani, coccyges
sling appearance

Question 4

What is the purpose of the anterior gap between the medial borders of the pelvic diaphragm?

Answer 4

urogenital hiatus

passage for urethra (M&F) and vagina (F)

Question 5

what is the tendinous arch of levator ani?

Answer 5

thickened area of fascia which covers obturator internus

Question 6

What does the levator ani attach?

Answer 6

pubic bones, ischial spines and tendinous arch of levator ani

Question 7

List the 3 parts of levator ani muscle.

Answer 7

puborectalis
pubococcygeus
iliococcygeus (from ilium to coccyx)

Question 8

When levator ani contracts, it allows urination and defaecation.
T/F?

Answer 8

FALSE

levator ani is tonically contracted most of the time - it must relax to allow urination and defaecation

Question 9

which nerves innervate levator ani?

Answer 9

pudendal nerve and nerve to levator ani

Question 10

What is the perineal body?

Answer 10

between urogenital hiatus and rectum (in both sexes) and is site where most muscles attach. if damaged, then the patient is much more likely to suffer incontinence and prolapse.

Question 11

What are the pelvic ligaments?

Answer 11

fibrous endo-pelvic fascia provide support to pelvic organs
uteruosacral 
transverse cervical (aka. cardinal)
lateral ligament of bladder
lateral rectal

Question 12

Where is the deep perineal pouch?

Answer 12

lies below the fascia covering the inferior aspect of the pelvic diaphragm
lies above the perineal membrane

Question 13

What does the deep perineal pouch contain?

Answer 13

part of the urethra (+ vagina in F), bulbourethral (Cowper’s) glands in M, neurovascular bundles for penis/clitoris, extensions of the sischioanal fat pads and muscles.

Question 14

What is the name for the female equivalent of the bulbourethral gland in males?

Answer 14

Bartholin’s gland

Question 15

Where does the perineal membrane attach?

Answer 15

laterally to the sides of the pubic arch - closing the urogenital triangle

Question 16

How many openings does the perineal membrane have in females?

Answer 16

2 - one for urethra and one for vagina

Question 17

what gives passive support to the pelvic organs?

Answer 17

perineal body + perineal membrane

Question 18

What does the superficial perineal pouch (males) contain?

Answer 18

root of penis - bulb, crura and associated muscles
also proximal spongy urethra, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve

Question 19

corpus spongiosum is found in which part of penis?

Answer 19

bulb

Question 20

corpus cavernous is found in which part of penis?

Answer 20

crura

Question 21

Which muscles are associated with the penis and the superficial perineal pouch?

Answer 21

bulbospongiosus and ischiocavernosus

Question 22

Describe the blood flow through the male erectile tissue.

Answer 22

crura and bulb = erectile tissue (differ in tissue type)
90% of blood flow will go through corpus cavernosum during erection. It wouldn’t be good for blood to go through spongiosum since it contains the urethra and sperm still needs to pass through it

Question 23

What does the superficial perineal pouch (female) contain?

Answer 23

clitoris and crura
bulbs of vestibule
associated muscles - bulobospongiosus and ischicavernosus
also greater vestibular glands, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve.

Question 24

What is the name for the area where the 2 crura come together in females?

Answer 24

the clitoris

Question 25

What are the different names for the greater vestibular glands depending on sex?

Answer 25

bartholin's glands in females | cowper's glands in males

Question 26

Where is a lateral episiotomy directed?

Answer 26

away from perineal body to avoid tearing it

Question 27

Describe how the pelvic floor helps maintain faecal continence.

Answer 27

tonic contraction of puborectalis bends anorectum anteriorly | active contraction maintains continence after rectal filling - reduces angle of anorectum

Question 28

What is prolapse?

Answer 28

common gynaecological disorder, can involve uterus, vagina or both (also bladder and rectum) - failure of support of pelvic organs

Question 29

Describe vaginal prolapse.

Answer 29

Herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia. Presents as a lump in vaginal wall.

Question 30

Describe the presentation of uterine prolapse.

Answer 30

"dragging" sensation feeling of a "lump" urinary incontinence

Question 31

Describe the different degrees of uterine prolapse.

Answer 31

1st - cervix drops into upper vagina 2nd - cervix low in vagina but above its opening 3rd - cervix completely exits vagina 4th - both cervix and uterus outside the vagina

Question 32

What is the treatment/repair for prolapse? Describe it.

Answer 32

Sacrospinous fixation sutures placed in sacrospinous ligament - just medial to ischial spine to repair cervical/vault descent performed vaginally

Question 33

What are the risks of sacrospinous fixation?

Answer 33

injury to pudendal NVB and sciatic nerve

Question 34

Describe incontinence surgery (trans-obturator approach).

Answer 34

Mesh through obturator canal - create a sling around urethra

Question 35

89 y/o woman lives in nursing home, her carers noticed she is needing chawed several times a day due to wet underwear. Difficulty starting to urinate and aware of an increasing vulval swelling. Limited mobility and ex-smoker with BMI of 32. Diagnosis and why?

Answer 35

urinary obstruction with overflow Difficulty initiating micturition (voiding) Constantly wet underwear, vulval swelling = prolapse

Question 36

58 y/o nurse concerned with increasing damp episodes when physically active and sometimes on coughing and sneezing. married with 4 children, smokes 20/day, BMI 39. Diagnosis and why?

Answer 36

stress urinary incontinence physical activity / coughing and sneezing causing damp episodes (raised IAP) 4 kids, smoker, BMI are risk factors

Question 37

75 y/o retired lawyer reports having to rush to the toiler otherwise she leaks. Increased frequency, especially at night. having to restrict daily activities. Not married, no kids, non-smoker; drinks at least 1 bottle of wine/night. BMI 26. Diagnosis and why?

Answer 37

Overactive bladder increased urgency and frequency - night rising. risk factors: drinks at least 1 bottle of wine a night

Question 38

When investigating urinary incontinence in a woman, which investigations would you consider?

Answer 38

``` abdo and vaginal exam urinalysis renal function test (U&Es) frequency volume chart (FVC) urodynamics ```

Question 39

What sort of values would you expect to see on a fluid volume chart and urodynamics in a patient with stress UI?

Answer 39

normal urinary volumes | cough signs on urodynamics and detrusor muscle pressure peaks when not filling bladder (sign of stress)

Question 40

What sort of values would you expect on a fluid volume chart and urodynamics of a patient with an ovaractive bladder?

Answer 40

going often and little urinary volumes on FVC increased rate, frequency, volume detrusor muscle pressure has multiple peaks once filled

Question 41

What treatment would you give to a patient with stress urinary incontinence?

Answer 41

pelvic floor exercises

Question 42

What would you treat an OAB with?

Answer 42

oxybutynin (ACh inhibitor)

Question 43

What is the first line pessary? PROS/CONS?

Answer 43

ring pessary PROS: easily inserted/removed, cheaper CONS: changed every 6/12

Question 44

Which pessary would you recommend in advanced stage prolapse? PROS/CONS?

Answer 44

cube PROS: can be removed if you want to have sex, self-insertion, removal CONS: removed every night (very few scenarios this would be used)

Question 45

Which pessary is 2nd line? PROS/CONS?

Answer 45

Gelhorn pessary for severe prolapse CONS: change every 6/12, more expensive (washed then reinserted)

Question 46

Which pessary is 3rd line? | PROS/CONS?

Answer 46

shelf PROS: cheap, every 6/12 CONS: if wrong size, e.g. too big, the vagina wall around it undergoes pressure necrosis