Urinary Incontinence and Prolapse

Question 1

what does the pelvic floor do?

Answer 1

separates pelvic cavity from perineum

provides support to pelvic organs and maintains urinary and faecal continence in women

Question 2

what 3 muscles are involved in urinary continence in females?

Answer 2

external urethral sphincter
compressor urethrae
levator ani

Question 3

what muscle is involved in faecal continence in females?

Answer 3

puborectalis muscle

Question 4

what are the 3 layers of the pelvic floor from external to internal?

Answer 4

perineal muscle
muscles of perineal pouches
pelvic diaphragm

Question 5

what are the 2 muscle groups in the pelvic diaphragm?

Answer 5

levator ani

coccygeus

Question 6

what are the 3 parts of levator ani from medial to lateral?

Answer 6

PPI

• puborectalis (U shaped sling behind rectum)
• pubococcygeus
• iliococcygeus

Question 7

normal state of pelvic diaphragm?

Answer 7

normally contracted

must relax to release urine and faeces

Question 8

innervation of pelvic diaphragm?

Answer 8

pudental nerve

nerve to levator ani

Question 9

what are the 2 supporting structures to the pelvic diaphragm?

Answer 9

endopelvic fascia

ligaments

Question 10

innervation of detrusor muscle?

Answer 10

parasympathetics derived from pelvic splanchnic nerves S2, 3 and 4

Question 11

innervation of urethral smooth muscle?

Answer 11

sympathetics derived from spinal cord at T10 to L2

these decsend to the urethra and bladder via the hypogastric nerves

Question 12

innervation of urethral sphincter and pelvic floor (levator ani) muscles?

Answer 12

branches of the pudental nerve, S2, 3 and 4

Question 13

what are the main supportive ligaments of the pelvis?

Answer 13

utero-sacral ligament
transverse cervical ligament (cardinal ligament)
tendinous arch of pelvic fascia
tendinous arch of levator ani
lateral ligament of bladder

Question 14

what are the 3 levels of support at the pelvic floor?

Answer 14

support at cervix and upper vagina
support at middle vagina
support at lower vagina

Question 15

support at cervix and upper vagina?

Answer 15

uterosacral, transverse cervical and pubocervical ligaments

Question 16

support at middle vagina?

Answer 16

pelvic fascia

Question 17

support at lower vagina?

Answer 17

levator ani muscles and perineal body

Question 18

where is the deep perineal pouch?

Answer 18

superficial to the pelvic diaphragm

above the perineal membrane

Question 19

what does the deep perineal pouch contain in females?

Answer 19

part of urethra
vagina
clitoral neurovascular bundle
extensions of ischioanal fat pads
smooth muscle
external urethral sphincter and compressor urethrae

Question 20

what does the deep perineal space contain in males?

Answer 20

part of urethra
bulbourethral glands
neurovascular bundle of penis
extensions of ischioanal fat pads
smooth muscle
external urethral sphincter and compressor urethrae

Question 21

what is the most superior structure in the deep perineal pouch?

Answer 21

dorsal vein of clitoris/penis

sits above urethra (commonly mistaken for urethra)

Question 22

where is the perineal membrane?

Answer 22

superficial to deep perineal pouch

Question 23

what is perineal membrane made of?

Answer 23

tough deep fascia

Question 24

function of perineal membrane?

Answer 24

completes urogenital triangle by attaching to sides of the pubic arch
final line of defence for the pelvic organs along with the perineal body
provides an area of attachment for the external genitalia

Question 25

where is the superficial perineal pouch?

Answer 25

superficial to perineal membrane | contains female erectile tissue/male root of penis and their relevant muscles

Question 26

what is contained within the female superficial perineal pouch?

Answer 26

clitoris and crura (legs of clitoris, invisible to naked eye) bulbs of vestibule bulbospongiosus ischiocavernosus greater vestibular glands superficial transverse perineal muscle branches of internal pudendal vessels and pudendal nerve

Question 27

what is contained within the male superficial perineal pouch?

Answer 27

``` bulbospongiosus ischiocavernosus anal sphincter deep transverse perineal superficial transverse perineal pelvic diaphragm/levator ani muscles obturator internus perineal body ano-coccygeal body sacrum and coccyx ischial tuberosities sacrotuberous ligament ```

Question 28

where is ischiocavernosus found in both males and females?

Answer 28

lateral to bulbospongiosus

Question 29

what can cause the pelvic floor to weaken?

Answer 29

increased intra-abdominal pressure (obesity, cough, constipation, mass etc) pelvic floor trauma and denervation (obstetric, fracture, surgery, congenital) connective tissue disorder (age, oestrogen deficiency, drug related, congenital/acquired connective tissue disorder)

Question 30

what is stress incontinence?

Answer 30

involuntary leakage of urine when there is increased intra-abdo pressure with absence of detrusor muscle contraction

Question 31

causes of stress incontinence?

Answer 31

after childbirth pelvic surgery oestrogen deficiency (menopause)

Question 32

clinical features of stress incontinence?

Answer 32

triggered by coughing, sneezing, exercise etc (anything that increases abdo pressure) leakage usually a small volume prolapse of urethra and anterior vaginal wall may be present

Question 33

investigations in stress incontinence?

Answer 33

exclude UTI frequency/volume chart (bladder diary) - diary will show normal frequency and bladder capacity in stress incontinence should do urodynamic studies

Question 34

how is stress incontinence managed?

Answer 34

lifestyle conservative measures (pelvic floor exercise for 3 months, use of pads) medical management if patient declines or unsuitable for surgery

Question 35

medical management of stress incontinence?

Answer 35

duloxetine (SNRI antidepressant) | need to discuss side effects with patient

Question 36

side effects of duloxetine?

Answer 36

``` difficulty sleeping headaches dizziness blurred vision change in bowel habit nausea and vomiting dry mouth sweating decreased appetite weight loss decreased libido ```

Question 37

surgical management of stress incontinence?

Answer 37

bulking agents autologous rectus fascial sling laparoscopic or open colposuspension artificial urinary sphincters (only in severe cases where previous surgery failed)

Question 38

what is urge incontinence?

Answer 38

increased urgency and frequency to void urine | often have nocturia

Question 39

clinical features of urge incontinence?

Answer 39

can be triggered by hearing running water, cold weather etc usually larger volumes of urine leak compared to stress little warning

Question 40

causes of urge incontinence?

Answer 40

idiopathic pelvic surgery multiple sclerosis spina bifida

Question 41

investigations in urge incontinence?

Answer 41

frequency/volume charts (bladder diary) - will show increased frequency urodynamic testing should be done - shows over-activity of detrusor muscle

Question 42

management of urge incontinence?

Answer 42

lifestyle bladder retraining with incontinence team medical surgical

Question 43

medical management of urge incontinence?

Answer 43

oxybutynin (anti-cholinergic) - tolterodine/solifenacin preferred in elderly due to cog impairment mirabegron (esp safer in elderly) intra-vaginal oestrogen (good in vaginal atrophy) consider desmopressin if nocturia present

Question 44

surgical management of urge incontinence?

Answer 44

botox percutaneous sacral nerve stimulation augmentation cystoplasty

Question 45

what is overflow incontinence?

Answer 45

leakage of urine from a full urinary bladder | often with the absence of an urge to urinate

Question 46

causes of overflow incontinence?

Answer 46

inactive detrusor muscle (neurological conditions eg MS) causing lack of an urge to urinate involuntary bladder spasms can occur in cardio disease and diabetes cytocele or uterine prolapse can block exit if severe prostate related conditions

Question 47

who is overflow incontinence more common in?

Answer 47

men | due to prostate related conditions

Question 48

investigations in overflow incontinence?

Answer 48

frequency/volume charts | urodynamic testing shows inactivity of detrusor muscle

Question 49

management of overflow incontiencne?

Answer 49

treat the cause

Question 50

1st degree prolapse?

Answer 50

mild protrusion on examination (-1cm away from interoitus)

Question 51

2nd degree prolapse?

Answer 51

prolapse present at interoitus of vagina/anus/urethra (between -1cm and +1cm of interoitus)

Question 52

3rd degree prolapse?

Answer 52

prolapse protruding outside of the interoitus (beyond +1cm of interoitus)

Question 53

4th degree prolapse?

Answer 53

procidentia (complete prolapse)

Question 54

risk factors for prolapse?

Answer 54

``` age multiparity vaginal deliveries obesity spina bifida ```

Question 55

clinical signs of prolapse?

Answer 55

sensation of pressure, heaviness or "bearing down" | urinary incontinence, frequency, urgency

Question 56

management of prolapse?

Answer 56

``` doesnt need management if mild and asymptomatic lifestyle changes pelvic floor training ring pessary surgery ```

Question 57

what surgery can be done for a cystocele/cystourethrocele?

Answer 57

anterior colporrhaphy

Question 58

what surgery can be done for a uterine prolapse?

Answer 58

hysterectomy sacrohysteropexy sacrospinous fixation

Question 59

what surgery can be done for a rectocele?

Answer 59

posterior colporrhaphy

Question 60

management of UTI in non-pregnant women?

Answer 60

trimethoprim or nitrofurantoin for 3 days | send urine culture if age >65 or haematuria present

Question 61

how is UTI managed in symptomatic pregnant women?

Answer 61

nitrofurantoin (1st and 2nd trimester) trimethoprim (3rd trimester) urine culture done

Question 62

how is UTI managed in asymptomatic pregnant women?

Answer 62

nitrofurantoin (avoid near term pregnancy), amoxicillin or cefalexin for 7 days urine culture should be done at 1st antenatal visit and another done after to treatment to test for cure high risk of progressing to pyelonephritis

Question 63

how is UTI managed in catheterised patients?

Answer 63

only treat if symptomatic with bacteria in urine | antibiotics for 7 days