urogenital aging: prolapse + incontinence

Question 1

muscles supporting perineum/pelvis

Answer 1

leavtor ani -
pubovaginalis, puborectalis, pubococcygeus, iliococcygeus

coccygeus

Question 2

nerves supporting pelvis / perineum

Answer 2

pudendal (s2, s3, s4)
sacral plexus (s2, s3)

Question 3

RFs for pelvic floor prolapse + urinary incontinence

Answer 3

• age
• menopause
• parity (incl operative deliv)
• obesity
• chronic cough
• constipation
• heavy lifting
• CT disorders (ehlers danlos)
• neuropathies:
  S1-S4, DM, congenital

Question 4

symptoms of prolapse

Answer 4

mass/bulge at introitus

feeling of heaviness (esp with standing, lifting, end of day)

bladder or bowel symptoms

Question 5

cystocele signs + symptoms

Answer 5

fullness/pressure
occasional urgency
incomplete emptying
incontinence
splinting/digitation for emptying
recurrent UTI
ureteric obstruction

Question 6

rectocele signs + symptoms

Answer 6

pressure in vag
constipation
splinting/digitation for defecation
incomplete emptying

Question 7

procidentia

Answer 7

complete protrusion of cervix/uterus from vagina

Question 8

enterocele definition

Answer 8

true hernia of pelvic floor

procidentia or post-hysterectomy

bowels/omentum protrude through uterosacral lig into rectovaginal pouch

Question 9

vault prolapse

Answer 9

protrusion of apex of vault into vagina after hysterectomy

Question 10

physical exam for prolapse

Answer 10

• atrophy
• strain/cough
• speculum to isolate each compartment + grade
• reduce prolapse + cough for occult stress urinary incontinence
• check levator ani strength (kegel)

Question 11

grading systems for prolapse

Answer 11

baden walker

• 0 normal
• 1 halfway to hymen
• 2 at hymen
• 3 halfway beyond hymen
• 4 more than half way

POPq

Question 12

managment of prolapse

Answer 12

• expectant - minimal symptoms
• kegels or pelvic floor physio
• pessaries: if don’t want surgery, not candidate, or waiting, clean every 3 months (or self), risks = bleeding, infection, worse urine/bowel, rare: fistulas
• surgery

can combine above /w vag estrogen + lubricants

Question 13

surgeries for prolapse

Answer 13

• cystocele: ant repair
• rectocele: post repair
• uterine prolapse: vag hyst + vault suspension
• enterocoele: purse string closure of sac +/- McCall culdoplasty
• vault prolapse: vag vault suspesnion or lap sacrocolpopexy with mesh

if not sex active or want lower risk surg:
- colpocleisis or vaginectomy surgeries for procindentia

• can also do incontinence surg at same time

Question 14

continence mechanisms

Answer 14

invol internal sphincter
external sphincter
mucosal coaptation

Question 15

urinary symptoms

Answer 15

freq
nocturia
urgency - can be motor or sensory

incontinence (urgency, stress, mixed)
enuresis (incontinence)
noctural enuresis
continuous urinary incontinence

Question 16

urinary incontinence types/causes

Answer 16

• stress
• urgency (OAB)
• mixed
• overflow incontinence - full bladder, often no urge (weak bladder or outlet obstruction)
• functional - incontinence from mobility, cognitive impairment

other causes

• infection
• tumour
• bladder stone
• foreign body
• suburethral diverticulum
• fistulae
• interstitial cystitis

Question 17

over active bladder diagnosis

Answer 17

• triad: urgency, freq, nocturia +/- incontinence
• dx on symptoms
• r/o other causes: UTI, GSM

Question 18

points on urinary hx

Answer 18

• freq
• urge
• incontinence: stress, running water, activity, overflow, cont, fistula
• nocturia
• impact on QOL
• voiding: slow, dribble, hesitancy, strain, bladder sensation, pain
• UTI - dysuria, hematuria
• contributing: caffeine, medhx, DM, thyroid, CNS disease, disc disease, drugs, psych

Question 19

physical exam for urinary system

Answer 19

• genitourinary atrophy
• cough/strain: bladder neck hypermobility
• palpate bladder neck + urethra for diverticulum
• reduce prolapse and cough for SUI

Question 20

work up for evaluation

Answer 20

• PVR urine (bladder scan or by in-and-out)
• urinalysis and urine C + S
• +/- cystoscopy for stone/tumour
• consider urodynamics if hx + phx inconsistent, tx not working, prev surgery, distinguishes SUI + OAB

Question 21

urodynamics components

Answer 21

• filling cystometrogram:
• first sensation: 100-250cc
• first desire to void: 200-330
• strong desire: 350-650
• detrusor stable/overactive
• compliance (change in pressure /w change in vol)

for SUI:

• max urethral closure pressure
• valsalva leak point pressure

Question 22

tx for OAB

Answer 22

• r/o other cuases
• behaviour: eliminate irritants (caffeine), total fluids < 1.5 - 2L
• bladder retrain: timed voiding every 2-3 hrs, double void to ensure empty
• pelvic floor physio/training
• meds: anticholinergics (se - dry), mirabegron (B3 adrenergic agonist, se - HTN)
• botox injections
• sacral neuromodulation

Question 23

treatment for stress urinary incontinence

Answer 23

• expectant
• bladder drills
• pelvic floor physio/exercise
• surgery:
• retropubic urethropexy (burch)
• lap. sling (mesh)
• autologous fascial sing
• midurethral slings: retropubic (TVT), transobturator tape