Popular Links - UNC School of Medicine
Download
Report
Transcript Popular Links - UNC School of Medicine
Urinary Incontinence and
Pelvic Organ Prolapse
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Division of Urogynecology/
Reconstructive Pelvic Surgery
Objectives
Describe normal pelvic anatomy and pelvic support
Describe screening questions to elicit signs and
symptoms of urinary incontinence
Differentiate the types of urinary incontinence
Describe the anatomic changes associated with
urinary incontinence and pelvic organ prolapse
Describe medical and surgical management options
for urinary incontinence and pelvic organ prolapse
Rationale
Patients with conditions of pelvic relaxation and
urinary incontinence present in a variety of ways.
The physician should be familiar with the types of
pelvic relaxation and incontinence and the approach
to management of these patients.
Definition of Urinary Incontinence
International Continence Society
Involuntary urine loss
Severe enough to constitute a social or hygiene problem
Leakage is objectively demonstrable
Questions for Patients
Do you leak urine when you cough, sneeze, laugh, or
exercise?
Do you leak on the way to the bathroom?
Do you know the locations of bathrooms when you are
shopping or travelling?
Do you leak during intercourse?
Stress or Urge Incontinence?
Epidemiology
Estimates of prevalence vary
Bias in sample surveys
Patient under-reporting
Differences in definitions, populations studied and
methods used
~ 13 million Americans are incontinent
10-35% of adults
Economics in Urinary Incontinence
Direct health care costs
> $15 billion/yr
Indirect health care costs
Incontinence products
Loss of work/productivity
Classifying Urinary Incontinence
Stress
Loss of bladder support -> leak with cough/sneeze/valsalva
Urge
Overactive bladder spasms -> leak with urge
Mixed
Both of above
Overflow
Hyposensitive bladder -> leak when reach capacity
Other
Functional – can’t make it to bathroom (physical or
cognitive impairment)
Unconscious or Reflex – hyperreflexia of detrusor
Fistula – tract between bladder and vagina
Tenants of Effective Management
Assessment of patient
Risk factors and
reversible causes
Treatment of reversible
conditions
Education
Treatment options
QOL improvement
Management plan
Risk Factors
Gender
Immobility
Environmental Barriers
Altered Cognition &
Delirium
Medications
Smoking
Collagen Disorders
Neurologic Disease
Diabetes
Stroke
Menopause
Childbirth
Increased Abd Pressure
Obesity
Chronic Constipation
Chronic Cough
High Impact Physical Activity
Patient Evaluation
History
Physical Exam
Laboratory Tests
Urodynamic Testing
Voiding Diary
History
HPI
Mental Status Evaluation
Functional Assessment
Environmental Assessment
Social Factors
Voiding Diary
HPI
# Incontinent episodes
Triggers
Stress +/- Urge
Volume of urine loss
Difficulty starting stream
(hesitancy)
Sensation of incomplete
emptying
Straining to empty
Number of pads/day
Frequency
Urgency
Nocturia
Enuresis
Dysuria
Hematuria
Post-void dribbling*
*Sign of what?
PMH
Parity
Birth trauma
Length of labor, especially 2nd stage
Previous gynecologic and/or incontinence
surgery
Back injury
Medical History
MS, DM, CVA, Parkinsons
Medications
Alpha-adrenergic
Cholinergic
Retention
Bladder irritability
Alpha-blocking
Anti-cholinergic
sphincter tone
Retention
b
b
b
a
TCA’s are both anticholinergic and alpha adrenergic
Diet
Caffeine
Citrus Foods & Drinks
Cranberry Juice!
Spicy Foods
Alcohol
Functional and Environmental Assessment
Manual Dexterity
Mobility
Patient toilet unaided?
Access
Distance to toilet or bedside commode (BSC)
Chair/bed transfers
Voiding Diary
Date and Time
Fluid consumption w/ type and volume
Voiding episodes w/ volume
Leaking episodes
Urgency
Physical Examination
General
GU
Neurologic
Direct Observation of Urine Loss
Post-Void Residual
Q-Tip Test
Physical Examination: Gynecologic
External Genitalia: excoriation, erythema
Vaginal Introitus and Mucosa: caliber, atrophy
Anterior Vagina: urethral diverticulum
Lateral Vaginal Sidewalls
Posterior Vagina
Uterine or Vaginal Cuff: procidentia, prolapse
Urethra: caruncle
Anus and Rectum: rectal prolapse, sphincter integrity
Physical Examination: Neurologic
S2 - S4
Sharp and dull touch
Perineum and buttocks
Reflexes
Bulbocavernosus
Anal Wink
Physical Examination: Q-tip Test
Assesses bladder neck mobility
Sterile technique
Anesthetic gel
+ 30o = UVJ hypermobility
SUI often has hypermobility
Hypermobility not necessarily SUI
- 20o
Urodynamics
Uroflowmetry
Cystometrogram
Leak Testing
Electromyography
Micturition Study
Urethral Pressure
Profile
Videocystourethrography
Cystoscopy
Urodynamics
Male or Female?
Laboratory Testing
Urinalysis and Culture
Bacterial mucosal irritation
Unsuppresible detrusor activity
Endotoxin inhibition of alpha-adrenergic
receptors in urethra
Treatment Options
Treating Reversible Conditions
Behavioral Therapy
Medications
Devices
Surgical
Reversible Conditions
UTI
Atrophic urethritis/vaginitis
Stool Impaction
Dietary
Medications
Inadequate/Excess fluid intake
How many mL/day?
Reversible Conditions
Delirium
Psychological
Restricted Mobility
Treatment: Detrusor Overactivity
Dietary
Toileting Habits
Scheduled Toileting +/- BSC
Urge Strategies
Pelvic Muscle Exercises
Biofeedback
Electrical Stimulation
Treatment: Detrusor Overactivity
Bladder has muscarinic receptors (M3)
Medications
Ditropan
Detrol
Sanctura
Vesicare
Enablex
Imipramine
Side Effects
Dry mouth
Dry eyes
Constipation
Cognitive dysfunction
Surgical Treatment: Detrusor Overactivity
Refractory cases
InterStim Device
Percutaneous Tibial Nerve Stim (PTNS)
Augmentation Cystoplasty
Many associated complications
Last resort procedure
Treatment: Stress Incontinence
Burch Retropubic Urethropexy
Pubovaginal Sling
Mesh or Fascial
Urethral Bulking
Transurethral injection
Non-Surgical Treatment:
Stress Incontinence
PESSARY
Low morbidity
Requires regular care
Managed by patient
Fem-Soft
When to Refer?
Failed trial of conservative therapy
Pronounced anatomic defect
Persistent infection
Desire or need for surgery
Associated problems
Bottom Line Concepts
Insert other bottom line concepts here.
Investigation of the incontinent patient
History
Physical Exam
Urinalysis and Culture
+/- Urodynamic Testing
Despite high prevalence and cost, less than 50% of people
with urinary incontinence seek help!
So ASK your patients about it!
Definition: Prolapse
ANTERIOR
Anterior Wall Defect AKA Cystocele
POSTERIOR
Posterior Wall Defect AKA Rectocele
Small Bowel Herniation AKA Enterocele
LATERAL WALLS
Paravaginal Defect
APICAL
Uterine Prolapse
Vaginal Vault Prolapse
Etiology
Childbirth
Increased Intra-abd
Pressure
Lifting
Coughing
Obesity
Constipation/Straining
Neurologic Injury
Genetic Predisposition
Connective Tissue
Abnormalities
Estrogen Deficiency
Normal Pelvic Anatomy
What is
Prolapse?
- loss of support
of vaginal walls
Vesicovaginal
septum
Rectovaginal
septum
Symptoms of Prolapse
Pressure
Bulging
Vaginal irritation/Ulcers
PAIN IS NOT A PRESENTING SYMPTOM
Compartment-Specific Prolapse Symptoms
ANTERIOR
Stress urinary incontinence
Incomplete bladder emptying
Possible increased frequency of UTIs
POSTERIOR
Incomplete stool evacuation
Splinting to assist defecation
Consequence of Prolapse
Prolapse Diagnosis: Pop Q
Prolapse Therapy
Conservative Therapy
Pelvic Floor Muscle Exercises
Pessary
Surgical Therapy
Based on location of prolapse
Anterior, Posterior, Apical, Uterine
Pelvic Organ Prolapse Repair
Anterior
Compartment
Weakness of
vesicovaginal septum
Pelvic Organ Prolapse Repair
Anterior
Colporrhaphy
Reinforcement and
repair of vesico-vaginal
supportive tissue
Non-permanent
plication sutures
Pelvic Organ Prolapse Repair
Posterior
Compartment
Weakness of
rectovaginal septum
Denonvillier’s “fascia”
Pelvic Organ Prolapse Repair
Posterior
Colporrhaphy
Reinforcement
and repair of
rectovaginal
septum
Non-permanent
plication
sutures
Pelvic Organ Prolapse Repair
Lateral
Compartments
Detachment of lateral
walls of vagina from
Arcus Tendinius Fascia
Pelvis
“White line”
Pelvic Organ Prolapse Repair
Lateral Compartments
Reattachment of vaginal supportive tissue to white
line
Pelvic Organ Prolapse Repair
Apical
Compartment
Uterosacral ligaments
to …
Uterus/cervix
Vaginal cuff
Cervical Os
Pelvic Organ Prolapse Repair
Apical
Compartment
Attachment of
uterosacral
ligaments to
vaginal cuff
Pelvic Organ Prolapse Repair
Apical
Compartment
Attachment of
vaginal cuff to
anterior longitudinal
sacral ligament
using a graft
Sacrum
Vagina
Robotic Sacrocolpopexy
Apical Compartment
Robotically-Assisted
Laparoscopy
da Vinci® surgical system
Approved in 2005
Hysterectomy
Myomectomy
Sacrocolpopexy
Questions?
Bottom Line Concepts
Many types of Urinary Incontinence
Stress
Urge
Mixed
Overflow
Other
Functional
Unconscious or Reflex
Fistula
Treatments include
Diet
Medication
Biofeedback
Pessary
Surgery
Bottom Line Concepts
Prolapse is associated with pressure, but not pain
Site-specific exam
Assess each compartment – anterior, posterior, apical, uterine
Use Q-tip and speculum to identify specific prolapse
Site-specific approach to repair
Anterior, posterior, apical, uterine
Treatment focused on symptom improvement, not anatomical
correction
References and Resources
APGO Medical Student Educational Objectives, 9th edition, (2009),
Educational Topic 37 (p78-79).
Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 28 (p259-268).
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
Calvin J Hobel. Chapter 23 (p276-289).