Tutorial – Incontinence and prolapse

1. Tutorial – Incontinence and prolapse

2. Urinary incontinence • Involuntary and objectively demonstrable loss of urine. • Social and hygienic problem. • Prevalence 20% ( 60% in geriatric institutions) • Frequency- passage of urine D/N= >7/1 • Urgency- Sudden desire to void

3. Stress incontinence • Stress incontinence- Loss of urine on physical effort i.e. with coughing/exercise. It occurs in absence of detrusor contractions. • Mechanism: - Urethral sphincter incompetence - Mechanical & denervation injury to the pelvic floor & urethral sphincter mechanism during child birth • Oestrogen deficiency- Menopause • Congenital- Nulliparous adolescent

4. Case 1 • A 53 year old patient, P3, Has a BMI 30. Attends the GP with a complaint of leaking urine every time she coughs or sneezes. She needs to wear a pad most days and this restricts her socially. She has had no operations in the past and is well otherwise. She noticed this 5 years ago and feels that the problem is getting worse. She has had normal vaginal deliveries for two of her children and the last one was delivered by forceps. She smokes 10 cigarettes a day.

5. What is the most likely diagnosis? Stress incontinence What symptoms patient presents with? - leakage of urine on coughing/sneezing/exercise - good volume - no frequency /urgency / nocturia What other features in the history are relevant? What additional features will you elicit in the history ? - Menopause, parity, smoking( chronic cough), BMI - H/O constipation ; Symptoms of prolapse

6. What examination would you perform and what features would you be looking for? Abd/pelvic examination: Abd/pelvic mass : Demonstrate cough leak : Prolapse What investigations would you perform? Justify these. - MSSU- exclude UTI - Frequency/volume chart- excess fluid intake, voided volume - Urodynamics- to confirm diagnosis What are your management options? - weight loss, stop smoking , Pelvic floor exercise - Surgical- colposuspension, TVT (tension free vaginal tape), TOT (transobturator tape) - Urethral bulking agents - SSRI (duloxetine)

7. TVT /TOT

8. Urge incontinence • Urge incontinence- involuntary loss of urine associated with a strong desire to void. It is associated with detrusor contraction. • Mechanism- Detrusor instability/unstable bladder. Neuropathic eg Multiple sclerosis Non-neuropathic

9. Case 2 • A 65 year old patient complains of urgency of micurition and increased frequency. She has the urge to pass urine almost every hour and has to wake up 3- 4 times at night to void. She also notices that she leaks urine when she cannot reach the toilet immediately. There has not been any burning or stinging on passing urine

10. What is the most likely diagnosis? Urge incontinence What symptoms patient presents with? - Sudden desire to void, leakage of urine without control, frequency - Small volumes - Nocturia What additional features will you elicit in the history ? Excessive consumption of tea/coffee/fizzy drinks/spicy food

11. What examination would you perform? What are your findings? Abd/pelvic examination- Abd/pelvic mass -uterine prolapse What investigations would you perform? Justify it. - MSSU- exclude UTI - Frequency/volume chart- excess fluid intake, voided volume What are your management options? - Fluid & dietary advice - Bladder retraining - Anticholenergic medication - Botulinum toxin - Tibial nerve stimulation - Urinary diversion procedure

12. Overflow incontinence-loss of urine when bladder is over distended and occurs in absence of detrusor contraction. Causes- UMN/LMN lesion - Urethral Obstruction - Chronic bladder distension Symptoms- poor stream - Incomplete bladder emptying - straining to void Treatment- Clean intermittent self catheterization - Indwelling urethral/suprapubic catheter Other causes of incontinence - Congenital - urinary fistula

13. Prolapse Prolapse occurs when there is damage to or weakness of the structures which support the pelvic organ, so that they descend from their normal positions and finally herniate through the vaginal introitus.

14. Cystocoele- prolapse of bladder & ant. Vaginal wall. Urethrocoele- prolapse of urethra/bladder neck. Rectocoele- prolapse of rectum and post. vaginal wall. Usually associated with perineal deficiency caused by child birth. Enterocoele- hernia of POD through the posterior vaginal fornix. It contains small intestine.

15. Case 3 • A 56 year old lady presents with a history of a ‘lump in the vagina’. This gets worse at the end of the day. She also has backache associated. She has had 5 children , all born vaginally and large babies. She stopped having periods five years ago and has never had HRT.

16. Uterine prolapse • Prolapse of uterus accompanied by inversion of vaginal vault. -I degree- Uterine decent but cervix does not reach the introtus. -II degree- Uterine decent with cervix appears at the vaginal introitus. -III degree/procidentia- vaginal vault is everted to such a degree that uterus lies outside the introtus.

17. What symptoms patient presents with? - lump in the vagina that worsen at the end of the day - dragging sensation in the vagina - Backache What features in history and additional features are relevant for diagnosis? - Menopause (Atrophy of ligaments due to lack of E2) - parity, big babies, prolonged labour (Tearing / over stretching of perineum) - chronic cough, constipation, heavy work and intra-abdominal mass (Increase intra abdominal pressure) - Urinary/ bowel sypmtoms (related to cystocoele & rectocoele)

18. What examination would you perform?What are the findings? Abd/pelvic examination (Dorsal & Sim’s position) - Abd/pelvic mass -uterine prolapse, cystocoele & rectoenterocoele What investigations would you perform? Justify these. None unless urinary symptoms( urine dipstick, Urodynamics) What are your management options? - Pelvic floor exercise - Ring / shelf pessary - Operative: • vaginal hysteretomy± Anterior colporrhaphy ± Posterior colpo- perineorrhaphy • Manchester(Fothergill) operation • Colpoclesis (Lefort’s operation)