1. IncontinenceCh 24 2009-2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

2. Case Study 65 yo G4P4 presents to the Gyn clinic with c/o “losing urine”. It occurs most frequently when she coughs, sneezes, or laughs. She also thinks that things “are falling out of her vagina” after she stands for a prolonged period of time. She first noticed the problem 4 years ago, slowly worsening since then. No Meds. No PSHx. SVD x4, largest baby 9 lbs 4 oz. USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

3. Questions to consider 1. What if the patient were 23 years old? • Need to consider connective tissue disorders if no other risk factors (I.e. multiple deliveries, etc). 2. What if this were a 34 yo who is 12 weeks postpartum? • Symptoms often improve after delivery; in general you want to wait 6-12 months before invasive treatment. 3. Do future child-bearing plans make a difference in your counseling? • Future child-bearing can worsen sx’s, can cause treatment failures; in general conservative therapy until completed child bearing. USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

4. 4. What are the risk factors for prolapse? • Age; multiparity; Forceps/Vacuum; Caucasian; chronic cough, ascites, heavy lifting, straining (increased intra-abdominal pressure) 5. Discuss laboratory tests and physical exam evaluation in this patient. • Labs: Urinary analysis • Exam: BME, Q-tip test, Stress Test, Complex cystometrics, Ultrasound USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

5. Q-Tip testIncreased mobility of urethra with incontinence USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

6. APGO Educational Topic 37 • A. Incorporate screening questions for urinary incontinence when eliciting a patient history. • B. Discuss the difference between stress, urge, and overflow incontinence. • C. Identify the following on physical exam: Cystocele, rectocele, vaginal vault/uterine prolapse. • D. List behavorial, medical, and surgical methods to appropriately treat incontinence and pelvic organ prolapse. USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

7. Screening Questions for Incontinence • Do you leak urine when you cough or sneeze? • Do feel like you don’t empty your bladder? • Do you feel like you are going to the bathroom all the time? How many times a day? How many times during the night? (Frequency / Nocturia) • Do you need to wear a pad or carry a change of clothes? • Do you experience urgency (if you don’t get to the bathroom right away, you will leak)? USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

8. Screening Questions for Rectocele • Do you have difficulty having bowel movements? • Do you need to splint? (Place a finger in the vagina to help have a bowel movement) USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

9. Types of Urinary Incontinence • Stress • Leaking with increases in intra-abdominal pressure • NOT associated with bladder contraction • Urge • IS associated with bladder contraction • Involuntary and uninhibited detruser spasm • Overflow • Urinary retention and subsequent overflow due to low bladder tone (neurologic injury, Diabetes) • Urinary retention and overflow due to outlet obstruction USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

10. www.irishhealth.com USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

11. Physical Exam Findings: Cystocele www.healthlibrary.epnet.com USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

12. Phyical Exam Findings: Rectocele www.healthlibrary.epnet.com USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

13. Physical Exam Findings: Vaginal Vault Prolapse www.centracare.com USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

14. Physical Exam Findings: Uterine Prolapse www.centracare.com USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

15. USUHS MSIII Ob/Gyn Clerkship Self Directed Studies