Prolapse and Urogynae Incontinence. Lucy Tiffin and Hannah Wheldon-Holmes

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1 Prolapse and Urogynae Incontinence Lucy Tiffin and Hannah Wheldon-Holmes

2 66 year old woman with incontinence PC: 7 year Hx of urgency, frequency, nocturia (incl. incontinence at night), and stress incontinence PMH: 4 children (normal vaginal delivery), total hysterectomy & oophorectomy aged 38, left knee replacement (awaiting right knee), osteoarthritis, untreated constipation DH: NKDA; mirabegron, co-codamol FH: prolapse (mother), liver cancer (father), leukaemia (brother) SH: lives with son, smoked 3/day from 16-40, no alcohol, not sexually active, retired NHS domestic supervisor

3 CASE HISTORY - Examination Inspection: normal Tone: reduced Speculum: Anterior wall prolapse (cystocele)

4 Why are we continent? 1 2 3

5 Stress incontinence: involuntary leakage of urine caused by coughing, sneezing etc. due to loss of sphincter tone Urge incontinence: a feeling of urgency to urinate either before or with an involuntary leakage of urine due to detrusor muscle instability

6 Mixed incontinence: a combination! Overflow incontinence: involuntary leakage of urine when the bladder gets too full, generally due to chronic bladder outflow obstruction

7 Epidemiology of incontinence Approximately 3.5 million women have urinary incontinence in the UK 46% of women >80 years old 50% of adults in institutions Many do not seek help with their incontinence and will not admit they have a problem

8 Risk factors for incontinence Pregnancy (particularly vaginal delivery) Diabetes mellitus Oral oestrogen therapy High BMI Hysterectomy - mainly related to stress incontinence Neurological disease Obstruction Constipation

9 Risk factors for incontinence Pregnancy (particularly vaginal delivery) Diabetes mellitus Oral oestrogen therapy High BMI Hysterectomy - mainly related to stress incontinence Neurological disease Obstruction Constipation

10 Symptoms of incontinence Stress incontinence Urge incontinence Frequency Nocturia Dribbling Feeling of incomplete voiding Loss of bladder control Dysuria Bladder spasms

11 Symptoms of incontinence Stress incontinence Urge incontinence Frequency Nocturia Dribbling Feeling of incomplete voiding Loss of bladder control Dysuria Bladder spasms

12 Investigations Examination: assessment of pelvic floor muscle contraction, look for prolapse, signs of vaginal atrophy, abdominal/pelvic/neuro exams should be performed Urinary dipstick Bladder scan Urodynamic studies

13 Management of incontinence Stress incontinence: retropubic urethropexy, urethral sling procedure, bulking injection procedures Urge incontinence: behaviour modifications, medications (anticholinergic agents - oxybutynin, duloxetine, mirabegron), botox injections Overflow incontinence: treat cause, intermittent/continuous catheterisation Treatment depends on the cause

14 Prolapse Protrusion of the uterus and/or vagina beyond normal anatomical confines. The bladder, urethra, rectum and bowel are also often involved. Oxford Handbook of Obstetrics and Gynaecology, 3rd Edition Due to weakening of the support structures - Levator ani, endopelvic fascia.

15 Epidemiology In a Women s Health Initiative Study, 41% of women age showed some degree of pelvic organ prolapse (POP). POP may occur in up to 50% of parous women. Difficult to determine incidence as many women do not seek medical help.

16 Risk factors for prolapse Pregnancy and vaginal delivery Menopause Chronic increased abdominal pressure Congenital factors Obesity Iatrogenic Family history

17 Risk factors for prolapse Pregnancy and vaginal delivery Menopause Chronic increased abdominal pressure Congenital factors Obesity Iatrogenic Family history

18 Symptoms Asymptomatic Sensation of vaginal bulging Pelvic pressure, heaviness Urinary frequency/incontinence Incomplete bladder emptying Defecatory dysfunction Dyspareunia

19 Symptoms Asymptomatic Sensation of vaginal bulging Pelvic pressure, heaviness Urinary frequency/incontinence Incomplete bladder emptying Defecatory dysfunction Dyspareunia

20 Types of Prolapse Hacker & Moore s Essentials of Obstetrics and Gynaecology 6th Ed.

21 Grading of prolapse POP-Q (Pelvic organ prolapse quantification) Scoring system Measures distance of prolapse in cm above or below the hymen. Stage 0 = no prolapse Stage 4 = Complete vaginal eversion.

22 Complete uterine prolapse (procidentia) Hacker & Moore s Essentials of Obstetrics and Gynaecology 6th Ed.

23 Examination Bimanual examination to exclude pelvic masses. Vaginal examination - Sims speculum used to check each wall in turn for descent. Prolapse may only be visible with woman standing/straining.

24 Management Conservative: Watchful waiting Identify and treat causes of elevated intra-abdominal pressure Pelvic floor exercises Pessaries Hacker & Moore s Essentials of Obstetrics and Gynaecology 6th Ed.

25 Management Surgical: Vaginal/abdominal Surgical complications - vaginal bleeding, dyspareunia, urine retention, pelvic pain.

26 Prevention - it s better than cure! Pelvic floor exercises - Start now! Girls should start before first pregnancy Incorporate as part of daily routine Not just for women!

27 References BMJ 2014; 349:g7378 Oxford Clinical Handbook of Gynaecology 3rd edition Hacker and Moore s Essentials of Obstetrics and Gynaecology (Hacker) 6th ed. Essentials of Kumar and Clark s Clinical Medicine (Ballinger) 5th ed.