Urinary Incontinence and Pelvic Relaxation

Pelvic Relaxation: Types

Anterior compartment: • Urethrocele- urethra • Cystocele- bladder Posterior compartment: • Rectocele- rectum Apical compartment: • Enterocele-small bowel • Uterine prolapse • Procidentia- cervix beyond the vulva • Vaginal vault- after hysterectomy

Pelvic Relaxation: Treatment Asymptomatic and non-surgical

Asymptomatic or mild symptoms: observe at regular intervals Nonsurgical options: always discuss • Pessaries- removable devices made of rubber, plastic, or silicone •Various shapes and sizes, supportive or space occupying • pelvic floor exercises • symptom directed options

Neurogenic bladder:

Name given to numerous urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem. •May be urge incontinence, overflow incontinence, or a combination • Spinal injuries, spina bifida, multiple sclerosis (40-90%, 50-90% with DI), Parkinson's (37-72%), diabetes, stroke (15%) •Mean age 62.5 years • Treat with I/O catheterization, anticholinergics if DI present

What structures prevent uterine prolapse

Suspenders = Round Ligaments (keeps uterus anteverted) Belt = Uterosacral Ligaments (provides apical support)

Baden-Walker System

Uterine Prolapse Grades from 0 - 4 0 = Normal 1 = Halfway to hymen 2 = At the hymen 3 = Halfway pass hymen 4 = Max descent - need pessary

Prolapse: Procendentia

complete eversion of the vagina

Rectocele

hernia of the rectum into the vagina

Cystocele

hernia of the urinary bladder into the vagina

Pelvic support defects-

loss of connective tissue support of the reproductive tract organs (include uterus, paravaginal tissue, bladder wall, urethra, urethrovesical angle, distal rectum)

Pelvic organ prolapse-

organs have lost their support and descend through the urogenital hiatus

Enterocele

pouching sac of peritoneum between the vagina and the rectum

Uterine Prolapse

the condition in which the uterus slides from its normal position in the pelvic cavity and sags into the vagina

Urinary Incontinence: Evaluation History

• Associated symptoms (malodor, hematuria, dysuria, nocturia, pelvic pain) • Amount of loss • Duration of loss • Associated event • Position • Fluid intake (timing, type) • Medications Physical Exam Direct observation of urine loss

Urinary Incontinence

• Definition- loss of urine involuntarily • Prevalence gradually increases during young adulthood, broad peak in middle age, and then steadily increases in older adults •May affect social, clinical and psychological well-being •Many women never seek care

Pelvic Relaxation: Treatment Surgical options

• Hysterectomy and uterine suspension • Sacral colpopexy- attachment of the vaginal cuff to the sacral promontory • Fixation of cuff to uterosacral or sacrospinous ligament • Colpocleisis- obliteration of the vaginal lumen (women at high risk for surgical complications and do not desire vaginal intercourse)

Overflow Incontinence:

• Inability of detrusor muscle to contract • Bladder does not empty completely • Continuous leakage of small amounts of urine • Due to obstruction or neurologic deficit

Stress Incontinence:

• Increased abdominal pressure is usually transmitted along the entire urethra • SUI- abdominal pressure is transmitted to the bladder not the urethra • Bladder neck is not stable • Urinary loss is during activities with increased intra-abdominal pressure like coughing, sneezing, or laughing

Urinary Incontinence: Treatment Nonsurgical Options:

• Lifestyle interventions ( weight loss, caffeine/alcohol reduction, fluid management, reduction of physical exertion, smoking cessation, relief of constipation) • Kegel exercises - pelvic muscle training • Especially useful for stress incontinence • Strengthen pelvic floor and decrease urethral (UVJ) hypermobility • Pessaries/continence tampons • Behavioral training (increase time between voids) - works best for urge incontinence • Pharmacologic agents

Pelvic Relaxation: Causes

• Loss of support by levator muscles, fascia and ligaments • Birth trauma • Elevated intra-abdominal pressure • Intrinsic weakness • Atrophic changes (aging or estrogen loss) • Result of attenuation, stretching or even breaks or tears of site specific connective tissue

Urinary incontinence diagnosis

• Post-void Residual Volume (PVR) < 50-100 mL • Urinalysis • Urine Culture • Voiding Diary • Urodynamic testing- measures pressure and volume of the bladder as it fills and the flow rate as it empties • Cystourethroscopy- lighted scope placed inside the bladder to identify lesions and/or foreign bodies

Urinary Incontinence: Treatment Surgical Options:

• Retropubic colposuspension (Burch) • Sling procedures • Bulking agents (collagen)- injected transurethral or periurethral • TVT and Burch have 85% success at 5 years • Cure rate of Burch may decrease over 10-12 years • 10% may require at least one additional surgery to cure SUI

Pelvic Relaxation: Evaluation • History:

• Symptoms - urinary or fecal loss or retention, vaginal pressure or heaviness, abdominal pain, low back pain, vaginal or perineal pain, mass sensation, difficulty walking, difficulty with sexual relations, anxiety or fear related to condition • Physical Examination: thorough to exclude other problems and form differential diagnosis, POP-Q, Baden-Walker • Q-tip test for urethral hypermobility (cystocele or urethrocele)

Mixed incontinence:

• Symptoms of both urge and stress incontinence • Diagnostic challenge •May be treated as either depending on dominant symptom

Urge Incontinence: (Detrusor Overactivity)

• Uninhibited detrusor contractions • Bladder pressure overrides urethral pressure • Leak urine without evidence of increased intra-abdominal pressure • Patient feels the need to run to the bathroom frequently and urgently • Spontaneously, after stress incontinence surgery or extensive bladder dissection during pelvic surgery

Pelvic Relaxation Risk and signs

•More common in women of advancing age • Tissues become less resilient • Risk factors: genetics, parity, menopause, advancing age, prior pelvic surgery, connective tissue disorders, chronic smoking, factors associated with elevated intra-abdominal pressure (obesity, chronic constipation/cough, excessive straining) • Signs: cervical hypertrophy, excoriation, ulceration, bleeding •Most with defect on exam are asymptomatic and exam findings do not correlate with specific symptoms

Urinary Incontinence: Treatment Pharmacologic agents:

•Musculotropic (muscle relaxant and anticholinergic): oxybutinin (Ditropan), tolterodine (Detrol) • Antimuscarinic (avoids suppression of salivary glands): solifenacin (Vesicare), mirabegron (Myrbetriq) • Tricyclic antidepressants (anticholinergic properties and stimulates alpha 1 adrenoreceptors on urethral sphincter): Imipramine (25-75 mg QHS), Amitriptyline, Nortriptyline