anterior repair is the repair of?
The anterior wall of the front of the vagina - sutures under the urethra stabilising it whilst coughing
Stress incontinence?
leakage with coughing due to weakness of the urethra and supports.
Urge incontinence?
leakage with urgency due to spasms of the detrusor muscle
What is urodynamics ?
measures the pressure inside bladder wall during filling
What is unstable bladder?
rhythmic contractions of the bladder muscle during filling.
if a patient leaks with cough or sneeze, I do an anterior repair, if the patient leaks with urgency, I send her to a urologist.
recommendation
what are pessaries used for?
manage prolapses
what surgical procedure is used for prolapse
anterior repair with or without hysterectomy
where is the sacrospinous ligament
ligament attached to ischial spine and lateral side of sacrum, coccyx
main function of the Pendundal artery and nerve
main nerve of perineum, sensation of external genitalia and skin around anus and perineum.
what are current prolapses managed with
vaginal mesh to strenghten the repair
what are the 3 types of urinary incontinence
- stress incontinence
-urge incontinence
-voiding dysfunction or incomplete emptying
classic features of stress incontinence
patient leaks when coughing, sneezing, laughing, running, lifting objects
what is the structure of the bladder?
urethra is surrounded by an anatomical sphincter which connects to the pelvic floor. proximal urethra between the bladder and the urethra does not have muscle surrounding it.
what effects does prazocin have on the bladder?
relaxes the muscles at the outlet of the bladder - smooth muscles
what are the classic features of urge incontinence
rushes to the toilet with an urge/desire to urinate, but once there urine has already begun and sometimes before patient has sat down. patient unable to control these symptoms
what is also associated with urge incontinence?
triad of urgency, frequency and nocturia
definition of urgency?
the desire to go to the toilet for fear of leakage.
how to define frequency
voiding more than 8 times per day. (average person voids 4-6 times)
what is Nocturia
being woken by your bladder needing to void, somewhat age dependent
kidneys and nocturia
greater perfusion of kidneys - more urine is made at night
three types of urge incontinence
idiopathic, obstructive, neuropathic detrusor overactivity
6 theories of Idiopathic detrusor overactivity
1. Myogenic = damage to the detrusor muscle
2. Neurogenic = damage to the nerve supply to the detrusor muscle is abnormal
3. Urothelium = (neural receptors) cells lining the bladder become abnormal, sense of urgency is increased.
4. Inflammation = chronic low grade inflammation and abnormal microbiome
5. Artherosclerosis = hardening of the arteries that supply the bladder muscle and nerves.
6. History of bedwetting, daywetting, congential subgroups
Obstructive detrusor overactivity
occurs mainly in men with an enlarged prostate = urethral stenosis
which theory applies to obstructive overactivity
Myogenic and neurogenic
Neuropathic detrusor overactivity main categories
stroke, brain tumours
Parkinson's disease
Spinal cord injuries and MS
Cauda Equina syndrome (rare)
Where are the messages arising from the higher brain relayed to?
Pontine Micturition centre (PONS)
Parkinsons disease - lack of relaxation causes the urethral sphincter to remain tight and the outcome of this causes
incomplete emptying
spinal cord injuries and MS cause an abnormality in the urethral relaxation causing
voiding dysfunction and urge leaking
Cauda equina syndrome causes the detrusor muscle to not contract, the person ends up with
dribbling and worsening retention due to reduces sensation in feeling full in their bladder.
can Neuropathic detrusor overactivity be cured?
No, but it can be managed.
if non-responding patients, obstructive and neuropathic detrusor overactivity occurs, who should the patient be referred to?
Urologist.
afferent
messages sent towards the CNS
efferent
messages sent away from the CNS
bladder is half full at 250mls - what occurs during this time
afferent messages are sent to CNS of the frontal lobe of cerebral cortex (desire to void)
if an inappropriate time, the frontal lobe sends an automatic message to ward part of the body
sacral parasympathetic nerves at S2-S4
The urothelium sends a strong message for the desire to urinate at what mls
450-500mls
what are the definitive underlying problems of idiopathic urge incontinence
1 -afferent nerves are overly abundant, messages sent to cerebral cortex of frontal lobe with a bladder "full" at 100-150mls.
2- cerebral deferment of micturition is poor, with the inability of their bladder saying "no" to their own bladders.
3- detrusor muscle contractions are overactive, contracting vigorously at a low threshold of bladder filling (250-350ml) - no guarding reflex of the urethral sphincter causing urine to spill.
Typical voiding dysfunction/emptying difficulty causes the patient to?
Strain to commence voiding (hesitancy)
what is post micturition dribble incontinence?
the need to re-void soon after voiding, sometimes the patient will leak when getting off the toilet, sensation of not completely emptying the bladder or urine dribbling.
in males micturition dribbling incontinence occurs when males have ? causing ?
an enlarged prostate causing a urethral obstruction, making it hard to void.
what are the two most common reasons for voiding dysfunction in women?
vaginal prolapse kinking the urethra or previous incontinence surgery which partially obstructs the urethra.
what is silent urinary retention
when a woman has a swollen urethra from second stage labour due to prolonged pushing from the baby's head pushing on the periurethral tissues.
what is a bladder chart
a 3 day chart used to record the capacity of the bladder and fluid intake
what does a bladder chart help to distuinguish?
urge incontinence from stress incontinence
how to explain to a patient how to "Double voiding"
void as normal - sit in normal seated position, once 'finished' stand up up, rotate pelvis to stimulate afferent nerves, sit back down and lean forward with elbows on knees, relax pelvic muscles and remain for 2-3 mins to await further flow.
treatment of primary nocturia advise
drink in morning, ?promote use of lasix, feet up after lunch to promote kidney flow, thirsty in evening, drink small cups of fluid.
Chronic constipation can form issues of
stress incontinence and prolapse due to straining which weakens the pelvic muscles. Also promotes formation of rectocele (prolapse of rectum into vagina)
How to treat vaginal atrophy? (vaginal thinning, dryness and inflammation)
Topical vaginal Oestrogen applicable to both stress and urge incontinence.