Urogynaecology

Urinary incontinence

• Structures
  • Detrusor tone
  • Urethra
  • Urethral sphincter: Provides 50% of urethral resistance
  • Pubourethral ligaments: Suspend and hold urethra close to pubic bone
• Autonomic nervous sytem
  • Parasympathetic S2-4 cause detrusor contraction ! Sympathetic T10-L2
  • Alpha fibres stimulate bladder neck and urethral contraction + detrusor relaxation
  • Beta-fibres relax urethra and contract detrusor muscle
  • Pudendal nerves: stimulate voluntary urethral contraction
• Levator ani: Maintains intraurethral pressure during abrupt increases in intra-abdominal pressure

• History
  • Onset and course
  • Leakage frequency
  • Associated symptoms
  • Precipitants
  • Bowel and sexual function
• Examination
  • Functional/cognitive
  • Neurological, muscular, cardiovascular, abdominal and vaginal examinations

• Functional incontinence – Impaired cognition, mobility, dexterity
• Medication-related incontinence
• Urge incontinence
• Stress incontinence
• Mixed incontinence
• Overflow incontinence

Urge incontinence

• Urgency, frequency, nocturia, incontinence and ‘overactive bladder’
• Seen in women of all ages but mostly older women
• In younger women, often due to interstitial cystitis
• Involuntary detrusor contractions are seen in urodynamic studies
• Rx
  • Lifestyle modification
  • Behavioural therapy
  • Electrical stimulation
  • Biofeedback ! Medications
  • Antimuscarinics, alpha agonists, TCA, anticholinergics, antispasmodics, botulinum, hyoscine, CCB and NSAid’s ! Surgery is not a first-line therapy

Stress incontinence

• Leakage with raised IAP
• Occurs in absence of detrusor contractions
• Most common type in younger women and seen in pregnancy, multiparity, menopause, chronic cough
• Rx
  • Kegel exercise
  • Oestrogen
  • Alpha agonists
  • Continence pessaries
  • Biofeedback
  • TENS
  • Surgery has highest cure rates but increased morbidity

Mixed incontinence

Most common type in women and is thought to be due to detrusor overactivity combined with impaired urethral sphincter function

Overflow incontinence

• Constant dribbling and continuous leakage from impaired detrusor contractility or bladder outlet obstruction
• Can be seen post-spinal injury, pelvic organ prolapse or previous injury
• Post-void residual volume determines diagnosis
• Treatment involves therapy for underlying cause and intermittent selfcatheterisation

Total incontinence

• Urinary fistula post-pelvic surgery radiation or obstetric injury
• Treatment is with diverting Foley catheter, which may allow complete healing or allow surgical correction to be performed
  

Prolapse

• Due to disruption of pelvic floor and supporting ligaments/fascia ! Risk factors
• Genetic predisposition
• Operative vaginal delivery
• Parity
• Obesity
• Pelvic floor disruption
• Age
• Increased intra-abdominal pressure

• Types
  • Cystocoele – Hernia of bladder and displacement of anterior vaginal wall
  • Cystourethrocoele – Cystocoele with associated prolapse of urethra
  • Uterine
  • Vaginal vault prolapse – After hysterectomy
  • Rectocoele – Hernia of rectum with displacement of posterior vaginal wall
  • Enterocoele – Herniation of small bowel into vagina
• Symptoms
  • Heaviness or pressure in pelvis +- palpable mass
  • Symptoms tend to worsen throughout day or with raised IAP
  • Presence and severity of symptoms does not correlate with degree of prolapse

• Examination
  • Both lying and standing
  • Single blade (Sims) speculum is utilised to visualise all four walls of vagina
• Rx
  • Weight loss and exercise can help
  • Pelvic floor exercises
  • Physical therapy
  • Behaviour modification
  • Vaginal pessaries
  • Oestrogen IS NOT beneficial
  • Surgery is preferred for severe prolapse with slings, suspension, urethropexies, hysterectomy.etc.

Urethral syndrome

• Urinary frequency, dysuria, suprapubic discomfort with no objective findings on studies
• May also complain of difficulty urinating, incomplete bladder emptying and incontinence
• Diagnosis of exclusion
• Refer for cystourethroscopy and urodynamic studies
• Treatments include oestrogens, TCA, antispasmodics, alpha blockers
• Psychology referral is helpful

Last Updated on September 27, 2021 by Andrew Crofton