2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

IncontinenceCh 24

2009-2010 Academic Year

MSIII Ob/Gyn Clerkship

Self-Directed Study

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

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.

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

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.

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

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

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Q-Tip testIncreased mobility of urethra with incontinence

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

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.

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

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)?

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

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)

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

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

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

www.irishhealth.com

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Physical Exam Findings: Cystocele

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2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Phyical Exam Findings: Rectocele

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2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Physical Exam Findings: Vaginal Vault Prolapse

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2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Physical Exam Findings: Uterine Prolapse

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2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Treatments Behavioral Medical Surgical

Stress UI Kegel Exercises

Pessary

Topical Estrogen

A-Adrenergics

Slings (TVT/TOT)Abdominal retropubic urethropexy

Collagen injection

Urge UI Bladder Training (Other – nerve stimulation)

Anticholinergic

B-Agonists

Musculotropic

Tricyclic antidepressants

Dopamine Agonist

None

Overflow UI Self-catheterization None Remove obstruction

Prolapse Kegel Exercises

Pessary

None

**Usually hysterectomy in combo with surgery

Anterior or posterior colporrhaphy

Colpocleisis

Colpopexy