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Urinary Incontinence
This is a very important gynaecological condition which has a huge impact of patients’ lives.
– There are two main types of incontinence in females, each of which have different pathologies and treatments.
– It affects about 4-5% of the population, being more common in elderly females
i) Urge Incontinence
This is the involuntary leakage preceded/accompanied by a sudden desire to pass urine
– It occurs due to an overactive bladder due to increase detrusor muscle overactivity
Causes:
Mostly idiopathic but can be associated with neurological conditions (e.g. MS, PD)
– Can be made worse by diuretics, coffee, alcohol, concurrent UTIs
ii) Stress Incontinence:
This is the involuntary leakage upon increased intra-abdominal pressure (e.g. coughing, sneezing)
– It occurs due to weakening of the pelvic floor muscles, so they do not compress the bladder neck
Causes:
Pregnancy, vaginal delivery, obesity (these all weaken the pelvic floor muscles)
Tests:
These are needed to distinguish between the two main types of incontinence
– Abdominal examination –> to look for palpable, enlarged bladder suggesting retention
– Vaginal examination –> to assess pelvic muscle tone and look for prolapse (a sign of pelvic floor weakness)
– Urine dipstick –> to check for UTI
– Bladder diaries –> Ask to patient to complete a bladder diary for a minimum of 3 days
– It allows you to see if there are any triggers and how much fluids patients drink
If it is still unclear, then urodynamic studies are indicated.
Urodynamic studies
Management (NICE1):
– Common to both types, reduce caffeine, regulating fluid intake, weight loss (if BMI 30+) and stop smoking
For Urge Incontinence:
1st line = Bladder retraining (at least 6 weeks)
2nd line = Antimuscarinics: Oxybutynin, Tolterodine, or Darifenacin
3rd line = Mirabegron (B3 agonist) if antimuscarinics are contraindicated
Secondary care treatments:
• Botox —> Dangerous side effect is urine retention, so patients must be willing to self-catheterize
• Sacral nerve stimulation —> used for women who refuse to have catheters with Botox
For Stress Incontinence:
1st line is Pelvic floor muscle exercises (3-month trial of 8 contractions, 3 times a day)
2nd line = Surgery -> options include:
• Autologous rectal fascial sling: abdominal wall fascia is used to form a sling around the urethra
• Retropubic mid-urethral mesh sling: procedure in which mesh is used as a urethral sling
• Intramural bulking agents: silicone injection which adds bulk to urethral sphincter (wears off)
• Colposuspension: procedure in which the bladder neck is tethered to the surrounding tissues
3rd line = if the patient does not want surgery, offer duloxetine
Urogenital Prolapse
This refers to a descent of one of the pelvic organs resulting in protrusion on the vaginal walls
– It is most often due to childbirth
– It is defined by the organ which protrudes on/out of the vagina.
– Bladder = Cystocele
– Uterus = Uterine prolapse
– Rectum = Rectocele
– Procidentia = Whole uterus + Cervix
Risk factors:
Weakening of the pelvic floor -> older age, pregnancy and vaginal delivery, obesity
Symptoms:
– Dragging discomfort/sensation of heaviness in the vagina
– Feeling that something is coming out of the vagina –> patient may be able to feel a protruding bulge
– Urinary symptoms –> increased frequency, incomplete emptying, stress incontinence
Staging:
It is staged according to the distance the organs reach from the hymenal ring
– Stage 1 = when you can displace the uterus but not up to 1cm of the vaginal opening
– Stage 2 = when the prolapse reaches the hymenal ring
– Stage 3 = when the prolapse reaches 1cm out of the hymenal ring
– Stage 4 = When the whole organ prolapses out of the vagina
Tests:
– Speculum examination –> Ask the patient to adopt the left lateral position and insert a Simms speculum
– After insertion, ask the patient to cough raising abdominal pressure
– Bimanual examination –> Uterus is more mobile and moveable
Management:
1st line is pelvic floor exercises (8 contractions, 3 times/day for 3 months)
2nd line is pessary –> This must be changed every 6 months and gives small risk of urinary retention
– If rectal or bladder prolapse –> use ring pessary
– If uterine –> use shelf pessary
3rd line is surgical repair:
– Cystocele –> Anterior repair
– Rectocele –> Posterior repair
– Uterine –> Laparoscopic hysteropexy
4th line is Hysterectomy
If stage 4 prolapse an option is sacral-spinous fixation (SSF)
–> Organs are fixed to the sacrum and spinous processes completely immobilising them
–> Risk of bleeding due to damage to pudendal venous plexus + bad buttock pain due to irritation to the pudendal nerve
Pelvic Inflammatory Disease (PID)
An inflammatory condition affecting the pelvic organs like the uterus, oviducts, ovaries and peritoneum
– It is usually caused by ascending sexually transmitted infections which arise from the endocervix
– Chronic inflammation gives scarring and fibrosis which leads to pain and menstrual problems
Causes:
Chlamydia trachomatis (most common), Neisseria Gonorrhoea, Mycoplasma genitalium
Symptoms:
– Fever
– Pelvic + lower abdominal pain
– Deep dyspareunia (different to the superficial dyspareunia experienced in menopause)
– Vaginal/cervical discharge
– Abnormal vaginal bleeding
– On bimanual examination -> adnexal tenderness, cervical excitation (pain elicited when two fingers used to move cervix), abnormal discharge
N.B. If untreated, can lead to Fitz-Hugh Curtis syndrome ➔ RUQ pain
– Other complications of PID include increased risk of infertility, chronic pain and ectopic pregnancy
Diagnosis:
Clinical diagnosis is made, and treatment started before test results
– 1st do pregnancy test to exclude ectopic pregnancy
– High vaginal swab and Chlamydia and Gonorrhoea tests
– Blood tests –> show raised WBC and high CRP/ESR
Management:
Doxycycline + metronidazole + single-dose IM ceftriaxone or Ofloxacin + metronidazole
– If severe –> start with doxycycline + IV metronidazole + IV ceftriaxone
