74
Urinary Incontinence and Pelvic
Prolapse
Epidemiology and Pathophysiology
Gary E. Lemack; Jennifer Tash Anger
Questions
1.An example of a sign of lower urinary tract (LUT) dysfunction is:
a.incontinence while playing tennis.
b.urodynamic stress incontinence with Valsalva leak point pressure (VLPP) of 60 cm H2O.
c.a symptom score of 19 on AUA Symptom Index.
d.the finding of urinary incontinence on supine stress test.
e.the presence of stage 2 anterior pelvic organ prolapse on cystogram.
2.Which of the following is most consistent with the diagnosis of mixed urinary incontinence?
a.Leakage of urine with coughing and a VLPP of 60 cm H2O
b.Leakage of urine with urgency and detrusor overactivity incontinence
c.Leakage of urine while coughing and detrusor leak point pressure of
50 cm H2O
d.Leakage of urine while coughing and leakage of urine with urgency
e.Leakage of urine and feces while straining
3.The most common form of urinary incontinence (UI) in a woman aged 40 years is:
a.stress incontinence.
b.urgency incontinence.
c.mixed incontinence.
d.detrusor overactivity incontinence.
e.continuous incontinence.
4.A 73-year-old white woman is G2P2 with two prior cesarean deliveries. She is taking glucophage. She has a 20-pack-year smoking history. The aspect of her history that does NOT predispose her to the development of stress urinary incontinence (SUI) is:
a.her age.
b.her race.
c.mode of delivery.
d.history of depression.
e.smoking history.
5.Remission of incontinence would most likely to be noted in a:
a.42-year-old woman.
b.41-year-old man.
c.65-year-old woman.
d.73-year-old man.
e.74-year-old woman.
6.The symptom most closely associated with the presence of advanced pelvic organ prolapse is the sensation of:
a.pelvic pressure.
b.pelvic pain.
c.constipation.
d.voiding difficulty.
e.vaginal bulge.
7.Which of the following Pelvic Organ Prolapse Quantification System (POP-
Q)scores is implausible?
a.Aa of − 2
b.Ap of + 4
c.Ba of + 5
d.Bp of 0
e.C of − 7
8.A woman with POP-Q scores of Aa − 1, Ba − 1, C − 5, Ap + 1, Bp + 2 would be considered to have what stage prolapse?
a.Stage 0
b.Stage 1
c.Stage 2
d.Stage 3
e.Stage 4
9.A patient with a POP-Q score of Aa + 2, Ba + 2, Ap − 2, Bp − 2, and C 0 should be counseled to undergo:
a.anterior colporrhaphy.
b.posterior colporrhaphy.
c.anterior and posterior colporrhaphy.
d.anterior colporrhaphy and sacrospinous fixation.
e.sacrospinous fixation.
.During bladder storage, which is (are) most quiescent?
a.pelvic nerve
b.hypogastric nerve
c.pudendal nerve
d.A delta nerves
e.Onuf nucleus
Answers
1.d. The finding of urinary incontinence on supine stress test. A sign of LUT dysfunction is one that is observable by the clinician. A report of incontinence while playing tennis is a urinary symptom. A VLPP result is a urodynamic observation, whereas a cystogram report of a cystocele is a radiologic observation.
2.d. Leakage of urine while coughing and leakage of urine with urgency.
Mixed incontinence is the symptomatic complaint of both stress urinary incontinence and urgency incontinence.
A VLPP of 60 cm H2O is an observation of urodynamic stress incontinence.
Detrusor overactivity incontinence is a urodynamic observation. Detrusor leak point pressure is a urodynamic observation that typically indicates altered compliance.
3.a. Stress incontinence. Stress urinary incontinence (SUI) is the most common form of UI in young women. In contrast, urge UI and mixed UI appear to become more prevalent forms of UI with aging. Continuous incontinence is uncommon—often associated with iatrogenic injuries to the lower urinary tract resulting in fistulae.
4.c. Mode of delivery. Of the risk factors noted in her history, only the mode of delivery has not been associated with an increased risk of SUI later in life.
Age is strongly correlated with the development of UI of all types. White women appear to be at greater risk for UI compared with African-
American and Asian women in particular. Depression, regardless of concurrent treatment, appears to be associated with a greater likelihood of UI. A history of smoking has been linked to the development of UI, particularly in women selecting surgical treatment.
5.b. 41-year-old man. Remission rates as high as 40% have been noted in men, whereas remission rates are considerably lower in women (less than 5%). This speaks to the transient causes of UI that are more prevalent in men, particularly younger men.
6.e. Vaginal bulge. Although all of the symptoms described can be associated with POP, only the specific complaint of a vaginal bulge has been consistently demonstrated to be associated with the presence of POP. All others can be associated with other conditions distinct from the presence of POP. For example, pelvic pressure can be related to pelvic floor dysfunction or a variety of other conditions, and pelvic pain can be associated with various forms of pelvic pathology including adnexal pathology.
7.b. Ap of + 4. POP-Q points are measured by their distance from the hymenal ring (in centimeters). By definition, Aa and Ap are the points 3 cm from the hymen on the anterior and posterior vaginal walls, respectively. It would be impossible for this point to be greater than 3 cm proximal (or distal) to the hymen. In advanced prolapse, this point could be up to 3 cm distal to the hymen. C point represents the distance from the hymen to the cervix or vaginal cuff (post hysterectomy). Ba and Bp point represent the leading edge of the most advanced aspect of the prolapse on the anterior and posterior vaginal walls, respectively. As such, they can be well beyond + 3 in advanced prolapse.
8.d. Stage 3. Staging in POP-Q is based on the leading edge of prolapse.
This equates to the highest (positive) number associated with the points listed (Aa, Ba, Ap, Bp, C). The leading edge of the most advanced POP is greater than 1 cm proximal to the hymen in patients with stage 1 prolapse. Stage 2 patients will have their leading edge between 1 cm proximal to and distal to the hymen. Stage 3 indicates a leading edge greater than 1 cm beyond the hymen but not completely everted (stage 4).
9.d. Anterior colporrhaphy and sacrospinous fixation. This patient has both anterior compartment prolapse (based on Aa and Ba points beyond the hymen) and apical prolapse (C point at the hymen) based on the POP-Q score. Therefore, the patient should be counseled to have both anterior repair
of some type (anterior colporrhaphy in this example) and apical repair (sacrospinous fixation in this example).
.a. Pelvic nerve. During bladder storage, parasympathetic transmission (via the pelvic nerve) is suppressed and sympathetic transmission (via the hypogastric nerve) is active. Pudendal innervation to the external sphincter is active.
Pudendal innervation is derived from Onuf nucleus in the sacral cord. A delta nerves (afferent) are active during storage and are involved in the spinal reflex mechanism that promotes closure of the bladder neck.
Chapter review
1.Pelvic organ prolapse may mask incontinence.
2.The prevalence of urinary incontinence in women is between 25% and 40%. Ten percent of women experience weekly incontinence episodes. Fecal incontinence occurs in 17% of women with pelvic organ prolapse.
3.The female bladder neck is weaker than the male bladder neck and is often incompetent.
4.In women the majority of the urethra should be considered an active area of sphincter control; however, in the female the most important portion of continence is the mid-urethra.
5.A Valsalva leak point pressure of less than 60 cm H2O indicates but does
not confirm intrinsic sphincter dysfunction.
6.Twelve percent of men report terminal dribbling.
7.Rates of overactive bladder increase with age.
8.Oral estrogen treatment is associated with the development of incontinence. Topical estrogen therapy is not linked to stress incontinence.
9.Intrinsic properties of the urethra mucosa and urethra wall are important in maintaining continence in women.
10.The anterior vaginal wall provides posterior support of the urethra allowing for compression of the mid-urethra. The urethra is attached laterally to the arcus tendineus by the urethra pelvic ligaments.
11.Urge UI and mixed UI appear to become more prevalent forms of UI with aging.
12.Age is strongly correlated with the development of UI of all types. White women appear to be at greater risk for UI when compared with AfricanAmerican and Asian women in particular.
13.POP-Q points are measured by their distance from the hymenal ring (in
centimeters). By definition, Aa and Ap are the points 3 cm from the hymen on the anterior and posterior vaginal walls, respectively. Ba and Bp point represent the leading edge of the most advanced aspect of the prolapse on the anterior and posterior vaginal walls, respectively. Thus they can be well beyond + 3 in advanced prolapse. C point represents the distance from the hymen to the cervix or vaginal cuff (post hysterectomy).
14.The leading edge of the most advanced POP is greater than 1 cm proximal to the hymen in patients with stage 1 prolapse. Stage 2 patients will have their leading edge between 1 cm proximal to and distal to the hymen. Stage 3 indicates a leading edge greater than 1 cm beyond the hymen but not completely everted.