1. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Incontinence Ch 24 2009-2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study

2. 2009-2010USUHS MSIII Ob/Gyn Clerkship 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.

3. 2009-2010USUHS MSIII Ob/Gyn Clerkship 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.

4. 2009-2010USUHS MSIII Ob/Gyn Clerkship 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

5. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Q-Tip test Increased mobility of urethra with incontinence

6. 2009-2010USUHS MSIII Ob/Gyn Clerkship 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.

7. 2009-2010USUHS MSIII Ob/Gyn Clerkship 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)?

8. 2009-2010USUHS MSIII Ob/Gyn Clerkship 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)

9. 2009-2010USUHS MSIII Ob/Gyn Clerkship 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

10. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies www.irishhealth.com

11. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Physical Exam Findings: Cystocele www.healthlibrary.epnet.com

12. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Phyical Exam Findings: Rectocele www.healthlibrary.epnet.com

13. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Physical Exam Findings: Vaginal Vault Prolapse www.centracare.com

14. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Physical Exam Findings: Uterine Prolapse www.centracare.com

15. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies TreatmentsBehavioralMedicalSurgical 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-catheterizationNoneRemove obstruction Prolapse Kegel Exercises Pessary None **Usually hysterectomy in combo with surgery Anterior or posterior colporrhaphy Colpocleisis Colpopexy