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PelvicGU pathology or weak sphincter toneKnack- pelvic muscle contraction timed to intra-urethral pressure before/during event causing leakageDiagnostics- Voiding diary 2-3 days’ (when incontinence occurs), UA, PSA, post-voidCystourethrogram or uroflowmeter (obstruction?), cough stress testLeak point pressure test- catheter in bladder, measure intra-abdominal pressurePrevention- Kegel, treatment of prostatic hyperplasiaNon Rx- treat underlying, voiding diary 3 days, perineal hygiene, regular emptying, KegelIntermittent cath for retention, incontinence pads (cones), Caffeine/EtohBiofeedback, Surgery (TURP, bladder sling), treat constipation, nerve stimulationBladder training- URGE UI- Urgency and FrequencyTampons- do not absorb, but provide gentle pressure to support urethraRefer- refractory incontinence to Rx or lifestyle, gross/microscopic hematuria (malignancy)Botox injections in detrusor muscle if 1stline failsCystocele (Pelvic Organ Prolapse)Herniation of pelvic organs to or beyond vaginal wallsEnterocele- hernia of intestines to or through the vaginal wallRectocele- descent of the rectumCystocele- anterior compartment prolapsePathogenesis- Levator ani muscle provides primary support to pelvic organsEndopelvic fascial attachments (uterosacral and cardinal ligaments)- stabilize pelvisS2, S3, S4 segments innervate pelvic regionRisk- advancing age, parity (w/ vaginal births), obesity, hysterectomy, chronic constipationAA have lower prevalenceAssessmentAsymptomatic, bulge or pressure in vagina or pelvis (“something falling out”)
Urinary- stress incontinence/difficulty voiding/retentionDefecation- constipation and incomplete emptying (most common symptoms)Fecal urgency/incontinence, obstructive (straining); fecal during sexDiagnosis- Pelvic examination; POPQ- Stage 2 to IntroitusManagement- Treatment indicated- urinary/bowel/sex dysfunction; Hydronephrosis- ureteral kinkingStarted regardless of degree of prolapse and not indicated in asymptomaticExpectant management- watch and wait for those who prefer to avoid treatmentConservative- 1stline- lifestyle modifications/ pelvic muscle training/ pessary (mainstay)Estrogen therapy (no data to suggest as a primary treatment)Surgical- Colpocleisis, hysterectomy, MeshPregnant- conservative management- pelvic floor exercises and pessary managementInterstitial Cystitis (Bladder Pain Syndrome)Characterized by pain w/ bladder filling that is relieved by emptyingOften associated w/ urgency & frequencyEtiology- Unknown, most likely not a single disease but several diseases w/ similar sxSevere allergies, IBS, IBDAssessment- DyspareuniaPain w/ bladder filling relieved w/ urination Urgency, frequency, and nocturia are most commonHas there been pelvic radiation exposure or treatment w/ cyclophosphamideCheck for genital herpes, vaginitis, urethral diverticulumDiagnostics- Diagnosis of ExclusionUA w/ CultureUrodynamic testing- bladder sensation and complianceThis is to exclude Detrusor Instability