Genuine stress incontinence

Genuine stress incontinence

Q. 1

Bonney’s test is used to demonstrate :

 A

Stress incontinence

 B

Urge incontinence

 C

Fibroids

 D

True incontinence

Q. 1

Bonney’s test is used to demonstrate :

 A

Stress incontinence

 B

Urge incontinence

 C

Fibroids

 D

True incontinence

Ans. A

Explanation:

Stress incontinence


Q. 2

Stress incontinence is repaired by ….. repair :

 A

Manchester

 B

Fothergill’s

 C

Marshall Marchatti Krantz

 D

Bonney’s

Q. 2

Stress incontinence is repaired by ….. repair :

 A

Manchester

 B

Fothergill’s

 C

Marshall Marchatti Krantz

 D

Bonney’s

Ans. C

Explanation:

Marshall Marchatti Krantz


Q. 3

 

Stress incontinence is a common symptom in :

 

 A

Prolapse uterus

 B

Fibroid

 C

Adenomyosis

 D

VVF

Q. 3

 

Stress incontinence is a common symptom in :

 

 A

Prolapse uterus

 B

Fibroid

 C

Adenomyosis

 D

VVF

Ans. A

Explanation:

Prolapse uterus


Q. 4

Kelly’s plication operation is done in :

 A

Stress incontinence

 B

Vault prolapse

 C

Rectal prolapse

 D

Uterine prolapse

Q. 4

Kelly’s plication operation is done in :

 A

Stress incontinence

 B

Vault prolapse

 C

Rectal prolapse

 D

Uterine prolapse

Ans. A

Explanation:

Ans. is a i.e. Stress incontinence 

Kelly’s plication : It is done for management of stress incontinence.

The technique includes anterior colporrhaphy with plication of bladder neck.

Extra Edge :

Friends, let’s first understand what is stress incontinence and why it occurs then we will be able to appreciate its management better.

Genuine stress incontinence (GSI) is defined as involuntary loss of urine when intravesical pressure exceeds the maximum urethral pressure in the absence of detrusor activity.

Etiopathogenesis : In a normal continent woman, the bladder neck and proximal urethra are intra abdominal structures and lie above the pelvic floor in standing position and urethral pressure is more than intra vesical pressure.

Any factor which leads to distortion of normal urethro vesical anatomy or decreased urethral pressure leads to GSI like Developmental weakness, child birth trauma, pregnancy (due to increased progesterone which is a relaxant), menopause (it leads to atrophy of supporting structures), accidental trauma, obesity and following surgeries like Ant. Colporrhaphy, repair of VVF (as they lead to fibrosis of urethra).

Management :

Aim :

  1. To restore the function of muscles of Urethro vesical junction.
  2. Strengthen the support of urethra.

Conservative Approach :

  • Pelvic floor exercises
  • Drugs : Sympathomimetic drugs (a- adrenergic drugs) as they increase tone of urethra and bladder neck. eg.       

 – Imipramine

– Ephedrine

  • Paraurethral implants using teflon or Periurethral injection of Glutraldehyde linked collagen.

Surgical Approach :

Principles :

  • Restoration of normal anatomy.
  • Strengthening the support of bladder neck.
  • Increasing the functional length of urethra.

This can be done by :

Vaginal operations Abdominal Operations Combined Abdominal & Vaginal operation
  • Kelly’s repair (anterior colpo­rrhaphy + bladder neck repair)
  • Marshall Marchetti Krantz Operation bladder neck & vault of vagina are sutured to the  eriosteum of Pubic sym­physis
  • Pereyra’s operation
Pacey’s repair- In this technique medial fibres of Puborectalis muscle are apposed in midline under the bladder neck to elevate it
  • Burch Colposuspension­Here bladder neck and va­gina vault are suspended using the ileopectineal ligaments.
 

Laparoscopic colposuspension is also being done.


Q. 5

Urinary incontinence in uterovaginal prolapse is mostly is due to :

 A

Detrusor instability

 B

Stress incontience

 C

Urge incontinence

 D

True incontinence

Q. 5

Urinary incontinence in uterovaginal prolapse is mostly is due to :

 A

Detrusor instability

 B

Stress incontience

 C

Urge incontinence

 D

True incontinence

Ans. B

Explanation:

Stress incontience


Q. 6

Treatment of genuine stress incontinence

 A

Anterior colporrhaphy

 B

Pelvic floor exercise

 C

Colposuspension

 D

All

Q. 6

Treatment of genuine stress incontinence

 A

Anterior colporrhaphy

 B

Pelvic floor exercise

 C

Colposuspension

 D

All

Ans. D

Explanation:

Ans. is a, b & c i.e. Anterior colporrhaphy; Colposuspension; Pelvic floor exercise; and Sling operation

Genuine stress incontinence (GSI) is defined as involuntary loss of urine when intravesical pressure exceeds the maxitnum urethral pressure in the absence of detrusor activity.

Etiopathogenesis : In a normal continent woman, the bladder neck and proximal urethra are intra abdominal structures and lie above the pelvic floor in standing position and urethral pressure is more than intra vesical pressure.

Any factor which leads to distortion of normal urethro vesical anatomy or decreased urethral pressure leads to GSI like Developmental weakness, child birth trauma, pregnancy (due to increased progesterone which is a relaxant), menopause (it leads to atrophy of supporting structures), trauma, obesity and following surgeries like Ant. Colporrhaphy, repair of VVF (as they lead to fibrosis of urethra).

Management

Aim :

  1. To restore the function of muscles of Urethro vesical junction.
  2. Strengthen the support of urethra.

Conservative approach :

  • Pelvic floor exercises
  • Drugs  Sympathomimetic drugs (a- adrenergic drugs) as they increase tone of urethra and bladder neck.eg. – lmipramine

– Ephedrine

  • Paraurethral implants using teflon or periurethral injection of Glutaraldehyde linked collagen.

Surgical approach :

Principles : Restoration of normal anatomy.

  • Strengthening the support of bladder neck.
  • Increasing the functional length of urethra.

Now a days – Laparoscopic colposuspension is also being done.


Q. 7 A 59-yrs-old woman undergoes vaginal hysterectomy and anteroposterior repair for uterine prolapse. Which of the following is a complication of this procedure that often develops within 2 weeks of surgery?
 A Dyspareunia
 B Stress urinary incontinence
 C Nonfistulous fecal incontinence
 D Enterocele
Q. 7 A 59-yrs-old woman undergoes vaginal hysterectomy and anteroposterior repair for uterine prolapse. Which of the following is a complication of this procedure that often develops within 2 weeks of surgery?
 A Dyspareunia
 B Stress urinary incontinence
 C Nonfistulous fecal incontinence
 D Enterocele
Ans. B

Explanation:

Many patients who have uterine prolapse or a large protuberant cystocele will be continent because of urethra obstruction caused by the cystocele or prolapse. In fact, at times these patients may need to reduce the prolapse in order to void. Following surgical repair, if the urethrovesical junction is not properly elevated, urinary incontinence may result. This incontinence may present within the first few days following surgery. Dyspareunia can be caused by shortening of the vagina or constriction at the introitus after healing is complete. If the vaginal vault is not properly suspended and the uterosacral ligaments plicated, vaginal vault prolapse or enterocele may occur at a later date. Fecal incontinence is not a complication of vaginal hysterectomy with repair. It may occur, however, if a fistula is formed through unrecognized damage to the rectal mucosa.


Q. 8 Bead cystogram is used for the diag­nosis of:
 A Ca bladder
 B Stress incontinence
 
 
 C Thimble bladder
 D Diverticulum
Q. 8 Bead cystogram is used for the diag­nosis of:
 A Ca bladder
 B Stress incontinence
 
 
 C Thimble bladder
 D Diverticulum
Ans. B

Explanation:

Stress incontinence


Q. 9

The recommended non surgical treatment of stress incontinence is:

 A

Pelvic floor muscle exercises

 B

Bladder training

 C

Electrical stimulation

 D

Vaginal cone / weights

Q. 9

The recommended non surgical treatment of stress incontinence is:

 A

Pelvic floor muscle exercises

 B

Bladder training

 C

Electrical stimulation

 D

Vaginal cone / weights

Ans. A

Explanation:

Clinical research published in the British Medical Journal compared pelvic floor exercises, vaginal weights and electro-stimulation in a randomised trial.

The research recommended that pelvic floor exercise should be the first choice of treatment for genuine stress incontinence because simple exercises proved to be far more effective than electro-stimulation or vaginal cones.

Ref: Dewhurst’s Textbook of Obstetrics and Gynaecology, 7th Edition, Page 526 and 10th Edition, Page 486 ; The Urinary Incontinence Sourcebook By Diane Kaschak Newman, Mary K. Dzurinko, Page 61 ; Textbook of Gynecology By D C Dutta, 5th Edition, Page 386 ; Novak’s Textbook of Gynaecology, 14th Edition, Page 875


Q. 10

Which of the following is not a treatment modality for stress incontinence?

 A

Kelly suture

 B

Stanley’s combined vaginal and supra pubic operation

 C

Marshall-Marchetti-Krantz Procedure

 D

Fothergill’s repair

Q. 10

Which of the following is not a treatment modality for stress incontinence?

 A

Kelly suture

 B

Stanley’s combined vaginal and supra pubic operation

 C

Marshall-Marchetti-Krantz Procedure

 D

Fothergill’s repair

Ans. D

Explanation:

Fothergill’s repair is used to treat uterine prolapse.

Ref: Shaw’s Textbook of Gynaecology, 12th Edition, Pages 138-39.

Q. 11

A woman presents to the Gynecology outpatient department with history of stress incontinence. Which of the following is the treatment of choice for genuine stress incontinence?

 A

Burch Colposuspension

 B

Kelly’s Procedure

 C

Sling Suspension Procedure

 D

Tension Free Vaginal Taping (TVT)

Q. 11

A woman presents to the Gynecology outpatient department with history of stress incontinence. Which of the following is the treatment of choice for genuine stress incontinence?

 A

Burch Colposuspension

 B

Kelly’s Procedure

 C

Sling Suspension Procedure

 D

Tension Free Vaginal Taping (TVT)

Ans. D

Explanation:

The latest modification of the midurethral sling into a tension-free vaginal mesh made up of polypropylene and it is placed at the level of the midurethra.

This pioneering technique, developed in Sweden, was introduced to the United States in the late 1990s.

It is used as a minimally invasive technique for surgical correction of genuine SUI.

Report have determined that TVT is the treatment of choice for stress urinary incontinence.
 
Ref: Danforth’s obs & gyn – 9th edition, Page 54; Shaw’s  textbook of Gynaecology 12th edition, Pagees 135-139.

Q. 12

To differentiate between stress incontinence and detrusor instability investigation done is 

 A

Cystosurethroscopy

 B

Urodynamic study

 C

MCU

 D

Retograde urethroscopy

Q. 12

To differentiate between stress incontinence and detrusor instability investigation done is 

 A

Cystosurethroscopy

 B

Urodynamic study

 C

MCU

 D

Retograde urethroscopy

Ans. B

Explanation:

Ans is ‘b’ ie Urodynamic study 

  • Genuine stress incontinence

is defined as urinary leakage occuring during increased bladder pressure when this is solely due to increased abdominal pressure and not due to increased true detrusor pressure.

–         It is caused by sphincter weakness.

  • Detrusor instability

–         this is phasic increase in detrusor pressure (due to phasic contraction of detrusor muscle) giving rise to sensation of urgency of micturition and urge incontinence.

It is found in pts with several types of neurogenic bladder dysfunction such as multiple sclerosis (MS) Parkinson disease or following a stroke or certain types of spinal injury when it is known as detrusor hyperreflexia.

  • Usefulness of Urodynamic testing:

1)         Distinguishing genuine stress incontinence from detrusor instability in women.

2)         Classification of neurogenic bladder dysfunction

3)         Distinguishing bladder outflow obstruction from idiopathic detrusor instability in men.

4)         Investigation of incontinence.



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