Twenty-four year old female, G1P1, six weeks postpartum, presents with complaints of recurring right Skene’s gland cysts and urinary incontinence with gaping urethra. She has an unremarkable medical, surgical and family history. PNV’s only and no allergies. Height and weight appropriate. 1) Right Skene’s gland drained 4 times while pregnant. Placed on antibiotics initially but culture negative. Today with complaints of painful intercourse due to the Skene’s gland. Examination revealed a mildly inflamed right Skene’s gland with minimal tenderness on palpation. Patient states it has improved tremendously on its own. Discussed conservative management to wait and see if remains a problem, initiated referral to Gynecology and talked about the potential role of the Skene’s glands in intercourse. 2) Patient states urinary incontinence occurs about 10 times throughout the day and it is not related to coughing, sneezing or the urge to urinate. She wears a minipad 24/7 to catch the urine and changes it about 5 times a day. Concerned it is not getting better since delivery. No incontinence issue prior to pregnancy. Urethra visualized on exam but not remarkable. When performing bimanual after Pap 2-3cc of urine was expressed. Treatment consisted of conservative management with Kegels 10 times every time she urinated intentionally or accidentally, referral to Gynecology and I educated her on the role of the Pelvic Floor Physical Therapist if conservative management failed.
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MAJ Frisbie-A couple questions from your excellent presentation: 1. Did this pt deliver vaginally or via C-section? 2. Any issues/problems with the delivery such as prolonged pushing or lengthy contractions? 3. Did you check the strength of the patient's pelvic floor muscles during your vaginal exam? 4. Did you check urethral mobility (Q-tip test), or for presence of a cystocele during your exam? 5. Did the pt say she was urinating overnight while she was sleeping? 6. With the multiple Skene's gland drainages (x4) perhaps there was some unseen damage done to the pt's urethra that was contributing to her incontinence? 7. Did you consider Overflow incontinence in your differential, as you said the pt did not have symptoms of incontinence with Stress (coughing/sneezing), nor Urge?
ReplyDeleteOverflow incontinence could have developed from pressure of the pregnant uterus on the urethra, causing partial obstruction of urine outflow and leading to enlargement of the bladder which subsequently becomes less contractile, and results in Overflow incontinence when the bladder is not completely emptied after urinating. One would have to have the pt keep a bladder diary and then also measure post-void residuals, with results of more than 50-75cc indicating need for further work-up and treatment (bladder re-training using timed self-catherization until the bladder muscle returned to its pre-pregnancy size and resumed appropriate full contraction and emptying, and decreased/stopped incontinence).
Also, if treatment with the Kegel's to strengthen and increase the tone of the pelvic muscles, including the urethra, did not work, were any medications discussed which could be tried? Mention is made in our textbook and in ACOG pamphlets of medications that can be used to help strengthen the urethral muscle (by increasing tone and resistance), such as alpha adrenergic agonists like pseudophed-these might help with Stress Incontinence (like Kegel's will), however they would be contraindicated in Overflow incontinence which would be made worse by again blocking outflow). Also, alpha adrenergic agonists are contraindicated in pt's with HTN, hyperthyroidism, arrhythmias and/or agina which your pt would have to be prescreened for.
Nice post MAJ Frisbie-thanks for getting us thinking and learning!
Great case and great comments! ;) This is the second case where a Pelvic Floor PT colleague might have made a difference. Historically, that's a topic that doesn't get good "marks" on the evaluation...but it's a very common problem, and it would be nice if EVERYONE had access to a trained professional like Kendra Harrington.
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