18) Urogynaecology Flashcards
1
Q
Assessment of patient presenting to urogynae
A
- Pelvic muscle contraction assessment
- Urine dipstick
- Post void residual
- QOL questionnaire
- Bladder diary (minimum 3 days)
2
Q
Lifestyle adjustments in overactive bladder
A
Lose weight if BMI >30
Reduce caffeine
Modify fluid intake
3
Q
First line treatment for overactive bladder
A
Bladder training (minimum 6 weeks)
4
Q
Medical treatment options for overactive bladder
A
- Oral anti-cholinergic (oxybutynin, tolterodine, darifenacin)
- Transdermal anti-cholinergic
- Mirabegron
Others:
- Desmopressin for nocturia
- Intravaginal oestrogen if atrophy
5
Q
Who shouldn’t receive oxybutynin?
A
Frail elderly ladies
6
Q
Who shouldn’t receive desmopressin?
A
Cystic fibrosis
Age > 65 years with cardiovascular disease or hypertension
7
Q
When to review patients after starting anticholinergic?
A
4 weeks
Then review at 6m or 12m intervals (6m if >75 years) if remain on medication.
8
Q
When to consider invasive procedures for overactive bladder?
A
If detrusor overactivity confirmed at urodynamics and medical options failed.
9
Q
Invasive options for management of detrusor overactivity
A
- Bladder wall botulinum toxin A (100 units initially, can increase to 200 units)
- Percutaneous sacral nerve stimulation
- Augmentation cystoplasty
- Urinary diversion
10
Q
Initial management option for stress incontinence
A
Supervised pelvic floor exercises
- 8 contractions TDS
- 3 months
Consider electrical stimulation/biofeedback if can’t actively contract.
11
Q
Medical option for stress incontinence
A
Duloxetine (if PFE not worked and wanting to avoid invasive treatments)
12
Q
Surgical options for stress incontinence
A
- Colposuspension
- Autologous rectus fascial sling
- Retropubic midurethral mesh sling
- Artificial urinary sphincter
13
Q
Other invasive options for management of stress incontinence
A
Intramural bulking agents
14
Q
NICE guidance on mesh if doing midurethral sling
A
- Type 1 macroporous polypropylene mesh
- Coloured for high visibility
- Don’t use transobturator approach
- Don’t use “top down” approach or single incision suburethral
15
Q
First line treatment for stage 1/2 prolapse
A
Pelvic floor exercises for 16 weeks.
16
Q
Non-surgical management for prolapse
A
Pessaries (change every 6 months)
17
Q
Surgical management options for prolapse
A
Anterior/Posterior: Anterior/Posterior repair Uterine Prolapse: - Uterus preserving - vaginal sacrospinous hysteropexy or manchester repair or abdominal sacrohysteropexy - VH +/- SSF - Colpocleisis Vault prolapse: - Colpocleisis - SSF - Sacrocolpopexy
18
Q
What percentage of adults are affected by overactive bladder?
A
75%
19
Q
Contraindications to anti-muscarinics
A
Myasthenia gravis Significant bladder outflow obstruction Severe ulcerative colitis Toxic megacolon GI obstruction/atony
20
Q
Contraindication to mirabegron
A
Uncontrolled hypertension
21
Q
How long do the effects of bladder botox last?
A
3-6 months
22
Q
What proportion of women will need to ISC after bladder botox?
A
10-15%
23
Q
How is bladder botox administered?
A
Cystoscopic injection at 20 injection sites across the dome of bladder.
24
Q
Which antibiotics potentiate botox?
A
Aminoglycosides
25
What percentage of patients become continent after botox?
30%
26
How does sacral nerve stimulation work?
Modulates afferent pathway of reflexes including bladder and pelvic floor responses.
27
Process of sacral nerve stimulation
- Initial evaluation which can either be a temporary electrode inserted under LA or a permanent electrode inserted under GA.
- Assessment of improvement over 7d (temporary) or 14d (permanent).
- If evaluation effective then procedure under GA to insert SC stimulator +/- permanent electrode.
28
Long term success rate of sacral nerve stimulation
65%
29
Re-operation/revision rate with sacral nerve stimulation
33%
30
When should posterior tibial nerve stimulation be offered for overactive bladder?
Only after MDT if failed medical and don't want botox/SNS
31
How does posterior tibial nerve stimulation work?
Fine needle inserted under LA 4-5cm superior to medial malleolus with surface electrode on foot connected to stimulator
- 12 weekly sessions lasting 30 minutes
32
Mortality rate associated with cystoplasty/urinary diversion
1%
33
Proportion of women with prolapse
1/9
34
Proportion of women with stress urinary incontinence
1/3
35
Incidence of urinary incontinence over the age of 40
25-45%
36
Most common type of urinary incontinence
SUI
37
In what proportion of women with prolapse, does SUI also coexist?
80%
38
Lifetime risk in UK for surgery for POP or SUI
10%
39
Incidence of occult stress incontinence
30%
40
Management options for women with POP and asymptomatic for SUI
Colposuspension at time of abdominal sacrocolpopexy or midurethral sling at time of vaginal prolapse repair reduces risk of SUI.
41
What proportion of women with SUI may experience improvement of their SUI after POP surgery alone?
1/3
42
Incidence of post-hysterectomy vaginal vault prolapse
11. 6% if hysterectomy done for prolapse
1. 8% if hysterectomy done for other benign diseases
6-8% require surgical repair
43
POP-Q
Aa: Anterior vaginal wall, 3cm proximal to hymen. Range -3 to +3.
Ba: Anterior vaginal wall, most distal position. Range -3 to tvl.
C: Cervix (or vaginal cuff scar)
D: Posterior fornix (N/A if post hysterectomy)
Ap: Posterior vaginal wall, 3cm proximal to hymen. Range -3 to +3.
Bp: Posterior vaginal wall, most distal position. Range -3 to tvl.
44
Staging criteria for prolapse
Stage 0: Aa/Ba/Ap/Bp all -3cm and C/D +1 but tvl-2
45
Techniques for preventing post hysterectomy vaginal vault prolapse
- McCall culdoplasty at time of vaginal hysterectomy
- Suturing cardinal and uterosacral ligaments to vaginal cuff at time of vaginal/abdominal hysterectomy
- SSF at time of VH if vault descends to introits during closure
46
Surgical options for management of vaginal vault prolapse
Abdominal sacrocolpopexy (can be done laparoscopically or open) or vaginal SSF or colpocleisis.
47
Comparison of ASC and SSF for management of vaginal vault prolapse
- Both effective
- ASC lower recurrence, dyspareunia and post -op SUI
- SSF earlier recovery but not appropriate if short vaginal length or dyspareunia
48
When to do urodynamics?
- Urge incontinence: Prior to any surgery
- Stress incontinence: Only if suggestion of voiding dysfunction, anterior prolapse or previous surgery (ICI-UDT also recommends before any surgical treatment)
- Neurological incontinence
- Children/Frail elderly before any invasive treatments.
49
What percentage of cases are pure SUI and what is the effect of pre-op urodynamics in these patients?
5% are pure SUI
| Pre-op urodynamics do not affect outcome or further management.
50
What to do if evidence of UTI when attends urodynamics?
Treat UTI and postpone test
51
What to do with prolapse during urodynamics?
Reduce using pessary/speculum/finger
52
Normal maximum flow rate (Qmax)
20-36ml/s
53
Normal post void residual
<100mL not clinically significant
54
Non-pathological causes of reduced Qmax (reduced flow rate)
Low voided volume (<150mL)
Bladder over distension (>550mL)
Inhibited patient
Technical errors
55
Causes of high post void residual
Anticholinergic médication
Neurological
Outlet obstruction
56
What causes you to see several peaks of Qmax during uroflowmetry?
Repeated straining, outflow obstruction, unsustained detrusor contraction.
57
What causes reduced Qmax? (Plateau after rapid upstroke)
Obstruction/sphincter
| Acontractile detrusor
58
What causes very high Q max
Possible detrusor over activity
| High speed squirting to overcome obstruction
59
Normal intravesical pressure
5-50cm H20
60
Normal abdominal pressure
5-50 cm H20
61
Normal detrusor pressure
-5 to 15 cm H20
62
What size catheter is used for cystometry?
5-7F double/triple lumen
63
Where should the external transducers be placed for cystometry?
Upper edge pubic symphysis
64
What rate for bladder filling?
10% of maximum voided volume (detrusor OA may need slower 10ml/min)
65
What is physiological rate of bladder filling?
1-2ml/min
66
What sensations are the patient instructed to report during cystometry?
First sensation of filling
First desire to void
Strong desire to void
Urgency/leaking/pain
67
What is the pad test?
Pad for 1 hour, exercise for 30 minutes. Positive test is weight gain >1g.
OR pad for 24-48h at home (changing every 4-6h), weight gain >1.3g
68
What is Fowler's syndrome?
Syndrome of painless urinary retention affecting women of reproductive age, with no underlying urological/gynaecological/neurological cause.
69
Straining in Fowler's syndrome?
Doesn't help
70
Sensation with catheterisation in Fowler's syndrome
"Something gripping" on removal
71
Proportion of women with Fowler's syndrome on opiates
1/3
72
Conditions associated with Fowler's syndrome
PCOS and endometriosis
73
Other associations with Fowler's syndrome
- Often an antecedent surgical procedure (anaesthetic is implicated)
- Hormonal impact (EMG findings vary across cycle)
74
Urodynamics findings in patient with Fowler's
Large capacity bladder without usual filling sensations and inability to pass urine.
Detrusor acontractility or hypocontractility.
75
Investigations in Fowler's (once other things excluded)
Urodynamics
Urethral pressure profile
Urethral ultrasound
Urethral sphincter EMG
76
Findings in urethral pressure profile in Fowlers
Maximum urethral closure pressure >100cmH20 (normal is 92-age)
77
Findings on urethral ultrasound in Fowlers
Measure sphincter volume and look for other causes
78
Findings on urethral sphincter EMG in Fowlers
Complex repetitive discharge with decelerating burst activity.
79
What are the implications of the EMG findings in Fowlers?
Discharge causes involuntary contraction of striated sphincter (prevents bladder emptying) and activation of the sphincter afferents (which inhibit detrusor activity --> complete retention)
80
Treatment for Fowlers
```
Sacral neuromodulation (70-80% success rate)
Botox into sphincter
```
81
Increase in urinary incontineence after hysterectomy
60% increased
82
Dyspareunia after anterior repair
15% (higher for a posterior repair)
83
Risk of adverse effects with vaginally placed mesh
6.5%
84
Risk of worsening sexual function with vaginally placed mesh
15.3%
85
Current limitations on mesh use:
- CAN be used if placed abdominally
| - CAN'T be used for vaginal placement for POP or stress urinary incontinence procedures
86
Indications for cystoscopy
Visible and unexplained haematuria:
- Either without UTI or that persists after successful treatment of UTI age >45
- Raised WCC age >60
```
Dysuria with unexplained, non-visible haematuria >60
Recurrent UTI
Voiding symptoms
Fistula
Stricture
COngenital genital tract anomalies
```
87
Contraindication to cystoscopy
Untreated UTI
88
How often does mild dysuria/haematuria occur after cystoscopy?
>1/10
89
How often is biopsy of abnormal areas after cystoscopy?
>1/10
90
How often is infection of bladder requiring antibiotics after cystoscopy?
1/10-1/50
91
How often is temporary insertion of catheter required after cystoscopy?
<1/50
92
How often is delayed bleeding requiring removal of clots or further surgery required after cystoscopy?
<1/50
93
How often is there an injury to urethra causing delayed scar formation after cystoscopy?
<1/50
94
How often is bladder perforation after cystoscopy?
Very rarely, <1/50
