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Laura MRCOG Part 2 > 18) Urogynaecology > Flashcards

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)
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2
Q

Lifestyle adjustments in overactive bladder

A

Lose weight if BMI >30
Reduce caffeine
Modify fluid intake

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3
Q

First line treatment for overactive bladder

A

Bladder training (minimum 6 weeks)

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4
Q

Medical treatment options for overactive bladder

A
  1. Oral anti-cholinergic (oxybutynin, tolterodine, darifenacin)
  2. Transdermal anti-cholinergic
  3. Mirabegron

Others:

  • Desmopressin for nocturia
  • Intravaginal oestrogen if atrophy
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5
Q

Who shouldn’t receive oxybutynin?

A

Frail elderly ladies

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6
Q

Who shouldn’t receive desmopressin?

A

Cystic fibrosis

Age > 65 years with cardiovascular disease or hypertension

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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.

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8
Q

When to consider invasive procedures for overactive bladder?

A

If detrusor overactivity confirmed at urodynamics and medical options failed.

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9
Q

Invasive options for management of detrusor overactivity

A
  1. Bladder wall botulinum toxin A (100 units initially, can increase to 200 units)
  2. Percutaneous sacral nerve stimulation
  3. Augmentation cystoplasty
  4. Urinary diversion
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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.

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11
Q

Medical option for stress incontinence

A

Duloxetine (if PFE not worked and wanting to avoid invasive treatments)

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12
Q

Surgical options for stress incontinence

A
  1. Colposuspension
  2. Autologous rectus fascial sling
  3. Retropubic midurethral mesh sling
  4. Artificial urinary sphincter
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13
Q

Other invasive options for management of stress incontinence

A

Intramural bulking agents

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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
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15
Q

First line treatment for stage 1/2 prolapse

A

Pelvic floor exercises for 16 weeks.

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16
Q

Non-surgical management for prolapse

A

Pessaries (change every 6 months)

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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
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18
Q

What percentage of adults are affected by overactive bladder?

A

75%

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19
Q

Contraindications to anti-muscarinics

A 
Myasthenia gravis
Significant bladder outflow obstruction
Severe ulcerative colitis
Toxic megacolon
GI obstruction/atony
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20
Q

Contraindication to mirabegron

A

Uncontrolled hypertension

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21
Q

How long do the effects of bladder botox last?

A

3-6 months

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22
Q

What proportion of women will need to ISC after bladder botox?

A

10-15%

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23
Q

How is bladder botox administered?

A

Cystoscopic injection at 20 injection sites across the dome of bladder.

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24
Q

Which antibiotics potentiate botox?

A

Aminoglycosides

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25
Q

What percentage of patients become continent after botox?

A

30%

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26
Q

How does sacral nerve stimulation work?

A

Modulates afferent pathway of reflexes including bladder and pelvic floor responses.

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27
Q

Process of sacral nerve stimulation

A
  • 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.
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28
Q

Long term success rate of sacral nerve stimulation

A

65%

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29
Q

Re-operation/revision rate with sacral nerve stimulation

A

33%

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30
Q

When should posterior tibial nerve stimulation be offered for overactive bladder?

A

Only after MDT if failed medical and don’t want botox/SNS

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31
Q

How does posterior tibial nerve stimulation work?

A

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

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32
Q

Mortality rate associated with cystoplasty/urinary diversion

A

1%

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33
Q

Proportion of women with prolapse

A

1/9

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34
Q

Proportion of women with stress urinary incontinence

A

1/3

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35
Q

Incidence of urinary incontinence over the age of 40

A

25-45%

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36
Q

Most common type of urinary incontinence

A

SUI

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37
Q

In what proportion of women with prolapse, does SUI also coexist?

A

80%

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38
Q

Lifetime risk in UK for surgery for POP or SUI

A

10%

39
Q

Incidence of occult stress incontinence

A

30%

40
Q

Management options for women with POP and asymptomatic for SUI

A

Colposuspension at time of abdominal sacrocolpopexy or midurethral sling at time of vaginal prolapse repair reduces risk of SUI.

41
Q

What proportion of women with SUI may experience improvement of their SUI after POP surgery alone?

A

1/3

42
Q

Incidence of post-hysterectomy vaginal vault prolapse

A
  1. 6% if hysterectomy done for prolapse
  2. 8% if hysterectomy done for other benign diseases

6-8% require surgical repair

43
Q

POP-Q

A

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
Q

Staging criteria for prolapse

A

Stage 0: Aa/Ba/Ap/Bp all -3cm and C/D +1 but tvl-2

45
Q

Techniques for preventing post hysterectomy vaginal vault prolapse

A
  • 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
Q

Surgical options for management of vaginal vault prolapse

A

Abdominal sacrocolpopexy (can be done laparoscopically or open) or vaginal SSF or colpocleisis.

47
Q

Comparison of ASC and SSF for management of vaginal vault prolapse

A
  • Both effective
  • ASC lower recurrence, dyspareunia and post -op SUI
  • SSF earlier recovery but not appropriate if short vaginal length or dyspareunia
48
Q

When to do urodynamics?

A
  • 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
Q

What percentage of cases are pure SUI and what is the effect of pre-op urodynamics in these patients?

A

5% are pure SUI

Pre-op urodynamics do not affect outcome or further management.

50
Q

What to do if evidence of UTI when attends urodynamics?

A

Treat UTI and postpone test

51
Q

What to do with prolapse during urodynamics?

A

Reduce using pessary/speculum/finger

52
Q

Normal maximum flow rate (Qmax)

A

20-36ml/s

53
Q

Normal post void residual

A

<100mL not clinically significant

54
Q

Non-pathological causes of reduced Qmax (reduced flow rate)

A

Low voided volume (<150mL)
Bladder over distension (>550mL)
Inhibited patient
Technical errors

55
Q

Causes of high post void residual

A

Anticholinergic médication
Neurological
Outlet obstruction

56
Q

What causes you to see several peaks of Qmax during uroflowmetry?

A

Repeated straining, outflow obstruction, unsustained detrusor contraction.

57
Q

What causes reduced Qmax? (Plateau after rapid upstroke)

A

Obstruction/sphincter

Acontractile detrusor

58
Q

What causes very high Q max

A

Possible detrusor over activity

High speed squirting to overcome obstruction

59
Q

Normal intravesical pressure

A

5-50cm H20

60
Q

Normal abdominal pressure

A

5-50 cm H20

61
Q

Normal detrusor pressure

A

-5 to 15 cm H20

62
Q

What size catheter is used for cystometry?

A

5-7F double/triple lumen

63
Q

Where should the external transducers be placed for cystometry?

A

Upper edge pubic symphysis

64
Q

What rate for bladder filling?

A

10% of maximum voided volume (detrusor OA may need slower 10ml/min)

65
Q

What is physiological rate of bladder filling?

A

1-2ml/min

66
Q

What sensations are the patient instructed to report during cystometry?

A

First sensation of filling
First desire to void
Strong desire to void
Urgency/leaking/pain

67
Q

What is the pad test?

A

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
Q

What is Fowler’s syndrome?

A

Syndrome of painless urinary retention affecting women of reproductive age, with no underlying urological/gynaecological/neurological cause.

69
Q

Straining in Fowler’s syndrome?

A

Doesn’t help

70
Q

Sensation with catheterisation in Fowler’s syndrome

A

“Something gripping” on removal

71
Q

Proportion of women with Fowler’s syndrome on opiates

A

1/3

72
Q

Conditions associated with Fowler’s syndrome

A

PCOS and endometriosis

73
Q

Other associations with Fowler’s syndrome

A
  • Often an antecedent surgical procedure (anaesthetic is implicated)
  • Hormonal impact (EMG findings vary across cycle)
74
Q

Urodynamics findings in patient with Fowler’s

A

Large capacity bladder without usual filling sensations and inability to pass urine.

Detrusor acontractility or hypocontractility.

75
Q

Investigations in Fowler’s (once other things excluded)

A

Urodynamics
Urethral pressure profile
Urethral ultrasound
Urethral sphincter EMG

76
Q

Findings in urethral pressure profile in Fowlers

A

Maximum urethral closure pressure >100cmH20 (normal is 92-age)

77
Q

Findings on urethral ultrasound in Fowlers

A

Measure sphincter volume and look for other causes

78
Q

Findings on urethral sphincter EMG in Fowlers

A

Complex repetitive discharge with decelerating burst activity.

79
Q

What are the implications of the EMG findings in Fowlers?

A

Discharge causes involuntary contraction of striated sphincter (prevents bladder emptying) and activation of the sphincter afferents (which inhibit detrusor activity –> complete retention)

80
Q

Treatment for Fowlers

A 
Sacral neuromodulation (70-80% success rate)
Botox into sphincter
81
Q

Increase in urinary incontineence after hysterectomy

A

60% increased

82
Q

Dyspareunia after anterior repair

A

15% (higher for a posterior repair)

83
Q

Risk of adverse effects with vaginally placed mesh

A

6.5%

84
Q

Risk of worsening sexual function with vaginally placed mesh

A

15.3%

85
Q

Current limitations on mesh use:

A
  • CAN be used if placed abdominally

- CAN’T be used for vaginal placement for POP or stress urinary incontinence procedures

86
Q

Indications for cystoscopy

A

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
Q

Contraindication to cystoscopy

A

Untreated UTI

88
Q

How often does mild dysuria/haematuria occur after cystoscopy?

A

> 1/10

89
Q

How often is biopsy of abnormal areas after cystoscopy?

A

> 1/10

90
Q

How often is infection of bladder requiring antibiotics after cystoscopy?

A

1/10-1/50

91
Q

How often is temporary insertion of catheter required after cystoscopy?

A

<1/50

92
Q

How often is delayed bleeding requiring removal of clots or further surgery required after cystoscopy?

A

<1/50

93
Q

How often is there an injury to urethra causing delayed scar formation after cystoscopy?

A

<1/50

94
Q

How often is bladder perforation after cystoscopy?

A

Very rarely, <1/50

Laura MRCOG Part 2 (56 decks)

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