cOGText: Urogynaecology Flashcards
1
Q
The pelvic floor
- Separates the ? from the ?
- Functions?
- Urinary continence is provided via what structures?
- Faecal continence is provided by contraction of which muscle?
- Comprises which 3 layers? (ext to int)
A
- pelvic cavity from the perineum
- Provides support to pelvic organs AND maintains both urinary and faecal continence in women
- the external urethral sphincter, compressor urethrae and levator ani
- puborectalis
- Perineal membrane > muscles of perineal pouches > pelvic diaphragm
2
Q
- The pelvic diaphragm is made up of which 2 muscle groups?
- Coccygeus is located inferiorly to which muscles? It connects the ____ ___ to the ___
- Levator ani covers most of the area and has which 3 parts? (medial to lateral; ‘PPI’)
- Normal state is RELAXED/ CONTRACTED
- Pelvic diaphragm innervation?
A
- Levator ani and coccygeus
- The levator ani. Ischial spines, coccyx
- Puborectalis, Pubococcygeus, Iliococcygeus
- CONTRATED - they must relax to release urine and faeces
- pudental nerve and nerve to levator ani
NB: The best way to determine these muscles from a diagram is to look at their origin and insertion e.g. pubococcygeus = pubic bone to coccyx
3
Q
Which structures provide support to the Pelvic Diaphragm?
A
- Endopelvic fascia
- Supporting ligaments
4
Q
Describe the nerve of the following muscles of micturition
- Detrusor muscle
- Urethral smooth muscle
- The striated urethral sphincter and pelvic floor (levator ani) muscles
A
- parasympathetic nerves derived from the pelvic splanchnics S2-4.
- sympathetic nerves derived from the spinal cord at T10-L2, but descending to the bladder and urethra via the hypogastric nerves
- branches of the pudendal nerve, S 2-4.
5
Q
Name the pelvic floor supports at each of the following 3 levels:
- The cervix and upper vagina
- The middle vagina
- The lower vagina
A
- Uterosacral, transverse cervical and pubocervical ligaments
- The pelvic fascia
- Levator ani muscles and perineal body
6
Q
Deep Perineal Pouch
- Lies where in relation to the pelvic diaphragm and perineal membrane?
- What does it contain in females?
- In males?
A
- Superficial to the pelvic diaphragm, above the perineal membrane
- Part of urethra, vagina, Clitoral neurovascular bundle, Extensions of ischioanal fat pads, Smooth muscle, External urethral sphincter and compressor urethrae
- Part of urethra, Bulbourethral glands, Neurovascular bundle of penis, Extensions of ischioanal fat pads, Smooth muscle, External urethral sphincter and compressor urethrae
7
Q
Is this showing the deep or superficial perineal pouch?
A
Deep
NB: Remember the dorsal vein is most superior so you don’t confuse it with the urethra
8
Q
Perineal Membrane
- Lies where in relation to the deep perineal pouch?
- Completes the ____ triangle by attaching to the sides of the ___ ___
- Function?
A
- Superficial. Composed of tough, deep fascia.
- Urogenital, pubic arch
- Final line of defence for the pelvic organs along with the perineal body. Provides an area of attachment for the external genitalia
9
Q
Superficial Perineal Pouch
- Lies where in relation to the perineal membrane?
- Contents in females?
- Conents in males?
- Ischiocavernosus is MEDIAL/ LATERAL to bulbospongiosus in both males and females
A
- superficial
- Female erectile tissue/male root of penis and their relevant muscles
- Clitoris and crura, Bulbs of vestibule, Bulbospongiosus, Ischiocavernosus, Greater vestibular glands, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve
- Root of penis, Bulbs of vestibule, Bulbospongiosus, Ischiocavernosus, proximal spongy (penile) urethra, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve
- lateral
10
Q
Causes of pelvic floor weakness?
A
- Increased intra-abdominal pressure: obesity, chronic cough, occupational/recreational exercise, constipation, intra-abdominal mass
- Pelvic floor muscle trauma and denervation: obstetric, pelvic fracture/ surgery, congenital
- Connective tissue disorder: Age related, Oestrogen deficiency, Congenital or acquired connective tissue disorders, Drug related: e.g. steroids
11
Q
What is urinary Incontinence?
Typical demographic?
A
Involuntary leakage of urine
Often in elderly, parous women and postmenopausal women.
12
Q
Stress Incontinence
- What is this?
- Commonly seen in which patients?
- Triggers?
- T/F: leakage is often a small volume
- Which types of prolapse may be present
A
- Involuntary leakage of urine when there is increased intra-abdominal pressure, with the absence of detrusor muscle contraction.
- Post childbirth, pelvic surgery and oestrogen deficiency
- Coughing, sneezing, exercise
- True
- Prolapse of urethra and anterior vaginal wall
13
Q
Stress incontinence
- Investigations?
- Lifestyle management?
- Conservative?
- Medical?
- Surgical?
A
- After excluding a UTI, frequency/volume charts should be done (show normal frequency and bladder capacity). Urodynamic studies.
- Weight loss, smoking cessation, avoid constipation/ heavy lifting, caffeine reduction
- Pelvic floor muscle exercises for 3 months (often with physiotherapists), use of pads
- Duloxetine (not a 1st line treatment) + adequate counselling of its side effects - difficulty sleeping, headaches, dizziness, blurred vision, change in bowel habits, nausea and vomiting, dry mouth, sweating, decreased appetite and weight loss and decreased libido
- Bulking agents, Autologous rectus fascial sling, Laparoscopic or open colposuspension, Artificial urinary sphincters (severe cases), Tension free vaginal tape
14
Q
Urge Incontinence
- what ees eet?
- may experience which urinary symptom?
- triggers?
- T/F: associated with larger volumes of leakage as compared to stress incontinence
- Causes?
A
- When an individual has increased urgency and frequency to void urine.
- Nocturia
- Hearing running water, cold weather
- True. Individual often says “If I have to go, I have to go immediately”
- Idiopathic, pelvic surgery, MS, spina bifida
15
Q
Urge incontinence
- Ix?
- Lifestyle management?
- Conservative?
- Medical?
- Surgical?
- T/F: Oxybutynin is the first line anti-cholinergic in the elderly
A
- Frequency/volume charts (show increased frequency). Urodynamic (shows over-activity of the detrusor muscle)
- Decrease fluid intake, minimise caffeine and diuretics (alcohol), use of pads
- Bladder retraining with Incontinence team
- Oxybutynin (anticholinergic), Intravaginal oestrogens (useful for vaginal atrophy). Consider desmopressin if nocturia
- Botox, Percutaneous sacral nerve stimulation, augmentation cystoplasty
- False - not first line, esp in elderly as can cause cognitive impairment. Tolterodine or Solifenacin preferred. - Mirabegron esp in the elderly is safer.
