Complications of Delivery - POP, FUI Flashcards
epidemiology of POP?
- 50% of parous, 12-30% multiparous, 2% nulliparous - 10% of the 50% asymtptomatic
- 20% of the waiting list fr major gynaecological surgery
what are the main structures in the pelvis that will increase the abdominal pressure?
- bladder
- rectum
- uterus
the 3 pelvic floor layers and their function.
- endopelvic fascia - forms a hammock and holds the visceral structures together.
- pelvic diaphragm - levator ani and coccygeus muscle + fascial coverings
- urogenital diaphragm - superficial/deep transverse perineal muscles and fascial coverings.
what are the 4 fascial structures that make up the endopelvic fascia? Just the name
- cardinal/uterosacral complex
- pubocervicalis fasica
- rectovaginalis fascia
- endopelvic coverings
what are the 3 levels of prolapse that can happen in endopelvic covering, and what damage to which structures will cause which prolapse?
level 1: apical prolapse - uterosacral/cardinal ligaments complex
level 2: post/ant vaginal wall prolapse - pubocervicalis fascia, rectovagianlis fascia, arcus tendineus fascia
level 3: perineal plasty - perineal body, urogenital diaphragm
what are the attachments and most likely damage of the cardinal ligament?
fibromuscular connective tissue btw cervix and sacrum, allows restricted side to side movement of cervix
attachments:
- medially: uterus, cervix, vaginal fornices, puborectalis/vaginalis fascia
- laterally: sacrum, fascia over the piriformis
damage:
- medially –> uterine prolapse when the ligament is flaccid (during sleep)
what are the attachments and most likely damage of the pubocervicalis fascia?
trapezoid fibromuscular tissue that provides the main support between the bladder and ant vaginal wall.
attachements:
- medially: base of cervix and cardinal ligament
- laterally: arcus tendineus fascia pelvis
- distally: urogential diaphragm
damage:
- lateral vaginal damage: worsens with central suture
- central damage: needs central suture
what are the attachments and most likely damage of the rectovaginalis fascia?
fibromuscular ELASTIC tissue
attachments:
- medially: cardinal/uterosacral ligament, peritoneum
- laterally: levator ani fascia
- distally: perineal body
defects:
- upper defect: enterocele
- lower defect: rectocele
etiology/risk factors for POP (10) - which is the strongest risk factor?
- higher parity - MAIN
- large baby
- forceps delivery
- obesity
- increasing maternal age
- hormonal issues (decreased E with age)
- quality of connective tissue
- previous pelvic surgery
- prolonged second stage labor
- increased intra-abdominal pressure: constipation, heavy lifting, exercise, lung conditions that cause coughing.
what are the types of pelvis surgery that puts people at risk of POP (3)
- continence procedures
- 25% burch colposuspension (fixing lateral vaginal fornices to the iliopectineal ligaments, resulting in posterior vaginal wall damage)
- hysterectomy (11.9%, esp for previous prolapse)
types of prolapse (5) - describe the location of prolapse and the organ it involves
- urethrocele - lower anterior wall, involving the urethra
- cystocele - upper anterior wall, involving the bladder
- uterovaginal prolapse - apical, involving the uterus/cervix/upper vagina
- enterocele - upper posterior wall, involving the small bowels
- rectocele - lower posterior wall, involving the rectum
presentation of POP, divide into vaginal (3), urinary (3), and bowel (4) symptoms.
vaginal:
- sensing/seeing the bulge/protrusion
- feeling of pressure and heaviness
- difficulty inserting tampons
urinary:
- frequency/urgency - MAIN
- incontinence
- retention (prolapse resulting in kink in the urethra) - hesitancy, weak/prolonged stream, incomplete emptying –> manual reduction of the prolapse is needed
bowel:
- incontinence of flatus/liquid/solid
- incomplete emptying
- constant feeling of urgency
- digital evacuation through the vagina instead of rectum is needed
how is POP diagnosed?
clinical diagnosis + examination
POP investigations are not for diagnosis but for its symptoms. List some (5)
- examination (to exclude pelvic mass)
- POPQ score (GOLD standard)
- USS/MRI (identify fascial/muscle defects)
- urodynamics (exclude SUI)
- IVU/renal USS (ureteric obstruction)
management of POP? (5) Which are the main conservative managements?
- *pelvic floor muscle training (PFMT)
- *vaginal pessaries
- avoid increased intra-abdominal pressure (treat constipation, lung conditions)
- constant perineal message
- surgery
the roles of surgery in POP (3)
- relieve symptoms
- restore/maintain bladder and bowel function
- maintain vaginal sexual function
what are some of the prophylactic/post surgical management you need to consider after POP surgery?
- prophylaxis abx
- thrombo-embolic prophylaxis
- post-op catheter/SPC
is PFMT useful all the time?
no, it is only useful in mild (stage I/II) POP, and in those who still wish to get pregnant
what are the surgery needed for each type of POP?
- ant/post wall prolapse: wall repair
- apical prolapse: (can combine)
- vaginal hysterectomy/hysteropexy
- sacrospinous fixation
- abdominal sacrocolpopexy/hysteropexy
- colpocelsis (only in those who are no longer sexually active)
what is the clinical significance of the vesicoureteric mechanism?
allows urine to pass from 1 direction only and protects the nephrons from back pressure and infection from the bladder
the 4 parts of the nervous system and its control over micturition.
- sympathetic (hypogastric n. T10-12) –> storage
- contraction of urethral sphincters
- relaxation of bladder
- parasympathetic (pelvic n. S2-4) –> voiding
- relaxation of urethral sphincters
- contraction of bladder
- autonomic (pudendal n. S2-4) –> voluntary
- contraction of pelvic floor muscles
- contraction of urethral sphincter
- cortical activity and higher centers (pontine micturition center)
- storage: (+SNS, -PNS) contraction of rhabdosphincter and bladder base
- voiding: (-SNS, +PNS) detrusor contraction, urethral sphincter relaxation, sphincter coordination
- voluntary: hypothalamus override
3 different types of incontinence and their definition.
- stress UI (SUI): involuntary leakage on effort or exertion, like sneezing/coughing
- urgency UI (UUI): involuntary leakage with immediate or preceded by urgency
- mixed UI (MUI): involuntary leakage immediately followed or preceded by urgency upon exertion.
epidemiology of FUI
- 10-25% 15-60 yrs (> 45 yrs)
- 15-40% > 60 yrs
- 50% women in care homes
risk factors of FUI
(same as POP with addition of smoking)
- parity
- instrumental delivery
- age
- medical conditions
- poor connective tissue quality
- smoking
- menopause (hormones)
- trauma to pelvic floor
- pervious surgery (if previous conservative treatment failed, they would need continence surgery)
- denervation
- increased intra-abdominal pressure
what are some of the medical conditions that can result in FUI and how?
- DM - polyuria/nocturia
- hypertension - diuretic meds
- closed angle glaucoma - need anticholinergics, which worsens incontinence
- heart/kidney/liver disease - FUI treatment plans must be altered
- cognitive/depression problems - antidepressants/psychotics like oxybutynin have anticholinergic effects.
presentation of FUI (divide into irritation symptoms, incontinence symptoms, voiding symptoms, and others)
- irritation symptoms:
- urgency
- dysuria
- frequency (daytime >7)
- nocturia (nighttime > 1)
- haematuria
- incontinence symptoms:
- SUI
- UUI
- coital incontinence
- voiding symptoms:
- straining to void
- interrupted flow
- recurrent UTI
- others:
- prolapse
- bowel symptoms
what are the two red flag signs in FUI that needs urgent followup?
- frank haematuria with no signs of cystitis or Hx of smoking
- recurrent UTI
investigation for FUI (3 main ones) and their purpose
- urinalysis (dipstick +/- MSSU) - rule out UTI
- post voiding residual bladder scan
- urodynamics
- (3 days bladder diary)
Urodynamics is usually avoided due to its invasive nature requiring specialized professionals. When is urodynamics performed? (2 conditions)
- for OAB (overactive bladder) or DO (detrusor overactivity)
- for SUI if there are voiding symptoms, prolapse, or planning to do surgery
what scale is used to assess the pelvic floor muscles strength?
oxford scale (out of 4)
what is the main treatment method for FUI?
conservative management:
- lifestyle changes:
- stop smoking
- lose weight
- eat healthy to avoid constipation
- reduce alcohol intake, caffeine, fizzy drinks, chocolate
- physio:
- PFMT - 60-70% cure
what are the 3 goals for PFT in FUI?
- reinforcement of cortical awareness of the muscle groups
- hyperplasia of pre-existing muscles
- general increase in muscle strength and tone
what is the single pharma management for FUI?
duloxetine (SNRI) - GOLD standard
- increases nerve stimulation to muscle
- recommended dose 40 mg x2/day, but if high risk of side effects start with 20 mg x2/day for 2 wks
- used after/with PFMT in those who still wishes to get pregnancy and doesn’t want surgery
what are the 2 theories of incontinence?
- pressure transmission theory - in SUI, bladder neck descends out of pelvic cavity –> must be elevated to fix
- integral theory - prolapse and SUI pelvic floor symptoms arise from laxity of anterior vaginal wall and pubourethral ligament (PUL) which acts in the high pressure zone at the mid urethral level. The laxity of this hammock structure underneath the urethra –> bladder neck closure dysfunction –> stretch receptors activated –> premature micturition reflex.
the 4 surgical treatment for SUI, which one is GOLD standard?
- synthetic midurethral sling (MUS)/tension free vaginal tape (TVT) - GOLD standard
- minimally invasive with the same outcome (80% cure at 8 yrs followup as colosuspension)
- hammock created at mid urethral level for reinforcement
- minimally invasive with the same outcome (80% cure at 8 yrs followup as colosuspension)
- autologous rectus fascial strings
- using flap taking from abdominal rectus sheath –> hammock
- colposuspension: open/laparoscopic lifting of vaginal wall at the bladder of the bladder neck up to the iliopectineal ligament and forming a hammock around the bladder neck.
- urethral bulking - injected to bulk surrounding tissue, must be repeated every 6-9 months, 70% 1 yr cure rate, and reserved for frail ppl who still want to get pregnant or doesn’t want surgery
risks for OAB (4)
- age
- DM
- smoking
- recurrent UTI
what are the 3 presentations of OAB
(is a type of UUI, chronic disease and therefore symptoms wax and wane)
- urgency +/- UUI
- frequency
- nocturia
what are the conservative management for OAB?
- lifestyle changes - same as FUI
2. bladder training (timed voiding with increasing interval)
what are some of the pharma management of OAB? Divide this into oral (6) and transdermal (2)
oral: antimuscarinic, anticholinergics
1. oxybutynin (5-10 mg/tds)
2. solifenacin (5-10 mg)
3. fesoterodine (4-8 mg)
4. trospium chloride (60 mg)
5. darifenacin (7.5-15 mg)
6. lyrinel XL (10-20 mg)
transdermal:
1. impiramide (tricyclic antidepressant) - noctuira
2. mirabegron (B3 antagonist antispsmodic)
what are the 2 newer treatments available for OAB, and when are they used?
used after failure of medications:
- botox (butulinum toxin) injection
- 70% cure, effective for 6-9 months
- 10% needs CISC
- neuromodualtion (sacral n. stimulation)
- pacemaker of bladder implanted in the buttocks and sending impulses to S2
- inhibition of micturition center –> inhibited detrusor muscle –> decreased incontinence
- minimally invasive and cheap
- 70% improvement in refractory OAB
