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Obstetrics and Gynaecology > Continence and Prolapse > Flashcards

Continence and Prolapse Flashcards

1
Q

What are the types of genitourinary prolapse?

A

Anterior compartment
- urethrocele or cystocele or cystourethrocele

Posterior compartment
- rectocele

Middle compartment
- uterine or vaginal vault (post-hysterectomy) or enterocele (pouch of douglas and small bowel)

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2
Q

How can genitourinary prolapses be classified into stages?

A

Based on where the most distal part of the prolapse lays on straining
1 - >1cm above hymen
2 - Within 1cm distal or proximal to hymen
3 - >1cm below hymen
4 - Complete eversion

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3
Q

How can genitourinary prolapses present?

A 
Feeling of vaginal fullness/pressure
Seeing bulge
urinary incontinence (any type) 
feeling of incomplete emptying
constipation or fecal incontinence 
dyspareunia 
vaginal flatus
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4
Q

How would you examine a patient with a genitourinary prolapse?

A

Standing and left lateral positions

Ask patient to strain and cough

Sims speculum

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5
Q

How can genitourinary prolapses be managed conservatively?

What would you prescribe if there was co-existing vaginal atrophy?

A

Treat cough or constipation
Weight loss and smoking cessation
Stop heavy lifting

Atrophy: Vaginal oestrogen creams

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6
Q

What are the side affects and risks of vaginal pessaries for prolapse?

A

Can cause discharge, odour, vaginal erosions, fistulas and sepsis

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7
Q

What surgical options are available for genitourinary prolapse? What type of prolapse would each be used for?

A

Cystourethocele: anterior colporrhaphy or colposuspension

Rectocele: posterior colporrhaphy

Uterocele: hysterectomy

Vaginal vault: sacrocolpoplexy

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8
Q

What is the first line non-surgical management option for urogenital prolapse?

A

16 weeks of pelvic floor muscle exercises
AND/OR
vaginal pressary

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9
Q

What is a colposuspension?

A

Sutures to suspend bladder neck to pelvic side wall

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10
Q

What is colpocleisis?

A

Closing off of vaginal canal

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11
Q

What are the types of urinary incontinence?

A 
Stress
Urge
Mixed
Overflow
Functional
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12
Q

What is stress incontinence?

A

Involuntary leaking of urine upon exertion

e.g. when coughing or sneezing

Due to incompetent sphincter

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13
Q

What is urge incontinence?

A

Involuntary leakage of urine alongside or just after urgency

Due to detrusor overactivity

e.g. Suddenly need toilet then v quickly leak

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14
Q

What is mixed incontinence?

A

Both stress and urge together

Leak when coughing and also get sudden urges with leakage

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15
Q

What is overflow incontinence?

A

Involuntary leakage of urine due to chronic bladder outflow obstruction

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16
Q

What is functional incontinence?

A

Can’t get to toilet in time due to mobility issues

17
Q

What are the main risk factors for urinary incontinence?

A

Advancing age
Vaginal delivery
Overweight

Others include:
Forceps, heavy baby, diabetes, frequent UTI, neurological disease, pelvic tumours, stool impaction, family history, hysterectomy

18
Q

How is urinary incontinence investigated?

A

Bladder diary for 3 days
Urine dip - infection, glucose, protein?
Speculum - prolapse? visualise if able to contract pelvic flood muscles
Quality of life questionnaire
Post micturition bladder scan - residual volume

19
Q

When are urodynamic studies done for urinary incontinence?

A

When you are unsure of the cause following bladder diary, examinations etc.

20
Q

How can urinary incontinence be temporarily managed?

A

Pads - done until diagnosis and full management plan in place

21
Q

What lifestyle changes are suggested in the management of urge incontinence?

A

Reduce caffeine
Lose weight - if BMI >30
Drink 2L per day

22
Q

What is the stepwise management plan for urge incontinence?

A

1 - Bladder training
2 - Medication
3 - Botulinin toxin A injections
4 - percutaneous sacral nerve stimulation

23
Q

What is bladder retraining?

A

6 week plan where patients have scheduled voiding times with increasing time intervals

24
Q

What medication can be used for urge incontinence?

What is given to frail elderly women?

A

Antimuscarinics - effect may take 4 weeks to be seen

  • Oxybutynin - immediate release
  • Tolterodine - immediate release
  • Darifenacin

Mirabegron for elderly as oxybutynin contraindicated

25
Q

What is the MOA, ADR’s and CI’s for antimuscarinics in urge incontinence?

A

MoA - Relax urinary smooth muscle
ADR - Constipation, dizzy, dry mouth and eyes, flushing, temperature
CI - severe UC and urinary retention, oxybutynin not for frail elderly

26
Q

How long does botulinin toxin A for incontinence last?

What are the risks?

A

Benefits seen after 4 days. Last 6-9 months

Risks - urinary retention requiring catheter, UTI

27
Q

Describe the use of percutaneous sacral nerve stimulation in urge incontinence

A

Done in 2 stages - test phase and then implantation if test successful

Percutaneous sacral nerve stimulation

28
Q

What medication can be used if nocturnal symptoms of urge incontinence are particularly severe?

A

Desmopressin

29
Q

What is the conservative management for stress incontinence?

A

Pelvic floor exercises

8 Contractions 3x a day for 3 months

30
Q

What is the surgical management for stress incontinence?

A

Colposuspension

Autologus rectal fascial sling

Retropubic mid-urethral mesh sling - NICE recommend offering the other 2 first as some concerns over mesh slings

31
Q

What are the risks of surgical management of stress incontinence?

A 
Damage to bladder and bowel
Damage to nerves
Urge incontinence
Pelvic pain
Dyspareunia
32
Q

What are the specific risks of using a mesh sling for stress incontinence?

A

Vaginal mesh exposure can lead to pain

Discharge and bleeding

Mesh may come through bladder or urethra –> urinary symptoms

Women should be warned it is not reversible - the mesh may never be able to be completely removed

33
Q

What management options are available for stress incontinence if the women doesn’t want surgery?

A

Intramural bulking agents

Duloxetine

34
Q

What are the risks of intramural bulking agents?

A

Urinary retention

Urge incontinence

UTI

35
Q

What are the ADR’s associated with duloxetine?

A 
GI disturbance
Dry mouth
Headache
Decreased libido
Anorgasmia
36
Q

What is the first line management for mixed incontinence?

A

Either bladder retraining therapy or pelvic floor muscle exercises

37
Q

a bladder diary shows

a) reduced volume that is always the same
b) reduced volume that differs each time

What is the likely diagnosis?

A

a) bladder wall pathology eg carcinoma

b) overactive bladder i.e. detrusor overactivity

38
Q

Describe the appearance of a flow rate graph (x axis is time and y axis is rate) for

a) stress
b) obstruction

A

a) very quick rise and then fall in flow rate as little resistance so get superflow
b) reduced flow rate and urinates over a longer period of time i.e. takes longer to empty bladder as reduced flow rate

Obstetrics and Gynaecology (21 decks)

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