Gynae - Urogynae

Question 1

what is the managment for stress incontinence?

Answer 1

1st line: Pelvic floor muscle training
§ NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months

o 2nd line: Surgical procedures
§ Mid-urethral sling:
- TVT or TOT (has less risk of perforation)
- type depnds on personal case

§ Consider periurethral bulking agents (older its/ if above dont work)

o 3rd line: Duloxetine then r/v in 2-4 weeks if unsuitable for surgery/prefer
pharmacological to surgical Rx

Question 2

what is the management for urge incontinence?

Answer 2

Conservative: avoid caffeinated drinks or artificially flavoured drinks, aim for 1.5-2.5 L of water per day, lose weight

o 1st Line: Bladder retraining for 6 weeks
§ Aim to gradually increase the intervals between voiding

o 2nd Line: Bladder stabilising drugs - antimuscarinics
- oxybutynin or tolterodine

o 3rd Line: Mirabegron (beta-3 agonist)
§ May be useful if there is concern about anticholinergic side-effects in frail elderly patients

o 4th Line: Surgical & Other Procedures
§ Botox injection
§ Percutaneous tibial nerve stimulation (PTNS) or sacral nerve stimulation (SNS)
§ Augmentation cystoplasty - severe resistant tissue

Question 3

how would one ivx stress and urge incontinence?

what might you find?

Answer 3

stress:
urine dipstick (exclude for uti - if suspected then MCS) Urodynamics - cystometry

urge:
bladder/urine diary - will be nocturia and small volumes
Urodynamics - cystometry
cystoscopy - contractions on filling - doesnt tell you about bladder function

Question 4

what are some contraindications to oxybutinin?

Answer 4

oxybutynin should, however, be avoided in ‘frail older women’

Question 5

define acute urinary retention ?

Answer 5

unable to pass urine for 12hours +

Question 6

list some causes of chronic retention and overflow incontinencee?

Answer 6

Pelvic masses and incontinence surgery are common causes of urethral obstruction

Autonomic neuropathies (e.g. diabetes) and previous overdistension of bladder cause detrusor
inactivity

Question 7

a distended, non-tender bladder may indicate which presentation?

Answer 7

chronic retention and overflow incontinence

Question 8

Suprapubic pain related to bladder filling may indicate which presentation?

Answer 8

Painful Bladder Syndrome and Interstitial Cystitis

may have frequency in absence of UTI

Question 9

what are the most common types of fistulae and how are they inveestigated?

Answer 9

Most common are vesicovaginal and urethrovaginal

Ix: CT urograms or cystoscopy

Question 10

where does endomeetriosis usually occur?

Answer 10

uterosacral ligaments and on or behind ovaries

Question 11

accumulated blood as a result of endometrioisis can cause?

Answer 11

endometrioma aka chocolate cyst

Question 12

Most severe form of endometriosis is what?

Answer 12

Frozen pelvis:

refers to a condition in which pelvic organs are distorted and tethered to each other as a consequence of adhesive processes

Question 13

what is the aetiology of endometriosis?

Answer 13

retrograde menstruation

More distant foci due to mechanical, lymphatic or blood-borne spread

Question 14

what are the preesenting sx of endometriosis?

Answer 14

Dysmenorrhoea before onset of menstruation

 Deep dyspareunia
 Subfertility
 Pain passing stool
 Menstrual problems

o Rupture of chocolate cyst may be first symptom

Cyclical haematuria, rectal bleeding or bleeding from umbilicus = late and suggestive of extensive disease

Question 15

what might examinations reveal in endometriosis?

Answer 15

if mild: can be normal

o Tenderness and or thickening behind the uterus or in adnexa
o Uterus may be retroverted and immobile
o Rectovaginal nodules of endometriosis may be apparent on DRE

Question 16

what are the ivx for endometriosis?

Answer 16

1st linee - TVUS
o Confirms endometrioma

LOL have you been into clinic before?
1 - Bimanual ; reduced uterine motion, tethering seen. very tender on exam.

others;
1. Diagnostic Laparoscopy
o Visualisation + biopsy
o Active lesions = red vesicles or punctate marks on peritoneum

Question 17

Extensive adhesions and ovarian endometrioma suggest?

Answer 17

severe disease in endometriosis

Question 18

less active endometriosis looks like what on laparoscopy

Answer 18

White scars or brown spots (‘powder burn’)

Question 19

what is the Relationship between disease severity and sx?

Answer 19

limited / unclear

Question 20

how is endometriosis treated?

Answer 20

1. NSAIDs - dysmenorrhoea and pelvic pain

o COCP
more effective if tricycled (3 packets taken back to back)
§ can be taken without a break to induce amenorrhoea

§ If ineffective :

o Progestogens - if contraindications for the COCP
§ The depot-medroxyprogesterone acetate and levonorgestrel IUS

o GnRH Agonists - not used for more than 6 months -
osteoporosis

Surgery

1. Laparoscopic endometrioma/Cyst inner lining excision
   1b. OR only chocolate cyst drainage - fertility sparing
2. diathermy – used laparascopically at time of diagnosis to destroy endometriotic lesions ; improvees fertility
3. Radical surgery involves dissection of adhesions and removal or endometriomas (even TAH+BSO)

Question 21

endometriosis is driven by?

Answer 21

estrogen

Question 22

define chronic pelvic pain?

Answer 22

intermittent or constant pain in lower abdomen or pelvis for 6m duration,

not occurring exclusively with menstruation or intercourse

Question 23

list some examples of anti-muscarinics?

who cant receive these drugs

Answer 23

oxybutinin
tolterodine

If frail older patient, use mirabegron (beta-3-agonist) due to anti-cholinergic side effects

Question 24

what are the downsides of surgical procedures for correcting stress incontinence?

Answer 24

The most commonly reported problem associated with the use of slings is difficulty emptying the bladder completely when peeing.

A small number of people who have the procedure also find they develop urge incontinence afterwards.

Question 25

what are the details of sling proceedures that patients should know?

Answer 25

can be performed as outpatient

local/general or regional (spinal/epidural) sedation

15 minutes procedure?

very quick. can go home straight if local. if general used, will stay for few hours post surgery.

if problems passing urinee after - stay overnight

Question 26

what is the overall impact of urinary incontinence on patients?

Answer 26

UTI
AKI
Depression (effect on sexual and social functioning)
Falls

Question 27

how is the management of urinary incontinence determined?

Answer 27

often by determining the effect of the symptoms on the patients quality of life.

Question 28

what are the degrees of uterine descent?

Answer 28

Graded by cervical position

First degree: Cervical descent within the vagina

Second degree: Cervical descent to the introitus

Third degree: Cervical descent outside the introitus (procidentia)

Question 29

what is the risk facotr for vaginal vault descent in particular?

Answer 29

After hysterectomy, the proximal end of the vaginal vault can prolapse within or outside the vagina (so there are degrees of descent)