Gynae - Urogynae Flashcards
what is the managment for stress incontinence?
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
what is the management for urge incontinence?
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
how would one ivx stress and urge incontinence?
what might you find?
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
what are some contraindications to oxybutinin?
oxybutynin should, however, be avoided in ‘frail older women’
define acute urinary retention ?
unable to pass urine for 12hours +
list some causes of chronic retention and overflow incontinencee?
Pelvic masses and incontinence surgery are common causes of urethral obstruction
Autonomic neuropathies (e.g. diabetes) and previous overdistension of bladder cause detrusor inactivity
a distended, non-tender bladder may indicate which presentation?
chronic retention and overflow incontinence
Suprapubic pain related to bladder filling may indicate which presentation?
Painful Bladder Syndrome and Interstitial Cystitis
may have frequency in absence of UTI
what are the most common types of fistulae and how are they inveestigated?
Most common are vesicovaginal and urethrovaginal
Ix: CT urograms or cystoscopy
where does endomeetriosis usually occur?
uterosacral ligaments and on or behind ovaries
accumulated blood as a result of endometrioisis can cause?
endometrioma aka chocolate cyst
Most severe form of endometriosis is what?
Frozen pelvis:
refers to a condition in which pelvic organs are distorted and tethered to each other as a consequence of adhesive processes
what is the aetiology of endometriosis?
retrograde menstruation
More distant foci due to mechanical, lymphatic or blood-borne spread
what are the preesenting sx of endometriosis?
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
what might examinations reveal in endometriosis?
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
what are the ivx for endometriosis?
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
Extensive adhesions and ovarian endometrioma suggest?
severe disease in endometriosis
less active endometriosis looks like what on laparoscopy
White scars or brown spots (‘powder burn’)
what is the Relationship between disease severity and sx?
limited / unclear
how is endometriosis treated?
- 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
- Laparoscopic endometrioma/Cyst inner lining excision
1b. OR only chocolate cyst drainage - fertility sparing - diathermy – used laparascopically at time of diagnosis to destroy endometriotic lesions ; improvees fertility
- Radical surgery involves dissection of adhesions and removal or endometriomas (even TAH+BSO)
endometriosis is driven by?
estrogen
define chronic pelvic pain?
intermittent or constant pain in lower abdomen or pelvis for 6m duration,
not occurring exclusively with menstruation or intercourse
list some examples of anti-muscarinics?
who cant receive these drugs
oxybutinin
tolterodine
If frail older patient, use mirabegron (beta-3-agonist) due to anti-cholinergic side effects
what are the downsides of surgical procedures for correcting stress incontinence?
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.
what are the details of sling proceedures that patients should know?
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
what is the overall impact of urinary incontinence on patients?
UTI
AKI
Depression (effect on sexual and social functioning)
Falls
how is the management of urinary incontinence determined?
often by determining the effect of the symptoms on the patients quality of life.
what are the degrees of uterine descent?
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)
what is the risk facotr for vaginal vault descent in particular?
After hysterectomy, the proximal end of the vaginal vault can prolapse within or outside the vagina (so there are degrees of descent)
