Gynecology Flashcards
What is the UVJ?
Urethrovesical junction
– where the Bladder meets the Urethra (NOT the ureters!)
The balance of what 2 pressures are the cause of urinary continence vs. incontinence?
Intra-urethral pressure must exceed intra-vesical pressure for urinary continence at rest.
What are Estrogen’s effects on urinary continence?
Estrogen increases intra-urethral pressure.
Lack of estrogen, decreases intra-urethral pressure, causing INcontinence at rest.
Internal vs. External urethral sphincter: which is continuously contracted, maintaining continence?
Internal urethral sphinctor is continously contracted & maintains intra-vesical pressure.
The External provides about 50% of urethral resistance & is second line of defense against incontinence
4 major types of incontinence
- Stress: urine loss w/ exertion/straining such as laughing, coughing, exercising. Ass’d w/ pelvic relaxation & displacement of urethrovesical junction.
- Urge: leakage due to involuntary & uninhibited bladder contractions; detrusor instability.
- Total: continuous leakage due to urinary fistula resulting from pelvic surgery or pelvic radiation.
- Overflow: poor/absent bladder contractions leading to urine retention & overdistension of bladder
Cotton swab test
Hypermobility = Stress incontinence
A swab is placed in the urethra to the bladder neck. Movement of the UVJ w/ Valsalva (straining) should be less than 30 degrees.
When pelvic relaxation results in hyper mobility of the bladder neck, there is a large change of UVJ w/ Valsalva
Cystometrogram – what is it & what’s it’s use?
Pressure sensors used to determine bladder & sphincter tone as bladder is filled w/ fluid.
Used to distinguish between genuine stress incontinence & detrusor instability.
Risk factors for stress incontinence?
Cause Pelvic Relaxation:
Childbirth, Aging, Genetics
Cause Chronic Increases in Intra-Abdominal Pressure:
- Constipation, chronic coughing (lung disease, smoking), chronic heavy lifting, obesity (worsens incontinence, doesn’t cause it)
Cause Weakening of Urethral Closing Mechanism:
- Estrogen deficiency (menopause), scarring, denervation, meds
Stress Incontinence diagnostic findings?
- Poor anatomic support w/ Cotton swab test, X-ray, or Urethroscopy
- Demonstratable leakage w/ stress (stress test or pad test)
- Normal urinalysis, Neuro exam, Cystometrogram or Urethrocystometry
- Negative Urine Culture
Common cause of stress incontinence?
Usually due to pelvic relaxation (i.e. w/ aging or childbirth) that results in a hyper mobile bladder neck or from intrinsic sphincter deficiency
Detrusor instability, o/w known as ____ incontinence.
Urge
– results from involuntary & uninhibited bladder contractions
Causes of urge incontinence?
- Idiopathic (most common)
- UTIs
- Bladder stones
- Cancer
- Diverticula
- Neurologic disordes (stroke, MS, Alzheimer’s, cerebrovascular accident)
Urge incontinence symptoms?
Urinary urge
- Frequency
- Nocturia
Meds that treat urge incontinence?
Anticholinergics (Imipramine, Tolterodine, Oxybutynin)
- can also use bladder training
- if neuro cause present, treat neurologic disorder
Total incontinence causes?
Usually Fistulas:
Vesicovaginal, Urethrovaginal, or Ureterovaginal
- caused by pelvic radiation & pelvic surgery in >95% of cases in U.S.
- in developing countries, usually attributable to obstetric trauma, leading to urinary fistula
Total incontinence Tx?
Surgical repair of fistula
Overflow incontinence causes?
Most commonly Detrusor insufficiency caused by meds or neurologic disease
– obstruction & post-operative distension occur less frequently in women
Overflow incontinence Tx?
Self-catheterization
Meds:
- Cholinergic agents (increase contractility)
- α-adrenergics (lower urethral resistance)
HPV types ass’d w/ cancer & hyperplasia?
16, 18, 31, & 45
Management of high risk Pap smears?
Colposcopy & directed biopsy
includes:
- - ASC-H, LSIL, HSIL,
- - ASC-US w/ high risk type of HPV
CIN I management?
Followed w/ repeat pap smears q 6 months x 1 year
CIN II management?
CIN II or III should be treated w/ surgical excision (LEEP/loop/Lletz)
CIN II or III confined to ectocervix management?
Destruction of lesion w/ LEEP, laser therapy, or cryotherapy
CIN II or III confined to endocervix management?
2-stage LEEP or cold knife conization (CKC)
