MIsc Flashcards
random factoids
pudendal nerve comes from which nerve roots
S2-4
IC cysto findings?
Hunner’s ulcer
reduced bladder capacity
glomerulations
increased capillary vasculature
Patient presents with burning/pain from the labia to the pubic symphysis after labiaplasty for labial elongation.
What nerve was injured?
dorsal nerve of the clitoris
MOA of methenamine
raises pH in the bladder making it in hospitable to GI bacteria
What is the generic name for elmiron
pentosan polysulfate sodium
risk of occult SUI after anterior or apical POP surgery
40%
UDS patient start to get dizzy, sweating, high BP, spasticity,
ddx?
autonomic dysrreflexia (lesion at T6 or above)
nervous
treatment for autonomic dysrreflexia
empty the bladder
nifedipine 10mg IR tablets OR
nitroglyercine paste above the level of the injury (wipe off when BP improves)
indications for video UDS
spinal cord injury
ureteral reflux
obstruction
Elmiron
- generic name
- dose
- how long to see effects
- side effects
- MOA
- pentosan polysufate
- 100 mg TID
- 6 months
- reversible hair loss,
-elevated LFTs (get labs at 6 months
-permanent retinal pigmentary changes if more than 3 years!!! - reconstitutes the GAG layer of the urothelium
what is the normal pH of the vagina?
3.5-4.5
what is your risk of FI at age 40 after 1 OASI
26%
what is your risk of FI at age 40 after 2 OASI
33%
What is your risk of FI af age 60 after 2 OASI
48%
What are the properties of restorelle Y mesh
weight 19 g/m^2
pore size is 3.24 millimeters^2
180 microns thickness
how often does lichen sclerosus become malignant?
6%
describe the 4 classes of female genital cutting?
type 1- removal of the prepuce with or without partial or total removal of the clitoris
type 2-removal of the clitoris with all or part of the labia minora
type 3- removal of part or all of the labia minora and sewing the labia majora together, leaving only a small hole for urination and menstural fluid.
Type IV includes any other injury to the female genital organs (eg, pricking, piercing, incising, scraping, and cauterizing).
patient presents with vulvovaginal pain and itching.
ddx?
genitourinary syndrome of menopause
vulvar dermatosis- lichen
vuvlovaginitis
atopic dermatitis
malignancy
You see vulvar skin changes suggestive of lichen sclerosis, but it is not responding to standard treatment. you elect to perform a bx.
describe the key areas you would target.
sclerotic lesions or ulcerative areas, it is preferable to biopsy the edge of the lesion including a border with normal skin
when sampling hyperpigmented areas, biopsy of the thickest region is recommended
lichen sclerosis
Describe the dosing frequency of topical steroid
OINTMENT nightly for 4 weeks, every other night for 4 weeks, 2x weekly for 4 weeks
data shows 56 weeks of aintenance dosing should be safe
options for surgical mgmt of rectal prolapse?
transrectal-delorme for mucosal prolapse, altmeier for full thickness
abdominal-ventral rectopexy with or without mesh, with or without partial bowel resection
risk factors for failure of pessary fitting?
GH >4cm
TVL 6cm or less
obesity
prior prolapse surgery
prior hysterectomy
atrophy
lack of pelvic floor tone
pessary options for POP with SUI beside incontinence ring or incontinence dish
marland- looks like a ring with a shelf
your POP patient wants expectant management. What is the chance of the prolapse progressing?
78% will have little or no progression over the following year
how to diagnose bladder outlet obstruction in women?
flow rate < 12 ml/sec
pdet > 20 cm H2O
elevated PVR
risk of de novo oab after a sling?
5-10% after 12 weeks
risk of recurrent SUI after a sling release:
simple transection?
complete removal?
7%
60%
What is the risk of malignancy in a urethral diverticulum?
6-9%
adenocarcinoma
list the risk after urethral diveritculetomy
urethrovaginal fistula (mean, 4.2%)
recurrent diverticulum (mean, 12.2%),
stress incontinence (mean, 8.5%),
recurrent urinary tract infections (mean, 11.7%), urethral strictures (mean, 2.1%).
Patient is planning urethral diverticulectomy.
risk of SUI after diverticulectomy?
8.5%
Patient is planning urethral diverticulectomy.
risk of urethrovaginal fistula?
4.2%
Patient is planning urethral diverticulectomy.
risk of recurrent diverticulum
12.2%
Patient is planning urethral diverticulectomy.
risk of urethral stricture
2.1%
name 5 options for abx ppx for rUTI.
fosfomycin 3g q 10 days,
nitrofurantion 50mg
trimpethoprim 100mg,
TMP/SMX 40/200mg daily or three times weekly
keflex 125 mg or 250mg daily
What is a relapsing UTI vs recurrent UTI?
relapsing- positive infection with the same organism within 2 weeks despite appropriate treatment
recurrent- 2+ culture proven in 6 months or 3 in one year.
Name 3 risk factors for recurrence of urethral diverticulum.
urethral infection at the time of surgery
difficult dissection
excessive suture line tension
How do you counsel patients regarding rUTI treatment?
abx vs non-abx treatment
- Cranberry-lots of variability in the cranberry amounts so it’s hard to replicate the studies.
- 1.5L of water
- vaginal estrogen, even a small amount for premenopausal patient on OCPs
UTI and fosfomyin
Insurance is most likely to cover fosfomycin for treatment of what organsim?
Extended-Spectrum Beta-Lactamase producing bacteria
risk factors for rUTI in premenopausal patients
spermicide
low dose OCPs can create mild atrophy
what is the evidence regarding D-mannose for UTI?
-binds to bacteria surface ligands to prevent adherence to the urothelium
-no quality studies to demonstrate significant benefit or harm
what is the evidence regrading methanamine?
1000mg BID converts to formaldehyde
GI upset
what is the lowest acceptable GFR for methenamine use?
> 10 mL/min
how long would you rx ppx abx for rUTI?
6 months to 1 year and reassess
Discuss the abx and dose for intravesical abx for rUTI that is the most commonly used.
Gentamicin 80mg with 50-60cc of normal saline
your rUTI patient has a GFR of less than 30 mL/min.
What are her abx ppx options?
Trimethoprim at 100 mg daily
Fosfomycin at 3 gm every 10 days
NO nitrofurantoin, methenamine or sulfa
how do you mix botox?
how to administer botox?
instill 10cc of injectable NS, mix by rotating the vial. use within 24hrs, keep refrigerated (2° to 8°C) for up to 24 hours until time of use.
give 20 injections 1cm apart 0.5cc each
flush with 1cc saline
pee before you leave
stop anti-platelets 3 days before
what makes a fistula complex?
-size greater than 2.5cm
-urethra, ureter or rectal involvement
-more than 1 fistula
-radiation
chornic inflammation
f-ailed prior repairs
describe your basic urogyn exam
-visual inspection- atrophy, skin break down
-neuro exam- anal wink, bulbocavernosis reflex
-CST/urethral mobility, UA, PVR
-POP-Q
-speculum exam
-digital exam- levator tone and pain points
-bimanual exam- anterior wall/GYN abnormalities
-rectal exam
name the perineal branches of the pudendal nerve.
dorsal nerve of the clitoris
perineal
inferior rectal
You suspect a VVF bc of pooling on pelvic exam and complaint of UI.
next steps
explain findings
dual dye test
foley for bladder rest
obtain op report
What imaging studies can you do to rule out concomitant Uterovaginal fistula in the setting of VVF?
CT urogram
RPG
MRI- better fore vesicouterine fistula
IVP- can miss ureteral injury at the trigone
Patient presents with UTI symptoms. What is the lowest trhreshold for CFU for UTI treatment?
10^2 CFU
rUTI
At what threshold of community resistance would you not use a specific abx for ppx?
20%
when would you order imaging fro rUTI work up?
short interval UTI
proteus or pseudomonas UTI
concern for colovesical fistula if diverticular disease
rule out foreign body/history of sling
Define these terms
- mesh compliance
- mesh elasticity
- mesh tensile strength
- mesh creep behavior
- mesh fatigue
- ability to move with the body
- ability for mesh to stretch and return to it’s original shape
- the max strength a mesh
- the deformation of a mesh over time when it’s under constant stress
- the way a mesh structure responds to cyclic loading and accumulates damage, which can lead to mechanical failure
What is the typical thickness of the anterior longitudinal ligament?
2 mm
Do you reperitonealize SCP mesh?
yes, but there is evidence to suggest reperitonealizing mesh does not reduce the risk of small bowel obstruction.
what percent of ectopic ureters come with duplicate ureters?
75%
chance of bladder problems in MS?
90%
6 risk factors for bladder cancer
-irritative lower urinary tract symptoms
* prior pelvic radiation therapy
* history of cyclophosphamide/ifosfamide
chemotherapy
* family history of urothelial carcinoma or
Lynch syndrome
* occupational exposure to benzene
chemicals or aromatic amines (oil, gas, plastics)
* chronic indwelling foreign body in the
urinary tract.
microheme
Intermediate-Risk factors
- Women age ≥60; Men age 40-59
- 10-30 pack-years smoking
- 11-25 RBC/HPF on one UA
- One or more additional risk factors for urothelial cancer1
- Previously low/negligible-risk, no prior evaluation and 3-25 RBC/HPF on repeat UA
at what age should low risk women get cysto/renal sono
60
evidence for trigger point injection
3-4 months
SE of triamcinolone
muscle atrophy and risk of abscess
monitoring for methenamine longterm
monitor LFTs at least once per year
can try for 6 months and take a holiday
read that pessary paper!!
https://journals.lww.com/fpmrs/pages/articleviewer.aspx?year=2023&issue=01000&article=00002&type=Fulltext
contraindication to methanamine
renal and liver tox
