O&G:Urogynae Flashcards
What are the two main causes of incontinence in females?
1) Uncontrolled increases in detrusor pressure
- Increased bladder pressure beyond that of normal urethra, most common cause OAB
2) Increased intrabdominal pressure
- Most common cause is urinary stress incontience
What is urinary stress incontinence?
Involuntary leakage of urine on effort or exertion eg. sneezing or coughing. aka urodynamic stress incontinence.
Causes of urinary stress incontinence?
- Pregnancy
- Vaginal delivery
- Prolonged labour
- Forcep delivery
- Obesity
- Age
- Prev hysterectomy
- Prolapse usually coexists
Mechanism of urinary stress incontinence?
Increased abdominal pressure compresses the bladder, but weak sphincter causes incontinence.
Clinical features of urinary stress incontinence?
Frequency, urgency, urge incontinence, faecal incontience (due to childbirth injury)
On examination of stress incontinence?
Sims speculum: Cystocele, urethrocele
Leakage with coughing
Palpate abdomen to exclude distended bladder
Investigations for stress incontinence/
Urine dipstick to exclude infection
Cystometry to exclude OAB
What is the conservatiive management of stress incontinence?
- Pelvic floor muscle training for minimum 3 months. At least 8 contractions 3 times a day
- Vaginal cones - held in position by voluntary muscle contraction
- Lose weight, decrease excessive fluid intake, address underlying cough eg smoking
What is the pharmaceutical management of stress incontinence?
- Duloxetine: an SNRI, enhances urethral striated sphincter activity.
S/e: Nausea, dyspepsia, dry mouth, dizzy, insomnia, drowsy
What is the surgical management of stress incontinence?
- Tension free vaginal tape
- Transobturator tape
- Injectable peri-urethral bulking agents
What is overactive bladder?
Urgency, with or without urge incontinence, usually with frequency or nocturia, in the absence of proven infection.
Causes of OAB?
- Mostly idiopathic
- Bladder neck obstruction, post USI operation
- Underlying neuropathy eg.ms
- Detrusor overactivity
What is detrusor overactivity?
A urodynamic diagnosis characterised by involuntary detrusor contractions during the filling phase. Either spontaneous or provoked eg. coughing
Clinical features of OAB?
- Urgency
- Urge incontinence
- Frequency
- Incontinence
- Nocturia
- Stress incontinence
- Leak at night or at orgasm
- Faecal urgency
- Hx of childhood enuresis is common
Investigations of OAB?
Examination: often normal (may be incidental cystocele)
Urinary diary:
- Frequent passage of small volume of urine, especially at night.
- High intake of caffeine
Cystometry:
- Contractions on filling or provocation
- Indicated after failure of lifestyle changes and drug management
Conservative management of OAB?
Conservative:
- Reduce fluid intake and caffeine
- Bladder training
Drug management of OAB?
Drugs:
- Anticholinergics/antimuscarincs - block detrusor smooth muscle action eg Oxybutynin s/e dry mouth
- Oestrogens - in post-meno it reduces sx of vaginal atrophy and decreases sx
- Botulinum toxin a - blocks the neuromuscular transmission, so weakens detrusor. s/e retention, voiding dysfunction
Other managemnt of OAB?
Other tx:
- Neuromodulation and sacral nerve stimulation
- Surgery - Clam-augmented iliocystoplasty
What is a level one prolapse?
Cervix and upper 1/3rd of vagina
- Cardinal ligament
- Uterosacral ligament
What is a level two proplapse?
Midportion of vagina
- Endopelvic fascia attach vagina laterally to side walls
What is a level three prolapse?
Lower 1/3rd of vagina
- Supported by levator ani muscles and the perineal body
What is a Urethrocele?
Prolapse of lower anterior vaginal wall involving urethral only
What is a Cystocele?
Prolapse of upper anterior vaginal wall involving the bladder
What is a Cystourethrocele?
Prolapse involves bladder and urethra
What is an apical prolapse?
Prolapse of uterus, cervix and upper vagina
What is an enterocoele?
Prolapse of upper posterior wall of vagina, resulting pouch may contain loops of bowel
What is a rectocele?
Prolapse of lower posterior wall of vagina, involving anterior wall of rectum.
What is the ICS pelvic organ prolapse scoring system?
0: No descent of pelvic organs during strainign
1: Leading surface of proplapse does not descend below 1cm above the hymenal ring
2: Leading edge of prolapse extends from 1cm above to 1cm below the hymenal ring
3: Prolapse extends 1cm or more below the hymenal ring but without complete vaginal eversion
4: Vagina completely everted (complete procidentia)
Risk factors for prolapse?
- Vaginal delivery and Pregnancy: Large infants, Prolonged 2nd stage, Instrumental delivery
- Congenital factors: Abnormal collagen metabolsim eg. Ehlers-Danlos syndrome
- Menopause: Deterioration of collagenous connective tissue following oestrogen withdrawal
- Chronic predisposing factor: Obesity, chronic cough, constipation, heavy lifting, pelvic mass
- iatrogenic: Hysterectomy, incontinence procedures
Presentation of prolapse?
- often asymptomatic
- Dragging sensation or sensation of lump
- Stress incontinence
- Severe prolapse will interfere w/ intercourse, ulcerate and bleed
- Cystourethrocele - freq incomplete bladder emptying
- Rectocoele - difficulty defecating
- Back pain
Examination of prolapse?
- Abdo exam
- Bimanual pelvic exam
- Sims: Inspect anterior and posterior walls separately
- Large prolapse may be visible from outsie
- Cough or bear down to demonstrate
Management of prolapse?
Lifestyle: lose weight, reduce constipation, stop smoking, pelvic floor exercises, physio
Pessaries: For those unwilling/unfit for surgery, act as artificial pelvic floor. placed in vagina behind pubis and in front of sacrum. Ring and Shelf. Change every 6 months.
Surgical management
What are complications of pessaries?
- Vaginal ulceration
- Pain
- Urinary retention
- Infection
- Fall out
