OGCO Urogynaecology manual Flashcards
Define urinary incontinence
complaint of involuntary loss of urine
Define stress urinary incontinence
complaint of involuntary loss of urine on effort or physical exertion, or on sneezing or coughing
Define urgency urinary incontinence
complaint of involuntary loss of urine associated with urgency
Define mixed urinary incontinence
complaint of involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing
Define nocturia
complaint of interruption of sleep one or more times because of the need to micturate. Each void is preceded and followed by sleep
Define nocturnal enuresis
complaint of involuntary urinary loss of urine which occurs during sleep
Define bladder pain
complaint of suprapubic or retropubic pain, pressure or discomfort, related to the bladder, and usually increasing with bladder filling. It may persist or be relieved after voiding.
Define recurrent UTI
at least three symptomatic and medically diagnosed UTI in the previous 12 months. The previous UTI(s) should have resolved prior to further UTI being diagnosed
Define painful bladder syndrome
the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and night-time frequency, in the absence of proven urinary infection or other obvious pathology
Define interstitial cystitis
a specific diagnosis requires confirmation by typical cystoscopic and histological features.
Define overactive bladder syndrome
urgency, with or without urge incontinence, usually with frequency and nocturia
What is occult/latent stress incontinence?
Stress incontinence only observed after the reduction of coexistent prolapse (can be concealed –> hence must check for stress urinary continence –> so that this issue can be fixed concomitantly)
Define anterior vaginal wall prolapse
observation of descent of the anterior vaginal wall
Define prolapse of the apical segment of the vagina
descent of the vaginal cuff scar or cervix, below a point which is 2 cm less than the total vaginal length above the plane of the hymen
Define posterior vaginal wall prolapse
observation of descent of the posterior vaginal wall
How to asess pelvic floor muscle function?
place one finger partly in the vagina and exert very gentle downward traction on the pelvic floor muscles about 2 cm inside the introitus and explain that this is the muscle we want to contract
What is the frequency volume chart (FVC)?
the recording of the time of each micturition and the volume voided for at least 24 h.
What is the bladder diary?
adds to the FVC, the fluid intake, pad usage, incontinence episodes, degree of incontinence, episode of urgency and sensation, activities performed during or immediately preceding the involuntary loss of urine. Bladder diaries should be used in the initial assessment of women. Women should be encouraged to complete a minimum of 3 days of the diary covering variations in their usual activities, such as both working and leisure days.
What information from the frequency volume chart?
What is observed in filling cystometry?
this is the pressure/volume relationship of the bladder during bladder filling. It begins with the commencement of filling and ends when a “permission to void” is given by the urodynamicist.
What is observed in physiological filling rate?
filling rate less than the predicted maximum – predicted maximum body weight in kg divided by 4, expressed as ml/min
Bladder oversensitivity: increased perceived bladder sensation during bladder filling with:
an early desire to void;
an early strong desire to void, which occurs at low bladder volume;
a low maximum cystometric bladder capacity
no abnormal increase in detrusor pressure
Define detrusor overactivity
the occurrence of involuntary detrusor contractions during filling cystometry
Define bladder compliance
this decribes the relationship between a change in bladder volume and change in detrusor pressure (2 standard points – destrusor pressure at the start of bladder filling and the corresponding bladder volume, and the detrusor pressure and corresponding bladder volume at cystometric capacity or immediately before the start of any detrusor contraction that causes significant leakage)
Define the urethral pressure measurements
Maximam urethral pressure: maximum pressure in the urethral pressure profile Maximum urethral closure pressure(MUCP): the maximum difference between the urethral pressure and the intravesical pressure
Define voiding cystometry/pressure flow studies of voiding
this is the pressure volume relationship of the bladder during micturition
Define detrusor underactivity
detrusor contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span
Define post void residual (PVR)
olume of urine left in the bladder at the completion of micturition (upper limit or normal 30 ml with immediate measurement using USG, 50 ml or 100 ml using urethral catheterization up to 10 min delay)
How to make a dx of urodynamic stress incontinence
(by symptom, sign and urodynamic investigations) the finding of involuntary leakage during filling cystoscopy, associated with increased intra-abdominal pressure, in the absence of a detrusor contraction
How to make a dx of detrusor overactivity?
(by symptoms and urodynamic investigations) lower urinary tract symptoms (more commonly OAB-type symptoms) when involuntary detrusor muscle contractions occur during filling cystometry
How to make a dx of bladder oversensitivity?
(by symptoms and urodynamic investigations) with symptoms of frequency and nocturia and a voiding diary showing a clearly reduced average voided volume and with compatible findings in filling cystometry. There should be no known or suspected urinary tract infection.
How to make a dx of voiding dysfunction?
(by symptoms and urodynamic investigations) abnormally slow and/or incomplete micturition. Abnormal slow urine flow rates and abnormally high post-void residuals as defined above.
Define significant microscopic haematuria
> 30RBCs/ul on 2 microscopic urinanalysis without recent excercise, menses, sexual activity or instrumentation
Define recurrent UTI and need to differentiate bacterial persistance or bacterial reinfection
Complicated UTI should be ruled out by history and PE
What is the recommend regimen for antibiotics prophylaxis of UTI?
Advise for overactive bladder
Reduction of caffeine in women
Advise for mild stress incontinence and good pelvic floor muscle strength
start home pelvic floor training
Mx if severe primary stress incontinence and wants surgery
book urodynamic
study and discuss TVT briefly
Mx if severe urge incontinence and if long wait for urodynamic study
give therapeutic trial of anticholinergic drugs, with bladder training
Mx if stress incontinence is the predominant symptom in mixed urinary incontinence
discuss the benefit of conservative management including OAB drugs before surgery
first-line treatment to women with stress and mixed urinary incontinence
Offer a trial of supervised pelvic floor muscle training at least 3 months’ duration
first-line treatment to
women with urgency or mixed UI
Offer bladder training lasting for a minimum of 6 weeks
When conservative management failed Stress urinary incontinence
Mx
Offer synthetic mid-urethral tape/ open colposuspension/ autologous rectus fascial sling to patient with stress incontinence
Follow up appointment including vaginal examination to exclude erosion should be arranged within 6 months to all women who have had continence surgery
When conservative Mx failed for overactive bladder what is Mx?
If not achieving satisfactory benefit from bladder training programme, can consider combination of an OAB drug with bladder training if frequency is a troublesome symptoms
Indications for uroflowmetry?
Before surgery for stress incontinence
Recurrent UTI
Indications for multichannel filling and voiding cystometry
- Symptoms of overactive bladder leading to a clinical suspicion of detrusor overactivity
- Symptoms suggestive of voiding dysfunction or anterior compartment prolapse
- Previous surgery for stress incontinence
- Past history of voiding difficulty
- Pure urge symptoms who have failed bladder training and anticholinergic therapy
Indications for urethral function testing
In women with USI preop
In women with unexplained incontinence
Who is offered pelvic floor training
What is the principle of this training
1st line treatment to women with stress or mixed UI –> supervised pelvic floor muscle training of at least 3 months duration
Must contract the muscle as hard as possible for as long as she can, up to her maximum when fatigue is noted e.g. 3s. Then rest the muscle for 5s to let oxygen back into the muscle e.g. 3 sec squeeze, 4 squeezes per set, 5 sets per day and should be spread out.
Drug therapy for stress urinary incontinence?
Duloxetine: increases the concentration of both serotonin and noradrenaline in the synaptic clefts in onufs nucleus, which promotes enhanced activity of the striated urethral sphincter via the pudendal nerve and increased bladder capacity.
Not routinely used as 1st line treatment for women with predominant stress UI. May be offered as 2nd line treatment if women prefer pharmacological to surgical treatment or not suitable for surgical treatment
What is the surgical treatment for stress urinary incontinence (2nd line)?
- Synthetic mid urethral tape manufactured from type 1 macroporous polypropyele tape, open colposuspension or autologous rectus fascial sling should be offered when conservative Mx for stress urinary incontinence failed
Top down retropubic tape approach should only use as part of a clinical trial.
Principles of bladder training?
- Bladder training lasting for a minimum of 6 weeks should be offered as 1st line treatment to women with urge or mixed UI.
- If women do not achieve satisfactory benefit from bladder training programs, the combination of an antimuscarinic agent with bladder trianing should be considered if frequency is a troublesome symptoms.
Drug therapies for detrusor overactivity?
Before prescription, any coexisting conditions, use of other existing medicaitons affecting total anticholinergic load and risk of AE should be taken into account.
Some AE such as dry mouth and constipation may indicate that treatment is starting to have effect. Full benefits not seen until treatment has continued for 4 weeks.
Choice of AOB drugs
* Do not offer oxybutynin (immediate release) to frail older women
* Women with OAB or mixed UI: immedaite release oxybutynin/immediate release tolterodine/once daily preparation darifenacin
* Mirabegron is the new medication for treatment of OAB.
What drug can be used specifically to reduce nocturia in women with UI or OAB who find it a troublesome symptom?
Desmopressin
Not a good long term strategy
Caution in women with cystic fibrosis
Avoid in those over 65 years with CVS disease or hypertension
What are the non surgical options for Mx of prolapse?
Insertion of ring pessaries
* Insert 2 fingers int othe vagina and spread them apart to measure the vaginal diamaeter
* Can try touble rings with the top ring smaller in size than the lower one
* Remove the ring pessaries if vaginal erosion occurs and prescribe a course of premarin cream
Insertion of cube pessaries
* On trial basis for patients with C/I to surgery and failed ring pessary treatment
What are the surgical options for organ prolapse?
- Cystocele alone: anterior colporrhaphy
- Enterocele: McCall culdoplasty
- Rectocele: posterior colporrhaphy
- Deficient perineal body: perineorrhaphy
- Vault prolapse: sacrospinous fixation or abd sacrocolpopexy or colpolceisis
- Other: high uterosacral ligament suspension
Preop treatment with local estrogen for 2-4 weeks
Prophylactic antibiotic cefazolin 1g IV at induction
