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Gynaecology > Pelvic floor > Flashcards

Pelvic floor Flashcards

1
Q

Definition

overactive bladder

A

IT is a syndrome characterised by urgency
with out without urge urinary incontinence
often with frequency and nocturia
(in absence of infection or other pathology)

dx on hx or exam

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2
Q

Detrusor overactivity

Definition

A

involuntary detrusor contractions during filling that may be spontaneous or provoked

neurogenic or idiopathic

dx on urodynamics

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3
Q

Definition of urgency

A

Complaint of sudden compelling desire to pass urine which is difficult to defer

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4
Q

Definition of urge incontinence

A

Involuntary passing of urine that is associated with urgency

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5
Q

uroflowmetry

What is it

A

Measure of flow rate over time
Woman voids in a commode and it funnels urine onto a device that can measure the flow rate

If low - outlet obstruction
If high - decreased resistance commonly seen in SUI
Flow pattern is usually a bell shaped curve

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6
Q

Cystometry

What is it?

A

IS the measure of the pressure volume relationship in the bladder
Measured with concurrent bladder and abdominal pressure measurements
with probes in the bladder and rectum (or vagina)
Measurements in cmH2O
The bladder is filled and pressures observed
detrusor pressure is Pressure bladder - pressure abdomen

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7
Q

How to dx SUI on urodynamics

USI - urodynamic stress incontinence

A

leakage occurring on coughing in the absence of detrusor contraction

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8
Q

OAB

prevalence

A

17% of the population

Increases with age esp over 40

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9
Q

Conservative treatments for OAB

A

Optimise co morbidity
(OSA, T2DM, constipation)

Weight loss
Loss 5-10% body weight reduces (stress and urge) by 70%

Reduce irritants (caffeine / tea independent risk factor, diet coke or caffeine free coke worse then normal coke)

Pelvic floor physio
Bladder retaining and deferment strategies

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10
Q

Conservative treatments for OAB

A

Optimise co morbidity
(OSA, T2DM, constipation)

Weight loss
Loss 5-10% body weight reduces (stress and urge) by 70%

Stop smoking

Reduce irritants (caffeine / tea independent risk factor, diet coke or caffeine free coke worse then normal coke)
avoid late evening fluid

Pelvic floor physio
Bladder retaining
(pass more urine less often - increases functional bladder capacity)
deferment strategies
stop still, cross legs
remove stimuli
Perineal or clitoral pressure ( hand, towel, edge of seat) contract pelvic muscles
Standing on toes / tighten buttocks, curl toes uses sacral nerve pathways and overrides sensation to the bladder
distract the mind

Topical oestrogen - reverse urogenital atrophy and help with irritating sx

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11
Q

Medication options for overactive bladder

A

antimuscarinics

B3 adrenoreceptor agnostics

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12
Q

How many types of muscarinic receptors are there and where are they?
Which are in the bladder?
Which neurotransmitter do they use?

A

There are 5 subtypes

M2,3 in the bladder - most important is M3

M2 also in cardiac smooth muscle
M3 bowel, eye, salivary glands

Neurotransmitter is Acetylcholine

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13
Q

anticholinergic blockage causes symptoms everywhere

What are they and what receptors involved

A

Detrusor M2,3 - decreased contraction - urinary retention

Salivary glands - M1,3,4 - dry mouth

Cardiac M2 - palpitations, tachycardia

Eye M3,5 - dry eyes, blurred vision, mydrasis

Gastrointestinal M1,2,3 - slower transit time, constipation, effect on sphincter tone, gastric acid secretion

CNS All 5 - effect on memory, cognition, psychomotor speed, confusion delirium

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14
Q

Contraindication of the use of anti muscarinics

A

Narrow angle glaucoma

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15
Q

What is the affect of anti muscarinics on the bladder

A

Reduced intra vesicle pressures
Increased bladder capccity
Reduce uninhibited contractions

75% reduction in major sx

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16
Q

Examples of Types of antimuscarinics
Non selective
Selective

(what does this mean? what are they selecting for? )

A 
Non selective 
(all Ms)
Oxybutynin (oxytrol, ditropan) 
Tolterodine (detrusitol)
Imipramine (tofranil)

Selective - for M3
Vesicare (solifenacin)
Enablex (darifenacin)

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17
Q

Oxybutynin comes in a oral formulation IR and ER
and a patch

What is the difference with SA profiles

A 
Oxybutynin oral IR
greatest affinity M1,2 
More salivary then bladder 
Lots of dry mouth, constipation, blurred vision (dose related)
Impaired cognition in elderly people
Most SEs from N-desethyloxybutinin from first gut metabolism - well documented effectiveness 
2.5-5mg 4 times / day
ER - once daily
better tolerated

(in cochrane review tolerodine has less dry mouth)
Transdermal misses first pass metabolism,
3.9 mg drug / day
no more SE then placebo
good efficacy
(same as tolterodine)
20% application site puritis and erythema

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18
Q

Vesicare / solifenacin
how does it work
dose?
SEs?

A

Blocks M3 receptor
more selective for M3 in bladder then salivary glands
low rates dry mouth, less discontinuation
Effective
once daily dosing 5-10mg

(Cochrane review better then tolterodine, less SE more efficacious)

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19
Q

Darifenacin / Enablex

What is

A

Relatively M3 selective
Low affinity for M1 and 2 so less cognition or CVS SEs
well documented effectiveness

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20
Q

trospium

anything interesting?

A

Does not cross blood brain barrier
impaired gut absorption
Non selective

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21
Q

Imipramine aka tofranil

What are its uses and limitations ?

A 
Blockade of reuptake of serotonin, noradrenaline, and ACH 
cardiovascular SEs, drowsiness
Antidepressant dosages  
Low dose 
Good for nocturia and nocturnal enuresis
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22
Q

Prescribing in the elderly

How does it change

A

Drug distribution changes due to muscle mass and renal impairment

Consider overall antimuscarinic burden (meds for dementia, parkinsons)

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23
Q

Anticholinergics and the eldery

A

Metanalysis 2015 120,000 participants - increase risk cognitive impairment, falls, mortality

Caution for elderly pts with pre existing dementia

2015 Grey et al 3500 pts without dementia increased risk of developing dementia on anticholinergics

2018 - retrospective case control study - high risk of dementia in pts that used anticholinergics

? confounder as drugs are used with sx of early dementia

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24
Q

What is the function of beta adrenoreceptors in the bladder

A

There are 3 subtypes B1,2,3
They are in human detrusor and urothelium

Detrusor relaxation and stability is achieved through activation of beta adrenoreceptors
B3 is most important

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25
Q

What is mirabegron

A

Selective B3 adrenoreceptor agonist

Stimulates these receptors and relaxed the detrusor smooth muscle increasing bladder capacity

Decreases number or voids and incontinence compared with placebo

25 or 50mg

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26
Q

SEs of mirabegron

A

no increase in dry mouth

GI disturbance, headache, HTN

Cardiovascular effects, increased HR (1 beat per minute) increase BP (1 mmHg) - uncertain relevance

Long term effects not fully investigated

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27
Q

Mirabegron is contraindicated in?

use with caution in?

A

Contraindications

severe uncontrolled HTN
Impaired liver function
ESRD
Pregnancy
breastfeeding
under 18

Caution
Reduced liver and renal function
HTN
Prolonged QT

may increase QT
May effect liver metabolism
May result in increased digoxin levels

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28
Q

Mirebegron safety alert

A

Cases of severe HTN with hypertensive crises, CVA and cardiac events with a clear temporal association with mirabegron

SO therefore it is contraindicated in uncontrolled HTN

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29
Q

What is the role for mirabegron ?

A

First or second line
If anticholinergics are not tolerated
Neurological concerns

Combination therapy? with anticholinergics

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30
Q

Percutanous tibial nerve stimulation

Who is it for?

How is it done?

A

Stimulates the tibial nerve up to the sacral plexus
Outpatient neuromodulation

Previously trialed medical treatment

fine needle 3 fingers above medial malleolus
- close to posterior tibial nerve
Insertion depth 2-4 cm
60-90 degrees
Electrode to food
Connected by low voltage stimulator - 12 OP sessions
1-2 X / week
no SEs
improvement for 60% of people
- same efficacy as medications without SEs!

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31
Q

Botulinum neurotoxin for the bladder

What is BoNT
How does it work

A

BoNT is formed by gram + anaerobic forming bacteria clostridium bolulinum

It stops the release of neurotransmitters for autosomal and somatic nerve endings

Temporarily blocks the presynaptic release of ACh from the parasympathetic nerve resulting in paralysis of the detrusor smooth muscle
The axons regenerate after 3-6 months
Subsequent central desensitization may follow therefore a longer lasting response

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32
Q

Botox
how is it done practically

Does it work?
Complications?

A

Local, regional, GA
Rigid or flexible cystoscope
Intradetrusor or sub urothelial injection

Success 60%
response 9-12 months
Retention 5%
catheterisation 16% 
mean retreatment 8 motnhs
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33
Q

What are the indications for sacral nerve stimulation?

A

OAB, chronic retention, voiding dysfunction secondary to urethral sphincter overactivity, faecal incontinence
Chronic bowel dysfunction

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34
Q

What is sacral nerve stimulation?

A

Low amplitude electrical stimulation via a lead to S3/4
Stimulates the urethral sphincter - inhibits detrusor contraction
overall success 70%

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35
Q

What is the autonomic nerve supply to the bladder ?
From what spinal levels?
What are the neurotransmitters and the function ?

A

Sympathetic
T11-L2
Inhibits contractility of the detrusor
Noradrenaline binds to the B3 adrenergic receptors on the detrusor
Internal urethral sphincter contraction by stimulation of alpha 1 receptors on the internal sphincter

Parasympathetic
S2,3,4
Contraction of the detrusor
ACh binds to M3 receptors on the detrusor

External sphincter S2-4
Skeletal muscle - voluntary control

36
Q

What is the IUGA definition of urodynamic stress incontinence?

A

Diagnosis by symptom, sign and urodynamic investigations involves the finding of involuntary leakage, associated with increased intra-abdominal pressure, in the absence of a detrusor contraction

37
Q

Conservative tx stress incontinence?

A

Pelvic floor rehabilitation - at elast 3 months

  • bladder retraining
  • pelvic floor muscle training
  • voiding techniques

Vaginal devices

  • tampon
  • contiform

Vaginal oestrogen

38
Q

How long for pelvic floor physio?

what makes the most difference?

A

Consistent pattern of more self-reported improvement with more health professional contact was observed i.e. women receiving regular supervision were more likely to report improvement than women doing PFMT with little or no supervision

It should be first line for ALL types of incontinence

39
Q

How to approach a pt with urinary stress incontinence?

A

Ideal pre-operative situation
o Initial conservative management
 Exclude pathology, infection etc
 Bladder diary
 Pelvic floor rehabilitation
 Lifestyle changes – fluids, diet, bowel, weight
o Compliance
o Confirm diagnosis
o Discussion regarding surgical options, risks
o Realistic expectations for outcomes for procedures

40
Q

What are the surgical options for USI

A

Colposuspension
o Until recently, considered Gold Standard
• Slings – autologous, synthetic, xenografts
o Pubovaginal
o Mid-urethral

• Others e.g. Bulking agents

41
Q

The Burch colposuspension

Success?

A

• 1961: 2-3 permanent sutures each side o Paraurethral vaginal to iliopectineal ligament

• Open colposuspension: Cochrane 2016
o Overall continence rate 85-90% 1 year; 70% at 5 years
o Superior to anterior colporapphy
o Compared to MUS – no significant difference in incontinence rates
 Limited data on long-term performance of newer sling

42
Q

Approaches to slings for USI

what are the 2 main types

Cochrane review in 2017 advised re technique

A

Retropubic
bottom to top better then top to bottom

Transobturator
lateral or medial same as medial to lateral

No difference in short term subjective cure rates

43
Q

Meta analysis of long term FU for SUI for TOT vs TVT

A

High objective cure rates with retropubic

No difference in urinary retention infection de novo OAB or LUTs (?)

44
Q

SUI surgical tx reoperation rate within 5 years
how do different surgical techniques compare?
What affects recurrence?

A

Re operation rate 6%after RPMUS, burch PVS
TOT 2X higher reoperation rate
Bulking agent 12 X high reoperation rate

BMI over 35 had highest proportion of re operations

45
Q

What are the pros and cons of autologous fascial sling

A

short term
higher early post op voiding dysfunction
as effective as MUS

Long term
more effective then colposuspension

46
Q

Colposuspension

pros and cons

A

lap comparable to open in short and medium term

poorer outcome then TVT

47
Q

What is the success rate of TOT

A

Cure rate decreases as BMI increases
normal weight over 90%
88% overweight
78% obese

48
Q

Long term TVT FU

A 
TVT 17 year follow up 
Nilsson C et al 
1 asymptomatic mesh exposure
87% cured or significantly better
91% negative stress test

Norwegian study 540 woman
90% objective cure 10 year FU

49
Q

Are slings any use in woman with mixed incontinence?

A

Subjective cure MUI – 56%
• Stress incontinence
o Lower cure of stress in women with urgency predominant or equal MUI than stress predominan

50
Q

What is the MUCP ?

A

Maximum urethral closure pressure

51
Q

How does MUCP (maximal urethral closure pressure) affect sling choice

A

Low MUCP
- RPMUS
TO 15X greater reoperation risk at 3 years
MUCP <42 TOT 6X more likely to fail

TOT better is MUCP is higher - over 40 cm H20

52
Q

Urethral bulking agents

A

Variable cure rate at 12 months: 34-57%
Efficacy may reduce over time
No particular type of bulking agent demonstrated superiority No difference in outcomes whether transurethral or paraurethral injection technique

53
Q

Mesh drama - what did the Senate Inquiry reported back March 2018: recommendations

A

TGA & Australian Commission on Safety and Quality in Health Care (ACSQHC) –

info sheet on action to take if adverse event

o Aust Govt to establish registry for implantable devices

o ACSQHC to provide material on effective informed consent

o ACSQHC develop guidance for credentialing

o College & specialist societies implement governance arrangements that require member are trained, adequately skilled, monitor & report patient outcomes, maintain record & complications

Guidance documents April 2018
• ‘supervised training undertake as many surgeries as necessary…. to demonstrate that he or she can independently undertake the procedure safely and efficiently’
• ‘..obtaining the patient’s informed consent, including the ability to clearly and accurately explain and document the alternative treatments available’
• ‘..demonstrate requisite knowledge and understanding in the treatment of SUI, including both mesh and non-mesh surgical treatments and other non-surgical treatments..’

54
Q

Immediate potential complications sling surgery

A

Retropubic
Haemorrhage
Injury to urinary tract
viscera

Distance from medial border of vascular anastomosis to pub pubic symph 3-9 cm
- suprapubic sites should be no more then 4 cm apart

TOT
degree of hip flexion affections distance between trocar and obturator nerve
flexion 90 degrees increases distance compare to flexion at 30 degrees

55
Q

Sling short term complications

A

Infection, voiding difficulty, fistula, osteitis pubis, nerve injury, OAB, SI
o Trial of void – local protocol needs to be in place

• Transobturator – thigh pain

56
Q

o Structures traversed by or in close proximity to TOT:

A

• Thigh skin, gracilis, adductor longus, adductor brevis, obturator externus, obturator membrane, obturator internus, inferior pubic ramus, urethra, vaginal mucos

57
Q

Sling long term complications

A

Detrusor overactivity, prolapse, pain, mesh complications, voiding difficulty, recurrent SI

Severity, any neuropathic component, mobility
• Early – cystoscopy (viscus penetration); ? Remove sling

  • Late – refer to urogynae credentialed to remove sling
  • ACSQHC – credentialing guidelines, patient information
58
Q

post sling voiding difficulty risk factors

A

Pre-op post void residual ≥ 200 mls – 2.15 x risk

• Pre-existing abnormal voiding pattern
o Qmax > 30 mls/s – lowest risk post-sling retention
o Qmax < 15 mls/s – 77% failed first trial of void

Diabetes mellitus 3x risk

 • Post-op care 
o Over-hydration 
o Pain 
o Constipation 
o Complications : UTI, haematoma 
o Voiding position, anxiety
59
Q

Why is cystoscopy routinely recommended (RANZOG and ACOG)

A

Avoid and recognise injuries
o Manage injuries intra-operatively
o DON’T go more lateral or cephalad if bladder injury with retropubic slings ( This only increases the risk of intraabdominal injuries and vascular injuries)

Cystoscopy following continence surgery •Use 70 degree telescope
•Ensure height of table is adequate to allow visualisation
•Adequate filling of bladder
•Re-focus camera to view urethra •Competency in use of cystoscope

60
Q

What is normal Urine output in 24 hours?

If excessive what could it be?

A

Normal UO is 1.5L / 24 hours

excessive

  • bad habits (EtOH)
  • diabetes
61
Q

How could excessive urine output be treated?

A

Correct contributing habits
Diuretric in the afternoon to reduce nocturnal volumes
Minirin (antidiuretic hormone - often in combination with a diuretic)

62
Q

What are the causes of OAB?

A 
Idiopathic - familial tendency – genes on  chromosomes 4, 8, 12, 13, 22. 
• Onset at any age [e.g. Childhood]. 
• Usually longer duration than first admitted. 
• Males = Females. 
• Neurological : 
1. Sudden onset. 
2. Often more severe. 
3. neurological symptoms/signs
63
Q

What medications can exacerbate incontinence?

A

Cholinergic agents
•Bowel stimulants incl maxolon
•Methotrexate
•SSRI antidepressants

64
Q

Definition of bladder pain syndrome

Previously called interstitial cystitis

what is the etiology?

A

American Urological Association has described BPS as ‘an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks duration, in the absence of infection or other identifiable causes

BPS is a chronic condition with unknown aetiology

65
Q

What are ‘Hunner’s ulcers’

A

in 1914 Hunner described the nontrigonal ulcers and bladder epithelial damage, known as ‘Hunner’s ulcers’. More recently, these are referred to as Hunner lesions

Previous diagnosis of interstitial cystitis included
pain associated with bladder or urinary frequency, and glomerulations (pinpoint petechial haemorrhages) on cystoscopy or classic Hunner lesions seen after hydrodistension under anaesthesia to 80–100 cm water pressure for 1–2 minutes, where the glomerulations must be diffuse and present in at least three quadrants of the bladder at a rate of at least 10 per quadrant and not along the path of the cystoscope as this may be an artefact. Hunner lesions may be seen as inflamed friable areas or nonblanching areas in the chronic state.

66
Q

What do you classically see with cystoscopy in bladder pain syndrome?

A

Characteristic cystoscopic findings that have been ascribed to BPS include post distension glomerulations, reduced bladder capacity and bleeding

Not sensitive or specific findings

There was no correlation observed between severity of symptoms and the finding of glomerulations or bleeding following hydrodistension. Pain, urgency and reduced bladder capacity were associated with the presence of Hunner lesions in 11.7% of the women. Similar findings have been reported in other studies along with glomerulations in asymptomatic women

67
Q

Associations of bladder pain with chronic pelvic pain?

A

Between 30% and 61% of patients presenting with chronic pelvic pain have BPS, so although there are no data available about the efficiency of different forms of analgesia in the treatment of BPS, simple analgesia, such as paracetamol and ibuprofen, may be useful at treating the key symptom of pain in this condition.
However, opioids should be used with caution as there is little evidence they are useful for long-term chronic pain. Early referral to a pain clinic should be considered for patients with refractory symptoms.4

68
Q

What is first line medical tx when conservative (including basic analgesia) has failed?)

A

Oral amitriptyline or cimetidine may be considered when first-line conservative treatments have failed. Cimetidine is not licensed to treat BPS and should only be commenced by a clinician specialised to treat this condition.

Compliance is often affected by the adverse effects, which include dry mouth, constipation, sedation, weight gain and blurred vision.

69
Q

Prevalence of POP

A

50% of parous woman

10-20% seek treatment

70
Q

POP q examination

How to standardise?

A

Document position, lithotomy supine or standing

Empty bladder
Note rectal loading
Valsalva (max)
Reference = hymen

71
Q

Stages POP and what measurements they relate to

A

Stage 0
Vaginal points all -3
C+D are between TVL and TVL -2

Stage 1
Most distal part more negative then -1

Stage 2
Most distal part between -1 and +1

Stage 3
Most distal part between +1 and (TVL-2)

Stage 4
Most distal part between (TVL-2) and TVL

72
Q

What causes POP ?

A 
Pregnancy 
child birth
Ageing 
Menopause
Obesity
smoking
constipation
chronic lung disease
congential collagen deficiency 
race
73
Q

How does MOD affect POP

A

Swedish 25 year FU study
90 000 woman
Vaginal delivery increased risk of POP 9X
Forceps increases risk of POP surgery

It is dose dependent
SUI increases by 2-3 fold 1 baby vs 3

74
Q

Sx of POP

A 
None
Dragging
Lump
Urinary sx - voiding difficulty slow stream, incomplete emptying
Bowel sx - incomplete emptying, digitation, constipation 
laxity with sex 
Urinary incontinence
faecal urgency / incontinence
constipation
sexual dysfunction
75
Q

Conservative management for POP

A 
Weight loss
Manage constipation
Smoking cessation
Avoid heavy lifting
Pelvic floor safe exercising
Pelvic floor muscle therapy
pessaries
76
Q

Does pelvic floor physio work for POP?

A

Compared to nothing there is an improvement in anatomical and sx severity after 6/12 of supervised PFMT

BUUUUT
not strong evidence that PFMT with change surgical outcomes

77
Q

How common in POP surgery ?

A

Risk is 11 % by age 80

30% reoperation rate

78
Q

How to measure surgical success of POP intervention

A 
Objective - POP stage 0-1 
Validated questionaires
patient satisfaction
complication rates
reoperation
combination of outcomes
79
Q

What are level 1 2 3 pelvic supports?

A

Level 1
2
3

80
Q

What are the surgeries for level 1 supports?

How do they compare?

A

Level 1
SSF
Abdominal Sacral colpopexy
Uterosacral suspension, vaginal or abdominal, illeococcygeus fixation

ASC (abdominal sacrocolpexy) is better in terms of recurrence but SSF is quicker and easier to perform, earlier return to life
Success 96% vs 85%
No difference in reoperation rate

81
Q

Complications of abdominal sacrocolpopexy

A 
Intra abdominal organ injury
laparotomy
mesh complications
functional complications (uncovers USI) 
Recurrence POP
82
Q

SSF complications

A 
Buttock pain
Nerve damage (sciatic, pudendal)
Vascular injury - pudendal, inferior gluteal
Dysparunia
Recurrent POP esp anterior
83
Q

For POP leave or take the uterus ?

A

Slightly higher recurrence rate
May decrease blood loss
Ongoing uterine pathology
Would not recommend future pregnancy after a repair

84
Q

What is uterosacral suspension?

A

A native vaginal repair suturing the uterosacral to the vault
Success rates 65%
retreatment 5%

85
Q

Anterior repairs have higher failure rate 60-70%
Mesh may be indicated when a native tissue repair has failed
What are the benefits of permanent mesh repair over native tissue repair

A

Decreased awareness of prolapse
decreased repeat surgery for prolapse but combined repeat surgery for POP / SUI or mesh exposure 7-18 % ( VS 5%

Increased denovo USI / bladder injury
No difference in denovo dysparunia

70% of anterior wall support is from the apex
- it is not symptomatic until it is beyond the introitus

Gynaecology (27 decks)

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