Pelvic floor Flashcards

Question

What is mirabegron

Answer 1

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

Answer 2

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

Answer 3

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

Answer 4

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

Answer 5

First or second line If anticholinergics are not tolerated Neurological concerns Combination therapy? with anticholinergics

Answer 6

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!

Answer 7

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

Answer 8

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 ```

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

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

Answer 13

Pelvic floor rehabilitation - at elast 3 months - bladder retraining - pelvic floor muscle training - voiding techniques Vaginal devices - tampon - contiform Vaginal oestrogen

Answer 14

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

Answer 15

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

Answer 16

Colposuspension o Until recently, considered Gold Standard • Slings – autologous, synthetic, xenografts o Pubovaginal o Mid-urethral • Others e.g. Bulking agents

Answer 17

• 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

Answer 18

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

Answer 19

High objective cure rates with retropubic | No difference in urinary retention infection de novo OAB or LUTs (?)

Answer 20

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

Answer 21

short term higher early post op voiding dysfunction as effective as MUS Long term more effective then colposuspension

Answer 22

lap comparable to open in short and medium term | poorer outcome then TVT

Answer 23

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

Answer 24

``` 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

Answer 25

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

Answer 26

Maximum urethral closure pressure

Answer 27

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

Answer 28

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

Answer 29

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..’

Answer 30

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

Answer 31

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

Answer 32

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

Answer 33

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

Answer 34

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 ```

Answer 35

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

Answer 36

Normal UO is 1.5L / 24 hours excessive - bad habits (EtOH) - diabetes

Answer 37

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

Answer 38

``` 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 ```

Answer 39

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

Answer 40

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

Answer 41

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.

Answer 42

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

Answer 43

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

Answer 44

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.

Answer 45

50% of parous woman | 10-20% seek treatment

Answer 46

Document position, lithotomy supine or standing Empty bladder Note rectal loading Valsalva (max) Reference = hymen

Answer 47

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

Answer 48

``` Pregnancy child birth Ageing Menopause Obesity smoking constipation chronic lung disease congential collagen deficiency race ```

Answer 49

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

Answer 50

``` 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 ```

Answer 51

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

Answer 52

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

Answer 53

Risk is 11 % by age 80 30% reoperation rate

Answer 54

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

Answer 55

Level 1 2 3

Answer 56

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

Answer 57

``` Intra abdominal organ injury laparotomy mesh complications functional complications (uncovers USI) Recurrence POP ```

Answer 58

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

Answer 59

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

Answer 60

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

Answer 61

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

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Pelvic floor Flashcards

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