PROLOG: Urogynecology Flashcards
Gartner duct: embryonic remnant of mesonephric or wolffian duct
Commonly found along posterior or lateral vagina and are filled with serous or mucinous fluid
What are Skene’s glands?
Periurethral glands responsible for lubrication and are the closest female analog to the male prostate gland
65 yo woman P3 has stage 3 anterior vaginal wall prolapse. The surgical repair that is most likely to resolve her underlying pelvic support defect is:
Anterior repair with sacrospinous ligament fixation
Definition of recurrent UTI
Two or more infections in 6 months or 3 or more infections in 1 year
How does vaginal estrogen protect against UTI?
Increase maturation index of vaginal epithelial cells, lower vaginal pH, and shift vaginal flora away from Enterobacter colonization
First-line approach to treatment of urgency incontinence
- Behavioral modification, such as modulation of amount and timing of fluid intake
- Timed voiding
- Weight loss
What are the principal support mechanisms of the pelvic floor?
Levator ani muscle complex (PR, PC, IC) and the connective tissue attachments of the pelvic organs (endopelvic fascia)
What does SSLF involve?
Attaching the vaginal apex to one or both sacrospinous ligaments to treat vaginal vault prolapse
85% success rate
Forceps-assisted delivery is associated with a ____-fold higher risk of obstetric anal sphincter injury than vacuum-assisted delivery.
1.5-4
- Aa: urethrovesical crease: the midline point on the anterior vaginal wall 3 cm inside the hymen in a woman with no support deficits
- Ba: most prolapsed point on the anterior vaginal wall
- C: cervix or vaginal cuff in a woman with a prior total hyst
- D: posterior fornix (women with a prior total hysterectomy will not have a point “D”)
- gh: external urethral meatus to hymen
- pb: hymen to midanal opening
A 32 yo P1 has urinary incontinence. She hopes to become pregnant within the next year. After delivery of her son 8 mo ago, she developed urine leakage with exercise, and specifically with running. The leakage interferes with her QOL. No symptoms of urgency urinary incontinence.
Dx?
The best treatment option for her is?
Stress Urinary Incontinence
Incontinence dish pessary (often are effective temporizing devices for women who have not completed childbearing)
A 44 yo P3 reports that she leaks urine with coughing, sneezing, and jogging. On exam, she has a positive cough stress test. She is interested in undergoing surgical treatment and recently heard about retropubic midurethral slings.
You counsel her that the most common complication associated with a retropubic midurethral sling procedure is:
A) bladder perforation
B) hemorrhage
C) neurologic symptoms
D) persistent voiding dysfunction
E) UTI
E) UTI
Clinical evaluation of patients with symptoms of SUI
- Complete physical exam (assessment of vulva, urethra, vagina, uterus, adnexa, pelvic floor muscles, rectum)
- Screening neurologic exam
- PVR measurement
- UA
A 42 yo has SUI. She does not report symptoms of urgency or urgency incontinence. She voids 7x day, and has no prolapse or vaginal bulge. Her PVR is 55 mL. Urine culture is neg. The most important test in the evaluation of this patient for surgery is:
A) urodynamic testing
B) cough stress test
C) U/S
D) cystoscopy
E) CT urography
B) cough stress test
Women with persistent bothersome symptoms or who decline conservative treatments may opt for surgical management of their stress urinary incontinence.
Given that this patient has uncomplicated SUI (typical bothersome symptoms, no urgency, no prolapse, normal PVR, negative UC), she does not need urodynamic testing.
A cough stress test demonstrating fluid loss from the urethra with cough is adequate. Cough stress test sensitivity is maximized in the standing position with a full bladder or at 300 mL bladder volume.
A 55 yo comes in with urgency incontinence. She has tried behavioral therapy, including timed voiding and decreasing bladder irritants. She most recently tried two anticholinergic medications with no improvement in symptoms.
She decides to try an intradetrusor injection of onabotulinumtoxinA. You counsel her that this is a very effective therapy but is accompanied by a high rate of UTIs and the adverse effect of:
A) dry eye
B) nausea
C) urinary retention
D) leg weakness and numbness
E) psychosis
C) urinary retention
65 yo has daily episodes of urgency urinary incontinence, despite the fact that she has reduced her fluid intake and performs Kegel exercises correctly. She tried oxybutynin chloride TID with good success initially. However, she developed adverse effects (dry mouth, dry eyes, constipation), which led her to stop using it. Her PCP is currently performing a workup for episodic HTN. The next best step is to prescribe:
A) Mirabegron QD
B) Oxybutynin chloride XL QD
C) Oxybutynin XL BID
D) Tolterodine tartrate BID
B) oxybutynin chloride XL QD
Oxybutynin is a tertiary amine with M3 affinity, but it has some M1 affinity, which can result in CNS adverse effects.
For this patient, tolterodine BID would
How do antimuscarinic agents work for urgency incontinence?
Block the M2 and M3 receptors on the detrusor muscle, which prevents the binding of ACh
In the bladder, M2 receptors are more common than M3 recepotrs (70-80% vs 20-30%). However, M3 receptors are thought to be most responsible for initiating bladder contractility.
For patients with refractory overactive bladder syndrome (i.e., who have failed conservative therapy or medical or anticholinergic therapy), what are the treatment options?
A woman develops leakage per vagina on POD 2 s/p lpsy hyst. Her surgery involved some intraop bleeding at the vaginal cuff, which was controlled with suture ligation, and she went home after she voided on POD 1.
She was prescribed oral phenazopyridine to confirm that the fluid was urine, and there was orange fluid on her pad. She underwent an office cystoscopy on POD 3, which revealed a 0.5-cm x 0.5-cm defect in the bladder posterior to the trigone and 1 cm posterior to the trigone and medial to the R ureteral orifice.
The best next step in management is:
A) indwelling foley for 2-3 weeks
B) renal scan with furosemide
C) CT urography
D) immediate operative repair of fistula
E) renal U/S
C) CT urography
When a vesicovaginal fistula occurs, an evaluation must be done to confirm there is no ureteral injury. For this patient, the important issue is identification of a concomitant ureteral injury, so use of a Foley would not be the best next step.
An 87 yo multiparous woman with multiple medical comorbidities comes to your office for evaluation of POP noted during recent hospitalization for MI. She reports no typical prolapse symptoms but has urinary incontinence. On exam, her anterior vaginal wall is prolapsed 6 cm beyond the hymen, and her cervix is at the hymen. You obtain a PVR volume: 260 mL. UA is negative for nitrites, leukocytes, and blood.
The best next step in her management?
A) indwelling Foley
B) antimuscarinic meds
C) prolapse reduction with pessary
D) urodynamic testing
E) colpocleisis and rectus fascial sling
C) prolapse reduction with pessary
A healthy 35 yo woman P2, comes to office 6 weeks after uncomplicated placement of retropubic midurethral sling. She reports urinary frequency, a slow dribbling urinary stream, and a sensation of incomplete bladder emptying. Her SUI symptoms have resolved after surgery. She reports no dysuria or hematuria. Her PVR volume is 340 mL and her urine dipstick is negative. She is using self-catheterization. The most appropriate management of her condition is:
A) trial of bethanechol
B) pelvic floor therapy
C) surgical sling lysis
D) recheck PVR volume after 6 weeks of self-cath
E) insertion of suprapubic catheter
C) surgical sling lysis
midurethral sling = first-line procedure for SUI
the described patient’s symptoms and significantly elevated PVR are reflective of clinically significant urinary retention that requires sling lysis in order to avoid long-term sequelae of BOO
First-line treatment of mesh erosion
Estrogen cream
A 65 yo sexually active woman desires surgical management of her stage III POP. The vaginal bulge interferes with her daily activities and she sometimes has difficulty emptying her bladder. She does not have symptoms of stress or urgency urinary incontinence. She experiences 3 episodes of nocturia each night. Her PVR volume is 175 mL. She wants a procedure that will offer the best anatomic and functional outcome. The best next treatment for this patient is:
A) Sacrocolpopexy with Burch colposuspension
B) Sacrocolpopexy without Burch colposuspension
C) Colpocleisis with rectus fascial sling
D) Colpocleisis without rectus fascial sling
E) SSLF with midurethral sling
A) Sacrocolpopexy with Burch colposuspension
At 2-year follow-up, abdominal sacrocolpopexy was associated with significantly lower rates of recurrent vaginal vault prolapse compared with SSLF. Sacrocolpopexy is associated with less dyspareunia than vaginal SSLF.
Burch colposuspension places two permanent sutures on either side of the midurethra and urethrovesical junction, then passes each suture through the Cooper ligament (iliopectineal line) to stabilize the urethrovesical junction.
A 57 yo woman comes to your office with a 6-month history of urinary urgency and frequency + bladder pain. She has been treated for recurrent UTI but reports negative urine cultures. On exam, she has pain with insertion of the speculum and bladder tenderness on bimanual exam. Otherwise, her pelvic exam is normal. Her UA is negative. The most appropriate next step:
A) office cystoscopy
B) potassium sensitivity test
C) pelvic floor PT
d) pentosan polysulfate
e) amitriptyline
C) pelvic floor PT
Painful bladder syndrome is an unpleasant sensation (pain, pressure, or discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks in duration, in the absence of infection or other identifa
