RANZCOG questions

Question 1

Define the terms “over active bladder” (OAB) and “urge incontinence” (UI). (2 marks)

Answer 1

OAB: frequent and urgent desire to pass urine that is difficult to control. Often results in increased frequency, passing small volumes and nocturia in the absence of infection or other pathology Urge incontinence: involuntary loss of urine associated with a strong desire to void

Question 2

Complete the table below regarding the autonomic nerve supply to the bladder detrusor muscle. (2 marks) Sympathetic and PS = y axis Action on detrusor and Releases with neurochemical = x axis

Answer 2

Action on detrusor: - Sympathetic: Relaxation of detrusor and contraction of internal sphincter -Parasympathetic: Contraction Releases with neurochemical: - Sympathetic: Noradrenaline - Parasympathetic: Acetylcholine

Question 3

60 year old woman presents with symptoms consistent with OAB noticed increasingly over the last year. Clinical history confirms she experiences urge incontinence 3-4 times a week.

List and justify the assessments you will make to further evaluate this patient’s symptoms/problem. For your answer you may use a table with the headings “assessment” and “justification”. (5 marks)

Answer 3

Question 4

Outline six (6) management strategies available for urge incontinence in this patient. (6 marks)

Answer 4

• Lifestyle interventions

­Reducing daily fluid intake to 1-1.5L/day

­Avoiding tea, coffee and alcohol

­Dietary advice to improve constipation if present

­Wight loss if BMI >30

­Smoking cessation advice

• Behavioural therapy

­Bladder drill. Timed voiding which aims to increase the intervals between voids and the bladder capacity, as well as reduce the number of urge incontinence episodes.

• Physiotherapy

­Pelvic floor muscle training. Contract the pelvic floor muscles at least 8x on three occasions in a day.

­Vaginal cones

­Functional electrical stimulation

• Medications

Antimuscarinic drugs

­SE’s dry mouth, blurred vision, tachycardia, drowsiness and constipation

­Oxybutamin 5mg tdss

­Tolterodine 2mg bd

­Intravaginal oestrogens may improve symptoms of OAB in women with vaginal atrophy

These meds can take up to 4 weeks to start working

• MDT review to consider any other invasive treatments as below

­Sacral nerve root stimulation

­Injection of botox

­Blocks the release of acetylcholine and when injected into the bladder wall using a flexible cystoscope can relax the overactive detrusor muscle.

Question 5

Both sacrospinous fixation and sacrocolpopexy can be performed to repair post hysterectomy vaginal vault prolapse.

Complete the following table using the headings provided to compare these operations.
(The two (2) benefits and two (2) risks must be different for each procedure). (6 marks)

Answer 5

Question 7

Describe briefly the micturition reflex and the centres affecting micturition. (4 marks)

Answer 7

Bladder filling – activates stretch receptors – send afferent impulses via pelvic splanchnic nerves to spinal cord, triggering simple spinal reflexes.

Pontine micturition centre and pontine storage centre control simple spinal reflexes to achieve micturition or storage.

In micturition:

Spinal reflexes:

1. somatic - efferents from S2-S4 via pudendal nerve are inhibited – external urethral sphincter relaxes.
2. ANS – SNS efferents via hypogastric nerve are inhibited, and PNS effferents via pelvic splanchnic nerve are promoted, resulting in contraction of detrusor muscle and relaxation of internal urethral sphincter.

The pontine storage centre has the opposite effects on these reflexes resulting in storage of urine.

Question 8

Outline the principles of filling cystometry including the variables measured and aim of the test. (4 marks)

Answer 8

Aim of test is to characterize detrusor and urethral function during the filling phase via assessment of the pressure/volume relationship of the bladder during filling and voiding. To determine relative contributions of USI and detrusor overactivity or other factors e.g. neurological disorders.

Variables measured:

1. Total bladder capacity (volume).
2. Intra-abdominal, intravesical pressure (from which detrusor pressure can be calculated).
3. Presence of – involuntary detrusor contraction (provoked or unprovoked), urgency or leakage
4. Patient’s sensation of first desire to void and strong desire to void

Indications:

Failed conservative management.

Previous failed surgery.

To determine relative contributions of USI and DOA.

If surgery planned – assess most appropriate operation and likely success.

Procedure:

Bladder emptied. (post void residual can be measured here). IDUC.

Pressure catheters placed in bladder (measure IVP) and rectum (measure IAP).

Machine calibrated and checked.

Saline instilled into bladder. IAP and IVP continuously measured. Pt notes 1^st desire to void and strong desire to void. When sustained strong desire to void then filling stopped and total volume is measured.

Question 9

A 60 year old patient is referred to you complaining of urinary frequency, urgency and urge incontinence. Physical examination is normal and an MSU is negative.

Describe in detail the management options available for her. (7 marks)

Answer 9

1. Lifestyle – weight loss if indicated, decrease intake of fluid, caffeine, EtOH. Smoking cessation.
2. PFMT – some improvement in urgency symptoms.
3. Bladder retraining – scheduled voids and aim to increase the interval between voids. Needs to be performed for 6/12 for improvement.
4. Pharmacological – pure antimuscarinics e.g. tolteradine or agents with mixed action (antimuscarinic/Ca channel blocker/LA) e.g. oxybutinin.

• ADRs include dry mouth, constipation and visual disturbances.

1. Other medical therapies – PV oestrogen if cocominant urogenital atrophy or desmopressin if nocturia (off-license).
2. Inravesical therapies – botulinum toxin or capsaicin – block Ca-channel dependent release of Acetylcholine.
3. Neuromodulation – percuateous sacral neruomodulation or peripheral (posterior tibial).

Note: they don’t want surgical mgmt included in answer.

Question 10

A 55 year old woman is referred by her GP with symptoms of prolapse. She had a vaginal hysterectomy 10 years ago for menorrhagia. For the past 6 months she has noted a vaginal bulge which is getting bigger. Her bladder and bowel function are normal and there is no pain, bleeding or discharge. She is on no medication and describes herself as “fit and active”. She has no co-morbidities.

1. What additional information elicited from her gynaecological history will influence her treatment options? (5 marks)

Answer 10

• Severity of symptoms and impact on everyday life
• Sexual activity
• Previous prolapse or treatments tried
• Menopausal symptoms
• PMHx
• Other gynae history or abdo surgery
• Expectations and wishes regarding treatment

Question 11

You proceed to examine the patient and quantify her prolapse using the Pelvic Organ Prolapse Quantification System (POP-Q).

1. i) Outline the POP-Q quantification system (POP-Q). (2 marks)

ii) Comment on its usefulness in this setting. (2 marks)

Answer 11

• Classifies prolapse into grades by measuring points in respect to hymen – minus is above, plus is below (Aa 3cm from ext urethral meatus, Ba leading edge of ant prolapse, C cervix/leading edge vault, D post fornix, Ap 3cm from hymen posteriorly, Bp leading edge of post prolapse, GH length genital hiatus, PB length perineal body, TVL total vaginal length)
  
  • 0 = no prolapse
  • 1 = prolapse to -1
  • 2 = prolapse lower than -1 but higher than +1
  • 3 = prolapse below +1 but higher than +(TVL-2)
  • 4 = complete procidentia, lower than +(TVL-2)

II):

• System for objectively describing pelvic organ prolapse, especially helpful to compare pre and post treatment
• Helps determine severity of prolapse to guide management decisions (however does not necessarily correlate with severity of symptoms)

Question 13

On examination you find that the woman has a prolapse of the vaginal vault (middle compartment prolapse) presenting 2cm beyond the introitus when at rest.

1. Describe two benefits and two risks for each of one non-surgical and two surgical treatment options available for this condition. You do not need to describe the surgical methodology. You may use a table. (6 marks)

Answer 13

Benefit

Risk

Vaginal pessary

• No surgical/anaesthetic risk
• Can be inserted immediately
• Vaginal infection/ulceration
• Not suitable for sexual function

SSF

• Highly effective 90%
• Quicker recovery
• Buttock pain.
• Pudendal neurovascular damage

SCP

• Most effective 90-98%
• Can treat other intra-abdominal pathology
• Sacral osteomyelitis
• Rectal trauma

Question 14

The RANZCOG Statement C-Gyn 20 “Prolpropylene Vaginal Mesh Implants for Vaginal Prolapse” (2013) is a guide to current practice.

1. According to this statement, prior to undertaking a transvaginal mesh procedure, what issues should be addressed in the informed consent process regarding vaginal surgery for uterovaginal prolapse including those related specifically to the use of mesh (5 marks)?

Answer 14

• Explain limited robust data on efficacy and safety of transvaginal mesh
• Potential benefits and complications of prolapse surgery generally vs conservative treatment on status quo
  
  • Non-surgical: pessaries
  • No treatment (especially if mild, relatively asymptomatic prolapse)
• Potential benefits and complications of transvaginal mesh specifically:
  
  • Mesh exposure/erosion
  • Vaginal scarring/strictures
  • Fistula formation
  • Dyspareunia
  • Chronic pelvic pain – which may persist even after mesh removal
• Discuss surgical alternatives eg conventional native tissue repair or abdominal sacrocolpopexy/sacrospinous fixation
• The surgeons experience with mesh as evidenced by logbooks/training/peer review

Question 15

1. According to the above statement:
2. What is the current evidence regarding the benefits (if any) of transvaginal mesh versus native tissue prolapse repair with respect to procedure success/longevity for the anterior compartment, posterior compartment and vault? (3 marks)

Answer 15

• Anterior
  
  • Mesh more successful than native tissue prolapse repair - 10% vs 30% failure rates
  • Reoperation rates lower (?)
• Posterior
  
  • No difference in success
  • Reoperation rates similar (?)
• Vault
  
  • Mesh less successful than native tissue prolapse repair eg with SSF/sacrocolpopexy
  • Reoperation rates similar (small numbers in study)

Question 16

1. What are the complications associated with the use of transvaginal mesh? (3 marks)

Answer 16

• Mesh erosion
• Vaginal scarring/strictures
• Dyspareunia
• Chronic pelvic pain – which may persist even after mesh removal

Question 17

1. According to the above statement, caution should be exercised in using transvaginal mesh implants in which patients? (4 marks)

Answer 17

• Age <50
• Chronic pelvic pain
• Primary prolapse repair
• Posterior prolapses without significant apical descent
• Postmenopausal women unable to use ovestin (as first line management mesh erosion)
• Mild prolapses (less than grade 2)

Question 18

A 45 year old woman with a body mass index (BMI) of 35 kg/m2 presents to the gynaecology clinic with symptoms suggestive of stress urinary incontinence.

a. How would you make the diagnosis of ‘pure’ stress incontinence on history (3 marks), examination (1 mark) and investigation (1 mark)?

Answer 18

• History
  
  • Involuntary urine leakage with cough/sneeze/strain/exertion
  • Not associated with urgency, frequency
  • Usually small – mod volumes of leakage
  • Absence of leakage at rest
• Exam
  
  • May see leakage with coughing/straining
  • Otherwise usually normal exam
• Investigation
  
  • Urodynamics – observation of leakage of urine associated increased intraabdominal pressure in the absence of an involuntary detrusor contraction.
  • Bladder diary

Question 19

List six factors that predispose to genuine stress urinary incontinence. (3 marks)

Answer 19

• Increasing age
• Parity
• Vaginal births
• Obesity
• Chronic cough
• Postmenopausal

Question 20

Describe two non‐surgical interventions that can benefit pure stress incontinence symptoms. (2 marks)

Answer 20

• Pelvic floor exercises - best if taught by physio, do 3 times per day for at least 3 months. Involves awareness of pelvice floor and ability to isolate and contract.
• Lifestyle interventions – reduction in fluid intake, reduce caffeinated drinks, weight loss

Question 21

Describe in detail the operative technique of a tension‐free vaginal tape (TVT) procedure. Assume appropriate sedation or anaesthesia and sterile preparation has been performed. (5 marks)

Answer 21

• Prophylactic antibiotics, Teds
• Lithotomy position
• IDC – 18G with rigid guide
• Local anaesthetic diluted with saline
  
  • Over mid urethra vaginally
  • Retropubic hydrodissection – start just above symphysis, 2cm from midline on either side, aiming towards fornix on either side to level of urogenital diaphragm with 20-30mls
• Stab incisions through skin just above symphysis 2cm from midline on either side
• Vertical incision 1.5cm from external urethral meatus, approx. 2cm long over mid urethra
• Dissection of vaginal mucosa from pubocervical fascia with fine scissors towards inferior pubic ramus to level of urogenital diaphragm
• Rigid catheter used to move bladder away then trocar with tape inserted through vaginal incision and previously created tunnel, through urogenital diaphragm aiming towards stab incision, do both sides
• Remove IDC
• Cystoscopy – check no bladder injury from trocar/tape
• Bring trocars through skin, cut
• Tension tape eg over Hegar 8 dilator
• Remove plastic sleeves
• Cut tape below level of skin
• Ensure vaginal skin freed up over tape, close with interrupted absorbable sutures
• Close stab incisions with interrupted suture, apply dressings
• Can remove IDC, ensure postvoid residuals measured, may require reinsertion if high, or if thought high risk of retention, leave IDC on free drainage overnight and TROC the following morning

Question 22

a. List causes of a vesico-vaginal fistula. (4 marks)

Answer 22

Obstetric fistula:

• Obstructed labour
• Operative vaginal delivery and MROP
• After Caesarean section, peri-partum hysterectomy, and uterine rupture at term

Post-surgical fistula:

• Direct injury at dissection or crush injury, cautery, or suture placement (e.g. at hysterectomy)

Radiation therapy: due to a small vessel endarteritis that impairs the vascular supply of tissues and impairs the healing from surgical procedures

Inflammation: PID, diverticultis, or IBD can cause fistulae. Other severe pelvic pathology such as cancer can also be a cause

Penetrating injuries and retained foreign bodies

Congenital anomaly including a fistula

Question 23

A 45 year old woman underwent an abdominal hysterectomy. One week later she attends your clinic complaining of a watery loss on her underwear.

b. How would you diagnose a vesico-vaginal fistula? (8 marks)

Answer 23

History:

• Reason for hysterectomy: for benign or malignant disease
• Immediate post-operative course: any severe abdominal pain, trouble with passing urine, haematuria, ascites, or other reasons to suspect a bladder or ureteric injury?
• Symptom onset and duration
• Volume of leakage: changing heavy pads frequently?
• Colour and smell of leakage
• Flow characteristics of leakage: continuous, intermittent, and flow, precipitating factors e.g. cough
• Bowel habit
• Associated stress or urge incontinence pre-or post procedure ‘
• Associated symptoms such as pain, fever, urinary symptoms, vaginal bleeding
• Smoking status
• Past medical, surgical, gynae and obstetric history, radiation or trauma
• Review notes from previous admission and for the surgery

Examination:

• Observations (HR, BP, Temp, RR, SAO2) and BMI
• Abdominal examination: ascites or masses present? Pelvic examination?
• Pelvic examination: gentle examination with a split speculum looking at the integrity of the vaginal cuff- the entrance to the fistula is typically in the upper 1/3 of the vagina or at the cuff- most are obvious on examination, urine leakage may be seen or a hole may be present, smell of urine may also be present
• PR exam to check integrity of anal sphincter
• EUA can be performed if this is not well-tolerated

Investigations (if no obvious fistula on clinical examination):

• 3 swab or Tampon test: place a tampon into the vagina and fill the bladder via a bladder catheter with methylene blue or indigo carmine. The tampon should be checked for dye after a cough or Valsalva manoeuvre. Blue staining on the tampon from the vaginal apex indicates a vesico-vaginal fistula
  
  • Clear urine on the tampon/last swab indicates a potential ureterovaginal fistula
• MSU for urinalysis and culture
• Cystoscopy: assess the bladder for the location of the injury, any stitches that may be present and the number of openings into the bladder. May need to be carbon dioxide cystoscopy after filling the vagina with saline to look for bubbles
• Other tests such as retrograde pyelography, CT IVurogram with contrast, pelvic MRI can be used if these tests do not reveal the location of the fistula and to assess ureteral integrity
• Consider EUA if examination difficult for the patient to tolerate- may need to have lacrimal probes to demonstrate a very small fistula

Question 24

. List the treatment options if a vesico-vaginal fistula is diagnosed. (3 marks)

Answer 24

Non-surgical

• Continuous urinary drainage with a bladder catheter may be effective in a small number of women with a small fistula that is recognised early (within 2-3 weeks post-op)- the fistula may close spontaneously
• Treat UTI if present, treat vaginitis if present
• Incontinence pads and barrier creams can be used if continued leakage to protect the skin from urine dermatitis

Surgical

• Fistula repair can be early (if tissue is healthy) but delayed is preferred (6-12 weeks post-op to allow for healing and reduction in granulation tissue/necrosis)
• She should be referred early to experienced clinicians as the first repair has the highest chance of closure.
• Choice will be determined by severity and location of fistula
• An episiotomy may be required to enable adequate exposure for a vaginal repair
• Traditional repair (flap splitting technique) is performed in layers with absorbable sutures. There is wide lateral dissection to expose healthy vaginal tissue and to create a flap to cover the defect without tension, the tract is dissected and the healthy tissue is repaired in layers. The ureters may need to be stented pre-procedure as they are often close to the repair site. After suturing is complete use methylene blue to ensure repair is water tight, then perform cystoscopy and check ureteric patency
  
  • Does not shorten the vagina and has a success rate equivalent to the Latzko procedure
• The Latzko method would be appropriate if her fistula is small. A foley catheter is placed inside the fistula, the surrounding vaginal is excised in quadrants (the vesical edges of the fistula are not debrided). A 3 layer closure is then completed over the area. Urothelium will overgrow the defect.
• IDC in for at least 10-14 days week for bladder rest- may need longer drainage depending on the type and location of repair
  
  • Must use a large-bore catheter to prevent blockages
• Follow up in urology with cystogram +/- cystoscopy before IDC is removed
• Complex fistula repair:
  
  • Complex and scarred fistulas may need to be repaired abdominally using a trans-vesical approach (beware the ureters!)- this may be necessary in a post-hysterctomy vault fistula that may not come down easily
  • Grafts may be needed to cover the area in a large fistula eg a Martius fat graft or a muscle graft (Mackenrodt technique uses part of the gracilis)

Question 25

Feb 2017 Question 11

A 55 year old woman is referred by her GP with symptoms of prolapse. She had a vaginal hysterectomy 10 years ago for menorrhagia. For the past 6 months she has noted a vaginal bulge which is getting bigger. Her bladder and bowel function are normal and there is no pain, bleeding or discharge. She is on no medication and describes herself as “fit and active”. She has no comorbidities.

a. What additional information elicited from her gynaecological history will influence her treatment options? (5 marks)

Answer 25

• Urinary incontinence- stress, urge or mixed in continence
• Symptoms of menopause- vasomotor symptoms, vulvovaginal atrophy
• Obstetric history- number of children and mode of delivery (CS vs vaginal delivery)
• Sexual history- whether current sexually active/prolapse interfering with sexual activity
• Her preferences with regards to management options eg conservative, medical, surgical
• Previous treatments for prolapse and other previous surgery
• Chronic cough, constipation
• Smoking

Question 26

You proceed to examine the patient and quantify her prolapse using the Pelvic Organ Prolapse Quantification System (POP-Q).

b. i) Outline the POP-Q quantification system (POP-Q). (2 marks)

Answer 26

Staging system which allows objective quantification of prolapse.

Point of reference is the hymenal ring: counted as 0

• Point Aa and Ap are 3cm into the vaginal from the hymenal ring: - 3
  
  • Corresponding points Ba and Bp which define the most dependent part of the prolapse, if there is not prolapse they are also -3
• C = cervix or vaginal cuff
• D= posterior fornix, absent after hysterectomy
• Total vaginal length- from the hymen to the posterior fornix
• Genital hiatus- from the bottom of the urethra to the posterior forchette

Question 27

ii) Comment on its (POP-Q) usefulness in this setting. (2 marks)

Answer 27

• Gives objective quanitification of prolapse
• Good intra- and inter-observer consistency of measurement and definition of prolapse
• Allows objective comparison of pre- and post-surgical state

Question 28

On examination you find that the woman has a prolapse of the vaginal vault (middle compartment prolapse) presenting 2cm beyond the introitus when at rest.

c. Describe two benefits and two risks for each of one non-surgical and two surgical treatment options available for this condition. You do not need to describe the surgical methodology. You may use a table. (6 marks)

Answer 28

Benefits

Risks

Vaginal pessary

Outpatient procedure

Does not require surgery

Cheaper

Patient can remove and replace

Pessary erosion

Higher failure

Sacrocolpopexy (laparoscopic or abdominal)

Low risk of reoperation

Treat concurrent abdominal pathology

Mesh exposure

Sacral osteomyelitis

Sacrospinous fixation

Vaginal surgery with shorter operating time

Buttock pain

Bleeding risk from inferior gluteal artery

Higher recurrence risk

Question 29

A 55 year old woman is referred by her GP with symptoms of prolapse. She had a vaginal hysterectomy 10 years ago for menorrhagia. For the past 6 months she has noted a vaginal bulge which is getting bigger. Her bladder and bowel function are normal and there is no pain, bleeding or discharge. She is on no medication and describes herself as “fit and active”. She has no co-morbidities.

1. What additional information elicited from her gynaecological history will influence her treatment options? (5 marks)

Answer 29

• Severity of symptoms and impact on everyday life
• Sexual activity
• Previous prolapse or treatments tried
• Menopausal symptoms
• PMHx
• Other gynae history or abdo surgery
• Expectations and wishes regarding treatment

Question 30

You proceed to examine the patient and quantify her prolapse using the Pelvic Organ Prolapse Quantification System (POP-Q).

1. i) Outline the POP-Q quantification system (POP-Q). (2 marks)

Answer 30

• Classifies prolapse into grades by measuring points in respect to hymen – minus is above, plus is below (Aa 3cm from ext urethral meatus, Ba leading edge of ant prolapse, C cervix/leading edge vault, D post fornix, Ap 3cm from hymen posteriorly, Bp leading edge of post prolapse, GH length genital hiatus, PB length perineal body, TVL total vaginal length)
  
  • 0 = no prolapse
  • 1 = prolapse to -1
  • 2 = prolapse lower than -1 but higher than +1
  • 3 = prolapse below +1 but higher than +(TVL-2)
  • 4 = complete procidentia, lower than +(TVL-2)

Question 31

ii) Comment on its (POP-Q) usefulness in this setting. (2 marks)

Answer 31

• System for objectively describing pelvic organ prolapse, especially helpful to compare pre and post treatment
• Helps determine severity of prolapse to guide management decisions (however does not necessarily correlate with severity of symptoms)

Question 32

On examination you find that the woman has a prolapse of the vaginal vault (middle compartment prolapse) presenting 2cm beyond the introitus when at rest.

1. Describe two benefits and two risks for each of one non-surgical and two surgical treatment options available for this condition. You do not need to describe the surgical methodology. You may use a table. (6 marks)

Answer 32

Benefit

Risk

Vaginal pessary

• No surgical/anaesthetic risk
• Can be inserted immediately
• Vaginal infection/ulceration
• Not suitable for sexual function

SSF

• Highly effective 90%
• Quicker recovery
• Buttock pain.
• Pudendal neurovascular damage

SCP

• Most effective 90-98%
• Can treat other intra-abdominal pathology
• Sacral osteomyelitis
• Rectal trauma

Question 33

The RANZCOG Statement C-Gyn 20 “Prolpropylene Vaginal Mesh Implants for Vaginal Prolapse” (2013) is a guide to current practice.

According to this statement, prior to undertaking a transvaginal mesh procedure, what issues should be addressed in the informed consent process regarding vaginal surgery for uterovaginal prolapse including those related specifically to the use of mesh (5 marks)?

Answer 33

• Explain limited robust data on efficacy and safety of transvaginal mesh
• Potential benefits and complications of prolapse surgery generally vs conservative treatment on status quo
  
  • Non-surgical: pessaries
  • No treatment (especially if mild, relatively asymptomatic prolapse)
• Potential benefits and complications of transvaginal mesh specifically:
  
  • Mesh exposure/erosion
  • Vaginal scarring/strictures
  • Fistula formation
  • Dyspareunia
  • Chronic pelvic pain – which may persist even after mesh removal
• Discuss surgical alternatives eg conventional native tissue repair or abdominal sacrocolpopexy/sacrospinous fixation
• The surgeons experience with mesh as evidenced by logbooks/training/peer review

Question 34

1. According to the above statement:
2. What is the current evidence regarding the benefits (if any) of transvaginal mesh versus native tissue prolapse repair with respect to procedure success/longevity for the anterior compartment, posterior compartment and vault? (3 marks)

Answer 34

• Anterior
  
  • Mesh more successful than native tissue prolapse repair - 10% vs 30% failure rates
  • Reoperation rates lower (?)
• Posterior
  
  • No difference in success
  • Reoperation rates similar (?)
• Vault
  
  • Mesh less successful than native tissue prolapse repair eg with SSF/sacrocolpopexy
  • Reoperation rates similar (small numbers in study)

Question 35

1. What are the complications associated with the use of transvaginal mesh? (3 marks)

*

Answer 35

• Mesh erosion
• Vaginal scarring/strictures
• Dyspareunia
• Chronic pelvic pain – which may persist even after mesh removal

Question 36

1. According to the above statement, caution should be exercised in using transvaginal mesh implants in which patients? (4 marks)

Answer 36

• Age <50
• Chronic pelvic pain
• Primary prolapse repair
• Posterior prolapses without significant apical descent
• Postmenopausal women unable to use ovestin (as first line management mesh erosion)
• Mild prolapses (less than grade 2)

Question 37

1. Define the terms “over active bladder” (OAB) and “urge incontinence” (UI). (2 marks)

Answer 37

“Overactive bladder”: Syndrome of urinary urgency with or without incontinence, which is accompanied by nocturia and urinary frequency

“Urge incontinence”: Incontinence is preceded or accompanied by an immediate urge to void

Question 38

b. Complete the table below regarding the autonomic nerve supply to the bladder detrusor muscle. (2 marks)

Answer 38

Action on detrusor muscle

Releases which neurochemical

Sympathetic

Causes relaxation and increased bladder compliance

Contraction of the urethral sphincter

Acetylcholine pre-ganglionic

Noradrenaline post-ganglionic

Parasympathetic

Causes contraction of detrusor and relaxation of the sphincter

Acetylcholine

Question 39

A 60 year old woman presents with symptoms consistent with OAB noticed increasingly over the last year. Clinical history confirms she experiences urge incontinence 3-4 times a week.

1. List and justify the assessments you will make to further evaluate this patient’s symptoms/problem. For your answer you may use a table with the headings “assessment” and “justification”. (5 marks)

Answer 39

Assessment

Justification

History

Full history of urinary (frequency, incontinence, urge, nocturia, overflow, duration) and bowel symptoms, sexual function, symptoms of prolapse, past medical history, past surgeries, obstetric history, family history will help guide towards the likely source of the problem and aid with selecting investigations and management

ETOH and caffeine intake- can increase overactive bladder symptoms

A questionnaire can be used to supplement the history eg the international consultation on incontinence questionnaire

BMI

Elevated BMI is linked to prolapse and may contribute to urinary incontinence and also UTI if poor hygiene is present

Cardiorespiratory examination

Guided by medical history as conditions such as COPD can cause raised intra-thoracic pressure and therefore cause prolapse and/or incontinence

Abdominal examination

Abdominal masses can cause prolapse and incontinence, suprapubic region and flanks should be palpated to evaluate for pyelonephritis/enlarged bladder/uterus

Pelvic examination

Smear if due, review if atrophic vaginitis is present as this can be treated, ensure no pelvic masses are palpable, evaluate the strength of the pelvic muscles, ensure no saddle anaesthesia

Evaluate for prolapse using POPQ- helps to plan surgery

Cough stress test- confirms urinary incontinence

Neurological examination

Examination of leg strength and sensation to review function of nerve roots S1-S4

MSU

UTI can cause symptoms of urge incontinence

Bladder diary

Bladder diary will be most revealing as to when the urge is felt, how long the patient can hold on when she feels urge, when she leaks, the volume of drinking and the type of drinking, and the amount of urine passed. Points towards triggers and may help diagnose stress or urge incontinence or both.

Urodynamics

This can be used if the picture is unclear e.g. with mixed incontinence to clarify the type of incontinence and guide towards potential treatment

Medications

Antihistamines, antidepressants, sedatives, diuretics- may need to be adjusted if worsening urinary incontinence

Pelvic USS

Ensure no fibroid/mass causing symptoms, look at post-void residual on USS to review if there is an element of retention (a bladder scan can also be done in an outpatient clinic setting)

Question 40

d. Outline six (6) management strategies available for urge incontinence in this patient. (6 marks)

Answer 40

1. Treat UTI with antibiotics, consider prophylaxis with cranberry juice for recurrent UTIs
2. Reduce “bladder irritating” agents- caffeine, carbonated beverages, and alcohol to try to reduce bladder spasm

• Trial caffeine reduction
• Modify under or over drinking behaviours e.g. too much urine or too little urine which is irritating

Smoking cessation

Avoid constipation (trial fibre supplements

Weight loss

3. Bladder retraining- starting with the shortest tolerated time between voids, timed voids then start using that interval. Once three or four days have gone by without incontinence and timed voids, then the time between voids is extended.
   * This should be done in conjunction with physiotherapy review and pelvic floor muscle training (to learn how to relax the pelvic floor, contractions as distraction from need to void, other strategies to avoid voiding eg tapping on the perineum/clitoris)
4. Medication- anticholinergic drugs which aim to stop the release and/or uptake of acetylcholine at the nerve-muscle junction, e.g. oxybutynin, solifenacin. Advise regarding side effects e.g. dry mouth and explain this is not due to dehydration.
5. Give oestrogen in the context of urethral and vaginal atrophy- will help with the irritation created by vaginal atrophy
6. Botox injection at cystoscopy- botox injection of the detrusor can help in women who do not respond to or cannot tolerate pharmacotherapy, this aims to relax the detrusor muscle to stop urinary frequency and urge. Should have MDT review prior to this.
7. Sacral nerve stimulation- minimally invasive nerve stimulation. A lead is placed in the S3 foramen and nerve stimulation occurs to this nerve. This causes contraction of the external sphincter and pelvic floor, which in turn causes inhibition of bladder contractions which may be involuntarily passing urine. Should have MDT review prior to this.

Question 41

A 45 year old woman with a body mass index (BMI) of 35 kg/m2 presents to the gynaecology clinic with symptoms suggestive of stress urinary incontinence.

a. How would you make the diagnosis of ‘pure’ stress incontinence on history (3 marks), examination (1 mark) and investigation (1 mark)?

Answer 41

• History
  
  • Involuntary urine leakage with cough/sneeze/strain/exertion
  • Not associated with urgency, frequency
  • Usually small – mod volumes of leakage
  • Absence of leakage at rest
• Exam
  
  • May see leakage with coughing/straining
  • Otherwise usually normal exam
• Investigation
  
  • Urodynamics – observation of leakage of urine associated increased intraabdominal pressure in the absence of an involuntary detrusor contraction.
  • Bladder diary

Question 42

List six factors that predispose to genuine stress urinary incontinence. (3 marks)

*

Answer 42

• Increasing age
• Parity
• Vaginal births
• Obesity
• Chronic cough
• Postmenopausal

Question 43

c. Describe two non‐surgical interventions that can benefit pure stress incontinence symptoms. (2 marks)

*

Answer 43

• Pelvic floor exercises - best if taught by physio, do 3 times per day for at least 3 months. Involves awareness of pelvice floor and ability to isolate and contract.
• Lifestyle interventions – reduction in fluid intake, reduce caffeinated drinks, weight loss

Question 44

Describe in detail the operative technique of a tension‐free vaginal tape (TVT) procedure. Assume appropriate sedation or anaesthesia and sterile preparation has been performed. (5 marks)

Answer 44

• Preop discussion and consent
• Prophylactic antibiotics, Teds
• Lithotomy position
• IDC – 18G with rigid guide
• Local anaesthetic diluted with saline
  
  • Over mid urethra vaginally
  • Retropubic hydrodissection – start just above symphysis, 2cm from midline on either side, aiming towards fornix on either side to level of urogenital diaphragm with 20-30mls
• Stab incisions through skin just above symphysis 2cm from midline on either side
• Vertical incision 1.5cm from external urethral meatus, approx. 2cm long over mid urethra
• Dissection of vaginal mucosa from pubocervical fascia with fine scissors towards inferior pubic ramus to level of urogenital diaphragm
• Rigid catheter used to move bladder away then trocar with tape inserted through vaginal incision and previously created tunnel, through urogenital diaphragm aiming towards stab incision, do both sides
• Remove IDC
• Cystoscopy – check no bladder injury from trocar/tape
• Bring trocars through skin, cut
• Tension tape eg over Hegar 8 dilator
• Remove plastic sleeves
• Cut tape below level of skin
• Ensure vaginal skin freed up over tape, close with interrupted absorbable sutures
• Close stab incisions with interrupted suture, apply dressings
• Can remove IDC, ensure postvoid residuals measured, may require reinsertion if high, or if thought high risk of retention, leave IDC on free drainage overnight and TROC the following morning

Question 45

a. Both sacrospinous fixation and sacrocolpopexy can be performed to repair post hysterectomy vaginal vault prolapse. Complete the following table using the headings provided to compare these operations. (The two (2) benefits and two (2) risks must be different for each procedure). (6 marks)

Answer 45

Sacrospinous fixation

Sacrocolpopexy

Anatomical level of support

Level 1

Level 1

Operative approach

Vaginal

Abdominal (laparoscopic or abdominal)

Benefit 1

Quicker recovery

Shorter operating time

No synthetic mesh

Concurrent abdominal surgery can be performed if needed eg cystectomy

Benefit 2

Can also do concurrent anterior or posterior wall repair

Effective- better objective success rates compared to SSF

Lower risk of recurrence

Risk 1

Post-operative buttock pain (injury to pudendal or sciatic nerves)

Mesh exposure <1%

Sacral osteomyelitis

Risk 2

Vascular injury- inferior gluteal artery

Shorten vaginal length

Infection

Presacral nerve injury

Question 46

A 62 year old woman presents with a history of mixed urinary incontinence. She has a BMI of 33kg/m2 but is otherwise in good health. She underwent menopause aged 48 years and had two instrumental deliveries in the past. She describes urge symptoms three times a week with occasional urinary incontinence. With coughing she can experience stress incontinence. She has no prolapse symptoms. You proceed to examine her.

b. List four (4) differential diagnoses you will consider. (2 marks)

Answer 46

• Vulvovaginal atrophy
• Urinary tract infection
• Central causes eg spinal cord lesions
• Overflow incontinence
• Overactive bladder syndrome
• Intrinsic sphincter deficiency
• Urethral hypermobility
• Functional disorder
• Temporary causes: diuretics, caffeine, ETOH, hyperglycaemia/excessive fluids,

Question 47

c. Outline your initial assessment and management over the next three months to further assess the cause of her symptoms. (7 marks)

Answer 47

Assessment

History taking: urinary sx, bowel sx, lifestyle sx, prolapse sx, previous surgeries, gynae surgeries, obstetric histories, medical history, medications, sexual history, quality of life

a. Cardiorespiratory examination if applicable: features of chronic lung disease and/or causes for chronic cough
b. Abdominal examination: masses, enlarged bladder
c. Vaginal examination:

• Examination with Sim’s speculum in reclined position and left lateral, examining for atrophic vaginitis, prolapse and incontinence with and without Valsalva- grade according to POP-Q system (prolapse can be aysmptomatic)
• POPQ
• Digital examination to assess for pelvic masses, assess length of vagina and mobility of uterus to review what surgical approach may be appropriate, evaluate pelvic floor muscle contraction by asking patient to squeeze as she would to try to stop urine or gas
• Ensure there is no saddle anaesthesia

d. Neurological examination of legs to ensure there is no sign of S1-S4 nerve root damage
e. Investigations: smear if due, swabs if symptoms or signs of infection, MSU, pelvic mass if indicated, bladder diary

Management

Conservative/Medical

Aim to treat her urge incontinence symptoms first and then address the stress incontinence

1. Treat infection with antibiotics and atrophic vaginitis with oestrogen topical cream
2. Bladder diary- record intake of fluid and types of fluid (e.g. alcohol, caffeine, water) and frequency of leak and urgency symptoms
3. Smoking cessation if smoker, advise to abstain from caffeine, carbonated beverages and ETOH as these can worsen incontinence
4. Review current medication- if any are implicated in urinary incontinence then discuss with GP regarding changing regular medications
5. Weight loss: advise exercise and weight loss are good for general health and weight loss in her case (BMI 33) may improve incontinence on its own
6. Evaluate for concurrent constipation and treat this if it is present, ideally with dietary modification as this may cause incontinence
7. Bladder training: starts with timed voiding and the aim is to train the bladder to tolerate higher volumes of urine. Bladder retraining starts with timed voids at the shortest interval that women can tolerate voiding and then increased.
8. Pelvic floor exercises: supervised by physiotherapy

• Aim to include with bladder retaining to allow start initially with three sets of 8-12 contractions sustained for 8-10 seconds each three times a day for 15-20 weeks. Most women who perform these will see an improvement in their symptoms. If women have trouble localising the pelvic floor muscles, biofeedback techniques, vaginal cones, or supervised pelvic floor exercises may be necessary.
• These aim to teach the woman kegels to help her distract from her symptoms and pelvic floor training if necessary

If in 3 months not improved

9. Consider a trial of oxybutynin and solifenacin to try to decrease urge incontinence symptoms

10 Urodynamics- failed conservative management with a mixed stress picture

Question 48

a. Name six (6) specific types of urodynamic tests that may be performed to assess function of the lower urinary tract. Explain what each test measures. (6 marks)

Answer 48

Uroflowmetry

Measures global voiding function- strength and stream with void

Post-void residual

Measures urine remaining in the bladder after voiding- global voiding function

Filling cystometry

Storage and sensation during filling

Measures volume at first urge to void

Measures detrusor contractility with filling

Urethral pressure measurement

Evaluates urethral closing forces

Evaluates for intrinsic sphincter deficiency

Detrusor leak point pressure

Urethral competence against the pressure generated against by a detrusor contraction

Valsalva leak point pressure

Urethral competence against increased abdominal pressure (Valsalva)

Pressure-flow studies

Assesses voiding function with IDC still in situ- detrusor contractility with voiding and outlet obstruction

Question 49

b. Explain when you would undertake urodynamic testing before contemplating surgery in a woman with stress incontinence. (4 marks)

Answer 49

• • In any woman with a mixed picture when there are features of both urge and stress incontinence. Pure stress incontinence is rare and complicating factors such as detrusor overactivity can affect the surgical decision and consenting process.
• In a woman who has had previous repairs done for stress incontinence and these have failed
  
  • Pelvic radiation
• Suspicion of non-stress aetiology eg continuous leakage, nocturia
• The RCOG recommendation is for all women having any procedure for stress incontinence, urodynamics is done- particularly filling cystometry, uroflowmetry and residual urine measurement.

Question 50

A 65 year old woman of BMI 35 with utero-vaginal prolapse presents with a history of urge incontinence that improved (but still symptomatic) as the prolapse worsened over the years. She also describes the need to manually replace the prolapse to void. She has no co-morbidities, keeps good health and takes no medication. Examination confirms a Stage II Pelvic Organ Prolapse (POP).

c. Describe how you would manage her problem. (5 marks)

Answer 50

Investigations

• MSU to exclude UTI
• Pelvic USS- review if there is a cause for increased intra-abdominal pressure and prolapse eg fibroids
• Urodynamic studies to evaluate if there is detrusor over-activity as this will need to be fixed prior to any surgical option for treatment
• Bladder diary

Conservative treatments

• Advise weight loss, which may improve her prolapse symptoms
• Recommend stopping smoking if she smokes
• Recommend avoiding caffeinated and carbonated beverages and alcohol as this worsens symptoms of urge incontinence
• Recommend review by pelvic floor physiotherapy for bladder retraining and exercises to help improve prolapse- women often have good results with physiotherapy for bladder retraining

Medical treatment

• Vaginal oestrogen cream can help improve symptoms of prolapse and may improve irritative symptoms of urgency and frequency by reversing urogenital atrophy
• Oxybutynin and other antimuscarinic drugs (also solfacenacin or mirabegnan) can also help with symptoms of urgency as this reduces intravesical pressure, raises the volume threshold for voiding and reduces uninhibited contractions
• Vaginal pessaries can be helpful to relocate the prolapse and this may mimic surgical repair to evaluate what the effect of this may be on bladder function

Surgical treatment

• For overactive bladder:
  
  • Botox injections via cystoscopy
  • Sacral nerve stimulation
• For prolapse:
  
  • Sacrospinous fixation, sacrocolpopexy, uterosacral suspensions are an option for her to improve her prolapse- she does not need a routine hysterectomy
  • Consider a hysterectomy if the above are unsuccessful or if there are other indications eg a large multi-fibroid uterus