RANZCOG questions Flashcards
1
Q
Define the terms “over active bladder” (OAB) and “urge incontinence” (UI). (2 marks)
A
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
2
Q
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
A
Action on detrusor: - Sympathetic: Relaxation of detrusor and contraction of internal sphincter -Parasympathetic: Contraction Releases with neurochemical: - Sympathetic: Noradrenaline - Parasympathetic: Acetylcholine
3
Q
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)
A
4
Q
Outline six (6) management strategies available for urge incontinence in this patient. (6 marks)
A
- 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.
5
Q
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)
A
6
Q
A
7
Q
Describe briefly the micturition reflex and the centres affecting micturition. (4 marks)
A
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:
- somatic - efferents from S2-S4 via pudendal nerve are inhibited – external urethral sphincter relaxes.
- 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.
8
Q
Outline the principles of filling cystometry including the variables measured and aim of the test. (4 marks)
A
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:
- Total bladder capacity (volume).
- Intra-abdominal, intravesical pressure (from which detrusor pressure can be calculated).
- Presence of – involuntary detrusor contraction (provoked or unprovoked), urgency or leakage
- 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 1st desire to void and strong desire to void. When sustained strong desire to void then filling stopped and total volume is measured.
9
Q
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)
A
- Lifestyle – weight loss if indicated, decrease intake of fluid, caffeine, EtOH. Smoking cessation.
- PFMT – some improvement in urgency symptoms.
- Bladder retraining – scheduled voids and aim to increase the interval between voids. Needs to be performed for 6/12 for improvement.
- 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.
- Other medical therapies – PV oestrogen if cocominant urogenital atrophy or desmopressin if nocturia (off-license).
- Inravesical therapies – botulinum toxin or capsaicin – block Ca-channel dependent release of Acetylcholine.
- Neuromodulation – percuateous sacral neruomodulation or peripheral (posterior tibial).
Note: they don’t want surgical mgmt included in answer.
10
Q
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.
- What additional information elicited from her gynaecological history will influence her treatment options? (5 marks)
A
- 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
11
Q
You proceed to examine the patient and quantify her prolapse using the Pelvic Organ Prolapse Quantification System (POP-Q).
- i) Outline the POP-Q quantification system (POP-Q). (2 marks)
ii) Comment on its usefulness in this setting. (2 marks)
A
- 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)
12
Q
A
13
Q
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.
- 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)
A
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
14
Q
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)?
A
- 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
15
Q
- According to the above statement:
- 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)
A
- 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)
16
Q
- What are the complications associated with the use of transvaginal mesh? (3 marks)
A
- Mesh erosion
- Vaginal scarring/strictures
- Dyspareunia
- Chronic pelvic pain – which may persist even after mesh removal
17
Q
- According to the above statement, caution should be exercised in using transvaginal mesh implants in which patients? (4 marks)
A
- 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)
18
Q
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)?
A
- 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
19
Q
List six factors that predispose to genuine stress urinary incontinence. (3 marks)
A
- Increasing age
- Parity
- Vaginal births
- Obesity
- Chronic cough
- Postmenopausal
20
Q
Describe two non‐surgical interventions that can benefit pure stress incontinence symptoms. (2 marks)
A
- 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
21
Q
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)
A
- 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
22
Q
a. List causes of a vesico-vaginal fistula. (4 marks)
A
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
23
Q
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)
A
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
24
Q
. List the treatment options if a vesico-vaginal fistula is diagnosed. (3 marks)
A
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)
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)
* 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
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)
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
27
ii) Comment on its (POP-Q) usefulness in this setting. (2 marks)
* 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
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)
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
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)**
* 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
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)**
* 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)
31
**ii) Comment on its (POP-Q) usefulness in this setting. (2 marks)**
* 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)
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)**
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
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)?**
* 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
34
1. **According to the above statement:**
1. **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)**
* 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)
35
1. **What are the complications associated with the use of transvaginal mesh? (3 marks)**
*
* Mesh erosion
* Vaginal scarring/strictures
* Dyspareunia
* Chronic pelvic pain – which may persist even after mesh removal
36
1. **According to the above statement, caution should be exercised in using transvaginal mesh implants in which patients? (4 marks)**
* 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)
37
1. Define the terms “over active bladder” (OAB) and “urge incontinence” (UI). (2 marks)
“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
38
b. Complete the table below regarding the autonomic nerve supply to the bladder detrusor muscle. (2 marks)
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
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)
**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)
40
d. Outline six (6) management strategies available for urge incontinence in this patient. (6 marks)
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.
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**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)?**
* 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
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**List six factors that predispose to genuine stress urinary incontinence. (3 marks)**
*
* Increasing age
* Parity
* Vaginal births
* Obesity
* Chronic cough
* Postmenopausal
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c. **Describe two non‐surgical interventions that can benefit pure stress incontinence symptoms. (2 marks)**
*
* 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
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**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)**
* 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
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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)
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
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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)
* 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,
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c. Outline your initial assessment and management over the next three months to further assess the cause of her symptoms. (7 marks)
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
8. 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.
7. 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
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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)
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
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b. Explain when you would undertake urodynamic testing before contemplating surgery in a woman with stress incontinence. (4 marks)
* - 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.
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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)
_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
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