Sept14 M1-Urogynecology Flashcards
list of pelvic floor disorders
- urinary incontinence
- voiding dysfunction
- pelvic organ prolapse
- fecal incontinence
- non dangerous, negative qol
what is stress urinary incontinence
a type of UTI
important cause of PFD
childbirth
causes of PFDs
- incite (childbirth, hysterectomy, vaginal surgery, radical pelvic surgery, radiation)
- predispose (sex, race, neuro, muscular, anat, collagen, family)
- promote (obesity, lung dz, smoking, menopause, constip, occupation, meds, infection)
- decompensate (aging, dementia, debility, disease, environment, meds)
obstetrical RFs for PFDs
- lot of vaginal deliveries
- fetal macrosomia
- prolonged 2nd stage of labor (head stretches vagina)
- operative delivery
- tearing of muscles supporting pelvic organs (3rd and 4th degree)
urinary incontinence PFD types
- stress UI (involuntary leakage with effort (sneezing, laughing, coughing, running))
- urge incontinence (involuntary leakage + urgency)
- mixed incontinence (stress + urge mix)
- overflow incontinence (incomplete bladder emptying. impared contractility OR bladder outlet obstruction)
most common form of UI as PFD
stress UI
stress UI pthophgy
increased abd P overcomes urethral sphincter closure mechanisms in ABSENCE of bladder contraction
2 types of stress UI
- hypermobile urethra (=MUSCLE weakness and the urethra moves when you cough bc it’s not supported)
- intrinsic sphincter deficiency
urge incontinence pathophgy
- uncontrolled contraction of the detrusor muscle
- common triggers are running water, hand washing, going out in the cold, trying to lock the door
UI key thing in management
tx the sx
UI key things in hx
- assess bladder emptying, etc
- precip factors
- CAFFEIN USE, CARBONATED BEVERAGES (irritants to the bladder and worsen urinary sx) + faily fluid intake
- assoc pelvic disorders
UI PFD PE with imp things (2)
- vitals, BMI
- neuro exam
- abd exam (tenderness, masses)
- pelvic exam (inspection + cough stress test**), peripheral neuro exam, split speculum exam to check urethra hypermobility*, bimanual
(imp?) cough stress test is what
ask pt to cough and see if leaking
investigations in UI PFD
- UA and urine culture
- post void residual volume
conservative management of UI
-weight loss, exercise, smoking cessation, less coffee, less carbonated beverages, less fluid intake, tx chornic cough, tx constipation, pelvic floor muscle exercises, pessaries = rings in vagina,
medical management of UI
- *Are used for urge urinary incontinence to relax the detrusor muscle**
- anticholinergics
- beta agonist
surgical management of UI
- *for stress urinary incontinence**
- mid urethral slings, to compress urethra
- support tissue around urethra to abdomen
- fascial slings = capsule of rectum m used instead of synthetic material
- urethral bulking agents
3 types of POP (pelvic organ prolapse)
- anterior vaginal prolase (cystourethrocele or cystocele) (anterior wall of vagina comes down with bladder)
- apical vaginal prolapse (uterovaginal, vaginal, vault) (or vaginal fault prolapse)
- posterior vaginal prolapse (rectocele, enterocele)
what’s a complete procidentia
COMPLETE prolapse of the uterus
prolapse evaluation (hx)
- Qol (no complains = don’t treat)
- reducible?
- onset and severity?
- assoc sx
PE for POP with important steps
same as UI but important steps are *check for prolapse in each compt at a team (anterior, apical, posterior)
- POP quantity (measurement and grading of prolapse*
- *this is part of the SPLIT SPECULUM EXAM**
split speculum exam done how
push on diff sides of vagina with one half of speculum and ask to bear weight and see if something coming down
when do you treat asymptomatic prolapse
only when extensive (UTI concern, bladder obstruction, kinked uterers leading to hydronephrosis, etc.)
POP conservative management
- same lifestyle modifications as UI
- pelvic floor muscle exercises with Kegels again (pelvic floor physio)
- pessaries
pessaries advantages and disadv
adv = effective, inexpensive, minimal risk disadv = need regular care, possible discharge, odor, risk of ulceration
when is surgery indicated for POP
- SYMPTOMATIC pt
- desire surgical correction
- pessaries cause erosions, discomfort or ineffective
main categories of POP repair
- reconstructive (put as was before. native tissue repair or augmented repair)
- obliterative (close skin of vagina if non sexually active)
(imp?) what is the role of vaginal estrogen in patients with PFDs
- vaginal irritation and ulceration from pessaries is better tolerated (makes vagina more moist)
- HELP FOR URGE UI BUT NOT FOR STRESS UI
- improves stasis ulcers
(imp?) what is the role of oral estrogens in patients with UI
NOT recommended. neither for prevention nor tx
how to test for urethral hypermobility
- used to do vaginal cottom swab or urethral Q-tip but now just look at pelvic inclination
- ask the patient to strain (abd muscles)
- if angle variation is greater than 30 degrees = it means hypermobile urethra, pelvic floor muscles weak
