Sept14 M1-Urogynecology

Question 1

list of pelvic floor disorders

Answer 1

• urinary incontinence
• voiding dysfunction
• pelvic organ prolapse
• fecal incontinence
• non dangerous, negative qol

Question 2

what is stress urinary incontinence

Answer 2

a type of UTI

Question 3

important cause of PFD

Answer 3

childbirth

Question 4

causes of PFDs

Answer 4

• 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)

Question 5

obstetrical RFs for PFDs

Answer 5

• 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)

Question 6

urinary incontinence PFD types

Answer 6

• 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)

Question 7

most common form of UI as PFD

Answer 7

stress UI

Question 8

stress UI pthophgy

Answer 8

increased abd P overcomes urethral sphincter closure mechanisms in ABSENCE of bladder contraction

Question 9

2 types of stress UI

Answer 9

• hypermobile urethra (=MUSCLE weakness and the urethra moves when you cough bc it’s not supported)
• intrinsic sphincter deficiency

Question 10

urge incontinence pathophgy

Answer 10

• uncontrolled contraction of the detrusor muscle

- common triggers are running water, hand washing, going out in the cold, trying to lock the door

Question 11

UI key thing in management

Answer 11

tx the sx

Question 12

UI key things in hx

Answer 12

• assess bladder emptying, etc
• precip factors
• CAFFEIN USE, CARBONATED BEVERAGES (irritants to the bladder and worsen urinary sx) + faily fluid intake
• assoc pelvic disorders

Question 13

UI PFD PE with imp things (2)

Answer 13

• 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

Question 14

(imp?) cough stress test is what

Answer 14

ask pt to cough and see if leaking

Question 15

investigations in UI PFD

Answer 15

• UA and urine culture

- post void residual volume

Question 16

conservative management of UI

Answer 16

-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,

Question 17

medical management of UI

Answer 17

• *Are used for urge urinary incontinence to relax the detrusor muscle**
• anticholinergics
• beta agonist

Question 18

surgical management of UI

Answer 18

• *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

Question 19

3 types of POP (pelvic organ prolapse)

Answer 19

1. anterior vaginal prolase (cystourethrocele or cystocele) (anterior wall of vagina comes down with bladder)
2. apical vaginal prolapse (uterovaginal, vaginal, vault) (or vaginal fault prolapse)
3. posterior vaginal prolapse (rectocele, enterocele)

Question 20

what’s a complete procidentia

Answer 20

COMPLETE prolapse of the uterus

Question 21

prolapse evaluation (hx)

Answer 21

• Qol (no complains = don’t treat)
• reducible?
• onset and severity?
• assoc sx

Question 22

PE for POP with important steps

Answer 22

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**

Question 23

split speculum exam done how

Answer 23

push on diff sides of vagina with one half of speculum and ask to bear weight and see if something coming down

Question 24

when do you treat asymptomatic prolapse

Answer 24

only when extensive (UTI concern, bladder obstruction, kinked uterers leading to hydronephrosis, etc.)

Question 25

POP conservative management

Answer 25

• same lifestyle modifications as UI
• pelvic floor muscle exercises with Kegels again (pelvic floor physio)
• pessaries

Question 26

pessaries advantages and disadv

Answer 26

adv = effective, inexpensive, minimal risk
disadv = need regular care, possible discharge, odor, risk of ulceration

Question 27

when is surgery indicated for POP

Answer 27

• SYMPTOMATIC pt
• desire surgical correction
• pessaries cause erosions, discomfort or ineffective

Question 28

main categories of POP repair

Answer 28

• reconstructive (put as was before. native tissue repair or augmented repair)
• obliterative (close skin of vagina if non sexually active)

Question 29

(imp?) what is the role of vaginal estrogen in patients with PFDs

Answer 29

• 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

Question 30

(imp?) what is the role of oral estrogens in patients with UI

Answer 30

NOT recommended. neither for prevention nor tx

Question 31

how to test for urethral hypermobility

Answer 31

1. used to do vaginal cottom swab or urethral Q-tip but now just look at pelvic inclination
2. ask the patient to strain (abd muscles)
3. if angle variation is greater than 30 degrees = it means hypermobile urethra, pelvic floor muscles weak