Specialist Gynae Flashcards
What is Urinary incontinence?
Involuntary leakage of urine that is objectively demonstrable and sufficient enough to cause physical and/ or emotional distress.
What is the physiology of urinating?
- Detrusor muscle makes up bladder wall
- Parasympathetic nerves aid voiding. Sympathetic nerves prevent voiding
- Micturition reflex controlled at the pons
- Afferent fibres respond to distension of the bladder wall at spinal cord
- Efferent parasympathetic fibres = contraction of detrusor muscle and opening of bladder neck
- Sympathetic fibres inhibit this
- Cerebral cortex modifies reflex and can relax or contract striated muscle of urethra and pelvic floor
What are the causes of Urinary incontinence?
• Reduced intra-urethral pressure compared to intra-vesicular
• Abnormal descent of neck of bladder = negative urethral closure pressure
• Laxity of sub-urethral support from vaginal wall, levator ani, endopelvic fascia
• Stress incontinence –
- When intravesical pressure exceeds the closing pressure on the urethra
- Childbirth is the most common causative factor, leading to denervation of the pelvic floor, usually during delivery.
- Oestrogen deficiency at the time of menopause leads to weakening of the pelvic support and thinning of the urothelium.
- Occasionally, weakness of the bladder neck can occur congenitally, or through trauma from radical pelvic surgery or irradiation.
What is Stress urinary incontinence (SUI)?
involuntary leakage of urine on effort or exertion, or on sneezing or coughing. Relaxed pelvic floor. Increased abdominal pressure.
What is Urodynamic Stress Incontinence (USI)?
Leakage of urine due to an increase of intra-abdominal pressure in the absence of detrusor activity (50% of female incontinence).
Unlike SUI, USI can only be diagnosed by urodynamic testing
What is urge incontinence?
Overactive bladder ( – Chronic condition, defined as urgency, with or without urge incontinence, usually with frequency or nocturia. Caused by detrusor over activity, diagnosis made by urodynamic testing. Incidence increases with age. Most common cause of incontinence in older women. Bladder oversensitivity. Neurological disorders
What is Overflow Urinary incontinence?
Outflow obstruction or retention
• Acute – overwhelms sphincter
• Chronic - stretches the detrusor and damages it so over time can be incontinent. Causes include neuronal, obstruction or pharmacological
Urethral blockage, bladder unable to empty properly.
What are Congenital causes of Urinary incontinence?
bladder exstrophy and ectopic ureter
What do you find when taking the history of Urinary incontinence?
• Presenting complaint – onset, duration, SEVERITY on QoL
Urological Sx – incontinence (inc. volume + frequency), frequency, urgency, nocturia, dysuria, foul smell, poor stream, straining, prolonged/incomplete emptying, dribbling, UTIs, nocturnal enuresis/childhood problems, retention, catheterization/past Rx, faecal incontinence, haematuria
Colorectal symptoms
Genitourinary prolapse (lump, dragging, sitting on football)
• Gynae Hx – LMP, menstrual Hx, general, surgery (prolapse/other gynae)
• Obstetric – parity, MOD, birth weights, ages
• Past medical
o Respiratory (cough); Cardiac; GI (constipation); CNS; Diabetes; Psychiatric. Neurology (MS) Anything that increases intra-abdominal pressure. Anaesthetic requirements
• Drug
o Diuretics; Beta-Blockers; Anti-Cholinergics (for urge incontinence)
• Social
• Impact on ADLs, smoking, alcohol, caffeine, carbonated drinks, volume of FLUID INTAKE, prev. ketamine use, heavy lifting at work
• Systemically unwell – UTI?
o Quality of life assessment – Stop them from going to work?
o Can fill in a frequency/ volume chart
What do you find when taking an Examination of Urinary incontinence?
• General examination
o Weight (BMI= incontinence/prolapse. And also surgery less successful)), BP, urinalysis.
o Check for signs of systemic disease.
o Mobility and mental state.
o Motivation and manual dexterity.
o Neurological examination, if there are any symptoms that point to a
possible neurological cause.
• Abdominal examination
o Exclude an abdominal or pelvic mass (cysts, retention, fibro uterus and pregnancy-= pressure on bladder)
o Exclude a full bladder (obstruction/retention).
• Pelvic examination
o Condition of the vulval skin (any atrophy, erythema, or oedema).
o Presence and degree of any concurrent uterovaginal prolapse.
o Assessment of urethral and bladder neck descent on straining.
o Assessment of pelvic floor muscle strength
o Post menopausal atrophy
o Vaginal discharge
o Ask patient to bear down/cough
• Prolapse – cystocele/urethrocele
• Incontinence
• Speculum and bimanual
• Sims speculum for prolapse
• Rectal examination can evaluate rectal sphincter tone or the presence of fecal impactation
What are the investigations for stress incontinence?
• Urinalysis – rule out UTI, DM, bladder malignancy (haematuria); if +ve: MSU MC&S
• Pad test
• Bladder diary
o volume intake and voids – Indicates bladder capacity, frequency and drinking habits. More than 7 voids a day per day = frequency.
• Residual check USS/catheterisation
• MRI – for prolapses
• Urodynamic testing
• Intra-venous pyelogram – indicates presence of a fistula
• Cystourethroscopy (+ biopsies) – exclude malignancy/stones
o Indications for cystourethrothroscopy –
- Recurrent UTIs, haematuria, bladder pain, suspected urinary tract injury or fistula, exclude bladder tumour or stones, if interstitial cystitis is suspected.
What are the indications for imaging of Urinary incontinence?
– USS and MRI • Recurrent UTIs • Haematuria • Urethral diverticula, which need to be differentiated from paravaginal cysts • Suspected ureteric injuries • Suspected urethral or vesical fistulae • Suspected malignancy or renal stones *More notes on urodynamics
What is the Management for stress urinary incontinence?
Try conservative management first; – 3 month follow-up
• Lifestyle interventions – weight reduction if BMI >30, smoking cessation, treatment of chronic cough and constipation
• Pelvic floor muscle training: 1st line. For at least 3mths should be considered as the first-line treatment:
o physiotherapists usually individualize the programme, but 3 sets of
8–12 slow maximal contractions sustained for 6–8s each per day is
a common regimen
o the exercises need to be continued long term.
• Biofeedback: refers to the use of a device to convert the effect of pelvic floor contraction into a visual or auditory signal to allow women objective assessment of improvement.
• Electrical stimulation: can assist in production of muscle contractions in women who are unable to produce muscle contraction.
• Vaginal cones: have been developed as a way of applying graded resistance against which the pelvic floor muscles contract.
• Pharmacological management of SUI
o Duloxetine: is the only medical treatment for moderate to severe SUI
It is an SNRI that enhances urethral striated sphincter activity via a
centrally mediated pathway
not recommended for first-line use by NICE = suicidal risk + withdrawal Sx
• Surgery – transvaginal tape: S/E = mesh erosion, infection and dyspareunia
What are the Indications for conservative treatment of stress urinary incontinence?
- Mild or easily manageable symptoms
- Family incomplete
- Symptoms manifest during pregnancy
- Surgery contraindicated by co-existing medical conditions
- Surgery declined by patient
What are the Investigations for urge incontinence?
• Urine culture
o Exclusion of infection is mandatory, as symptoms overlap those of UTI.
• Frequency/volume chart
o Typical features are i diurnal frequency associated with urgency and episodes of urge incontinence
o Nocturia is a common feature of OAB
• Urodynamics
o Characterized by involuntary detrusor contractions during the filling phase of the micturition cycle, which may be spontaneous or provoked
o Video-urodynamic testing is more appropriate in women with neurological diseases, to exclude vesicoureteric reflux or renal damage secondary to a persistent significant rise in intravesical pressure.
*Urodynamic assessment is essential for the diagnosis of OAB in women with multiple and complex symptoms. Other factors, such as metabolic abnormalities (diabetes or hypercalcaemia), physical causes (prolapse or faecal impaction), or urinary pathology (UTI or interstitial cystitis), need to be excluded before the diagnosis of OAB is made.
What is the Management for urge incontinence?
Conservative management
Behavioural therapy
• Advice to consume 1–1.5L of liquids per day.
• Avoid caffeine-based drinks (tea, coffee, cola) and alcohol.
• Various drugs, such as diuretics and antipsychotics, alter bladder function and should be reviewed.
Bladder retraining/pelvic muscle training
• ability to suppress urinary urge and extend the intervals between voiding.
Medical management – 3 month follow-up
Anticholinergic (antimuscarinic) drugs
• Block the parasympathetic nerves, thereby relaxing the detrusor muscle.
o Patients should be advised about the side effects before starting treatment can’t see, can’t pee, can’t shit, can’t spit
o Contraindications to anticholinergics - • Acute (narrow angle) glaucoma.
• Myasthenia gravis.
• Urinary retention or outflow obstruction. • Severe ulcerative colitis.
• Gastrointestinal obstruction.
Oestrogens
• Treatment with vaginal oestrogen often helps with symptoms of urgency, urge incontinence, frequency, and nocturia.
Surgery – Reserved as a last resort: cystoscopy and botox; percutaneous sacral nerve stimulation; augmentation cytoplast and urinary diversion
What is Urogenital prolapse?
(causes STRESS incontinence)
A prolapse is a protrusion of an organ or structure beyond its normal confines. 50% of parous women have a degree of prolapse – 10-20% seek help.
What is the Classification of Urogenital prolapse?
- Anterior vaginal wall prolapse
- Urtherocele – urethral decent
- Cystocele – bladder decent
- Cystourethrocele – bladder and urethral decent
- Posterior vaginal wall prolapse
- Rectocele – rectal decent
- Enterocele – small bowl decent, pouch of douglas
- Apical vaginal prolapse (mid compartment)
- Uterovaginal – uterus out of the vagina – see cervix – dirt
- Vault – post-hysterectomy inversion of the vaginal apex. No uterus just a rectangular chunk
What is the Grading of Urogenital prolapse?
Baden – Walker classification: POPQ
1st degree: the lowest part of prolapse descends halfway down the vaginal axis to the introituse.
2nd degree: the lowest part of the prolapse extends to the level of the introituse and through the introituse on straining
3rd degree: the lowest part of the prolapse extends through the introituse and lies outside the vagina (halfway past intraoitus).
4th degree: max. possible descent = procidentia
Beecham classification • 3 degrees of prolapse. • 1st degree: descent within the vagina • 2nd degree: descent into the introitus • 3rd degree: descent outside the introitus (third degree uterine prolapse = procidentia)
What is Anterior Urogenital prolapse?
• Anterior vaginal wall prolapse
• Urtherocele – urethral decent
• Cystocele – bladder decent
• Cystourethrocele – bladder and urethral decent
Symptoms: Urinary symptoms (stress IC, urinary frequency)
What is Central Urogenital prolapse?
Cervix/uterus
Symptoms: Bleeding/discharge from ulceration associated with procidentia
What is Posterior Urogenital prolapse?
• Rectocele – rectal decent
• Enterocele – small bowl decent, pouch of douglas
Symptoms: Bowel symptoms, feeling of incomplete evacuation and something having to press the posterior wall backwards to pass stool
What do you find when taking a History of Urogenital prolapse?
- Dragging sensation – worse at end of day or standing up
- Non-specific symptoms including local discomfort, lump present, bleeding / infection if ulcerated, dyspareunia
- Can get specific symptoms depending on where the prolapse is;
- Rectocele get constipation, incomplete bowl emptying and passive anal incontinence.
- Cystocele or urethrocele get urinary frequency and urgency, voiding difficulty, UTIs and stress incontinence.
- Prolapse may require reducing in order to pass urine or stool
What do you find when taking an Examination of Urogenital prolapse?
- Abdominal and bimanual to examine pelvic masses
- Do a vaginal examination to see extent of prolapse and grade it
- Assess anterior and posterior vaginal walls and cervical descent with a sims speculum.
- Ask patient to bear down
- Can do a combined rectal and vaginal digital examination to aid differentiation between a rectocele and an enterocele – finger will be seen bulging in rectocele
What are the Investigations of Urogenital prolapse?
- If urinary symptoms exclude UTI on dipstick
- Pelvic USS if pelvic mass suspected
- ECG, CXR, FBC and U&Es to assess fitness for surgery
What is the Management of Urogenital prolapse?
• Prevention – weight loss, avoid heavy lifting, pelvic floor exercises, avoid obstructed labour, adequate suturing of pelvic lacerations, avoid prolonged 2nd stage
• Conservative:
o Ring pessary or shelf pessary - if not sexually active (shelf; if sexually active ring), not fit for surgery or do not want surgery
• May require topical oestrogens in post-meopausal women to prevent ulceration
• May cause pain, urinary retention, fall out, infection
• Pelvic floor exercises
• Loss weight <30 BMI and stop smoking
• Bladder training – hold on urine for 10 minutes before urinating.
• Fluid and diet management - You may need to cut back on or avoid alcohol, caffeine or acidic foods.
• Surgical – 30% recurrence
• Cystourethrocele: Do an anterior repair (colporrhaphy), or a colposuspension
• Rectocele: Do a posterior repair (colporrhaphy)
• Uterovaginal: Do a sacrohysteropexy (AKA Manchester repair, lift it back up and attach to sacrum), or a hysterectomy in major grades (consider fibroids/ ovarian cancer mass pushing it down or whether bowel is likely to be adhered to uterus)
• Vault prolapse - Sacrospinous fixation/sacrospinous colpopexy (suspend vault to sacrospinous ligament), vaginal mesh
• Vaginal mesh repairs – improves strength and support (increased risk of complications: mesh erosion, infection, dyspareunia – not being used now)
• No surgery with BMI >30
Total vault prolapse condition refers to complete eversion of the vagina following a hysterectomy..
Why should you offer chest XRAYs in Gynaecology Cancers?
*Gynae cancers spread to the lung so offer CXR’s
• 10% of female cancers (2nd commonest)
• Cancer - Peak 35-44 and 75-85
• CIN peak – 25-29
What is the Aetiology of cervical cancer?
- HPV 16 and 18, 31, 33
- 80% of adults who are sexually active have had HPV infection, 70% of infections resolve in one year but some go onto develop CIN
- Produce proteins E6 and E7 that turn off tumour suppressor genes
- Risks = unprotected sex and previous STI
- Smoking – immunosuppressive and a cofactor with HPV for developing cancer
- Immunosuppression – AIDS etc
