Stress Urinary Incontinence Flashcards
What are MUSTS for a workup in SUI?
History (voiding diary, pad test)
Physical (pelvic exam): abdominal exam, urethral mobility, any prolapse, vaginal health, NEUROLOGIC
Reproduce the stress urinary incontinence
U/A
PVR
What is in history ?
Characterize the leakage
what have you tried
bother
any urge incontinence
prolapse
hematuria, dysuria
previous surgeries
fluid intake
medicine
PADS!
What are possible reasons to do more testing?
cannot replicate SUI
reduction of POP does not replicate SUI
more urge incontinence
equivocal diagnosis
neurogenic concern
abnormal U/A
elevated PVR
voiding dysfunction
- failure of prior incontinence surgery
- prior prolapse surgery
Do you do cystoscopy routinely?
NO
only if indicated - abnormal U/A, or prior anti incontinence surgery
Is UDS required?
NO
again only if indicated
What are tx options for SUI?
observation
pelvic floor muscle exercises +/- biofeedback
non-surgical options - pessary, vaginal inserts
surgery (bulking agents, colposuspenion, pubovaginal sling, midurethral synthetic slings
What are possible issues post surgery?
SUI persists or recurs
usual surgery risks
PAIN - dyspareunia, leg pain
worsening of urinary symptoms (urgency, storage issues)
obstruction - requiring catheterizations
further surgeries - sling excision
UTI
wound infection (in particular fascial harvest sites)
How to counsel patient on benefits and risks of mesh?
First, must say MUS is not superior to other treatments.
But it is one of the most well studied, with good data in its efficacy
Minimal procedure, only second to bulking agents
Mesh has risks of vaginal extrusion, urinary tract perforation, or other neurologic issues
Which patients have higher risk factors for mesh extrusion?
diabetics, poor wound healing patients, older , smoking , previous vaginal surgery
What are different types of MUS?
retropubic, transobdurator, single incision
(it seems there was data on more urethral / bladder perf and voiding dysfunction with retropubic, and more groin pain and repeat surgery with TO)
What are harvest points for PVS?
fascia lata or rectus fascia
When is Burch considered?
mostly if an abdominal surgery is to be already done (hysterectomy), or if no mesh is strongly considered
there is suggestions it may be inferior to fascial slings
What are the bulking agents (this has to be bonus)
calcium hydroxyapatite
PAHG - polyacramide hydrogel
What happens when placing synthetic sling and urethral injury?
ABORT the procedure.
Or finish with fascial sling
How to treat SUI with fixed urethra?
PVS is preferred!
followed by retropubic MUS, and bulking agents
Retropubic MUS that can be tension adjusted is preferred
When should a synthetic sling not be used?!
urethral diverticulotomy (concomitant)
urethralvaginal fistula
urethral mesh excision
poor wound healing patients (radiation, vaginal atrophy, long term steroid use)
Can you put synthetic MUS in women of childbearing age?
YES
but should suggest to do after, as may have worsening SUI
What are ways to close continence?
autologous PVS or bladder neck closure
Are there many early potential issues post sling?
YES - and that is why early communication is key
What is required at postop?
At six months—
RE-do history (pads etc), is patient happy
residual LUTS
Sexual fxn
physical exam - look for tenderness at trocar sites, mesh extrusion (use spec - but also palpate anterior vaginal wall - if any doubt EUA)
PVR
Questionnaire (optional)
If patient with retention high PVR - what do you do in fascial vs synthetic sling?
BOTH is CIC first
fascial - loosens up with time - give it 3 months
synthetic - give it one month
if doesn’t loosen, then incise
Where do you pass the trochar for transobdurator?
medially and inferiorly, to avoid obdurator nerve, artery, and vein (which is superolateral)
