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MRCOG Part 2 > Urinary incontinence and urogynaecology including NICE Urinary Incontinence, Post hysterectomy vault prolapse GT46 > Flashcards

Urinary incontinence and urogynaecology including NICE Urinary Incontinence, Post hysterectomy vault prolapse GT46 Flashcards

1
Q

What are the 2 most common adverse effects following Botox for Overactive bladder?

A
  1. UTI

2. Voiding difficulties requiring self catheterisation

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2
Q

What are the first line medications for medical management of OAB

A

oxybutinin (immediate release) - anticholinergic
tolterodine (immediate release) - antimuscarinic
darifenacin (once daily prep) - antimuscarinic

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3
Q

what is the % risk of bladder perforation in TVT

A

0.9-25%

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4
Q

What is the risk of de novo urgency in TVT

A

0.2-15%

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5
Q

what is the risk of bleeding in TVT

A

0.9-2.3%

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6
Q

what is the recommended surgical procedure for SUI if conservative management has failed?
What type of material should be used?

A

mid-urethral tape
Bottom- up approach
macroporous type 1 polypropylene mesh

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7
Q

of the following 3 options, which ones influence the outcome of surgery for SUI?
BMI
menopause status
Agenig

A

menopause status

ageing

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8
Q

what is the cure rate for pelvic floor exercises for management of SUI

A

21-84%

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9
Q

what percentage of women remain symptomatic of incontinence following delivery?

A

12%

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10
Q

what percentage of women experience prolapse in their lifetime

A

40%

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11
Q

What are the main risk factors for pelvic organ prolapse (POP)

A

caucasian, age, multiparity, obesity, smoking, occupation

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12
Q

what is the lifetime risk of prolapse surgery?

What is the risk of repeat surgery?

A

Life time risk- 11%.

11% Risk of repeat surgery in 11 years

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13
Q

True or false; Buttock pain is a recognised complication of sacrocolpopexy

A

FALSE.

Buttock pain is a complication of sacrospinous fixation

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14
Q

What is the gold standard procedure for post-hysterectomy vaginal vault prolapse?

A

sacrocolpopexy- fixing the vaginal vault to the sacral promontory using mesh.

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15
Q

A woman presents in clinic with a vaginal bulge. She had a hysterectomy 10 years ago. In a POP-Q assessment, which value is ommitted?

A

D- posterior fornix

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16
Q

Which procedure at the time of vaginal hysterectomy is effective at preventing subsequent post-hysterectomy vault prolapse?

A

McCall Culdoplasty (i.e. reattach the uterosacral-cardinal ligament complex to the vagina)

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17
Q

What procedure should be considered during vaginal hysterectomy if the vault descends to the introitus during closure?

A

Sacrospinous fixation

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18
Q

Which procedure for vault prolapse has lower rates of recurrence, dyspareunia and postoperative stress incontinence?

A

Abdominal sacrocolpopexy vs SSF

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19
Q

When can colpocleisis be considered for vault prolapse?

A

In frail elderly women and/or those who do not wish to retain sexual function

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20
Q

What is an effective measure to reduce postoperative SUI in previously continent women at the time of sacrocolpopexy?

A

Colposuspension at the same time.

Not effective for those previously symptomatic with SUI

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21
Q

To which body should mesh complications be reported to?

A

MHRA (Medicines and healthcare products regulatory agency)

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22
Q

When may SSF not be appropriate?

A

In women with a short vaginal length, particularly if pre-exising dyspareunia

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23
Q

How many days should a bladder diary be kept for initial assessment of OAB/UI symptoms?

A

3 days

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24
Q

When should urodynamics be performed prior to surgery?

A

Symptoms of OAB leading to suspicion of detrusor overactivity

Symptoms of voiding dysfunction or anterior compartment prolapse

Previous surgery for stress incontinence

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25
Q

What lifestyle interventions should be first line for women with OAB

A

Reduce caffeine
Modify fluid intake
If BMI >30 lose weight

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26
Q

What is first line treatment for women with SUI or mixed incontinence?

A

3/12 trial supervised pelvic floor muscle training

8 contractions TDS

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27
Q

What is first line treatment for women with urge incontinence or mixed UI?

A

6/52 bladder training

Consider combination with OAB drug if not good effect and frequency troublesome

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28
Q

When should percutaneous posterior tibial nerve stimulation be considered in OAB?

A

After MDT review
Conservative (including drugs) treatment not worked
Woman doesn’t want Botox/percutaneous sacral nerve stimulation

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29
Q

How long can it take to feel the full benefit of OAB pharmacological treatment?

A

4 weeks

30
Q

Which drug treatment for OAB should be avoided in older, frail women?

A

immedite release oxybutynin

31
Q

How often should women be reviewed in primary care once commenced on an OAB drug?

A

Yearly, or 6 monthly if >75

32
Q

When can desmopressin be used for OAB and when is it contraindicated?

A

If nocturia troublesome symptom

Care in cystic fibrosis, or >65 if have cardiovascular disease/hypertension

33
Q

Which pharmacological treatment is available for SUI (not first line)

A

Duloxetine (SSNRI)

34
Q

When should Botox A be offered?

A

OAB with proven detrusor overactivity not responded to conservative mx (incl drugs)

35
Q

If Botox A is effective when should follow up/repeat treatment be offered?

A

6 months, or sooner if symptoms return (without MDT)

36
Q

When should percutaneous sacral nerve stimulation be offered for OAB?

A

After MDT discussion
Conservative management failed
Unable to perform ISC

37
Q

What are the side effects of augmentation cystoplasty?

A 
Bowel disturbance
Metabolic acidosis
Mucus production
Retention in the bladder
UTI
Small risk of malignancy
38
Q

What is second line treatment of SUI after conservative management?

A

Synthetic midurethral tape
Open colposuspension
Autologous rectus fascial sling

39
Q

When should follow up be arranged following continence surgery?

A

6/12 including vaginal examination to check for mesh erosion

40
Q

When should mirabegron be considered for OAB?

A

If antimuscarinics are contraindicated or clinically ineffective, or with unacceptable side effects
(b-3 adrenergic agonist)

41
Q

What is the first line pharmaceutical management of bladder pain syndrome (when conservative measures failed)?

A

Oral amitryptilline or cimetidine (not licenced)

42
Q

What intravesical options are there for bladder pain syndrome?

A 
Lidocaine
Hyaluronic acid
Botox A
Dimethyl Sulfoxide (DMSO) - teratogenic
Heparin
Chondroitin sulphate
43
Q

When can cystoscopic fulguration, laser treatment and transurethral resection of lesions be considered in bladder pain syndrome?

A

If Hunner lesions identified at cystoscopy

subtype of interstitial cystitis

44
Q

What procedures can be considered if conservative, oral and intravesical therapies have failed in bladder pain syndrome?

A

Neuromodulation (posterior tibial/sacral)
Oral cyclosporin A
Cystoscopy +/- hydrodistension
Major surgery - last line in refractory BPS

45
Q

Which anticholinergic does not cross the blood brain barrier?

A

Trospium

46
Q

Which type of prolapse is associated with morbid obesity?

A

Rectocele (75%)
Cystocele (57%)
Uterine (40%)

47
Q

What is the risk of de novo prolapse (cystocele) after sacrocolpopexy (mesh) vs sacrospinous fixation (no mesh)

A

31% vs 14%

48
Q

What is the rate of mesh erosion in vaginal prolapse surgery?

A

As high as 12%

49
Q

What is the most common cause of urethral diverticulum?

A

Acquired - repeat infections and obstruction of the periurethral glands

50
Q

What is the normal Qmax at uroflowmetry?

A

20-36ml/s

51
Q

What happens to urge symptoms following midurethral tape if mixed incontinence?

A

50% resolution
25% no change
25% worsen

52
Q

What SUI surgery should be performed for neurogenic stress incontinence?

A

Autologous fascial sling

Mesh should not be used

53
Q

When should a pad test be used?

A

When there is discrepancy between urodynamics and symptoms (ideal - ambulatory urodynamics)
24 hours more accurate than 1 hour

54
Q

How would voiding difficulty appear on urodynamics?

A

A steep rise in detrusor pressure during filling

55
Q

What is the estimated prevalence of OAB in the general population?

A

15-20%

56
Q

How many women are affected by urinary incontinence at some point in their lives?

A

70%

57
Q

If which patients should desmopressin be used with particular caution

A

Cystic fibroisis

Avoid >65 with cardiovascular disease or hypertension

58
Q

how does caffeine contribute to OAB?

A

increase in detrusor pressure and detrusor overactivity seen with caffeine

59
Q

which type of drink is the only one associated with SUI and OAB

A

carbonated drinks

60
Q

how does smoking affect urinary incontinence?

A

smoking associated with increased urinary incontinence. Thought to be related to an increase in bladder contractions

61
Q

how does the use of bladder cones compare to PFMT for SUI?

A

beneficial effects seen with cones, comparable to those seen with PFMT

62
Q

what are the benefits of suprapubic catheter over urethral catheter?

A

lower rates of symptomatic UTI and catheter bypassing

63
Q

what percentage people FAIL to achieve satisfactory improvement in incontinence with anticholinergics?

A

25-40%

64
Q

what are the main contraindications for antimuscarinic drugs for OAB?

A

myasthenia gravis, significant bladder outflow obstruction, severe ulcerative colitis

65
Q

are anticholinergic medications first line or second line medical treatment for OAB?

A

anticholinergics are first line (Oxybutinin)

antimuscarinics are second line (tolterodine, darifenacin)

66
Q

what is the main contraindication to the use of mirabegron

A

uncontrolled hypertension

67
Q

what percentage of women will need to perform ISC after botox for OAB?

A

10-15%

68
Q

single dose Antibiotic phrophylaxis is commonly given prior to botox for OAB. Which type of antibiotics should be avoided and why?

A

aminoglycosides should be avoided as they can potentiate the effect of botox A

69
Q

what percentage of ppl who have had sacral nerve stimulation end up having to undergo re-operation? what are the main reasons?

A

33%.

mainly due to pain and infection at implantation site, or lead migration.

70
Q

what percentage of ppl having undergone sacral nerve stimulation needed permanent removal of electrodes?

A

9%

MRCOG Part 2 (97 decks)

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