Urinary incontinence/POP Flashcards
Initial Mx of UI/POP c/b confusion
Scenario 1 - 78yo pw confusion + POP + SUI
- UI/POP w delirium
- collateral baseline vs new onset
- capacity vs MPOA
- full delirium screen - bloods/imaging
- rx reversible
- admission/MDI…
SUI/UUI/POP (include vault) initial conservative mx
Scenario 1 - 67yo multi-comorbidities with sx vault prolapse + UUI, sexually active, chronic cough, constipation, topical E2
Scenario 2 - 64yo vault prolapse 15yr post hysterectomy, counsel re: options and discuss mesh complications
- UEC/BSL/MSU +/- pelvic USS
- risk - pain/bleed/UTI/sepsis/delirium
- multi-D - Gyn/Urogyn/PT+/- physician
- Bladder diary over 3 days
- Supervised PF exercise
- Bladder training (for OAB)
- Optimize OAB/UUI first if co-existent
- fix cough/constipation/coffee
- LS mod - weight loss/fluid intake
- Topical estrogen
1. urogenital atrophy
2. procedentia w ulceration (rx before pessary) - Pessary
1. space occupy or support
2. avoid surg, self-change
3. erosion, ulceration, rv - Encourage FOBT/MMG/CST
- Follow-up in 3 months
- +/- UDS if sx remain or need surgery
if conservative fails then the other options aka medical or surgical would include…
Mx options after failed conservative mx of UUI –> medical/surgical mx
Refer to Urogynae
+/- UDS +/-Cystoscopy
- non-selective anti-chol
(SE - dry mouth, palpitation, cognition) - M3 selective anti-chol
(SE - less compared to non-selective, $$) - B3 adrenoceptor agonist
(SE - less cf anti-chol, no cog issues $$) - Botox, nerve stimulation
Mx options after failed conservative mx of SUI -> surgical mx
Refer to Urogynae
+/- UDS +/-Cystoscopy
Urethral bulking agent
- good pre-existing urethral support
- no mesh cx, day procedure
- less effective, need repeat
Colpo-suspension/Pubovaginal sling
- stabilize bladder neck
- open or lap
- no mesh cx, similar efficacy as TVT
- long op, long recovery
Tension-free tape
- support bladder neck/occlude/with raised IAP
- vaginal/external
- short op, quick recovery, similar efficacy as non-mesh procedures
- mesh cx, de-novo UUI/worsen, retention - need for IDC/SC
Discuss
- specific mesh cx
(CPP/erosion/expos/dyspar/removal)
- general surgical risks
- cystoscopy post procedure
Mx options after failed conservative mx of POP (vault) -> surgical mx
Refer to Urogynae
+/- UDS +/-Cystoscopy
SC
- vault attached to sacral prom
- open or lap
- lower recurrence
- mesh, bladder/bowel injury/osteomye
SSF
- vault attached to ischial spine
- no mesh, quick recov, restore VL
- dyspareunia, SUI, buttock pain
All options include general surgical risks in addition to specific risks mentioned
Mx options after failed conservative mx of POP (Ut) - surgical
- 35yo P4 postpartum w persistent POP
- 74yo failed conservative mx
- 64yo failed pessary, procedentia
- 64yo 1st dx of POP
Refer to Urogynae
+/- UDS +/-Cystoscopy
Ut-non-sparing - 1 option
1. VH+/-vault suspension+/- AP repair
- compared to TAH/TLH
- less cx/pain/scar/hernia
- quick recovery/return to work
Ut-sparing - 4 options
(1 mesh vs 3 non-mesh)
- Sacrohysteropexy (most common)
- lift uterus/restore vaginal wall
- lap or open
- good success rate
- mesh cx - Vag sacrospinous hysteropexy
- fix back of vag/cervix/USL to SSL
- vaginal approach
- no mesh, good success
- buttock pain - USL suspension
- USL to vag apex
- vag/lap/open
- no mesh, good success
- buttock pain - Colpocleisis
- close vagina
- not sexually active
- quick surgery
All options include general surgical risks in addition to specific risks mentioned
Routine post vaginal surgery mx
- vaginal pack
- IDC -> TOV
- antibiotics
- analgesia
- aperients
- follow-up
Mx of postop abdo pain post TVT
DDx
- urinary retention
- retropubic hematoma -> causing urinary retention
- Risk - expansion of hematoma
- NBM/IVC - FBE/UEC/Coag/G&S
- Pelvic USS vs CTAP
- MDI … include IR
- Inform senior…
- Mx depends on clinical condition
- Conservative vs Medical vs Surgical/Radiological
- Conservative - observe, serial Hb, imaging, analgesia
- Medical 4As - anti-fibrinolytic, analgesia, antibiotic, anaemia mx
- Surgical - RTT - drainage
- Radiological - CT-guided drainage, embolisation
- Debrief
- Follow-up 6/52
- Gynae M&M
Mx of postop cx of vaginal surgery
Scenario 1 - PV/PR bleeding after posterior vaginal all repair
de novo SUI/UUI
- anterior/apical repair
- self-catheterisation
buttock pain
- apical repair
- analgesia - NSAID
- reassurance
- persistent pain - RTT - identify/remove
constipation/defecation pain
- posterior repair
- stool softener/fibers
- avoid straining
- impact on healing
rectovaginal fistula
- posterior repair esp w mesh
- foul smelling vag discharge
- pain/systemic signs of infection
mild wound dehiscence
- Compress/pack/haemostasis, IDC
- NBM while achieving haemostasis
- IV ABx, broad spectrum.
- +/- EUA/debride/repair
dyspareunia
- topical lub/E2/LA
- physical therapy +/- dilator
- systemic anxiolytic -> PF relax
delirium
- full delirium workup - FBE/UEC/LFT…CTB/CXR/AXR/CTAP
- involving medical team for delirium mx
- suspect local source (e.g. vault haemotoma)
- pain/constipation/urinary retention -> delirium!!!
- IV ABx +/- RTT
Mx of vesico-vaginal fistula
- post hysterectomy
- post vag surg, p/w vag loss of fluid
- post TAH c/b bladder injury, p/w vag loss of fluid
DDx
- worsening incontinence
- vesico-vaginal fistula
- vaginal discharge
- intra-abdominal collection
Hx
- pain/bleed/fever/chills
- Intra-op difficulties
- RFs - DM/Smoking/CTD/chemo..
Exam
- vitals
- abdo palp - ? peritonism
- translucent speculum ?VV
- pool of urine or blood
- vault health ? dehiscence
+/- HVS
Ix
- FBE/CRP, UEC (serum cr)
- vaginal fluid creatinine
- MCS - HVS/MSU
- CT IVP
Risks = persistent fistula/urosepsis
Mx
- Admit
- Inform Gynae consultant
- MDI - Urogynae/Urology
- IDC (spont resolution if small tract)
vs Primary repair
- IDC insertion +/- Abx
- IDC remain in till repair
Repair - within 48/24 (of initial surgery) vs delay 6/52
- Identify
- Excise
- Debride
- multi-layer/tension free closure
- cystoscopy
- defunction - IDC 10 days
- consider Abx
Follow-up
- Cystogram pre-IDC removal
- Urology follow-up
- Gynae follow-up - vault
- Gynae M&M
