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Gynaecology > Urinary tract and genital tract > Flashcards

Urinary tract and genital tract Flashcards

1
Q

1st

A

1st

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2
Q

What is the normal capacity of the bladder?

A

500ml

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3
Q

When does the first urge to void start - volume?

A

200ml

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4
Q

Sympathetic/parasympathetic control of voiding

A

Para aids voiding, sympathetic prevents it

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5
Q

What is the micturition reflex?

A

Afferent fibres respond to the distention of the bladder pass to spinal cord, efferent para fibres pass back to detrusor muscle cause contraction and enable opening of bladder neck. Also efferent fibres to the detrusor are inhibited

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6
Q

Where is micturition reflex controlled?

A

In the spinal cord at the level of the pons

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7
Q

How is micturition reflex controlled?

A

Cerebral cortex modifies the reflex and can relax or contract the pelvic floor and striated muscle of the urethra

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8
Q

What is continence dependent on?

A

Urethral pressure being higher than the pressure in the bladder

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9
Q

What controls bladder pressure?

A

Detrusor pressure and external (intra-abdominal) pressure

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10
Q

What controls urethral pressure?

A

Inherent urethral muscle tone and also by external pressure - namely from the pelvic floor and intra-abdominal pressure

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11
Q

Why does raised intra-abdominal pressure eg.coughing not normally cause incontinence

A

Because it affects both urethral and bladder pressure equally

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12
Q

Two main causes of female incontinence

A

Uncontrolled increases in detrusor pressure and

Increased intra-abdominal pressure transmitted to bladder

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13
Q

What is the most common cause of increased detrusor pressure?

A

Overactive bladder or urinary urge incontinence - previously called detrusor instability

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14
Q

What is the mechanism of increased bladder pressure over urethral pressure?

A

increased intra-abdominal pressure is transmitted to the bladder but not to the urethra because the upper urethra neck has slipped from the abdomen - therefore when coughing or raising intra-abdominal pressure it is only transmitted to the bladder - stress incontinence

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15
Q

What causes overflow incontinence?

A

Pressure of urine overwhelming sphincter due to overfilling of the bladder due to neurogenic causes - or due to outlet obstruction

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16
Q

Where is bladder pain felt?

A

Suprapubically or retropubically

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17
Q

What does bladder pain indicate?

A

Intravesical pathology - eg. interstitial cystitis or malignancy

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18
Q

What does haematuria on urine dipstick suggest?

A

Bladder carcinoma or calculi

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19
Q

What investigation (non-medical) can you do with patient presenting with urinary frequency etc problems

A

Urinary diary - keeping a record for a week of fluid intake and micturition

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20
Q

What investigation do you do to look for chronic retention of urine?

A

Post-micturition ultrasound or catheterisation

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21
Q

What is cystometry?

A

It directly measures, via a catheter, the pressure in the bladder whilst the bladder is filled and provoked by coughing
A pressure transducer is also placed in the rectum (or vagina) to measure abdominal pressure

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22
Q

What is calculated from cystometry?

A

True detrusor pressure can be calculated by subtracting the abdominal pressure from the vesical pressure

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23
Q

How are the results of cystometry interpreted?

A

If leaking occurs with coughing in the absence of detrusor contraction then problem is likely to be ‘urodynamic stress incontinence’
If involuntary detrusor contraction occurs then ‘detrusor overactivity’ is likely diagnosis

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24
Q

What does a CT urogram look for?

A

Integrity and route of the ureter is examined

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25
Q

What is the test for leakage from places other than the urethra ie fistula?

A

Methylene dye test - blue dye instilled into the bladder

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26
Q

What are causes of stress incontinence?

A 
Pregnancy + vaginal delivery 
esp. prolonged labour and forceps 
Obesity 
Age (esp. post menopausal)
Previous hysterectomy
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27
Q

What commonly coexists with stress incontinence?

A

Prolapse

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28
Q

Conservative treatment for stress incontinence

A

Pelvic floor muscle training

First line treatment for at least 3 months - taught by a physiotherapist

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29
Q

What does Pelvic floor muscle training (PFMT) consist of?

A

At least 8 contractions, 3x a day

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30
Q

What can be added to PFMT

A

Vaginal cones or sponges - inserted into the vagina and held in position by voluntary muscle contraction - increasing sizes used as muscle strength increases

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31
Q

What drug is used to treat stress incontinence

A

Duloxetine - SNRI enhances urethral sphincter activity via a centrally mediated pathway

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32
Q

Most common side effect with duloxetine for stress incontinence

A

Nausea

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33
Q

When is surgery considered for stress incontinence?

A

When conservative measures have failed and womans quality of life is compromised

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34
Q

First line surgical treatment for stress incontinence

A

Mid-urethral sling procedures such as tension-free vaginal tape and trans-obturator tape

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35
Q

Cure rates with sling procedures for stress incontinence

A

90%

36
Q

Complications with sling procedures for stress incontinence x6

A

Bladder perforation, postoperative voiding difficulty, bleeding, infection, de novo detrusor overactivity and suture/mesh erosion

37
Q

How is tension-free vaginal tape procedure performed for stress incontinence?

A

Synthetic tape placed in U-shape under mid-urethra via a small vaginal anterior wall incision - then tension is adjusted to prevent leakage as woman coughs

38
Q

How is transobturator tape procedure performed for stress incontinence? Why is it better than tension-free vaginal tape?

A

Tape is inserted via the transobturator foramen through the transobturator and puborectalis muscles - therefore doesn’t enter retropubic place and bladder perforation isn’t a risk

39
Q

What sort of incontinence occurs with overactive bladder?

A

Urgency with or without urge incontinence

40
Q

What % of incontinence is due to urge incontinence and was % is due to stress incontinence

A

50% due to stress and 35% due to urge

41
Q

Causes of urge incontinence

A

Most commonly idiopathic
Can occur following operations for USI - probably as a result of bladder neck obstruction
Occasionally due to involuntary detrusor contractions as a result of neuropathy

42
Q

Investigation for urge incontinence

A

Cystometry - shows detrusor overactivity (but only done if lifestyle changes and drug management haven’t worked or if surgery is considered for stress incontinence)

43
Q

Conservative management for urge incontinence

A

Reducing fluid intake , avoiding caffeinated products
Drugs that alter bladder function should be reviewed (antipsychotics and diuretics)
Bladder training - education, timed voiding and positive reinforcement - resist sensation of urgency

44
Q

Drugs for urge incontinence x3

A

Anticholinergics (oxybutynin, tolterodine, darifenacin) suppress detrusor overactivity - side effects include dry mouth
Oestrogens - after the menopause can help improve symptoms
Botox injections

45
Q

Other non-drug treatments for urge incontinence

A

Neuromodulation and sacral nerve stimulation - continuous stimulation of S3 nerve root via implanted electrical pulse generator

46
Q

What can occur in 10% of incontinence

A

Mixed stress incontinence and overactive bladder

47
Q

What is acute urinary retention?

A

Patient is unable to pass urine for 12h or more and catheterising produces as much or more urine than normal bladder capacity

48
Q

Symptoms of acute urinary retention

A

It is painful - except when due to epidural anaesthesia or failure of afferent pathways

49
Q

Causes of acute urinary retention x7

A 
Childbirth, esp with epidural 
Vulval or perineal pain (eg. herpes simplex)
Surgery 
Anticholinergics 
Retroverted gravid uterus 
Pelvic masses
Neurological disease
50
Q

Management of acute urinary retention

A

Catheterisation and maintenance for 48h whilst cause is treated

51
Q

What happens in chronic urinary retention?

A

Leaking because of bladder overdistension and overflow

52
Q

Causes of chronic urinary retention

A

Urethral obstruction or detrusor inactivity - pelvic masses and urethral incontinence surgery are common causes

53
Q

Presentation of chronic urinary retention

A

Could mimic stress incontinence or could have continuous urinary loss

54
Q

Examination in chronic urinary retention

A

Distended non-tender bladder

Dx confirmed by US or catheterisation after micturition

55
Q

Management of chronic urinary retention

A

Intermittent self-catheterisation is commonly required

56
Q

What is painful bladder syndrome

A

Patient experiences suprapubic pain related to bladder filling
Other symptoms such as frequency
Absence of UTI or other obvious pathology

57
Q

When does painful bladder syndrome become intersitial cystitis

A

When characteristic cystoscopic and histological features are confirmed

58
Q

Cause of painful bladder syndrome/interstitial cystitis

A

Aetiology unknown

59
Q

Treatment of painful bladder syndrome/interstitial cystitis x4

A

Dietary changes
Bladder training
TCAs
Analgesics

60
Q

What are most common types of fistulae

A

Vesicovaginal and urethrovaginal

61
Q

Causes of fistula in western world

A

Surgery, radiotherapy or malignancy

62
Q

Investigations of fistula

A

CT urogram or cystoscopy

63
Q

Management of fistula

A

Usually surgery is required

64
Q

What is endometritis?

A

Infection of the cavity of the uterus

65
Q

What is endometritis usually due to?

A

Instrumentation of the uterus or complications of pregnancy (maintained products of conception)

66
Q

What are the usual infecting organisms in endometritis

A

Chlamydia, Gonorrhoea - if they are present in the genital tract
E.coli, staph and even clostridia may be implicated

67
Q

Symptoms of endometritis

A

Persistent and often heavy vaginal bleeding - usually accompanied by pain
Tender uterus and cervical os is open

68
Q

What is pelvic inflammatory disease?

A

Infection of female genital tract, including the womb, the fallopian tubes and the ovaries

69
Q

Who is most at risk of PID?

A

Young, poorer, sexually active, nulliparous women

70
Q

What causes PID?

A

Ascending infection from bacteria in the vagina and cervix - can spontaneous or as a result of uterine instrumentation and/or complications of child birth
Descending infection from local organs eg. appendix can also occur

71
Q

Protective factors against PID

A

COC and Mirena IUS

72
Q

Infecting organisms in PID?

A

Frequently polymicrobial

Chlamydia and gonococcus

73
Q

Symptoms of PID

A

May be asymptomatic - present later with subfertility or menstrual problems
Or bilateral lower abdominal pain with deep dyspareunia - usually with abnormal vaginal bleeding or discharge

74
Q

Examination in severe PID x6

A

Tachycardia
High fever
Lower abdominal peritonism
Bilateral adnexal tenderness
Cervical excitation (pain on moving cervix)
Mass may be palpable vaginally (pelvic abscess)

75
Q

Investigation in PID

A

Endocervical swabs for Chlamydia and gonococcus
Blood cultures if fever
WBC and CRP (raised)
Ultrasound to exclude abscess

76
Q

Gold standard investigation for PID

A

Not commonly performed

Laparoscopy with fimbrial biopsy and culture

77
Q

Treatment of PID

A

Analgesics
Parenteral cephalosporin - eg. IM ceftriaxone followed by doxy and metrondiazole or ofloxacin with metronidazole
If febrile then IV treatment

78
Q

Complications of PID

A

Early - formation of abscess or pyosalpinx
Later - tubal obstruction and subfertility, chronic pelvic infection or chronic pelvic pain
Ectopic pregnancy 6x more common

79
Q

Chance of tubal damage following one episode of acute PID

A

12%

80
Q

What is chronic pelvic inflammatory disease?

A

Persisting infection as a result of non-treatment or inadequate treatment of acute PID

81
Q

What occurs in chronic PID?

A

Dense pelvic adhesions and fallopian tubes may be obstructed or dilated with fluid (hydrosalpinx) or pus (pyosalpinx

82
Q

Symptoms of chronic PID x6

A 
Chronic pelvic pain 
Dysmenorrhoea 
Deep dyspareunia 
Heavy and irregular menstrual bleeding 
Chronic vaginal discharge
Subfertility
83
Q

Examination findings in chronic PID x3

A

Similar findings to endometriosis
Abdominal and adnexal tenderness
Fixed retroverted uterus

84
Q

Investigations in chronic PID x2

A

TV USS - may reveal fluid collections within fallopian tubes or surrounding adhesions
Laproscopy best diagnostic tool

85
Q

Treatment of PID x4

A

Analgesics
Antibiotics if signs of current active infection
May respond to cutting of adhesions (adhesiolysis) but removal of affected tubes (salpingectomy) is required in some cases

Gynaecology (8 decks)

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