urogyanecological problems

Question 1

Types of incontinence

Answer 1

urge - directly preceded by urge
stress - involuntary leakage when intra-abdo pressure increases a bit (laugh/cough)
overactive bladder - increased frequency and nocturia - not necessarily incontinent
mixed: both
Overflow incontinence - due to detrusor underactivity or bladder outlet obstruction
Continuous

Question 2

innervation of bladder muscles

Answer 2

detrusor is inactivated by muscarinic cholinergic

urethral sphincter has dual inervation - sympathetic and somatic (voluntary)

Question 3

What type of muscle is in internal and external sphincter

Answer 3

interna; - smooth

external striated

Question 4

what is intrinsic sphincter deficiency

Answer 4

when sphincter closing pressure is very low
caused by weakness of sphincter muscles
rare

Question 5

RF for stress incontinence

Answer 5

age
traumatic delivery
obesity
previous pelvic surgery

Question 6

What is detrusor overactivity

Answer 6

Pt complains of overactive bladder cause detrusor goes crazy
Only causes incontinence if it’s associated with urethral sphincter weakness
Urge incontinence

Question 7

What are RF for urge incontinence

Answer 7

smoking, obesity, childhood bed wetting

Question 8

What symptoms are associated with incontinence?

Answer 8

sexual dysfunction, faecal incontinence, prolapse

Question 9

What are some red flags?

Answer 9

haematuria, rectal bleeding, singificant pain

Question 10

Ix for incontinence

Answer 10

MSU
bladder diary for 3 days
Pad test (give pad and do provocation tests - washing hands, climbing stairs)
Pelvic, renal tract US if in pain

Question 11

Conservative measures for incontinence

Answer 11

Reducing fluid intake (<2.5L)
Reducing caffeine
Bladder retraining - longer interval between voiding
Pelvic floor exercises

Question 12

What diagnoses can you make from urodynamic studies

Answer 12

Detrusor overactivity
Detrusor overactivity incontinence
Urodynamic stress incontinence (leakage associated wiht increased abdo pressure)
mixed incontinence - features of both

Question 13

s/e off anticholinergic

Answer 13

dry mouth
constipation
blurred vision

Question 14

Surgical mx of stress incontinence

Answer 14

1. mid urethral tape (can lead to bladder perforation and voiding problems)
2. burch colposuspension
   SUrgery gives good outcomes

Question 15

Mx of detrusor overactivity

Answer 15

botulinum toxin is good

surgery is second line

Question 16

presentation of prolapse

Answer 16

Bulge, heaviness or protrusion at introitus
lower abdo pain and dragging
back pain
diff voiding bowels and bladder/incontince
sexual difficulty

Question 17

What are the three stages of prolapse

Answer 17

1. doesn’t reach hymen
2. reaches hymen
3. vagina is outside hymen

Question 18

What is prolapse of anterior wall called

Answer 18

cystocele if upper half

uterocele if lower half

Question 19

What is prolapse of posterior wall called

Answer 19

enterocele if upper half

rectocele if lower half

Question 20

Cause of stress incontinence

Answer 20

pelvic floor weakness

intrinsic sphincter deficiency

Question 21

Mx stress incontinence

Answer 21

Conservative: avoid caffeine, restrict water intake, BMI <30, stop smoking
1st line: pelvic floor retraining for 3 months
REFER TO SECONDARY CENTRE
2nd line: surgical procedure - colposuspension to lift neck of bladder
3rd line: duloxetine (enhances sphincter contraction) if they don’t want surgery

Question 22

Mx urge incontinence

Answer 22

Conservative: avoid caffeine, restrict water intake, BMI <30, stop smoking
1st line: bladder retraining for 6 weeks (increase intervals between voiding)
2nd line: bladder stabilising drugs antimuscarinics (OXYBUTYNIN)
3rd line: beta-3 agonist (mirabegron) if s/e from antimuscarinic
4th line: botox injection

Question 23

Mx of vaginal prolapse

Answer 23

Lifestyle: lose weight, don’t lift, treat constipation
Medical:
pelvic floor exercises
oestrogens - relieve symptoms and offer help if vaginal atrophy
Vaginal ring pessary (change every 6 months) this can cuase irritation and interfere w/ sex
Surgical:
if not preference for preserving uterus - hysterectomy
preservation of uterus - vaginal sacrospinous hysteropexy
vault prolapse - vaginal sacrospinous hysteropexy