Urogyn

Question 1

Urodynamics

Answer 1

1. Uroflowmetry
   - flow rate, max flow rate, voided volume, voiding pattern
2. Post void residual
3. Cystometrogram
4. Pressure flow studies: relationship between pressure in bladder and Urine flow during emptying
5. Urethral pressure profilometry (MUCP)
6. Leak point pressures detrusor leak point pressure
   - abdo leak point pressure

Question 2

Definition OAB

Answer 2

Urinary urgency with or without urgency urinary incontinence, usually with frequency and nocturia in absence of other proven infections and pathologies

Question 3

Urinary urgency

Answer 3

Sudden compelling desire to pass urine that is difficult to defer

Question 4

Detrusor overactivity

Answer 4

Occurrence of detrusor contractions during filling cystometry (may be spontaneous or provoked)

Question 5

4 long term complications of sling surgery

Answer 5

Mesh exposure 2%
Detrusor overactivity
Failure of sling/ongoing symptoms 
Chronic pain 5% even if sling removed
Voiding dysfunction 11% - need for loosening tape, self cath

Question 6

Describe principles filling cystometry

Answer 6

Urodynamic test assessing bladder sensation, bladder capacity, detrusor activity and compliance, urine leakage.

Measurement of the pressure-volume relationship of the bladder during filling.

Involves pressure probe in bladder and also rectum (surrogate for intraabdominal pressure) bladder filled and woman asked to report when first feel sensation, desire to urge, strong desire, fear of leakage.
Can obtain the presence of detrusor overactivity

Question 7

Describe the mictruition reflex and centres affecting mictruition

Answer 7

Voiding - voluntary control
Bladder - sacral spinal reflex
Urethra - pudendal nerve

Filling - bladder wall stretch receptors stimulate pelvic splanchnic nerve ➡️ sacral nerve s2-4➡️ lateral spinothalamic tract ➡️ pontine mictruition centre
This triggers descending signals to stimulate SNS ➡️ NORAD from hypo gastric plexus causing detrusor relaxation, contraction of urethral sphincter, and causes inhibition PSNS, inhibits ACh at muscarinic receptors

As it becomes more full, signals become faster, descending signals inhibit sympathetic drive, and allow PSNS impulses to contract detrusor and relax sphincter

Question 8

Differentials for mixed incontinence

Answer 8

Recurrent urinary tract infections
Stress incontinence from hyper mobile urethra or intrinsic sphincter deficiency
Urge urinary incontinence from detrusor overactivity
Urinary retention with overflow incontinence

Question 9

Informed consent regarding mesh for vaginal implants

Answer 9

1. Withdrawn by TGA, limited robust data on efficacy and safety
2. Risk of cut current prolapse and considered suitable - recruited into a clinical research trial assessing efficacy and safety

3 Asymptomatic people don’t necessarily need surgery

4. Benefits and complications
5. Alternatives - pelvic floor muscle training, vagina supports
6. Surgical Alternatives - native tissue, abdo sacrocolpo
7. Complications: mesh exposure/erosion, vagina scarring/structure, fistula formation, dyspareunia/unprovoked pelvic pain at rest ➡️ excising may not resolve symptoms
8. If complications arise, may require more surgery, removal may not be possible

Question 10

Mesh complications

Answer 10

Exposure/erosion
Vagina scarring and structure
Fistula formation
Dyspareunia/unprovoked pelvic pain at rest

Pain at rest difficult to manage, removing mesh may not remove problems, symptoms or issues can occur years down the track

Question 11

Investigations for fistula

Answer 11

Usually visible on speculum
Swab dye test
Cystoscopy
CT IV pyelogram - looking for contrast leak in delayed phase

If worries about urethra specifically could do a retrograde pyelography