Urogyn Flashcards
Pubocervical fascia damage can result in…
Cystocele or urethrocele
Endopelvic fascia damage of the rectovaginal septum can result in
Rectocele
Injury or stretching of the uterosacral and cardinal ligaments can result in
Uterine prolapse
What can happen after hysterectomy?
Enterocele or vaginal vault prolapse
Common conditions that compromise pelvic support
- Chronic cough eg. COPD
- Pregnancy and subsequent delivery
- Chronic heavy lifting
- Connective tissue disorders
- Atrophic changes due to aging or estrogen deficiency
Risk factors of pelvic organ prolapse?
- AGE
- Parity
- Menopause
- 4x with one vaginal deliveries, 8x with two
- Obstructed labor or traumatic delivery
- Elevated intra-abdominal pressure (chronic)
When a woman with prolapse reports that her stress incontinence has improved…
…it’s usually from a worsening prolapse. As support for anterior vaginal wall weakens and the bladder descends, there’s a kink into the urethra causing MECHANICAL OBSTRUCTION.
What do women with prolapse-related defecatory issues do to compensate?
“Splinting” by applying pressure on the perineum or posterior vaginal wall
What is complete procidentia?
Complete eversion of the vagina with the entire uterus prolapsing outside it.
Scoring system?
Baden-Walker Halfway System- relates 4 points to prolapse’s relation to hymen as the point of reference
Pelvic organ prolapse quantitative scale (POP-Q)- focuses on the physical extent of the vaginal wall prolapse (not which organ is prolapsing)
Diagnosis?
Cystoceles and urethroceles- urine cultures, cystoscopy, urethroscopy, urodynamic studies
Rectocele- r/o obstructive lesions via anoscopy or sigmoidoscopy
Differential diagnosis for cystocele and urethrocele?
RARE IN COMPARISON…
- Urethral diverticula
- Gartner cysts
- Skene gland cysts
- Tumors of the urethra/bladder
Differential for rectocele?
Obstructive lesions of colon and rectum…
- Lipomas
- Fibromas
- Sarcomas
Treatment options
1) Expectant management
2) Conservative- Kegel exercises and pessaries
3) Surgical repair
4) LOW-DOSE VAGINAL ESTROGEN
What do you do in a pregnant woman with prolapse?
PESSARY
Note: incontinence often resolves after recovery form the peripartum period
Risks of pessary?
Pain, ulcerations, bleeding, leukorrhea (white or yellowish discharge), infection
If you do a hysterectomy, what else is needed?
Apical suspension procedure (of the vaginal vault)
Poor surgical candidates who no longer desire intercourse?
Colpocleisis
Another thing that improves pelvic floor pathology?
WEIGHT LOSS
Who is more likely to have a successful pessary fitting
Long vagina and narrower introitus
Stress incontinence
Intra-abdominal pressure increases.
Usually with hyper mobile urethra.
The detrusor muscle hasn’t contracted
What do a small proportion of stress incontinence ppl have?
Intrinsic sphincter deficiency (internal sphincter muscle is weak)
Treatment for stress incontinence?
Lifestyle changes
Surgery! Resuspend the hyper mobile urethra with abdominal retro-pubic urethropexies, bladder neck slings, tension-free midurethral slings
For ppl with intrinsic sphincter deficiency, can inject bulking agent like collagen around the urethra.
Urge incontinence
Detrusor is overactive (usually but not necessarily). “DETRUSOR INSTABILITY”
Involuntary urgency, frequency, nocturia. Dribbling or leaking triggered even by seeing bathroom.
IDIOPATHIC!
Urge incontinence treatment?
- Lifestyle changes
- Anticholinergic drugs- bladder capacity increases and the urgency decreases
- Sacral neuromodulation for the retention sx
- Posterior tibial nerve stimulation for the frequency and urgency sx
- Botox (NOT FDA approved)
- Augmentation cystoplasty (rare)
Important to remember about anticholinergic drugs?
Effect may take up to 4 wks.
CONTRA for gastric retention and angle closure glaucoma
CAUTION in dementia
Names of the anticholinergic drugs
Oxybutynin Tolterodine Fesoterodine Solifenacin Trospium Darifenacin
Overflow incontinence?
- Underactive or acontractile detrusor muscle (constant dribbling)
- Bladder outlet obstruction
- Postoperative overdistension
Treatment of overflow incontinence?
- Striated muscle relaxants (diazepam, dantrolene)
- alpha blockers (prazosin…reduce urethral closing pressure)
Bypass incontinence?
Urinary fistula–> continuous incontinence
Ureterovaginal fistula
Usually due to devascularization than direct injury, happen in radical hysterectomies (rare)
Diagnose by giving IV indigo carmine which passes thru kidneys and would stain tampon in the vagina
When do you repair a post-surgical fistula?
In 3-6 months
How do you ID number and location of fistulas?
Cystourethroscopy
Voiding cystourethrogram
