Urogynae Flashcards

Question

SACROCOLPOPEXY

Answer 1

Support vaginal vault by fixing it to the sacral promontory using a piece of mesh (or rectus sheath fascia) Can perform abdominally or laparoscopically Division of adhesions and handling of tissue as may be required Traction and counter traction techniques by use of vaginal probes and forceps to facilitate dissection of peritoneum and bladder from vaginal vault with attention to tissue planes, integrity of bladder and haemostasis Retroperitoneal dissection from the vaginal vault to sacral promontory between the large bowel and right ureter to allow clear exposure of sacral promontory and retroperitoneal space Mesh is attached over the vagina and retroperitoneally to sacral promontory - Tension free fashion Closure of peritoneum from sacrum to vaginal vault Cystoscopy to exclude bladder or ureteric injury PR to exclude rectal injury Haemostasis and closure

Answer 2

Bleeding - Especially from the pre-sacral venous plexus and sacral artery Injury to the right ureter and sigmoid colon Infection Mesh erosion and infection (rare, decreased erosion rates <3% compared to vaginal mesh surgery) Gold standard for post-hysterectomy vaginal vault prolapse Success rates from 93-100% reported Backward displacement of the vagina exposes the anterior vaginal wall to increased intra-abdominal pressure

Answer 3

Good long term results Procedure of choice in younger, sexually active patients Significantly lower rates of recurrent vault prolapse, dyspareunia and post-op SUI. This is not reflected in significantly lower reoperation rates or higher patient satisfaction. SSF - Earlier recovery, cheaper, quicker. Increased dyspareunia

Answer 4

``` Obliterate the vagina either partially or totally Precludes sexual activity Can perform under LA Usually reserved for frail Direct recurrence 3% Need endometrial sampling prior ```

Answer 5

1-2% of midurethral slings 10-12% of operations where TVM is used for prolapse In some cases, erosion is asymptomatic May cause bleeding, discomfort, awareness by either or both partners during sex Tender or exposed area may be treated with Ovestin, or require minor procedure to relieve symptoms

Answer 6

Posterior and apical compartment - No evidence to support use of mesh Anterior compartment - polypropylene mesh anterior vaginal wall repair associated with significantly improved subjective outcome without difference in dyspareunia. But higher operating time, blood loss, indirect recurrence and de novo SUI. Mesh exposure in 10%, with 6.8% requiring surgical intervention. Can access mesh via national MDT by approved practitioners on case-by-case basis or under ethics-approved trial

Answer 7

Patient consent and written info Explain type of mesh and use of mesh Details of procedure Short and long term outcomes on national registry

Answer 8

Take Hx of all past surgical procedures including types of mesh, site and dates Using pelvic floor Sx and pain questionarie Perform vaginal exam - Is mesh palpable, exposed or extruded? - Localised pain and its anatomical relationship to mesh PR - ? Perforation or fistula Neurological exam - Assess distribution of pain, sensory alteration, or muscle weakness If mesh related complication confirmed, refer to specialist, report to clinical auditing systems If exposure <1cm, and no other symptoms, start topical oestrogen and review after trial of this

Answer 9

3-5cm in length Three layers - each provides 1/3 of resting closure pressure of the urethra Inner mucosal and submucosal layer - Cushion like effect which occludes the lumen Smooth muscle layer - inner longitudinal and outer circular layer. Runs the length of the urethra. Suppliesd by sympathetic and parasympathetic nerves Outer striated muscle layer - formed by circular muscle of the striated urogenital sphincter, spans 60% of the length of the urethra. Supplied by the pudendal nerve. Can be voluntarily contracted when increased closure pressure is required to avoid leakage

Answer 10

Bladder stretch receptors → feed back to Spinal cord micturition centre (S2, S3) →feedback to PMC → PMC activated once certain level of stretch → activation of parasympathetic neurons in spinal cord and inhibition of sympathetic neurons → contraction of detrusor muscle and relaxation of internal and external urethral sphincter → voiding In later life, PMC receives information from higher brain centres and can be switched on or off through voluntary control Parasympathetic nerves: S2-4 - Pelvic nerve (efferent) and pelvic plexus Sympathetic nerves: T10-L2 - Hypogastric nerve (efferent) and pelvic plexus Pudendal nerve (S2, 3, 4)

Answer 11

Guarding reflex - Abrupt increase in bladder stretch receptor activity, e.g. coughing --> activation of Onuf's nucleus in spinal cord --> pudendal nerve --> contraction of the straited urethral sphincter

Answer 12

1. Uroflowmetry - assess flow rate, max flow rate, voided volume, voiding pattern. 2. Cystometry - measure of pressure / volume relationship of bladder during bladder filling - assess bladder sensation during filling, bladder capacity, detrusor pressure 3. Post-void residual (PVR) 4. Pressure flow studies - relationship between pressure in bladder and urine flow during emptying, i.e. detrusor contractility 5. Urethral pressure profilometry - the urethral ability to maintain a closed bladder outlet Urethral closure pressure <25cm H2O suggests weak urethral sphincter. >25cm H2O suggests hypermobility due to loss of suburethral support 6. Leak pressure points - Abdominal LPP - intravesical pressure at which urine leakage occurs due to increase intra-abdominal pressure in absence of detrusor contraction

Answer 13

Void into flowmeter / commode - Records urine volume - Reports urine flow rate Maximum flow rate (Qmax) should be >15ml/s Dependent on volume voided, should be >200ml for the test to be valid Prolonged flow and decreased Qmax --> Obstruction or hypocontractile bladder

Answer 14

Evaluates filling and voiding phases of micturition - Measurement of the pressure-volume relationship of the bladder during filling Two catheters in bladder - One for filling the bladder - One for measuring bladder pressure = intravesical pressure (Pves) One catheter in the rectum to measure intra-abdominal pressure (Pabd) Detrusor pressure (Pdet) = Pves - Pabd Used to diagnose: - Detrusor overactivity - Urodynamic SUI - Records bladder sensations at different bladder volumes OAB = if pressure change seen on Pves and Pdet but not on Pabd, then due to detrusor contraction If changes seen in both Pves and Pabd but not Pdet, it is due to raised intra-abdominal pressure. If leakage occurs then SUI Volume at which subjective sensations occur are recorded as the bladder is filled - Increased bladder sensation occurs when sensations occur at reduced bladder volumes - Detrusor overactivity, interstitial cystitis (causing a small bladder). Hypocontractile bladder suggested if sensations occurs at higher bladder volumes

Answer 15

Patient voids after cystometry Flow rate correlated with detrusor pressure Low pressure and low flow rate = hypocontractile bladder High pressure and low flow rate = obstruction, e.g. cystocele

Answer 16

Prevalence ranges from 13-35% - Increases with age, reaches an initial peak in the 50s, then proceeds to dip slightly - Rises again in the 60s and continues to do so thereafter SUI most common - 50% - MUI - 36% - tends to be more severe / significant, women experience higher impact on QoL and more functional limitations UUI - 11%

Answer 17

``` 33% of women in Australia avoid physical exercise because of incontinence Depression Hinders: - Healthy lifestyle - Travel - Self-esteem - Sex life Increased falls risk in elderly ```

Answer 18

Stress incontinence - Describes a symptoms, sign and a diagnosis - Can only diagnosis urodynamic stress incontinence after urodynamic investigation Overactive bladder / detrusor overactivity - Detrusor overactivity = urodynamic observation - OAB describes the symptom complex of urgency with or without UUI, in the absence of UTI or any other obvious pathology - usually with frequency and nocturia ``` Overflow incontinence Fistulae Urethral diverticulum Congenital anomalies (ectopic ureter) Functional incontinence, e.g. immobility Temporary incontinence, e.g. constipation, UTI ```

Answer 19

Age - other factors associated with aging can undermine continence (e.g. dementia) Pregnancy and childbirth - if develop UI antenatally or sooner after delivery, the RF for developing UI in the longer term Smoking >20/day ? Due to coughing or collagen changes Obesity - weight loss reduces SUI from 61% to 12% Hysterectomy ? Damage endopelvic fascia and nerves. Subtotal hysterectomy does not decrease the risk Menopause - loss of oestrogen --> OAB Sx Connective tissue abnormality

Answer 20

Poor suburethral support - Urethral hypermobility - Suburethral support is provided by the anterior vaginal wall - fused to proximal 2/3 A weak urethral sphincter (intrinsic sphincter deficiency) - Causes: scarring, ischaemia, denervation from pelvic or vaginal surgery or radiotherapy - Childbirth can cause denervation injury (pudendal nerve shows delayed nerve conduction)

Answer 21

Clinical suspicion of detrusor overactivity Hx of previous surgery for stress UI or anterior compartment prolapse Symptoms of voiding dysfunction

Answer 22

Exclude pathology, infection Bladder diary Behavioural modification - diet, fluids, bowel WEight loss Duloxetine - not first line, SNRI, alternative to surgery All women should be recommended to have PF PT and / or see a continence nurse for PFE, and bladder training as first line If fail conservative treatments, can offer continence surgery PFMT - Cure rates for SUI between 21-84% have been reported Greater effect if SUI alone, supervised PFMT programme for >3/12 =/>8 contractions performed 3 times/day

Answer 23

90% cure rate if appropriate, properly performed primary procedure Aim: elevate bladder neck and proximal urethra into an intra-abdominal position Vaginal: - Urethral bulking agents - Retropubic tape procedures - Transobturator tape procedures Abdominal (open or laparoscopic): - Burch colposuspension Combined: - Fascial sling / endoscopic bladder neck suspension

Answer 24

Injection of pliable bulking agent into the submucosal tissues of the urethra, or bladder neck May increase the resistance to flow within the urethra Transurethral via cystoscope or blind approach Success rates tend to be lower than with midurethral tape procedures ``` Can be done under LA or GA Minimally invasive Repeat injections may be needed Effectiveness decreases over time Uncertainty over long term safety ```

Answer 25

Corrects both SUI and cystocele - At the expense of increasing tendency for posterior wall prolapse Simultaneous hysterectomy does not improve results- only do if uterine pathology Cochrane 2016 - Overall continence rate 85-90% at 1y, 70% at 5y - Superior to anterior repair - Compared to MUS - no significant differences in continence rates COMPLICATIONS Voiding difficulties - Usually resolve. If persist, then made need self-catheterisation Urgency or UUI may arise de novo Exacerbation of rectoenterocele due to repositioning of the vagina Complications are more common compared to MUS

Answer 26

Low transverse suprapubic incision, just above the symphysis pubis (lower than a pfannenstiel) Bladder, bladder neck and proximal urethra are dissected medially off the underlying paravaginal fascia 2-4 pairs of PDS sutures are inserted between the paravaginal fascia and the ipsilateral iliopectineal ligament. Tied to elevate bladder neck. Leave suction (redivac) drain in retropubic space IDC on free drainage for at least 2/7, then clamp regimen initiated Use perioperative Abs

Answer 27

Gold standard for SUI Complete cure or significant improvement 80-90% Retropubic (RP) MUS - TVT = tensionfree vaginal tape Transobturator (TO) MUS Single incision (SIS) MUS - third generation, only under trial conditions in Au/NZ Exit site is what varies Vaginal incision usually 1cm proximal to external urethral meatus

Answer 28

Sling too loose - persisting incontinence Sling too tight - retention Sling may erode into the urethra or vagina Pain Mesh exposure rate 2% Early pain - cystoscopy, ? Remove sling (not too difficult to remove sling within 7 days)

Answer 29

Drain bladder Abdominal incisions: mark the two planned abdominal exit points for the tap at the superior margin of the pubic bone, 2cm lateral to the midline Appropriate sub urethral infiltration and incision. Lateral dissection to the urogenital diaphragm bilaterally. Insert the tape needles through the vaginal incision negotiating up through the retropubic space on each side, ensuring safe passage to minimise risk of bladder and vascular injur. Appropriate tape placement and tensioning dependent upon make of sling and manufacturers guidelines and instructions for use Repeat the same process on the contralateral side Appropriate tape tensioning technique ensuring a tension-free placement Exclude bladder / urethral injury by cystoscopy Exclude vaginal sulcal mucosal tears at completion Close vaginal incision Post-op: voiding trial prior to discharge

Answer 30

Bladder injuries and haematomas less common than with TVT Risk of thigh pain Compared to retropubic - Higher failure rate - Lower visceral injury, shorter length of hospital stay, and post-op voiding dysfunction - Higher rates of post-op pain and reoperation - Also removal is harder TO approach may be preferred in: - Women with extensive previous abdo surgery - Unable to cease anti-coagulation

Answer 31

Median subjective cure rate 70% Longer operation and post-op stay Recovery is slower Success rates similar to MUS

Answer 32

MUS surgery should only be undertaken by those regularly carrying out MUS surgery Cystoscopy recommended for insertion of all types of MUS Chronic pain in MUS - up to 5% - Variable severity Removal for severe pain occurs in 1 in 150 Resolution of pain in 81% with removal of mesh. Difficult to remove in 1 in 5 RANZCOG strongly emphasise that the US FDA publications clearly state that traditional MUS were not the subject of their safety communication

Answer 33

Prevalence ranges from 13-16% Symptom-based diagnosis Defined as urgency, with or without urge incontinence (wet or dry OAB), usually with frequency and nocturia, in the absence of UTI or other underlying bladder pathology ~1/3 also have urge leakage

Answer 34

Neurogenic detrusor overactivity - Lesions above the pons --> loss of voluntary inhibition of micturition, e.g. cerebrovascular disease, Parkinson's, dementia, tumours - Spinal cord lesions initially cause retention, then get detrusor overactivity from reorganisation of spinal reflexes Detrusor overactivity due to obstruction - Can occur after continence surgery Idiopathic detrusor overactivity - Muscle denervation found in detrusor biopsies

Answer 35

``` If mixed UI, treat the OAB symptoms prior to resorting to surgery Lifestyle changes and behavioural intervention - Optimise underlying conditions - Reduce fluid intake to 1-1.5L/day - Avoid tea, caffeine, alcohol - Reduce fluids in the evening - Weight loss may improve Sx of UUI - Review medications ``` Bladder training / re-education - min of 6/52, void every 1.5h - 90% continent after 6/12 - 40% relapse within 3y Acupuncture - RCT compared with placebo - reduction in incontinence episode frequency and improvement in QoL

Answer 36

Antimuscarinic medication - Oxybutynin - Vesicare = solifenacin (better, less side effects) Reduce OAB symptoms by up to 75% ADR: Dry mouth, Constipation , Blurred vision Associated with low compliance and persistence rates - Poor efficacy and troublesome side effects <20% of women continue to take them at 6/12 Symptomatic improvement greater than with bladder retraining alone Caution in the elderly - Anticholinergic drugs may be associated with significant decline in cognitive ability (dementia, Alzheimer's)

Answer 37

β3 adrenoreceptor agonist Selective agonist --> detrusor relaxation and increased stability during bladder storage Mirabegron not inferior to solifenacin Lower rates of dry mouth Improved symptoms with combination mirabegron + solifenacin, compared to either alone - No difference in ADR

Answer 38

Indication: refractory OAB Interfere with neural transmission by blocking calcium-dependent release of neurotransmitter, acetylcholine --> affected muscle becoming weak and atrophic New development of nerve terminals and synaptic contacts allows recovery of function Success rates over 60% Duration of clinical response: 9-12 months Complications - dose dependent: - Urinary retention approx 5% - Catheterisation up to 16%

Answer 39

PTNS = posterior tibial nerve stimulation Tibial nerve is a mixed nerve containing L4-S3 fibres - Originates from the same spinal cord segments as the innervation to the bladder and pelvic floor 60% success rate PTNS vs. antimuscarinic meds -no significant different in the change in bladder diary parameters, less side effects for PTNS

Answer 40

Stimulation of the dorsal sacral nerve root using a permanent implantable device in the S3 sacral foramen Somatic fibres are larger in diameter and therefore have a lower threshold of activation, therefore can selectively stimulate pelvic floor without causing bladder activity 50% improvement

Answer 41

Clam cystoplasty - Bladder bisected almost completely and patch of gut (ileum) equal in length to the circumference of the bisected bladder (~25cm) is sewn in place - Converts high pressure system to low - Need to strain to PU - Side effects: Chronic exposure of ileal mucosa to urine may --> malignant change (5% adenocarcinoma risk) Detrusor myectomy - Excise whole thickness of detrusor from the bladder dome to create bladder diverticulum with no intrinsic contractility Urinary diversion - Ileal conduit to create an incontinence abdominal stoma

Answer 42

``` Neurological Inflammatory - Urethritis - e.g. honeymoon cystitis - Vulvitis - e.g. herpes - Vaginitis - e.g. severe candidiasis Drugs - TCA - Antimuscarinic agents - Ganglion blockers - Epidural anaesthesia Obstruction - Urethral stenosis or stricture - Oedema following surgery or parturition - Fibrosis due to repeated dilation or irradiation - Pelvic mass Myogenic - Atonic detrusor secondary to overdistension ```

Answer 43

Post-surgical fistula - Direct injury during dissection - Process takes from days up to a month - Transvaginal mesh for prolapse After Childbirth / obstetric fistula - Operative delivery, MROP - After CS, uterine rupture Pelvic pathology- Advanced malignancy Inflammation - PID, diverticulitis, IBD After radiation therapy Trauma - Pessaries not removed

Answer 44

Dye test - Methylene blue into bladder - Tampon or large cotton swabs placed in the vagina and checked for dye - Blue staining - suggests vesicovaginal fistula - No staining - may indicate ureterovaginal fistula Cystoscopy - Can assess the bladder for residual injury, surgical materials Intravenous urography - Might miss leak of ureter near bladder (would obscure small leak) CT urogram MRI

Answer 45

Surgical - Fistula must be fully mobilised and the edges debrided - Repair performed with absorbable sutures in one or two layers Uretero-vaginal fistula - repair ASAP to prevent upper urinary tract damage Vesicovaginal fistula are usually treated conservatively initially - Bladder drainage and antibiotics - works in 10% - If spontaneous closure does not occur, then surgical Post-op care - IDC for 3/52 with antibiotics until removed - Cystogram to check integrity prior to TROC - Avoid sex for 3/12

Answer 46

Pouch or pocket that forms along the urethra Becoming more common, due to increased incidence of STIs Clinical presentation: - Pain, particularly after micturition - Postmicturition dribble - Recurrent UTI - Dyspareunia

Answer 47

Radiologically - Micturating cystogram - Video cystourethrogram - Urethroscopy - MRI - Can help identify the anatomy and location of the ostia draining into the urethra MANAGEMENT: Conservative initially - Intermittent antibiotics if necessary If severe symptoms --> surgical excision of diverticulum . Do subtotal diverticulectomy to avoid urethral stricture formation

Answer 48

IAS responsible for 80% of resting pressure Distended rectum --> cerebral cortex --> IAS relaxation If appropriate to BO, impulses sent for contraction of rectal muscles and relaxation of EAS, pelvic floor, puborectalis sling

Answer 49

Anorectal manometry - Assessment of anorectal physiology (pressure, muscle tone, coordination of anal sphincters and rectum) Endoanal USS -Assess anatomy of anal sphincter complex Defecating proctogram - Assessment of dynamic defecation

Answer 50

Previously referred to an interstitial cystitis Chronic pain syndrome Pelvic pain, pressure or discomfort perceived to be related to the bladder lasting >6/12 and accompanied by >1 other urinary symptoms (e.g. urgency, frequency in the absence of other identifiable causes Associated medical problems: - IBS - Vulvodynia - Endometriosis - Chronic fatigue syndrome - Autoimmune diseases Typical cystoscopic appearance: - Glomerulations and bleeding during draining the bladder - Hunner's ulcer

Answer 51

Conservative - Education - Avoid caffeine, alcohol, acidic foods and drinks - Stress management - Regular exercise - Analgesia Pharmacological: Amitriptyline Intravesical treatments Last resort: Total cystectomy and urinary diversion

Answer 52

Rule out and treat UTI Renal USS Cystoscopy Refer urology

Answer 53

Primary prolapse cases Patients younger than 50y of age Lesser grades of prolapse (POP-Q original grade 2 or less) Posterior compartment prolapse without significant apical descent Patients with chronic pelvic pain Post-menopausal patients who are unable to use vaginal oestrogen therapy (first line therapy in the event of erosion)