Urogynae Flashcards
Micturition reflex
PHYSIOLOGY
Normal urethral closure due to:
- Extrinsic factors: levator ani, endopelvic fascia and pubourethral ligaments forming hammock below urethra for support which tenses with increased intra-abdominal pressure; hypermobile with incontinence
- Intrinsic factors: striated and smooth muscle of urethral wall
- Continence is when urethral pressure > bladder pressure
Bladder - beta receptors
Urethra - alpha receptors
Sympathetic nervous system (T11 – L3)
- Bladder STORAGE
- Hypogastric plexus - act on receptors to relax detrusor muscles
- Contracts external sphincter and store urine
Parasympathetic nervous system (S2 – S4)
- Bladder EMPTYING
- Pelvic nerve
- FROM BLADDER TO SPINE
Somatic/voluntary nervous system (S2 – S4)
- Pudendal- ACh on M3 receptors causing contraction of detrusor and relaxation of external sphincter to empty bladder
- FROM SPINE TO BLADDER
Cortex usually inhibits PMC (pontine micturition reflex) and when needed to pass urine, cortex stops inhibiting PMC
MICTURITION REFLEX
Empty bladder -> slow impulses from destrusor muscle with urine -> via sensory pelvic nerve to sacral spinal cord to PMC -> PMC inhibited -> spinal cord -> hypogastric nerve with noradrenaline and detrusor muscle relaxes AND pudendal nerve to external sphincter to contract external sphincter -> hold urine
Increased impulses -> voiding
Full bladder -> stretches receptors in destrusor muscle detect stretch -> stretch receptors are pelvic nerve -> increase firing of pelvic nerve -> signal via pelvic nerve to spinal cord S2-4 -> stop inhibition of PMC -> PMC activated –> activate parasympathetic nerve and inhibit hypogastric sympathetic nerve -> no relaxation of destrusor muscle AND signal back from spinal cord via pudendal nerve via S2-4 to relax urethral sphincter -> empty bladder
CAUSES OF INCONTINENCE
DIAPPERS D = delirium I = infection A = atrophic vaginitis P = pharmaceuticals (e.g. diuretics, sedatives) P = psychological disorders (e.g. depression) E = excessive urine (high fluid intake) R = restricted mobility S = stool impaction
Also consider neurological conditions
Stress incontinence
Definition: leakage with increased intra-abdominal pressure; most common especially young women and pregnant women
Pathophys: urethra and bladder neck hypermobility; increased abdominal pressure that overwhelms sphincter muscle and allows urine to leak out
Risk factors: age, pregnancy, parity, obesity, functional or cognitive impairment, postmenopausal (oestrogen receptors in urethra and bladder), hysterectomy
Urinary Sx:
- Storage (frequency, nocturia, urgency, leak)
- Voiding (hesitancy, straining, poor flow)
- Postmicturition symptoms (incontinence, incomplete emptying)
- Bowel Sx
- Prolapse Sx
- Sexual Sx (dyspareunia, vaginal dryness, coital incontinence)
- Obstetric + Gynae Hx
- Medical Hx (diabetes, peripheral oedema, neurological conditions, chronic cough)
- Meds - diuretics
- Smoking, EtOH, caffeine
- QOL/mood/psych
Ex:
- BMI
- Abdo exam
- Pelvic exam: atrophy, masses, urine leakage on cough, prolapse
Ix:
- Urine MCS, cytology
- Voiding diary
- Postvoid residual
- Urodynamics
Urodynamics:
Uroflowmetry
= measures urine flow/flow time/volume voided overtime
= should be bell shaped curve
Cystometry
= measures detrusor pressure = intravesical pressure - intraabdominal pressure)
= gradually fill bladder and check storage phase (1st desire to void), provocation testing (cough for SUI and tap water for UUI) and voiding phase (sit on uroflow commode and measure pressure and postvoid residual)
- Maximal urethral closure pressure - highest pressure along urethra
- Valsalva leak point pressure - intravesical pressure at which leakage occurs
Management - conservative:
- Pelvic floor exercises** first line
- Weight loss
- Reduce caffeine/EtOH
- Treat constipation
- Stop smoking
- Bladder training
- Voiding techniques
- Vaginal pessary - to support bladder neck/urethra
- Continence rings to support urethra
Management - medical:
- Oestrogen
- Duloxetine
- Usually meds not recommended for SUI
Management - surgical:
- Midurethral sling (retropubic, transobturator or single incision) - mesh under midurethra with minimal tension
- > Recommended
- Colposuspension (Burch) - open or laparoscopic; hitches paraurethral tissue to Cooper’s ligament and elevates urethra
- Pubovaginal fascial sling - sling at urethrovesical junction
- Urethral bulking agent - narrows bladder neck e.g. collagen, silicone
MUS better success at long term follow up
Colposuspension has 9% urinary retention
Trial showed TVT vs colposuspension - similar cure rates, more intraop complications with TVT (bladder injury) but more postop complications with colposuspension (delayed micturition); similar operating time and length of stay
TO vs RP complications
- TO has more pelvic and groin pain
- TO higher fail rate and more likely to need re-operation in mid to long term
- RP more likely to injure viscera especially bladder
- RP longer hospital stay
- RP more likely post op voiding dysfunction and need for re-intervention short term
- TO less likely to completely remove mesh
Urge incontinence
Definition: leakage immediately preceded by urgency; most common in older women
Can have WET (with incontinence) and DRY (without incontinence)
Detrusor overactivity: urodynamic diagnosis indicating detrusor contractions during filling phase, neurogenic or idiopathic; causes UUI
Pathophys: uninhibited detrusor muscle that contracts randomly leading to increased frequency and nocturia
Risk factors: age, parity, obesity, functional or cognitive impairment, postmenopausal (oestrogen receptors in urethra and bladder), hysterectomy
Urinary Sx:
- Storage (frequency, nocturia, urgency, leak)
- Voiding (hesitancy, straining, poor flow)
- Postmicturition symptoms (incontinence, incomplete emptying)
- Bowel Sx
- Prolapse Sx
- Sexual Sx (dyspareunia, vaginal dryness, coital incontinence)
- Obstetric + Gynae Hx
- Medical Hx (diabetes, peripheral oedema, neurological conditions, chronic cough)
- Meds - diuretics
- Smoking, EtOH, caffeine
- QOL/mood/psych
Ex:
- BMI
- Abdo exam
- Pelvic exam: atrophy, masses, urine leakage on cough, prolapse
Ix:
- Urine MCS, cytology
- Voiding diary
- Postvoid residual
- Urodynamics
Urodynamics:
Uroflowmetry
= measures urine flow/flow time/volume voided overtime
= should be bell shaped curve
Cystometry
= measures detrusor pressure = intravesical pressure - intraabdominal pressure)
= gradually fill bladder and check storage phase (1st desire to void), provocation testing (cough for SUI and tap water for UUI) and voiding phase (sit on uroflow commode and measure pressure and postvoid residual)
- Maximal urethral closure pressure - highest pressure along urethra
- Valsalva leak point pressure - intravesical pressure at which leakage occurs
Management - conservative:
- Weight loss
- Reduce caffeine/EtOH
- Hydration as concentrated urine irritates bladder
- Treat constipation
- Stop smoking
- Bladder retraining** first line - choose interval then make it longer by doing breathing/PFEs; effective for DO
Management - medical:
- Anticholinergics (ContraInd glaucoma) - trial 2 weeks e.g. oxybutynin (nonselective antagonist, oral or patch which has less SE), solifenacin (selective M3 antagonist, contraInd HTN/prolonged QT, less SE but more expensive)
- B3 agonist - detrusor relaxation and increased bladder capacity (e.g. mirabegron)
- Oestrogen
- Desmopressin for nocturia
- TCA antidepressants
- Duloxetine
Management - surgical:
- Neuromodulation - sacral nerve stimulation therapy to inhibit detrusor contractions
- TENS - reduces urgency and feeling of bladder fullness
- Botox - inject into detrusor, lasts 8-10months, risk of retention; need to fail 2x medical treatment
Pelvic organ prolapse
Definition: herniation/protrusion of pelvic organs through vaginal canal; 50% of parous women have POP
Levels of support:
Level 1 = apical, cardinal-uterosacral ligaments- attaches uterus/cervix/upper vagina to pelvic wall
- Damage: uterine or vault prolapse
Level 2 = middle, pubocervical fascia - attaches pubic bone to anterior cervix and laterally to arcus tendineus fascia pelvic (ATFP)
- Damage: cystocoele
Level 3 = distal, endopelvic fascia attaches anterior (urethra), lateral (levator ani muscles), posterior (perineal body)
- Damage: rectocoele, urethral mobility, stress incontinence
POP-Q
- Standardised measurements taken relative of various points relative to hymen to demonstrate maximum extent of prolapse
- Defines 6 points above (-ve) or below (+ve) hymen
- Defines 3 other landmarks - genital hiatus, perineal body, total vaginal length
Aa = anterior, 3cm from hymen, proximal Ba = distal part of anterior vaginal wall Ap = posterior 3cm from hymen, proximal Bp = distal part of posterior vaginal wall C = lower edge cervix D = posterior fornix or POD GH = external urethral meatus to posterior hymenal ring TVL = hymen to most distal point; not measured on complete valsalva, need to reduce prolapse PB = posterior hymen to anus
Types of prolapse:
ANTERIOR VAGINAL WALL
- Weakened anterior wall supports mainly pubocervical fascia
POSTERIOR VAGINAL WALL
- Weakened rectovaginal septum and pararectal fascia between posterior vaginal wall and rectum
- Can cause rectocoele (prolapse of rectum into vaginal lumen) or enterocoele (prolapse of small bowel through upper posterior vaginal wall)
UTERINE PROLAPSE
- Weakened cardinal-uterosacral ligaments which can cause traction on vaginal walls causing cystocele and rectocele
VAGINAL VAULT PROLAPSE
- Vaginal vault prolapse post hysterectomy as cardinal-uterosacral ligaments are detached from vaginal apex
- Often associated with enterocoele
Risk factors:
- Age
- Postmenopause
- Parity
- Vaginal trauma
- Connective tissue disorders
- Neurological disorders (spina bifida)
- Obesity
- Chronic cough
- Constipation
- Heavy lifting
- Hysterectomy - risk of apical prolapse
- FHx
Symptoms:
- Bulging sensation/pressure/heaviness
- Urinary incontinence/frequency/flow
- Bowel symptoms - incomplete emptying/incontinence
- Sexual symptoms - dyspareunia/lack of sensation
- Effect on quality of life
Ex:
- Aim to reproduce maximum protrusion
- Empty bladder
- BMI
- Abdominal/vaginal exam
- POP-Q, PR exam for tone
- Urodynamics
Management - conservative:
- Lifestyle - reduce BMI, stop smoking, reduce caffeine/EtOH
- Pelvic floor exercises
- Topical oestrogen
Management - mechanical:
- Pessary (stage 2-4)
Supportive (ring) or space occupying (shelf)
Pros: 80% improvement in symptoms, easy, cheap, non-operative, immediately effective
Cons: discharge, vaginal ulcers, fibrous bands, some incompatible with sexual function, need regular surveillance
Management - surgical: ANTERIOR WALL PROLAPSE - Anterior colporrhapy, mesh repair - Pros: less recurrence with mesh - Cons: urinary retention, stress incontinence, vesico-vaginal fistula, mesh erosions
POSTERIOR WALL PROLAPSE:
- Posterior colporrhapy, enterocoele repair
- Pros: vaginal reduces rate of recurrent rectocoele and enterocele
- Cons: dyspareunia, worsening of bowel symptoms, recto-vaginal fistula
UTERINE PROLAPSE:
- VH or LAVH
- Sacral hysteropexy
- Colpocleisis
VAULT PROLAPSE:
- Vaginal hysterectomy
Pros: if finished childbearing, good option
Cons: may need more surgery
- Sacrocolpopexy (open = lap in effectiveness)
Mesh from anterior and posterior vault to anterior sacral ligament; can do colposuspension at same time only to PREVENT postop symptomatic SUI (not treat)
Pros: gold standard for vault repair, cure 75-100%, less dyspareunia, less SUI
Cons: injury to rectum/nearby organs, mesh erosion and infection, longer operative time, longer recovery
- Sacrospinous fixation
Suture vaginal apex to sacrospinous ligament
Pros: cure 90%, shorter surgery, quicker recovery, cheaper
Cons: buttocks pain, cystocele, new SUI, dyspareunia, neurovascular damage, not for short vaginal length, anterior compartment prolapse
- Vaginal mesh
- Colpocleisis
Vaginal closure
Pros: improves symptoms, unlikely to require repeat procedure, short operating time, low incidence of complications
Cons: no intercourse
- McCall’s culdoplasty
This can also be done at hysterectomy to prevent vault prolapse - can also do SSF to prevent it
Mesh
Type 1 polyprophylene mesh most commonly used
- Large pore size - less infection
- Low erosion rate
- Infections can be treated without removal
- Not recommended as first line treatment of any prolapse
Complications of mesh:
- Erosion
- Vaginal scarring/stricture
- Infection
- Fistula
- Dyspareunia
- Pelvic pain
Large trial showed mesh for cystocele repair had higher rates of treatment success but also higher rates of surgical complications and post-operative adverse events
RANZCOG statement (for VAGINAL MESH):
- Most cases of POP could be treated without mesh
- No compelling evidence that vaginal mesh improves success rates
- Adverse events common
- UGSA: need informed patient consent about limited data, benefits and complications of mesh, alternative surgeries, alternative treatments (pessary), use native tissue instead
- Need to be specially trained, operate regularly enough to maintain expertise, can perform non-mesh repairs, can perform cystoscopy, can manage complications
- Avoid if older >50yrs, primary prolapse, POP-Q<2, chronic pelvic pain, if posterior prolapse as well
- May have benefit in obese, young, chronically raised abdominal pressure, stage 3/4 prolapse
- Consider 2nd opinion prior to using mesh
- To monitor safety/efficacy, do RCT or maintain self-audit and report adverse effects to TGA
- Can only use transvaginal permanent mesh in the context of the TGA special access scheme
Can use abdominal mesh (not vaginal mesh) as higher risk of success and reduced risk of recurrence
Prolapse questions
Jan 2020
POPQ, mesh, abdo sacrocolpopexy
• 55 year old hx hysterectomy for HMB, 6 months vaginal bulge, no bladder/bowel symptoms, BMI ?30-35 otherwise well
• List 6 landmarks on examination that enable you to objectively assess POP (3 marks)
Aa = 3cm above hymen anterior proximal
Bb = 3cm above hymen anterior distal
Ap = 3cm above hymen posterior proximal
Bp = 3cm above hymen posterior distal
Genital hiatus = urethral opening to posterior hymen
Total vaginal length = vaginal apex to hymen, not measured on complete Valsalva, need to reduce prolapse
Perineal body = posterior hymen to anus
• conservative options (4 strategies, 2 marks) Weight loss Pelvic floor exercises Oestrogen cream Pessary
• asking for surgical management, worried about mesh
• why are we allowed to use mesh for abdo sacrocolpopexy when TGA removed vaginal mesh (3 marks)
Proven to have good outcomes for abdominal sacrocolpopexy – high cure rate, and reduced recurrence rate
Not same risk of infection and vaginal mesh
• given her a handout and discussed it (commission something something??)
• what are the things you counsel her on from this statement (8, 4 marks)
Conservative and medical options
Non-mesh surgical options – SSF, colpocleisis (however cannot be sexually active), lap sacrocolpopexy
Risks of mesh - erosion, infection, fistula, scarring, dyspareunia
Risk of failure of surgery
Done by experienced specialists who do this surgery regularly
Recommended for younger, increased BMI, with bulge grade 3-4
• 3 advantages of abdominal sacrocolpopexy over other surgical option (3 marks) High cure rate Reduced recurrence rate Less dyspareunia Less SUI
• Risks of sacrocolpopexy
Long surgery
Longer recovery
Risks of mesh
2015 – July – Pelvic Floor
Question 7 - Pelvic Floor
a. Both sacrospinous fixation and sacrocolpopexy can be performed to repair post hysterectomy vaginal vault prolapse. Complete the following table using the headings provided to compare these operations.
(The two (2) benefits and two (2) risks must be different for each procedure). (6 marks)
** ASK LUCY **
Sacrospinous Fixation Sacrocolpopexy
Anatomical level of support Fixation of vaginal vault to right sacrospinous ligament (Level 1) Attachment from vaginal vault to sacral promontory (anterior longitudinal liagament of the sacrum) (Level 1)
Operative approach Vaginal Laparoscopic or abdominal (open)
Benefit 1 Success >90%; recurrence only 5% More durable apical prolapse procedure with lower rates of recurrence (success 93-100%)
Benefit 2 Quick recovery; avoid open surgery Less dyspareunia
Risk 1 Recurrent prolapse after repair (especially anterior POP) 8-30% Abdominal surgery (visceral injury – bladder, bowel, ureter, vessel); increased SUI following repair
Risk 2 Pudendal/sciatic nerve injury
Buttock pain Mesh complications – erosion, chronic pain
Longer recovery A 62 year old woman presents with a history of mixed urinary incontinence. She has a BMI of 33kg/m2 but is otherwise in good health. She underwent menopause aged 48 years and had two instrumental deliveries in the past. She describes urge symptoms three times a week with occasional urinary incontinence. With coughing she can experience stress incontinence. She has no prolapse symptoms. You proceed to examine her. b. List four (4) differential diagnoses you will consider. (2 marks) - Mixed incontinence - Genuine stress continence - Overactive bladder - Urinary tract infection - Bladder malignancy - Vaginal atrophy - Bladder neuropathy c. Outline your initial assessment and management over the next three months to further assess the cause of her symptoms. (7 marks)
History:
- Urinary history including frequency of voiding, nocturia, urgency, urge incontinence, incontinence with intercourse, how many pads per day PLUS quality of life, impact
- Bladder diary of use to elicit history if difficult to get from patient
- Fluid intake – caffeine, EtOH, carbonated drinks, evening intake
- Smoking history
- Bowel function – constipation, IBS
- Comorbidities – DM, HTN (may exclude some medications), neurological conditions e.g. MS, spinal
injury
- Obstetric history – vaginal delivery vs. caesareans, grand multiparity, instrumental/forceps
- Menopausal status, use of topical oestrogen
- Sexual history/function – dyspareunia, incontinence with intercourse
- Previous surgery (gynaecological)
- Medication review – calcium channel blockers (cough), prazosin
- Previous treatments and outcomes
Examination:
- Stress incontinence on Valsalva
- Vaginal atrophy
- Pelvic floor examination and level of support
- Concurrent prolapse
- BMI (weight + height)
Investigation:
- Urine culture (MC&S) – exclude UTI
- Urine cytology x 3 (bladder malignancy)
- Consider urodynamics – if operative management, unclear on history
- Consider cystoscopy if persistent haematuria
Initial conservative management:
- Pelvic floor physiotherapy/PFE
- Bladder training; hygiene practices
- Topical oestrogen replacement if atrophy on examination (can improve symptoms both OAB, SUI)
- Weight loss (diet, exercise) if high BMI
- Dietary changes – cut down alcohol, caffeine, evening fluids; cease smoking
Feb 2014
a. According to this statement, prior to undertaking a transvaginal mesh procedure, what issues should be addressed in the Informed Patient Consent process regarding vaginal surgery for uterovaginal prolapse including those related specifically to the use of mesh? (5 marks)
• Limited robust data exists on the efficacy and safety of TV mesh products
• Decision to operate should be based on symptomatic bother, rather than POP-Q stage
• Mesh is not first line – consider native repair
• Alternatives to surgical management available
- conservative – PFME, pessaries
- expectant
• Alternatives to use of TV mesh for surgical repair
- Abdominal sacrocolpopexy
- Use of native tissue repair (autograft)
• Potential complications of TV mesh
- Mesh erosion
- Vaginal scarring
- Fistula formation
- Dyspareunia
- Pelvic pain unprovoked at rest – removal of mesh may not resolve symptoms
Give written information and can get second opinion
b. According to the above statement:
i) What is the current evidence regarding the benefits (if any) of transvaginal mesh versus native tissue prolapse repair with respect to procedure success/longevity for the anterior compartment, posterior compartment and vault? (3 marks)
- Current evidence does not support use of polypropylene mesh as first-line treatment for anterior, posterior or vault prolapse
- Benefits of use of mesh include reduction in prolapse symptoms and re-operation for prolapse for anterior repair
However, significant problems include: - Higher combined re-operation rate (prolapse, urinary incontinence or mesh exposure, bladder injury, stress urinary incontinence and prolapse in other vaginal sites) – mesh exposure in 8-15% patients
- Data of use in recurrent prolapse is lacking but this is the area where generally can be considered or if other risk factors present
- No benefit compared to native tissue repair in apical or posterior prolapse
- Use of mesh standard for abdominal sacrocolpopexy (repair of anterior or apical prolapse)
ii) What are the complications associated with the use of transvaginal mesh? (3 marks)
Dyspareunia Erosion Infection Strictures Scarring Fistulas Pain Difficult to remove New stress incontinence Bladder injury
c. According to the above statement, caution should be exercised in using transvaginal mesh implants in which patients? (4 marks)
- Yet to try conservative management
- Primary prolapse cases
- Younger patient (<50)
- Lesser grade POP (POP-Q 2 or less)
- Posterior compartment prolapse without apical descent
- Pre-existing chronic pelvic pain
- Post-menopausal patients who are unable to use topical oestrogen
2012 – Feb – prolapse
Question 10
A 55 year old woman is referred by her GP with symptoms of prolapse. She had a vaginal hysterectomy 10 years ago for menorrhagia. For the past 6 months she has noted a vaginal bulge which is getting bigger. Her bladder and bowel function are normal and there is no pain, bleeding or discharge. She is on no medication and describes herself as “fit and active”. She has no co- morbidities.
a. What additional information elicited from her gynaecological history will influence her treatment options? (5 marks)
Sexually active
Dyspareunia
Incontinence – stress or urge
Previous pelvic/abdominal surgery – more details about hysterectomy, total or subtotal, did they do concurrent SSF
Parity
CST history
Abnormal bleeding
Symptoms of menopause – genito-urinary symptoms
BMI
is this bothering her
You proceed to examine the patient and quantify her prolapse using the Pelvic Organ Prolapse Quantification System (POP-Q).
b. i) Outline the POP-Q quantification system (POP-Q). (2 marks)
- Standardised system of measuring prolapse
- 9 measurements taken
- Describe maximum descent of midvagina, vault, and posterior mid vagina all relative to hymen
- Influence management and grade of prolapse
- To be done after emptying bowel and bladder
- Measurements are: Aa, Ba (anterior vaginal wall), TVL (total vaginal length), B (perineal body), C (cervix/vault), GH (genital hiatus), Ap, Bp (posterior vaginal wall), D (vault or insertion of uterosacral ligaments). All measurements taken at Valsalva (maximum descent) except TVL
ii) Comment on its usefulness in this setting. (2 marks)
- Symptoms don’t always correlate with grade of prolapse so have standard way to measure severity of prolapse
- Way to communicate degree of prolapse to another clinician
- Influences management options
- Objective way of communicating between clinicians who will be involved with care for patient including assessing improvement/effect of management implemented
- Can use pre and post op to assess improvement
- BUT does not always correlate with symptoms
On examination you find that the woman has a prolapse of the vaginal vault (middle compartment prolapse) presenting 2cm beyond the introitus when at rest.
c. Describe two benefits and two risks for each of one non-surgical and two surgical treatment options available for this condition. You do not need to describe the surgical methodology. You may use a table. (6 marks)
Risk Benefit
Pessary Failure
Erosion/ulceration
Disadvantage:
Regular follow-up required
Can make intercourse difficult (depending on pessary type) Avoid surgical/non-anaesthetic risk
Effective in >50% cases
Cost-effective and readily available
Surgical – reconstructive e.g. sacrospinous fixation Surgical risk (infection, bleeding, anaesthetic risk)
Visceral injury risk – bladder, rectum, bowel
Worsening or new urinary symptoms (SUI most common de novo)
Buttock pain Vaginal surgery with low complications and quick recovery
Improves vault prolapse with minimal recurrence and good patient satisfaction
Maintain sexual function
Cheaper
Faster than abdominal sacrocopopexy
Surgical – obliterative e.g. colpocleisis No longer able to have intercourse
Risks of procedure (anaesthetic, damage to surrounding structures) Reduced risk failure and therefore unlikely to require repeat procedure
Effective in improving symptoms
Abdominal colpopexy GA
Open surgery with longer hospital stay and recovery time Less SUI
Less dyspareunia
90% cure rate
Less risk of recurrence
Risks associated with mesh
Comment:
Information about the extent of her symptoms, menopausal state, previous treatment and sexual activity was expected. The POP-Q system is internationally recognised and enables comparative outcomes after surgery, for research and audit. Candidates were expected to know the relevant non- surgical and surgical options for middle compartment prolapse and provide two benefits and risks for the three correct options that they chose
Incontinence and fistula questions
Jan 2019
- Stress incontinence
a) 2 most common anatomical reasons for SUI and their causes:
1. Poor urethral sphincter function – e.g. secondary to urogenital atrophy in menopause
2. Chronically increased intravesical pressure secondary to increased intra-abdominal pressure more easily overcome urethral sphincter closing pressure and lead to stress incontinence e.g. obesity, chronic cough.
b) Describe the pathophysiology,
Urethral hypermobility – insufficient support of pelvic floor muscle leading to less support of urethra; increased intra-abdominal pressure causes weakness of internal urethral sphincter
Intrinsic urethral sphincter deficiency - neuromuscular damage with multiple previous pelvic surgeries; want to do retropubic not transobturator sling (higher rate of failure)
c) What are the conservative management, Lifestyle – weight loss, exercise, manage constipation Pelvic floor exercises Bladder diary Bladder retraining Reducing fluid intake Reducing caffeine Not drinking fluids too late into night Topical oestrogen
d) MUS options – what are the options and how would you compare them
Transobturator vs retropubic
Retropubic
- Higher risk of bladder injury
- Higher risk of post-op dysfunction
- Reduces re-operation risk
Transobturator
If had previous extensive abdominal surgery
Approach Success Risks Benefits
RPR Overall similar success (Cochrane meta-analysis)
Higher success rates in women with intrinsic sphincter deficiency (ISD)
Short-term success 71-97% (Cochrane); long-term 51-88% - Higher rate visceral injury (bladder perforation)
- Higher major vascular injury
- Higher rate post-op voiding dysfunction
- Mesh exposure (2%) similar - Less risk groin pain
- Higher success rate in women with ISD
TOR Similar success rates (except in those with ISD)
Short-term 62-98%; long-term 43-92% - Higher risk groin pain at 12 months (and beyond) – may require removal of mesh
- Mesh exposure 2% (similar) - Better if previous abdominal surgeries (difficult anatomy with higher risk visceral injury with RPR) or if on anti-coagulant and unable to stop pre-operatively
- Less risk voiding dysfunction post-operatively
d) Urodynamic studies are commonly performed pre-operatively. Describe findings of recent systematic review/meta-analysis (2017 Canadian Urology Association Journal)
Paucity in data to suggest improvement in women having pre-operative urodynamic studies. Recent systematic review showed that women who are undergoing PRIMARY surgery for SUI or stress-predominant MUI without evidence of voiding dysfunction; pre-operative urodynamics does not improve outcomes (as long as thorough history/examination performed). Implications on money/health care resources; risk of infection with bladder/rectal catheterisation; more acceptable to patients (urodynamics invasive).
e) Genuine or pure stress incontinence can be defined as:
Involuntary leakage of urine with increased intra-abdominal pressure in the absence of a bladder contraction.
Stress incontinence = sign.
Urodynamic stress incontinence = urodynamic diagnosis.
July 2019
SUI with MuS
68F presents with incontinence
a) Outline the clinical features of stress urinary incontinence
- Increased abdominal pressure causing urinary leakage e.g. leaking when coughing/sneezing
- Absence of urge symptoms (urgency, frequency, nocturia_
b) What early interventions are recommended to treat SUI
- Conservative and medical treatment as above
c) What is the pathophysiological mechanism that causes SUI
- Above
Her early interventions have not worked and she asks about surgical methods.
d) What are the short and long term complications of MUS
- Short
Urinary retention
Bladder injury
Rectal injury
Bleeding
Pain
Infection
- Long
o Failure
o Chronic pain
o Mesh complications
o Dyspareunia
e) Compare the risks of Retropubic compared to TVTo
- Retropubic = increased risk of bladder injury and viscera, voiding function postoperatively; can remove mesh
- Transobturator = increased risk of failure or re-operation; can’t remove mesh; more pain
f) Outline the evidence for UDS prior to SUI surgery based on the recent RCT
NEED TO ASK
July 2018
Question 11 - Urge Incontinence and Overactive Bladder
a. Define the terms “over active bladder” (OAB) and “urge incontinence” (UI). (2 marks)
Overactive bladder = syndrome of urgency, nocturia and urinary frequency; can be wet or dry; confirmed by detrusor contraction/activity without full bladder
Urge incontinence = is a diagnosis based on symptoms where there is a strong “urge” or feeling to pass urine and need to rush to bathroom or may be incontinent
b. Complete the table below regarding the autonomic nerve supply to the bladder detrusor muscle. (2 marks) Action on detrusor muscle
Action on detrusor
Sympathetic – store urine, action is relax detrusor; noradrenaline
Parasympathetic – pass urine, action is to contract detrusor; acetylcholine
A 60 year old woman presents with symptoms consistent with OAB noticed increasingly over the last year. Clinical history confirms she experiences urge incontinence 3-4 times a week.
b. List and justify the assessments you will make to further evaluate this patient’s symptoms/problem. For your answer you may use a table with the headings “assessment” and “justification”. (5 marks)
Further history – amount of fluid, type of fluid (caffeine), nocturia, episodes of incontinence, symptoms of stress incontinence, constipation
Background – parity (instrumental, perineal tears), medical conditions, medications (diuretics), pelvic surgery
Examination – general exam (BMI), abdominal exam (masses), speculum and pelvic exam, POP-Q, look for prolapse
Urodynamics – looking for signs of overactive bladder using
Assessment Justification
Clarify symptoms Urge symptoms vs stress symptoms (leakage with increased intra-abdominal pressure), nocturia, amount of times going to toilet, fluid intake/caffeine
Further history Medical history, medications, previous surgeries, parity
POP-Q Symptoms of prolapse worsening incontinence symptoms
Urine MCS To exclude UTI
Bladder diary Record number
Urodynamics For detrusor overactivity
c. Outline six (6) management strategies available for urge incontinence in this patient. (6 marks)
- Bladder diary and retraining – improve ability to hold urine for longer times; retrains bladder; needs to be with physio
- Pelvic floor exercises – to be with physio
- Oestrogen cream – treat vaginal dryness and atrophy
- Anticholinergics – act on parasympathetic nervous system
- Mirabegron – act on sympathetic nervous system; beta agonist
- Botox A injections – to temporarily paralyse bladder
Feb 2018 and feb 2013
Question 12 – VVF (Repeat – see Feb 2013)
a. List the causes of a vesico-vaginal fistula. (4 marks)
Infection
Mesh
IBD – Crohn’s disease
Bladder injury/perforation
Radiation
Inflammation
Iatrogenic
Surgery – caesarean section, post hysterectomy
Prolonged obstructed labour (top cause in developing country)
A 45 year old woman underwent an abdominal hysterectomy. One week later she attends your clinic complaining of a watery loss on her underwear.
b. How would you diagnose a vesico-vaginal fistula? (8 marks)
History – parity (NVB, instrumentals, obstructed labour), previous surgery before hysterectomy, IBD, medical issues, medications
Symptoms – type of loss, clear, is she passing urine normally, bowels, symptoms of fever, vaginal discharge, continuous urine loss is characteristic
Read operation report for hysterectomy – indications, complications including perforation, IDC insertion, post-op retention, blood loss
History of radiation
Examination – PV exam, speculum, look for watery loss, look for holes, look for erythema, signs of infection, discharge. Most common location post-hysterectomy is upper 1/3 vagina at vaginal cuff.
Bloods – serum creatinine, renal function, inflammatory markers
Methylene blue test – inject into IDC, put cotton swab in vagina and see if it stains
Ix – MRI, cystoscopy, IVP
c. List the treatment options if a vesico-vaginal fistula is diagnosed. (3 marks)
- If tissue appears healthy can do early repair especially post obstretric; if not can wait 6-12wks for granulation tissue to heal then repair especially post gynae surgeries
Conservative:
- Insert IDC can let is spontaneously resolve and drains urine to allow healing
- Should have cystogram prior to IDC removal then TOV
- If small defect <1cm
- Give antibiotics
Surgical repair:
- Latsgo technique – 7-20% failure rate
- Layered approach with 3-0 or 4-0 absorbable suture to bladder and 2-0 or 3-0 to vaginal mucosa. Vaginal approach usually possible but may require abdominal for complex repairs. Always perform cystoscopy at end of repair.
Two options for timing of surgical approach:
1. Early – best prognosis if defect detected and closed intra-operatively. If not found intra-operatively best time to repair is when tissue is healthy (exclude infection). If adequate tissue can operate now as has been within 1-2 weeks.
2. Late – if concurrent infection treat this first or if poor tissues. Allow 6-12 weeks post surgery to allow granulation tissue to dissipate and therefore best chance successful repair.
Mechanical – if unsuitable for surgery (complex co-morbidities, advanced cancer etc.) a well-fitted diaphragm with a central catheter or percutaneous continuous drainage via nephrostomy may be more appropriate.
d. When during a hysterectomy can they be caused?
During reflection of bladder peritoneum
During anterior colpotomy
During vaginal vault suturing
July 2016
a. Name six (6) specific types of urodynamic tests that may be performed to assess function of the lower urinary tract. Explain what each test measures. (6 marks)
- Filling cystometry – volume pressure, detrusor pressure = intravesical pressure (via bladder) – intraabdominal pressure (via rectum); fills bladder and records first urge to void and the volume this occurs in
- Uroflometry – measures flow rate (Qmax) by measuring volume of urine and time; non-invasive. Provide information of obstructed voiding picture if low flow rate.
- Urethral pressure profile – measures maximal urethral closing pressure; if low, can diagnose intrinsic sphincter deficiency in internal sphincter
- Post void residual – indicator of incomplete emptying
- Leak point pressure – vesicle pressure at which leakage occurs when a Valsalva manouvre is performed
- Pressure flow studies – measures pressure against urine flow
b. Explain when you would undertake urodynamic testing before contemplating surgery in a woman with stress incontinence. (4 marks)
- Unclear diagnosis
- Mixed urinary incontinence
- Neuropathy
- Refractive to treatment
- Concomitant pelvic organ prolapse and considering surgery as can worsen OAB
- Failed ssurgery – can determine underlying issue and target further investigations
A 65 year old woman of BMI 35 with utero-vaginal prolapse presents with a history of urge incontinence that improved (but still symptomatic) as the prolapse worsened over the years. She also describes the need to manually replace the prolapse to void. She has no co-morbidities, keeps good health and takes no medication. Examination confirms a Stage II Pelvic Organ Prolapse (POP).
c. Describe how you would manage her problem. (5 marks)
Elicit symptoms – is it bothering her Urinary incontinence symptoms Medical history – diabetes, spinal cord injury, neurological conditions Meds Previous surgery Constipation Vaginal bleeding
O/E:
POP-Q
Pelvic exam
Management: - Conservative: weight loss, exercise, PFE - Bladder diary - Reduce bladder irritants – caffeine, alcohol - Oestrogen - UDS - ACE-I, beta agonist - TCA - Botox - Sacral nerve stimulation - Pessary for prolapse Feb 2016 – same as previous
- Define the terms “over active bladder” (OAB) and “urge incontinence” (UI). (2 marks)
- Complete the table below regarding the autonomic nerve supply to the bladder detrusor muscle. (2 marks)
Action on detrusor muscle Releases which neurotransmitter
Sympathetic
Parasympathetic
A 60 year old woman presents with symptoms consistent with OAB noticed increasingly over the last year. Clinical history confirms she experiences urge incontinence 3-4 times a week.
c. List and justify the assessments you will make to further evaluate this patient’s symptoms/problem. For your answer you may use a table with the headings “assessment” and “justification”. (5 marks)
Assessment Justification
d. Outline six (6) management strategies available for urge incontinence in this patient. (6 marks)
Management Outline
2013 July SAQ
Question 12 – stress urinary incontinence
A 45 year old woman with a body mass index (BMI) of 35 kg/m2 presents to the gynaecology clinic with symptoms suggestive of stress urinary incontinence.
a. How would you make the diagnosis of ‘pure’ stress incontinence on history (3 marks), examination (1 mark) and investigation (1 mark)?
History:
- Increased abdominal pressure (cough, sneeze, jump) causing leaking
- No symptoms of urge incontinence (urgency, frequency, nocturia)
- Presence of risk factors e.g. parity, instrumental, vaginal deliveries
Ex:
- Stress provocation test: Valsalva causing urinary leakage
- Urine MCS negative
Ix:
- UDS: urinary leakage on exertion + intrinsic sphincter deficiency
- UDS: normal bladder capacity, normal bladder compliance, normal intravesical pressure; increased abdominal pressure causes leakage of urine without detrusor activity
b. List six factors that predispose to genuine stress urinary incontinence. (3 marks)
- Parity/grandmultiparaity
- Instrumental vaginal births
- Age
- Increased BMI
- Chronic cough
- History of chronic heavy lifting
- Connective tissue disorders
- Previous prolapse or pelvic surgery
- Constipation
- Smoking
- Pregnancy
- Postmenopausal
c. Describe two non‐surgical interventions that can benefit pure stress incontinence symptoms. (2 marks)
- Pelvic floor exercises – to strengthen pelvic floor muscles and improve bladder neck support
- Lifestyle – weight loss, smoking cessation, treat constipation, treat chronic cough
- Reducing bladder irritants – caffeine, EtOH
- Topical oestrogen if post-menopausal; increased tissue support once atrophy reversed
- Duloxetine
d. Describe in detail the operative technique of a tension‐free vaginal tape (TVT) procedure. Assume appropriate sedation or anaesthesia and sterile preparation has been performed. (5 marks)
- Lithotomy position
- Small incision in anterior vaginal wall in midline at level of midurethra and 1cm skin incision on either side of suprapubic area immediately above and 2cm lateral to pubic symphysis
- Rigid catheter inserted into bladder to better delineate urethra
- Urethra displaced to contralateral side using rigid catheter i.e. pulled to right side as left side is dissected
- • Blunt bilateral dissection through anterior vaginal wall, and paraurethral space
- • Trocar containing mesh inserted through anterior vaginal incision and tunnel which has been bluntly dissected in paraurethral fascia and then through retropubic fascia with trocar directed anteriorly and parallel to pubic symphysis to meet suprapubic skin incision
- Angle needle laterally and perforate endopelvic fascia
- o Guide needle through retropubic space along back of pubic symphysis
- • Same performed on other side
- • Needle detached, plastic sheath removed, tape cut without tension
- • Vaginal incision closed 2-0 vicryl
- • Cystoscopy often performed at conclusion of procedure to ensure no bladder or ureteric injury
- • Must pass TOV prior to discharge
August 2011
Question 3
a. Describe briefly the micturition reflex and the centres affecting micturition. (4 marks)
Empty bladder -> slow impulses from destrusor muscle with urine -> via sensory pelvic nerve to sacral spinal cord to PMC -> PMC inhibited -> spinal cord -> hypogastric nerve with noradrenaline and detrusor muscle relaxes AND pudendal nerve to external sphincter to contract external sphincter -> hold urine
Increased impulses -> voiding
Full bladder -> stretches receptors in destrusor muscle detect stretch -> stretch receptors are pelvic nerve -> increase firing of pelvic nerve -> signal via pelvic nerve to spinal cord S2-4 -> stop inhibition of PMC -> PMC activated –> activate parasympathetic nerve and inhibit hypogastric sympathetic nerve -> no relaxation of destrusor muscle AND signal back from spinal cord via pudendal nerve via S2-4 to relax urethral sphincter -> empty bladder
Outline the principles of filling cystometry including the variables measured and aim of the test. (4 marks)
Parameters measured:
1. Bladder pressure (pves)
2. Abdominal pressure (pabd) - via rectal or vaginal probed
3. Detrusor pressure (pdet) calculate by substracting pabd from pves = pdet
Bladder filled naturally or by pump with normal saline and pressures measured.
Also show bladder compliance (pressure related to capacity); large rise in bladder pressure relative to bladder capacity = low compliance.
Gives relationship between intravesical pressure to subjective urge to void, first sensation of urgency, pressure with Valsalva and pressure at which there is incontinence.
Aim of test is to diagnosed detrusor overactivity and urodynamic stress incontinence.
c. A 60 year old patient is referred to you complaining of urinary frequency, urgency and urge incontinence. Physical examination is normal and an MSU is negative.
Describe in detail the management options available for her. (7 marks)
Elicit symptoms Exclude UTI symptoms Effect on QOL Urinary incontinence symptoms Medical history – diabetes, spinal cord injury, neurological conditions Meds Previous surgery Constipation Vaginal bleeding
O/E: POP-Q Pelvic exam – astrophic changes Pressure test – leak on valsalva Urine cytology – exclude bladder cancer
Management:
- Conservative: weight loss, diet, exercise, PFE
- Bladder diary
- Bladder retraining
- Reduce bladder irritants – caffeine, alcohol
- Oestrogen
- UDS
- ACE-I, beta agonist and their side effects
- TCA
- Botox – paralyse detrusor muscle, need to fail 2x medical options, may need repeats
- Sacral nerve stimulation
