Urogynae Flashcards
Indications for urodynamics
Failure of conservative management for urge urinary incontinence
Prior to any surgical procedure for urinary incontinence (unless clearly pure SUI with no symptoms of OAB or prolapse which is only 5% of urogynae population)
Any previous anterior compartment or incontinence surgery
Symptoms suggestive of voiding dysfunction
Symptoms suggestive of overflow incontinence
Neurological symptoms
Severe prolapse prior to surgery esp if pre- existing urinary incontinence
Definition of overactive bladder syndrome
Urgency + daytime frequency +/- nocturia +/- urinary incontinence
Urgency definition
A sudden compelling desire to void which is difficult to defer
Urge urinary incontinence
Incontinence accompanied by or immediately preceded by urgency
Urodynamic stress incontinence definition
Urodynamic diagnosis
Involuntary leakage provoked by increased intra- abdominal pressure and in the absence of increased detrusor contraction during filling cystometry
Detrusor overactivity definition
Urodynamic diagnosis
Involuntary detrusor contraction during filling cystometry which may be provoked or spontaneous
Things to do prior to urodynamics
Rule out UTI
Stop anticholinergics 10 days prior
Check compliance with conservative measures
Check bladder diary
Tell me about uroflowmetry
Measurement of flow rate over time
Woman voids in a commode that funnels urine into a device that measures flow rate over time
Looks at:
- max flow rate
- average flow rate
- total volume voided (must be >150ml to be interpretable)
This helps to diagnose or exclude voiding difficulties
You then look at post- void residuals with bladder scan or in + out catheter
Tell me about cystometry
Measure of the pressure- volume relationship of the bladder during filling and voiding.
Fluid (water/ saline) is infused into the bladder via a catheter.
Catheter in bladder measures intravesical pressure.
Catheter into rectum or vagina to measure IAP.
Detrusor pressure Pdet= Pves - Pabd
Assess:
- bladder sensation
- bladder capacity
- detrusor activity and compliance
- sphincter competence
- urine leakage
Do some provocative tests like coughing or wash hands
Aims to diagnose detrusor overactivity or urodynamic stress urinary incontinence
Voiding phase: pressure- flow study
- high pressure voiding= obstruction
- low pressure voiding = detrusor hypo- contractility
Pressure- flow studies
Pt voids while pressure transducer is still in
Relationship between pressure in the bladder and urine flow during emptying = detrusor contractility
Urethral pressure profile
Measures urethral closure pressure= bladder pressure- urethral pressure
Normally, urethra closure pressure is maintained during filling even with increased IAP.
Leakage occurs when bladder pressure exceeds urethral pressure
Clinical value is unknown
Leak point pressures
The bladder pressure at which leakage occurs.
Abdominal leak point pressure- the intravesicular pressure at which leakage occurs due to increased abdominal pressure in the absence of detrusor contraction. Provoked by coughing/ position change
Detrusor leak point pressure- the intravesicular pressure at which leakage occurs due to a detrusor contraction in the absence of increased abdo pressure. Provoked by running water/ visual cues.
A low abdo leak point pressure (<60) can be associated with intrinsic sphincter deficiency
Videocystourethrography
Combines cystometry with contrast as filling fluid, with radiological assessment of the bladder and urethra
Anatomical and functional features can be reviewed simultaneously.
Use in patients with neuro conditions or suspected bladder neck opening reflux or fistula
Normal post void residual
< 100ml
Intrinsic sphincter deficiency
Urodynamic diagnosis
ALPP < 60 cmH2O
MUCP < 20 cm H2O
Anticholinergics for OAB
M2 and M3 main urinary receptors. M3 responsible for detrusor contraction.
MOA:
- reduce uninhibited detrusor contractions
- reduce intravesicular pressure
- therefore increased volume threshold
CI:
- myasthenia gravis
- closed angle glaucoma
- tachy arrhythmia
Some evidence that increases risk of dementia with exposure from 1- 11 years
Beta- 3 adrenoreceptor agonist (Betmiga)
Promotes detrusor relaxation and increases stability during bladder storage.
Decreases number of voids and incontinence episodes compared to placebo
CI:
- severe uncontrolled HTN
- severely reduced liver function
- pregnancy
- breastfeeding
- < 18 yo
Caution with:
- prolonged QT interval
What is the vaginal mesh exposure rate?
2%
Level 1 pelvic organ support
Uterosacral and cardinal ligaments
Vertical suspension of the uterus, cervix and vagina
Supports the upper 1/3 of the vagina and cervix
Level 1 defects lead to apical descent
Level 2 pelvic organ support
Paravaginal fascia (part of the endopelvic fascia) which connects the vagina to the white line or arcus tendinuos fascia pelvis (ATFP) which is the origin of the levator ani muscles
Supports the upper 2/3 of the vagina and rectum
Level 2 defects lead to cystocele
Level 3 pelvic organ support
Fusion of the vaginal endopelvic fascia to the:
- perineal body posteriorly
- levator ani muscles laterally
- urethra anteriorly
Supports the lower 1/3 of vagina, urethra and anal canal
Level 3 defects lead to rectocele, urethral hypermobility and SUI
Prolapse stage
Stage 0: Aa, Ba, Ap, Bp = -3cm and C or D </= (tvl- 2) cm
Stage 1: leading edge of prolapse at or < -1cm
Stage II: leading edge at or > +1cm
Stage III: leading edge is > 1cm but without complete eversion
Stage IV: complete vaginal eversion
Ideal patient for conservative management of prolapse
Mild to moderate prolapse/ symptoms
Not completed family
Frail patients
Women wishing to avoid/ delay surgery
Women not fit for surgery
POPPY Trial for prolapse
One- to- one PFMT vs pamphlet giving lifestyle advice only.
Mostly stage I- II prolapse
Outcome: PFMT reduced symptoms of POP but does not alter severity/ stage of prolapse
PREVPROL RCT 2015 for POP
One- to- one PFMT (over 16 weeks) + Pilates based PFMT classes + a DVD for home use vs a prolapse lifestyle advice leaflet
Results:
- significantly improved POP sx at 1 and 2 years.
- Prolapse related QOL did not differ significantly between groups over 2 years but the intervention group sought less further treatment over 2 years
