Urogynae

Question 1

What are the different types of incontinence

Answer 1

Stress- leak after coughing etc
Urge- bladder suddenly feels full and then leak
Mixed- combination of stress and urge
Functional- due to dementia, immobility etc
Overflow- from bladder outlet obstruction

Question 2

Risk factors for incontinence

Answer 2

Multiple pregnancies
Obese
Fhx
Hysterectomy
Age

Question 3

What is urge incontinence the same as

Answer 3

Overactive bladder

Question 4

What causes OAB/urge incontinence

Answer 4

Detrusor overactivity

Question 5

How should incontinence be investigated

Answer 5

Bladder diary for 3 days
Vaginal exam to assess for organ prolapse and ability yo initiate contraction of pelvic floor muscles
Dipstick

Question 6

If in investigation for incontinence dipstick comes back positive for leukocytes and nitrites what do

Answer 6

Treat for UTI
Take MSU

Question 7

If in investigation for incontinence dipstick comes back negative for leukocytes and nitrites but symptoms indicative what do

Answer 7

Treat UTI
Take MSU

Question 8

Management of incontinence

Answer 8

Recommend less fluids and caffeine
Ascertain whether urge, stress or if mixed what is the predominant one
If stress, pelvic contractions 3x a day with 8 contractions for 3 months
If urge/predominant, bladder training for 6 weeks

Question 9

Management of stress incontinence

Answer 9

Pelvic floor training for 3months, 3x a day 8 contractions
Second line- offer surgical options. First line colposuspension or autologous rectal fascial sling
If decline these or not appropriate then offer duloxetine

Question 10

MOA of duloxetine

Answer 10

Combined noradrenaline and SSRI
Increased firing of pudendal nerve which stimulates muscle in the sphincter

Question 11

Surgical options for stress incontinence

Answer 11

Colposuspension- lift neck of bladder up and stitch it
Retro-pubic mid-urethral mesh sling- sling is placed behind the urethra to lift it up
Autologous rectus fascial sling- sling is placed behind the urethra to lift it up made out of tissue from abdominal fascia

Question 12

Management of urge incontinence

Answer 12

First line- bladder training for 6 weeks
Second line- anti-muscarinics like oxybutinin unless frail and old
If oxybutynin CI then use mirabregon a beta 3 agonist

Question 13

Why cant use oxybutynin in an old frail person

Answer 13

Cognitive impacts

Question 14

How can incontinence be further investigated

Answer 14

Urodynamic testing

Question 15

Causes of overflow incontinence in a woman

Answer 15

Neurogenic from DM
Alcoholics
Surgery to pelvic area

Question 16

In who are urine dips useless

Answer 16

Over 65
Catheter

Question 17

When are urodynamic studies indicated

Answer 17

Diagnostic uncertainty or pre surgery

Question 18

When are vesicovaginal fistulas suggested

Answer 18

Prolonged labour
Recent childbirth
Coming from a country with poor obstetric services
Lots of pelvic surgeries

Question 19

How are vesicovaginal fistulas investigated

Answer 19

Urinary dye studies

Question 20

Presentation of prolapses

Answer 20

Sensation of heaviness
Urinary sx- incontinence, frequency, urgency

Question 21

What happens in vaginal vault prolapse

Answer 21

Top half of vagina falls down- common after hysterectomy

Question 22

How does bartholins cyst present

Answer 22

Posterior labia mass
Redness around the area
Discomfort while walking or having sex

Question 23

How are bartholins cysts managed

Answer 23

If symptomatic then marsupalisation which involves drainage and suturing inner wall of bartholins gland to the skin

Question 24

Second line for a bartholins cyst

Answer 24

Surgical excision of bartholins gland however can lead to vulvar dryness and itching

Question 25

What is a sitz bath

Answer 25

A shallow warm bath

Question 26

What are the types of prolapse

Answer 26

Cystocele Rectocele Uterine prolapse

Question 27

What is first line management of symptomatic organ prolapses

Answer 27

Lifestyle including losing weight Physiotherapy for 16 weeks Can assess if need vaginal oestrogen for vaginal dryness

Question 28

Second line for symptomatic organ prolapses

Answer 28

Ring pessary

Question 29

Surgical management of cystocele

Answer 29

Anterior wall repair (anterior colporrhaply)

Question 30

Surgical management of rectocele

Answer 30

Posterior wall repair (posterior colporrhaply)

Question 31

Surgical management options for uterine prolapse

Answer 31

Manchester repair- shorten cervix Vaginal hysterectomy Vaginal sacrospinous hysteropexy- attaches cervix to sacrospinal ligament Sacro hysteropexy- attach uterus to sacral bone

Question 32

How can cystocele present

Answer 32

Urinary symptoms Recurrent UTIs Fullness feeling

Question 33

How can rectocele present

Answer 33

Problems defaecating Sense of fullness Feeling of not fully emptying bowels

Question 34

Most common incontinence in women

Answer 34

Stress

Question 35

How are prolapses classified

Answer 35

Pelvic organ prolapse quantification 1- descent of uterus and cervix but doesnt reach introitus 2- cervix reaches introitus 3- protrusion outside of vagina 4- complete prolapse which may lead to cervical ulceration

Question 36

What is a urethrocele

Answer 36

When get descent of anterior part of vagina which attaches to urethra

Question 37

Operations for vaginal vault prolapse

Answer 37

Sacrocolpopexy with mesh Vaginal sacrospinous fixation with sutures

Question 38

What is management of bartholins abscess

Answer 38

Abx- doxycycline Marsupialisation

Question 39

What are non-surgical interventions for urge incontinence

Answer 39

Botulinum A toxin injection however need self catheterisation Percutaneous sacral nerve stimulation

Question 40

What position on vagina are bartholins cysts

Answer 40

4 and 8 o'clock

Question 41

How are suspected prolapses examined

Answer 41

With Sims speculum

Question 42

When operate on a prolapse immediately

Answer 42

If very symptomatic and severe

Question 43

In developed world what is most common cause of vesicovaginal fistulas

Answer 43

Pelvic surgeries

Question 44

Cause of urine coming from the vagina

Answer 44

Vesico-vaginal fistula

Question 45

Difference between enterocele and rectocele on examination

Answer 45

Rectocele if do a digital exam the finger will protrude against the vaginal wall

Question 46

If frail and old what use after bladder retraining in urge incontinence

Answer 46

Non-oxybutynin anticholinergic like tolterodine or mirabregon

Question 47

Most suitable operation for uterine prolapse if wanting to perserve fertility

Answer 47

Vaginal sacrospinous hysteropexy or sacro hysteropexy

Question 48

What do for asymptomatic bartholins cysts

Answer 48

Warm compress and sitz baths

Question 49

Incontinence when is burning on urinating and pallor of vulva

Answer 49

Vaginal atrophy