Urogynae Flashcards
What are the different types of incontinence
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
Risk factors for incontinence
Multiple pregnancies
Obese
Fhx
Hysterectomy
Age
What is urge incontinence the same as
Overactive bladder
What causes OAB/urge incontinence
Detrusor overactivity
How should incontinence be investigated
Bladder diary for 3 days
Vaginal exam to assess for organ prolapse and ability yo initiate contraction of pelvic floor muscles
Dipstick
If in investigation for incontinence dipstick comes back positive for leukocytes and nitrites what do
Treat for UTI
Take MSU
If in investigation for incontinence dipstick comes back negative for leukocytes and nitrites but symptoms indicative what do
Treat UTI
Take MSU
Management of incontinence
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
Management of stress incontinence
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
MOA of duloxetine
Combined noradrenaline and SSRI
Increased firing of pudendal nerve which stimulates muscle in the sphincter
Surgical options for stress incontinence
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
Management of urge incontinence
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
Why cant use oxybutynin in an old frail person
Cognitive impacts
How can incontinence be further investigated
Urodynamic testing
Causes of overflow incontinence in a woman
Neurogenic from DM
Alcoholics
Surgery to pelvic area
In who are urine dips useless
Over 65
Catheter
When are urodynamic studies indicated
Diagnostic uncertainty or pre surgery
When are vesicovaginal fistulas suggested
Prolonged labour
Recent childbirth
Coming from a country with poor obstetric services
Lots of pelvic surgeries
How are vesicovaginal fistulas investigated
Urinary dye studies
Presentation of prolapses
Sensation of heaviness
Urinary sx- incontinence, frequency, urgency
What happens in vaginal vault prolapse
Top half of vagina falls down- common after hysterectomy
How does bartholins cyst present
Posterior labia mass
Redness around the area
Discomfort while walking or having sex
How are bartholins cysts managed
If symptomatic then marsupalisation which involves drainage and suturing inner wall of bartholins gland to the skin
Second line for a bartholins cyst
Surgical excision of bartholins gland however can lead to vulvar dryness and itching
What is a sitz bath
A shallow warm bath
What are the types of prolapse
Cystocele
Rectocele
Uterine prolapse
What is first line management of symptomatic organ prolapses
Lifestyle including losing weight
Physiotherapy for 16 weeks
Can assess if need vaginal oestrogen for vaginal dryness
Second line for symptomatic organ prolapses
Ring pessary
Surgical management of cystocele
Anterior wall repair (anterior colporrhaply)
Surgical management of rectocele
Posterior wall repair (posterior colporrhaply)
Surgical management options for uterine prolapse
Manchester repair- shorten cervix
Vaginal hysterectomy
Vaginal sacrospinous hysteropexy- attaches cervix to sacrospinal ligament
Sacro hysteropexy- attach uterus to sacral bone
How can cystocele present
Urinary symptoms
Recurrent UTIs
Fullness feeling
How can rectocele present
Problems defaecating
Sense of fullness
Feeling of not fully emptying bowels
Most common incontinence in women
Stress
How are prolapses classified
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
What is a urethrocele
When get descent of anterior part of vagina which attaches to urethra
Operations for vaginal vault prolapse
Sacrocolpopexy with mesh
Vaginal sacrospinous fixation with sutures
What is management of bartholins abscess
Abx- doxycycline
Marsupialisation
What are non-surgical interventions for urge incontinence
Botulinum A toxin injection however need self catheterisation
Percutaneous sacral nerve stimulation
What position on vagina are bartholins cysts
4 and 8 o’clock
How are suspected prolapses examined
With Sims speculum
When operate on a prolapse immediately
If very symptomatic and severe
In developed world what is most common cause of vesicovaginal fistulas
Pelvic surgeries
Cause of urine coming from the vagina
Vesico-vaginal fistula
Difference between enterocele and rectocele on examination
Rectocele if do a digital exam the finger will protrude against the vaginal wall
If frail and old what use after bladder retraining in urge incontinence
Non-oxybutynin anticholinergic like tolterodine or mirabregon
Most suitable operation for uterine prolapse if wanting to perserve fertility
Vaginal sacrospinous hysteropexy or sacro hysteropexy
What do for asymptomatic bartholins cysts
Warm compress and sitz baths
Incontinence when is burning on urinating and pallor of vulva
Vaginal atrophy
