urogynae

Question 1

out of the following which is the most common cause of urinary incontinence

a) OAB
b) stress incontinence
c) overflow incontinence
d) mixed incontinence

Answer 1

b) stress incontinence (37%)
then mixed 33% and then urge 22%

Question 2

what type of urinary incontinence is the following definition describing:

“involuntary bladder SM contraction of the detrusor muscles during the filling phase that can be provoked or unprovoked”

a) Urge incontinence
b) stress incontinence
c) overflow incontinence
d) mixed incontinence

Answer 2

a) urge incontinence = OAB = detrusor muscle overactivity

Question 3

what type of urinary incontinence is the following definition describing:

“involuntary leakage of urine during increases in intra-abdominal pressure in the absence of detrusor contraction”

a) Urge incontinence
b) stress incontinence
c) overflow incontinence
d) mixed incontinence

Answer 3

b) stress incontinence

Question 4

what are the some of the causes of overactive bladder

Answer 4

detrusor muscle overactivity can be due to:-

main risk factor = increasing age (rises in middle age, plateaus age 50-70, then rises again)

often idiopathic

neurological: MS, parkinsons, DM, spinal cord injury

co-morbidities increase risk: obesity, type 2 DM

medications: parasympathethetics (as stimulation of this nerve makes us Pee) aceytlcholine, anti-depressants

can be exacerbated by alcohol, caffeine, acidic fruit drinks

Question 5

what are some of the causes/contributing factors to causing stress incontinence

Answer 5

age
obesity
smoker= chronic cough
multiparty with vaginal deliveries
constipation
drugs that cause chronic cough e.g. ace inhibitors

damage to integrity of pelvic floor muscles e.g. hysterectomy, PMW low oestrogen, a/s with prolapse

Question 6

Sonia comes to clinic complaining of having to strain to wee and feeling as though she is unable to empty her bladder fully. What type of urinary incontinence could be causing her symptoms

Answer 6

overflow incontinence; due to detrusor muscle inactivity or bladder outflow obstruction

Question 7

what are some of the causes of overflow urinary incontinence

Answer 7

a/s with neurological conditions
medications that decrease detrusor muscle contractility:-

ACE inhibitors
Antidepressants
Antihistamines
Antimuscarinics
Antiparkinsonian drugs
Beta–adrenergic agonists (e.g. salbutamol)
Calcium channel blockers
Opioids
Sedatives & hypnotics

Question 8

Sue comes to clinic complaining of a constant need to urinate. She denies any features of urgency or stress incontinence, has a normal BMI and non-smoker. what type of urinary incontinence do you think she is describing

Answer 8

continuous incontinence can be due to severe overflow incontinence (detrusor under-activity) or a fistula

Question 9

out of the following list of anti cholinergic used in treatment of OAB which are non selective:-

A) oxybutynin
b) tolterodine
c) solifenacin
d) Propiverine
e) Trospium
f) Fesoterodine

Answer 9

non selective (remember the Ts and Ps)

= b) tolterodine
d) propiverine
e) trospium

Question 10

out of the following list of anti cholinergic used in treatment of OAB which are selective selective:-

A) oxybutynin
b) tolterodine
c) solifenacin
d) Propiverine
e) Trospium
f) Fesoterodine

Answer 10

selective - a, c, f

Question 11

out of the following list of anti cholinergic used in treatment of OAB which would you avoid in elderly females and why?

A) oxybutynin
b) tolterodine
c) solifenacin
d) Propiverine
e) Trospium
f) Fesoterodine

Answer 11

a) oxybutynin due to effect on cognitive impairment –> falls risk

Question 12

what assessment model can be used to assess pelvic floor muscle strength? briefly describe

Answer 12

modified oxford grading system (scoring system of 0-5)

0= no pelvic floor strength, no contraction
5= strong pelvic floor strength, good contraction

Question 13

how can you assess the severity of urinary incontinence

Answer 13

bladder diary for 3 DAYS (3 days important bit), ensuring it covers variation in days e.g. work/home life etc

Question 14

what are some of the lifestyle interventions you should suggest to someone with urinary incontinence

Answer 14

reduce BMI < 30
reduce caffeine, alcohol intake, reduce fluid intake
smoking cessation

(note these are the same for stress and urinary incontinece)

Question 15

when should we consider doing urodynamics

Answer 15

avoid if obvious stress incontinence

can do if urge incontinence (OAB), or mixed, unsure
- previous surgery for stress incontinence
- anterior or apical prolapse
- symptoms of voiding dysfunction

Question 16

what is the first line management in urge incontinence (OAB) once lifestyle modifications

Answer 16

supervised bladder retaining for minimum 6 weeks

( if no improvement after 6 weeks then consider pharmacological management)

Question 17

what is first line pharmacological management in OAB

Answer 17

antimuscarinics/anticholinergics - bind to M3 receptor on the bladder detrusor muscle and block action of acetylcholine leads to relaxation of detrusor muscle.

(remember parasympathetic = peeing, pelvic splanchnic nerves s2-s4, release Ach that bind to M3 receptors in bladder muscle - causes contraction –> peeing)

use one with the lowest cost e.g. oxybutynin, tolterodine, darifenacin

Question 18

how long does it take for anticholinergics to work and what are common SE

Answer 18

can take up to 4 weeks to work
dry mouth, constipation, dry eyes, impairment in cognition

Question 19

if anticholinergics don’t work or CI what is the second line pharmacological management for OAB (urge incontinence)

Answer 19

mirabegron - selective B3 agonist

Question 20

what nerve and neurotransmitter are responsible for micturition?

Answer 20

parasympathetic nerves specifically pelvic splanchnic nerves (s2-s4), release acetylcholine that bind to M3 receptors in the bladder and cause contraction of the detrusor muscle –> peeing

Question 21

If prescribing an anticholinergic to treat OAB (urge incontinence) when should you review the patient? what would you warn them re SE

Answer 21

SE can indicate the drug is starting to work!
review everyone at 4 weeks to assess efficacy/ SE and consider titrating or switching alternative or referral to secondary care etc.

Question 22

what is the longterm f.u for patients established on anticholinergic treatment for OAB

Answer 22

annual review, unless >75 years then 6 monthly

Question 23

in a post menopausal woman with urinary incontinence and vaginal atrophy what could you consider prescribing

Answer 23

vaginal oestrogen e.g. estring (vaginal ring used for 3 months continuous release of oestrogen), review annually

Question 24

for patients with troublesome nocturia symptoms what pharmacological adjunct could be prescribed? what populations would you avoid

Answer 24

desmopressin (avoid in over 65 year olds, known hyponatraemia or hypertension, CVD)

Question 25

what is the advice regarding urine aids/ pads etc

Answer 25

advised not to use as a treatment but can be used as an aid whilst a/w Rx/ assessment. If using review annually to assess skin integrity etc

Question 26

if pharmacological methods fail to improve symptoms of urge incontinence (OAB) then referral to secondary care is indicated. What options would be considered there?

Answer 26

botox injections into bladder wall - botulinum toxin A blocks acetylcholine release
percutaneous sacral nerve stimulation
augmentation cystoplasty ( uses part of bowel to make the bladder bigger!)
urinary diversion

Question 27

after lifestyle measures what is the next step in management of stress incontinence (urinary leakage on coughing/exercise)

Answer 27

pelvic floor physio for minimum trial of 3 months

(minimum of 8 contractions three times a day)

squeezy app

Question 28

Lydia has been completed 3 months of pelvic floor training with pelvic physios but hasn’t seen a huge improvement in her stress incontinence symptoms. What is the next step

Answer 28

refer to urogynae (secondary care referral) consider surgical options

Question 29

what are the surgical options for stress incontinence

Answer 29

colposuspension
rectal sheath sling
bulking agents

Question 30

if a patient declines surgical options for stress incontinence what is a second line pharmacological option that could be considered

Answer 30

duloxetine (SNRI)- increases contraction of the urethral sphincter

Question 31

what is the name of the grading system used for assessment of pelvic organ prolapse

a) DSRP
b) ROME III
c) POP P
d) POP Q

Answer 31

d) POP Q

Question 32

when should you consider imaging in management of prolapse

Answer 32

if urinary symptoms with prolapse and considering surgery
pain
symptoms not explained by examination findings
symptoms of obstructive defecation or faecal incontinence

Question 33

what type of prolapse might be found in each anatomical landmark

Anterior

Posterior

Central

Procidentia

Answer 33

anterior = cystocele or urethrocele
posterior = rectocele or enterocele

central: vault prolpapse, uterine prolpase

procidentia: prolapse of the apical, anterior and posterior vaginal components through the introitus

Question 34

describe the POP Q assessment of pelvic organ prolapse

Answer 34

Stages 0 - 4, as stage increases to 4 = increase in decent of the prolapse beyond the hymen and introitus

stage 0 = no prolapse/decent of pelvic organs

stage 1 = prolapse is > 1cm superior to the level of the hymen

stage 2 = prolapse is within 1cm of the hymen

stage 3 = prolapse is >1cm below level of the hymen but not protruding > 2cm below level of total vaginal length

stage 4 = complete eversion = procidentia

Question 35

name the first stage of lifestyle interventions that can be used to help prolapse symptoms

Answer 35

decrease weight <30kg/m2
treat constipation
avoid excessive straining/heavy lifting

Question 36

if the prolapse demonstrates signs of atrophy what topical treatment could you use

Answer 36

topical oestrogen

Question 37

what is the first line treatment of stage 1 or 2 prolapse

Answer 37

pelvic floor training for at least 16 weeks

Question 38

name the mainstay of treatment (non-pharmacological) used in the management of prolapse excluding surgical options

Answer 38

pessaries - need to be changed every 6 months to avoid complications
consider impact on sex (can still have sex with a ring pessary)
can be used in conjunction with pelvic floor training

Question 39

what is the next step in management of prolapse if pessaries and pelvic floor training don’t improve symptoms

Answer 39

surgical management

• Manchester repair (uterine saving)
• hysterectomy + sacrospinous fixation
  -Vaginal sacrospinous hysteropexy with sutures (uterus preserving)