Urogynae Flashcards
Pelvic floor muscle training for SUI.
Treatment vs no treatment:
1. Subjective cure rates
2. Objective cure rates
3. Reductions in leakage episodes
- Subjective cure rates 16-56% vs 3%
- Objective cure rates (1 hour pad test or negative stress test) 44-65% vs 0-7%
- Reductions in leakage episodes 54-72% vs 6%
First line treatment for women with stress or mixed urinary incontinence?
Pelvic floor muscle training for at least 3 months.
8 contractions performed at least 3x/day.
PFMT is more cost effective than duloxetine alone, as first line treatment for stress urinary incontinence.
Is there any additional benefit in pelvic floor muscle training in women undergoing treatment with tolterodine for OAB?
No additional benefit conferred.
Urinary incontinence occurs in what % of women post partum?
17-32%
Surgery for SUI?
If non surgical management has failed, and the woman wishes to think about a surgical procedure, offer:
- Colposuspension (open or laparoscopic)
- An autologous rectus fascial ring
Also include option of retro pubic mid-urethral sling in this choice.
Consider intramural bulking agents if alternative surgical procedures are not suitable or acceptable.
Mid urethral mesh sling procedures.
Use a device manufactured from?
Type 1 macroporous polypropylene mesh.
Consider using a mesh sling coloured for high visibility, for ease of insertion and revision.
Procedures that should NOT be offered to treat stress urinary incontinence?
- Anterior colporrhaphy
- Needle suspension
- Paravaginal defect repair
- Porcine dermis sling
- Marshall-Marchetti-Krantz procedure
Biological and synthetic materials available for use as urethral bulking agents?
- Silicone
- Hyaluronic acid/dextran copolymer
- Carbon coated zirconium beads
- Polytetrafluroethylene
Urethral bulking agents - NICE recommendations?
Consider for the management of SUI if conservative management has failed.
Women should be made aware that:
1. Repeat injections may be needed to achieve efficacy
2. Efficacy diminishes with time
3. Efficacy is inferior to that of synthetic tapes or autologous recurs fascial slings
Detrusor over activity, define.
Occurrence of uncontrolled spontaneous contraction of detrusor muscle filling, or on provocation, while the patient is trying to inhibit micturition.
Diagnosis made at filling cystometry:
1. Rise in detrusor pressure of > 15cm H2O
2. Rise in detrusor pressure of < 15cm H2O in the presence of urgency or urge incontinence
OAB - conservative treatments
- Lifestyle change - clothing/ location of toilet, reduction of caffeine, modification of meds eg, diuretics
- Weight loss if BMI > 30
- Bladder training for 6 weeks
- up to 90% become continent compared to 23% in control group
OAB - medical management considerations
- Oxybutinin - caution in older women
Offer Transdermal OAB treatment for women unable to tolerate oral medicines.
- Desmopressin - can reduce nocturia in women with urinary incontinence or OAB. Caution in women with CF and those > 65 with CVD or HTN.
- Do not use duloxetine as first like in women with prominent stress urinary incontinence.
- Offer intravaginal oestrogen to treat OAB symptoms in postmenopausal women with vaginal atrophy.
OAB - Medical management
- Oxybutinin (IR)
- Tolterodine (IR)
- Darifenacin (once daily preparation)
Oxybutinin - side effects?
- Nausea, constipation, diarrhoea and abdominal discomfort
- Dry mouth (88%)
- Blurred Vision
- Voiding difficulties
- Headache, dizziness, drowsiness, restlessness and disorientation
- Rash, dry skin, photosensitivity
- Arrhythmia
- Angioedema
Darifenacin - who to offer to for OAB treatment ?
Darifenacin has the least confusion type side effects and is recommended for the elderly with dementia.
It is also taken once daily.
Botulinum toxin A for OAB
- Potent neurotoxin derived from the bacterium Clostridium Botulinum
- Two strains are available for clinical
Use - A and B - Blocks the release of acetylcholine and temporarily paralyses any muscle into which it is injected
- Injected directly into bladder wall - flex or rigid cystoscope under LA or GA
Percutaneous Sacral Nerve Stimulation (P-SNS)
- Electrical stimulation of the sacral reflex pathway will inhibit the reflex behaviour of the bladder and reduce detrusor over activity
- chronic stimulation to S3 nerve roots
The Urge Syndrome
- Symptoms
- Causes
Symptoms:
Urinary frequency, urgency, urge incontinence and nocturia.
Causes:
- Extra-Vesical:
a. Diabetes mellitus/Insipidus
b. Large fluid intake
c. Pelvic mass
d. Diuretic therapy
e. Pregnancy
f. Hypothyroidism
g. Chronic renal failure - Sensory:
Hypersensitivity of the bladder mucosa and or urethra causing a constant desire to void which is not relieved by voiding.
UTI commonest cause.
Other causes include bladder calculus.
Normal cystometric parameters:
1. Bladder capacity
2. First sensation to void
3. Rise in detrusor pressure
4. Voiding detrusor pressure
5. Peak urine flow rate
6. Residual volume
Normal cystometric parameters:
1. Bladder capacity 400-600ml
2. First sensation to void 150-250ml
3. Rise in detrusor pressure < 15cmH2O
4. Voiding detrusor pressure < 70cmH2O
5. Peak urine flow rate > 15ml/sec
6. Residual volume < 50ml
Cholinergic receptors of the bladder
5 muscarinic receptor subtypes (M1 to M5)
Bladder has mainly M1, M2 (80%) and M3 (20%). But only M3 responsible for the parasympathetic detrusor contraction.
M3 receptors of the bladder are found in smooth muscle and glands.
Stimulation of M3 receptors with acetylcholine causes the release of IP3 and calcium which leads to muscle contraction.
Fowler’s Syndrome
A complete urinary retention with specific EMG activity recorded with a concentric needle electrode from the striated urethral sphincter, in you d women with clinical features of PCOS.
Clinical features:
- women of reproductive age, 3rd decade
- no evidence of Gynae, neuro or urological disease
- urinary retention with volumes > 1000ml
- no sense of urinary urge despite large volumes
- associated with PCOS and Endometriosis
Investigations:
- cystometry
- Detrusor under activity
- urethral pressure profilometry
- urethral US
Treatment:
1. Sacral neuro modulation (S3) - only treatment found to restore voiding
2. Botulinum toxin into urethral sphincter
Duloxetine
1. Mode of action
2. Uses
3. SE’s
Duloxetine 40mg BD
- Combined serotonin. (5HT) and noradrenaline re uptake inhibitor
- increased synaptic contractions of noradrenaline and 5HT within the pudendal nerve results in increased stimulation of the urethral sphincter
SE:
1. GI disturbance, nausea and dry mouth
2. Headache, decreased libido, anorgasmia
Contraindications of Duloxetine?
- Pregnancy, lactation
- Hepatic impairment
- lowers seizure threshold therefore avoid in epilepsy
- can enhance anti coagulant effects of warfarin
- metabolised by the same enzymes as ciprofloxacin and fluvoxamine - avoid co prescription
- avoid co prescription with SSRIs and tricyclic antidepressants
NICE Recommendations for Duloxetine
NOT recommended as a first line treatment for women with prominent stress incontinence.
NOT routinely used as a second line treatment for women with stress incontinence.
May be offered as second line therapy if women prefer pharmacological to surgical treatment.
Mirabegron
1. MOA
2. Uses
3. SE
4. CI
- B3 adrenoreceptor agonist
- Acts by enhancing bladder relaxation during the storing phase of micturition - Safe and effective treatment of OAB
- SE: Tachycardia, UTI
- Uncontrolled Hypertension
Mirabegron Drug Interactions
Clarithromycin
Digoxin
Itraconazole
Metoprolol
Ritonavir
POP-Q staging for POP
Stage 0: No descent of pelvic structures during straining
Stage 1: Leading edge of the prolapse is >1cm above the hymenal ring
Stage 2: Leading edge of the prolapse extends from 1cm above the hymen to 1cm below the hymenal ring
Stage 3: Leading edge of the prolapse extends 2-3cm below the hymenal ring, but there is not complete vagina eversion
Stage 4: Vagina is completely everted
Post hysterectomy vault prolapse followed what % of hysterectomies performed for :
1. Prolapse
2. Benign Disease
- Prolapse - 11.6%
- Benign disease - 1.8%
Prevention of post hysterectomy vault prolapse during Hysterectomy?
McCall Culdoplasty at the time of VH
Suturing the cardinal and uterosacral ligaments to the vaginal cuff at the time of hysterectomy is effective in preventing PHVP following both abdominal and vaginal hysterectomies.
Sacrospinous fixation (SSF) at the time of vaginal hysterectomy should be considered when the vault descends to the introitus during closure.
Management of vaginal vault prolapse - open abdominal sacrocolpopexy vs SSF?
- Both are effective treatments for PHVP
- ASC - lower rates of recurrence, dyspareunia and postoperative SUI
- SSF may not be appropriate in women with short vaginal length
Abdominal Sacrocolpopexy
Involves apical suspension of the vault with a permanent mesh fixed to the longitudinal ligament of the Sacrum.
Long term success rates 78 - 100%
Complications: bowel injury, sacral myelitis and severe bleeding - 2%
Sacrospinous Fixation
Unilateral anchoring of the vaginal vault to the sacrospinous ligament. Can be done bilaterally.
8-30% risk of anterior compartment prolapse with SUI.
18% risk of post op buttock pain.
Pudendal nerve injury reported
SSF sutures should be placed 1.5 - 2cm medial to the ischial spines
Most commonly injured vessel in SSF?
Inferior Gluteal Artery
Risk of mesh erosion?
2 - 7%
The probability of a woman becoming continent with bladder re training is?
Up to 90%
The relapse rate within 3 years of successful bladder retraining is?
40%
Open colposuspension is associated with ? continence rates at 5 years?
70 - 80%
Which receptor sub types have been shown to be present in the human bladder?
Beta 1
Beta 2
Beta 3
Using the POP-Q score post hysterectomy vault prolapse is defined as?
Descent of point C
During an abdominal scar colpopexy, the vaginal vault is attached to?
Using?
The anterior longitudinal ligament using non absorbable mesh
Which is a recognised complication of McCall Culdoplasty?
Ureteric Injury
Proportion of women with pelvic organ prolapse?
10 - 20%
Mesh related complications should be reported to?
MHRA - Medicines and healthcare products regulatory agency
Oxybutinin contraindications?
Avoid in:
1. Frail, elderly patients
2. Severe UC
3. Narrow angle glaucoma
4. Hepatic or renal impairment
5. Myasthenia Gravis
6. Coronary Heart Disease/CCF
7. Hyperthyroidism
Which cholinergic receptors are mainly responsible for parasympathetic detrusor muscle contraction?
M3
Management of mesh exposure <1cm3?
Topical Oestrogen Cream.
Consider complete to partial removal of vaginal mesh in women:
1. Who do not want treatment with topical oestrogen
2. If the area is 1cm3 or larger
3. No response to non surgical treatment after a period of 3 months
Most frequently occurring risk of SSF?
Recurrence of anterior compartment prolapse - 8 - 30%
Normal Cystometric Values:
1. Residual volume
2. FDV (first desire to void) between
3. Bladder Capacity
4. Detrusor pressure rise on filling
5. Normal flow rate
- < 100ml
- 150-250ml
- 400-600ml
- <3cm/100ml
- > 15ml/sec
No detrusor contraction during filling.
No leakage on coughing.
No detrusor contraction on provocation.
Urodynamics studies and SUI.
- Do consider UDS in women who have failed non surgical management and have ..
- Voiding dysfunction
- Anterior/apical prolapse
- Prev surgery for SUI
As per NICE, if non surgical mgmt of SUI has failed, what surgical procedures can be offered?
- Colposuspension (lap or open)
- Autologous fascial sling
- Intramural bulking agents
When planning a retropubic mid urethral mesh sling procedure, surgeons should use..
A device manufactured from type 1 macroporous polypropylene mesh!
Use a coloured sling for ease of insertion and revision!!
