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GOSH > urogynae > Flashcards

urogynae Flashcards

1
Q

What are the main things covered by urogynae?

A

Urinary problems eg. incontinence, voiding disorder, cystitis, UTI, fistulae

Prolapse

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2
Q

What things should you include in a urogynae history?

A 
Urological history
Gynaecological history
Obstetric history
Colorectal history (presence of any bowel Sx)
Medical history
Drug history
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3
Q

What questions should you include in the urological history?

A

Incontinence - onset
stress/urge
volume
frequency

Irritative - frequency
urgency
nocturne
dysuria

Voiding - poor stream, straining, prolonged, incomplete emptying, dribbling after leaving toilet

UTI’s
Nocturnal enuresis
Prolapses
Childhood problems
Catheterisation
Retention
Past treatments
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4
Q

What questions should you include in the gynaecological history?

A 
Menstrual
Prolapse
Surgery
General
Sexual dysfunction
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5
Q

What questions should you include in the obstetric history?

A

parity
MOD
birthweights

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6
Q

What questions should you include in the medical history?

A 
Respiratory (cough)
Cardiac
GI (constipation)
CNS
Diabetes
Psychiatric
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7
Q

What questions should you include in the drug history?

A

Diuretics
Beta-blockers
Anti-cholinergics

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8
Q

What should be included in an urogynae examination?

A

General (BMI important)

Abdominal (pelvic masses)

Digital examination of pelvic floor muscles

Bimanual vaginal examination (to assess fro prolapse)

Speculum:
Post menopausal atrophy
Vaginal discharge
Prolapse

Incontinence

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9
Q

What investigations are commonly done in urogynaecology?

A

Urine dipstick +/- MSU
Frequency/volume charts
Post-voidal residual volume (bladder scan)
Urodynamics

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10
Q

What is urodynamics? How is it done?

A

Assessment of bladder function

Outpatient
Bladder filled and emptied whilst pressure readings taken from bladder and abdo

(Important before any surgical intervention or if initial treatment failed)

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11
Q

What is incontinence?

A

Objectively demonstrable involuntary loss of urine

social or hygienic problem

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12
Q

What are the 4 types of incontinence?

A
  1. STRESS URINARY INCONTINENCE
  2. URGE URINARY INCONTINENCE
  3. MIXED URINARY INCONTINENCE
  4. CONTINUOUS URINARY INCONTINENCE
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13
Q

What is stress urinary incontinence?

A

Involuntary loss of urine on effort or exertion or on
coughing/sneezing etc

Any factor which increases intra-abdominal pressure will cause SUI

Due to an incompetent sphincter.

(Stress incontinence may be associated with genitourinary prolapse)

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14
Q

What is urge urinary incontinence also known as?

A

detrusor overactivity - detrusor instability or hyperreflexia leading to involuntary detrusor contraction

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15
Q

What is urge urinary incontinence?

A

Urgency - strong desire to void

Urge incontinence: involuntary loss of urine preceded by an intense desire to void

nocturnal enuresis

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16
Q

What are common anterior compartment prolapses? What is the most common?

A

Urethrocele (urethra)
Cystocele (bladder)
cystourethrocele

Protrusion of urethra/bladder into vaginal canal

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17
Q

What are common mid compartment prolapses?

A

uterine - uterus into vaginal canal

vaginal vault - vaginal vault post-hysterectomy

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18
Q

What are common posterior compartment prolapses?

A

rectocele (rectum into vagina)

enterocoele (pouch of douglas into vagina)

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19
Q

What is a pelvic organ prolapse? Why does it happen?

A

Protrusion of pelvic organs into (or out of) the vaginal canal

Caused by damage to vagina and its pelvic support system - weakens support structure

(pelvic organs supported by levator ani muscles and endoplasmic fascia)

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20
Q

What are some examples of direct injuries to vagina and pelvic support system? What causes these?

A

Detachments and lacerations of connective tissue or stretching and tearing of elevator ani muscles

eg. muscle trauma
Neuropathic injury
Vaginal delivery (most commonly)

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21
Q

What are some examples of indirect injuries to vagina and pelvic support system?

A

hypoestrogenic atrophy and denervation

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22
Q

What are some non-surgical methods of managing prolapse?

A

reduce weight (BMI <30)

Physiotherapy (pelvic floor exercise)

Pessaries

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23
Q

What are some surgical methods of managing prolapse?

A

Anterior repair (bladder)

Posterior repair

Vaginal hysterectomy

(Use of vaginal mesh)

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24
Q

Which type of incontinence if the most common? What is the second dos common?

A

urodynamic stress incontinence (USI)

Detrusor over-activity (overactive bladder)

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25
Q

What are some risk factors for USI?

A

Age (menopause)
Vaginal delivery
Prolapse
Previous bladder neck surgery

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26
Q

How does USI usually present?

A

Stress incontinence

can also have concomitant urgency/urge incontinence

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27
Q

How is USI diagnosed?

A

Urodynamics: if urine leaks with no change in pressure in the bladder muscle. Leaking is provoked by an increase in pressure inside the abdomen (eg. when coughing)

Urine leak occurs with:
Increase in abdo pressure
No increase in bladder pressure

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28
Q

What are some non-surgical managements of USI?

A

Conservative: Containment products
Physiotherapy/pelvic floor exercises: first-line
Reduce weight (BMI <30)
Vaginal Cones

Second line: Duloxetine (effects on urethra)
SE: hesitancy in initiating urination

Electrical stimulation

Surgical: if conservative measures fail.
Retropubic mid-urethral tape
Colposuspension
Autologous rectal fascial sling

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29
Q

What are some surgical managements of USI?

A

Trans-Vaginal-Tape

Burch’s colposuspension

Artificial sphincter

(Injectables
Collagen
Macroplastic
Teflon)

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30
Q

What is the second most common cause of incontinence? What age group is this most associated with?

A

Detrusor overactivity

Older women

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31
Q

How does detrusor activity usually present?

A 
Irritative symptoms: frequency
urgency
urge incontinence
nocturia
dysuria
Abdo discomfort
32
Q

How is detrusor overactivity diagnosed?

A

Urodynamics:
If involuntary bladder muscle activity causes an increase in pressure in the bladder and leads to leaking.

Urine leak with:
Involuntary pressure increase in bladder

33
Q

What are the non-surgical management options for detrusor overactivity?

A

Reduce tea/coffee (alter fluids)

Weight loss

Stop Smoking

Bladder retraining. First line. (min. 6 weeks)

Drug therapy:
Antimuscarinic - oxybutynin

(Tricyclic antidepressants
Desmopressin)

34
Q

What are the surgical/secondary care management options for detrusor overactivity?

A

Intra-Vesical Botox - first line
(risk of UTI and self-catheterisation)

Sacral Nerve Stimulation - second line

Surgery: if intractable/v. severe
Clam cystoplasty
Neromodulator implant
Detrusor myomectomy

35
Q

What are some common causes of detrusor activity/urge incontinence?

A

idiopathic

secondary to neurological problems, eg. stroke, Parkinson’s disease, multiple sclerosis, dementia or spinal cord injury

Local irritation due to infection or bladder stones.

36
Q

What is mixed urinary incontinence?

A

involuntary leakage of urine associated with both urgency and exertion, effort, sneezing or coughing.

37
Q

What is continuous urinary incontinence?

A

There is continuous leakage of urine.

May be fistulous track between the vagina and the ureter, or bladder, or urethra.

38
Q

What are some risk factors for urinary incontinence?

A 
Pregnancy and vaginal delivery (incl. forceps and heavier baby)
DM
High BMI
Peri-menopausal (stress incontinence)
hysterectomy
39
Q

What is bladder training?

A

pelvic muscle training

scheduled voiding intervals with stepped increase

Suppression of urge with distraction or relaxation techniques

40
Q

How does oxybutynin (anti-muscarinic) impact over-active bladder?

A

Reduced detrusor over-activity
Relax urinary smooth muscle
Increase bladder capacity

41
Q

Other than urodynamic study, what other investigations should be done for someone with detrusor over-activity?

A

Bloods: U&Es, creatinine, glucose, calcium

urine dip +/- MSU

42
Q

Which patients should be considered for 2 week cancer referral?

A

Microscopic haematuria >= 50 yrs

Macroscopic haematuria

Recurrent UTI + haematuria >= 40yrs

Suspect malignant match

43
Q

How should mixed urinary incontinence be managed?

A

Treat predominant symptoms

Pelvic floor and bladder training: first line

Anti-muscarinics: oxybutynin = second line (or if neurological disease)

May need to consider botulin toxin type A injections

44
Q

What are some side effects of anti-muscarinics to warn patients about?

A

Constipation
Urinary retention
Confusion

45
Q

What are some symptoms of urethrocele?

A

stress incontinence

46
Q

What are some symptoms of cystocele?

A

Often ASx
Frequency
Recurrent UTI
Pressure sensation

47
Q

What are some symptoms of cystourethrocele?

A

Mixed urinary symptoms eg. stress incontinence, frequency etc.

48
Q

What are some symptoms someone might experience with vaginal vault prolapse?

A

Urinary retention

Sx of ureteric obstruction

49
Q

What are some symptoms someone might experience with enterocoele?

A

usually ASx (esp. if small)

Cough impulse

Strangulation rare

50
Q

What are some symptoms someone might experience with rectocele?

A

Difficulty or pain voiding bowels,

dragging sensation

May need to self-digitate

51
Q

How is the severity of a prolapse classified?

A

Based on most distal portion of prolapse during straining

52
Q

What is a stage 0 prolapse?

A

no prolapse

53
Q

What is a stage 1 prolapse?

A

> 1cm above hymen

54
Q

What is a stage 2 prolapse?

A

within 1 cm of hymen

55
Q

What is a stage 3 prolapse?

A

> 1cm below hymen but protrudes no further than 2cm less than total length of vagina

56
Q

What is stage 4 prolapse?

A

complete eversion of the vagina

57
Q

What are some risk factors for prolapse?

A 
Age
Vaginal delivery
Increasing parity
Obesity
Hx of hysterectomy
58
Q

What are some vaginal/general symptoms of prolapse?

A

Pressure
Fullness/heaviness
Bulge/protrusion or something coming down
Difficulty retaining tampons
Spotting (if prolapse or vagina/cervix has ulcerated)

59
Q

What are some urinary symptoms of prolapse?

A 
Incontinence
Frequency
Urgency
Feeling of incomplete emptying
Weak or prolonged stream
May need to change position to pee
May need to reduce prolapse to pee
60
Q

What are some coital difficulties associated with prolapse?

A 
Dyspareunia
Loss of vaginal sensation
Vaginal flats
Loss of arousal
Change of body image
61
Q

What are some bowel symptoms associated with prolapse?

A 
Constipation/straining
Urgency of stool
Incontinence  of flatus or stool
Incomplete evacuation
Digital pressure on posterior vaginal wall to defecate
Digital evacuation
62
Q

What examinations should be conducted if suspect a prolapse?

A

Abdo (masses + tenderness)

SIMS speculum in L lateral position
Cuscos speculum

Rectal examination

63
Q

What investigations should be conducted on someone with prolapse and urinary symptoms?

A 
urinalysis 
MSU
Post-voidal residual urine volume
Urodynamic Ix (if suspect overactive bladder, prolapse or Hx of surgery)
Urea and creatinine
Renal US
64
Q

What investigations should be conducted on someone with prolapse and bowel symptoms?

A

Anal manometry
Defecography
Endo-anal ultrasound

65
Q

What the conservative management options for a prolapse?

A

Mild or ASx = no treatment

Watchful waiting

Lifestyle: treat cough, smoking cessation, weight loss, treat constipation

Pelvic floor exercises

?oestrogen cream

66
Q

When might conservative management be considered the best course of action?

A 
Mild prolapse
Pt wants future pregnancies
Frail or elderly
High anaesthetic risk
Pt doesn't want surgery
67
Q

When might vaginal pessaries be considered to treat prolapse? How do they work?

A

Alternative to surgery
Short term prior to surgery

Insert ring in to vagina: reduces prolapse, provides support and relieved pressure on bladder and bowel

Change every 6-12 months

Can have intercourse with ring in

68
Q

What complications are associated with vaginal pessaries in prolapse?

A

Vaginal discharge and odour

Vesicovaginal + rectovaginal fistulas

Faecal impaction

Hydronephritis

Urosepsis

69
Q

When might surgery be considered to treat prolapses?

A

Failure of conservative treatment

Presence of voiding symptoms or obstructed defecation

Recurrence of prolapse after previous surgery

Ulceration

Irreducible prolapse

Preference of patient

70
Q

What is the aim of surgical treatment? What should patients be warned about?

A

Aim: to return organs back to normal function

May need a number of operations

May need re-op in years following procedure

71
Q

What are the surgical options for anterior compartment prolapse?

A

colporrhaply

colposuspension

72
Q

What are the surgical options for uterine prolapse?

A

hysterectomy
sacrohysteropexy
sacrospinous fixation

73
Q

What are the surgical options for vaginal vault prolapse?

A

Sacropsinous fixation

Sacrocolpopexy

74
Q

What are the surgical options for a rectocele?

A

colporrhaphy

75
Q

What are the sings of a good prognosis in prolapse? What are the sings of a poor prognosis in prolapse?

A

young
low BMI
Good physical health

Poor: the opposite of the above

76
Q

What are some complications associated with prolapse?

A

Ulceration and infection if prolapsed outside introitus

Urinary complications

Bowel dysfunction

GOSH (33 decks)

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