Urogynae Flashcards
Define urinary incontinence
Involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem
Define urinary continence
Ability to store urine and have conscious control over time and place of voiding
Risk factors for urinary incontinence
• Damage during childbirth (pelvic floor muscles, nerve supply of sphincter and pelvic floor)
• Menopause/tissue atrophy
• Connective tissue disease
• Chronic increased abdominal pressure (obesity, cough, constipation and straining)
• Smoking (cough, tissue weakening, 2-3xrisk)
• Radiotherapy
• Neuro conditions (MS, Parkinson’s)
Age (43% of over 85s!)
Name 9 types of urinary incontinence
- Stress incontinence (eg after coughing)
- Detrusor overactivity
- Retention with overflow (full bladder, inability to fully empty bladder)
- Congenital (wet 24hrs a day)
- Acute infection
- Urethral diverticulae
- Bladder extrophy
- Ectopic ureters
- Vesicovaginal fistula
Describe stress incontinence
- Abnormal bladder neck/proximal urethra descent
- Intraurethral pressure less than intravesical pressure at rest
- Lax sub-urethral support
- Involuntary leakage on cough, laugh, sneeze
- Leakage on intercourse
- Associated prolapse?
Treatment for stress incontinence
- Lose weight, avoid irritants
- Treated with pelvic floor exercise
- Continence pessary
- Electrical stimulation of pelvic floor muscles
- Trans vaginal tape (TVT tension free vaginal tape, TOT transobturator tape)
- Burch colposuspension (own tissue)
- Bladder neck injection/bulking (wears off after 1 yr)
Define overactive bladder
- Frequency
- Urgency
- Urge incontinence
- Nocturia
- Toilet mapping
- Detrusor overactivity seen in urodynamics (uninhibited detrusor activity)
- Also associated with incomplete emptying, poor flow or straining to void
Treatment of overactive bladder
• Avoid irritants, stop smoking • Lose weight • Antichoinergic medication OXYBUTININ§ (SE dry mouth, constipation) • Mirabegron • Botox • Nerve stimulation Bladder retraining
What Qs should you ask in a urogynae hx?
• Symptoms (bowels, sexual, prolapse)
• Obstetric history (size of largest baby)
• Medical history (diabetes, neuro conditions, depression)
• Fluid intake (tea!)
• Bladder irritants (caffeine, fruit juice, fizzy drinks)
• Smoking
• Medications (diuretics)
Neuro? MS, spinal lesions
What investigations should be done for urinary incontinence?
- BMI
- Abdo (masses, bladder palapable?)
- Urinalysis, MC&S
- Bladder USS (residual volume)
- Capillary glucose
- Bladder diary
- Pad tests (discharge versus urine leakage)
- Urodynamics
- Cystoscopy
- Cystometry (abdo pressure, intravesical pressure while filling bladder and voiding)
How is detrusor overactivity diagnosed in urodynamics?
No abdominal muscle activity is seen, just a spike in detrusor activity when not actively voiding
Define prolapse
The protrusion of an organ or structure beyond its normal confines
Is uterovaginal prolapse common?
Yes, 50% of women >40yrs have experienced it, 7% of women will undergo an operation for it in their lifetime
Name 6 risk factors for uterovaginal prolapse
- Raised intra-abdominal pressure (obesity, chronic cough, COPD, constipation, heavy lifting, pregnancy
- Congenital (collagen structure, spina bifida, bladder extrophy)
- Post-operative (hysterectomy due to importance of vaginal vault support)
- Vaginal delivery (higher parity, larger babies, instrumental delivery, poor repair of tear/episiotomy, mechanical or nerve injury to pelvic floor)
- Post-menopausal (loss of oestrogen)
- Pudendal/perineal neuropathies
Name 4 categories of uterovaginal prolpase
- Anterior vaginal wall prolapse (urethrocele/bladder cystolcele)
- Posterior vagina wall prolapse (rectocele, small bowel enterocele)
- Apical vaginal prolapse (uterus and inversion of upper vagina=uterovaginal)
- Vaginal apex, post hysterectomy= vault prolapse
What is a bladder prolapse into vaginal wall called?
Cystocele
Define enterocele
Small bowel prolapse into posterior vagina wall
What are the types of uterine prolapse?
1st degree: descent within vagina
2nd degree: descent to introitus
3rd degree: procidentia
Symptoms of uterovaginal prolapse
- Dragging sensation (discomfort/pain)
- Feeling a lump in the vagina
- Dyspareunia
Cystolcele symptoms
- Stress incontinence
- Urinary frequency/obstructive symptoms
- Recurrent UTIs
- Urgency/frequency
Rectocele symptoms
- Incomplete bowel emptying
- Difficulty wiping clea/soiling/incontinenc
- Splinting (use finger to push rectum straight again while defaecating
Severe prolapse symptoms
- Renal failure due to ureteric kinking
- Urinary retention
- Bleeding/ulceration
- Infection
- Sacral back pain
How do assess a pt with a prolapse?
- Evaluate in both the lithotomy and standing positions, during relaxation, and during maximal straining.
- Sims speculum
- Note the point of maximal descent of the anterior, lateral, and apical walls in relation to the ischial spines and hymen.
- Place 2 fingers into the vagina and ask the patient to bear down
- Evaluate the lateral vaginal support system, assess the apex (cervix and apical vagina). Repeat the examination with the patient standing and bearing down
- Assess the external genitalia, noting oestrogen status, diameter of the introitus, and length of perineal body.
- Perform a rectal examination, assessing the external sphincter tone and checking for the presence of rectocele or enterocele.
Treatment options for prolapse?
No symptoms/mild: no treatment
Correct risk factors (obesity, chronic cough, constipation)
Physiotherapy
Vaginal ring pessaries to restore anatomy
Surgery (sexual function needs? Wish to preserve uterus?)
