Urogynae Flashcards
Incidence of Subtypes of Urinary Incontinence in Women
Stress Incontinence 50%
Urge Incontinence 20%
Mixed 30%
SUI definition
Involuntary loss of urine when the intravesicular pressure exceeds the resistance provided by the urethral closure mechanisms in the absence of an urge to void/bladder activity.
Pathophysiology of Stress Incontinence
- Urethral hypermobility (90%) As the bladder neck support is weakened, the increase in intra-abdominal pressure is no longer transmitted equally to the bladder outlet.
- Intrinsic Sphincter Dysfunction (10 - 20%) Damage to sphincter
Facia repaired during anterior repair
Pubocervical facia
Anterior repair complications
- Bladder/urethra/ureter injury
- Haematoma
- Denervation
- De novo SUI or difficultly voiding
- Vaginal narrowing/sexual dysfunction
Posterior repair facia
Rectovaginal facia
Posterior repair complications
- Bowel injury/entry to peritoneum
- Transverse ridge if elevator ani incorporated causing dyspareunia
- 10% failure at 5 years
No role for mesh, level 1 evidence no benefit
Storage reflexes and nerves
- Bladder distension stimulates sympathetic hypogastric and pudendal nerves
- Hypogastric nerve causes internal urethral sphincter and urethral smooth muscle contraction and inhibits detrusor (guarding reflex)
- Pudendal nerve stimulates external urethral sphincter contraction (guarding reflex)
Oxford score system
Pelvic floor strength assessment Two fingers into vagina and squeeze: 0 - no contraction 1 - flicker 2 - weak 3 - moderate 4 - good 5 - good with lift 6 - strong Also note duration
Type of UI
- SUI
- Urge/OAB wet or dry
- Mixed
- Continuous (fistula)
- Transient - DIAPPERS: delirium, infection, atrophy, psych, prescriptions, excess output, restricted mobility, stool impaction
Micturation reflex
• The micturation reflex is an autonomic spinal cord reflex that initiates urination.
• Bladder filling activates stretch receptors which send afferent impulses via pelvic splanchnic nerves to spinal cord, triggering simple spinal reflexes.
• Pontine micturition centre and pontine storage centre control simple spinal reflexes to achieve micturition or storage.
• In micturition - spinal reflexes:
o Somatic - efferents from S2-S4 via pudendal nerve are inhibited – external urethral sphincter relaxes.
o ANS – SNS efferents via hypogastric nerve are inhibited, and PNS effferents via pelvic splanchnic nerve are promoted, resulting in contraction of detrusor muscle and relaxation of internal urethral sphincter.
Urinary retention mechanism following epidural/anaesthetic
Acute urinary retention is one of the most common complications after surgery and anesthesia. Overfilling the bladder can stretch and damage the detrusor muscle, leading to atony of the bladder. It can occur in patients of both sexes and all age groups and after all types of surgical procedures. Micturition depends on coordinated actions between the detrusor muscle and the external urethral sphincter. Motorneurons of both muscles are located in the sacral spinal cord and coordination between then occurs in the pontine tegmentum of the caudal brain stem. Motorneurons innervating the external urethral sphincter are located in the nucleus of Onuf, extending from the S1 to the S3 segment. The smooth detrusor muscle is inner-vated by parasympathetic fibers, which reside in the sacral intermediolateral cell group and are located in S2-4. Sympathetic fibers innervating the bladder and urethra play an important role in promoting continence and are located in the intermediolateral cell group of the lumbar cord (L1-L4). Most afferent fibers from the bladder enter the sacral cord through the pelvic nerve at segments L4-S2 and the majority are thin myelinated or unmyelinated.
Management of detrusor instability
Detrusor instability is a urodynamic diagnosis made when the detrusor is shown objectively to contract, spontaneously or on provocation, during the filling phase of a cystometrogram while the patient is attempting to inhibit micturition. It often is responsible for symptoms of urgency, frequency, nocturia, urge incontinence, and nocturnal enuresis, but is not synonymous with any of them. Furthermore, it may be responsible for urinary incontinence which appears to be simple stress incontinence, and should be excluded before an operation for genuine stress incontinence is undertaken. Patients with mixed incontinence should have their detrusor instability treated before an attempt at surgical correction of stress incontinence is made. A number of therapeutic options exist for the unstable bladder. The simplest is bladder drill. My own preference is to start patients on bladder drill in conjunction with oxybutynin chloride 5 mg orally three times daily, with the plan of weaning them off the medication if possible in 3-6 months. Patients who do not experience improvement with behavioral intervention and pharmacologic treatment may be candidates for electric stimulation therapy or surgery. The efficacy of electric stimulation therapy is diminished in many cases by poor patient acceptance. The most effective surgical treatment for refractory detrusor instability appears to be augmentation cystoplasty, which should be attempted only by a trained reconstructive urologist, and which should be reserved for the most refractory and difficult cases.
Anterior colporrhaphy procedure
Commonest technique.
Lloyd-Davis, buttock just past edge of operating table, antibiotics given within 60minutes of incision.
Sterile prep and drape. Foley catheter inserted 16Fr.
Weighted speculum placed in vaginal.
Lidnocaine + epinephrine placed below epithelium into the midline (decreased bleeding and aid in dissection).
Midline incision in anterior vaginal mucosa with lateral dissection of the vaginal mucosal nflaps to separate with vaginal epithelium from the endoplevic fascia.
Exposes the bladder and proximal urethra.
Endopelvic fascia is plicated in midline with absorbable sutures (mattress or simple interrupted).
Can give additional support by plication to the periurethral tissue under the bladder neck (Kelly plication).
Remove excess vaginal skin, suture closed remaining vaginal tissue with absorbable suture.
Paravaginal repair (anterior) procedure
Aims to correct lateral defects by reattaching the lateral vaginal sulcus to the ATFP.
Can be performed either vaginally or abdominally.
Vaginal flaps developed as for colporrhaphy.
Blunt dissection to expose the ATFP occurs identify the ischial spine and symphysis pubis
Midline plication as for anterior repair is performed.
Multiple sutures (3-6) are placed around the ATFP either using suture or Capio device.
Suture is then passed through plicated anterior repair and tissue from undersurface of vaginal flap from urethra to apex.
Technique repeated on opposite side.
Sutures are tied from urethra to apex alternating sides. Vaginal flaps then trimmed and closed as per anterior repair.
Retropubic approach
Reattaches the anterolateral vaginal sulcus with its overlying endopelvic fasica to the ATFP.
Enter retropubic space laparoscopically, bladder and vagina are depressed. Blunt dissection occurs until the ischial spine is palpated. AFTP often visualised as a white band – the paravaginal defect is seen as an avulsion of the vagina off the AFTP. These two landmarks are then sutured together (5-6 sutures) and then the peritoneum is closed.
Cystoscopy for ureteric patency and injury should be performed. Obturator nerve and vascular bundle at risk of injury.
