Urogynae Flashcards
Key features of a urogynae history
Bladder symptoms - Incontinence - Nocturia - Haematuria - Voiding dysfunction
Bowel
POP
Quality of life
Sexual function
Treatment trial to date
Stage of POP
POP-Q
Examination
Abdominal exam
Vaginal exam- POP-Q at maximal
Investigations
Urinalysis and MSU
Bladder diary (for 3 days)
Bladder scan for residual volume (RV ≥100ml considered abnormal)
Quality of life questionaries (SF-36 or i-QOL)
Ultrasound
- adnexal pathology
- ET
- Cervical length
Urodynamics
Indications for urodynamics
- Pure SUI can be managed surgically without confirmatory urodynamics prior
Indications for urodynamics:
- Unclear diagnosis
- Invasive surgical interventions are being considered, as choice of procedure is influenced by urodynamic results
- Coexisting pathologies to determine which should be treated first, such as obstruction and detrusor overactivity, or stress incontinence and detrusor overactivity
- Complex problems such as recurrent incontinence, neurological pathology, previous lower urinary tract surgery, pelvic surgery or pelvic radiation.
- (NICE 2019)
Pressure measures in urodynamic studies
- Intravesical pressure (pves) is the pressure within the bladder and is measured by the bladder catheter. It is the sum of the pressure generated by the bladder (detrusor pressure pdet) and the intra-abdominal pressure (pabd).
- Abdominal pressure (pabd) is measured by the rectal catheter.
- Detrusor pressure (pdet) is the pressure generated by the bladder muscle. In ‘subtraction’ urodynamics (the commonest type) it is calculated electronically using the equation: pdet = pves – pabd.
Explain the phases of urodynamic studies
- Uroflowometry (assess flow/volume)- A graph of flow rate (ml/s) against time (s) is recorded, which is normally continuous and bell-shaped. The maximum flow rate (Qmax) should be above 15 ml/s. The volume voided should be more than 200 ml for the test to be valid.
- Cystometry (assess pressures) - This part of the test diagnoses detrusor overactivity, urodynamic stress incontinence and records bladder sensations at different bladder volumes.
- The filling phase: assesses bladder sensation and presence of detrusor overactivity (an involuntary contraction of the detrusor muscle) as well as bladder compliance (the ability of the bladder to store urine at low pressures).
- The voiding phase uses pressure-flow measurements to assess detrusor function and identify obstruction. Pressure flow nomograms can be used and a high pressure/low flow voiding pattern indicates obstruction. Urine flow rate is measured in mL/sec by a urine flowmeter
How is bladder sensation assessed?
Bladder sensation is assessed by recording the volume at which the patient experiences:
- the first sensation of bladder fullness
- the first desire to void,
- a strong desire to void and urgency.
What is leak point pressure?
Lowest bladder pressure (pves) that causes urine leakage with a rise in intra-abdominal pressure. Estimated by valsalva or cough.
Measure of urethral sphincter weakness. A lower leak point pressure indicates worse urethral function.
What is uroflowmetry?
Measures the flow of urine (fastest flow is Qmax):
How fast, how much, and how long it takes.
A slow/low flow rate may mean there is an obstruction at the bladder neck or in the urethra, or a weak detrusor contraction.
A fast or high flow rate may mean there are weak muscles around the urethra, or urinary incontinence problems.
Filling cystometry, normal result
Describe this picture:
Unprovoked rises in detrusor activity
Sensation to void and urgency
suggestive of detrusor overactivity
Approach to urodynamics
Explain the parasympathetic innervation of the bladder
Parasympathetic afferents arise from S2-4 and travel via pelvic plexus and pelvic nerve to stimulate bladder contraction, by ACh release which acts on M3 muscarinic receptors in the detrusor muscle.
They cause internal urethral sphincter relaxation by release of nitric oxide and detrusor contraction.
Explain the sympathetic innervation of the bladder
Sympathetic nerves arise from T10-L2 and travel via the pelvic plexus and hypogastric nerve. They release noradrenalin which acts on a-adrenoreceptors causing contraction of the internal urethral sphincter and inhibiting parasympathetic effects on bladder, causing relaxation of detrusor.
Diagram of sympathetic and PNS innervation of bladder
Overactive bladder management
- Lifestyle/conservative
- Reduce caffeine
- Avoid bladder irritants - fizzy drink, artificial sweeteners
- Advise re fluid intake 1.5-2L
- Change of medication e.g diuretics
- Bladder training with timed voiding
- Medical
- Ovestin if atrophy
- Anticholinergics e.g. oxybutinin or tolterodine (contraindicated in narrow angle glaucoma, SE: dry mouth, blurred vision, constipation) or vesicare/solifenacin 2nd line and better tolerated
- Desmopressin if significant nocturia
- Surgical
- Intravesical botox (1st line)
- Sacral nerve neuromodulation (2nd line)
- Augmentation cystoplasty (3rd line)
- Urinary diversion (4th line)
Stress incontinence management
Conservative
- Weight loss if BMI>30
- Reduce fluid intake 1.5-2L, modify fluids
- pelvic PT - 3 months guided strengthening exercises
- Electrical stimulation and/or biofeedback should be considered in women who cannot actively contract pelvic floor muscles in order to aid motivation and adherence to therapy
- Ring pessary with knob
Medical
- Ovestin if signs atrophy
- Duloxetine 40mg BD (if surgery contraindicated or declined)
Surgical
- Support bladder neck
- Burch Colposuspension (pfannenstiel or laparoscopic approach; 2-4 pairs of non-absorbable suture between paravaginal fascia and coopers ligament either side of urethra)
- Retropubic Mid urethral sling - (autologous rectus fascial sling or mesh sling)
- Only offer transobturator tape if retropubic approach is unfeasible
- Augment urethral closure
- Urethral bulking agents (bulkamid)
- Artificial urinary sphincter
Conservative management of pelvic organ prolapse
- Lifestyle:
- Pelvic floor exercises
- Weight loss
- Stop smoking
- Manage chronic cough or constipation
- Vaginal oestrogen if vaginal atrophy
- Physiotherapy referral - 16 week program of directed exercise recommended by NICE (first line Rx if stage 1 or 2 prolapse)
- Pessary
- Follow-up every 6 months if high risk of complications (i.e. if not able to remove and replace at home)
Pathogenesis of POP
- Damage to levator ani
- Decreased muscle tone and strength, atrophy
- Widened levator hiatus
- Unopposed intra-abdominal pressure on tissues
- Connective tissue stretches over time
- POP
Describe the POP-Q measurement sites
What are the aims of surgical management for POP?
- Relieve symptoms
- Restore anatomy
- Improve visceral function
- Improve sexual function
- Lifetime risk for prolapse surgery 11%
- Increased to 16% if hysterectomy
Mesh complications?
- Mesh erosion/exposure (8-15%)
- Chronic pelvic Pain – may be unprovoked and at rest
- Dyspareunia (10%)
- Scarring/strictures
- Fistula formation
Pt should be informed:
- Complications may happen even years down the line
- May need return to theatre for complications
- Complications can be difficult to treat
- It may not be possible to remove mesh in entirety
- Even after removal, symptoms may persist
What is the evidence for transvaginal mesh placement for prolapse?
Cochrane 2016
- Use of mesh resulted in lower rate of prolapse recurrence, symptoms of prolapse, and need for repeat surgery for prolapse symptoms
- BUT women in mesh repair group were more likely to need return to theatre for prolapse, mesh exposure/erosion or SUI.
- 5% native tissue repair need return to theatre; 7-18% in the mesh group.
- Mesh associated with increased risks of new onset SUI or bladder injury
- No difference in new onset dyspareunia
- NB. new light weight mesh in current use has not been evaluated in RCTs; there is a lack of evidence for its outcomes/long term complications
RANZCOG statement on Mesh - summary
https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Polypropylene-vaginal-mesh-implants-for-vaginal-prolapse-(C-Gyn-20)-Review-November-2016.pdf?ext=.pdf
Mesh not recommended as first line treatment for any form of vaginal prolapse
May have some benefit for anterior compartment, but risks outweigh benefits
Newer, lightweight mesh in current use has not been assessed in RCTs - lack of evidence
Transvaginal mesh has been removed from use by TGA/MEDSAFE. This does not include TVT mesh or abdominal mesh use.
Transvaginal mesh should only be used by experienced operator in a centre with significant expertise in mesh vaginal POP repair.
Surgeons must be part of CU fellowship OR have significant hands on experience and evidence of ongoing training and large enough case numbers to maintain competence
Operators should be able to perform cystoscopy and manage any intra- or post operative complications of mesh surgery
Mesh can only be accessed as part of a Special Access Scheme, and utilised as part of a clinical trial with adequate follow-up and data collection about its outcomes/ complications.
Should be monitored by audit and national reporting systems
Any complications should be reported to MEDSAFE (NZ) or TGA (Aus)
Prior to using mesh patients should be carefully reviewed and counselled by 2 experienced operators:
- explain evidence of benefit over native tissue repairs unclear, and lack of evidence for current light weight mesh
- permanent implant
- discuss other non-surgical and surgical options
- discuss complications
- explain complications may require secondary surgery, may not be easily fixed, may continue despite mesh removal, and complete mesh removal may not be possible
Definition stress urinary stress incontinence
the complaint of any involuntary loss of urine on effort or physical exertion (e.g sporting activities) or on sneezing or coughing
Definition urinary incontinence
the unintentional, accidental, loss of urine
Definition urge incontinence
unintentional loss of urine which may be caused by the bladder muscle contraction, associated with a sense of urgency
What is a neurogenic bladder?
Autonomic dysregulation and loss of bladder control due to a neurogenic cause e.g. spinal cord problem
Bladder can be over or under active. Frequently have increased tone of bladder outlet predisposing to obstruction.
Causes of a neurogenic bladder
MS
Spinal cord lesion
Parkinson’s disease
Diabetes
Stroke
Complication of pelvic surgery
Management of intersitial cystitis
- Exclude infection
- Diet changes: e.g. avoid caffeine, carbonated drinks, citrus fruits, alcohol, spicy food, artificial sweeteners
- Avoid stress - can trigger
- Increase fluids and avoid concentrated urine
- Medications:
- amitriptyline
- pregabalin
- Pentosine polysulphate sodium (expensive and takes > 6 weeks to work)
- Others:
- cystoscopy and hydrodistension
- pelvic floor physio
- Bladder instillation (bladder filling with soothing medication e.g. lidocaine)
Prevalence of incontinence.
And in post menopausal women.
25% all women
50% postmenopausal women
definition of incontinence.
Any involuntary leaking of urine.
3 Categories for the different types of lower urinary tract symptoms.
- Storage symptoms (e.g. frequency, urgency, nocturia, stress)
- Voiding (hesitancy, intermittent stream)
- Post micturition (incomplete emptying, post void dribbling)
Prevalence of different types of incontinence.
- 50% SUI
- 35% MUI
- 10-20% UUI
Risk factors for incontinence.
- Increasing age
- Dementia
- Impaired mobility
- medical comorbidity (e.g. diabetes)
- medications (e.g. diuretics)
- Parity (directly proportional to number of births; for SUI and MUI)
- Mode of delivery (forceps >NVD > CS)
- Obesity
- Smoking
- connective tissue disease (marfans, ED)
- Hysterectomy (SUI)
Anatomy of the lower urinary tract.
The lower urinary tract consists of the bladder and urethra.
The bladder consists of the dome and the trigone at the base of the bladder, which incorporates the ureteric openings and urethra and the apex of the bladder. There are three layers to the smooth muscle of the bladder; a circular-oblique middle layer and longitudinal outer and inner layers. The bladder mucosa is lined by transitional cell epithelium.
The urethra is 3–5 cm in length and extends from the bladder neck to the external urethral meatus. It has three layers:
- an inner mucosal and submucosal layer, forms a vascular spongy layer. The cushion-like effect of these layers occludes the lumen of the urethra and contributes to a third of resting closure pressure
- a smooth muscle layer in the middle, consists of an inner longitudinal and outer circular layer. It is supplied by both sympathetic (contraction via α-adrenergic receptors) and parasympathetic (relaxation via nitric oxide) nerves. This provides a third of resting closure pressure of the urethra
- an outer striated muscle layer including the circular muscle of the EAS. It is supplied by the pudendal nerve. The striated sphincter is responsible for a third of resting closure pressure of the urethra.
Embryology of the bladder.
- Majority of bladder is formed from the urogenital sinus of the cloaca and is endodermal in origin.
- The trigone is formed by the invagination of the caudal mesonephric duct into the developing bladder, and it mesodermal in origin.
2 explanations of pathophysiology of SUI.
The two causes of SUI are:
- loss of suburethral support leading to increased urethral mobility (urethral hypermobility) - the urethra is adherent to the anterior vagina which provides a hammock against which the bladder neck and urethra can be compressed during activation of the urethral sphincter. This hammock is largely created by pubovesicalcervical fascia and levator ani, and can be damaged during vaginal birth.
- intrinsic sphincter deficiency – due to defective function of the striated and smooth urethral muscle and mucosal and submucosal cushions. Causes include scarring, ischaemia and denervation as a result of pelvic or vaginal surgery or radiotherapy.
Describe the micturition reflex.
- Stretch receptors in the bladder detect distension
- They send information to ganglia in the spinal cord via the pelvic nerves (parasympathetic) and hypogastric (sympathetic efferents)
- Impulses are sent via the spinal cord to the pontine micturition centre in the brainstem, and to higher centres involved in voluntary control of micturition
- When a threshold is met , the PMC is switched on and sends excitatory impulses via the spinal cord to parasympathetic ganglia and afferents, and switches off sympathetic afferents
- Parasympathetic afferents arise from S2-4 and travel via pelvic plexus and pelvic nerve to stimulate bladder contraction, by ACh release which acts on M3 muscarinic receptors in the detrusor muscle. They cause internal urethral sphincter relaxation by release of nitric oxide.
- Higher centres can influence the PMC activation and allow voluntary control of micturition. when it is an appropriate time the external urethral sphincter relaxes under control by the pudendal nerve S2-4.
- Once the bladder empties, input to the stretch receptors reduces, and the PMC is switched off.
- The PMC stops driving parasympathetic stimulation and sympathetic innervation takes over.
- Sympathetic nerves arise from T10-L2 and travel via the pelvic plexus and hypogastric nerve. They release noradrenalin which acts on a-adrenoreceptors causing contraction of the internal urethral sphincter and inhibiting parasympathetic effects, causing relaxation of detrusor.
What reflex prevents micturition during increases in intraabdominal pressure by coughing/sneezing/exertion?
- ‘Guarding reflex’ - coordinated at the spinal cord level (unlike micturition which is coordinated by the PMC in brainstem)
- Stretch receptors in bladder note sudden increase in pressure and send signals to Onuf’s ganglia in the spinal cord
- Sympathetic afferents cause contraction of the internal sphincter and bladder neck
- Pudendal nerve stimulate striated muscle in external urethral spincter to contract
Definition of POP.
The International Urogynecological Association (IUGA) and International Continence Society (ICS) define pelvic organ prolapse (POP) as:
“…falling, slipping or downward displacement of the uterus and/or the different vaginal compartments and their neighboring organs such as bladder, rectum or bowel.”
What is the incidence of POP? Symptomatic POP?
Incidence 30-40% women
10% women will be symptomatic
10-20% women will require surgery for POP during their lifetime.
(RCOG e-learning)
Risk factors for POP.
- Increasing age
- Obesity
- Parity and MoD
- heavy lifting
- chronic cough
- Smoking
- connective tissue disorders
- Chronic constipation
- hispanic ethnicity
- 1st degree relative with POP
What are Delancey’s ‘levels of support’ preventing uterine prolapse?
The diverse structures that take part in supporting the female genital tract and preventing pelvic organ prolapse were captured by DeLancey(link is external) (1992), who described three levels of support:
- Level I (suspension) – cardinal and uterosacral ligaments.
- Level II (attachment) – arcus tendinous fascia and fascia over the pubococcygeus and iliococcygeus muscles.
- Level III (fusion) – urogenital diaphragm (Urethral sphincter, Deep transverse perineal muscle, Perineal membrane) and perineal body.
The backward direction of the vagina, which keeps it in the horizontal position on standing, and the anteversion flexion of the uterus mean that increased intra-abdominal pressure is likely to lead to compression of the uterus against the vagina, thereby preventing any prolapse of pelvic organs (Schaffer et al, 2005
Anatomy of the pelvic floor muscles.
The levator ani muscles are broad U shaped sheet of muscles that stretch backwards and inwards from either side of the pelvis to meet in the middle line, encircling the urethra, vagina and the rectum and reaching the coccyx.
ORIGIN: the pectinate line of the pubic bone, and the white line/tendinous arch of fascia overlying the obturator interus muscle and the medial aspect of the ischial spines.
INSERTION: Some of the fibres are inserted as they encircle the urethra, some are inserted as they encircle the vagina, where they take part in forming the perineal body, some fibres are inserted as they encircle the rectum and the rest are inserted in the lower part of the coccyx and anococcygeal raphe.
The levator ani muscles can be described in three parts; puboccocygeus, iliococcygeus and ischeococcygeus (aka coccygeus). The puboccocygeus can be described in two parts, pubovaginalis and puborectalis. Some consider the coccygeus as a separate muscle. Clinically however, the levator ani are often considered as one part.
NERVE SUPPLY: S2-4
What are the attachments of the perineal body?
The perineal body is an irregular fibromuscular mass. It is located at the junction of the urogenital and anal triangles – the central point of the perineum. Attachments include:
- Levator ani.
- Bulbospongiosus muscle.
- Superficial and deep transverse perineal muscles.
- Perineal membrane
- External anal sphincter muscle.
- External urethral sphincter muscle fibres.
POP-Q Staging.
- point Aa – 3 cm proximal to the external urethral meatus, on the anterior vaginal wall
- point Ba – most distal part of the anterior vaginal wall
- point C – most distal part of the cervix, or vaginal vault
- point D – the posterior fornix, in those who still have their cervix
- point Ap – 3 cm proximal to the hymen, on the posterior vaginal wall
- point Bp – most distal part of the, on the posterior vaginal wall.
- GH - genital hiatus
- PB - perineal Body
- TVL - total vaginal length / distance to D (or to C if no cervix)
STAGES
- Stage 0 – No prolapse, points Aa, Ap, Ba and Bp are –3 and point C is between TVL and –TVL–2
- Stage 1 – Most distal point < -1 (more than 1cm above hymen)
- Stage 2 – Most distal point ≥ –1 and ≤1 (between 1 cm above and 1 cm below the hymen)
- Stage 3 – Most distal point > 1 but < TVL-2 (more than 1 cm below the hymen, but at least 2 cm less than the total vaginal length)
- Stage 4 – Most distal point > TVL –2 (complete vaginal eversion, with <2 cm of the vaginal wall still above the hymen).
What are the surgical options for uterine / apical prolapse?
Uterus preserving:
- Sacrospinous hysteropexy with sutures
- Manchester repair
- sacro-hysteropexy with mesh (laparoscopic or open)
Non-uterus preserving:
- Vaginal hysterectomy and sacrospinous fixation
Wanting minimally invasive option and not sexually active:
- colpocleisis
What are the surgical options for anterior and posterior wall prolapse?
- Anterior repair without mesh (70-90% effective)
- Posterior repair without mesh
What is the risk of prolapse recurrence after primary POP surgery?
around 6 % (IUGA)
Risks of SSF.
As with all surgery, there is a risk of bleeding requiring a blood transfusion (1%), infection (2–5%), or VTE (less than 1%)
There is a risk of damage to the bowel or bladder requiring further surgery (less than 1%)
1-in-9 women will have buttock pain from the sacrospinous sutures after the procedure, but this settles without further intervention in most cases (90%)
Painful sexual intercourse may occur (1–5%)
Approximately 10-15% of women will require subsequent prolapse surgery
Urinary incontinence that was not present prior to surgery may develop (1–5%)
Problems emptying your bladder completely requiring prolonged catheter use (less than 1%)
Risks of anterior repair.
- 5-15% women will develop recurrent bladder prolapse
- 1-5% after a large bladder prolapse is repaired may develop stress urinary leakage that was not present before the surgery.
- 1-2% have difficulty passing urine necessitating the need for catheters to be used for a prolonged period of time.
- Inadvertent damage to the urethra or bladder occurs rarely and is usually repaired during the surgery. If the damage is not repaired at the time of the surgery a fistula between the bladder and vagina can occur (1-2/1000 cases)
- 1-5% develop a urinary tract infection
- Excessive bleeding after this surgery is uncommon.
- Clots can form in the legs or lungs after surgery <1%
Posterior repair specific risks
- Constipation
- dyspareunia
- Damage to the rectum during surgery is a very uncommon complication
- recurrence 10-15%
What should women be told prior to starting anticholinergics?
- the likelihood of the medicine being successful
- that some adverse effects of anticholinergic medicines, such as dry mouth and constipation, may indicate that the medicine is starting to have an effect
- that she may not see substantial benefits until she has been taking the medicine for at least 4 weeks and that her symptoms may continue to improve over time
- that the long-term effects of anticholinergic medicines on cognitive function are uncertain and may increase risk of dementia progression
- Do not offer oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health.
Compare retropubic to transobturator mid urethral sling (MUS) procedures.
NICE and Australian commission recommend retorpubic approach first line, unless indication (e.g. multiple previous abdominal surgeries.
Retropubic:
- 85-90% effective at reducing/curing symptoms
- More effective in long term, and requires fewer repeat procedures for recurrent SUI
- More effective at managing SUI due to intrinsic sphincter deficiency than TOT
- Increased risk of haematoma
- Increased risk of bladder injury or major complications
- Increased risk voiding dysfunction post-operatively (may need catheterisation)
- Mesh exposure 2% (comparable)
- Mesh can usually be completely removed if needed
Trans obturator:
- Effectiveness comparable in the short/medium term- slightly reduced in the long term
- Higher rates of repeat surgery for recurrent SUI in long term
- increased risk of post operative pain
- increased risk of chronic groin pain
- Mesh exposure 2% (comparable)
- Mesh removal is difficult, requires groin dissection and can rarely be removed in entirety
What follow up is required after MUS surgery as per RANZCOG?
- Post-op review at 6 weeks and 6 months
- Follow-up for a MINIMUM of 6 months
- Careful review and documentation of:
- Patient satisfaction
- Objective examination finding of SUI
- Urinary retention
- OAB
- Pelvic pain or groin pain
- Offer women self reported patient satisfaction questionaries
- The surgeon should report any adverse events to TGA (Aus) or MEDSAFE (NZ)
- The surgeon should log outcomes with registry e.g. IUGA or Australian Pelvic Floor Procedures Registry (being created)
Main supportive structures for apex?
endopelvic fascia, uterosacral and cardinal ligaments with the levator ani muscle
Risk factors for recurrence of prolapse after POP surgery?
Parity
Age
Obesity
Levator ani avulsion,
advanced prolapse stage,
family history
What are the steps of sacrocolpopexy.
(Assume pt is prepped and draped etc already)
- Pfannenstiel incision (open) or laparoscopic approach
- Longitudinal incision over sacral promontory to enter presacral space. (Identify and avoid middle sacral vessels and right ureter and hypogastric plexus of nerves).
- Dissect peritoneum down to cul de sac
- Place end-to-end anastomosis probe into vagina
- open rectovaginal septum and dissect rectum away from vaginal vault
- Open vesicovaginal space and dissect bladder away from vaginal vault
- Attach polypropylene mesh (3-4cm by 14cm) to PVC of anterior vaginal wall and rectovaginal fascia of posterior vaginal wall with interrupted delayed absorbable monofilament sutures
- Attach other end to ANTERIOR SACRAL LIGAMENT with interrupted non absorbable monofilament sutures, to elevate vaginal vault without tension
- Peritoneum closed over mesh
- Cystoscopy to confirm patency of ureters and no bladder injury
- Abdominal incisions closed
What are the steps for SSF?
- After vaginal hysterectomy if being performed
- Can be performed with anterior or posterior wall incision, often at the same time as anterior or posterior repair - choose the side which has most prominent prolapse to give best elevation and end effect
- Anterior incision, dissect paravesical space into para rectal space on right
- Posterior incision, enter pararectal space
- Digitally palpate ischial spine and sacrospinous ligament
- Blunt dissection with metzenblum scissors toward ischial spine - clear tissue off sacrospinous ligament
- Use suture capturing device - place 1st suture on sacrospinous ligament, 2cm medial from ischial spine and 2nd suture another 1cm medial
- Secure suture to vaginal cuff and tie to elevate vault
- Close vaginal mucosa with delayed absorbable sutures
- perform cystoscopy to confirm ureter patency and no bladder injury
