Urogynae

Question 1

Outline the quantitative tools for incontinence.

Answer 1

Urinalysis
diaries
pad tests - >75g - likely to require surgery
USS/IVP for renal tract abnormalities
cystoscopy - For patients with recurrent infection, haematuria and pain associated with bladder filling or voiding (rule out bladders tumours, stone and painful bladder syndrome)

Question 2

What does cystometry look at?

Answer 2

• bladder capacity (sensation patient feels during filling and functional capacity patient can achieve
• Flow rate and voiding function
• Demonstrate leakage with intravesical pressure

Question 3

cystometry stress incontinence result?

Answer 3

Dx of urodynamic stress incontinence: cystometry shows leakage in absence of detrusor pressure rise

Question 4

Cystometry result of detrusor overactivity

Answer 4

• reduced capacity bladder
• leakage with detrusor pressure rise
• often large loss
• triggers include running water, washing hands

Question 5

Stress incontinence Tx? Adv disadv?

Answer 5

Physio:
- Adv: simple, no SEs
- Disadv: requires patient motivation
can use biofeedback, cones and electrical stimulation to help to identify pelvic floor muscle and be aware of contractions

Medication: Duloxetine
SEs: Nausea

Question 6

Basic Ix of LUT?

Answer 6

urinalysis
MSU
post-void residual check (overflow incontinence - residual volume is 50% of bladder volume)
Pad test

Question 7

Indications for cystoscopy?

Answer 7

R ecurrent UTIs.
• H aematuria.
• B ladder pain.
• S uspected urinary tract injury or fi stula.
• T o exclude bladder tumour or stones.
• I f interstitial cystitis is suspected.

Question 8

4 urodynamic investigations?

Answer 8

Uroflowmetry (non-invasive - screen for voiding problems)
cystometry (Involves measuring the pressure/volume relationship of the bladder
during filling and voiding)
videourodynamics
ambulatory urodynamic monitoring

Question 9

What signs may be present for SUI?

Answer 9

prolapse of the urethra and anterior vaginal wall may be present.
It may be possible to demonstrate stress incontinence by asking the
woman to cough with a fairly full bladder.

Question 10

Ix for SUI?

Answer 10

MSU - exclude infection and glycosuria
Frequency/volume chart - may see slightly increase diurnal frequency as women may void more frequently to prevent leakage
Urodynamic studies (considered when surgery is indicated) - to confirm the diagnosis, check for any co-existing detrusor overactivity, check for voiding dysfunction.

Question 11

Conservative Mx of SUI?

Answer 11

lifestyle - reduce weight if BMI>30, smoking cessation, Tx chronic cough/constipation

pelvic floor muscle training (for at least 3mo)

biofeedback, electrical stimulation, vaginal cones

Question 12

Medical Mx of SUI?

Answer 12

duloxetine - SNRI
mediocre efficacy, sign. SEs

SEs: Nausea, dyspepsia, dry mouth, insomnia, drowsiness, dizziness

Question 13

SUI surgical management? Adv, disadv.

Answer 13

Peri-uretheral injections
- Disadv: lower immediate success rate. long-term continued decline in continence
- Adv: low morbidity, can be performed under LA in outpatient setting
Useful for frail, older, or unfit women and young women who have yet to complete their family.

Burch colposuspension
- Adv: High efficacy, can repair anterior prolapse at same time?
- Disadv: Requires GA, complications
Complications: haemorrhage; injuries to the bladder or
ureter; voiding difficulties; de-novo detrusor overactivity; enterocele or
rectocele formation.

laparoscopic colposuspension - surgery is technically more demanding and requires considerable laparoscopic expertise.

TVT -
Adv: Can be done under LA, RA or GA, minimally invasive and most women return to normal activity within 2wks
Complications:
- moderately high risk of bladder injuries 5–10%, but these do not
seem to have long-term sequelae, if treated appropriately
• bleeding in retropubic space, infection, and voiding difficulties
• tape erosion into the vagina and urethra has also been reported.

Transobturator tape - polypropylene tape is passed via a transobturator foramen, through the transobturator and adductor muscles.
Adv - lower risk of bladder perforation and retropubic space not entered
Disadv: higher risk
of nerve trauma, with chronic groin pain described in up to 20% of
patients.

Question 14

Ix for OAB?

Answer 14

Urine culture
frequency/volume chart
urodynamics - involuntary detrusor contractions during filling,

Question 15

Conservative Mx of OAB?

Answer 15

Behavioural therapy - A dvice to consume 1–1.5L of liquids per day, Avoid caffeine-based drinks (tea, coffee, cola) and alcohol.
• Various drugs, such as diuretics and antipsychotics, alter bladder function and should be reviewed.

bladder retraining

Question 16

Pharma therapy for OAB? CIs? SES?

Answer 16

Anticholinergic drugs: 
Oxybutynin (oral or transdermal patch)
Propiverine
solifenacin
tolterodine
trospium
fesoterodine

SEs: dry mouth (up to 30%)
• constipation, nausea, dyspepsia, and flatulence
• blurred vision, dizziness, and insomnia
• palpitation and arrhythmias.

CIs: Acute (narrow angle) glaucoma.
• Myasthenia gravis.
• Urinary retention or outfl ow obstruction.
• Severe ulcerative colitis.
• Gastrointestinal obstruction.

Also oestrogens (intravaginal) in vaginal atrophy

Question 17

Surgical Mx of OAB?

Answer 17

Botulin toxin A injection (LA) - can cause urinary retention (so may require intermittent self-catheterisation

Neuromodulation and sacral nerve stimulation