urogynae Flashcards
urogynae Hx and examination
Prolapse
Symptoms of vaginal bulge
is it associated with back pain discharge or bleeding
Bladder
How often do you pass urine and how much urine each time?
Does your bladder completely empty
Do you need to digitate to help passing urine?
Do you have urinary urgency or dysuria?
How many times per night do you pass urine?
Do you ever leak urine?
- urge associated
- precipitating factors?
- cough sneeze leakage
- how much
fluid intake amount and timing
irritants - tea / coffee/ EOTH
Bowels How often do you open your bowels and do you feel as you empty them completely? Do you need to digitate to aid in emptying your bowels? Constipation or loose stools? Urgency or leakage of faeces or flatus Treatment?
Do you have impairment of you sexual function or Dyspareunia?
Menopausal symptoms - hot flushes, night sweats, vaginal dryness and mood disturbance
Every used HRT?
OE
BMI Observations urine dip blood glucose protein leucocytes and nitrites
STBCR
Abdominal examination for scars masses tenderness organomegaly and nodes
Vaginal examination
Signs of atrophy
assess pelvic floor for levator ani avulsion and strength with the oxford scoring system
(5= strong 0 = weak)
POPQ all on full valsalva for all measurements except for TVL
Bimanual to assess uterine size and mobility and rule out a pelvic pass or other pathology
Observe for urethral hypermobility
Cough stress test
PR if bowel symptoms
lower limb neurology S2-4 if new UI
Post void residual
Use a validated pelvic floor questionnaire to aid assessment and decision making
Initial assessment
(incontinence)
MSU
Bladder diary 3/7 over work and over leisure days
Use a validated questionnaire to assess and document symptom severity
SUI
initial Ix and management
SUI is caused by urethral hypermobility or instrinsic sphincter defect
Use a validated urinary incontinence specific questionnaire
Ix
MSU
Post void residual (bladder scan or in and out catheter)
Bladder diary 3/7 over work and over leisure days
Consider urodynamics if mixed incontinence, apical / anterior prolapse, voiding difficulty or previous surgery
Conservative management
advice around reducing bladder irritants (alcohol and caffeine)
Treat exacerbating factors - chronic cough, exercise constipation
modification
Optimise/ maintain BMI as this affects success of repair
Vaginal E
Supervised Pelvic floor physiotherapy for at least 3 months is first line treatment
Can include a continence pessary
Surgical option are individualized with the aim is to support the bladder neck
The first line treatment would typically be the Retropubic sling with mesh.
Other options are
A transobturator sling can be an option or avoid mesh with a Fascial sling
burch colposuspension is an abdominal procedure that can be open laparoscopic
or urethral bulking agents which are less effective
Bladder concerns
Bladder diary
MSU
Post void residual
urodynamics
Mesh as an option
referral to urogynaecology
Very little robust data on the safety and efficacy
If deemed indicated they need to be recruited to a clinical trial
Asymptomatic prolapse do not necessarily need surgical management – decision is based on symptom bother as per the patient
Discuss alternative to surgical intervention – pelvic floor and vaginal pessaries
Alternatives – native tissue repair, abdominal sacrocolpopexy (open or laparoscopic)
Limited data
contraindications
Complications Mesh exposure, erosion Vaginal scarring or stricture Fistula formation Dysparunia Unprovoked pelvic pain at rest These complications may occur years after implantation and can be difficult to treat
If complications arise, this may require surgical intervention and the complication may not resolve even when mesh removed. - complete removal is not always possible
“As a surgeon planning on using vaginal mesh kits in your practice what do you need to take into consideration?”
Understanding patient selection and where to exercise caution:
- Primary prolapse cases
- Patients younger than 50
- Lesser grades of prolapse (POP-Q ordinal grade 2 or less)
- Posterior compartment prolapse without significant apical descent
- Patients with chronic pelvic pain
- Postmenopausal patients who are unable to use vaginal oestrogen therapy since this will be 1st line therapy for erosion
Performing mesh procedures requires:
- Adequate training in native tissue repair and other forms of apical support
- Audit of outcomes and complications
- Surgeons performing vaginal mesh surgery should ensure that they perform pelvic floor surgery (both with and without mesh) regularly enough to maintain expertise
- Specific knowledge for a particular product
- Experience in intraoperative cystoscopy
- Demonstrate knowledge of the management of intra and post operative complications of vaginal mesh surgeries
SSF vs sacrocolpopexy
abdominal sacrocolpopexy Gold standard less dysparunia Mesh Abdominal procedure laparoscopic or open longer recovery osteomyelitis medically well mesh exposure 6%
SSF
SSF is associated with earlier recovery compared with ASC.
SSF may not be appropriate in women with short vaginal length and should be carefully considered in women with pre-existing dyspareunia.
More ongoing awarenes of prolpase, repeat surgery for prolapse, prolapse in any compartment
No difference in the need for repeat surgery, denovo UUI VD PISQ scores, injury, mesh exposre and length of hospital stay and blood transfusion
Vagina surgery shorter
Pudendal neurovascular bundle can be injured
Performed to the R as sigmoid on the left
ASC is associated with significantly lower rates of recurrent vault prolapse, dyspareunia and postoperative stress urinary incontinence (SUI) when compared with SSF
However, this is not reflected in significantly lower reoperation rates or higher patient satisfaction.
Technically difficult especially if laparoscopically
Hysterectomy ?
Pro
uterine pathology
Con
TVT
GA IVAB
Prepped/draped in lithotomy
Empty bladder
LA infiltration suprapubically and suburethrally to retropubic space
Stab incisions 4cm apart suprapubically, 2cm either side of midline
1cm vertical incision 1 cm below urethral opening
Sharp dissection to inferior pubic rami bilaterally
Place IDC with guidewire to deflect bladder away
Place TVT into retropubic space bilaterally
Check cystoscopy
Tension TVT with hegar dilator in urethra, cut mesh
Skin glue to exit wounds
Close vaginal mucosa 2.0 vicryl
TVT
Counselling
written information
Advise the woman that it is a permanent implant and complete removal might not be possible
GA IVAB
Prepped/draped in lithotomy
Empty bladder
LA infiltration suprapubically and suburethrally to retropubic space
Stab incisions 4cm apart suprapubically, 2cm either side of midline
1cm vertical incision 1 cm below urethral opening
Sharp dissection to inferior pubic rami bilaterally
Place IDC with guidewire to deflect bladder away
Place TVT into retropubic space bilaterally
Check cystoscopy
Tension TVT with hegar dilator in urethra, cut mesh
Skin glue to exit wounds
Close vaginal mucosa 2.0 vicryl
FU within 6 momths
OAB
Management
you have an Overactive bladder (OAB) This is usually due to detrusor instability.
Conservative
losing weight, if the woman has a BMI greater than 30 kg/m2 / maintaining weight if normal
precipitating factors eg fluid restrict avoid irritants caffiene
chronic conditions - heart failure
Conservative management
Vaginal E
Physio -
Offer bladder training lasting for a minimum of 6 weeks as first-line treatment to women with urgency or mixed urinary incontinence.
If mixed with stress then offer a trial of supervised pelvic floor muscle training of at least 3 months’ duration
products - Give advice around containment products
Medical treatment options include
Anti muscarinics
adrenergic agonists
Medications are 60% effective and SEs are constipation and dry mouth. Vesicare 5mg
Adrenergic agonists eg mirabigron
This has less dry mouth and constipation but is expensive
Surgical management can be considered after urodynamics This includes bladder distension, botox and neuromodulation
Urodynamics
Indications
explanation
urge-predominant mixed urinary incontinence or urinary incontinence in which the type is unclear
symptoms suggestive of voiding dysfunction
Anterior or apical prolapse
a history of previous surgery for stress urinary incontinence.
pessary counselling
A pessary is a soft, flexible device that is placed in the vagina to help support the bladder, vagina, uterus, and/or rectum
Women, who have gone through menopause, may use vaginal estrogen to prevent injury to the vaginal tissue.
The estrogen cream makes the lining of the vagina thicker and healthier this is used at night, twice a week
Side effects of a pessary can be vaginal discharge, irritation and discomfort, trouble passing urine or your bowels, and scarring over or around the pessary
You can be taught how to insert and remove your pessary
If you are able to care for your pessary at home, we typically recommend that you take it out and clean it daily. You should use a mild soap with water, rinse and dry it completely, and reinsert it into the vagina the next morning. It is OK to keep it in for a longer period of time but never more than 3 months at a time.
Sexual activity is possible with a ring pessary insitu. if there is difficult with sexual activity you can remove and replace it
If you are unable to remove and reinsert your own pessary, we will want to see you in the office for cleaning and examination every three months.
Prolapse
Pelvic organ prolapse is defined as descent of 1 or more of vaginal compartments and only needs treatment of symptomatic.
I will use visual aids to explain the anatomy of the prolapse, can give you written information and a contact for support groups
Lifestyle modification
losing weight, if the woman has a BMI greater than 30 kg/m2 / maintaining weight if normal
precipitating factors eg heavy lifting, exercise
chronic conditions - cough / constipation
Conservative management
Vaginal E
Physio
Pessary
Surgical management
Offer surgery for pelvic organ prolapse to women whose symptoms have not improved with or who have declined non-surgical treatment.
Options include anterior or posterior native tissue repair
apical support
Sacrospinous fixation
Sacrocolpopexy
colpocliesis
indications and risks for a concurrent hysterectomy
Prolapse management
Condition:
Pelvic organ prolapse is defined as symptomatic descent of 1 or more of: the anterior or posterior vaginal wall, the cervix or vaginal apex
Prolapse can affect your quality of life and affect bowel and bladder function.
I will use visual aids to explain the anatomy of the prolapse, can give you written information and information for support groups
Lifestyle modification
losing weight, if the woman has a BMI greater than 30 kg/m2 / maintaining weight if normal
minimising heavy lifting
preventing or treating constipation
Conservative management
Consider vaginal oestrogen if atrophy present
Consider a programme of supervised pelvic floor muscle training for at least 16 weeks as a first option for women with symptomatic POP‑Q (Pelvic Organ Prolapse Quantification) stage 1 or stage 2 pelvic organ prolapse.
Use of a Pessary
Surgical management
Offer surgery for pelvic organ prolapse to women whose symptoms have not improved with or who have declined non-surgical treatment.
Options include anterior or posterior native tissue repair
Sacrospinous fixation
indications and risks for a concurrent hysterectomy
Abdominal suspension procedure
Explain to women considering surgery for anterior or apical prolapse who do not have incontinence that there is a risk of developing postoperative urinary incontinence and further treatment may be needed.
Consider concurrent surgery if SUI
Do not perform propholactically
