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MFSRH Part 2 (2023) > Urogynaecological Symptoms > Flashcards

Urogynaecological Symptoms Flashcards

1
Q

How would you assess a pelvic organ prolapse in secondary care?

A
  • POP Q (assess prolapse of anterior, central and posterior compartments)
  • Pelvic floor activity
  • Vaginal atrophy
  • Rule out pelvic mass / pathology
  • Use validated pelvic floor symptom questionnaire to aid assessment and decision making
  • Don’t routinely perform imaging
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2
Q

Who might you perform imaging in when assessing pelvic organ prolapse?

A
  • If associated with bothersome urinary symptoms and considering surgery
  • If symptoms of obstructive defecation or faecal incontinence
  • Pain
  • Symptoms not explained by examination findings
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3
Q

Describe the stages of pelvic organ prolapse

A

Stage 0 = no prolapse
Stage 1 = most distal portion >1cm above level of hymen
Stage 2 = most distal portion within 1cm of plane of hymen
Stage 3 = most distal portion >1cm below plane of hymen but not protruding by more than 2cm of total length of vagina
Stage 4 = complete eversion of vagina / procidentia

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4
Q

What lifestyle management options are reecommended for pelvic organ prolapse?

A
  • Lose weight if BMI >30
  • Minimise heavy lifting
  • Prevent / treat constipation
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5
Q

What topical / vaginal conservative options are there for treating pelvic organ prolapse?

A
  • Topical estrogen (estring could be inserted with pessary)
  • Pessaries
  • Change every 6 months to prevent complications
  • May have an effect on sex
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6
Q

What are the main types of pessaries available for pelvic organ prolapse?

A
  • Ring: usually for 1st or 2nd degree, can still have sex with these
  • Gellhorn: usually for 3rd degree, no full penetrative sex
  • Shelf: as for Gellhorn, but more rigid
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7
Q

What surgical management options are there for uterine prolapse?

A
  • Vaginal hysterectomy +/- vaginal sacrospinous fixation
  • Vaginal sacrospinous fixation (uterus preserving)
  • Machester repair (cardinal ligaments, shortens cervix, preserves uterus)
  • Sacrohysteropexy with mesh (not commonly performed now)
  • Colpocleisis
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8
Q

What surgical management options are there for a vault prolapse?

A
  • Vaginal sacrospinous fixation
  • Sacrocolpopexy (abdominal or laparoscopic) with mesh (not commonly performed now)
  • Colpocleisis
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9
Q

Complications associated with mesh surgery (assessment of)

A

Pain or sensory change in the back, abdomen, vagina, pelvis, leg, groin, perineum
- Unprovoked, or provoked by movement or sexual activity and
- Generalised, or in the distribution of a specific nerve, such as obturator nerve
- Vaginal problems including discharge, bleeding, painful sex, penile trauma in sexual partners
- Urinary problems including recurrent infection, incontinence, retention, pain on voiding
- Bowel problems including difficulty/pain on defecation, faecal incontinence, rectal bleeding, passage of mucus
- Symptoms of infection

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10
Q

How would you examine someone with complications associated with mesh surgery?

A

Vaginal examination
- Is the mesh palpable, exposed, extruded?
- Localise the pain and its anatomical relationship to the mesh

Rectal examination
- If indicated, to assess for presence of the mesh perforating or a fistula

Neurological assessment
- Distribution of the pain, sensory alteration, muscle weakness

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11
Q

What considerations are made before deciding to remove mesh after complications?

A

Limited evidence on best management
- Complications include organ injury, worsening pain, urinary/bowel/sexual dysfunction
- May not relieve symptoms
- May not be possible to remove all of the mesh
- Urinary incontinence or prolapse can recur after mesh has been removed

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12
Q

Describe stress urinary incontinence

A

Involuntary leakage on effort or exertion, or on coughing/sneezing

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13
Q

Describe urge urinary incontinence

A

Leakage accompanied by, or preceded by, a sudden compelling desire to void which is difficult to defer

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14
Q

Describe overactive bladder syndrome

A

Urinary urgency with or without incontinence, usually associated with urinary frequency and nocturia

Wet OAB: incontinence present
Dry OAB: incontinence absent

Symptoms without UTI or other obvious pathology

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15
Q

Describe mixed urinary incontinence

A

Symptoms of both SUI and OAB
Involuntary leakage associated with both urgency and physical stress

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16
Q

Describe overflow incontinence

A

Detrusor under-activity or bladder outlet obstruction
May be straining/feeling of incomplete emptying

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17
Q

Name some causes / contributing factors of stress incontinence

A
  • Age
  • Pregnancy and vaginal deliveries
  • Obesity
  • Constipation
  • Deficiency in supporting tissues (i.e. hysterectomy, lack of estrogen, prolapse)
  • Family history
  • Smoking
  • Medication (chronic cough?)
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18
Q

Name some causes / contributing factors of urgency incontinence

A
  • Overactive bladder syndrome
  • Mostly idiopathic
  • Neurological conditions (Parkinsons, MS, spinal injury)
  • Medical co-morbs (Obesity, T2DM, chronic UTI)
  • Medications (parasympathomimetics, drugs used in glaucoma anad sjogrens, antidepressants, diuretics)
  • Caffeine, alcohol, acidic drinks
19
Q

Name some causes / contributing factors of overflow incontinence

A
  • Detrusor underactivity in systemic neurological disorders
  • Bladder outlet obstruction
  • Medications
    – ACE inhibitors
    – Antidepressants
    – Antihistamines
    – Antimuscarinics
    – Antiparkinsons
    – Beta-adrenergic agonsts i.e. salbutamol
    – Calcium channel blockers
    – Opioids
    – Sedatives and hypnotics
20
Q

How might you assess which type of urinary incontinence a patient has?

A
  • Occurring on coughing, sneezing, exertion (stress)
  • Sudden urgency, frequency, nocturia (urge with OAB)
  • Equally with physical activity and urgency (mixed)
  • Without physical activity or urge (cause other than stress or urge?)
  • Voiding difficulty (straining, incomplete emptying) - suggests retention and overflow
  • Constant leakage suggests fistula
21
Q

What is the modified Oxford Grading System for pelvic floor strength

A

0 = no contraction, no discernible muscle contraction

1 = flicker or pulsation felt under the examiner’s finger

2 = weak, and increase in tension detected without any discernible lift

3 = moderate, with some lifting of the muscle belly and elevation of the posterior vaginal wall

4 = good, increased tension with a good contraction to elevate the posterior vaginal wall against resistance

5 = strong, strong resistance is applied to the elevation of posterior vaginal wall. Finger is squeezed and drawn into the vagina

22
Q

What complications may result from urinary incontinence?

A
  • AKI if urinary obstruction
  • Presence of depression
  • Risk of falls and fractures
  • Insomnia
  • Effect on QoL, sexual and social functioning
  • Impact of incontinence on family/carers
23
Q

What should be included in a bladder diary?

A

Kept for 3 days minimum, making sure variation in activities are covered (e.g. working and leisure days)
- Amount, type and timing of fluid intake
- Voided volume
- Frequency of micturition
- Episodes of urgency
- Episodes of incontinence
- Activities causing leakage
- Pad and clothing changes

24
Q

What are the 2WW guidelines for bladder cancer?

A

Aged 45 years and over with
- Unexplained, visible haematuria without UTI
- Or, visible haematuria that is persistent or recurrent after successful treatment of UTI

Aged 60 and over with
- Unexplained non-visible haematuria AND dysuria or a raised white cell count on a blood test

25
Q

Who might need referral to secondary care?

A
  • Bladder that is palpable on abdominal or bimanual examination after voiding
  • Voiding difficulty
  • Persistent bladder or urethral pain
  • Pelvic mass
  • Associated faecal incontinence
  • Suspected neurological disease
  • History of previous incontinence surgery, pelvic cancer surgery or radiotherapy
  • Recurrent UTI
  • Suspected urogenital fistulae
26
Q

What conservative options are there for management of stress incontinence?

A
  • Manage reversible causes or contributing factors
  • Lifestyle: reduce caffeine, avoid excessive fluid intake, weight loss if BMI >30, smoking cessation
  • Provide info about self-help resources
  • Referral for trial of 3 months supervised pelvic floor muscle training
27
Q

What management options does secondary care have for stress incontinence?

A

1st line: colposuspension, autologous rectal fascial sling, retropubic mid-urethral mesh sling, intramural bulking agents

2nd line: duloxetine (if not suitable for surgery or prefers medical therapy)

28
Q

What medical therapies are available for urgency incontinence (after conservative options)?

A

1st line: antimuscarinics (anticholinergics)
– oxybutynin, tolterodine, solifenacin, darifenacin
2nd line: mirabegron

29
Q

What can secondary care do for urgency incontinence?

A
  • Botox to bladder wall
  • Percutaneous sacral nerve stimulation
30
Q

What considerations are to be made on medical therapies for incontinence?

A
  • Take at least 4 weeks to work
  • Adverse effects (dry mouth, constipation)
  • Review after 4 weeks and consider titrating dose, or offer alternative, or consider mirabegron instead

Cautions
- Don’t give immediate release oxybutynin if older and risk of physical or mental deterioration due to falls risk

31
Q

Provide a summary of anticholingerics/antimuscarinics used in incontinence treatment

A

Non-selective = tolterodine (and fesoterodine)
Selective = oxybutynin (and solifenacin)

Side effects: dry mouth, constipation, dizziness, drowsiness, skin flushing

Don’t give to: oxybutynin in frail elderly

32
Q

Provide a summary of b agonists used in incontinence medical treatment?

A

Mirabegron

Side-effects: UTI, headache and BP (BP monitoring required), tachycardia, palpitations

Don’t give to: severe HTNN, hepatic or severe renal impairment

33
Q

Provide a summary of SNRI therapy in incontinence management

A

Duloxetine
Only offered if doesn’t want surgery for SUI

34
Q

Provide a summary of vasopressin analogues in incontinence management

A

Desmopressin
Off-label use for nocturia / nocturnal polyuria

Monitor serum sodium after starting

35
Q

Who would you perform cystometry on?

A

Before surgery
- Urge-predominant mixed UI or unclear type of UI
- Symptoms suggestive of a voiding dysfunctionn
- Anterior or apical prolapse
- History of previous surgery for SUI

36
Q

What conditions can cause faecal incontinence?

A
  • Acute, severe faecal loading
  • Infective, IBD, IBS
  • Warning signs for lower GI cancer
  • Rectal prolapse or third-degree haemorrhoids
  • Acute anal sphincter injury including obstetric and other trauma
  • Acute disc prolapse / cauda equina
37
Q

What conservative management is available for faecal incontinence (specialist management in a continence service)

A
  • Pelvic floor muscle training
  • Bowel retraining
  • Specialist dietary assessment and management
  • Biofeedback
  • Electrical stimulation
  • Rectal irrigation
38
Q

What specialist assessment studies are available for faecal incontinence?

A
  • Anorectal physiology studies
  • Endoanal ultrasound, MRI
  • Proctography e.g. defecating proctogram
39
Q

What does NICE CKS say about urine dips for UTI?

A

The following applies if under 65, no risk factors for complicated UTI and not catheterised

  • +ve nitrites OR +ve leucs AND +ve RBC = UTI likely (only send C+S if possibility of resistance, previous tx failed)
  • -ve nitrites but +ve leucocytes = UTI equally likely to other diagnosis (send C+S to confirm)
  • -ve nitrites, -ve leucocytes, -ve RBC = UTI less likely (don’t send culture)
40
Q

Send urine culture in all women with suspected UTI if…

A
  • Pregnant
  • > 65 years
  • Persistent symptoms / do not resolve with antibiotic treatment
  • Recurrent UTI
  • Urinary catheter in situ or recent catheterisation
  • Risk factors for resistance or complicated UTI such as GU abnormalities, renal impairment, residence in long-term care facility, hospitalisation for >7 days in last 6 months, recent travel to a country with increased resistance of UTI
  • Atypical symptoms
  • Visible or non-visible (on urine dipstick) haematuria
41
Q

What treatments are available for interstitial cystitis?

A
  • Simple analgesia
  • OTC antihistamines
  • Neuropathic analgesia (amitriptyline, gabapentin, pregabalin)
  • Tolterodine, solifenacin, mirabegron
  • Cimetidine (H2 blocker)

Non-medical
- Pelvic floor physio
- Bladder retraining
- Psychological input
- TENS machine

42
Q

What is first line abx treatment for UTI (if ruled out sepsis or pyelonephritis) if no haematuria, not pregnant, and not catheterised?

A
  • Nitro 100mg MR for 3 days (if eGFR >45)
  • Trimeth 200mg BD for 3 days (if low risk of resistance)

2nd line (if no improvement after 48 hours - send culture)
- Nitro 100mg MR 7 days
- Pivmecillinam 400mg stat, then 200mg TDS for 3 days
- Fosfomycin 3g single dose sachet

43
Q

What is first line abx treatment for UTI in pregnancy?

A
  • Nitro (avoid at term) 100mg MR for 7 days (if eGFR >45)
  • Second line amoxicillin or cefalexin

MFSRH Part 2 (2023) (22 decks)

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