Urogynaecological Symptoms Flashcards
How would you assess a pelvic organ prolapse in secondary care?
- 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
Who might you perform imaging in when assessing pelvic organ prolapse?
- If associated with bothersome urinary symptoms and considering surgery
- If symptoms of obstructive defecation or faecal incontinence
- Pain
- Symptoms not explained by examination findings
Describe the stages of pelvic organ prolapse
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
What lifestyle management options are reecommended for pelvic organ prolapse?
- Lose weight if BMI >30
- Minimise heavy lifting
- Prevent / treat constipation
What topical / vaginal conservative options are there for treating pelvic organ prolapse?
- Topical estrogen (estring could be inserted with pessary)
- Pessaries
- Change every 6 months to prevent complications
- May have an effect on sex
What are the main types of pessaries available for pelvic organ prolapse?
- 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
What surgical management options are there for uterine prolapse?
- 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
What surgical management options are there for a vault prolapse?
- Vaginal sacrospinous fixation
- Sacrocolpopexy (abdominal or laparoscopic) with mesh (not commonly performed now)
- Colpocleisis
Complications associated with mesh surgery (assessment of)
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
How would you examine someone with complications associated with mesh surgery?
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
What considerations are made before deciding to remove mesh after complications?
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
Describe stress urinary incontinence
Involuntary leakage on effort or exertion, or on coughing/sneezing
Describe urge urinary incontinence
Leakage accompanied by, or preceded by, a sudden compelling desire to void which is difficult to defer
Describe overactive bladder syndrome
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
Describe mixed urinary incontinence
Symptoms of both SUI and OAB
Involuntary leakage associated with both urgency and physical stress
Describe overflow incontinence
Detrusor under-activity or bladder outlet obstruction
May be straining/feeling of incomplete emptying
Name some causes / contributing factors of stress incontinence
- Age
- Pregnancy and vaginal deliveries
- Obesity
- Constipation
- Deficiency in supporting tissues (i.e. hysterectomy, lack of estrogen, prolapse)
- Family history
- Smoking
- Medication (chronic cough?)
Name some causes / contributing factors of urgency incontinence
- 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
Name some causes / contributing factors of overflow incontinence
- 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
How might you assess which type of urinary incontinence a patient has?
- 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
What is the modified Oxford Grading System for pelvic floor strength
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
What complications may result from urinary incontinence?
- 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
What should be included in a bladder diary?
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
What are the 2WW guidelines for bladder cancer?
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
Who might need referral to secondary care?
- 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
What conservative options are there for management of stress incontinence?
- 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
What management options does secondary care have for stress incontinence?
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)
What medical therapies are available for urgency incontinence (after conservative options)?
1st line: antimuscarinics (anticholinergics)
– oxybutynin, tolterodine, solifenacin, darifenacin
2nd line: mirabegron
What can secondary care do for urgency incontinence?
- Botox to bladder wall
- Percutaneous sacral nerve stimulation
What considerations are to be made on medical therapies for incontinence?
- 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
Provide a summary of anticholingerics/antimuscarinics used in incontinence treatment
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
Provide a summary of b agonists used in incontinence medical treatment?
Mirabegron
Side-effects: UTI, headache and BP (BP monitoring required), tachycardia, palpitations
Don’t give to: severe HTNN, hepatic or severe renal impairment
Provide a summary of SNRI therapy in incontinence management
Duloxetine
Only offered if doesn’t want surgery for SUI
Provide a summary of vasopressin analogues in incontinence management
Desmopressin
Off-label use for nocturia / nocturnal polyuria
Monitor serum sodium after starting
Who would you perform cystometry on?
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
What conditions can cause faecal incontinence?
- 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
What conservative management is available for faecal incontinence (specialist management in a continence service)
- Pelvic floor muscle training
- Bowel retraining
- Specialist dietary assessment and management
- Biofeedback
- Electrical stimulation
- Rectal irrigation
What specialist assessment studies are available for faecal incontinence?
- Anorectal physiology studies
- Endoanal ultrasound, MRI
- Proctography e.g. defecating proctogram
What does NICE CKS say about urine dips for UTI?
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)
Send urine culture in all women with suspected UTI if…
- 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
What treatments are available for interstitial cystitis?
- 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
What is first line abx treatment for UTI (if ruled out sepsis or pyelonephritis) if no haematuria, not pregnant, and not catheterised?
- 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
What is first line abx treatment for UTI in pregnancy?
- Nitro (avoid at term) 100mg MR for 7 days (if eGFR >45)
- Second line amoxicillin or cefalexin
