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Women's Health > Urogynaecology > Flashcards

Urogynaecology Flashcards

1
Q

What do you ask in a incontinence history?

A
  • Prolapse - use word ‘bulge’ or ‘something coming down’ which is worse on activity
  • Leakage of urine and when it occurs (urgency or stress)
  • Frequency of micturition - day and night
  • Any difficulty passing urine?
  • Any dysuria? Any UTIs? Any blood in urine?
  • Difficulty emptying bowels? Does she have to digitate the vagina or rectum when using the toilet? Does she need to strain? Blood/discharge?
  • Faecal leakage/incontinence
  • Impact of pelvic floor problems on sexual activity
  • Full O+G hx
  • Other PMH - diabetes, neuro disorders and previous abdominal/pelvic surgery
  • Symptoms affecting QoL
  • Coping mechanisms: pads, fluid restriction, staying home or avoiding exercise
  • DH: beta blockers, alpha adrenergic
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2
Q

What are the red flags in urogynaecology?

A
  • Visible haematuria (often painless) - could indicate bladder cancer
  • OR pain associated with bladder filling
  • Abdominal swelling may indicate pelvic mass
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3
Q

What is the GP management for incontinence?

A
  1. Urine analysis to exclude infection
  2. Examine to exclude pelvic masses
  3. Review medication e.g. alpha blockers can contribute to incontinence
  4. Lifestyle advice - stop smoking
  5. Refer to community physiotherapist or community continence team for pelvic floor muscle training
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4
Q

What is the physiology of micturition?

A

Urethra has internal urethral sphincter and external urethral sphincter that are supported by pelvic floor muscles. When bladder fills - stretches and send signals to brain. If it’s appropriate to urinate at this time, then the brain sends inhibitory feedback. During urination time, the inhibition is removed - pelvic floor muscles relax and bladder contracts.
Urinary incontinence = involuntary leakage of urine

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5
Q

What is the ICI-Q questionnaire?

A

Evaluates which pelvic floor symptoms a patient has and rates the degree of bother experienced by the patient.

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6
Q

What is asked in an obstetric hx?

A
  • How many deliveries, what type of delivery
  • How big was the baby
  • Any instruments used
  • How long was the 2nd stage of labour
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7
Q

What do you want to check in a systems review?

A
  • Skin: rash/swelling in genital area - infection, contact dermatitis, lichens disease etc
  • MSK: injury (maybe spinal), arthritis, fibromyalgia
  • Neuro: MS, stroke
  • GI: incontinence with bowel dysfunction, IBS, IBD, diverticulitis, rectal prolapse
  • Reproductive tract: pelvic organ prolapse, ovarian cyst, endometriosis, cancer
  • Urinary: infection, stones
  • Sexual: libido, pain, lubrication, incontinence with orgasm/intercourse
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8
Q

Describe stress incontinence (most common)

A
  • Leakage when sneezing, coughing, laughing or any activity that increases abdominal pressure
  • Usually due to pelvic floor muscles being too weak
  • Causes: usually pregnancy/childbirth (overstretched pelvic muscles), when oestrogen during menstrual cycle and menopause > increased incidence of incontinence
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9
Q

Describe urge incontinence

A
  • Can’t retain urine due to overactive bladder (muscles contract excessively)
  • Unknown cause: thought to be a CNS problem (could be excess caffeine)
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10
Q

Describe overflow incontinence (rare in women)

A
  • Constant dribbling of urine due to bladder not being completely emptied during urination
  • Could be weak bladder muscles or blocked urethra
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11
Q

Describe total incontinence

A
  • Continuous and total loss of urinary control
  • One cause is neurogenic bladder - neuro problem that prevents bladder from emptying as it should (can be due to spinal cord injury, MS etc)
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12
Q

What are the lifestyle changes recommended for incontinence?

A
  • Bladder diary
  • Limit fluid intake (especially before bed/long trip but increase fibre to prevent constipation)
  • Cut down on caffeine/alcohol
  • Strengthen pelvic floor muscles, timing, voiding/bladder training therapy
  • Wear incontinence/menstrual pads
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13
Q

What are the medications for incontinence?

A
  • Urge incontinence: antimuscarinics e.g. oxybutinin, tolteridone, anticholinergics
  • Stress incontinence: topical oestrogen (oestrogen helps tone muscles around the urethra), mirabegron (beta 3 adrenoceptor agonist), botox (paralyses muscles), duloxetine
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14
Q

What are the non-surgical therapies for stress incontinence?

A
  • Pessary: ring shaped device inserted into vagina to hold up the bladder neck (needs to be taken out and cleaned regularly)
  • Bulking agent injections: inject collagen or carbon-coated beads injected into area surrounding urethra to support and keep it closed (minimally invasive procedure but has to be done a few times to be effective long-term)
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15
Q

What are the surgical therapies for incontinence?

A
  • Overactive bladder: sacral nerve stimulation (device placed inside buttock - sends inhibitory signals to sacral nerve)
  • Stress incontinence: bladder suspension, sling - tightening of bladder neck/urethra to strong ligaments within pelvis or pubic bones
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16
Q

What are the normal bladder diary values?

A
  • Intake 1500-2000ml, voided 250-500ml, capacity up to 500ml

- Frequency: 3-7 voids per day, output 1000-2800ml per 24hrs

17
Q

What is an enterocele?

A

Small intestine herniates into lower pelvic cavity, pushing top of vagina, creating a bulge - a form of pelvic organ prolapse.

18
Q

What are the symptoms of a pelvic organ prolapse?

A
  • Vaginal pressure/heaviness
  • Discomfort during sex
  • Vaginal/perineal pain or discomfort
  • Lower back/abdo pain
  • Urinary or faecal loss or retention
19
Q

What are the risk factors for pelvic organ prolapse?

A
  • Pregnancy
  • Genetic predisposition
  • Menopause
  • Advancing age
  • Pelvic surgery
  • Connective tissue disorder
  • Increased abdo pressure
20
Q

What are the types of prolapse?

A
  • Posterior compartment prolapse (rectocele)
  • Anterior compartment prolapse (cystocele)
  • Uterine prolapse
  • Vaginal vault prolapse
21
Q

What is the Pelvic Organ Prolapse Quantification Examination (PCP-Q)?

A
  • Stage 0: no prolapse, vaginal cuff/cervix is at the top of the vagina
  • Stage 1: leading part of the prolapse is >1cm away from the hymen
  • Stage 2: leading part of prolapse is <1cm above or below the hymen
  • Stage 3: leading edge is >1cm beyond the hymen, but < the total vaginal length
  • Stage 4: complete eversion
22
Q

What is the treatment for pelvic organ prolapse?

A
  • Non-surgical: pessaries (1st line 75% of the time)
  • Surgical: hysterectomy, sacrohysteropexy (suspend uterus using strip of synthetic mesh), uterosacral ligament suspension, colpocleisis (complete removal of vaginal lumen
23
Q

What are the treatments for detrusor overactivity?

A
  • Micrabegron
  • Botox
  • Sacral nerve stimulation
24
Q

What is urodynamics?

A

Tests bladder function: how the body stores and empties urine. Initially looks at speed and pattern of bladder emptying, with no catheter in place (uroflometry) - any urine left behind in the bladder (post-void residual) is measured either using USS or by passing a catheter.

25
Q

What are pressure catheters used for?

A

Pressure catheters are inserted into the bladder (to measure vesical pressure) and the vagina/rectum (to measure intra-abdominal pressure) and the bladder is filled with fluid. During filling, the detrusor pressure (which is the abdominal pressure minus the vesical pressure) is continually measured and various provocations (such as coughing, straining, running on spot, running taps) are undertaken to try and reproduce the patient’s symptoms. At the end of filling, the patient is then asked to pass urine with the catheters in place, in order to measure the pressure generated by the bladder when voiding.

26
Q

What are possible diagnoses from urodynamic studies?

A

Urodynamic stress incontinence (USI), detrusor overactivity (DO) and voiding dysfunction (poor coordination between bladder muscle and urethra > incomplete relaxation or overactivity of pelvic muscles during urination).

27
Q

What are the surgical interventions for stress incontinence?

A
  • Mid-urethral sling (MUS): tension free tapes made of polypropylene mesh and inserted via vaginal incision - support the mid-urethra during times of raised intra-abdominal pressure. Not allowed in UK, only under exceptional medical circumstances.
  • Colposuspension (open or laparoscopic): sutures to elevate the neck of bladder to stabilise the urethra and allow normal sphincter function. Risks include prolapse of posterior wall of vagina, voiding dysfunction and overactive bladder.
  • Urethral bulking: outpatient, lower success rate. Injected into urethra to narrow it so leakage is less likely. Common agents are collagen and water based gels
  • Fascial sling: strip of fascia (commonly from rectus sheath) is fashioned into a sling under the urethra. Risks: hernia formation, voiding dysfunction and OAB symptoms (urgency/incontinence).
28
Q

What is the innervation of the pudendal nerve?

A

S2, 3, 4 - supplies external genitalia and pelvic floor muscles

Women's Health (19 decks)

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