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Gynaecology > Urogynaecology > Flashcards

Urogynaecology Flashcards

1
Q

What is the prevalence of ‘any’ incontinence?

A

25-45%

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2
Q

What is the prevalence of SUI (isolated)?

A

10-40%

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3
Q

What is the prevalence of mixed urinary incontinence?

A

7-25%

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4
Q

What is the prevalence of urge urinary incontinence?

A

1-7%

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5
Q

How does age impact on incontinence?

A

UI increases with age, can be explained by confounding factors

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6
Q

how does obesity impact on incontinence?

A

Obesity doubles the risk of UI

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7
Q

how does parity impact on urinary incontinence?

A

increased risk of UI with increased parity, particularly in 3rd and 4th decades

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8
Q

How does mode of delivery change risk profile for urinary incontinence?

A

C/S confers a short term protective effect
long term SUI risk doubles with h/o vaginal delivery
long term UUI risk mildly increased with h/o vaginal delivery
exclusively C/S - same rates of UUI in age matched peers

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9
Q

List 4 obstetric factors that impact on urinary incontinence - these are potentially modifiable risk factors

A

IOL and epidural associated with early pelvic prolapse and persistent UI
forceps delivery
episiotomy (evidence actually show no harm or benefit??)
birth weight/max weight at deliveries

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9
Q

List 4 obstetric factors that impact on urinary incontinence - these are potentially modifiable risk factors

A

IOL and epidural associated with early pelvic prolapse and persistent UI
forceps delivery
episiotomy (evidence actually show no harm or benefit??)
birth weight/max weight at deliveries

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10
Q

List 4 obstetric factors that impact on urinary incontinence - these are potentially modifiable risk factors

A

IOL and epidural associated with early pelvic prolapse and persistent UI
forceps delivery
episiotomy (evidence actually show no harm or benefit??)
birth weight/max weight at deliveries

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11
Q

How does MHT/HRT impact on urinary incontinence?

A

systemic estrogen (oral, +/- progesterone) increases incidence of UI
HERS study - MHT worsening incontinence over 4 years

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12
Q

In the HERS study it was shown that the MHT group had worsening incontinence over 4 years - what was the incidence difference between groups?

A

40% vs 27%

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13
Q

how does diet impact on incontinence?

A

caffeinated drinks may have an impact although this is unclear

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14
Q

How does socio-economic status impact on incontinence?

A

Higher SES - increased care seeking for UI (this does NOT mean a causal relationship however)

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15
Q

Does smoking impact on incontinence risk?

A

Likely not causal risk factor although there is an association

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16
Q

How does exercise impact on incontinence?

A

Low impact may be protective
High impact may be harmful

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17
Q

List 3 comorbidities that may impact incontinence?

A

diabetes - evidence conflicting
dementia (association but unlikely causation)
ischaemic heart disease

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18
Q

How does ethnicity impact on urinary incontinence

A

SUI 2x more common in European American women cf African American women
asian women report less SUI and UUI (does not mean they have less)

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19
Q

does genetics have a role to play in incontinence?

A

SUI and UUI strongly heritable (twin studies )
UUI» SUI

20
Q

What is the definition of overactive bladder?

A

a syndrome of urinary incontinence +/- UUI, characterised by increased urinary frequency during day and at night time

21
Q

What is the prevalence of OAB?

A

3-40% (median 15%)

22
Q

How can OAB impact on QOL?

A

increased risks of falls and fractures
nocturia - >2 at nighttime = symptomatic

23
Q

briefly describe the micturition reflex

A

3 muscles involved
Bladder and internal sphincter are smooth muscle and under involuntary control/ANS
The External sphincter is striated, skeletal muscle and under voluntary control

The bladder has predominantly beta adrenergic receptors
The internal sphincter has predominantly alpha 1 adrenoreceptors
Sympathetic stimulation of the beta adrenergic receptors of the bladder via the hypogastric nerve result in relaxation of the detrusor muscle which helps maintain continence
Sympathetic stimulation of the alpha adrenoreceptors of the internal sphincter via the hypogastric nerve causes contraction of the IS muscle which also maintains continence by blocking off the bladder neck
Parasympathetic stimulation of the detrusor SM and the IS SM is carried via the pelvic nerve and results in bladder emptying (contraction of detrusor and relaxation of IS)

The skeletal muscle of the ES is under voluntary control. The pudendal nerve sends signals from the sacral spinal cord (S2,3,4) causing contraction of the ES and maintaining continence.

The pontine micturition center has oversight of the micturition response.
When it is inappropriate to void - it does not send inhibitory signals, and allows the sympathetic nervous system via the hypogastric nerve to maintain continence, as well as allowing the pudendal nerve to continue to cause contraction of the ES.
When it IS appropriate to void - the PMC sends inhibitory signals which inhibit the sympathetic nervous system and the hypogastric nerve + inhibits the pudendal nerve. The parasympathetic nervous system via the pelvic nerve is able to cause; contraction of detrusor muscle, relaxation of IS. The pudendal nerve stops causing contraction of the ES. And the bladder can empty.

24
Q

What is bladder training best for?

A

Urge urinary incontinence
mixed urinary incontinence

25
Q

How does bladder training start?

A

start with voiding every 1 hour for first week then increase time in between voiding by 15-30 mins each week til 3-4 hourly void achieved

26
Q

What methods are used to train bladder when urge to void comes on?

A

when urge to void comes on
- sit down
- use distraction or mental relaxation techniques
- quick contraction of pelvic floor muscles

27
Q

What medications can be used for urge urinary incontinence?

A

Anti-cholinergics e.g. oxybutinin, vesi-care, solifenacin
Beta 3 agonists e.g. Betmiga/mirabegron
Botox

28
Q

What is the MOA of solifenacin and other anticholinergic agents?

A

competitive inhibition of acetyl choline action by binding to muscarinic receptors in bladder - reduced smooth muscle contraction of bladder
- increases bladder capacity
- reduces urgency

29
Q

What is the MOA of Betmiga/Mirabegron?

A

Stimulates B3 adrenergic receptors to facilitate smooth muscle relaxation

30
Q

What is the MOA of botulinum toxin in OAB?

A

Inhibits Acetyl-choline release from peripheral nerve cells into Neuro- muscular junction

31
Q

At a cellular level, how does Botox work?

A

Made up of a heavy chain and a light chain
Heavy chain binds to receptor at terminal nerve ending
endocytosis of peptide into the cytoplasm
in cytoplasm the light chain cleaves SNARE protein which are necessary for exocytosis of acetylcholine
acetylcholine remains in the neuron, unable to bind to receptors on muscle fibres - cannot stimulate muscle contraction

32
Q

At a cellular level, how does Botox work?

A

Made up of a heavy chain and a light chain
Heavy chain binds to receptor at terminal nerve ending
endocytosis of peptide into the cytoplasm
in cytoplasm the light chain cleaves SNARE protein which are necessary for exocytosis of acetylcholine
acetylcholine remains in the neuron, unable to bind to receptors on muscle fibres - cannot stimulate muscle contraction

33
Q

What is the regimen for botox?

A

Intra vesical injection
Given under GA or LA
takes 10-14 days to take effect
Lasts 6-9 months

34
Q

What are the risks of botox?

A

Urine infection - 25%
urinary retention - if this occurs need to self catheterise

35
Q

How would you make the diagnosis of ‘pure’ stress urinary incontinence?

A
  • involuntary leakage of urine only when increasing intra-abdominal pressure e.g. cough, sneeze, laugh, jump
  • urethral hyper-mobility on exam
  • urodynamics showing leak only with increasing IAP and no voluntary detrusor overactivity
36
Q

Give 2 conservative options for treatment of SUI

A
  • reduced fluid intake - urethral sphincters can hold against a certain pressure so aim to keep the IVP less than this
  • pelvic floor muscle exercises - increasing resting tone of Levator ani which supports the urethra, maintaining closure.
36
Q

Give 2 non surgical options for treatment of SUI

A
  • reduced fluid intake - urethral sphincters can hold against a certain pressure so aim to keep the IVP less than this
  • pelvic floor muscle exercises - increasing resting tone of Levator ani which supports the urethra, maintaining closure.
37
Q

If a woman presents to you asking about ‘mesh’ what would you tell her?

A

The US FDA have issued a warning against the use of TV mesh for pelvic organ prolapse
This is a separate issue to the use of mesh for mid urethral slings for the treatment of SUI
There is an extensive body of literature that supports the use of mesh in context of SUI
MUS is highly effective in the short and medium term for the treatment of SUI
MUS carries lower risk than other continence procedures
MUS is the operation of choice in USA, Europe and Australia for treatment of SUI

38
Q

What are the main differences between the transobturator and retropubic approaches to MUS for SUI?

A
  • TO approach associated with higher incidence of pelvic and groin pain post operatively
  • RP approach associated with higher rate of visceral injury
  • RP more effective than TO which has higher failure rate
  • same rates of mesh exposure - 2% each
  • easier to completely remove mesh when placed RP than TO
  • higher recurrent operation rates with TO than RP
39
Q

For which women would you offer TO approach over RP approach for a mid-urethral sling placement?

A
  • women who have had extensive abdominal surgery previously (higher rate of visceral injury)
  • women who are on anti-coagulation and unable to cease it
  • in women with compromised voiding pre-operatively
40
Q

what are the complications a woman undergoing MUS procedure must be consented for?

A

bleeding, damage to the bladder, bowel, urethra and major vessel perforation
voiding difficulties which may require self catheterisation, loosening or even division of the sling later on - which may result in recurrent SUI
de novo urge incontinence or worsening of overactive bladder symptoms may occur
sling insertion may cause pain, and with the TO approach possibly groin pain
This may become intractable but is usually short lived

41
Q

What would you advise about mesh erosion with the placement of MUS for SUI?

A
  • mesh erosion occurs in about 5% of women who under insertion of mesh material
  • only a small number of these women have ongoing issues
  • 1/150 women will require removal of MUS for mesh erosion symptoms - in these cases 80% have no further symptoms
42
Q

What is a normal void volume?

A

greater than 150ml

43
Q

what is a normal female flow rate?

A

> 14ml/sec

44
Q

what is a normal post void residual?

A

<100ml

45
Q

List 3 contraindications to the use of anti-muscarinic agents

A
  • uncontrolled narrow angle glaucoma
  • cardiac arrhythmias
  • urinary retention
46
Q

What is the basis of use of neuromodulation techniques for OAB?

A
  • Stimulation of the S3 nerve root modulates the bladder reflex pathways at spinal and supra spinal level
  • stimulation of the afferent nerve fibres results in activation of inhibitory sympathetic neurons resulting in inhibition of bladder activity
47
Q

what surgical options are available for OAB?

A
  • detrusor myomectomy
  • urinary diversion as a last option (ileal conduit)

Gynaecology (25 decks)

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