Urogynaecology Flashcards
What is urinary incontinence?
- the loss of control of urination
- it can be divided into stress incontinence & urge incontinence
- it is possible to have a mixed picture
What causes urge incontinence?
caused by overactivity of the detrusor muscle of the bladder
also called “overactive bladder”
the detrusor muscle contracts before the bladder is full
What is the typical presentation of urge incontinence?
- a sudden urge to pass urine
- there is a sudden need to rush to the bathroom and often not making it in time
this has a significant impact on QoL with many women avoiding work / activities where there is not easy access to a toilet
What causes stress incontinence?
- caused by weakness of the pelvic floor and sphincter muscles
- the urethral, vaginal and rectal canals become lax when they are poorly supported by the pelvic floor muscles
What is the typical presentation of stress incontinence?
- there is leakage when laughing, coughing, exercising or when surprised
- this is due to an increased pressure on the bladder
If someone presents with mixed incontinence, what is it important to establish?
- it is important to identify which type of incontinence is having the most significant impact
- this will be the primary focus of treatment
What is overflow incontinence and why does it occur?
- occurs in chronic urinary retention due to an obstruction to the outflow of urine
- chronic urinary retention results in an overflow of urine and incontinence WITHOUT the urge to pass urine
this is more common in males and rare in females
What medications / conditions are associated with overflow incontinence?
- anticholinergic medications
- fibroids
- pelvic tumours
- neurological conditions - MS, diabetic neuropathy, spinal cord lesions
What are the risk factors for urinary incontinence?
- increased age
- high BMI
- postmenopausal status
- previous pregnancies + vaginal deliveries
- pelvic floor surgery
- pelvic organ prolapse
- neurological conditions / cognitive impairment / dementia
What is the most important element of history taking in incontinence?
- establish whether it is stress or urge incontinence
- is there leakage when coughing / lauging
- is there a sudden urge to pass urine with a loss of control on the way to the toilet
What questions are asked in a history to establish the severity of incontinence?
- frequency of urination AND incontinence
- presence of nocturia
- use of pads / changing of clothes
- dysuria
- haematuria
- difficulty initiating urination / incomplete emptying
What gynae/obs questions need to be asked during an incontinence history?
- presence of a uterus
- pre- or post-menopausal
- pain / incontinence during intercourse
- previous pregnancies and delivery method including type of forceps used
- smear tests - are they up to date?
What type of forceps are associated with an increased risk of incontinence?
Kielland forceps
- these are used when rotation of the fetal head is required
- the rotary motion can disturb the pelvic floor muscles and result in stress incontinence
Why is it important to establish menopausal status in incontinence?
- vaginal atrophy can occur after the menopause
- this causes urinary frequency + recurrent UTIs
- the vaginal cells become more flaccid in the absence of oestrogen
replacing the oestrogen can often sort the symptoms
What other symptoms / medical conditions should be asked about in an incontinence history?
- presence of prolapse symptoms
- constipation
- chronic cough (can worsen stress incontinence)
- diabetes + how well controlled it is
polyuria can occur in poorly controlled diabetes
What questions are important to ask during a medication history in urinary incontinence?
- are they taking diuretics
- are they taking laxatives
- have they already tried medication for their urinary symptoms? - what was it? did it help? any side effects?
diuretic may be able to be discontinued or the dose changed
What questions need to be asked in the social history in urinary incontinence?
- caffeine consumption
- alcohol consumption
- use of ketamine
- smoking
- carbonated drinks
- occupation - is heavy lifting involved? does the environment contain dust / chemicals?
caffeine is found in tea (incl. green tea), chocolate, pro plus, energy drinks + coffee
What is involved in the physical examination in incontinence?
examination assesses the pelvic tone and examines for:
- atrophic vaginitis
- pelvic organ prolapse
- pelvic masses
- urethral diverticulum
- the patient is asked to cough to observe for leakage from the urethra
abdominal and vaginal examinations are performed
What investigation should be performed in all cases of incontinence?
urine dipstick +/- MSU
- this examines for microscopic haematuria
- if present, urine dip is repeated in 2 weeks
- if still present, patient is referred via 2WW pathway
- also can detect presence of chronic / recurrent UTIs
Why is it important to calculate BMI in incontinence?
- surgery is NOT performed unless BMI < 30
- there is an 80% chance of failure if BMI is > 30
How can the strength of the pelvic floor muscles be assessed?
bimanual examination
- ask the woman to squeeze against the examining fingers
- the modified Oxford grading system can be used to grade strength of pelvic muscle contractions
What is involved in the modified Oxford grading system?
- 0 - no contraction
- 1 - faint contraction
- 2 - weak contraction
- 3 - moderate contraction with some resistance
- 4 - good contraction with resistance
- 5 - strong contraction - firm squeeze + drawing inwards
What is involved in the modified Oxford grading system?
- 0 - no contraction
- 1 - faint contraction
- 2 - weak contraction
- 3 - moderate contraction with some resistance
- 4 - good contraction with resistance
- 5 - strong contraction - firm squeeze + drawing inwards
stage 1 can also be described as a “flicker” of contraction
What are the first 2 stages in the management of incontinence (of either kind)?
lifestyle changes:
- reduce caffiene / fizzy drinks / smoking / alcohol
- weight loss
physiotherapy:
- pelvic floor exercises
- this involves 8 contractions 3 times a day for 3 months
Following physiotherapy, what other interventions may be offered in urge incontinence?
bladder diary:
- tracks fluid intake + urination + episodes of incontinence
- should be tracked over at least 3 days
- days should be a mixture of work and leisure days
bladder drills
After initial interventions for incontinence management are implemented, what is done?
- follow up in 3 months
- this assesses whether lifestyle changes / physiotherapy has improved symptoms
- further intervention may be required
What test should anyone presenting with stress incontinence have?
urodynamic test
- can determine whether stress or urge incontinence is present
- 1 in 10 presentations of stress incontinence are actually urge
What is involved in urodynamic testing?
- a thin catheter is inserted into the bladder and into the rectum
- the catheters measure the pressure in the bladder / rectum
- the bladder is filled with fluid
- stress incontinence is present if the bladder pressure + rectal pressure rise equally, there is no influence from the detrusor muscle contracting
How do stress and urge incontinence appear on urodynamic testing?
stress incontinence:
- there is a matching rise in bladder pressure and abdominal (rectal) pressure
- there is no activity of the detrusor muscle
urge incontinence:
- there is an increase in bladder pressure + detrusor muscle activity
- there is no change in abdominal pressure
What is the leak point pressure on urodynamics and how is it measured?
- the point at which the bladder pressure results in leakage of urine
- the patient is asked to cough / move / jump when the bladder is filled to various capacities
- this assesses for stress incontinence
What is involved in the management of stress incontinence?
- a trial of duloxetine
- if this is unsuccessful, surgery is considered
- pelvic floor exercises must be performed for at least 3 months before surgery is considered
What are the surgical options for stress incontinence?
autologous sling procedures:
- a strip of fascia is used to support the urethra
colposuspension:
- involves pulling the vaginal wall forward to increase support to the urethra
intramural urethral bulking:
- injections around the urethra to reduce diameter + add support
What is the first line treatment for urge incontinence?
bladder retraining
- this involves gradually increasing the time between voiding
- it should be performed for at least 6 weeks before other treatment is considered
What are the first line medications for urge incontinence?
anticholinergics:
- oxybutynin and tolterodine are usually used
- solfencanin is sometimes used
vaginal oestrogens:
- given to post-menopausal women who have vaginal atrophy
What is an alternative medication to anticholinergics in urge incontinence?
mirabegron
(beta-3 agonist)
What are the side effects associated with anticholinergic medications?
- dry mouth / eyes
- urinary retention
- constipation
- postural hypotension
- can lead to cognitive decline, memory problems + worsening of dementia
- use with CAUTION in elderly patients
What are the contraindications to mirabegron?
uncontrolled hypertension
- blood pressure must be monitored during treatment
- mirabegron raises the BP, which can lead to a hypertensive crisis
- and increased risk of TIA / stroke
What is done if urge incontinence does not respond to anticholinergic medication?
- a second anticholinergic is trialled
- if this fails, invasive interventions are considered
What are the invasive options for treating urge incontinence?
botulinum toxin type A:
- a botox injection into the bladder wall
- repeated every 6 months
percutaneous sacral nerve stimulation:
- a device implanted in the back stimulates the sacral nerves
augmentation cystoplasty:
- bowel tissue is used to enlarge the bladder
urinary diversion:
- urinary flow is redirected to a urostomy
What are the invasive options for treating urge incontinence?
botulinum toxin type A:
- a botox injection into the bladder wall
- repeated every 6 months
percutaneous sacral nerve stimulation:
- a device implanted in the back stimulates the sacral nerves
augmentation cystoplasty:
- bowel tissue is used to enlarge the bladder
urinary diversion:
- urinary flow is redirected to a urostomy
What is pelvic organ prolapse?
- the descent of pelvic organs into the vagina
- occurs due to weakness + lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder
What are the 4 main types of prolapse?
- uterine prolapse
- rectocele
- cystocele
- vault prolapse
What is a uterine prolapse?
the uterus descends into the vagina
What is a vault prolapse?
- occurs in women who have had a hysterectomy and do not have a uterus
- the top of the vagina (vault) descends into the vagina
What is a rectocele?
- there is a defect in the posterior vaginal wall
- this allows the rectum to prolapse forwards into the vagina
What is the most prominent symptom of rectocele?
- faecal loading can occur in the prolapsed part of the rectum
- this causes significant constipation
- there is urinary retention as the urethra is compressed
How might a rectocele present?
- there may be a palpable lump in the vagina
- women may use their fingers to push the lump backwards, correcting the anatomical position and allowing them to open their bowels
What is a cystocele?
- there is a defect in the anterior abdominal wall
- the bladder prolapses backwards into the vagina
- prolapse of the urethra is possible (urethrocele)
- prolapse of the bladder + urethra is a cystourethrocele
What are the risk factors for pelvic organ prolapse?
- multiple vaginal deliveries
- instrumental, traumatic or prolonged delivery
- advanced age
- postmenopausal status
- obesity
- chronic coughing
- chronic constipation
the risk factors are all related to weak and stretched muscles / ligaments in the pelvic floor
What is the presentation of a pelvic organ prolapse?
- a dragging / heavy sensation in the pelvis
- a feeling of “something coming down” in the vagina
- urinary symptoms - frequency, urgency, retention, weak stream
- bowel symptoms - constipation, urgency, incontinence
- sexual dysfunction - pain, altered sensation
What do women often come presenting with in a prolapse?
- a lump / mass in the vagina
- they will sometimes be pushing back up themselves
- it gets worse on straining or bearing down
What should be done prior to examination of a prolapse?
ensure the patient has emptied their bladder + bowel
What position should the patient be in for examination of a prolapse?
- various positions are often attempted
- this includes the dorsal and left lateral positions
What is involved in a prolapse examination?
Sim’s speculum
- a U-shaped speculum used to support the anterior or posterior vaginal wall while the other walls are examined
- the woman is asked to cough / bear down to assess full descent of the prolapse
- Sim’s speculum held on anterior wall to assess for rectocele
- and it is held on the posterior wall to assess for cystocele
How is the severity of prolapse graded?
Baden-Walker system
What are the different grades in the Baden Walker system?
normal:
- normal position for each respective site
first degree:
- descent halfway to the hymen
second degree:
- descent to the hymen
third degree:
- descent halfway past the hymen
procidentia:
- maximum possible descent
What is uterine procidentia?
a prolapse extending beyond the introitus of the vagina
What are the 3 treatment options for prolapse?
- conservative management
- pessary
- surgery
When might conservative management for prolapse be chosen?
- women who can cope with mild symptoms
- they may not tolerate pessaries
- and not be suitable for surgery
What is involved in conservative management for prolapse?
- physiotherapy + pelvic floor exercises
- weight loss
- vaginal oestrogen cream
- lifestyle changes + treatment of symptoms if there is associated incontinence
How do vaginal pessaries treat prolapse?
- they are inserted into the vagina to provide extra support to the pelvic organs
- they are removed + replaced regularly (usually every 4 months)
How is it decided which type of pessary should be used?
- women often try a few types of pessary before finding the correct comfort / symptom relief
- the ring pessary allows for sexual intercourse without removal
- the cube pessary tends to be used by younger women as it is taken out every night and during sex
What should always be given alongside a pessary and why?
vaginal oestrogen cream
- this helps to protect the vaginal walls from irritation
- pessaries can cause irritation and erosion over time
When might surgery be considered for pelvic organ prolapse?
- this may be an anterior / posterior repair or hysterectomy
- the benefits are balanced against the risks
- e.g. wanting more children in the future, presence of comorbidities
What are the potential complications of pelvic organ prolapse surgery?
- recurrence of the prolapse
- altered experience of sex
- damage to the bladder / bowel
- pain, bleeding, infection, risk of DVT
- risk of anaesthetic
What are mesh repairs and what is significant about them?
- a plastic mesh is inserted to support the pelvic organs
- can be used to treat prolapse / incontinence
- they are no longer performed due to the risks, but complications from previous procedures may present
What are the complications associated with mesh repairs?
- chronic pain
- altered sensation
- abnormal bleeding
- urinary / bowel problems
- dyspareunia (painful sex) for the woman / her partner
