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Y4 - GOSH > Urogynaecology > Flashcards

Urogynaecology Flashcards

1
Q

What is urinary incontinence?

A
  • the loss of control of urination
  • it can be divided into stress incontinence & urge incontinence
  • it is possible to have a mixed picture
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2
Q

What causes urge incontinence?

A

caused by overactivity of the detrusor muscle of the bladder

also called “overactive bladder”

the detrusor muscle contracts before the bladder is full

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3
Q

What is the typical presentation of urge incontinence?

A
  • 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

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4
Q

What causes stress incontinence?

A
  • 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
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5
Q

What is the typical presentation of stress incontinence?

A
  • there is leakage when laughing, coughing, exercising or when surprised
  • this is due to an increased pressure on the bladder
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6
Q

If someone presents with mixed incontinence, what is it important to establish?

A
  • it is important to identify which type of incontinence is having the most significant impact
  • this will be the primary focus of treatment
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7
Q

What is overflow incontinence and why does it occur?

A
  • 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

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8
Q

What medications / conditions are associated with overflow incontinence?

A
  • anticholinergic medications
  • fibroids
  • pelvic tumours
  • neurological conditions - MS, diabetic neuropathy, spinal cord lesions
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9
Q

What are the risk factors for urinary incontinence?

A
  • increased age
  • high BMI
  • postmenopausal status
  • previous pregnancies + vaginal deliveries
  • pelvic floor surgery
  • pelvic organ prolapse
  • neurological conditions / cognitive impairment / dementia
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10
Q

What is the most important element of history taking in incontinence?

A
  • 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
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11
Q

What questions are asked in a history to establish the severity of incontinence?

A
  • frequency of urination AND incontinence
  • presence of nocturia
  • use of pads / changing of clothes
  • dysuria
  • haematuria
  • difficulty initiating urination / incomplete emptying
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12
Q

What gynae/obs questions need to be asked during an incontinence history?

A
  • 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?
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13
Q

What type of forceps are associated with an increased risk of incontinence?

A

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
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14
Q

Why is it important to establish menopausal status in incontinence?

A
  • 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

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15
Q

What other symptoms / medical conditions should be asked about in an incontinence history?

A
  • presence of prolapse symptoms
  • constipation
  • chronic cough (can worsen stress incontinence)
  • diabetes + how well controlled it is

polyuria can occur in poorly controlled diabetes

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16
Q

What questions are important to ask during a medication history in urinary incontinence?

A
  • 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

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17
Q

What questions need to be asked in the social history in urinary incontinence?

A
  • 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

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18
Q

What is involved in the physical examination in incontinence?

A

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

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19
Q

What investigation should be performed in all cases of incontinence?

A

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
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20
Q

Why is it important to calculate BMI in incontinence?

A
  • surgery is NOT performed unless BMI < 30
  • there is an 80% chance of failure if BMI is > 30
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21
Q

How can the strength of the pelvic floor muscles be assessed?

A

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
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22
Q

What is involved in the modified Oxford grading system?

A
  • 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
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23
Q

What is involved in the modified Oxford grading system?

A
  • 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

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24
Q

What are the first 2 stages in the management of incontinence (of either kind)?

A

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
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25
Q

Following physiotherapy, what other interventions may be offered in urge incontinence?

A

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

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26
Q

After initial interventions for incontinence management are implemented, what is done?

A
  • follow up in 3 months
  • this assesses whether lifestyle changes / physiotherapy has improved symptoms
  • further intervention may be required
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27
Q

What test should anyone presenting with stress incontinence have?

A

urodynamic test

  • can determine whether stress or urge incontinence is present
  • 1 in 10 presentations of stress incontinence are actually urge
28
Q

What is involved in urodynamic testing?

A
  • 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
29
Q

How do stress and urge incontinence appear on urodynamic testing?

A

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
30
Q

What is the leak point pressure on urodynamics and how is it measured?

A
  • 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
31
Q

What is involved in the management of stress incontinence?

A
  • 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
32
Q

What are the surgical options for stress incontinence?

A

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
33
Q

What is the first line treatment for urge incontinence?

A

bladder retraining

  • this involves gradually increasing the time between voiding
  • it should be performed for at least 6 weeks before other treatment is considered
34
Q

What are the first line medications for urge incontinence?

A

anticholinergics:

  • oxybutynin and tolterodine are usually used
  • solfencanin is sometimes used

vaginal oestrogens:

  • given to post-menopausal women who have vaginal atrophy
35
Q

What is an alternative medication to anticholinergics in urge incontinence?

A

mirabegron

(beta-3 agonist)

36
Q

What are the side effects associated with anticholinergic medications?

A
  • dry mouth / eyes
  • urinary retention
  • constipation
  • postural hypotension
  • can lead to cognitive decline, memory problems + worsening of dementia
  • use with CAUTION in elderly patients
37
Q

What are the contraindications to mirabegron?

A

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
38
Q

What is done if urge incontinence does not respond to anticholinergic medication?

A
  • a second anticholinergic is trialled
  • if this fails, invasive interventions are considered
39
Q

What are the invasive options for treating urge incontinence?

A

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
39
Q

What are the invasive options for treating urge incontinence?

A

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
40
Q

What is pelvic organ prolapse?

A
  • the descent of pelvic organs into the vagina
  • occurs due to weakness + lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder
41
Q

What are the 4 main types of prolapse?

A
  • uterine prolapse
  • rectocele
  • cystocele
  • vault prolapse
42
Q

What is a uterine prolapse?

A

the uterus descends into the vagina

43
Q

What is a vault prolapse?

A
  • occurs in women who have had a hysterectomy and do not have a uterus
  • the top of the vagina (vault) descends into the vagina
44
Q

What is a rectocele?

A
  • there is a defect in the posterior vaginal wall
  • this allows the rectum to prolapse forwards into the vagina
45
Q

What is the most prominent symptom of rectocele?

A
  • faecal loading can occur in the prolapsed part of the rectum
  • this causes significant constipation
  • there is urinary retention as the urethra is compressed
46
Q

How might a rectocele present?

A
  • 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
47
Q

What is a cystocele?

A
  • 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
48
Q

What are the risk factors for pelvic organ prolapse?

A
  • 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

49
Q

What is the presentation of a pelvic organ prolapse?

A
  • 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
50
Q

What do women often come presenting with in a prolapse?

A
  • a lump / mass in the vagina
  • they will sometimes be pushing back up themselves
  • it gets worse on straining or bearing down
51
Q

What should be done prior to examination of a prolapse?

A

ensure the patient has emptied their bladder + bowel

52
Q

What position should the patient be in for examination of a prolapse?

A
  • various positions are often attempted
  • this includes the dorsal and left lateral positions
53
Q

What is involved in a prolapse examination?

A

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
54
Q

How is the severity of prolapse graded?

A

Baden-Walker system

55
Q

What are the different grades in the Baden Walker system?

A

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
56
Q

What is uterine procidentia?

A

a prolapse extending beyond the introitus of the vagina

57
Q

What are the 3 treatment options for prolapse?

A
  1. conservative management
  2. pessary
  3. surgery
58
Q

When might conservative management for prolapse be chosen?

A
  • women who can cope with mild symptoms
  • they may not tolerate pessaries
  • and not be suitable for surgery
59
Q

What is involved in conservative management for prolapse?

A
  • physiotherapy + pelvic floor exercises
  • weight loss
  • vaginal oestrogen cream
  • lifestyle changes + treatment of symptoms if there is associated incontinence
60
Q

How do vaginal pessaries treat prolapse?

A
  • they are inserted into the vagina to provide extra support to the pelvic organs
  • they are removed + replaced regularly (usually every 4 months)
61
Q

How is it decided which type of pessary should be used?

A
  • 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
62
Q

What should always be given alongside a pessary and why?

A

vaginal oestrogen cream

  • this helps to protect the vaginal walls from irritation
  • pessaries can cause irritation and erosion over time
63
Q

When might surgery be considered for pelvic organ prolapse?

A
  • 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
64
Q

What are the potential complications of pelvic organ prolapse surgery?

A
  • recurrence of the prolapse
  • altered experience of sex
  • damage to the bladder / bowel
  • pain, bleeding, infection, risk of DVT
  • risk of anaesthetic
65
Q

What are mesh repairs and what is significant about them?

A
  • 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
66
Q

What are the complications associated with mesh repairs?

A
  • chronic pain
  • altered sensation
  • abnormal bleeding
  • urinary / bowel problems
  • dyspareunia (painful sex) for the woman / her partner

Y4 - GOSH (62 decks)

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