Urogynaecology Flashcards
How does urinary incontinence present / what is important to ask about in the history?
-Urinary frequency, nocturia, dysuria, haematuria, urgency, difficulty initiating / emptying
-Constipation?
-Problems with intercourse?
-Smear up to date?
-Taken any diuretics?
-Caffeine, fizzy drinks, alcohol, smoking, ketamine intake
-When does it occur? (distinguish between stress and urge)
What risk factors are there for urinary incontinence?
-Increasing age
-Previous pregnancy and vaginal delivery
-High BMI
-Hysterectomy
-FHx
How should you examine a patient with urinary incontinence?
-BMI
-Urine dip / MSU to rule out UTI
-Abdo exam (?mass)
-Cough - any leakage?
-Assess for prolapse
-Vaginal atrophy? Fibroid uterus?
What is the difference between stress and urge incontinence?
STRESS = involuntary leakage on:
-Effort
-Exertion
-Sneezing
-Coughing
URGE = involuntary leakage accompanied / preceded by sudden urgency
What is the aetiology of stress vs urge incontinence?
STRESS = lax pubo-urethral ligament
-Surrounds bladder neck , should contract to prevent leakage
URGE = suggests detrusor muscle overactivity
What does urodynamics involve?
Used to distinguish between SUI and UUI if initial management has had no effect
-Probes placed in bladder and rectum
-Bladder filled with saline
-Patient asked to cough / strain and observe for leakage
-Incontinence during coughing / straining in the absence of detrusor muscle overactivity –> SUI
What are the management steps for stress and urge incontinence?
STRESS
-Lifestyle changes (weight loss, fluids intake)
-Physiotherapy (pelvic floor exercises 8x 3x a day for 3 months)
-Follow up after 3 months
URGE
-Lifestyle changes (weight loss, fluids intake)
-Physiotherapy (pelvic floor exercises 8x 3x a day for 3 months)
-Bladder diary + bladder drills
-Anticholinergics (oxybutanin) / vaginal oestrogens
-Follow up after 3 months
What are the management options for stress and urge incontinence after urodynamics?
MDT discussion
STRESS
-Duloxetine (SSNRI)
-Surgery
URGE
-2nd anticholinergic eg darifenacin
-Cystoscopy and botox
–If not suitable –> percutaneous posterior nerve stimulation
-Percutaneous sacral nerve stimulation if no effect
-Augmentation cytoplast OR urinary diversion (external)
How is a prolapse defined?
-When the normal support structures for the organs within the pelvis are weakened
-Resulting in one or more organs dropping down into the vagina (uterus, bladder, rectum)
What are the 5 main types of prolapse?
-Urethrocele (urethra into vagina)
-Cystocele (bladder into vagina)
-Utero-vaginal prolapse (uterus into vagina
-Rectocele (front wall of rectum into back wall of vagina)
-Enterocele (herniation of peritoneal sac between vagina and rectum)
What are the main risk factors for developing a prolapse?
-General - menopause, obesity
-Chronic raised pressure - COCP, constipation
-Obstetric - multiparity
How does prolapse typically present?
-Sensation of something ‘coming down’
-Sexual dysfunction
-Urinary symptoms
-Able to see a bulge
-Generalised lower back pain
-Rectocele may cause problems with defecation
How should you examine a patient with prolapse?
-Assess for abdominal / pelvic mass
-Assess for vulval atrophy (menopause)
-Assess cough (may lower prolapse due to raised abdominal pressure)
-Vaginal examination (ask patient to bear down)
-Sims speculum with patient in LL position to assess vaginal wall
How should a prolapse be managed?
-Only treat if moderate/severe and experiencing symptoms
-Treat any causes of raised intra-abdominal pressure
-Conservation - weight loss, pelvic floor exercises, avoid heavy lifting
-Pessary
–Mechanical support, able to have intercourse with some, can change every 6 months
-Surgical repair
–Often includes vault suspension
