Urogynaecology

Question 1

What is urogynaecology?

Answer 1

-Issues with pelvic floor
-Prolapse
-Incontinence (stress and urge)
-Cross specialty working with urology and colorectal

Question 2

Examination in urogynaecology

Answer 2

-Abdominal
=Exclude pelvic mass
-Speculum and VE
=Best assessed using a Sims speculum in the left lateral position
=Check on straining/coughing/standing
==Can you see a prolapse?
==Where is the prolapse?
==How bad is the prolapse?
==Is there any urine leaking?
-Assess pelvic floor muscle strength (0-5; no contraction to strong contraction)

Question 3

Investigations in urogynaecology

Answer 3

-Bladder diary
-Urine dip
-Flow and scan (post void residual volume)
-Urodynamics
-Renal USS

Question 4

Main urogynaecology conditions

Answer 4

1. Prolapse
2. Incontinence
   =Stress
   =Urgency
   =Mixed

Question 5

What is a prolapse?

Answer 5

Protrusion of the uterus and/or vagina beyond its normal anatomical confides, bladder, urethra, rectum and bowel are often involved

Question 6

Symptoms of prolapse

Answer 6

-Dragging
-Pain
-Issues passing urine/ opening bowels
-Incomplete emptying
-Discomfort/ bleeding

-Ulceration
-Lump coming down
-Discharge

Question 7

Incidence of prolapse

Answer 7

-Difficult to define as many women do not present
-Clinical findings =/ symptoms
-Depends on how prolapse is defined
=50% women over 50/ 40% all women/ lump protruding out from introitus 2-12%/ 11.1% of women will have surgery for POP

Question 8

Aetiology of prolapse

Answer 8

-Pregnancy and SVD
=Uncommon nulip
=Mechanical injury and denervation
=↑ large babies, forceps, prolonged labour

-Congenital
=collagen abnormalities e.g. Ehlers-Danlos, Marfans

-Menopausal
=↑ incidence with increasing age
=? Deterioration of collagenases in connective tissue due to oestrogen withdrawal

-Chronic predisposing factors
=Chronic increased intra-abdominal pressure e.g. obesity, cough, constipation, pelvic mass

-Iatrogenic
=Hysterectomy; subsequent vaginal vault prolapse
=Continence procedures; elevating the bladder neck may lead to defects in other compartments ( Burch colposuspension ↑recto/enterocele)

Question 9

Types of prolpase

Answer 9

-Uterine
-Cystocele (bladder)
-Rectocele

Question 10

Grading of prolapse

Answer 10

0. No descent of pelvic organs during straining
1. Leading surface of prolapse does not descend below 1cm above the hymeneal ring
2. Leading edge of prolapse from 1cm above to 1cm below hymeneal ring
3. Prolapse extends >1cm below hymeneal ring but without complete vaginal eversion
4. Vagina completely everted (procidentia)

Question 11

Treatment of prolapse

Answer 11

-Life style
=Weight loss, alter fluid intake, stop smoking
-Pelvic floor exercises
-Pessary
=ring/donut, cube, gelhorn, shelf
-Physiotherapy
-Surgery
=Vaginal: vaginal hysterectomy, PFR (pelvic floor repair), SSF (stitches), Colpoclesis (close over vagina)
=Abdominal: sacrocolpopexy, sacrohysteropexy

Question 12

Urgency vs stress incontinence

Answer 12

Urgency
-Frequency; number of times
-Urgency; having to rush/ no warning
=Wet or dry
-Nocturia

Stress
-Leaking with increased abdominal pressure
=Coughing/ sneezing/ jumping/ walking

Feeling incomplete bladder emptying

Question 13

Treatment of stress incontinence

Answer 13

-Nothing
-Conservative
=Weight loss, alter fluid intake, stop smoking
-Physiotherapy
-Surgery
=Colposuspension, autologous sling, urethral bulking

Question 14

Treatment of urge incontinence

Answer 14

-Nothing
-Conservative
=Weight loss, alter fluid intake, stop smoking
-Physiotherapy
-Medical
=Anticholinergics, Beta 3 agonist; mirabegron, Botox, Surgery

Question 15

Prevention of prolapse and incontinence

Answer 15

-↓ prolonged labour
-↓ trauma secondary to instrumental delivery
-Postnatal pelvic floor exercises
-Weight reduction
-Rx constipation
-Rx chronic cough/stop smoking