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MSRA Content > Urogynaecology > Flashcards

Urogynaecology Flashcards

1
Q

How is the bladder function controlled?

A

 External sphincter and pelvic floor muscles maintaining urethral pressure > bladder pressure
 Micturition occurs when these muscles relax and bladder detrusor muscle contracts
 Neuronal – para aids voiding, symp prevents it

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2
Q

How common is stress incontinence? What is stress urinary incontinence? Causes?

A
  • Commonest urinary complaint, 1 in 10 will suffer
  • The involuntary leak of urine on effort or exertion, or on sneezing or coughing.
  • The leakage is usually a small discrete amount, coinciding with the physical activity
  • Due to urethral sphincter weakness or prolapse of sphincter below pelvic floor
  • Increased intra-abdominal pressure transmitted to the bladder but not the urethra. Bladder pressure > urethral pressure when intra-abdominal pressure is raised (e.g. when coughing).
  • Causes: pregnancy, oestrogen deficiency at menopause, surgery, radiation
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3
Q

How common is urge incontinence? What is urge urinary incontinence? Causes?

A
  • Common, affects 1 in 6 women
  • The involuntary leakage of urine accompanied by, or immediately preceded by, a strong desire to pass urine (void).
  • Uncontrolled increases in detrusor pressure increasing bladder pressure beyond that of the normal urethra.
  • ‘Overactive bladder’ previously called ‘detrusor instability’ is the most common cause of this mechanism.
  • Causes – idiopathic, MS, spina bifida, UMN lesions, surgery
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4
Q

What is mixed urinary incontinence?

A

• The involuntary leakage of urine associated both with urgency and with exertion, effort, sneezing or coughing.

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5
Q

What is overflow incontinence?

A
  • Occurs when the bladder becomes large and flaccid and has little or no detrusor tone or function.
  • This is usually due to injury or insult (e.g. blockage, after surgery or post-partum)
  • The condition is diagnosed when the urinary residual is more than 50% of bladder capacity.
  • The bladder simply leaks when it becomes full.
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6
Q

When does continuous urinary incontinence occur?

A

• Classically it is associated with a fistula or congenital abnormality (e.g. ectopic ureter)

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7
Q

Symptoms of urinary incontinence?

A

Stress - leakage of urine on sneezing, coughing, exercise, rising from sitting or lifting

Urge - urgency and failure to reach toilet, frequency and nocturia possible

Other symptoms to ask:
Frequency during day/night, dysuria, haematuria,, dribbling of urine after leaving toilet, feeling incomplete bladder emptying

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8
Q

Gynae history important in urinary incontinence?

A 
Uterus or not
Pre/Postmenopausal
Problems with intercourse
How many babies - delivery method
Smear tests up to date
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9
Q

PMH important in urinary incontinence?

A

Prolapse symptoms - dragging, feel mass, backache
Constipation
Chronic cough
Diabetes

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10
Q

DH important in urinary incontinence?

A

Diuretics
Laxatives
Medications for urinary symptoms in past

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11
Q

SH for urinary incontinence?

A 
Caffeine intake
Carbonated drinks
Alcohol
Smoking
Ketamine
Occupation - heavy lifting?
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12
Q

Examination performed in incontinence?

A 
History including obstetric, sexual and functional status
BMI and Urine dipstick & MSU
Abdominal and pelvic examination
Cough - any leakage?
Assess for prolapse
Assess for vaginal atrophy
VE
Smear
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13
Q

Investigations in urinary incontinence?

A
  • Urinalysis and MSU microscopy (culture and sensitivity)
    o Exclude UTI
  • OGTT if diabetes suspected
  • Frequency/volume chart
    o Should be filled in for 72h and give idea off fluid intake and voiding problems
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14
Q

When should a cystoscopy be performed in urinary incontinence?

A

o Used to visualise urinary tract

o Indicated if recurrent UTI, haematuria, bladder pain, suspected fistula, tumour

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15
Q

What are the specialist tests performed for urinary incontinence?How do they work?

A

Urodynamics

o Uroflowmetry
Ability of bladder to store and void urine
Patient voids in private onto commode with urinary flow meter, measuring voided volume over time and plotting graph
o Cystometry
Invasive and involves measuring pressure and volume in bladder during filling and voiding
Bladder filled with saline and intravesical & vaginal/rectal probe measure differences in pressure to give detrusor pressure
Patient first desire to void, strong desire to void and cough
Diagnoses stress incontinence

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16
Q

Initial management of stress urinary incontinence?

A 
Lifestyle interventions
•	Weight reduction if BMI >30
•	Smoking cessation
•	Reduce caffeine and fizzy drinks
•	Treatment of chronic cough and constipation

Pelvic floor muscle training
• For at least 3 months
• Exercises continued long-term.
• 8-12 slow maximal contractions sustained for 6-8 seconds each, 3x per day

Follow up 3 months

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17
Q

Follow up management of stress urinary incontinence?

A

Urodynamics

MDT Meeting

Duloxetine
• SNRI enhances urethral striated sphincter activity via a centrally mediated pathway.
• Dose-dependent decreases in frequency of incontinence episodes

Transvaginal tape

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18
Q

Pharmacological management of stress urinary incontinence?

A

Duloxetine
• SNRI enhances urethral striated sphincter activity via a centrally mediated pathway.
• Dose-dependent decreases in frequency of incontinence episodes

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19
Q

Surgical management of stress urinary incontinence ? When considered and what types?

A

Considered when other measures failed

Transvaginal Tape
• Polypropylene mesh tape placed under mid-urethra via small vaginal incision
• Risks – bladder injury, voiding difficulty, tape erosion

Periuretheral injections
• Bulking agents, better for older, frail or young women

20
Q

Initial management of urge urinary incontinence?

A

Lifestyle advice
• Weight reduction if BMI >30, smoking cessation, reduce caffeine and fizzy drinks, treatment chronic cough and constipation

Pelvic floor muscle training
• 3 months, exercises continued long-term, 8-12 slow maximal contractions sustained for 6-8 seconds each, 3x per day

Bladder diary (>3 days) - idea of fluid intake and bladder voiding problems

Bladder drills
• Ability to suppress urinary urge and extend the intervals between voiding

Anticholinergics - Oxybutynin (+/- vaginal oestrogen if vaginal atrophy)

Follow up 3 months

21
Q

Describe properties of initial pharmacological management of urge urinary incontinence? SE? CI?

When is botox used?

A

Anticholinergic (antimuscarinic) agents (oxybutynin)
• Block the sympathetic nerves thereby relaxing the detrusor muscle
• Side effects = dry mouth (up to 30%), constipation, nausea, dyspepsia, flatulence, blurred vision, dizziness, insomnia, palpitation, arrhythmias.
• Contraindications = acute (narrow angle) glaucoma, myaesthenia gravis, urinary retention or outflow obstruction, severe UC, GI obstruction.

Oestrogens
• In women with vaginal atrophy, intravaginal oestrogens may be tried

Botulinum Toxin A
• Blocks neuromuscular transmission – causing the muscle to become weak.
• Used in follow up and injected cystoscopically into the detrusor, usually under local anaesthetic.

22
Q

Follow up management of urge urinary incontinence?

A

Try 2nd anticholinergic (tolterodine)

Urodynamic study (increased detrusor pressure upon voiding)

MDT meeting

Cystoscopy & Botox (botulinum toxin A)

Nerve stimulation - percutaneous posterior nerve/percutaneous sacral nerve

Augmentation cystoplasty - if small bladder

Urinary diversion

23
Q

Management of overflow incontinence?

A

o Treat with catheter
• Can cause urinary retention in 5-20% of cases, in which intermittent self catherterisation may be required.
o Surgical
 Reserved as last resort for debilitating symptoms, failed therapies
 Bladder distension, sacral neuromodulation, detrusor myomectomy have limited efficacy

24
Q

How common is urogenital prolapse?

A
  • Occurs in 40-60% of parous women

* Most common reason postmenopausal women have hysterectomy

25
Q

Definition of urogenital prolapse?

A

o Weakness of supporting structures (levator ani muscles and endopelvic fascia) allows the pelvic organs to protrude within the vagina
o Can be bladder, urethra, rectum, and bowel

26
Q

Risk factors of urogenital prolapse?

A 
o	Increasing age
o	Vaginal delivery
o	Increasing parity
o	Obesity
o	FHx of prolapse
o	Constipation/Chronic cough
27
Q

Types of urogenital prolapse?

A

o Can occur in anterior, middle or posterior compartments of pelvis

28
Q

Anterior types of urogenital prolapse?

A 
	Cystocele
•	Prolapse of bladder into the vagina
	Urethrocele
•	Prolapse of urethra into the vagina, associated with USI
	Cysto-urethrocele when both (MC)
29
Q

Middle types of of urogenital prolapse?

A

 Uterine prolapse
• Descent of uterus into vagina
• Baden-Walker Graded

 Vaginal vault prolapse
• Descent of vaginal vault post-hysterectomy, associated cystocele, rectocele and enterocele common

 Enterocele
• Herniation of pouch of Douglas into vagina
• Pouch usually contains loops of small bowel

30
Q

Posterior types of urogenital prolapse?

A

 Rectocele

• Prolapse of rectum into vagina

31
Q

POPQ staging of urogenital prolapse?

A

o 0 = No prolapse
o 1 = >1cm above hymen
o 2 = At level of hymen
o 3 = >1cm below hymen but protrudes <2cm total length of vagina
o 4 = Complete eversion of vagina (complete procidentia)

32
Q

General symptoms of urogenital prolapse?

A
  • Dragging sensation discomfort, and heaviness within the pelvis.
     Usually worse at the end of the day or when standing up.
  • Feeling of ‘a lump coming down’
  • Dyspareunia or difficulty in inserting tampons.
  • Discomfort and backache.
33
Q

Cysto-urethrocele symptoms of urogenital prolapse?

A
  • Urinary urgency and frequency.
  • Incontinence
  • Incomplete bladder emptying
    o Urinary retention or reduced flow where the urethra kinked
34
Q

Rectocele symptoms of urogenital prolapse?

A
  • Constipation

- Difficulty with defecation (may digitally reduce it to defecate).

35
Q

Other symptoms of urogenital prolapse?

A
  • Symptoms tend to become worse with prolonged standing and towards the end of the day.
  • Grade 3 or 4 prolapse, there may be mucosal ulceration and lichenification, resulting in vaginal bleeding and discharge.
  • Symptoms can affect quality of life, causing social, psychological, occupational or sexual limitations to a woman’s lifestyle.
36
Q

Examinations performed in urogenital prolapse?

A

• Examine patient in both standing and left lateral position
o Ask woman to strain and observe
• Bimanual examination (exclude pelvic masses)
• Sims speculum examination
o Inspect anterior and posterior walls, ask to strain

37
Q

Investigations of urogenital prolapse?

A
  • USS to exclude pelvic or abdominal masses.
  • Urodynamics are required if urinary incontinence is present
  • Assess fitness for surgery – ECG, CXR, FBC, U&Es
38
Q

Prevention of urogenital prolapse?

Conservative management of urogenital prolapse?

A

Prevention

  • Reduction of prolonged labour, trauma caused by instrumental delivery
  • Encouraging persistence with post-natal pelvic floor exercises.

General Advice

  • Weight reduction
  • Avoid heavy lifting
  • Treatment of chronic constipation and cough (including smoking cessation)
  • Pelvic floor muscle exercises
39
Q

Further management of urogenital prolapse - Intravaginal (pessary) devices? When used? What is it? Instructions?

A
  • Conservative line of therapy for women who decline surgery, who are unfit for surgery, or for whom surgery is contraindicated.

o Artificial pelvic floor placed in the vagina to stay behind the symphysis pubic and in front of the sacrum.

o Sexually active women can use ring pessaries, either have sex with it in place or take it out and replace after

o They should be changed 6 monthly and if post-menopausal, topical oestrogen may be given to decrease risk of vaginal erosion.

40
Q

Types of pessary and when used?

A

Ring pessary = most commonly used
o Placed between the posterior aspect of the symphysis pubis and posterior fornix of the vagina.

Shelf pessary = used when a correctly sized ring pessary will not sit in the vagina and/or where the perineum is deficient

Others: Hodge pessary, cube and doughnut pessaries (very rarely used).

41
Q

Indications for surgical management of urogenital prolapse?

A
  • Failure of conservative treatment
  • Voiding or defaecation problems
  • Recurrent prolapse after surgery
  • Ulceration
  • Irreducible prolapse
  • Preference
42
Q

Surgical management of anterior compartment of urogenital prolapse?

A

• Anterior colporrhaphy (anterior repair)

- Appropriate for repair of a cysto-urethrocele.

43
Q

Surgical management of posterior compartment of urogenital prolapse?

A 
Posterior colporrhaphy (posterior repair)
-	Appropriate for correction of a rectocele and deficient perineum
44
Q

Surgical management of uterovaginal (apical) compartment of urogenital prolapse?

A
  • Vaginal hysterectomy (most common)
  • Sacrohysteropexy
  • Preserve the uterus.
  • Attaches the prolapsed uterus to the sacrum
45
Q

Surgical management of vaginal vault of urogenital prolapse?

A

• Sacrospinous ligament fixation

- Suturing vaginal vault to sacrospinous ligaments using a vaginal approach.

46
Q

Surgical management of recurrent compartment of urogenital prolapse?

A
  • ~1/3 of prolapse surgery is for recurrent prolapse.
  • Vaginal epithelium may be scarred and atrophic (makes surgery harder and gives increased risk of damage to bladder and bowel)

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