Urogynaecology Flashcards
How is the bladder function controlled?
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
How common is stress incontinence? What is stress urinary incontinence? Causes?
- 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
How common is urge incontinence? What is urge urinary incontinence? Causes?
- 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
What is mixed urinary incontinence?
• The involuntary leakage of urine associated both with urgency and with exertion, effort, sneezing or coughing.
What is overflow incontinence?
- 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.
When does continuous urinary incontinence occur?
• Classically it is associated with a fistula or congenital abnormality (e.g. ectopic ureter)
Symptoms of urinary incontinence?
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
Gynae history important in urinary incontinence?
Uterus or not Pre/Postmenopausal Problems with intercourse How many babies - delivery method Smear tests up to date
PMH important in urinary incontinence?
Prolapse symptoms - dragging, feel mass, backache
Constipation
Chronic cough
Diabetes
DH important in urinary incontinence?
Diuretics
Laxatives
Medications for urinary symptoms in past
SH for urinary incontinence?
Caffeine intake Carbonated drinks Alcohol Smoking Ketamine Occupation - heavy lifting?
Examination performed in incontinence?
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
Investigations in urinary incontinence?
- 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
When should a cystoscopy be performed in urinary incontinence?
o Used to visualise urinary tract
o Indicated if recurrent UTI, haematuria, bladder pain, suspected fistula, tumour
What are the specialist tests performed for urinary incontinence?How do they work?
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
Initial management of stress urinary incontinence?
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
Follow up management of stress urinary incontinence?
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
Pharmacological management of stress urinary incontinence?
Duloxetine
• SNRI enhances urethral striated sphincter activity via a centrally mediated pathway.
• Dose-dependent decreases in frequency of incontinence episodes
Surgical management of stress urinary incontinence ? When considered and what types?
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
Initial management of urge urinary incontinence?
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
Describe properties of initial pharmacological management of urge urinary incontinence? SE? CI?
When is botox used?
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.
Follow up management of urge urinary incontinence?
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
Management of overflow incontinence?
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
How common is urogenital prolapse?
- Occurs in 40-60% of parous women
* Most common reason postmenopausal women have hysterectomy
Definition of urogenital prolapse?
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
Risk factors of urogenital prolapse?
o Increasing age o Vaginal delivery o Increasing parity o Obesity o FHx of prolapse o Constipation/Chronic cough
Types of urogenital prolapse?
o Can occur in anterior, middle or posterior compartments of pelvis
Anterior types of urogenital prolapse?
Cystocele • Prolapse of bladder into the vagina Urethrocele • Prolapse of urethra into the vagina, associated with USI Cysto-urethrocele when both (MC)
Middle types of of urogenital prolapse?
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
Posterior types of urogenital prolapse?
Rectocele
• Prolapse of rectum into vagina
POPQ staging of urogenital prolapse?
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)
General symptoms of urogenital prolapse?
- 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.
Cysto-urethrocele symptoms of urogenital prolapse?
- Urinary urgency and frequency.
- Incontinence
- Incomplete bladder emptying
o Urinary retention or reduced flow where the urethra kinked
Rectocele symptoms of urogenital prolapse?
- Constipation
- Difficulty with defecation (may digitally reduce it to defecate).
Other symptoms of urogenital prolapse?
- 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.
Examinations performed in urogenital prolapse?
• 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
Investigations of urogenital prolapse?
- USS to exclude pelvic or abdominal masses.
- Urodynamics are required if urinary incontinence is present
- Assess fitness for surgery – ECG, CXR, FBC, U&Es
Prevention of urogenital prolapse?
Conservative management of urogenital prolapse?
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
Further management of urogenital prolapse - Intravaginal (pessary) devices? When used? What is it? Instructions?
- 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.
Types of pessary and when used?
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).
Indications for surgical management of urogenital prolapse?
- Failure of conservative treatment
- Voiding or defaecation problems
- Recurrent prolapse after surgery
- Ulceration
- Irreducible prolapse
- Preference
Surgical management of anterior compartment of urogenital prolapse?
• Anterior colporrhaphy (anterior repair)
- Appropriate for repair of a cysto-urethrocele.
Surgical management of posterior compartment of urogenital prolapse?
Posterior colporrhaphy (posterior repair) - Appropriate for correction of a rectocele and deficient perineum
Surgical management of uterovaginal (apical) compartment of urogenital prolapse?
- Vaginal hysterectomy (most common)
- Sacrohysteropexy
- Preserve the uterus.
- Attaches the prolapsed uterus to the sacrum
Surgical management of vaginal vault of urogenital prolapse?
• Sacrospinous ligament fixation
- Suturing vaginal vault to sacrospinous ligaments using a vaginal approach.
Surgical management of recurrent compartment of urogenital prolapse?
- ~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)
