Urogynaecology

Question 1

What is a cystocele?

Answer 1

Bladder prolapses backwards into vagina caused by a defect in the anterior vaginal wall.

Question 2

What is a rectocele?

Answer 2

A defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.

Question 3

How does a rectocele present?

Answer 3

Constipation and difficulty with defecation, faecal loading in the part of the rectum that has prolapsed into the vagina, urinary retention, tenesmus or sensation of pressure in the rectum

Question 4

What is enterocele and how does it present?

Answer 4

An enterocele is the prolapse of the small bowel into the vagina. It would typically present with a posterior vaginal wall bulge and lower back pain

Question 5

What are the different prolapses that can occur if there’s a defect in:

1. Anterior vaginal wall
2. Posterior vaginal wall
3. Apical vaginal wall

Answer 5

1. cystocele, urethrocele, urethrocystocele
2. rectocele, eneterocele
3. vaginal vault (roof of vagina common after hysterectomy), uterine prolapse

Question 6

What are the risk factors for developing pelvic organ prolapse?

Answer 6

Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining

Question 7

Sx of Pelvic organ prolapse?

Answer 7

Heavy feeling, dragging
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

Question 8

Describe examination for pelvic organ prolapse

Answer 8

1. px should empty bladder
2. Sim’s speculum (u-shaped, single bladed speculum) used to examine prolapse
3. Ask px to cough to assess full prolapse

Question 9

Describe conservative tx for pelvic organ prolapse.

Answer 9

Physiotherapy (pelvic floor exercises for 6 months)
Weight loss
Lifestyle changes for stress incontinence, such as reduced caffeine intake and incontinence pads
Vaginal oestrogen cream

Question 10

Describe medical/surgical tx for pelvic organ prolapse

Answer 10

Vaginal pessary - provide extra support to pelvic organs

Question 11

What is the complication of using pessaries and what can be used to relieve this?

Answer 11

They can cause vaginal irritation and erosion over time. Oestrogen cream helps protect the vaginal walls from irritation.

Question 12

What is urinary tract calculi?

Answer 12

aka renal stones. Solid concentrations formed in urinary tract from substance present in urine.

Question 13

What are the different types of kidney calculi?

What are they made from?

Answer 13

• Calcium oxalate (MC)
• Calcium phosphate

Other less common ones:
* Cystine
* Uric acid
* Struvite

Question 14

Sx of urinary tract calculi

Answer 14

Renal colic pain (colicky unilateral loin to groin pain)
Restlessness (always moving due to pain)
N+V
Haematuria
Decreased urinary output
Sepsis sx

Question 15

Ix of urinary tract calculi

Answer 15

Urine dipstick (haematuria)
FBC and U&E (hypercalcaemia)
Abdo x-ray
GS Non-contrast CT KUB

Question 16

Tx of urinary tract calculi

Answer 16

Analgesia (NSAIDs)
Watchful waiting
Tamsulosin (aid renal stone movement)

Surgical options:
ESWL (shock waves)
Ureteroscopy + laser lithotripsy
PCNL (for large stones)
Open surgery (last resort - complex surgery)

• Extracorporeal shockwave lithotripsy (ESWL) is a non-invasive procedure that uses shock waves to break up kidney and ureter stones
• Percutaneous nephrolithotomy (PCNL) is a minimally invasive procedure to remove kidney stones that are too large to pass on their own

Question 17

Define the following:

1. Uterine prolapse
2. Vault prolapse
3. Cystourethrocele

Answer 17

1. Uterus itself descends into the vagina.
2. The top of the vagina (the vault) descends into the vagina in women that have had a hysterectomy, and no longer have a uterus.
3. Prolapse of both both bladder and urethra into vagina

Question 18

What is overactive bladder?

Answer 18

A chronic condition that results from hyperactivity of the detrusor muscle, a layer of the urinary bladder wall.

Question 19

Sx of overactive bladder

Answer 19

Urinary urgency Sx:
* Urge incontinence: involuntary leakage accompanied by or immediately preceded by urgency
* Frequency: urinating more often than what is considered normal
* Nocturia

Question 20

Ix for overactive bladder

Answer 20

Urinalysis - rule out infection
Bladder diary
Urodynamics - evaluate bladder muscle function

Question 21

Mx for overactive bladder (OAB)

Answer 21

• Lifestyle modifications - reducing oral fluid intake, and avoiding caffeine and alcohol
• Anticholinergic drugs: Like oxybutynin and solifenacin
• Vaginal oestrogens: Used if urogenital atrophy present
• Botox

Anticholergic drugs - block acetylcholine which is responsible for stimulating the bladder to contract leading to urgent and frequent need to urinate. Therefore, blocking it helps manage sx of OAB.

Question 22

What is a genital tract fistula?

Answer 22

Abnormal opening between genital tract and another organ or surface of the body.

Question 23

RF for genital tract fistula

Answer 23

Prolonged or obstructed labor during childbirth
Obstetric trauma, such as perineal tears or episiotomy
Pelvic surgery, including hysterectomy or pelvic organ prolapse repair

Question 24

Sx of genital tract fistula

Answer 24

Urinary and faecal incontinence (passage of faeces through vagina)
Vaginal discharge (foul-smelling)
Recurrent UTI’s

Question 25

Ix for genital tract fistula

Answer 25

Pelvic examination
Pelvic USS or CT
Cystoscopy and sigmoidoscopy