Urogynaecology Flashcards
1
Q
What is Pelvic organ prolapse
A
The protrusion of bladder, rectum, intestines, uterus, cervix, and/or vaginal apex into the vaginal vault because of decreased pelvic floor support
2
Q
What is uterine prolapse
A
where the uterus itself descends into the vagina.
3
Q
what is vault prolapse
A
occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina.
4
Q
what is a rectocele
A
caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina
5
Q
what is rectocele associated with
A
constipation
6
Q
What can women with Rectoceles develop
A
faecal loading in the part of the rectum that has prolapsed into the vagina
7
Q
what are symptoms of faecal loading
A
significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina
8
Q
what is a cystocele
A
caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina
9
Q
what is cystourethrocele
A
Prolapse of both the bladder and the urethra
10
Q
what is urethrocele
A
Prolapse of the urethra
11
Q
what are RF for pelvic organ prolpase
A
- Multiple vaginal deliveries
- Instrumental, prolonged or traumatic delivery
- Advanced age and postmenopause status
- Obesity
- Chronic respiratory disease causing coughing
- Chronic constipation causing straining
12
Q
what are urinary symptoms of pelvic organ prolapse
A
incontinence, urgency, frequency, weak stream and retention
13
Q
what are bowel symptoms of pelvic organ prolapse
A
constipation, incontinence and urgency
14
Q
what are sexual dysfunction symptoms of pelvic organ prolapse
A
pain, altered sensation and reduced enjoyment
15
Q
how does pelvic organ prolapse present
A
may have identified a lump or mass in the vagina
A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms
bowel symptoms
sexual dysfunction
16
Q
how is pelvic organ prolapse examined
A
dorsal and left lateral position.
Sim’s speculum is a U-shaped, single-bladed speculum
held on anterior wall to examine for a rectocele, and the posterior wall for a cystocele.
asked to cough
17
Q
How are Uterine Prolapse graded
A
pelvic organ prolapse quantification (POP-Q) system:
18
Q
What is grade 0 uterine prolapse
A
Normal
19
Q
What is grade 1 uterine prolapse
A
The lowest part is more than 1cm above the introitus (the external opening of the vaginal canal)
20
Q
What is grade 2 uterine prolapse
A
The lowest part is within 1cm of the introitus (above or below)
21
Q
What is grade 3 uterine prolapse
A
The lowest part is more than 1cm below the introitus, but not fully descended
22
Q
What is grade 4 uterine prolapse
A
Full descent with eversion of the vagina
23
Q
What are 3 options for uterine prolapse
A
Conservative management
Vaginal pessary
Surgery
24
Q
What is conservative management for uterine prolapse
A
- Physiotherapy (pelvic floor exercises)
- Weight loss
- Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
- Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
- Vaginal oestrogen cream
25
What are vaginal pessaries
inserted into the vagina to provide extra support to the pelvic organs
26
What are types of vaginal pessaries
- ring --> sit around the cervix holding the uterus up
- shelf --> flat disc with a stem, that sits below the uterus with the stem pointing downwards
- cube
- donut
- hodge
27
WHat is the definitive management of pelvic organ prolapse
Surgery
28
what are complications associated with pelvic organ prolapse surgery
- Pain, bleeding, infection, DVT and risk of anaesthetic
- Damage to the bladder or bowel
- Recurrence of the prolapse
- Altered experience of sex
29
what are complications associated with mesh repairs for pelvic organ prolapse surgery
- Chronic pain
- Altered sensation
- Dyspareunia (painful sex) for the women or her partner
- Abnormal bleeding
- Urinary or bowel problems
30
What is Urinary Incontinence
loss of control of urination
two types of urinary incontinence
- urge incontinence
- and stress incontinence
31
What is urge incontinence
caused by overactivity of the detrusor muscle of the bladder
also known as overactive bladder
32
What does urge incontinence feel like
suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs.
33
what is stress Incontinence
due to weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder.
34
What does stress incontinence feel like
urinary leakage when laughing, coughing or surprised.
35
What three canals comprised the pelvic floor
urethral, vaginal and rectal canals
36
what is Mixed incontinence
combination of urge incontinence and stress incontinence
37
what is overflow incontinence
occurs when there is chronic urinary retention due to an obstruction to the outflow of urine.
results in an overflow of urine, and the incontinence occurs without the urge to pass urine
rare in women
38
what can cause overflow incontinence
anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries
39
What modifiable lifestyle factors that can contribute to incontinence symptoms
Caffeine consumption
Alcohol consumption
Medications
Body mass index (BMI)
40
What are RF for urinary incontinence
- Increased age
- Postmenopausal status
- Increase BMI
- Previous pregnancies and vaginal deliveries
- Pelvic organ prolapse
- Pelvic floor surgery
- Neurological conditions, such as multiple sclerosis
- Cognitive impairment and dementia
41
What questions can be asked in history to assessing severity of incontinence
Frequency of urination
Frequency of incontinence
Nighttime urination
Use of pads and changes of clothing
42
In examination for incontinence what should be examined
Pelvic organ prolapse
Atrophic vaginitis
Urethral diverticulum
Pelvic masses
43
How can pelvic muscle contractions be assessed
during a bimanual examination by asking the woman to squeeze against the examining fingers
44
How is pelvic muscle contractions graded
modified Oxford grading system
45
What are the levels (0-5) of the modified Oxford grading system?
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
46
How can incontinence be investigated
- A bladder diary
- Urine dipstick testing
- Post-void residual bladder volume
- Urodynamic testing
47
What is Urodynamic testing
A group of tests to assess function of the urinary tract and to identify sites of obstruction.
A thin catheter is inserted into the bladder, and another into the rectum. These two catheters can measure the pressures in the bladder and rectum for comparison. The bladder is filled with liquid, and various outcome measures are taken:
48
What routine tests are involved in Urodynamic tests.
- Cystometry - measures the detrusor muscle contraction and pressure
- Uroflowmetry - measures the flow rate
- Leak point pressure - the point at which the bladder pressure results in leakage
- Post-void residual bladder volume - tests for incomplete emptying of the bladder
49
How is stress incontinence managed
- Avoiding caffeine, diuretics and overfilling of the bladder
- Avoid excessive or restricted fluid intake
- Weight loss (if appropriate)
- Supervised pelvic floor exercises for at least three months before considering surgery
- Surgery
- Duloxetine is an SNRI antidepressant used second line where surgery is less preferred
50
What are surgical management options of stress incontinence
- *Tension-free vaginal tape* (TVT) a mesh sling looped under the urethra to This supports the urethra, reducing stress incontinence.
- *Autologous sling procedures* similar like TVT but strip of abdominal fascia is used
- *Colposuspension* involves stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra
- *Intramural urethral bulking* involves injections around the urethra to reduce the diameter and add support
51
how is urge incontinence managed
- Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
- Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
- Mirabegron is an alternative to anticholinergic medications
- Invasive procedures where medical treatment fails
52
What are anticholinergic side effects
- dry mouth
- dry eyes
- urinary retention
- constipation
- postural hypotension
can also lead to a cognitive decline, memory problems and worsening of dementia
53
What is a alternative to Anticholinergic medication and when is it CI
Mirabegron - beta-3 agonist
contraindicated in uncontrolled hypertension
54
What are surgical/invasive options of urge incontinence management
- Botulinum toxin type A injection into the bladder wall
- Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves
- Augmentation cystoplasty involves using bowel tissue to enlarge the bladder
- Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen
55
What can renal stones also be called
renal calculi
urolithiasis
nephrolithiasis
56
What are two key complications of renal stones
Obstruction leading to AKI
Infection with obstructive pyelonephritis
57
What are types of kidney stones
- Calcium-based stones (MC)
- Uric acid
- Struvite – produced by bacteria, therefore, associated with infection
- Cystine – associated with cystinuria, an autosomal recessive disease
58
What are types of calcium based kidney stones
- Calcium oxalate (MC)
- Calcium phosphate
59
What type of kidney stones are not visible on X Ray
Uric acid
60
How does renal stones present
- Unilateral loin to groin pain that can be excruciating (“worse than childbirth”)
- Colicky (fluctuating in severity) as the stone moves and settles
move restlessly due to the pain.
61
How are reneal stones investigated
- Urine dipstick usually shows haematuria
- Blood tests help establish signs of infection and also kidney function
- An abdominal x-ray can show calcium-based stones
62
What is the initial investigation of choice for renal stones
Non-contrast computer tomography (CT) of the kidneys, ureters and bladder (CT KUB)
63
What is a less preferred alternative to CT scan for kidney stones
Ultrasound of the kidneys, ureters and bladder (ultrasound KUB)
less effective at identifying kidney stone
negative test does not exclude kidney stones
64
What is a cause of calcium based renal stones
hypercalcaemia
65
How does hypercalcaemia present
renal stones
painful bones
abdominal groans
psychiatric moans
66
What are three causes of hypercalcaemia
calcium supplementation
hyperparathyroidism
cancer (e.g., myeloma, breast or lung cancer).
67
How are renal stones managed
NSAIDs - IM diclofenac
Antibiotics - if infection
Antiemetics - if nausea
Tamsulosin - passage
watch and wait
surgical management
68
What are surgical interventions for renal stones
- Extracorporeal shock wave lithotripsy (ESWL)
- Ureteroscopy and laser lithotripsy:
- Percutaneous nephrolithotomy (PCNL) if >20mm
- Open surgery
69
What are lifestyle recommendations to prevent further renal stones
- Increase oral fluid intake (2.5 – 3 litres per day)
- Add fresh lemon juice to water
- Avoid carbonated drinks
- Reduce dietary salt intake
- Maintain a normal calcium intake
70
What are oxalate rich foods
spinach, beetroot, nuts, rhubarb and black tea
71
what are purine rich foods
kidney, liver, anchovies, sardines and spinach
72
What medication can be used to reduce risk of renal stone recurrence
- Potassium citrate in patients with calcium oxalate stones and raised urinary calcium
- Thiazide diuretics (e.g., indapamide) in patients with calcium oxalate stones and raised urinary calcium
73
What is a Vesicovaginal
opening between the vagina and the bladder
74
what is a Rectovaginal
opening between the vagina and rectum/lower part of the large intestine, which carries stool out of the body
75
What are the symptoms of a vaginal fistula
Urinary and fecal leakage
Abnormal vaginal discharge
A foul odor in urine or vaginal discharge
Recurrent infection including recurrent UTIs
Abdominal pain
Rectal or vaginal bleeding
76
what are RF for vaginal fistula
Childbirth, especially prolonged or obstructed childbirth
Complications from pelvic surgery
Cancer/radiation treatment
Crohn’s Disease or ulcerative colitis
77
how are vaginal fistulas investigated
Urine speciman
vaginal examination
Dye Test
Cystoscopy and examination under anaesthetic
Urodynamics
Xray Ct and MRI
78
how can a fistula be managed
catheter - let fistula heal
surgery - throigh vagina, open or laparoscopically
