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RANZCOG -Gynaecology 2024 Edward > Urogynaecology > Flashcards

Urogynaecology Flashcards

1
Q

Discuss bladder pain syndrome
-Defintion (4)
-Difference with interstitial cystitis
-Prevalence

A
  1. Defintion
    -Pelvic pain, pressure and discomfort perceived from the bladder
    -Lasting 6/52 to 6/12 depending on association def chosen.
    -Includes at least one urinary sx (urge / frequency)
    -Infection or other identifiable cause has been rulled out
  2. Interstitial cyctitis is baldder pain syndrome + typical cystoscopic features
    -Hunners lesions, glomerulations, macroscopic haematuria on release of pressure.
  3. Prevalance 2-6%. Women 2-5x more common to expereince
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2
Q

How should bladder pain syndrome be investigated
(6) investigations
(3) not recommended

A
  1. Bladder diary for 3 days
  2. First morning void to assess bladder capacity
  3. Food diary to assess association with particular foods
  4. MSU for urine analysis - rule out infection
  5. Consider cystoscopy if persistant haematuria but don’t need to make diagnosis
  6. Consider urodynamics if coexsisting OAB symptoms, incontinence or voiding dysfunction
  7. Cystoscopy NOT recommended - findings don’t match well with sx. Important if needing to rule out other causes
  8. Hydrodistension
  9. Postassium sensitivity test
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3
Q

What are the findings on cystoscopy related to bladder pain syndrome (4)

A

Cystscopy is not required for dx of BPS
-Findings correlate poorly with sx
-Can exclude other possible causes though
-Hunner lesions - erythematous, superficial mucosal lesions
-Glomerulations - peticheal haemorrhages
-Painful filling

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4
Q

Discuss management of bladder pain syndrome
-Conservative measures (5)
-Medical measures (2)
-Intravesciular measures (3)
-fourth line treatment (3)
-fifth line treatment (1)

A
  1. Conservative management
    -Patient eduction
    -Fluid managment - avoid over filling or dehydration
    -Deitary modification - avoid acidic foods
    -Avoid irritants - caffeine, alcohol, artificial sweetners
    -Psychotherapy - mindfulness,stress release
  2. Medical measures
    -Analgesia - paracetamol, brufen, amytriptyline. Avoid opiates
  3. Intravesicular treatments
    -Intravesciular lidocaine
    -Intravesicular hyaluronic acid
    -Intravesicular botox
  4. Fourthline
    -Cystoscopy and fulgeration or laser of Hunner lesions
    -Hydrodistension
    -Neuromodulation
    -Cyclosporin A
  5. Urinary divesiosn +/- cystectomy
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5
Q

What are the definitions of the following
-Urinary incontinence
-Stress urinary incontinence
-Urge urinary incontinence
-Mixed urinary incontinence
-Postural urinary incontinence
-Continuous urinary incontinence
-Over active bladder syndrome-wet and dry
-Frequency
-Nocturia

A
  1. Involuntary urinary leakage expereinced in bladder storage phase
  2. Involuntary urinary leakage during periods of increased intra-abdominal pressure
  3. Involuntary urinary leakage associated with urge sx
  4. Involuntary urinary leakage assoiciated with urge sx and during increased intra-abdominal pressure
  5. Involuntary urinary leakage with change in position
  6. Continuous involuntary urinary leakage
  7. Urinary urgency associated with frequency and nocturia which can lead to urinary leakage (wet) or not (dry) in abscence of other pathology
  8. Frequency - defined by patient perception
  9. Nocturia - waking more than once to void
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6
Q

Discuss the prevalance of urinary incontinence (5)

A

25-45% of all women expereince some kind or UI
4-7% have daily incontince
Prevalence increases up to 50 yrs. Plateaus from 50-70 and increases thereafter
SUI tends to decrease after 50
UUI and MUI tend to increase after age 60

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7
Q

Discuss factors associated with urinary incontinence (11)

A
  1. Age
  2. Obesity
  3. Obstetric factors - parity, instrumental delivery, epi or perineal injury, BW, duration of second stage
  4. Menoapuse - low estrogen state - receptors in urinary tract, increase in UTI
  5. Hysterectomy if >60yr at time of operation - increases risk by 60%
  6. UTI
  7. Cognitive impairment
  8. Functional impairment
  9. Neurological disease
  10. Smoking
  11. Family hx
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8
Q

Discuss the investigations for urinary incontinence (7)

A
  1. Urinalysis
    -Infection, renal stone, cancer, diabetes
  2. Post void residual - assess by catheter or bladder scan
    -Large PVR can suggest neurological dx or detrousor failure
  3. Pad test - not recommended by NICE as no good evidence
    ->1g increase per hr or >4g in 24hrs is significant
  4. Bladder diary - 3 days sufficient
  5. Cystoscopy - Not routinely indicated
  6. Urodynamics - hx alone is 70-90% sens and 50% spec. unclear if hx alone is improved by urodynamics according to cochrane review
  7. Renal USS
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9
Q

Discuss how low intravesicular pressure is maintained (3)

A
  1. Transmission of intra-abdominal pressure to the proximal urethra and bladder neck prior to the bladder
  2. Distensibility of the bladder means it can fill while still maintaing low pressures
  3. Hydrostatic pressure in the bladder
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10
Q

Discuss how urethral function is maintained (4)

A
  1. Engorgment of the urethral submucosa and production of urethral secretions ensure water tight seal
  2. Intrinsic smooth muscles supply constant pressure at rest
  3. Extrinsic striated muscles contract the pelvic floor
  4. Urethral support from pubocervical fascia posteriorly with compression against these with increase abdominal pressure
  5. Urethral support from anterior and lateral pubourethral ligaments connecting urethra to pubic bone
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11
Q

Describe the storage phase of the micturition cycle

A

During the filling/storage phase the pelvic nerves sense an empty bladder (PNS) and stimulates the hypogastric nerve (SNS).
The hypogastric nerve is stimulated to enable detrusor relaxation and internal urethral sphincter contraction and therefore avoid micturition.
Suppression of the pontine micturition centre occurs by action of the periaqueductal grey. This results in suppression of the pelvic nerves and contraction of the perineal nerve which is somatic and under conscious control.

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12
Q

Discuss initiation phase of the micturition cycle

A
  1. As bladder becomes full sensory impulses become fast via afferent nerve S2-S4
  2. Conscious inhibition of micturition continues until appropriate time to void
  3. Initiation begins with relaxation of the pelvic floor
  4. Descending inhibitory impulses are suppressed
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13
Q

Discuss voiding phase or the micturition cycle

A

During voiding the pontine micturition centre is no longer suppressed and signals to the pelvic nerves which result in contraction of the detrusor muscle.
The hypogastric nerves are inhibited and this results in the relaxation of the internal urethral sphincter.
The pudendal nerve is inhibited and results in relaxation of the pelvic floor and external urethral sphincter.

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14
Q

Discuss recurrent UTI
-Prevalence (2)
-Definition (2)
-Investigations (4)
-Management (3)

A
  1. Prevalence:
    -50% of women will suffer 1 UTI
    -2.4% of women will have recurrent UTI
  2. Defintion
    -2 or more UTI in 6 months
    -3 or more UTI in 12 months
  3. Investigations
    -Urine microscopy + culture with sensitivities
    -STI screen if at risk
    -Post void residual volumes in post menopausal women
    -Cystoscopy if:
    -Gross haematuria, obstruction, high PVR, persistant bactauria post treatment
    -Cycstoscopy might show malakoplakia - yellow soft plaques ass with recurrent UTI
  4. Management
    -Conservative - hydration, optimal voiding, hygiene practices.
    -Cranberry - not that efective. Pills best.
    -Local oestrogen if vulvovaginal atrophy
    -Antibiotics - consider 6/12 trial.
    -Intravesicular antibiotics - gentamicin by self cath for 6/52
    -Hiprex - bacteriostatic agent RR for recurrent UTI 0.24
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15
Q

Discuss pelvic organ prolapse
-Defintion
-Epidemiology (3)
-Risk factors (7 groups)

A
  1. Defintion
    Herniation of pelvic or abdominal organs through the vaginal canal
  2. Epidemiology
    -41% of women 50-79yrs have a degree of uterine prolapse
    -Lifetime risk of POP surgery - 7-10%
    -Repeat surgery rate 30%
  3. Risk factors
  4. Age
  5. Obseity > 30 = OR of 1.4
  6. Pregnancy and child birth
    -Worse with VB 3 x CS = damage of 1 x VB
    -Worse with increase parity
    -Worse with foceps delivery
    -Levator avulsion
  7. Chronically raised intra-abdominal pressure
    -COPD, asthma, smokers cough, constipation
  8. Family Hix - 2-3x increased risk
  9. Collagen defects - hereditary or acquired _ Marfans, Erhlos Danlos ect
  10. Previous gynae surgery
    - highest if hysterectomy for prolapse
    -Burch colposuspension - prone to posterior prolapse
    -SSF prone to anterior prolapse
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16
Q

Discuss the support of pelvic organs
-Structures at each level
-What they support
-What a defect in them leads to in terms of POP

A
  1. Level 1
    -Uterosacral and cardinal ligament complex
    -Supports upper1/3rd of vaginal and cervix
    -Defect leads to apical descent
  2. Level 2
    -Paravaginal fascia attached to the arcuate tendinous fascia (WHite line)
    -Supports upper 2/3rds of vagina and rectum
    -Defect leads to cystocele
  3. Level 3
    -Fusion of vaginal endopelvic fascia to perineal body posteriorly, levator ani laterally and urethra anteriorly
    -Supports lower 1/3rd of vagina,, ureathra and anal canal
    -Defect leads to rectocele, urethral mobility, SUI
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17
Q

What is the pathogensis of pelvic organ prolase (5)

A
  1. Damage to levator ani muscles
  2. Decreased muscle tone from atrophy and aging
  3. Widened genital hiatus
  4. Unapposed intraabdominal pressure on tissue
  5. Connective tissue stretch over time
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18
Q

Discuss the POP-Q
-What it is
-How to use it
-What are the stages (5)

A
  1. Standardised way of assessing stage of POP with good inter-rater reliability
  2. How to use it
    -Outlines different points in the vagina
    -Level is recorded in realtion to the hymen which is at 0
    -More proximal to the hymen is negative, more distal is positive
    -Takes into consideration vaginal length, perineal body length, genital hiatus width
    -Range of decent.
  3. Stages
    Stage 0 - No decent (Both upper and lower anterior and posterior vaginal walls = -3
    Stage I - Leading edge < -1cm
    Stage II - Leading edge > -1 and < +1cm
    Stage III - Leading edge >+1 but not complete eversion
    Stage IV - Leading edge >2cm - complete eversion
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19
Q

Discuss conservative management options for POP (5)

A
  1. Do nothing - many women aSX. but unlikely to se
  2. Conservative measures
    -Decrease strain on pelvic floor
    -Weight loss
    -Treat chronic cough
    -Treat constipation
    -Avoid heavy lifting
  3. Pelvic floor muscle training
    -Improvement in sx
    -No improvement in POP score
    -No improvement in QoL
  4. Vaginal oestrogen - helps with vaginal irritation from exposed mucosa in those with vaginal atrophy
  5. Pessaries
    -Best for apical and anterior prolapse
    -Ring, continence or space occupying (equivalently good)
    -Use if not suitable for surgery
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20
Q

Discuss posterior colporrhapy (posterior repair)
-Method
-Indication
-Success rate
-Other considerations

A
  1. Method
    Either native tissue suture repair or graft augmented repair via vaginal approach.
    Midline plication of rectovaginal fascia
  2. Indication
    -rectocele (posterior compartment prolaspe)
  3. Success rate 86-93%
  4. Other considerations
    -No data to support benefit of mesh or biological graft
    -Sometimes combined with transervse perinei muscles (perineorrhaphy)
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21
Q

Anterior colporrhaphy (Anterior compartment repair)
-Method
-Indication
-Success rates
-Other considerations

A
  1. Method
    Either native tissue suture repair or graft augmented approach via vagina.
    Midline incision of anterio vaginal wall and mid line plication of pubocervical fascia with sutures.
  2. Success rates 40-88%
  3. Other considerations
    -Apical defects co-incide with anterior defects
    -Anterior compartment is the most prone to recurrence
    -Synthetic mesh or biological graft reduces the risk of recurrence.
    -Synthetic mesh associated with increase blood loss, long er surgery, denovo stress incontinence
    -Synthetic mesh = 11.4% risk of erosions, repeat surgeries for mesh 7%
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22
Q

Discuss sacrospinous ligament suspension /Sacrospinous colpopexy
-Method
-Indication
-Success rates
-Other consideration

A
  1. Method
    NTR via the vagina using delayed absorbable sutures to affix the vaginal apex to the sacrospinous ligaments.
    Do in women how have had a hysterectomy (can do concurrently)
  2. Indication
    -Repair of apical prolapse
  3. Success rates 90%
  4. Other considerations
    -Risk to pudendal nerve bundle
    -SSF can be unilateral. No evidence for bilateral. R side safest
    -Increases risk of cystocele as exaggerates horizontal axis of vagina
    -Maintains length of vagina
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23
Q

Discuss uterosacral ligament suspension
1. Method
2. Indication
3. Success rates
4. Other considerations

A
  1. Method
    Native tissue repair via the vagina using delayed absorable sutures to affix the apex of the vagina to the uterosacral ligaments
    Do in women how have had a hysterectomy (can do concurrently)
    Do vaginally
  2. Repair of apical prolapse
  3. Success rates 70-75%
  4. Other consideration
    -Risk of urethral injury 1-2%
    -Risk of neuropathic sciatic pain 7%
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24
Q

Discuss abdominal sacrocolpopexy
-Method
-Indication
-Success rate
-Other considerations

A
  1. Method
    Open or minimally invasive suspension of vaginal apex to the anterior longitudinal ligament of the sacrum using synthetic mesh or biological graft
  2. Indication
    -Apical prolapse
  3. Success rate 75-100%
    -Better for reducing symptoms and on exam, less repeat surgery, less PO SUI when compared to other operative prolapse methods.
  4. Other considerations
    -Minimally invasive and open approach have simillar anatomical outcomes
    -Mesh erosion risk 3-10%
    -Voiding issues - self cath <1%
    -Urge incontinence 5%
    -Considered gold standard of vault prolapse repair
    -If woman has her uterus can do but called sacrohysteropexy with mesh from cerix to anterior longitudinal liagment of the sacrum. Can do from cervix in subtotal hysterectomy = sacrocervicopexy
25
Q

Discuss colpoclesis
-Method
-Indication
-Success rates
-Other considerations

A
  1. Method
    Native tissue repair using sutures to obliterate the internal vaginal length
    Vaginal epithelium is stripped and anterior and posterior fascia is sutured together
  2. Indication
    -Repair of apical prolapse with or without hysterectomy
  3. Success rates 90-95%
  4. Other considerations
    -Suitable if no longer sexually active
    -Can do under LA if comorbid
    -If uterus in situ must have normal cervical screening
26
Q

Discuss pelvic organ prolpase surgery
-Goals (3)
-Considerations (5)
-Pre operative preparation (1)

A
  1. Goals
    -Restore anatomy and relieve symptoms
    -Maintain bowel and bladder function
    -Maintain vaginal length and capacity for sexual function
  2. Considerations
    -Approach open, vaginal, laparoscopic
    -Preserve or remove uterus
    -Primary or repeat surgery
    -Possible unmasking of occult SUI. Can be planned with concurrent SUI surgery
    -Should reinforcement material be used
    Mesh available for abdominal sacrocolpopexy
    Mesh NOT available for anterior and posterior repairs
    Limited evidence on biological grafts
  3. Pre-operative preparation
    -OPTIMAL trial shows no benefit with pre surgery PFMT
27
Q

Discuss vaginal vs abdominal approach for apical repairs of POP according to 2016 cochrane review (4)

A
  1. Vaginal approach
    -Increased awareness of prolpase
    -Increased repeat surgery
    -Increased recurrence in any compartment
    -Increased SUI and dysparenunia
28
Q

Discuss use of Mesh in POP (RANZCOG guidelines) (8)

A
  1. Use is not supported as first line treatment for anterior, posterior or apical compartment repair
  2. Mesh kits are classes as Class III high risk
  3. There is no current evidence for light weigh transvaginal permanent mesh
  4. If Mesh is to be suggested then requires exhaustive consent process
    -Limited data on efficacy and safety
    -Risks and benefits
    -Alternative options
    -Mesh complications and complexity around removal
  5. If Mesh is to be used it should be done by a skilled, experienced knowledgable surgeon knowledgeable in specific procedure and management of complications
  6. Intraoperative cystoscopy should be performed
  7. FDA find little benefit of mesh with posterior or apical repair but some benefit with anterior compartment repair
  8. If using new light weight mesh consider enrolling in RCT as data is lacking
29
Q

Discuss complications associated with mesh used in POP
-Intraoperatively (3)
-Post operatively

A
  1. Intraoperatively
    -Bleeding
    -Increased operative duration
    -Trauma to bladder, urethra, ureters, bowel
  2. Post operatively
    -SUI and voiding dysfunction
    -Sexual dysfunction
    -Mesh erosions - 11%
    -Fistulae formation
    -Reoperation
30
Q

Discuss how mesh complications should be managed

A
  1. Discuss at MDT
  2. Refer to centre with appropriately qualified surgeons
  3. Careful counselling of patient
    -Limited evidence improvement with removal
    -Surgery to remove mesh can have significant complications
    -New urinary or prolapse sx may occur
    -All mesh may not be able to be removed
  4. Topical oestrogen if exposure <1cm
31
Q

What are the main causes of vesicovaginal fistulae

A
  1. Obstetrics - obstructed birth(2%), prolonged second stage, operative delivery, MROP, Peripartum hysterectomy, uterine rupture
  2. Post surgical.
    -Most common in hysterectomy (Cause of 70% post surg fistulae). 0.5% after simple hyst, 10% after rad hyst.
    -5% after bladder injury repair
    -Can be direct or delayed injury
  3. Maesh
  4. Radiation therapy
  5. Inflammation - infection, IBS
  6. Pelvic malignancy
  7. Trauma
  8. Retained foreign body
32
Q

How are vesicovaginal fistulae investigated (5)

A
  1. Dye test
    -fill bladder with methylene blue or IV indigo carmine. Place swabs in vagina and assess swabs for dye
  2. Assess bladder injusy with cystoscopy and urethroscopy
  3. Assess uretal injury with retrograde pyelography
  4. CT urogram - looks for intraperitoneal urine collection
  5. MRI - most sensitive
33
Q

How should vesicovaginal fistulae be managed

A
  1. Prevention
    -Aim to prevent surgical injury
    -Detect any injury and fix at time of operation
  2. Conservative
    -Best if fistulae recognised within few weeks of surgery
    -IDC for 2 weeks with ABx cover
    -Reassess with imaging for resolution
    -Barrier cream and continence pads to protect the skin from breakdown
    -15% success rate. If no success after 6 weeks requires surgery
  3. Surgery
    -Refer to surgeon with expereince
    -Success best at first surgery and if tissue healthy
    -Surgery should be within 48hrs or after 6-12 weeks when inflammation and granulation tissue have reduced.
    -Approach - usually vaginal in first instance
    -Method:
    - mobilise vagnial epithelium to expose bladder,
    - dissect away scar tissue,
    - tesnion free 4 layer closure
    - Check integrity with dye
    - PO bladder draining
  4. Non surgical options
    -urinary diversion
    -perineal cares
    -draining diaphram
34
Q

Discuss stress urinary incontinence
-Defintion
-Mechanisms (2)
-Causes

A
  1. Definition
    -Involuntary leakage of urine associated with increased intra-abdominal pressure
    -Pure SUI implied SUI symptoms but no OABS
  2. Mechanisms
    -Urethral hypermobility - 80-90% of SUI
    Caused by insufficient tissue support to the urethra and bladder neck due to weak pelvic floor and vaginal connetive tissue - pubourethral ligament
    Caused by: Chronic abdominal pressure, Obstetric trauma
    -Intrinsic sphincter deficiency 10-20%
    Caused by loss of intrinsic urethral mucosa or muscle tone resulting in weak sphincter with low urethral closing pressure
    Caused by neuromuscular damage
    - Multiple pelvic or continence surgeries
    - Age
    - Radiation
35
Q

Discuss management options for stress urinary incontinence
-Conservative options (10)
-Medical options (2)
-Surgical options (4)

A
  1. Conservative options
    -Weight loss
    -Reduce fluid intake to 1-1.5L/day
    -Avoid bladder irritants - caffiene, alcohol
    -Smoking cessation
    -Optimise management of underlying health conditions
    -Review and optimise medications
    -Diuretics worsen SUI
    -ACEi can cause chronic cough
    -Alpha blockers lead to urethral relaxation
    -Biofeed back to encourage pelvic floor muscle training
    -Pelvic floor muscle training - supervised for at least 3 months (first line)
    -Functional electrical stimulation to stimulate pelvic floor muscle contraction
    -Vaginal devices - contiform, continence pessaries
  2. Medical
    -Vaginal oestrogen - esp for intrinsic sphincter deficiency (improves urethral blood flow)
    -Duloxetine (SNRI) acts to increase pudendal nerve activity increasing urethral spincter closure
  3. Surgical
    -Burch colposuspension
    -Mid urethral slings
    -Urethral bulking
    -Pubovaginal (fascial slings)
36
Q

Discuss surgical management of stress urinary incontinence
-Ideal candidate for surgery (9)

A

Ideal candidate
- Candidate selection is important as SUI surgery can worsen OAB sx
-Pure SUI on urodynamics
-Normal uroflometry and bladder capacity
-No OAB
-Normal BMI
-Tried and optimised conservative management
-Completed child bearing
-No previous procedures
-No significant co-morbidities

37
Q

Discuss stress urinary incontinence surgery: Burch colposuspension
-Aim
-Approach
-Method
-Success rates
-Complications and rates

A
  1. Aim: to augment urethral closure
  2. Approach - can be open or laparoscopic - simillar outcome in short and mid term
  3. Method:
    2-3 permanent sutures on each side of the paravaginal/urethral fascia at the level of the bladder neck to the iliopectineal ligament 3-4cm from the midline
  4. Success rates
    Continence rates 1 yr 90% 5yrs 70%
    No difference between MUS and burch colposuspension for continence rates
  5. Complications
    -Voiding difficulties - 6% (Highest of surgical techniques)
    -De novo over active bladder - 22%
    -Posterior wall prolapse 30%
38
Q

Discuss mid urethral slings for surgical management of stress urinary incontinence
-Aim
-Types (2)
-Types of sling material (4)
-Success rates (3)
-Complications (6)
-RANZCOG guidelines for MUS (10)

A
  1. Aim: Augmentation of urethral closure
  2. Types:
    -Retropubic
    -Transobturator
  3. Types of sling material
    -Prolene microporus mesh
    -Autologus fascial sling - rectus sheath or fascia lata
    -Allografts - from cadarvas
    -Xenografts - from pigs
  4. Success rates
    -90%
    -If MUI 56%
    -Impacted most by high BMI 90% cf 78% if obese
  5. Complication rates
    -Urethral perforation 0.5%
    -Bladder injury 4%
    -De novo OAB 6% (up to 12%)
    -Voiding dysfunction 11%
    -Mesh erosion 1%
    -Nerve injury 0.7%
    -Dyspareunia
  6. RANZCOG statement on MUS
    -Surgeons should be appropriately trained and keep up their skills (10 a yr)
    -Surgeons should be able to undertake periopertive cystoscopy and urethroscopy
    -Surgeons should be able to manage complication
    -Should undertake regular clinical audit
    -Should use a registry or data base
    -FU in 6/12 post MUS
    -Report adverse events
    -MUS is the recommended procedure for SUI
    -Transobturator should only be offered in exceptional circumstances
    -Single incision slings are not recommended and shouldn’t be used outside a research setting
39
Q

Compare retropubic and transobturator MUS for SUI surgery
-Success rates in the short term, 1 yr and 3 yrs (2)
-Complication rates (10)

A
  1. Short term success rates no signficant differnce
  2. 1yr and 3 yrs success rates - better with retropubic
  3. Complications
    -No difference with LUTS, Infection, urinary retention
    -No difference with de novo OAB (10%)
    -Less long term pain with retropubic
    -Less reoperation rates with retropubic 6% vs 12%
    -Less bladder injury with transobturator but higher urethral injury
    -Higher vaginal erosion with transobturator and groin pain
40
Q

Outline the steps for MUS placement (14)

A
  1. Routine consent, prep and drap
  2. Mark the exit sites for the abdominal trochar - 2cm from midline immediately above the pubic symphysis. Should be incontact with the dorasl aspect of the pubic bone
  3. Inject LA into the mucosa of the sub-urethra to create space between the peri urethral fascia and the vaginal wall
  4. Hydrodissect the rectopubic space with LA from the pubic symphysis to 1-2cm from the endopelvic fascia
  5. Make a sagittal incision 1.5cm from the urethral meatus
  6. Dissect laterally between the vaginal mucosa and peri-urethral fascia
  7. Drain the bladder then insert the catheter with a catheter guide to manipulate the urethra and bladder
  8. Move the bladder contralateral to the path of the trochar and tape
  9. Guide the trochar from the suburethral incision to the abdominal exit . Repeat bilaterally
  10. Remove the sheath from the tape.
  11. Stabilise the tape and tigthen the tape to achieve the required tension
  12. cut the tape at the skin
  13. close all incisions
  14. Perform cystoscopy
41
Q

Discuss the use of bulking agents for surgical management of stress urinary incontinence
-Aim
-Methods (2)
-Types of bulking agent (3)
-Success rates
-Re-operative rates

A
  1. Aim - To increse the bulk of the urethral submucosa at the bladder neck
  2. Inject bulking materials either transurethrally or paraurethrally
  3. Types of bulking agents - all equivalent
    -Polyacrylamide and water
    -Silicone
    -Hyaluronic acid
  4. Success rates
    -34-57%
  5. Re-operative rates 72% (12 x retropubic MUS)
42
Q

Define the different types of urge incontinence
-Detrusor over activity
-Over active bladder
-Over active bladder syndrome
-Urinary urgency
-Urge urinary incontinence

A
  1. Detrusor overactivity
    -Urodynamic diagnosis
  2. Over active bladder
    -Based on symptoms
    -Urge, nocturia, frequency with or without incontinence
  3. Over active bladder syndrome
    -OAB bladder sx with or without incontinence
  4. Urinary urgency
    -Complaint of sudden compelling desire to PU
  5. Urge urinary incontinence
    -Complaint of loss of urine associated with urgency
43
Q

Discuss the mechanism and causes of urge incontinence

A
  1. Detrusor overactivity leading to involuntary detrusor muscle contraction during bladder filling phase
  2. 90% idiopathic
  3. 10% Neurogenic - MS, spinal injury, CVA, Dementia
44
Q

Discuss conservative management options of urge incontinence (8)

A
  1. Lifestyle interventions
    -Avoid smoking
    -Restrict fluid intake -1-1.5L
    -Weightloss
    -Avoid bladder irriatants - caffiene, alcohol
  2. Optimise management of underlying health conditions
  3. Review medications - ACEi, Diuretics, alpha blockers, narcotics
  4. Bladder retraining - firstline
    -Increase time till voiding by 15-30mins per day over 6/52 period to achieve 3-4hrs between voids
  5. Bio-feedback with EMG electrodes in rectum and vagina to cause pelvic floor contractions
  6. Hypnotherapy - short lasting improvement
  7. Pelvic floor physio
    -Can help with bladder retraining
  8. Consider correction of any prolapse - pessary
45
Q

Discuss medical management of urge incontinence (4)
-Types
-Mechanism of action
-Success rates
-Side effects
-Contra-indications

A
  1. Topical oestrogen if PM and atrophic vagina
  2. Anticholinergics (anti-muscarinics)
    -Act on M2 and M3 receptors in the bladder to inhibit detrusor activity
    -Can reduce OAB sx by 75%
    -Side effects: - dry eyes, palpitations, dry mouth, dementia (Linked to dose and duration of use - caution with prescribing)
    -Contra-indicated in myasthenia gravis, closed angle glaucoma, tachycardia
    -Oxybutinin, solefenacin (M3 specific) - Simillar efficacy
  3. Beta-3 adrenoreceptors agonists - (betmiga)
    -activation of beta-adrenoreceptors results in bladder stability and detrusor relaxation
    -Decreased number of bladder contractions
    -Contra-indicated in uncontrolled HTN, ESRD, Impaired liver function
  4. Desmopressin
    -Acts to inhibit diuresis
    -Only use for severe nocturia in those over 65yrs
46
Q

Discuss surgical management of urge incontinence (6)
-Aim
-Success rates
-Complication

A
  1. Botox injections
    -Blocks release of Acetyl choline which inhibits detrusor contraction
    -Lasts 6-9 months
    -Success rate 30% dry rate
    -Complications: urinary retention (5-10%), high post void residual volumes, dysuria, UTI
  2. Neuromodulation
    -Acts to inhibit the sacral bladder reflex
    -Implantation to electrically stimulate S3-S4. S3 stimulation inhibits detrusor contraction and increases urethral sphincter contraction
    -Success rates 70%
    -Re-operative rate high
    -Can do percutaneously at tibial nerve 54% improvement
    -Can do centrally at sacral nerve root (Better) 70% improvement
  3. Bladder augmentation
    -Bladder wall bisected with bowel to form low pressure resevior
    -Success rate 50-90%
    -Complications: UTI, electrolyte imbalance, mucous retention
  4. Detrusor myomectomy
  5. Urinary diversion
  6. Permanent IDC
47
Q

What are the indications for urodynamics
-Indications (7)
-Not indicated (3)

A
  1. Indications
    -Failure of conservative management
    -Prior to any surgical management for urinary incontinence unless clearly pure SUI
    -Any previous anterior compartment or incontinence surgery
    -Symptoms suggestive of voiding dysfunction
    -Symptoms suggestive of overflow incontinence
    -Neurological conditions
    -Severe POP Stage 3-4
  2. Not indicated if:
    -For conservative management
    -Pure SUI with not sx of OAB or Prolapse (5% only)
    -Pure UUI as surgical options not recommended
48
Q

What are the normal measures for urodynamics?
-Peak flow rate
-First urge to void volume
-Post void residual
-Qmax
-Bladder capacity
-Detrousor pressure during filling phase
-Detrusor pressure rise during voiding
-Compliance

A
  1. Peak flow rate - >14mL/s
  2. First urge to void - 150-200mL
  3. Post void residual <100mL
  4. Qmax - usually 30mL/sec
  5. Bladder capacity >400mL
  6. Should be no detrusor pressure
  7. Detrusor pressure rise of <50cmH2O during voiding
  8. Compliance - measures distensibility of bladder >10cmH20 = poor compliance
49
Q

Discuss uroflowmetry / free uroflow
-How it is done
-What it evaluates
-Possible outcomes and what this suggests (5)

A
  1. Woman voids in private into comode that measures flow rate over time
    -Needs to void >150mL to interpret
  2. Evaluates:
    -Max flow rate (Qmax) Normal >14mL/s
    -Pattern of flow
    -Voided volume
    -Post void residual (<100mL = Normal)
  3. Possible outcomes
    -Continuous flow with reduced Qmax - reduced detrusor contractility, obstruction
    -Intermittent flow - reduced detrusor contractility, obstruction, increased risk of voiding dysfunction post-op
    -Prolonged flow - poor detrusor contractility or obstruction
    -Fast flow - SUI due to decreased outlet resistance
    -Flat plateau - Uerthral stricture
50
Q

Discuss cystometry
-How it is done (2)
-What it evaluates (3)

A
  1. Method:
    -Saline is infused into the bladder at a rate of <50ml/min
    -Assesses detrusor pressure by subtracting vesicular pressure (measured from a probe in the bladder) from abdominal pressure (measured by a probe in the rectum or vagina)
  2. What it evaluates:
    -Measures the pressure and volume relationship of the bladder during filling and voiding
    -Measures capacity, compliance
    -Sensation
51
Q

Discuss urethral closure mechanisms
-Method
-What it evaluates

A
  1. Method
    -Place additional probe in urethra and measure urethral pressure
    -Calculate urethral closure pressure = Bladder pressure - urethral pressure
  2. Evaluation
    -Measures urethral closure pressure (The pressure needed to just open the urethra
    -Leakage occurs when bladder pressure excedes urethral pressure
    -Clinical vaule unclear
52
Q

Discuss leak point pressures
-Defintion of detrusor leak point pressure
-Defintion of abdominal leak point pressure
-What is a significant leak point pressure

A
  1. The lowest intravesicular pressure at which leakage occurs due to detrusor contraction in the abscence of abdominal pressure
  2. The intravesicular pressure at which leakage occurs due to increase abdominal pressure in the abscence of detrusor contraction
  3. Leak point pressure of <60cmH2O = intrinsic sphincter deficiency
53
Q

Name 6 specific urodynamic tests and what they assess

A
  1. Uroflowmetry
    -Assess flow rate, max flow rate, voided volume, voiding pattern
  2. Post void residule (should be <50mL)
  3. Cystometrogram
    -Measures pressure/volume relationship of bladder during filling
    -Assess bladder sensation during filling, bladder capcaity, detrusor pressure
  4. Pressure flow studies
    -Relationship between pressure in the bladder and urine flow during emptying - detrusor contractility
  5. Video cystoureththrography
    -Assesses function and anatomical changes simultaneously. Not first line but GS
  6. Leak point pressures
    -Looks at pressure (detrusor / intraabdominal) at which leakage occurs
54
Q

What are the problems associated with urodynamics (6)

A
  1. No standard technique and different circumstances i.e. positions can alter results
  2. Patient embarressment or anxiety can cause artifical results
  3. Same patient can produce diferent results
  4. Wide range of physiological values in normal asx ppl
  5. Not all abnormalities are clinically significiant
  6. Absence of abnormality does not exclude problem
55
Q

What are the RANZCOG recommendations for sacrocolpopexy

A
  1. Sacrocolpopexy using synthetic mesh is a recommended treatment for vault prolapse esp if severe or recurrent prolapse.
  2. Laparoscopic sacrocolpopexy has better short term and equivalent long term outcomes as open
  3. If synthetic mesh is used a light weight type 1 mesh should be chosen.
  4. For women wanting to avoid mesh allographs, xenographs or autologous fascia can be used.
    -these are less well studied
  5. Should only be done by women who are credentialled for these procedures.
  6. Long books of patient demographics, operations outcomes and FU should be undertaken for these patients.
  7. Mesh procedures should be reported to an Australian/NZ registry
56
Q

Compare sacrocolpopexy to vaginal prolapse repairs in terms of outcomes.
1. In broad terms (5)
2. Compared with sacrospinus ligament suspension

A
  1. Scarocolpopexy has:
    -Lower risk of symptoms recurrence
    -Lower risk of recurrent prolpase on examination
    -Less repeat surgery for prolapse
    -Less post op SUI
    -Less dysparenuia
  2. Sacrocolpopexy has
    -Higher anatomical success rates
    -Less SUI
    -Less PO dyspareunia
    -Greater surgical morbidity -longer OT time, longer hosp stay, slower recovery
57
Q

What preventive techniques at time of vaginal hysterectomy should be undertaken to prevent prolapse (4)

A
  1. McCall culdoplasty
  2. Suturing in uterosacral and cardinal ligaments to vault for all hysterectomies
  3. SSF at time of VH if vault decends to introitus during close
  4. Subtotal hyst as a way to avoid prolpase is not recommended
58
Q

What are the treatment options for women with vault prolapse post VH.

A
  1. Pelvic floor PT - improves sx and severity
  2. Pessaries - ring or gelhorn
  3. Surgery - tailor to patient. No robust evidence to suggest any modality superior
    -Abdominal sacrocolpopexy
    -SSF
    -Colpoclesis
    -High uterosacral ligament suspension is not recommended outside of research setting
59
Q

Discuss pubovaginal slings
-What are they
-Success rates
-Complications

A
  1. What are they
    -Sling like the MUS but made from rectus sheath harvested from abdomen
    -Placed similarly to MUS
  2. Success rates
    -Same as MUS 80-90%
  3. Complications
    -Increased urinary retention cf MUS and harder to rectify

RANZCOG -Gynaecology 2024 Edward (11 decks)

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