Urogynaecology Flashcards
Pelvic Organ Prolapse refers to
descent of pelvic organs into the vagina.
prolapse - due to weakness and lengthening of ligaments and muscles surrounding uterus, rectum and bladder.
Types of pelvic organ prolapse
uterine - uterus descends into vagina
vault - women with hysterectomy and dont have uterus. top of vagina (vault) descends into vagina.
rectocele
cystocele
what is a rectocele
association with what sx
what can happen as a result.
sign for the above.
defect in posterior vaginal wall
rectum prolapses forward into vagina.
associated with constipation.
women can get faecal loading in part of rectum that has prolapsed into the vagina.
faecal loading leads to : constipation, urinary retention (compression of urethra) and palpable lumb in vagina.
women can use fingers to press lump backwards, correct anatomical position of rectum - allows them to open their bowels.
what is a cystocele?
defect in anterior vaginal wall
bladder prolapse backward into vagina.
urethra prolapse also possible (urethrocele)
prolapse of both ballder and urethra called cystourethrocele
risk factors of pelvic organ prolapse
result of weak and stretched muscles and ligaments.
multiple vaginal deliveries
obesity
chronic respiratory disease causing coughing
chronic constipation causing strain
advanced age and postmenopause status
instrumental, prolonged, traumatic delivery
how does pelvic organ prolapse present?
feel something coming down in vagina
dragging/heavy sensation in pelvis
urinary symptoms: incontinence, urgency, frequency, weak stream and retention
bowel sx: constipation, incontinence and urgency
sex dysfunction: pain, altered sensation and reduced enjoyment
women notice lump palpable in vagina, often push it back up themselves.
prolapse become worse on straining or bearing down.
How would you examine for pelvic organ prolapse?
get pt to empty bladder and bowel before exam.
exam in dorsal and left lateral position.
sim’s speculum: u-shaped single-bladed speculum used to support anterior/posterior vaginal wall while other walls examined.
held on anterior wall to examine for rectocele and posterior for cystocele
get woman to cough or “bear down” to asess full descent of prolapse
grades of uterine prolapse
pelvic organ prolapse quantification (POP-Q) :
0 - normal
1 - lowest part more than 1 cm above introitus
2 - lowest part within 1 cm of introitus (above or below)
3 - lowest part more than 1cm below introitus, not fully descended
4 - full descent with eversion of vagina
what do you call a prolapse extending beyong introitus?
uterine procidentia
how would you manage pelvic organ prolapse?
conservative
conservative: women with mild sx, cant have pessaries and no surgery:
physio
weight loss
lifestyle changes for stress incontinence like reduce caffeine and incontinence pads
tx related sx: treat stress incon with anticholinergics
vaginal oestrogen cream
talk to me about the vaginal pessary at tx for pelvic organ prolapse?
different types
how often should change
what to do for se of pessary?
insert into vagina provide extra support to pelvic organs.
easily removed and replaced.
typeS:
ring - ring shape, sit around cervix hold uterus up
shelf and gelhorn : flat disc with stem : sits below uterus with stem pointing down
cube: cube shape
donut: thick ring
hodge: rectangular: one side hooked around posterior aspect of cervix and other extends into vagina.
try a few before seeing which one comfrtable.
remove clean and change every 4 months.
can cause vaginal irritation and erosion over time.
oestrogen cream protect vaginal walls from irritation
definitive option for treating pelvic organ prolapse?
surgery.
cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
uterine prolapse: hysterectomy, sacrohysteropexy
rectocele: posterior colporrhaphy
potential complications of pelvic organ prolapse surgery
pain bleeding infection dvt , risk of anesthetic
damage to bladder or bowel
recurrence of prolapse
altered sex experience
they used to do mesh repair why should you do it now?
its inserting plastic mesh to support pelvic organs.
AVOID
chronic pain
altered sensation
dyspareunia
abnormal bleeding
urinary/bowel problems
Renal Stones - What are they?
they collect where?
most commonly?
renal calculim, urolithiasis, nephrolithiasis.
hard stones form in renal pelvis (where urine collects before travelling down the ureters.
2 key complications of renal stones
obstruction - leading to aki
infection with obstructive pyelonephritis
types of renal stones
radiograph appearance
calcium oxolate - 40% - opaque
mixed calcium oxolate/phosphate stones - 25% - opaque
triple phosphate stones - 10% - opaque
calcium phosphate - 10% - opaque
urate stones - 5-10% - radio-lucent - not visible on xray
cystine stones - 1% - semi-opaque, “ground-glass” appearance - associated with cystinuria, autosomal recessive disease
xanthine stones - <1% - radiolucent
struvite - produced by bacteria, associated with infection
what is staghorn calculus?
types of stones it caused in
imaging
how struvite formed
stone form in shape of the renal pelvis - appearance of antlers of a deer stag.
body sits in renal pelvis , horns extend into renal calyces (2 of them).
seen on plain x ray films.
struvite
triple pphosphate
reccurent uti, bacteria hydrolyse urea in urine to ammonia creating struvite
how does renal stones present?
can be asx
renal colic - presenting complaint :
unilateral loin to groin pain - can be excrutiating - worse than childbirth.
colicky - fluctuating in severity - as stone moves and settles
patient often mvoe restlessly due to pain
haematuria
n+v
reduced urine output
sx of sepsis, if infection present
how would you investigate renal stones?
urine dipstick - haematuria. normal urine dip doesnt exclude stones.
bloods - if infection and kidney function. serum calcim - hypercalcaemia cause of kidney stone
serum creatinine and electrolyte
abdo x ray - calcium bansed strone, uric acid stone no visible because radiolucent.
noncontrast ct of kidney ureter bladdder - initial ix. - within 24 hrs
uss of kub - less preffered. negative result doesnt exclude. - helpful in pregancy and children.
clotting if percutaneous intervention planned and blood cultures if pyrexial or septic signs.
stones bones groans moans.
3 main causes of renal stones
calcium supplementaiton
hyperparathyroidism
cancer - myeloma breast or lung cancer.
how would you manage renal stones
nsaids - im diclofenac. iv para alternative. opiates not helpful
antiemetic - n+v - metoclopramide, prochlorperazine, cyclizine
abx - if infection
watchful waiting - if stone less than 5mm - will pass without intervention. if 5-10 mm poss depends. - can take several weeks to pass.
tamsulosin - alpha blocker - help aid spontaneous passage
surgery - if large : 10mm or larger. if it wont pass spontaneous or complete obstruction or infection
what surgical procedures can you do for renal stones?
ESWL - extracorporeal shock wave lithotripsy - shock waves under x ray. break stone into smaller parts and pass thru urine.
ureteroscopy and laser lithotripsy: camera inset via urethra, bladder and ureter, stone identified and broken using lasers. (pregnant women) - stent left in situ for 4 weeks after procedure.
percutaneous neprholithotomy - PCNL: theatre general anesthetic. nephroscope via small incision in pt back. inset through kidney access ureter. broke into smaller pieces and remove.
can leave nephrostomy tube in place after to help drain kidney.
open surgery: to access kidney and remove stone. rare
lifestyle advice for recurrent renal stones
increase oral fluid - 2.5-3 lts.
add fresh lemon juice to water. – citric acid binds to urinary calcium reduce formation of stones.
avoid carbonated drinks - cola has phosphoric acid - promotes calcium oxolate
reduce dietary salt - less than 6g a day
maintain normal calcium intake. - low diet calcium might increase risk
common recommendation to avoid calcium stones
reduce oxolate rich intake food
spinach
beetroot
nuts
rhubarb
black tea
common recommendations to avoid uric acid stones
reduce purine rich food
kidney
liver
anchovies
sardines
spinach
limit dietary protein for all stones
2 meds to reduce risk of recurrence of renal stones
potassium citrate - pts with calcium oxolate stones and raised urinary calcium
thiazide diuretic - indapamide - pts with calcium oxolate stones and raised urinary calcium
increased risk of what when you diclofenac and ibuprofen
cardiovascular events
how do alpha blockers work in managing renal colic
promote smooth muscle relaxation and dilation of ureter.
ease stone passage.
if distal ureteric stone less than 10mm in size.
what differential should be excluded when doing non contrast ct kub in renal stones?
ruptured abdo aortic aneursym.
what to use for pregnant women with suspected renal stone?
uss
and for kids
sensitivity 45 %
specificity 90%
what options for renal stones and ureteric stones for mx depending on size?
renal stones
watchful wait if under 5mm and asx
5-10: shockwave lithotripsy
10-20 - shockwave or ureteroscopy
over 20 percutaneous nephrolithotomy
ureteric:
shockwave litho +/- alpha blockers
10-20 - ureterscopy
pt with ureteric obstruction due to stones together with infection what to d?
decompression
nephrostomy tube placement
insertion of ureteric catheter
ureteric stent placement.
prevention of uric acid stones
allopurinol
urinary alkalinization: oral bicarbonate
prevention of oxolate stones
chloesyramine - reduce urinary oxolate secretion
pyridoxine - same as above
