Urogynaecology

Question 1

Pelvic Organ Prolapse refers to

Answer 1

descent of pelvic organs into the vagina.

prolapse - due to weakness and lengthening of ligaments and muscles surrounding uterus, rectum and bladder.

Question 2

Types of pelvic organ prolapse

Answer 2

uterine - uterus descends into vagina

vault - women with hysterectomy and dont have uterus. top of vagina (vault) descends into vagina.

rectocele

cystocele

Question 3

what is a rectocele

association with what sx

what can happen as a result.

sign for the above.

Answer 3

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.

Question 4

what is a cystocele?

Answer 4

defect in anterior vaginal wall

bladder prolapse backward into vagina.

urethra prolapse also possible (urethrocele)

prolapse of both ballder and urethra called cystourethrocele

Question 5

risk factors of pelvic organ prolapse

Answer 5

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

Question 6

how does pelvic organ prolapse present?

Answer 6

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.

Question 7

How would you examine for pelvic organ prolapse?

Answer 7

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

Question 8

grades of uterine prolapse

Answer 8

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

Question 9

what do you call a prolapse extending beyong introitus?

Answer 9

uterine procidentia

Question 10

how would you manage pelvic organ prolapse?

conservative

Answer 10

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

Question 11

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?

Answer 11

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

Question 12

definitive option for treating pelvic organ prolapse?

Answer 12

surgery.

cystocele/cystourethrocele: anterior colporrhaphy, colposuspension

uterine prolapse: hysterectomy, sacrohysteropexy

rectocele: posterior colporrhaphy

Question 13

potential complications of pelvic organ prolapse surgery

Answer 13

pain bleeding infection dvt , risk of anesthetic

damage to bladder or bowel

recurrence of prolapse

altered sex experience

Question 14

they used to do mesh repair why should you do it now?

Answer 14

its inserting plastic mesh to support pelvic organs.

AVOID

chronic pain
altered sensation
dyspareunia
abnormal bleeding
urinary/bowel problems

Question 15

Renal Stones - What are they?

they collect where?

most commonly?

Answer 15

renal calculim, urolithiasis, nephrolithiasis.

hard stones form in renal pelvis (where urine collects before travelling down the ureters.

Question 16

2 key complications of renal stones

Answer 16

obstruction - leading to aki

infection with obstructive pyelonephritis

Question 17

types of renal stones

radiograph appearance

Answer 17

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

Question 18

what is staghorn calculus?

types of stones it caused in

imaging

how struvite formed

Answer 18

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

Question 19

how does renal stones present?

Answer 19

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

Question 20

how would you investigate renal stones?

Answer 20

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.

Question 21

3 main causes of renal stones

Answer 21

calcium supplementaiton
hyperparathyroidism
cancer - myeloma breast or lung cancer.

Question 22

how would you manage renal stones

Answer 22

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

Question 23

what surgical procedures can you do for renal stones?

Answer 23

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

Question 24

lifestyle advice for recurrent renal stones

Answer 24

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

Question 25

common recommendation to avoid calcium stones

Answer 25

reduce oxolate rich intake food

spinach
beetroot
nuts
rhubarb
black tea

Question 26

common recommendations to avoid uric acid stones

Answer 26

reduce purine rich food

kidney
liver
anchovies
sardines
spinach

limit dietary protein for all stones

Question 27

2 meds to reduce risk of recurrence of renal stones

Answer 27

potassium citrate - pts with calcium oxolate stones and raised urinary calcium

thiazide diuretic - indapamide - pts with calcium oxolate stones and raised urinary calcium

Question 28

increased risk of what when you diclofenac and ibuprofen

Answer 28

cardiovascular events

Question 29

how do alpha blockers work in managing renal colic

Answer 29

promote smooth muscle relaxation and dilation of ureter.
ease stone passage.

if distal ureteric stone less than 10mm in size.

Question 30

what differential should be excluded when doing non contrast ct kub in renal stones?

Answer 30

ruptured abdo aortic aneursym.

Question 31

what to use for pregnant women with suspected renal stone?

Answer 31

uss

and for kids

sensitivity 45 %
specificity 90%

Question 32

what options for renal stones and ureteric stones for mx depending on size?

Answer 32

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

Question 33

pt with ureteric obstruction due to stones together with infection what to d?

Answer 33

decompression

nephrostomy tube placement

insertion of ureteric catheter

ureteric stent placement.

Question 34

prevention of uric acid stones

Answer 34

allopurinol

urinary alkalinization: oral bicarbonate

Question 35

prevention of oxolate stones

Answer 35

chloesyramine - reduce urinary oxolate secretion

pyridoxine - same as above