Urogynaecology Flashcards
What causes cystocele/rectocele?
ATFP weakness
What are the types of pelvic organ prolapse?
Uterine, enterocele, cystocele, rectocele, and urethrocele
What is cystocele?
A cystocele is the prolapse of the bladder into the vagina, resulting from weakening of the pelvic floor muscles and supportive tissues.
Cystocele symptoms?
Recurrent UTI, difficulty passing urine. Symptoms may include a sensation of fullness or pressure in the pelvis and vagina, increased discomfort when straining, coughing, or lifting, urinary incontinence or retention, recurrent urinary tract infections, and a bulge of tissue protruding through the vaginal opening.
Sign of cystocele on exam?
Anterior protrusion into vaginal vault
List common risk factors for developing a cystocele.
Common risk factors include childbirth (especially multiple or difficult deliveries), aging, menopause, chronic constipation, heavy lifting, obesity, and previous pelvic surgery.
How is a cystocele diagnosed?
Diagnosis typically involves a pelvic examination to assess the extent of prolapse, and may include imaging studies like ultrasound or MRI, and urodynamic testing to evaluate bladder function.
Describe the grading system for cystoceles
Cystoceles are graded based on severity:
Grade 1 (Mild): Bladder drops only a short way into the vagina.
Grade 2 (Moderate): Bladder drops to the opening of the vagina.
Grade 3 (Severe): Bladder bulges through the opening of the vagina.
What conservative treatments are available for cystoceles?
Conservative treatments include pelvic floor muscle exercises (Kegel exercises), use of a pessary device to support the bladder, lifestyle modifications like weight loss and avoiding heavy lifting, and managing constipation to reduce straining.
When is surgery considered for a cystocele, and what does it involve?
Surgery is considered for severe cases or when conservative treatments fail. It typically involves anterior vaginal wall repair (anterior colporrhaphy) to reinforce the vaginal wall and support the bladder.
How can the risk of developing a cystocele be reduced?
Preventive measures include performing regular pelvic floor exercises, maintaining a healthy weight, avoiding heavy lifting, treating and preventing constipation, and managing chronic cough to reduce pelvic pressure.
The prolapse of the bladder into the vagina is known as a _______
cystocele
Conservative management of a cystocele may include the use of a __________ device to support the bladder.
pessary
Which of the following is NOT a risk factor for cystocele? A. Childbirth
B. Chronic constipation
C. Smoking
D. Obesity
C. Smoking
The surgical repair for a cystocele is called an anterior ________
colporrhaphy
A 55-year-old woman presents with pelvic pressure and a visible bulge through the vaginal opening. She reports urinary incontinence and difficulty fully emptying her bladder. What is the most likely diagnosis, and how would you classify this condition if the bulge extends beyond the vaginal opening?
Likely diagnosis: Cystocele.
Classification: Grade 3 (Severe).
Why might menopause increase the risk of a cystocele?
Menopause leads to a decrease in estrogen levels, which weakens the supportive tissues of the pelvic floor, increasing the risk of prolapse.
Discuss the lifestyle modifications that can help manage a mild cystocele and prevent worsening of the condition.
Perform regular pelvic floor exercises (Kegels) to strengthen muscles.
Maintain a healthy weight to reduce strain on the pelvic floor.
Avoid heavy lifting to decrease pressure on the bladder and pelvic region.
Address chronic constipation with a high-fiber diet and adequate hydration.
Manage chronic cough conditions (e.g., from smoking or asthma) to prevent repetitive pelvic strain
What is urinary incontinence?
Involuntary passage of urine
What is stress incontinence?
- urinary loss during a period of raised intra-abdominal pressure e.g. coughing, sneezing.
What characterizes urge incontinence?
urinary loss characterised by increased urge to pass urine - associated with detrusor muscle overactivity.
What is mixed incontinence?
Combination of stress and urge incontinence
The physiology of Continence is split into 2 phases, what are they called?
Storage and Voiding phases
What transmits impulses to the pontine continence centre?
Cerebral cortex
Which spinal cord segments are involved in the pontine continence centre signals?
T10-L2
What does the sympathetic hypogastric nerve stimulate?
Detrusor relaxation, Internal urethral sphincter contraction
Somatic innervation of the ______ also contributes to continence during bladder filling
external urethral sphincter
_____from the distended bladder ascend via the spinal cord to the pontine micturition centre and the cerebral cortex (conscious urge to pass urine)
Afferent signals
______________ signals to the detrusor cause it to contract, transmitted via S2-4 pelvic splanchnic nerve.
Efferent parasympathetic
Inhibition of _________ (due to pontine micturition centre activity) reduces sympathetic storage-promoting activity.
Onuf’s nucleus
Conscious relaxation of external urethral sphincter via __________ fibres allows passage of urine.
somatic pudendal nerve
What is the role of the detrusor muscle during voiding?
Contracts via parasympathetic signals
Which nerves transmit parasympathetic signals to the detrusor?
S2-4 pelvic splanchnic nerve
What effect does the pontine micturition centre have on Onuf’s nucleus?
Inhibits sympathetic activity
How is the external urethral sphincter relaxed during voiding?
Somatic pudendal nerve fibers
Role of Sympathetic Nerves (T10-L2)
Sympathetic - T10-L2 hypogastric - detrusor relaxation, IUS closing
Role of Parasympathetic Nerves (S2-4)
Parasympathetic - S2-4 pelvic splanchnic - detrusor contraction, IUS opening
Role of Somatic Afferent Nerves (S2-4)
Somatic afferent - S2-4 pudendal - sensation of bladder fullness
Role of Somatic Efferent Nerves (S2-3)
Somatic efferent - S2-3 pudendal - closes / opens EUS.
Continence Mechanism for Intra-abdominal Pressure
- Reflexive contraction of the pelvic floor muscles elevates the IUS. 2. Augmentation of pelvic floor muscle closure by suspensory ligaments. 3. Urethrovaginal sphincter and compressor urethrae muscle contraction assists with urethral closure.
What role do suspensory ligaments play?
Augment pelvic floor muscle closure
What assists with urethral closure?
Urethrovaginal sphincter contraction
What increases intra-vesical pressure in stress incontinence?
Raised intra-abdominal pressure
What leads to leakage in stress incontinence?
○ Raised intra-abdominal pressure increases intra-vesical pressure. ○ IVP exceeds resistance of urethral sphincters leading to leakage. ○ This typically occurs due to downward movement of the internal sp
What leads to urge incontinence?
Mechanism not fully understood - likely a combination of myopathy and neuropathy.
What causes urethral hypermobility?
Pelvic floor weakness
Urge incontinence mechanism?
Myopathy, neuropathy
Risk factors for incontinence
- Increasing age 2. High BMI 3. High parity 4. Pelvic organ prolapse
What is stress incontinence?
- involuntary passage of urine during activities that raise intra-abdominal pressure (sneezing, coughing etc.)
What is urge incontinence?
- involuntary passage of urine with associated urge to pass urine, increased urinary frequency.
What is the first line investigation for urinary incontinence?
urinalysis to rule out UTI, plus: ○ Bladder diary ○ Symptom questionnaire
What is included in the second line investigations?
urinary stress testing, e.g. ○ Cough stress test ○ Empty supine stress test
What is the first line management for stress incontinence?
pelvic floor exercises (8 contractions x3 per day) + lifestyle measures e.g. reducing caffeine, weight loss, moderate fluid intake
What is the second line management for stress incontinence?
(for some patients) - pseudoephedrine, topical oestrogen
What is the third line management for stress incontinence?
surgery such as retropubic colposuspension.
First Line (urge incontinence)
bladder training
Second Line (urge incontinence)
anticholinergic e.g. oxybutynin, solifenacin
Third Line (urge incontinence)
mirabegron (beta-3 agonist)
Plus (atropic vaginitis)
topical oestrogen if atrophic vaginitis present
What are urinary tract calculi?
Urinary tract calculi, or kidney stones, are solid masses formed from crystals that develop in the urinary tract.
Name the four primary types of urinary tract stones.
Calcium oxalate stones: The most common type, formed when calcium combines with oxalate in urine.
Uric acid stones: Formed when urine is excessively acidic, often due to a high-protein diet.
Struvite stones: Associated with urinary tract infections; can grow rapidly and become quite large.
Cystine stones: Rare and hereditary, occurring when cystine leaks into urine.
List common risk factors for developing urinary tract calculi.
Dehydration
High-protein, high-sodium, or high-sugar diets
Obesity
Family history of kidney stones
Certain medical conditions (e.g., hyperparathyroidism, urinary tract infections)
Specific medications and supplements
What are typical symptoms of urinary tract calculi?
Severe pain in the side and back, radiating to the lower abdomen and groin
Pain during urination
Pink, red, or brown urine (hematuria)
Cloudy or foul-smelling urine
Nausea and vomiting
Persistent need to urinate
Fever and chills if an infection is present
How are urinary tract calculi diagnosed?
Imaging tests: Such as non-contrast helical CT scans, ultrasounds, or X-rays to detect stones.
Urinalysis: To check for blood, crystals, or signs of infection.
Blood tests: To assess kidney function and detect high levels of stone-forming substances.
What are the treatment options for urinary tract calculi?
Small stones: May pass naturally with increased fluid intake and pain management.
Medications: Such as alpha-blockers to relax ureter muscles and facilitate stone passage.
Extracorporeal shock wave lithotripsy (ESWL): Uses sound waves to break stones into smaller pieces.
Ureteroscopy: Involves using a thin scope to locate and remove or break up stones.
Percutaneous nephrolithotomy: Surgical removal of large stones via a small incision in the back.
How can the formation of urinary tract calculi be prevented?
Staying hydrated by drinking plenty of fluids.
Reducing sodium and animal protein intake.
Consuming adequate dietary calcium.
Avoiding foods high in oxalates if prone to calcium oxalate stones.
Maintaining a healthy weight.
The most common type of urinary tract stone is composed of __________.
calcium oxalate
Which of the following is NOT a typical symptom of urinary tract calculi?
A. Severe side and back pain
B. Hematuria
C. Increased appetite
D. Nausea and vomiting
C. Increased appetite
What is pelvic organ prolapse?
Herniation of one more pelvic organ into the vagina.
What provides Level 1 support in the pelvis?
Uterosacral ligaments - extend posteriorly from cervix / upper vagina to the sacral spine.
What structure is involved in Level 2 support?
Arcus tendineus fasciae pelvis (ATFP) - runs from ischial spines to pubic tubercle, attaching to sheets of suspensory ‘slings’ of fascial tissue e.g. pubovesicocervical fascia.
What structures are involved in Level 3 support?
Perineal body - fibromuscular mass, point of attachment for pelvic muscles. - Pubourethral ligaments. - Pelvic floor - (levator ani and coccygeus muscles).
What is the role of the perineal body?
Attachment for pelvic muscles
What are the supporting structures of the pelvic floor?
Pubourethral ligaments, pelvic floor muscles (levator ani and coccygeus muscles), uterosacral ligament, and ATFP
What causes uterine prolapse?
Uterosacral ligament weakness
What is the primary cause of pelvic organ prolapse?
Loss of support due to factors like pregnancy, vaginal delivery, and surgery
What is the primary risk factor for pelvic organ prolapse?
Vaginal delivery
What are the contributing risk factors for pelvic organ prolapse?
Increasing age and high BMI
Why does vaginal delivery lead to pelvic organ prolapse?
(risk increased with increasing parity) - damage to nerves, muscles and fascia
Why does increasing age lead to pelvic organ prolapse?
- reduced elasticity of connective tissue
Why does high BMI lead to pelvic organ prolapse?
- raised intra-abdominal pressure
What is uterine prolapse?
descent of cervix +/- uterus into the vagina.
What causes urethrocele?
Pubourethral ligament weakness -
What is urethrocele?
- prolapse of the urethra into anterior vaginal wall
What is enterocele?
- prolapse of the small bowel through the Pouch of Douglas into the posterior vault of the vagina.
Uterine prolapse symptoms?
vaginal pressure, dyspareunia, feeling of something descending into the vagina.
Urethrocele symptom?
Stress incontinence
Enterocele symptom?
Dragging sensation
Sign of uterine prolapse?
Descended cervix/uterus
Sign of urethrocele on exam?
Anterior protrusion into vaginal vault
Sign of enterocele on exam?
Posterior protrusion into vaginal vault
How is the condition typically diagnosed?
Clinically based on symptoms
What is a conservative management option for pelvic issues?
○ Pelvic floor exercises. ○ Avoidance of triggers e.g. heavy lifting, straining in constipation. ○ Weight loss, if overweight. ○ Topical oestrogen (counteracts urogenital atrophy - see Menopause). ○ Pessaries
What is a surgical option for uterine management?
- options include hysterectomy, sacro-hysteropexy (mesh), Manchester repair
What is a surgical option for vaginal vault managment?
options include sacrospinous fixation, sacro-colpopexy (mesh)
What is a topical treatment for urogenital atrophy?
Topical oestrogen
What is overactive bladder (OAB)?
Overactive bladder is a condition characterized by a sudden, compelling urge to urinate, often with increased frequency and nocturia, and may include urge incontinence.
List common symptoms of overactive bladder.
Urgency: Sudden, strong need to urinate.
Frequency: Urinating more than eight times in 24 hours.
Nocturia: Waking up more than once per night to urinate.
Urge incontinence: Involuntary urine leakage following a strong urge to urinate.
What causes overactive bladder?
OAB is often due to involuntary detrusor muscle contractions during bladder filling, leading to increased bladder pressure and urgency.
Identify risk factors associated with overactive bladder.
Aging
Neurological conditions (e.g., stroke, Parkinson’s disease)
Diabetes mellitus
Urinary tract infections
Bladder abnormalities (e.g., tumors, stones)
How is overactive bladder diagnosed?
Detailed medical history and symptom assessment.
Physical examination, including pelvic and neurological exams.
Urinalysis to rule out infections or hematuria.
Bladder diary documenting voiding patterns.
Urodynamic studies in complex cases to assess bladder function.
What lifestyle modifications can help manage overactive bladder?
Bladder retraining to increase intervals between voiding.
Pelvic floor muscle exercises (Kegels) to strengthen pelvic muscles.
Limiting intake of bladder irritants (e.g., caffeine, alcohol).
Maintaining a healthy weight.
Managing fluid intake to prevent excessive bladder filling.
Name common medications used to treat overactive bladder.
Antimuscarinics (e.g., oxybutynin, tolterodine) to relax bladder muscles.
Beta-3 adrenergic agonists (e.g., mirabegron) to enhance bladder relaxation.
Which of the following is NOT a typical symptom of overactive bladder?
A. Urgency
B. Increased frequency
C. Nocturia
D. Dysuria
D. Dysuria
What is a rectocele?
A rectocele is a prolapse of the rectum into the posterior vaginal wall due to weakening of the pelvic floor muscles and connective tissues.
Rectocele symptoms?
Difficulty defecating. Sensation of vaginal pressure or fullness
Difficulty or pain with bowel movements (straining or incomplete evacuation)
Bulging of the vaginal wall
Pain during intercourse (dyspareunia)
Sign of rectocele on exam?
Posterior protrusion into vaginal vault
What are the primary causes of rectocele?
Vaginal childbirth, particularly multiple deliveries
Chronic constipation with straining
Aging and hormonal changes (especially post-menopause)
Previous pelvic surgeries such as hysterectomy
Increased intra-abdominal pressure
How is rectocele diagnosed?
Clinical examination: During a pelvic examination, the doctor will palpate for vaginal bulging.
Defecography: An imaging technique used to evaluate rectal function and the extent of prolapse.
MRI or Ultrasound: May be used in more severe cases to assess pelvic floor anatomy.
What are the treatment options for rectocele?
Conservative treatment:
Dietary changes to prevent constipation
Pelvic floor exercises (Kegel exercises) to strengthen the pelvic floor
Pessary insertion to provide support to the vaginal walls
Surgical treatment:
Posterior colporrhaphy: Surgical repair of the posterior vaginal wall
Rectocele repair surgery
The surgical procedure to repair a rectocele by tightening the posterior vaginal wall is called __________.
Posterior colporrhaphy
What are risk factors for developing a rectocele?
Multiparous women (multiple vaginal deliveries)
Obesity
Chronic constipation
Aging and menopause
What are some ways to prevent rectocele?
Maintaining a healthy weight
Avoiding constipation through diet (high-fiber) and hydration
Pelvic floor exercises
Using proper lifting techniques to avoid increasing intra-abdominal pressure
True/False
Q: Rectocele always requires surgery for treatment.
False – Conservative management, including pelvic floor exercises and the use of a pessary, may be effective for many women.
Which of the following is a common symptom of a rectocele?
A. Painful urination
B. Difficulty with bowel movements
C. Lower back pain
D. Night sweats
B. Difficulty with bowel movements
What is a genital tract fistula?
A genital tract fistula is an abnormal connection between the female genital tract and another organ, such as the urinary or gastrointestinal tract. This causes symptoms like urine or feces passing through the vagina.
What are the common types of genital tract fistulas?
Vesicovaginal Fistula: Connection between the vagina and bladder.
Rectovaginal Fistula: Connection between the vagina and rectum.
Urethrovaginal Fistula: Connection between the vagina and urethra.
Enterovaginal Fistula: Connection between the vagina and intestines.
What are the main causes of genital tract fistulas?
Obstetric trauma (e.g., prolonged or obstructed labor leading to tissue damage).
Pelvic surgery, such as hysterectomy, leading to accidental injury.
Radiation therapy for pelvic cancers.
Infections causing chronic inflammation or necrosis of tissue.
Trauma such as from accidents or injuries.
What are the typical symptoms of genital tract fistulas?
Vesicovaginal fistula: Leakage of urine from the vagina.
Rectovaginal fistula: Passage of feces or gas through the vagina.
Urethrovaginal fistula: Leakage of urine during intercourse.
Enterovaginal fistula: Passage of intestinal contents through the vagina.
How are genital tract fistulas diagnosed?
Clinical examination to identify visible signs of a fistula.
Cystoscopy or proctoscopy to directly visualize the fistula.
Imaging studies, such as MRI, CT scan, or contrast studies (e.g., cystography, defecography).
Fistulography: Injection of contrast media to assess the fistula tract.
What are the treatment options for genital tract fistulas?
Conservative management:
Indwelling catheter to divert urine or feces and allow healing.
Surgical repair:
Transvaginal approach: Closure of the fistula through the vaginal wall.
Transabdominal approach: Closure through the abdominal wall.
Laparoscopic or robotic surgery: Minimally invasive techniques to repair the fistula.
Tissue grafts or flaps: Used to reinforce the repair site.
What is the prognosis for genital tract fistula?
The prognosis is generally good with timely and appropriate surgical intervention, although it can depend on the size and complexity of the fistula and the presence of any underlying health conditions.
How can genital tract fistulas be prevented?
Proper obstetric care: Minimizing the risk of birth trauma through careful management of labor.
Avoiding pelvic surgery unless necessary: Taking precautions during surgery to prevent injury.
Managing infections effectively to avoid complications.
True/False
Q: Genital tract fistulas always require surgery.
False. In some cases, conservative management with catheterization may suffice, especially if the fistula is small or recent.
