Urogynaecology

Question 1

List 4 clinical features of uterine prolapse

Answer 1

1. Groin/back pain (stretching of uterosacral ligaments)
2. Feeling of heaviness/pressure in the pelvis - worse with standing and lifting; worse at the end of the day; relieved by lying down
3. ulceration/bleeding (particularly if hypooestrogenic)
4. +/- urinary incontinence

Question 2

What is uterine prolapse?

Answer 2

Protrusion of cervix and uterus into vagina

Question 3

What is vault prolapse?

Answer 3

Protrusion of apex of vaginal vault into vagina, post-hysterectomy

Question 4

What is a cystocoele?

Answer 4

Protrusion of bladder into the anterior vaginal wall

Question 5

List 5 clinical features of a cystocoele

Answer 5

Frequency
Urgency
Nocturia
Stress incontinence
Incomplete bladder emptying +/- associated increased incidence of UTIs

Question 6

What is a rectocoele?

Answer 6

Protrusion of rectum into posterior vaginal wall

Question 7

List 2 clinical features of a rectocoele

Answer 7

Straining/digitation to evacuate stool

Constipation

Question 8

What is the Baden Walker grading for prolapse?

Answer 8

Grade 1 - prolapse within vagina
Grade 2 - prolapse to the introitus
Grade 3 - Prolase beyond the introitus
Grade 4 - complete procidentia - failure of genital supports and complete protrusion of uterus through the vagina

Question 9

What is the Pop-Q?

Answer 9

Measure prolapse in relation to the most dependent part of the vagina (proximal to a point 3cm into the vagina) in relation to introitus

Stage 1 - less than -1
Stage 2 - -1 to +1
Stage 3 - more than +1 but less than TVL -2
Sage 4 - more than TVL -2

Question 10

How is pelvic organ prolase treated?

Answer 10

Conservative - physiotherapy/pelvic floor exercises, vaginal pessary

Surgery - dependent on type of prolapse

Question 11

List 3 surgical treatments for (pelvic organ) prolapse

Answer 11

1. Vaginal repair with or without mesh or biological graft reinforcement
2. Vaginal or uterine ‘hitch up’ to spine (sacral colpopexy or hysteropexy) or pelvis (sacrospinous fixation)
3. Vaginal hysterectomy or uterine conservation

Question 12

What is a colporrhapy?

Answer 12

Essentially vaginal wall repair; used to treat cystocoeles (anterior colporrhapy) and rectocoeles (posterior colporrhapy)

Question 13

What is stress incontinence?

Answer 13

Involuntary loss of urine with increased intra-abdominal pressure (coughing, laughing, sneezing, walking, running)

Question 14

What can stress incontinence be due to? (2)

Answer 14

1. Lack of support to upper urethra and bladder outlet (urethral hypermobility)
2. “Intrinsic sphincter deficiency” - more common in older, previous radiation, multiple previous continence surgeris

Question 15

List 6 risk factors for stress incontinence in women.

Answer 15

1. Pelvic prolapse
2. Pelvic surgery
3. Vaginal delivery
4. Hypooestrogenic state (post-menopause)
5. Age
6. Neurological/pulmonary disease

Question 16

What is urge incontinence?

Answer 16

Urine loss associated with an abrupt sudden urge to void

Question 17

What is the aetiology behind urge incontinence?

Answer 17

1. Idiopathic (90%)

2. Detrusor muscle overactivity

Question 18

How is urinary incontinence evaluated? (4)

Answer 18

Most patients can be diagnosed with clinical history alone

1. History and examination
2. Dipstick and/or MSU
3. Bladder diary
4. Urodynamics - gold standard

Question 19

What is the gold standard diagnostic test for urinary incontinence?

Answer 19

Urodynamics

Question 20

List 2 conservative measures of management for stress incontinence

Answer 20

pelvic floor exercise and bladder training

support devices - intravaginal support, external urethral occlusive and intraurethral plugs

Question 21

List 4 surgical treatment for stress incontinence

Answer 21

1. Mid-urethral tapes TVT/TOT (“tension free”)
2. Bladder neck suspension procedures - Burch colposuspension
3. Urethral injections
4. Reconstructive surgery - pubovaginal sling, artificial urethral sphincter

Question 22

List 3 non-operative treatments for urge incontinence

Answer 22

Behaviour modification - reduce caffeine/liquid, smoking cessation, regular voiding schedule

Pelvic floor exercises and bladder training

Medications: anticholinergics e.g. oxybutinin (oral or transdermal patch), tolterodine or solifenacin

Question 23

List 3 surgical treatments for urge incontinence

Answer 23

Botox injections into bladder
Sacral nerve stimulation
Bladder reconstruction (last resort!)