Urogynaecology

Question 0

What is genuine stress incontinence?

Answer 0

Involuntary loss of urine when bladder pressure exceeds maximum urethral pressure in the absence of detrusor contraction

Question 1

What is incontinence?

Answer 1

Objectively demonstrable involuntary loss of urine

Question 2

How common is stress incontinence?

Answer 2

50% of all causes of incontinence

Occurs in 10% of women

Question 3

What are causes of genuine stress incontinence?

Answer 3

Pregnancy and vaginal delivery
Particularly prolonged labour and forceps delivery
obesity and age
Previous bladder neck surgery
Prolapse often coexists but may not be related
More common after menopause connective tissue atrophies around pelvic floor - oestrogen cream
Fibroids may increase bladder pressure - hysterectomy

Question 4

What investigations are indicated in suspected stress incontinence?

Answer 4

Urine mc&s to exclude infection
Urinalysis
Urinary diary

Cytometry:
Required to exclude over active bladder if surgery is contemplated
Shows no increase in detrusor pressure with filling
No detrusor contraction with cough
Urine flow with cough

Question 5

What is the management of genuine stress incontinence?

Answer 5

Lose weight (aim bmi<30)
Treat causes of chronic cough

Pelvic floor exercises to strengthen pelvic floor or vaginal cones
Electrical stimulation
Duloxetine- may cause hesitancy

Surgical:
Burch colposuspension-
Tension free vaginal tape- less invasive, can be performed under spinal/local
These have up to 90% cure rates

Collagen injectables may also work, but will have to be repeated in 12 months

Question 6

What are the different types of anterior uterine prolapse?

Answer 6

Anterior
Utethrocoele- prolapse of uterus into the vagina, associated with stress incontinence

Cystocoele- prolapse of bladder into vagina, usually no symptoms

Cystourethrocoele- prolapse of both bladder and urethra

Question 7

What are types of middle compartment prolapse?

Answer 7

Uterine prolapse - descent of uterus into vagina

Vaginal vault prolapse - descent of vaginal vault after hysterectomy

Enterocoele- herniation of the pouch of Douglas, including small intestine , into the vagina- usually asymptomatic

Question 8

What are types of posterior compartment prolapse?

Answer 8

Rectocoele- prolapse of rectum into vagina

Question 9

How can the degree of prolapse be classified?

Answer 9

When straining, most distal portion is:
0- no prolapse
1- more than 1cm above hymen
2- within 1cm before or after hymen
3- more than 1cm below the plane of the hymen, protrudes no further than 2cm less the total length of the vagina
4- complete eversion of vagina

Question 10

How can prolapse be managed?

Answer 10

Reduce bmi to <30
Physio- pelvic floor exercises 
Pessaries- ring, shelf etc
Surgical- sacrocolpoplexy, hysterectomy, anterior posterior repair
Vaginal mesh repair is controversial

Question 11

What is detrusor over activity incontinence?

Answer 11

Involuntary urine loss due to uninhibited detrusor contractions on provocation or spontaneously when the patient is trying to inhibit micturition

Question 12

How does detrusor over activity present and what may be found on cystometry?

Answer 12

Urgency and urge incontinence
Frequency
Nocturia

Cystometry shows detrusor contractions on filling or provocation

Question 13

How is detrusor over activity managed?

Answer 13

Reduce tea and coffee
Stop smoking
Bladder retraining 
Anticholinergics - tolterodine/oxybutynin
Tricyclics 
Desmopressin- synthetic ADH

Surgical- Botox, sacral nerve stimulation, clam cystoplasty,