urogynaecology Flashcards
if you have failure of the pelvic floor at level 1 what type of prolapse is it?
utero-cervical or vault prolapse bc of cervical incompetence
what is a cystocele?
anterior vaginal wall prolapse/ bladder prolapse into the vagina
what do we mean by ‘apical descent’ prolapse?
uterine/vault prolapse
what is a rectocoele?
posterior vaginal wall prolapse/ rectal prolapse into the vagina
what is the difference between rectocoele and rectal prolapse?
rectocoele= refers to prolapse through the vagina
rectal prolapse= refers to prolapse through the anus
in what setting can a prolapse be life threatening?
If the prolapse is outside for a long time–> infection and sepsis
if there is obstructive uropathy–> urinary retention–> renal failure
If a woman has sudden onset prolapse, what do we think of?
a solid tumour causing prolapse
what are some causes of nulliparous prolapse?
Collagen tissue disorders like Marfans can cause weakness of endopelvic fascia and so these patients can have prolapse without having children
Spina bifida–> another cause of nulliparous prolapse
why are women who have had children and are subsequently heavy lifting in the gym are at high risk of prolapse?
heavy lifting- massive amount of pressure on the abdominal muscles and the levator ani muscles are NOT contracted –> risk of prolapse! So need to do pelvic floor exercises first before attending the gym
why might obese women be at risk of pelvic organ prolapse?
sheer weight on the abdomen –> endopelvic fascial trauma
Endopelvic fascia may also be infiltrated with fat –> causing weakened fascia
why are diabetic women at risk of pelvic organ prolapse?
poor tissue quality causing weakened endopelvic fascia
what are some contributing factors for pelvic organ prolapse?
multiparity, previous surgery, age and decreasing E2 levels
connective tissue disease and denervation conditions
increased intra-abdominal pressure such as obesity etc
what are some exacerbating factors for pelvic organ prolapse?
chronic cough, chronic constipation, menopause (endopelvic fascia needs oestrogen and hence becomes weakened during menopause)
what are some ways a woman can present with pelvic organ prolapse?
• Dragging pain, lump/bulge
- Bladder or bowel symptoms E.g. stress incontinence
- Or incomplete voiding + recurrent UTIs
- Or complete urinary obstruction if prolapse is massive –> urinary retention
Incomplete/obstructive defecation–> requires digitate vagina to allow defecation
• Faecal incontinence
Difficulty with sexual intercourse
Back ache
how might we grade the severity of pelvic organ prolapse?
Baden Walker Classification
0= no prolapse 1= descent halfway to hymen 2= descent to hymen 3= descent halfway PAST the hymen 4= maximal
what normally occurs at the levator ani muscles when there is increased intraabdominal pressure?
levator ani muscles contract reducing genital hiatus diameter, preventing pelvic organ prolapse
what are some clinical features of urge incontinence?
bladder empties > 8 times per day
bladder empties > 2 times overnight
associated with sense of urgency
Why do we always ask whether a patient who has urinary incontinence also has narrow angle glaucoma?
bc the treatment for overactive bladder is anticholinergics which can exacerbate closed angle glaucoma
what type of stress incontinence wont respond to kegel exercises?
will not work in stress incontinence due to intrinsic urethral sphincter deficiency
what exactly is detrusor overactivity?
involuntary detrusor contractions during the filling phase of the bladder
what do we see during urodynamics which confirms stress incontinence?
involuntary leakage of urine during increased abdominal pressure (e.g. cough) in the absence of a detrusor contraction
what are some ways we can manage pelvic organ prolapse?
- conservative management e.g. pelvic floor exercises, weight loss and avoiding lifting heavy objects
- Vaginal pessary rings
- Surgery
how might we examine pelvic floor prolapses?
If a pelvic organ prolapse is present, the examiner should ascertain what is prolapsing (e.g. bladder [cystocele] or bowel [enterocele]) and the degree of descent.
This is accomplished by using a Sims’ speculum and placing it inside the vagina to support either the anterior or posterior wall during the Valsalva manoeuvre.
Finally, a bimanual examination must be performed to evaluate the prolapse, determine uterine size and position, and identify the presence of pelvic masses
what does procidentia refer to in urogynaecology?
failure of genital supports and complete uterine prolapse through the vagina
what is the difference between uterine prolapse and vault prolapse?
uterine prolapse= protrusion of uterus and cervix into the vagina
vault prolapse= protrusion of apex of vaginal vault into vagina, post hysterectomy
what are important examination things to do for urinary incontinence?
- assess cognition
- assess mobility and gait
- neurological examination- back/lower limbs/perianal sensation etc
- abdominal examination- abdominal masses
- pelvic examination- cough impulse, bimanual, pelvic floor strength
what ix should we do for a woman presenting with urinary incontinence?
MSU looking for UTI or haematuria
post voidal residual volume using bladder scanner
bladder diary
QOL questionaires
refer for urodynamic studies
what type of urinary incontinence are pelvic floor exercises useful?
stress incontinence
overactive bladder
what are some general behavioural advice we can give for women with urinary incontinence?
restrict ETOH, caffeine intake or overall fluid intake
reduce fluid intake before bedtime
empty bladder before bed
zinc creams if atrophic vaginitis present
manage constipation if present
what medications can we offer a woman with OAB urinary incontinence? (for detruser overactivity)
anticholinergics like oxybutynin
mirabegron- b3 adrenoreceptor agonist
botox IM injection into detruser muscles
what is the gold standard surgery for stress urinary incontinence?
mid-urethral sling
what are some key questions you should ask on history of a woman with urinary incontinence?
ask about lower urinary tract symptoms
- dysuria, fever, haematuria, frequency, nocturia, urgency
- incontinence with coughing/sneezing
- volume of leak
- typical fluid intake
- sense of dragging sensation or bulge in vagina
- constipation
- dyspareunia, dryness of vagina
- Impact on QOL
- obstetric hx including parity, mode of delivery
- previous surgery e.g. mid urethral sling for incontinence or spinal surgery
- any trauma to back, neurological disease, diabetes
- ask about medications like diuretics/ace inhibitors
- ask about smoking and alcohol
what are some key examinations/assessments we should perform for a lady presenting with urinary incontinence?
Assess her cognition/mobility Perform abdominal exam looking for scars and masses Pelvic examination Cough stress test Bimanual examination for masses Pelvic floor muscle contraction Lower limb neuro exam
what is the first ix we should order for urinary incontinence?
MSU to rule out UTI or haematuria
what speculum do we use to assess pelvic organ prolapse?
sims speculum- support either side of the vagina to see which wal; (anterior/posterior) is prolapsing
