Urogynaecology

Question 1

What is urinary incontinence?

Answer 1

Defined as the involuntary voiding of urine that is objectively demonstrable & impacting on social/hygienic wellbeing

Question 2

Risk factors for urinary stress incontinence?

Answer 2

Pregnancy              
Previous hysterectomy       
Prolonged labour    
Forceps delivery
Vaginal delivery - may cause damage to the nerve supply of the pelvic floor/urethral sphincter 
Obesity

Question 3

What is the treatment for stress urinary incontinence?

Answer 3

Dulexitine: a serotonin & noradrenaline reuptake inhibitor; increased the urethral sphincter activity ⇒ associated with significant improvements to stress incontinence

Question 4

What is urge urinary incontience (detrusor overactiviy)

Detrusor overactivity risk

Answer 4

Urgency: A strong sudden desire to void
Urge incontinence: Involuntary loss of urine preceded by an
intense desire to void
Nocturnal Enuresis: loss of urine occurring during sleep

Diet: alcohol, caffeine
Age: post menopausal (↓ oestrogen)

Question 5

Treatment

Answer 5

↓irritants (decaf, drinks, smoking)

Bladder retraining

Anticholinergic drugs: anticholinergics (antimuscarinic drugs) - eg, oxybutynin

Oestrogens: oestrogen treatment in post-menopausal women improves sx of vaginal atrophy, dryness & irritation → urgency, frequency & nocturia

Botulinum toxin: blocks neuromuscular transmission →muscle becomes weak
Injected cystoscopically

Surgical: enlarging the bladder
Nerve stimulants

Question 6

What is genitourinary prolapse?

Answer 6

Genitourinary prolapse occurs when there is descent of one or more of the pelvic organs including the uterus, bladder, rectum, small or large bowel, or vaginal vault

Question 7

Describe anterior, mid & posterior compartment

Answer 7

Anterior Compartment:
Urethrocele (urethra)
Cystocele (Bladder)
Mid Compartment:
Uterine
Vaginal Vault
Posterior Compartment:
Rectocele
Enterocele (Bowel)

Question 8

Management of prolapse

Answer 8

Non-surgical

• Reduce weight (BMI <30)
• Physiotherapy (pelvic floor Exercises)
• Pessaries (Ring; Shelf; Gelhorn)

Surgical
Anterior Repair (bladder)
Posterior Repair
Vaginal Hysterectomy
Use of Vaginal Mesh

Question 9

Hx Questions for urogynae

Answer 9

Incontinence
- Onset, stress/urge, volume of urine, frequency

Irritative
- Frequency, urgency, nocturia, dysuria

Voiding
- Poor stream, straining, prolonged, incomplete emptying

Others
- UTIs (proven), nocturnal enuresis, childhood problems, catheterisation, retention, past treatments

Gynea Hx: menstrual, prolapse surgery
Obstetric Hx: parity, MOD, birth weight
Medical Hx: diabetes
Drug Hx

Question 10

What is a frequency volume chart

Answer 10

A Frequency Volume Chart records the volumes voided as well as the time of each visit to the toilet, both during the day and night.

Question 11

What is urodynamic studies?

Answer 11

Urodynamic studies (UDS) test how well the bladder, sphincters, and urethra hold and release urine. These tests can show how well the bladder works and why there could be leaks or blockages.

During the tests, bladder is filled and then emptied while pressure readings are taken from your bladder and your tummy (abdomen).

Question 12

When to use urodynamics?

Answer 12

Stress urinary incontinence
Urge urinary incontinence
Mixed urinary incontinence (stress and urge urinary incontinence). Used in out patient setting

Question 13

How to investigate incontience

Answer 13

Thorough History & Examination

Urine Dipstick +/- MSU

Frequency/Volume Charts

Urodynamics

Question 14

What is stress incontience

Answer 14

Involuntary loss of urine on effort or exertion or on
coughing/sneezing etc
Any factor which increases intra-abdominal pressure will cause SUI

Question 15

Explain the difference in urodynamics between stress incontinence and detrusor overactivity

Answer 15

stress: no increase in detrusor pressure the filling, no detrusor contraction with cough, urine flow with cough

Detrusor overactivity: detrusor contraction after cough urine flow with detrusor contraction if increase in bladder pressure to overcome urethral pressure

Question 16

management of stress incontinence

Answer 16

Encourage obese to lose weight - reduces intra abdominal pressure
Causes of chronic cough - e.g. smoking should be addressed & advise to stop should be given
Conservative Management
Focuses on increasing the strength & contractility of pelvic floor muscles with a physiotherapist (i.e. keegals etc.)
Cones may also be used - inserted in to the vagina & held in position via muscle contraction to strengthen tone
Drugs
Dulexitine: a serotonin & noradrenaline reuptake inhibitor; increased the urethral sphincter activity ⇒ associated with significant improvements to stress incontinence
Can cause dry mouth, dyspepsia & drowsiness
Surgery
For those who have failed to resolve with conservative mgmt. / drugs
Mid-urethral sling (tension free vaginal tape) placed under urethra to prevent leakage when coughing