Urogynaecology

Question 1

What happens normally to bladder when you cough?

Answer 1

Increase in intra abdominal pressure transmitted equally to bladder and upper urethra because both lie in abdomen –> no difference in pressure –> no incontinence.

Question 2

What is the pressure ratio in normal continence? What creates each pressure?

Answer 2

Urethral pressure > bladder pressure

Bladder pressure = detrusor pressure + intra abdominal pressure

Urethral pressure = inherent urethral muscle tone + external pressure (pelvic floor and intra-abdominal)

Question 3

What is the pressure ratio in normal micturation? What creates each pressure?

Answer 3

Bladder pressure > urethral pressure

Drop in urethral pressure (pelvic floor relaxation)
Increase in bladder pressure (detrusor contraction)

Question 4

What happens in urge incontinence/overactive bladder?

Answer 4

Uncontrolled increases in detrusor pressure –> increases bladder pressure beyond that of normal urethra.

Usually idiopathic (urodynamic diagnosis)

Question 5

What happens in stress incontinence?

Answer 5

Intra-abdominal pressure transmitted to bladder but not urethra because upper urethra neck has slipped from the abdomen because its supports are weak –> bladder pressure exceeds urethral pressure when IA pressure raised

Commonly due to urethral sphincter weakness (diagnosis only made after cystometry)

Question 6

Causes of stress incontinence?

Answer 6

Pregnancy/vaginal delivery, prolonged labour/forceps, obesity, age

Question 7

Things to ask in urological history?

Answer 7

Incontinence - Onset, stress/urge, volume 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

Question 8

Other facets of incontinence history other than urological?

Answer 8

Gynaecological history -Menstrual; Prolapse; Surgery; General

Obstetric history - Parity; MOD; Birth weights

Medical history - Respiratory (cough); Cardiac; GI (constipation); CNS; Diabetes (can cause issues with innervation of pelvic floor); Psychiatric

Drug history - Diuretics; Beta-Blockers; Anti-Cholinergics

Question 9

Invesitgations for incontinence?

Answer 9

Urine Dipstick/MSU

Frequency/Volume Charts

Postmicturation USS or Catheterisation

Urodynamic Studies - Cystometry

Ultrasonography

Question 10

When is cystometry necessary?

Answer 10

Necessary prior to surgery for stress incontinence or for those who don’t respond to medical therapy.

Question 11

What happens in cystometry?

Answer 11

Directly measures (via catheter) pressure in bladder (vesical pressure) whilst bladder is filled and provoked with coughing.

Pressure transducer also placed in rectum (or vagina) to measure abdominal pressure.

Vesical pressure – abdominal pressure = true detrusor pressure – does not normally alter with filling or provocation.

o If leaking with coughing –> USI
o If involuntary detrusor contraction –> detrusor overactivity

Question 12

Conservative management of stress incontinence?

Answer 12

• Pelvic floor muscle training (PFMT) at least 3 months, with physio.
• Vaginal ‘cones’ or sponges – held in position by voluntary muscle contraction.

Question 13

Conservative management of urge incontinence?

Answer 13

Advice
• Reducing fluid intake, avoiding caffeinated products.
• Drugs that alter bladder function should be reviewed.

Bladder Training
• Education
• Timed voiding with systematic delay in voiding
• +ve reinforcement – void according to timetable

Question 14

Medical management of stress incontinence?

Answer 14

Duloxetine (SNRI) –> enhances urethral striated sphincter activity. Side effects limit its use.

Question 15

Medical management of urge incontinence?

Answer 15

Anticholinergics
• Block mAchR that mediate SM contraction.
• Side effects = dry mouth etc.

Oestrogens
• Post-menopausal

Botulinum Toxin A (BTX)
• Blocks neuromuscular transmission in detrusor muscle.
• Used when anticholinergics fail

Question 16

Surgical management of stress incontinence?

Answer 16

• Consider when conservative measures have failed and is affecting QoL.
• ‘Mid-urethral sling’ procedures – TVT/TOT – cure rates up to 90%.

Question 17

What is a TVT?

Answer 17

Tension-Free Vaginal Tape (TVT)
• Synthetic polypropylene tape placed in U-shape under mid-urethra via small vaginal anterior wall incision. Tension then adjusted to prevent leakage as woman coughs.

• Minimally invasive.
• Complications = bladder perforation, postoperative voiding difficulty, bleeding, infection, de novo detrusor overactivity.

Question 18

What is a TOT?

Answer 18

Transobturator Tape (TOT)

• Like TVT but different insertion technique used. Tape passed via transobturator foramen and puborectalis muscles.
• Bladder peroration rare because retropubic space not entered.

Question 19

Definition of prolapse?

Answer 19

descent of the uterus and/or vaginal walls within the vagina. Behind the vaginal walls, other pelvic organs descend and therefore produce a form of hernia.

Question 20

What are the transverse cervical and uterosacral ligaments and what do they do?

Answer 20

o Attach to cervix and suspend uterus from pelvic side wall and sacrum respectively; upper vagina also suspended.

o Laxity allows uterus/upper vagina to prolapse.

Question 21

What does levator ani do?

Answer 21

o Forms floor of pelvis from attachments on bony pelvic walls and incorporates the perineal
body in the perineum.

o Suspends mid-vagina, urethra and rectum – which pass through it.

o Weakness allows prolapse of vaginal walls and bladder or rectum.

Question 22

Degrees of uterine prolapse?

Answer 22

1st Degree - Cervix still within the vagina

2nd Degree - Prolapse at the introitus

3rd Degree - Entire uterus comes out of vagina

Question 23

Types of anterior vaginal wall prolapse?

Answer 23

Cystocele - Prolapse of the bladder forming a bulge in the anterior vaginal wall

Urethrocele - Urethra bulges in the lower anterior wall

Question 24

Types of posterior vaginal wall prolapse?

Answer 24

Rectocele - Prolapse of rectum forming a bulge in the middle of the posterior wall

Enterocele - Prolapse of small bowel in the pouch of Douglas

Question 25

How to differentiate between a rectocele and an enterocele?

Answer 25

Finger in rectum will be seen to bulge into a rectocele but not an enterocele.

Question 26

What are the two overall causes of urogenital prolapse?

Answer 26

Weakened support of pelvic organs

Increased strain on supports

Question 27

What causes weakened support of pelvic organs?

Answer 27

Vaginal Delivery - Worse with more deliveries; Prolonged labour, instrumental delivery, poor suturing of obstetric tears, bearing down before full dilation.

Oestrogen Deficiency - After menopause –> partial atrophy of pelvic supports and vaginal walls.

Iatrogenic - Following hysterectomy – inadequately supported vaginal vault will prolapse.

Question 28

What causes increased strain on pelvic supports?

Answer 28

Obesity
Pelvic masses
Chronic cough

Produces extra weight on pelvic support and they may weaken

Question 29

History in prolapse?

Answer 29

• Symptomless sometimes
• Dragging sensation, sensation of a lump, usually worse at the end of the day or when standing up.
• Severe – can interfere with intercourse, ulcerate and cause bleeding and discharge.

Cystocele
o Urinary frequency and incomplete bladder emptying.

Rectocele
o Often symptomless, sometimes difficulty in defecating.

Question 30

Examination in prolapse?

Answer 30

• Sometimes visible from the outside

• Abdomen and bimanual examination
o Exclude pelvic masses

• Sims’ speculum
o Allows separate inspection of anterior and posterior vaginal walls.
o Patient asked to bear down to demonstrate prolapse.
o Temporarily reduce prolapse and ask patient to cough – stress incontinence.

Question 31

Investigations in prolapse?

Answer 31

Pelvic USS if mass suspected

Cystometry if incontinence is principal complaint