Urogynaecology Flashcards
What happens normally to bladder when you cough?
Increase in intra abdominal pressure transmitted equally to bladder and upper urethra because both lie in abdomen –> no difference in pressure –> no incontinence.
What is the pressure ratio in normal continence? What creates each pressure?
Urethral pressure > bladder pressure
Bladder pressure = detrusor pressure + intra abdominal pressure
Urethral pressure = inherent urethral muscle tone + external pressure (pelvic floor and intra-abdominal)
What is the pressure ratio in normal micturation? What creates each pressure?
Bladder pressure > urethral pressure
Drop in urethral pressure (pelvic floor relaxation)
Increase in bladder pressure (detrusor contraction)
What happens in urge incontinence/overactive bladder?
Uncontrolled increases in detrusor pressure –> increases bladder pressure beyond that of normal urethra.
Usually idiopathic (urodynamic diagnosis)
What happens in stress incontinence?
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)
Causes of stress incontinence?
Pregnancy/vaginal delivery, prolonged labour/forceps, obesity, age
Things to ask in urological history?
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
Other facets of incontinence history other than urological?
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
Invesitgations for incontinence?
Urine Dipstick/MSU
Frequency/Volume Charts
Postmicturation USS or Catheterisation
Urodynamic Studies - Cystometry
Ultrasonography
When is cystometry necessary?
Necessary prior to surgery for stress incontinence or for those who don’t respond to medical therapy.
What happens in cystometry?
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
Conservative management of stress incontinence?
- Pelvic floor muscle training (PFMT) at least 3 months, with physio.
- Vaginal ‘cones’ or sponges – held in position by voluntary muscle contraction.
Conservative management of urge incontinence?
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
Medical management of stress incontinence?
Duloxetine (SNRI) –> enhances urethral striated sphincter activity. Side effects limit its use.
Medical management of urge incontinence?
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
Surgical management of stress incontinence?
- Consider when conservative measures have failed and is affecting QoL.
- ‘Mid-urethral sling’ procedures – TVT/TOT – cure rates up to 90%.
What is a TVT?
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.
What is a TOT?
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.
Definition of prolapse?
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.
What are the transverse cervical and uterosacral ligaments and what do they do?
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.
What does levator ani do?
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.
Degrees of uterine prolapse?
1st Degree - Cervix still within the vagina
2nd Degree - Prolapse at the introitus
3rd Degree - Entire uterus comes out of vagina
Types of anterior vaginal wall prolapse?
Cystocele - Prolapse of the bladder forming a bulge in the anterior vaginal wall
Urethrocele - Urethra bulges in the lower anterior wall
Types of posterior vaginal wall prolapse?
Rectocele - Prolapse of rectum forming a bulge in the middle of the posterior wall
Enterocele - Prolapse of small bowel in the pouch of Douglas
How to differentiate between a rectocele and an enterocele?
Finger in rectum will be seen to bulge into a rectocele but not an enterocele.
What are the two overall causes of urogenital prolapse?
Weakened support of pelvic organs
Increased strain on supports
What causes weakened support of pelvic organs?
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.
What causes increased strain on pelvic supports?
Obesity
Pelvic masses
Chronic cough
Produces extra weight on pelvic support and they may weaken
History in prolapse?
- 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.
Examination in prolapse?
• 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.
Investigations in prolapse?
Pelvic USS if mass suspected
Cystometry if incontinence is principal complaint
