Urogynaecology Flashcards
What are the different types of chronic incontinence?
- Stress incontinence
- Urge incontinence
- Mixed
- Overflow incontinence
- Fistula
- Functional incontinence
What is the most common type of chronic incontinence?
Stress incontinence
What is the mnemonic for transient causes of incontinence?
DIAPPERS
What are the transient causes of incontinence?
Delirium Infection Atrophic changes Pharmacological Psychological Excessive urine output Restricted mobility Stool impaction
What is stress incontinence?
Involuntary leakage of urine upon exertion - i.e. an increase in intra-abdominal pressure
What is the cause of stress incontinence?
Urethral sphincter weakness
What are the risk factors for stress incontinence?
- Increasing age
- Increased parity
- Vaginal delivery - particularly deliveries that were instrumented, prolonged, or delivered a macrocosmic infant
- Obesity
How should suspected stress incontinence be investigated?
- Urine dip/culture
- Blood glucose
- Micturition diary
- Urodynamic evaluation with cystometry
What are the conservative methods of management, suitable for stress incontinence?
- Lifestyle modification - WL, smoking cessation, modify fluid intake, modify caffeine intake
- PRMT - e.g. vaginal cones
- Biofeedback
- Treat/prevent constipation
- HRT
- Pads
What is the medical management of stress incontinence?
Duloxetine - selective serotonin re-uptake inhibitor
What are the adverse effects of the medical management of stress incontinence?
Nausea (most commonly); dyspepsia; dry mouth; dizziness; drowsiness; insomnia
What examination should be performed when a woman is suspected to have stress incontinence?
- Patient cough
- Bimanual - to assess pelvic floor muscles by asking to squeeze
- Speculum (?prolapse)
- Abdominal examination
Of all the available treatments for stress incontinence, which is considered first-line?
Pelvic floor muscle training
Which is preferable - medical or surgical management of incontinence?
Surgical, due to the adverse effects of medical. Medical management should only be offered to women unsuitable for, or unwilling to undergo surgery
What are the surgical management options for stress incontinence?
1) Mid-urethral sling procedures
2) Injectable periurethral bulking agent
3) Artificial urinary sphincter
What is the first-line surgical management for stress incontinence?
Mid-urethral sling procedures
What are the two types of mid-urethral sling procedures?
1) Tension-free vaginal tape
2) Transoburator tape
What are the complications of mid-urethral sling procedures?
1) Bladder perforation
2) Postoperative voiding difficulty
3) Bleeding
4) Infection
5) Suture or mesh erosion
What are the differences between Tension-free vaginal tape (TVT) and transoburator tape?
Mesh is used to elevate the mid-urethra in both procedures, but transoburator tape is fitted in a different way such that there is less risk of bladder damage
What is urge incontinence?
Spontaneous OR provoked detrusor contraction results in bladder pressure>urethral pressure = incontinence
What are the conservative forms of management suitable for urge incontinence?
- Lifestyle modification
- PFMT
- Biofeedback
- Use of pads
How may an overactive bladder (due to detrusor contraction) be medically managed?
- Anticholinergics
2. Intravescial botox
How may an overactive bladder (due to detrusor contraction) by surgically managed?
- Augmentation enterocystoplasty
- Autoaugmentation
- Urinary diversion
What are the contraindications to anticholinergics?
- MG
- BOO
- Bowel disorders
- Uncontrolled narrow angle glaucoma
What are the S/Es of anticholinergics?
- Dry mouth
- Constipation
- Blurred vision
- Urinary retention
What are the contraindications to intravesical botox?
- MG
- Eaton-Lambert syndrome
- Breastfeeding
- Pregnancy
- Bleeding disorders
What are the S/Es of intravesical botox?
- Urinary retention
- Haematuria
- UTI
- Bladder pain
- Dysphagia
- Diplopia
What are the risk factors for overactive bladder?
Idiopathic
MS
Surgical treatment for stress incontinence
What are the different types of anterior vaginal wall prolapse?
- Cystocele
- Urethrocele
- Cystourethrocele
What are the different types of posterior vaginal wall prolapse?
- Rectotocele
2. Enterocele
What is a uterus prolapse?
Descent of entire uterus
What is a vaginal vault/apical prolapse?
Apex of the vagina, where the uterus used to be, can prolapse post-hysterectomy
What is a cystocele?
Upper anterior vaginal wall, causing descent of the bladder only
What is a urethrocele?
Lower anterior vaginal wall, causing descent of the urethra only
What is a cystourethrocele?
Descent of both the bladder and the urethra
What is a rectotocele?
Lower posterior vaginal wall, affecting the anterior wall of the rectum
What is a enterocele?
Upper posterior vaginal wall, creating a pouch containing loops of bowel
What are the risk factors for prolapse?
- Vaginal delivery
- Ageing - atrophy of connective tissues
- Obesity
- Raised intra-abdominal pressure - e.g. chronic cough from smoking
- Iatrogenic - poorly supported vaginal vault post-hysterectomy
- Congenital
What is a 1st degree prolapse?
Cervix down into the vagina, but above the introitus
What is a 2nd degree prolapse?
Cervix to introitus (opening that leads to the vaginal canal)
What is a 3rd degree prolapse?
Cervix outside introitus
How may prolapse be medically managed?
- HRT - when oestrogen withdrawal is responsible for the loss of tone
- Ring pessary
What are the S/Es of ring pessaries?
- Pain
- Urinary retention
- Infection
- Displacement
