Urogynaecology Flashcards
see urogynae notes
anatomy
How common is stress incontinence?
50% of incontinence in females
What are the causes of stress incontinence?
pregnancy and vaginal delivery esp prolonged labour and forceps delivery obesity age (esp postmenopausal) prolapse previous hysterectomy
What are the characteristic of stress incontinence?
involuntary leakage of urine on effort or exertion, on sneezing or coughing
many patients also complain of frequency, urgency or urge incontinence
faecal incontinence may also be present
may have cystocoele or urethrocoele
How common is urge incontinence?
35% of the cases of female incontinence
What are the causes of urge incontinence?
idiopathic
bladder neck obstruction
detrusor overactivity
What are the characteristics of urge incontinence?
urgency frequency and nocturne stress incontinence common leak at night or at orgasm history of childhood enuresis common as well as faecal urgency
What are the causes of urinary frequency?
high fluid intake caffeine and alcohol infections, UTIs and STIs Prostate glad problems diuretics DM DI pregnancy
What are the characteristics of urinary frequency?
Urinating more than 8 times a day
nosturia
bladder discomfort
strong urgent need to urinate
How common are UTIs in women?
1 in 3 women have had a UTI by the age of 24
What are the RFs for developing a UTI?
female children elderly indwelling catheters immunosuppression urinary tract abnormalities antibiotic exposure
What are the characteristics of a UTI?
strong persistent urge to urinate burning sensation when urinating frequent small amounts of urine cloudy strong smelling urine blood in urine pelvic pain
What is prolapse?
descent of uterus and/or vaginal walls beyond normal anatomical confines
result of weakness in supporting structures
herniation of bladder/urethra/rectum/small bowels
v common, present in most older porous women
What is a urethrocoele?
urethra prolapse only
What is a cystocoele?
bladder prolapse
What is an apical prolapse?
uterus, cervix and upper vagina prolapse
What is an enterocoele?
prolapse contains loops of small bowel
What is a rectocoele?
anterior wall of the rectum prolapse
What are the causes of prolapse?
vaginal delivery and pregnancy - mechanical injuries and denervation of the pelvic floor
congenital factors
menopause - deterioration of collagen due to lower oestrogen
chronic predisposing factors - obesity/chronic cough/constipation/heavy lifting/pelvic mass
Iatrogenic factors - hysterectomy and continence procedures
What are the characteristics of prolapse?
dragging sensation/sensation of the lump
worse at end of the day and when standing
can interfere with intercourse/ulcerate/discharge
urinary frequency/incomplete bladder emptying with cystourethrocele
can have difficulty defecating if rectocele
What are the indications for urodynamics investigation?
investigate symptoms of urinary incontinence
prior to surgery for stress incontinence/overactive bladder
What are the methods of assessing urodynamics?
catheter measures vesicle pressure (pressure in bladder) whilst bladder is filled and provoked with coughing
pressure transducer also on rectum (or vagina) to measure abdominal pressure
true detrusor pressure = vesicle pressure - abdominal pressure
for urodynamics interpretation
see notes
What are the indications for cystoscopy?
exclude tumours, stones, fistulae and interstitial cystitis
What are the method for cystoscopy?
inspection of the bladder cavity using cystoscope
inserted into urethra into bladder
What are the indications for imaging (US and IV urography)?
evaluate or detect blood in urine, kidney or bladder stones or cancer in urinary tract
What are the method of imaging the urinary tract?
IV urogram – IV contrast injected + X ray to look at kidneys, ureters, bladder + urethra
US – soundwaves to create image
What coping advice can you give to women for coping with incontinence and retention?
reduce excessive fluid intake avoid caffeinated products review medication if obese - lose weight reduce cause of chronic cough
What pads and garments can be given?
pad and pull ups are temporary measures
bed and chair protection with washable bed pads
specially adapted clothing and swimwear
What types of catheterisation can be used?
clean intermittent catheterisation - used to empty bladder at regular intervals
indwelling catheter
What are the steps of bladder training?
1 - education
2 - timed voiding with systematic delay in voiding
3 - positive reinforcement
4 - at least 6 weeks
What pelvic floor advice can be given?
Strengthing pelvic floor
First line treatment for 3+ months, taught by PT
>8 contractions, 3x/day
Poss use vaginal ‘cones’ or sponges – held in place in vagina by voluntary muscle
contraction
How can duloxetine be used?
treatment of moderate severe stress incontinence
SNRI that enhances urethral striated sphincter activity
How can antimuscarinics be used?
suppress detrusor overactivity in bladder overactivity
How can oestrogens be used?
in postmenopausal women
improves symptoms of vaginal atrophy and reduces symptoms of urge incontinence
How can botulinum toxin A be used?
blocks neuromuscular transmission
duration average 6 months
When is a vaginal repair +/- hysterectomy indicated?
recommended for incontinence caused by anterior vaginal wall prolapse
bladder and urethra lifted back into place and secure with stitches
mesh may be part of repair
How is tension-free vaginal tape used?
tape placed in U-shape under mid urethra via small
vaginal anterior wall incision, tension adjusted to prevent leakage as woman coughs
How is a trans-obturator tape used?
tape passed via transobturator foramen, through transobturator + puborectalis
What are the advantages of sling/tape procedures?
cure rates of up to 90%, minimally invasive
What is colposuspension?
Incision on lower abdomen + stitching neck of bladder in lifted position
What are the cons of colposuspension?
Can cause urinary retention, recurrent UTIs and discomfort during sex
What are the non-surgical treatment options for incontinence?
pads and garments catheterisation bladder retraining pelvic floor exercises drug treatment
What are the surgical treatment options for incontinence?
vaginal repair with or without hysterectomy
sing procedure and tapes
colposuspension
What are the investigations for incontinence?
urodynamics
cystoscopy
imaging including US and IV urography
What is the easiest investigation for urinary infection?
microbiology Ix
Dipstick
