Urogynaecology

Question 1

Give 5 predisposing factors for genitourinary prolapse

Answer 1

> 40 years old
Parous- multiple, long labour, large babies
Chronic increase in intra-abdominal pressure- constipation, cough
Obesity
Menopause
Pelvic surgery- hysterectomy
Connective tissue disorder- Ehlers Danlos, Marfans

Question 2

What is a urethrocele?

Answer 2

Prolapse of lower anterior vaginal wall involving the urethra only

Question 3

What is a cystocele/anterior prolapse?

Answer 3

Prolapse of the upper anterior vaginal wall involving the bladder

Question 4

What is an apical prolapse?

Answer 4

Prolapse of the uterus, cervix and upper vagina

Question 5

What is a uterine prolapse?

Answer 5

Uterus prolapses into vagina

Question 6

What is a vaginal vault prolapse?

Answer 6

Top of vagina sags down after a hypsterectomy

Question 7

What is an enterocele?

Answer 7

Small bowel prolapses into vagina

Question 8

What is a rectocele?

Answer 8

Rectum prolapses into vagina

Question 9

Suggest 4 clinical features of genitourinary prolapse

Answer 9

Sensation of a lump moving downwards in the pelvis
Dragging discomfort, worse if sat down all day
Can sometimes see a lump or bulge
Urinary symptoms- frequency, stress incontinence, cystitis
Numbness during sex

Question 10

How is a genitourinary prolapse diagnosed?

Answer 10

Speculum examination

Question 11

Describe the Baden- Walker Classification of genitourinary prolapse

Answer 11

0: no descent when straining
1: leading surface of prolapse does not descend to 1 cm above hymenal ring
2: leading surface of prolapse extends from 1cm above to 1 cm below hymenal ring
3: leading surface of prolapse does not extends > 1 cm below hymenal ring
4: vagina completely everted

Question 12

How is genitourinary prolapse managed conservatively?

Answer 12

Pelvic floor exercises
Lose weight 
Stop smoking 
Avoid high impact exercise 
Manage constipation

Question 13

How is genitourinary prolapse managed medically?

Answer 13

Oestrogen vaginal cream

Vaginal pessary- rubber or silicon device placed into the vagina to support the vaginal walls and pelvic organs

Question 14

What are the positives and negatives of medically treating genitourinary prolapse with a vaginal pessary?

Answer 14

+ = avoids surgery, can have sex

• = needs to be removed and cleaned regularly, not useful in posterior prolapse, side effects (UTI, stress incontinence, BV, irritation, bleeding)

Question 15

How is genitourinary prolapse managed surgically?

Answer 15

Uterine prolapse= vaginal hysterectomy

Vaginal vault prolapse= sacrocolpopexy, sacrospinous fixation

Vaginal wall prolapse= anterior/posterior repairs

Question 16

What is stress incontinence?

Answer 16

Involuntary leaking of urine on effort, exertion, sneezing or coughing

Question 17

Give 4 predisposing factors for stress incontinence

Answer 17

Pregnancy 
Vaginal delivery 
Obesity 
Hysterectomy 
Prolonged labour 
Forceps delivery 
Post-menopausal

Question 18

What is the pathophysiology of stress incontinence?

Answer 18

Increased intra-abdominal pressure causes the bladder to compress. Usually the bladder neck will also compress to compensate. If the bladder neck has slipped, its pressure will not change and incontinence occurs

Question 19

How is stress incontinence investigated?

Answer 19

Urine dip to exclude UTI

Cystometry to exclude overactive bladder

Question 20

How is stress incontinence managed conservatively?

Answer 20

Weight loss 
Reduce fluid intake 
Stop smoking 
Pelvic floor exercises- 1st line treatment, 8 contractions, 3 times a day for 3 months
Vaginal cones/sponges

Question 21

How is stress incontinence managed medically?

Answer 21

Duloxetine- SNRI which also increases urethral sphincter activity. Not routinely used due to side effect profile- nausea, dyspepsia, dry mouth

Question 22

How is stress incontinence managed surgically?

Answer 22

Tension free vaginal tape- tape placed in a U shape around mid urethra
Colposuspension- neck of bladder lifted up
Urethral bulking agents- increase size of urethral walls

Question 23

What is urge incontinence?

Answer 23

Do not feel the urge to go to the toilet until very late so bladder overflows and leaks

Question 24

What is the pathophysiology of urge incontinence?

Answer 24

Involuntary detrusor contractions during the filling phase causes detrusor overactivity. If the contraction is strong enough the bladder pressure is greater than the urethral pressure and urine leaks out.

Question 25

Give 3 clinical features of urge incontinence

Answer 25

Urgency
Frequency
Nocturia

Question 26

How is urge incontinence investigated?

Answer 26

Urinary diary

Cystometry

Question 27

How is urge incontinence managed conservatively?

Answer 27

Decrease fluid intake

Bladder training- wait longer between voiding

Question 28

How is urge incontinence managed medically?

Answer 28

Anticholinergics
Sympathomimetics
Oestrogens
Botulinum toxin A

Question 29

What is overflow incontinence?

Answer 29

Bladder is desensitised and so over fills causing leakage. Treat via clean intermittent catheterisation.