Urogynaecology Flashcards
What is meant by urinary frequency?
When the patient considers they go too often by day.
(some sources quote >7 times a day as the cut-off)
What is meant by nocturia?
Waking up at night ≥1 times to go to the loo to wee.
What is meant by urinary urgency?
A sudden, compelling desire to pass urine which is very difficult to defer.
What is meant by Urge incontinence?
Involuntary leakage accompanied by, or immediately preceded by urgency.
What is meant by Stress incontinence?
Involuntary leakage on effort, exertion, sneezing/coughing.
What is meant by mixed incontinence?
Where stress inconinence occurs with frequency, urgency and urge incontinence.
What is meant by overflow incontinence?
This occurs without any contraction of the detrusor muscle when the ballder is overdistended, i.e. filled too much.
What is meant by overactive bladder?
This describes the combination of symptoms or frequency, urgency and/or urge incontinence.
What is the presumed pathophysiology behind urinary stress incontinence?
- Abnormal descent of the bladder neck and proximal urethra.
- This means that when intra-abdominal pressure increases (cough etc), the pressure is only exerted on the bladder, and not the bladder neck and proximal urethra
- Ultimately, this leads to urine being pushed out into the urethra
pWhat is the aetiology behind urinary stress incontinence?
What are risk factors for USI?
The most important risk factor is vaginal childbirth:
- stretching/damage to pudendal nerve and the pelvic floor muscles
- This leads to weakening of the urethral spincter and/or the pelvic floor, which usually prevent the bladder neck from leaving the abdominal cavity
Risk factors include:
- Multiparity (vaginal births), esp if instrumental delivery
- Prolonged labour, large baby
- Perineal trauma
- Post-menopausal
- Chronic increased abdominal pressure, e.g. chronic cough (COPD)
- Doxazocin (alpha adrenergic antagonist for HTN), relaxes urethral sphincter
What is detrusor overactivity?
What are risk factors?
This is involuntary detrusor contractions during the filling phase of the bladder, i.e. premature contraction.
Woman often complain of symptoms without being incontinent, because the urethral spincter and pelvic floor prevent leakage.
It is a urodynamic test result (i.e. not a symptom) and can lead to overactive bladder syndrome and urge incontinence.
Aetiology is not fully understood. It is associated with smoking, obesity and previous continence/urogynae surgery.
What are the clinical features of urinary incontinence?
Stress Incontinence
Stress incontinence occurs when intra-abdominal pressure rises, typically resulting in leakage on coughing, sneezing or exercise.
On examination, prolapse of the urethra and anterior vaginal wall may be present.
Urge Incontinence
Patients will often complain of urgency, frequency and nocturia. There are often trigger factors such as hearing water, cold weather etc.
Compared to stress incontinence, there are typically larger volumes of leakage.
Patients can present with mixed incontinence where symptoms of both are present, though one may predominate over the other. This is more common than stress alone.
Other than the incontinence symptoms, what specific questions should you ask in an incontinence Hx?
- Any drugs, including OTC herbal diuretics, as some can exacerbate incontinence
- Symptoms of systemic disease such as diabetes mellitus
- Mobility/problems with cognitive ability
- Always ask about red flags of malignancy such as haematuria and pain and faecal incontinence
What investigation would you carry out in a woman with incontinence?
Bedside:
- Urine dip (send MSU for M,C&S), also check for glycosuria
- Use bladder diaries (record what fluid is consumed, how much and urine volume) for at least 3 days
- Use incontinence-specific QOL questionnaires to get baseline (allows assessment of treatment success)
Bloods:
- FBC (WCC for UTI)
- U&E to check for renal function
- HbA1c/blood glucose to look for signs of diabetes
Imaging:
- Consider imaging (USS) if incomplete voiding, mass felt or pain/haematuria or recurrent UTIs
Special tests:
- Urodynamic testing (only after conservative management tried)
- (Cystoscopy if bladder cancer suspected)
Describe the management of stress incontinence?
All women should begin with conservative management, as this can deliver significant symptom benefit. This involves:
- Advice about fluid balance - women should be encouraged to drink between 1.5L and 2.5L a day
- Reduce caffeine intake as well as fizzy drinks and drinks with artificial sweeteners.
The first-line conservative package for women with stress incontinence is supervised pelvic floor muscle training (PFMT). This is done under the supervision of a continence nurse, a clinical nurse specialist or a physiotherapistfor at least three months. They contract their pelvic floor muscles by direct coaching while being examined vaginally to ensure correct identification of the levator muscle complex; without supervision, only 40% correctly initiate contraction of the pelvic floor.
If after three months, and the woman complying with at least 3 times daily exercises, she requires further treatment, then refer to an MDTinvolving urogynaecologist/urologist, gynaecologist, continence nurse, and physiotherapist. They will make a decision with what surgical options to offer. These include:
- Synthetic mid-urethral tape (mesh) used to be first-line therapy, but now on hold by NICE due to concerns regarding chronic pain. It has a very high success rate.
- Burch colposuspension- It involves inserting sutures between the paravaginal fascia and Cooper’s ligament. Used to be first-line before mid-urethral tape.
- Periurethral injection - involves injecting bulking agentsperiurethrally under local anaesthetic. More appropriate for older patients.
Medical management is usually reserved for those who refuse surgery, or after surgical options have failed. This involves treatment with duloxetine (a SNRI).
What are the types of pelvic organ prolase?
- Urethrocoele is prolapse of the urethra into the lower anterior vaginal wall.
- Cystocoele (anterior vaginal prolapse) is prolapse of the bladder into the anterior vaginal wall.
- Uterine prolapse is prolapse of the uterus into the vagina. This can be graded on severity.
- Rectocele (posterior vaginal prolapse) is prolapse of the rectum into the posterior vaginal wall.
- Enterocoele is prolapse of the upper posterior wall of the vagina, with the resultant pouch usually containing loops of small bowel.
- Vaginal vault prolapse can occur after hysterectomy.
