Urogynaecology Flashcards
What is urinary incontinence?
Involuntary leakage of urine. Most commonly it is stress incontinence, urge incontinence, or mixed, although there are other types.
Wht are the other types of incontinence? (other than stress, urge, and mixed)
Overflow Bladder fistulae Urethral diverticulum Congenital anomalies Functional Temporary
What is overflow incontinence?
Leakage of urine from an overful urinary bladder often in the absence of any urge to urinate.
What is bladder fistulae incontinence?
Urinary leakage cause by an opening between the bladder and another organ
What is urethral diverticulum incontinence?
Urinary leakage via an out-pocketing of the urethra into the anterior vaginal wall
What is functional incontinence?
Physical and mental barriers that prevent the patient reaching the toilet e.g. dementia, immobility
What is temporary incontinence?
Urinary leakage due to reversible factors such as constipation or UTI
Define stress incontinence.
Involuntary leakage of urine during increased intra-abdominal pressure in the absence of a detrusor contraction.
Who is stress incontinence typically seen in?
Women after childbirth due to denervation of pelvic floor.
Define urge incontinence?
Presence of urgency (and often frequency and noctuira) in the absence of UTI or any other obvious pathology.
What is the pathophysiology of urge incontinence?
Detrusor muscle overactivity
When is urge incontinence seen?
Often idiopathic, but seen with:
- MS
- Spina bifida
- Other neurological conditions
- Hx pelvic or incontinence surgery
A woman presents to her GP with small volumes of urine leaking when she coughs and sneezes, or lifts anything heavy.
What might we find on examination of this woman?
Prolapse of urethra and anterior vaginal wall.
What kind of trigger factors do some people with urge incontinence have?
Cold weather
Hearing running water
Sometimes sneezing or coughing can cause detrusor activity, giving a false impression of stress incontinence.
How much urine leaks in urge incontinence compared to stress incontinence?
Typically larger volumes in urge incontinence.
How should urinary incontinence be investigated initially?
Bladder diary for 3 days min.
Vaginal examination to exclude pelvic organ prolapse.
Urine dipstick and culture if UTI suspected.
What should be documented in a bladder diary?
Frequency and volume of incontinence.
Triggers.
Normal frequency and baldder capacity if stress incont.
When are urodynamic studies done?
With stress incontinence when surgery is considered - confirms diagnosis and rules out concomitant detrusor over-activity.
What does management of urinary incontinence depend on?
What type of incontinence it is.
How should urge incontinence be managed?
- Bladder retarining for 6 weeks +
- Bladder stabilising drugs (antimuscarinics first line)
Describe bladder retraining.
Gradually increasing the time between voiding i.e. not going when they feel the urge.
What antimuscarinics are recommended by NICE for urge incontinence?
- Oxybutynin IR (avoid in older women)
- Tolterodine IR
- Darifenacin OD
How should stress incontinence be managed?
- Lifestyle modification
- Pelvic floor muscle training (8 contractions TDS for 3 months at least)
- Treat risk factors such as chronic cough
- Surgical procedures
What lifestyle modification can help with stress incontinence?
Weight loss
Smoking cessation
What lifestyle modification can help with urge incontinence?
Fluid intake changes
Avoid caffeine and alcohol
What surgical procedures can be used to manage stress incontinence?
Tension free vaginal tape = most commonly performed
- Burch colposuspension
- Laparoscopic colposuspension
- Periurethral injection
- Transobturator mid-urethral sling
What medical management is licenced for stress incontinence?
Duloxetine for moderate and severe, if post surgery, or pt is not suitable for surgery.
Other than antimuscarinics, what other medical management is offered for urge incontinence?
Intravaginal oestrogens
Butlinum toxin A
Neuromodulation and sacral nerve stimulation
When is surgery offered for urge incontinence, and what can be offered?
Detrusor myomectomy and augmentation cystoplasty - only offered for debilitating symptoms
What is urogenital prolapse?
Descent of one of the pelvic organs resulting in protrusion on the vaginal walls
What % of post-menopausal women does urogenital prolapse affect?
40%
What is the most common type of GU prolapse?
Anterior vaginal wall prolapse
Describe the pathophysiology of GU prolapse.
Pelvic floor organs are supported by levator ani muscle and endopelvic fascia.
When these structures are weakened e.g. by childbirth, one or more of the pelvic organs descends and can affect the vaginal wall.
Where can GU prolapse occur?
Anterior, middle, or posterior compartment of the vagina.
What are the 2 types of anterior GU prolapse? What are they?
Urethrocele - prolapse of the urethra.
Cystocele - prolapse of the bladder.
What are the 3 types of middle GU prolapse? What are they?
Uterine prolapse - what it says on the tin.
Vaginal vault prolapse - again, read the tin.
Enterocele - herniation of pouch of douglas into vagina. Inc. small bowel or omentum.
What is the posterior GU prolapse? What is?
Rectocele - prolapse of rectum into vagina
How are GU prolpases classified?
By type and position of the most distal portion of the prolapse during straining.
What system is used to classify prolapses?
POP-Q system
What are the prolapse stages according to the POP-Q method of classification?
Stage 0 - no prolapse Stage 1 - more than 1cm above hymen Stage 2 - within +-1cm to plane of hymen Stage 3 - more than 1cm below plan of hymen, no further than 2cm less than total length of vagina Stage 4 - complete eversion of vagina
What are the risk factors for GU prolapse?
- Increasing age
- Vaginal delivery
- Increasing parity
- Obesity
- Previous hysterectomy
A 65 year old woman comes to see her GP with a feeling of “something coming down, down below”. What other symptoms might she be experiencing?
- Sensation of pressure/fullness
- Feel a bulge/protrusion
- See or feel a protrusion
- Spotting
- Urinary symptoms
- Coital difficulty
- Bowel symptoms inc. needing to apply digital pressure to perienum to enable defecation
How should a pt with suspected GU prolpase be examined?
Offer a chaperone!
Examine 1st while standing in left lateral position if possible, while straining. Both standing and supine.
Speculum - strain, look for degree of descent while removing speculum.
Check for ulceration and hypertrophy of cervix and vaginal mucosa if report bleeding or stage 2+ prolapse seen.
How is diagnosis of GU prolpase made?
Clinically based on hx and ex.
How can GU prolpase be investiagted, and when is this appropriate?
If urinary symptoms - urinalysis and MSU, Ix for incontinence, U and Es, renal ultrasound - as appropriate.
Bowel symtpoms - USS.
How should a mild/asymptomatic prolapse be managed?
Not necessary generally to manage an aymptomatic prolapse.
What are the 3 Mx options for GU prolapse?
Conservative
Pessarys
Surgery
What conservative Mx can we offer for GU prolapse?
- Watchful waiting
- Lifestyle modification - weight loss, minimise heavy lifting, prevent/treat constipation.
- Pelvic floor muscle exercises
- Vaginal oestrogen creams
Why are vaginal pessaries useful?
Good alternative to surgery, and work well alongside pelvic floor exercises.
Can be for short term symptom relief or long term use.
What should a pt be told about vaginal pessaries before consenting to have one?
- May need repeated fittings
- May affect sexual intercourse
- Needs changing every 6 months
- Some complications
What are the complications associated with vaginal pessaries?
- Bleeding
- Discharge
- Difficult to remove
- Expelled
- Fistula formation (rare)
- Faecal impaction
- Hydronephrosis
- Infection/urosepsis
When should a pt be referred for surgical Mx of a GU prolapse?
- Conservative Rx fails
- Voiding problems or obstructed defecation
- Recurrence of prolapse after surgery
- Ulceration
- Irreducible prolapse
What are the surgical options for bladder/urethral prolapse?
Anterior colporrhaphy (anterior vaginal wall repair)
Colposuspension
What are the surgical options for uterine prolapse?
Hysterectomy
Sacrocolpoplexy (good if woman wants to keep uterus)
Sacrospinus fixation
What are the surgical options for rectal prolapse?
Posterior colporrhaphy
What are the complications associated with GU prolapse?
General: -Infection -Ulceration Urinary incontinence, chronic retention, recurrent UTIs. Bowel dysfunction.
What are recurrent UTIs generally considered to be?
UTI occuring twice in 6 months, or 3 times in a year. These should be proven episodes.
Who is affected by UTIs?
Everyone, but women mostly.
1 in 2 lifetime risk of UTI in a woman, and risk increases with age.
Which organism is usually responsible for a UTI?
E. coli
Other than E. coli, which organisms cause UTIs (mostly)?
Staphylococcus saprophyticus
Proteus mirabilis
What might predispose someone to having recurrent UTIs?
Diabetes Sexual intercourse Atrophic urethritis/vaginitis Abnormal urinary tract (congenital or iatrogenic e.g. catheter) Incomplete bladder emptying Contraception Urinary tract surgery Immune compromise First UTI under age 15 Hx of recurrent UTIs in mother
What are the symptoms of UTIs?
Dysuria Frequency Urgency Nocturia Haematuria Supra-pubic pain
What are the signs of a UTI?
Suprepublic tenderness
Cloudy and/or foul smelling urine
Incontinence/confusion/anorexia/fever/shock in elderly
Why is an MSU needed in Ix of recurrent UTIs?
Because resistant organisms are more likely so they need to be cultured to see which abx work best.
What would prompt you to refer a woman with recurrent UTIs to secondary care?
Underlying high risk factors for UTI
Cultures show multiresistant organisms
Pneumaturia/faecaluria/haematuria
How can we detect structural abnormalities causing recurrent UTIs?
CT scan, but can also use ultrasound as an alternative
How does antibiotic therapy differ in recurrent UTIs with underlying athology?
Treat for 5-10 days insetaed of 3-5.
Consider anticipatory prescribing for future episodes.
What does prophylaxis for recurrent UTIs depend on?
If it is related to sexual intercourse or not.
If it isn’t, 6/12 course of low-dose nitrofurantoin/trimethoprim.
If it is, change contraceptive measure, suggest use of lubricant, offer 100mg trimethoprim to be taken within 2 hours of sexual intercourse.
