Urogynaecology Flashcards
List six types of urinary incontinence
1) Stress urinary incontinence
2) Urge urinary incontinence
3) Mixed urinary incontinence
4) Overflow incontinence
5) Continuous incontinence
6) Others:
- Incontinence arising form UTI, medications, immobility or cognitive impairment
- Situational incontinence eg giggle incontinence
Which is the most common type of urinary incontinence? How common is it?
Stress urinary incontinence
1 in 10 will suffer it at some point in their lives
50% of incontinent women have purely stress incontinence
30-40% of incontinent women have mixed stress and urge incontinence
What is stress incontinence?
Involuntary leakage of urine on effort or exertion (eg sneezing or coughing)
It commonly arises as a result of urethral sphincter weakness
Increased intra-abdo pressure transmitted to the bladder but not to the urethra. Intravesical pressure exceeds the closing pressure on the urethra
May be associated with genitourinary prolapse
What are some causes of stress urinary incontinence?
Childbirth (most commonly) leading to denervation of pelvic floor, usually during delivery
Oestrogen deficiency during menopause leads to weakening of pelvic support and thinning of urothelium
Occasionally, weakness of the bladder neck occurs congenitally, or through trauma from radical pelvic surgery or radiation
What are the symptoms of stress urinary incontinence?
Complaints of urine leakage during coughing, sneezing, running, jumping or carrying heavy loads
Leakage usually small discrete amount, coinciding with physical activity
What are the signs of stress urinary incontinence?
Prolapse of urethra and anterior vaginal wall may be present
May be possible to demonstrate stress urinary incontinence by asking a woman to cough with a full bladder
What investigations are done for stress urinary incontinence?
MSU - exclude glycosuria
Freq/volume chart - usually shows a normal frequency and functional bladder capacity (or slightly raised)
Urodynamic studies
What factors does a frequency / volume chart? (7)
1) Functional bladder capacity
2) Volumetric summary of diurnal urinary frequency
3) Volumetric summary of nocturnal urinary frequency
4) Quantification of total fluid intake
5) Distribution of fluid intake throughout the day
6) Total voided volume and diurnal distribution of voiding
7) Evaluation of severity urinary incontinence
What does urodynamics involve?
A combination of tests that look at the ability of the bladder to store and void urine:
1) Cystometry
2) Ambulatory urodynamic monitoring
What is cystometry?
Involves measuring the pressure/volume relationship of the bladder during filling and voiding = useful measure of bladder function
The bladder is filled with saline via a catheter and the first sensation of filling, first desire to void and any strong desire to void are recorded
Electronic subtraction of the intra-abdo pressure from the intra-vesical pressure allows the detrusor pressure to be calculated
During filling the patient is asked to cough at regular intervals and to stand, in order to provoke the bladder
The presence of detrusor contractions and package through the urethra are noted
The woman is asked to void at the of the test for pressure / flow analysis
What is ambulatory urodynamic monitoring?
A small recording device is worn and information is later downloaded to a computer for analysis
The bladder is filled naturally and woman should carry out normal daily activities
Useful for investigating detrusor overactivity when standard laboratory urodynamics have failed to replicate symptoms experience (as not normal environment)
When are conservative managements indicated in stress urinary incontinence? (5)
1) Mild / easily manageable symptoms
2) Family incomplete
3) Symptoms manifest during pregnancy
4) Surgery CI by coexisting medical conditions
5) Surgery declined by pt
What are conservative management options for stress urinary incontinence?
1) Lifestyle interventions
- Weight reduction if BMI >30
- Smoking cessation
- Treatment of chronic cough and constipation
2) Pelvic floor muscle training (1st line)
- For at least 3 months but must be continued long term
- Subsequent to digital assessment of pelvic muscle contraction
- Common regimen = 8-12 slow maximal contractions sustained for 6-8s each per day
- Continue if successful
- Consider biofeedback and/or electrical stimulation in women who cannot actively contract pelvic floor muscles
Biofeedback:
- Use of a devise to convert the effect of pelvic floor contraction into a visual or auditory signal to allow objective assessment of improvement
Electrical stimulation:
- Can assist in the production of muscle contractions in women who are unable to produce muscle contraction
3) Vaginal cones
- A way of applying graded resistance against which the pelvic floor muscles contract
- The cones are inserted into the vagina and held in position by voluntary contraction
4) Duloxetine (2nd line)
- A SNRI (serotonin and noradrenalin reuptake inhibitor) that enhances urethral striated sphincter activity via a centrally mediated pathway
- Associated with significant and dose-dependent decreases in frequency of incontinence episodes
- Nausea = most frequently reported SE (25%
= Other SE inc dyspepsia, dry mouth, insomnia, drowsiness and dizziness
When is surgical management of stress urinary incontinence?
When conservative measures have failed and the woman’s (WO??) compromised
NB very important before attempting surgical repair to be clear about the underlying cause of the incontinence = stress incontinence may be successfully treated surgically but detrusor over-activity may be made worse
What are some surgical options for the management of stress urinary incontinence? (5)
1) Periurethral injections
2) Burch colposuspension
3) Laparoscopic colposuspension
4) Tension-free vaginal tape (TVT)
5) Transobturator tape (TOT)
What are periurethral injections?
Mainly for women who are fail, elderly, unfit or have had multiple failed procedures
- Intramural bulking agents (eg glutaraldehyde cross-linked collagen or silicone)
- Lower immediate success rate (not as effective as other treatments)
- Low morbidity
What is burch colposuspension?
Two or three stitches are used to attach the anterior wall of the vagina to Cooper’s ligament at the level of the bladder to add support = the neck of the bladder is ‘lifted’
- Complications include haemorrhage, bladder/ureter injury, detrusor overactivity, enterocele or rectocele formation
VS laparoscopic colposuspension (quicker recovery)
What is tension-free vaginal tape (TVT)?
= Most commonly performed procedure for stress incontinence
- A polypropylene tape is placed underneath the middle of the urethra via a small vaginal incision lift up bladder
- Cystourethroscopy is carried out to ensure there is no damage to the bladder or urethra
- Minimally invasive
- Most women return to normal activities within 2 weeks
- Complications = bladder injury, bleeding into retropubic space, infection, voiding difficulties and table erosion into vagina / urethra
- Cure rate = 82-99%
What is transobturator tape (TOT)?
Polypropylene tape is passed via transobturator foramen through the transobturator and puborectalis muscles
The main difference is that the retropubic space is not entered and the risk of bladder perforation is low
What is daytime frequency? What is the normal range?
The number for times a woman voids during her waking hours
Usually 4-7 voids / day
What is nocturia?
Having to wake at night one or more times to void
Up to 70yr, more than a single void is considered abnormal
What is nocturnal enuresis?
Urinary incontinence occurring during sleep
What is urgency?
The sudden compelling desire to pass urine, which is difficult to defer
Urgency is more commonly secondary to detrusor overactivity, although can occur with inflammatory bladder conditions such as interstitial cystitis
What are some potential voiding difficulties?
Hesitancy - difficulty initiating micturition
Straining to void
Slow or intermittent urinary stream
= all suggestive of urethral obstruction, an underachieve detrusor muscle, or loss of coordination between detrusor construction and urethral relaxation
Intermittency is seen with neurological disease
What is postmicturation?
Feeling of incomplete bladder emptying
Terminal dribble = a prolonged final part of micturition
Postmicturitional dribble = the involuntary loss of urine immediately after passing urine
When does absent or reduced bladder sensation occur? What does it lead to?
Usually due to denervation caused by spinal cord injuries or pelvic surgery
Leads to infrequent micturition and large capacity bladder
Often associated with overflow incontinence
Where is bladder pain felt? What is it often relieved / exacerbated by?
Felt suprapublically or retropubically
Typically occurs with bladder filling and is relieved by emptying
Indicative of an intravesical pathology such as interstitial cystitis or malignancy - warrants further investigation
Where is dysuria felt? What is it most commonly associated with?
Pain experienced in the bladder or urethra on passing urine
Most commonly associated with UTIs
What is haematuria?
The presence of blood in the urine
Can either be microscopic or macroscopic (frank)
It is always significant and always warrants further investigation
How common is urge urinary incontinence?
Urge urinary incontinence = Overactive bladder syndrome (OAB)
Common - affects 1 in 6 women
Second most common cause of urinary incontinence
Most common cause of urinary incontinence in older women
What is the pathophysiology of OAB?
Chronic condition defined as urgency, with or without urge incontinencce, usually with freq or nocturia
Involuntary detrusor contractions (detrusor overactivity = DO) during the filling phase, which may be spontaneous or provoked by increased abdo pressure - this is a diagnosis made on urodynamic testing
Detrusor contraction is normally felt as urgency - if strong enough, it causes the bladder pressure to overcome the urethral pressure and the pt leaks urge incontinence
What is the aetiology of OAB?
Idiopathic in most cases
Neurogenic DO found in the presence of conditions such as MS, spina bifida or UMN lesions
Secondary to pelvic or incontinence surgery (if already have urge incontinence, surgery for stress incontinence can worsen it)
OAB due to outflow obstruction is uncommon in women
What are some signs/symptoms of OAB?
1) Frequency
2) Urgency
3) Urge incontinence
4) Nocturia
5) Nocturnal enuresis
6) Provocative factors often trigger it eg hearing running water
7) Bladder contractions may be provoked by increasing intra-abdo pressure (eg coughing or sneezing) leading to a complaint of stress incontinence which can be misleading
QOL can be significantly affected
What investigations should be done for OAB?
Urine culture - exclude infection
Freq/volume chart
- Typical features are inc diurnal freq associated with urgency and episodes of urge incontinence
- Nocturia common feature of OAB
Urodynamics
- Characterised by involuntary detrusor contractions during the filling phase of the micturition cycle, which may be spontaneous or provoked
- Video-urodynamic testing more appropriate in women with neurological diseases
- Urodynamic assessment is essential for the diagnosis of OAB in women with multiple / complex symptoms
What are some ddx for OAB?
Metabolic abnormalities:
- DM / hypercalcaemia
Physical causes:
- Prolapse or faecal impaction
Urinary pathology:
- UTI or interstitial cystitis
What are some conservative management options for OAB?
Behavioural therapy:
- Consume 1-1.5L of liquid a day
- Avoid caffeine and alcohol
- Review drugs which may alter bladder function eg diuretics and antipsychotics
Bladder retraining:
- Based on ability to suppress urinary urge and extend intervals between voiding
- Cure rates = 44-90%
What are some pharmacological interventions for OAB?
1) Anticholinergic (antimuscarinic) agents:
- 1st line = block the sympathetic nerve thereby relaxing the detrusor muscle
SE = dry mouth (30%), constipation, nausea, dyspepsia, flatulence, blurred vision, dizziness, insomnia, palpitation, arrhythmias
CI = acute (narrow angle) glaucoma, myasthenia gravis, urinary retention or outflow obstruction, severe UC, GI obstruction
2) Antidepressants
- Imipramine has marked systematic and anticholinergic effects
3) Oestrogens
- Can try intravaginal oestrogen can be tried in women with vaginal atrophy
What are the surgical managements of OAB?
Reserved for those with debilitating symptoms, and who have failed to benefit from medical and behaviour therapy
Procedures such as bladder distension, sacral neuromodulation, detrusor myomectomy, and augmentation cystoplasty have limited efficacy and complication rates are high
Permanent urinary diversion occasionally indicated in women with intractable incontinence
How do botulinum toxin A help OAB?
Blocks neuromuscular transmission causing the muscle to become weak
Injected cystoscopically into detrusor, usually under LA
Can cause urinary retention in 5-20% of cases, in which intermittent self catheterisation may be required
Repeat injections required every 6-12 months
Long term effects of repeat injections unknown
What general investigations are useful to investigate urinary incontinence?
Residual check
- Postvoid either via USSS or catheter to exclude incomplete bladder emptying
Pad test
- Simple method of detecting and quantifying urinary leakage based on weight gain of absorbent pads during a set period of time (not helpful in identifying cause)
Neurological examination
- if symptoms point to a neurological cause
Sims speculum examination for prolapse
Assessment of urethral and bladder neck descent on straining
Assessment of pelvic floor muscle strength (0-5)
Cystourethroscopy
- Allows visualisation of all of the lower urinary tract
- Allows bladder biopsies to be taken to rule out cancer
What imaging is performed to investigate urinary incontinence?
Ultrasonography
- Used to exclude incomplete bladder emptying
Intravenous urography
- Indicated
What is urogenital prolapse?
Protrusion of the uterus and / or vagina beyond anatomical confines
The bladder, urethra, rectum and bowel are also often involved
What is a urethrocele?
(Anterior wall)
Prolapse of the lower anterior vaginal wall, involving the urethera only
What is a cystocele?
(Anterior wall)
Prolapse of the upper anterior vaginal wall, involving the bladder
Often associated prolapse of the urethra = cysto-urethrocele
What is an apical prolapse?
Prolapse of the uterus, cervix and upper vagina
If the uterus has been removed, the vault or top of the vagina, where the uterus used to be, can prolapse
How is uterine prolapse graded?
First degree - cervix is still within the vagina
Second degree - at the interoitus
Third degree (procidentia) - entire uterus comes out of the vagina
What is an enterocele?
(Posterior wall)
Prolapse of the upper posterior wall of the vagina (prolapse of the pouch of douglas)
The resulting pouch usually contains loops of small bowel
The perineum may also be deficient (the posterior vaginal opening is lapse)
What is a rectocele?
(Posterior wall)
Prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum
How is prolapse graded?
0 = no descent of pelvic organs during straining 1 = leading surface of prolapse does not descend below 1cm above the hymenal ring 2 = leading edge of prolapse extends from 1cm above to 1cm below the hymenal ring 3 = prolapse extends 1 cm or more below the hymenal ring but without complete vaginal eversion 4 = vagina completely everted (complete procidentia)
What is the aetiology of urogenital prolapse?
Laxity of:
1) Transverse cervical (cardinal) ligaments
2) Uterosacral ligaments
3) Levator ani msucle
What are some risk factors for urogenital prolapse? (7)
1) Vaginal delivery - both mechanical and neurological (pudendal nerve) injury
2) Oestrogen deficiency - atrophy of pelvic supports and vaginal walls
3) Iatrogenic prolpase - following hysterectomy
4) Familial collagen weakness
5) Obesity
6) Pelvic mass
7) Chronic cough
How many urogenital prolapse present? (4)
1) “Dragging” sensation discomfort, heaviness within the pelvis
- Usually worse at the end of the day / when standing
2) Feeling of ‘a lump down there’
3) Dyspareunia / difficulty inserting tampons
4) Discomfort and backache
How may a cysto-urethrocele present? (5)
1) Urinary urgency
2) Frequency
3) Incontinence
4) Incomplete bladder emptying
5) Urinary retention / incomplete flow where the urethra is kinked by decent of the anterior vaginal wall
How may a rectocele present? (2)
1) Constipation
2) Difficulty with defecation - may have to digitally reduce it to defecate
What may occur in grade 3 or 4 prolapse?
Mucosal ulceration
Lichenification
Can lead to vaginal bleeding and discharge
How is urogenital prolapse investigated?
1) Sims speculum examination
2) Bimanual pelvic exam - exlude pelvic masses
3) USS - exclude pelvic masses
4) Urodynamics if incontinence
5) Assess pelvic floor strength
How is pelvic floor strength classified (0-5)?
0 = no contraction 1 = flicker 2 = weak 3 = moderate 4 = good 5 = strong
What are some ddx for urogenital prolapse? (2)
1) Large polyps
2) Vaginal cysts
What conservative management options are available for urogenital prolapse? (3)
1) Prevention
2) Physio
3) Intravaginal devises - pessaries
How can urogenital prolapse be prevented? (6)
1) Reduction of prolonged labour
2) Reduction of trauma caused by instrumental delivery
3) Post-natal floor exercises
4) Weight reduction
5) Treatment of chronic constipation
6) Treatment of chronic cough - inc smoking cessation
What are pessaries used for the treatment of urogenital prolapse?
Act as an artificial pelvic floor, placed in the vagina to stay behind the symphysis pubis and in front of the sacrum
What instructions should be given to those receiving a pessary for urogenital prolapse?
Change 6 monthly
Use topical oestrogen to decrease the risk of vaginal erosion
What types of pessaries are used for urogenital prolapse?
1) Ring pessary
2) Shelf pessary
3) Hodge pessary (rare)
4) Cube pessary (rare)
5) Doughnut pessary (rare)
What is the most commonly used pessary?
Ring pessary
Placed between the posterior aspect of the symphysis pubis and the posterior fornix of the vagina
What is used if a ring pessary is not working?
Shelf pessary
What is the surgical management of an anterior compartment prolapse?
Anterior colporrhaphy
- Used for cysto-urethrocele
Paravaginal repair
- Abdo approach to correct anterior defect
- Cure rate >95%
What is the surgical management of a posterior compartment prolapse?
Posterior colpoperineorrhaphy
- Used for rectocele and deficient perineum
Enterocele repair
What is the surgical management of an apical (uterovaginal) prolapse?
Vaginal hysterectomy
- Can be combined with other procedures in cases where there is significant uterine descent or menstrual problems
Manchester repair
- Cervical amputation
- Rarely performed
- Combined with anterior / posterior colporrhaphy
Sacrohysteropexy
- If pt wishes to preseve uterus
- Attaches prolapsed uterus to the sacrum
What is the surgical management of a vaginal vault prolapse?
Sacrospinous ligament fixation
- Suturing vaginal vault to sacrospinous ligaments using a vaginal approach
- Success rate 70-85%
- Vaginal axis is changed by procedure = possible risk of postoperative dyspareunia
Sacrocolpoplexy
- Open or laparoscopic
- Fxiation of the vault to the scarum using a mesh
- Success rate 90%
- Better anatomical result than sacrospinous ligament fixation
- Possible complication = mesh erosion into the vagina / bladder / bowel
Posterior intravaginal slingplasty
