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O&G > Urogynaecology > Flashcards

Urogynaecology Flashcards

1
Q

Red flag symptoms

A
  • Visible haematuria (bladder cancer)
  • Pain associated with bladder filling (bladder cancer)
  • Abdominal swelling (pelvic mass)
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2
Q

Following presentation of incontinence - carry out the following:

A
  1. Urine analysis to exclude infection
  2. Examine to exclude pelvic mass
  3. Review medication (alpha blockers can cause incontienence)
  4. Give lifestyle advice (e.g. stopping smoking)
  5. Refer to community physiotherapy or community continence team for pelvic floor muscle training
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3
Q

Normal bladder diary values

  • Intake
  • Voided volumes
  • Capacity
  • Frequency
  • Output
A
  • Intake: 1500-2000 mls
  • Voided volumes: 250-500 mls
  • Capacity: up to 500 mls
  • Frequency: 3-7 voids per day
  • Output: 1000-2800 ml per 24 hours
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4
Q

Classification of URINARY incontinence

A
  • Stress incontinence
  • Urge incontinence
  • Mixed incontinence
  • Overflow incontinence
  • Continuous incontinence
  • Incontinence arising from UTIs, medications, immobility, cognitive impairment
  • Situational incontinence e.g. giggle incontinence
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5
Q

Stress incontinence: Definition

A

The involuntary leakage of urine on effort or exertion, or on sneezing or coughing. Commonly arises from urethral sphincter weakness.

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6
Q

Urge incontinence: Definition

A

The involuntary leakage of urine accompanied by, or immediatly preceded by, a strong desire to pass urine (void).

Urgency, with or without urge urinary incontinence, usually with frequency and nocturia is also defined as overactive bladder (OAB) syndrome

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7
Q

Mixed incontinence: Definition

A

The involuntary leakage of urine associated both with urgency and with exertion, effort, sneezing or coughing.

Usually, one of these is predominant i.e. either the symptoms of urge incontinence, or those of stress incontinence, are most bothersome.

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8
Q

Overflow incontinence: Definition

A

Occurs when the bladder becomes large and flaccid and has little or no detrusor tone or function.

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9
Q

Urinary symptoms

A
  • Urinary incontinence
  • Daytime frequency
  • Nocturia
  • Nocturnal enuresis
  • Urgency
  • Voiding difficulties
  • Post-micturition symptoms
  • Absent/reduced bladder sensation
  • Bladder pain
  • Urethral pain
  • Dysuria
  • Haematuria
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10
Q

Assessment of lower urinary tract: Hx + examination

A
  • History
  • Quality of life assessment
  • Frequency/volume chart
  • Physical exam (General, abdo + pelvic)
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11
Q

INFO obtainable from a Frequency/volume chart

A
  • Functional bladder capacity
  • Volumetric summary of diurnal urinary frequency
  • Volumetric summary of nocturnal urinary frequency
  • Quantification of total fluid intake
  • Distribution of fluid intake throughout the day
  • Total voided volume
  • Diurnal distribution of voiding
  • Evaluation of the severity of urinary incontinence.
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12
Q

Assessment of the lower urinary tract: Investigations

  • Basic (4)
  • Advanced (1)
A

Basic:

  • Urinalysis
  • Urine specimen (MC&S)
  • Post-void residual check
  • Pad test

Advanced:
- Cystourethroscopy

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13
Q

Urinalysis: Definition

A

Cheap and sensitive, tests for the following:

  • Leucocyte esterase
  • Nitrites
  • Protein
  • Blood
  • Glucose
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14
Q

Urine specimen: Definition

A

Bacteriological analysis of a midstream urine specimen for microscopy, culture and sensitivity (MC&S)

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15
Q

Post-void residual check: Definition

A

A post-void residual check should be carried out, either by USS or by catheterization to exclude incomplete bladder emptying.

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16
Q

Pad test: Definition

A

This is a simple method of detecting and quatifying urinary leakage based on weight gain of absorbant pads during a set period of time.

17
Q

Cystourethroscopy: Definition

A

Allows visualization of all the lower urinary tract: urethra, bladder, trigone and ureteric orifices.

Can be performed using rigid or flexible cytoscope, with or without anaeasthesia.

Bladder biopsies can be taken to obtain histological diagnosis and exclude malignancy.

18
Q

Indications for cystourethroscopy

A
  • Recurrent UTIs
  • Haematuria
  • Bladder pain
  • Suspected urinary tract injury or fistula
  • To exclude bladder tumour or stones
  • If interstitial cystitis is suspected
19
Q

Assessment of the lower urinary tract: Imaging

A
  • Ultrasonography
  • Plain abdominal radiograph
  • Contract-enhanced CT
  • IV urography
  • Micturating cystourethroscopy
  • MRI
20
Q

Urodynamics: Definition

A

Urodynamics describes a combination of tests that look at the ability of the bladder to store and void urine. The tests include:

  • Uroflowmetry
  • Post-void residual measurement
  • Cystometry

Additional tests:

  • Urethral pressure profilometry
  • Video-urodynamic investigations
21
Q

Incontinence: Initial investigations

A
  • Bladder diaries should be completed for a minimum of 3 days
  • Vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
  • Urine dipstick and culture
  • Urodynamic studies
22
Q

Management: URGE incontinence

A

If urge incontinence is predominant:

  • Bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
  • Bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in ‘frail older women’
  • Mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
23
Q

Management: STRESS incontinence

A

If stress incontinence is predominant:

  • Pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
  • Surgical procedures: e.g. retropubic mid-urethral tape procedures
24
Q

SURGICAL interventions for SUI: Mid- urethral slings (MUS)

A
  • Tension free tapes made of polypropylene mesh.
  • Inserted via a vaginal incision.
  • They work by supporting the mid-urethra during times of raised intra-abdominal pressure.
  • They are most commonly inserted by the retropubic route but may also be inserted by a transobturator technique.
  • There have been concerns raised about long term complications such as pain.
  • Other risks include damage to the urinary tract, voiding dysfunction, overactive bladder symptoms and exposure of the mesh in the vagina or urinary tract.
25
Q

SURGICAL interventions for SUI: Colposuspension (open or laparoscopic)

A
  • Colposuspension (open or laparoscopic)
  • Most common operation performed prior to the invention of MUS in the 1990’s.
  • Colposuspensions use sutures to elevate the neck of the bladder in order to stabilize the urethra and allow normal sphincter function.
  • Colposuspensions and MUS have similar efficacy.
  • Risks include prolapse of the posterior wall of the vagina (as the axis of the vagina is changed by lifting up the bladder neck), voiding dysfunction and overactive bladder.
26
Q

SURGICAL interventions for SUI: Urethral bulking agents

A
  • Urethral Bulking agents are an outpatient procedure which is less invasive, with a more favourable complication profile, but has a lower success rate than the more invasive options.
27
Q

SURGICAL interventions for SUI:

A
  • A fascial sling is similar in principle to a mid-urethral sling, but instead of using a synthetic polypropylene mesh, a strip of fascia (commonly from the rectus sheath), is taken from the patient and used to fashion a sling which is then passed underneath the urethra.
  • Slings have a similar success rate to MUS or colposuspension, but involve a vaginal incision plus another incision elsewhere to harvest the fascia.
  • Potential risks include hernia formation , voiding dysfunction and overactive bladder symptoms (urgency and urgency incontinence).
28
Q

Urinary incontinence: Risk factors

A
  • advancing age
  • previous pregnancy and childbirth
  • high body mass index
  • hysterectomy
  • family history
29
Q

Urogenital prolapse: Definition

A

In urogenital prolapse there is descent of one of the pelvic organs resulting in protrusion on the vaginal walls. It probably affects around 40% of postmenopausal
women

N.B. women who have incontinence do not necessarily have prolapse

30
Q

Urogenital prolapse: Types

A
  • Cystocele, cystourethrocele
  • Rectocele
  • Uterine prolapse
  • Less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)
31
Q

Urogenital prolapse: Risk factors

A
  • Increasing age
  • Multiparity, vaginal deliveries
  • Obesity
  • Spina bifida
32
Q

Urogenital prolapse: Presentation

A
  • sensation of pressure, heaviness, ‘bearing-down’

- urinary symptoms: incontinence, frequency, urgency

33
Q

Urogenital prolapse: Management

A
  • If asymptomatic and mild prolapse then no treatment needed
  • Conservative: weight loss, pelvic floor muscle exercises
  • Ring pessary
  • Surgery
34
Q

Urogenital prolapse: Management - SURGICAL options

A
  • Cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
  • Uterine prolapse: hysterectomy, sacrohysteropexy
  • Rectocele: posterior colporrhaphy
35
Q

Overactive bladder syndrome (OAB): Definition

A

OAB is a chronic condition, defined as urgency, with or without urge incontinence, usually with frequency or nocturia.

It is used to imply probably underlying detrusor overactivity (DO), but this is a diagnosis made on urodynamic testing.

36
Q

Overactive bladder syndrome (OAB): Clinical features (4)

A
  • Urinary frequency
  • Urinary urgency
  • Urge incontinence
  • Nocturia
37
Q

Overactive bladder syndrome (OAB): Investigations (3)

A
  • Urine culture
  • Frequency/volume charts
  • Urodynamics
38
Q

Overactive bladder syndrome (OAB):

  • Conservative (3)
  • Pharmacological (3)
A

Conservative:

  • Behavioural therapy
  • Bladder retraining
  • Hypnotherapy + acupuncture

Pharmacological:

  • Anticholinergic (antimuscarinic) drugs
  • Oestrogens
  • Botulinium toxin A

O&G (13 decks)

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