Urogynaecology

Question 1

What is the definition of prolapse?

Answer 1

Descent of the uterus and/or vaginal walls beyond normal anatomical confines

Question 2

What are the different types of prolapse?

Answer 2

• Urethrocele
• Cystocele (bladder)
• Apical prolapse (uterus, cervix and upper vagina)
• Enterocele
• Rectocele

Question 3

Give some risk factors for prolapse

Answer 3

• Pregnancy and vaginal delivery
• Menopause
• Predisposing factors, e.g. obesity, chronic cough, constipation
• Iatrogenic factors, e.g. pelvic surgery (hysterectomy, continence surgery)

Question 4

What are the clinical features of prolapse?

Answer 4

• Asymptomatic
• ‘Dragging’ sensation
• Cystourethrocele may cause LUTS
• Rectocele may cause difficulty defecating

Question 5

Describe the management of prolapse

Answer 5

1) Conservative:
- Small, asymptomatic prolapses may not require treatment
- Lifestyle factors, e.g. weight loss
- Pessary (ring or shelf - acts as an ‘artificial pelvic floor’)

2) Surgical management

Question 6

Describe a preventative measure to help avoid prolapse

Answer 6

Pelvic floor exercises are encouraged following childbirth to help to prevent prolapse

Question 7

What is the definition of urinary incontinence?

Answer 7

The involuntary leakage of urine

Question 8

What types of urinary incontinence are there?

Answer 8

• Stress incontinence
• Urge incontinence
• Mixed incontinence (most common)

Question 9

Describe the pathophysiology of stress incontinence

Answer 9

The involuntary leakage of urine during episodes of increased intra-abdominal pressure, e.g. sneezing, coughing, laughing

Question 10

What is the most common cause of stress incontinence?

Answer 10

Childbirth

Question 11

Describe the pathophysiology of urge incontinence

Urge incontinence is also known as…

Answer 11

• Sudden, involuntary contraction of the detrusor muscle resulting in a sudden urge to urinate that cannot be delayed
• Also known as overactive bladder

Question 12

What are the causes of urge incontinence?

Answer 12

• Idiopathic (most cases)
• Neurological conditions, e.g. MS
• Iatrogenic, i.e. pelvic surgery

Question 13

What is overflow incontinence?

What can cause this?

Answer 13

Leakage of urine from an overfull urinary bladder, often in the absence of any urge to urinate

Urinary retention due to bladder outflow obstruction

Question 14

Describe the investigation of urinary incontinence

Answer 14

• Urinalysis (to exclude infection)
• Frequency/volume charts (bladder diary)
• Urodynamic studies

Question 15

Describe the conservative, medical and surgical management of stress incontinence

Answer 15

Conservative:
- Pelvic floor exercises

Surgical:
- Various surgical options, e.g. TVT (tension free vaginal tape)

Medical:
- Duloxetine (in cases where surgery is contraindicated)

Question 16

Describe the conservative, medical and surgical management of urge incontinence

Answer 16

Conservative:
- Bladder retraining

Medical:

• Anticholinergic medications, e.g. oxybutynin, solifenacin, tolterodine
• Botox

Surgical:
- Only used in minority of patients with debilitating symptoms (e.g. detrusor myomectomy and augmentation cystoplasty)